Search

Introduction: Stroke is a severe complication of sickle cell anemia (SCA), with devastating sequelae. Transcranial Doppler (TCD) ultrasonography predicts stroke risk, but implementing TCD screening with suitable treatment for primary stroke prevention in low-resource environments remains challenging. SPHERE (NCT03948867) is a prospective phase 2 open-label hydroxyurea trial for SCA in Tanzania. Methods: After formal training and certification, local personnel screened children 2–16 years old; those with conditional (170–199 cm/s) or abnormal (≥200 cm/s) time-averaged mean velocities (TAMVs) received hydroxyurea at 20 mg/kg/day with dose escalation to maximum tolerated dose (MTD). The primary study endpoint is change in TAMV after 12 months of hydroxyurea; secondary endpoints include SCA-related clinical events, splenic volume and function, renal function, infections, hydroxyurea pharmacokinetics, and genetic modifiers. Results: Between April 2019 and April 2020, 202 children (average 6.8 ± 3.5 years, 53% female) enrolled and underwent TCD screening; 196 were deemed eligible by DNA testing. Most had numerous previous hospitalizations and transfusions, with low baseline hemoglobin (7.7 ± 1.1 g/dL) and %HbF (9.3 ± 5.4%). Palpable splenomegaly was present at enrollment in 49 (25%); average sonographic splenic volume was 103 mL (range 8–1,045 mL). TCD screening identified 22% conditional and 2% abnormal velocities, with hydroxyurea treatment initiated in 96% (45/47) eligible children. Conclusion: SPHERE has built local capacity with high-quality research infrastructure and TCD screening for SCA in Tanzania. Fully enrolled participants have a high prevalence of elevated baseline TCD velocities and splenomegaly. SPHERE will prospectively determine the benefits of hydroxyurea at MTD for primary stroke prevention, anticipating expanded access to hydroxyurea treatment across Tanzania.

To determine if differences between individual sonographers and radiologists performing and interpreting appendix ultrasound affect clinically important outcomes in children with suspected acute appendicitis.Patients18 years of age who presented to our emergency department (ED) with suspected acute appendicitis and underwent an appendix ultrasound were identified. Sonographers who performed fewer than 100 examinations and radiologists who interpreted fewer than 100 examinations during the study period were excluded. Multivariable logistic regression was performed to assess the effect of sonographer, radiologist, clinical variables, and system factors on key clinical outcomes, including hospital admission and appendectomy.In all, 9,283 appendix ultrasounds (mean age, 9.9 ± 4.2 years; 5,400 [58.2%] boys) performed by 31 sonographers (mean number of examinations, 299 ± 140 [range, 115-610]) and interpreted by 31 radiologists (mean number of examinations, 299 ± 157 [range, 101-845]) were included. Mean admission frequency per sonographer was 34.0% ± 3.3% (range, 27.8%-42.6%) and per radiologist was 33.5% ± 3.9% (range, 23.7%-41.6%). Mean appendectomy frequency per sonographer was 20.3% ± 2.6% (range, 14.9%-27.0%) and per radiologist was 20.3% ± 3.1% (range, 15.2%-28.7%). Significant multivariable predictors of hospital admission included temperature (P.0001), white blood cell count (P.0001), male sex (P = .002), imaging performed at the main hospital (versus satellite hospital) (P = .001), abdominal tenderness with ultrasound transducer compression (P.0001), presence of rebound tenderness (P = .001), and presence of acute appendicitis by ultrasound (P.0001), but not sonographer or radiologist. Predictors of appendectomy included weight (P.0001), white blood cell count (P.0001), male sex (P = .0004), abdominal tenderness with ultrasound transducer compression (P.0001), and the presence of acute appendicitis by ultrasound (P.0001), but not sonographer or radiologist.Differences in individual sonographers and radiologists did not predict clinically important outcomes in children undergoing ultrasound in the ED for suspected acute appendicitis.

To determine if individual sonographers and radiologists impact appendix visualization by ultrasound and utilization of computed tomography (CT) in children with suspected acute appendicitis. Appendix ultrasound examinations performed at Cincinnati Children’s Hospital Medical Center on Emergency Department patients ≤ 18 years old were retrospectively identified. Examinations performed/interpreted by sonographers/radiologists with fewer than 100 examinations were excluded. Multivariable logistic regression was used to assess the effect of sonographer, radiologist, clinical variables, and system factors on imaging outcomes, including appendix visualization and subsequent CT utilization. A total of 9271 ultrasound examinations (mean [SD] patient age, 9.9 [4.2] years; 5392 [58.2%] boys) performed by 31 sonographers (mean number examinations, 299 [139]; range, 115–610) and interpreted by 31 radiologists (mean number examinations, 299 [157]; range, 101–845) were included. The mean frequency of appendix visualization per sonographer was 57.8% [8.7%] (range, 40.9–76.0%) and per radiologist was 59.5% [4.1%] (range, 51.7–66.3%). The mean rate of CT utilization per sonographer was 9.2% [2.0%] (range, 5.9–14.0%) and per radiologist was 9.2% [1.8%] (range, 3.4–12.1%). Predictors of appendix visualization by ultrasound included patient weight (p < 0.0001), sex (p = 0.0003), white blood cell count (p < 0.0001), temperature (p = 0.002), abdominal tenderness (p = 0.004), presence of appendicitis (p < 0.0001), sonographer (p < 0.0001), and radiologist (p = 0.02). Predictors of CT utilization included patient weight (p < 0.0001), white blood cell count (p < 0.0001), abdominal tenderness (p < 0.0001), rebound tenderness (p = 0.0003), and presence of appendicitis (p < 0.0001), but not sonographer or radiologist. Individual sonographers and radiologists were associated with appendix visualization by ultrasound in children with suspected acute appendicitis; neither was associated with CT utilization. • Individual sonographers and radiologists are significantly and independently associated with appendix visualization by ultrasound in children with suspected acute appendicitis. • Frequency of appendix visualization per sonographer demonstrated significant and wide variability across 31 sonographers, ranging from 40.9 to 76.0%. • Fewer than 10% of patients with an ultrasound examination for suspected acute appendicitis underwent CT imaging within the following 24 h. Individual radiologists and sonographers were not predictive of CT utilization within 24 h.

Non-alcoholic fatty liver disease (NAFLD) is increasing in prevalence and is the most common cause of pediatric chronic liver disease. Objective US-based measures of hepatic steatosis are an unmet clinical need.To evaluate the diagnostic performance of quantitative measurement of liver echogenicity (hepatorenal index, or HRI) for hepatic steatosis in a pediatric cohort.We identified pediatric patients (≤18 years old) who underwent both clinically indicated abdominal US and MRI with liver proton-density fat fraction (PDFF) within the 3-month period during the timeframe of July 2015-April 2020 (n=69). Using ImageJ, we drew small circular regions of interest (ROIs) and large freehand ROIs in the liver and right kidney on single longitudinal and transverse images to measure echogenicity (arbitrary units). We calculated four HRIs (liver-to-kidney ratio) as well as liver histogram features. Five pediatric radiologists independently reported the qualitative presence/absence of hepatic steatosis. We used Pearson correlation (r) to assess associations and receiver operating characteristic (ROC) curve analyses to evaluate diagnostic performance. Multivariable logistic regression was used to further assess relationships.Mean patient age was 11.6 (standard deviation [SD] 4.7, range 0.3-18) years; 27/69 (39.1%) were female. Mean PDFF was 12.5% (SD 13.1%, range 1-48%); 34/69 (49.3%) patients were classified as having hepatic steatosis by MRI (PDFF ≥6%). There were significant, positive correlations between all four US HRI methods and PDFF (r=0.51-0.61); longitudinal freehand ROIs exhibited the strongest correlation (r=0.61; P0.0001). Longitudinal freehand ROI HRI had moderate diagnostic performance for the binary presence of steatosis (area under the curve [AUC]=0.80, P0.0001), with an optimal cut-off value1.75 (sensitivity=70.6%, specificity=77.1%). Radiologists' sensitivity for detecting hepatic steatosis ranged from 79.4% to 97.1%, and specificity ranged from 91.2% to 100%. Significant multivariable predictors of PDFF ≥6% included HRI (P=0.002; odds ratio [OR]=34.2), body mass index (BMI) percentile (P=0.005; OR=1.06), and liver gray-scale echogenicity standard deviation (P=0.02; OR=0.79) (receiver operating characteristic AUC = 0.92).Quantitative US HRI has moderate diagnostic performance for detecting liver fat in children and positively correlates with MRI PDFF. Incorporation of BMI-percentile and gray-scale echogenicity standard deviation improved diagnostic performance.

To determine if individual sonographers and radiologists impact appendix visualization by ultrasound and utilization of computed tomography (CT) in children with suspected acute appendicitis.Appendix ultrasound examinations performed at Cincinnati Children's Hospital Medical Center on Emergency Department patients ≤ 18 years old were retrospectively identified. Examinations performed/interpreted by sonographers/radiologists with fewer than 100 examinations were excluded. Multivariable logistic regression was used to assess the effect of sonographer, radiologist, clinical variables, and system factors on imaging outcomes, including appendix visualization and subsequent CT utilization.A total of 9271 ultrasound examinations (mean [SD] patient age, 9.9 [4.2] years; 5392 [58.2%] boys) performed by 31 sonographers (mean number examinations, 299 [139]; range, 115-610) and interpreted by 31 radiologists (mean number examinations, 299 [157]; range, 101-845) were included. The mean frequency of appendix visualization per sonographer was 57.8% [8.7%] (range, 40.9-76.0%) and per radiologist was 59.5% [4.1%] (range, 51.7-66.3%). The mean rate of CT utilization per sonographer was 9.2% [2.0%] (range, 5.9-14.0%) and per radiologist was 9.2% [1.8%] (range, 3.4-12.1%). Predictors of appendix visualization by ultrasound included patient weight (p0.0001), sex (p = 0.0003), white blood cell count (p0.0001), temperature (p = 0.002), abdominal tenderness (p = 0.004), presence of appendicitis (p0.0001), sonographer (p0.0001), and radiologist (p = 0.02). Predictors of CT utilization included patient weight (p0.0001), white blood cell count (p0.0001), abdominal tenderness (p0.0001), rebound tenderness (p = 0.0003), and presence of appendicitis (p0.0001), but not sonographer or radiologist.Individual sonographers and radiologists were associated with appendix visualization by ultrasound in children with suspected acute appendicitis; neither was associated with CT utilization.• Individual sonographers and radiologists are significantly and independently associated with appendix visualization by ultrasound in children with suspected acute appendicitis. • Frequency of appendix visualization per sonographer demonstrated significant and wide variability across 31 sonographers, ranging from 40.9 to 76.0%. • Fewer than 10% of patients with an ultrasound examination for suspected acute appendicitis underwent CT imaging within the following 24 h. Individual radiologists and sonographers were not predictive of CT utilization within 24 h.

The incidence of pediatric nephrolithiasis in the United States is increasing. There is a paucity of literature comparing the diagnostic performance of computed ultrasound (US) to tomography (CT) in the pediatric population. To determine the diagnostic performance of renal US for nephrolithiasis in children using a clinical effectiveness approach. Institutional review board approval with a waiver of informed consent was obtained for this retrospective, HIPAA-complaint investigation. Billing records and imaging reports were used to identify children (≤18 years old) evaluated for nephrolithiasis by both US and unenhanced CT within 24 h between March 2012 and March 2017. Imaging reports were reviewed for presence, number, size and location of kidney stones. Diagnostic performance of US (reference standard=CT) was calculated per renal unit (left/right kidney) and per renal sector (four sectors per kidney). For sector analysis, US was considered truly positive if a stone was identified at CT in the same or an adjacent sector. There were 68 renal stones identified by CT in 30/69 patients (43%). Mean patient age was 14.7±3.6 years, and 35 were boys. For detecting nephrolithiasis in any kidney, US was 66.7% (48.8–80.8%) sensitive and 97.4% (86.8–99.9%) specific (positive predictive value=95.2% [77.3–99.8%], negative predictive value=79.2% [65.7–88.3%], positive likelihood ratio=26.0). Per renal sector, US was 59.7% (46.7–71.4%) sensitive and 97.4% (95.5–98.5%) specific (positive predictive value=72.3% [58.2–83.1%], negative predictive value=95.4% [93.2–96.9%], positive likelihood ratio=22.5). Of the 30 stones not detected by US, only 3 were >3 mm at CT. In clinical practice, US has high specificity for detecting nephrolithiasis in children but only moderate sensitivity and false negatives are common.

To evaluate superb microvascular imaging (SMI) for the detection of high-grade vesicoureteral reflux (VUR). We reviewed the patients with urinary tract infection who underwent renal US with SMI and VCUG. The subjects were divided into a VUR group, which included 17 patients (20 kidney units, KU) with high-grade reflux (grade 4 or 5) on VCUG, and a group without VUR including the same numbers of subjects. The direction of urine movement at the distal ureter and the renal pelvis was reviewed on SMI. SMI and VCUG results were compared. Urinary flow "jets" into the bladder and direction of the flow were detectable on all SMI examinations in both groups. In the group with VUR, 20 KUs had grade 4 (n = 11) or grade 5 (n = 9) reflux (bilateral VUR in 3 patients). Among 20 KUs with VUR, 15 (75%) showed a reversed ureteral jet and/or renal pelvic swirl sign on SMI. None of the patients in the group without VUR showed those findings on SMI. SMI enables detection of the direction of urinary flow. The presence of a reversed ureteral jet and/or renal pelvic swirl sign correlates with high-grade VUR with 75% accuracy. • Superb microvascular imaging is feasible in children with urinary tract infection. • SMI enables detection of the direction of urinary flow. • Presence of reversed flow correlates with high-grade vesicoureteral reflux.

Magnetically controlled growing rods (MCGRs) are increasingly used in the treatment of early onset scoliosis (EOS). Few studies have reported whether desired lengthening can reliably be achieved, or if prior spine instrumentation and large tissue depths affect lengthening. In this clinical study of EOS patients, it was hypothesized that increases in rod length would equal programmed increases, patients with prior spine instrumentation would lengthen less than patients without prior surgery, and larger tissue depths would decrease lengthening success.A retrospective chart review was conducted on EOS patients with single and dual MCGRs placed between April 2014 to September 2015 and distracted at a single institution. Rod distraction was measured at each visit using ultrasound. Differences between programmed and actual distraction for each patient, and between groups with and without prior spine instrumentation, were determined by 2-tailed t tests. Regression and correlation were used to determine the relationship between tissue depth and length increases.Thirty-one patients were included, 18 males, 13 females, age 8.1 (±2.5) years, with major curves measuring 60 (±14.6) degrees at time of MCGR insertion. In the 12 patients with prior instrumentation, time from initial growing rod placement to MCGR insertion was 23.1 (±10.6) months. The number of surgical procedures before MCGR insertion was 2.8 (±2.0). Total length increase relative to the programmed distraction was 86% (±21) (P0.001). Length increases for patients with and without prior surgery were 87% (±23) and 86% (±19), respectively (P0.9). Total lengthening was inversely proportional to tissue depth (r=0.38, P0.01); the decrease in lengthening achieved was 2.1%/mm of tissue depth.Increases in rod length were 14% lower than the programmed distraction. Prior instrumentation did not impact the amount of rod distraction. Greater distance between the rod and the skin surface negatively affected the magnitude of distraction.

Although spinal cord tethering is known to be associated with certain clinical syndromes and cutaneous stigmata, its incidence in healthy infants with simple sacral dimples has not been thoroughly evaluated. Our objective was to determine the frequency of tethered cord in otherwise healthy patients with simple sacral dimples. We reviewed the lumbar spine US reports of all healthy neonates referred for a simple sacral dimple during a 12-year period at two children’s hospitals. A sonogram was considered abnormal for a conus medullaris terminating below the L2–L3 disc space, decreased conus or nerve root motion, an abnormal filum terminale, or for the presence of an intraspinal mass, osseous dysraphism, or a sinus leading to the thecal sac. The medical records of patients with abnormal screening sonograms were reviewed to determine the final clinical outcome. During the study period 3,991 infants underwent screening sonography. Of these, 107 were excluded because of the presence of other medical conditions. Of the remaining 3,884 healthy infants, 133 (3.4%) had an abnormal sonogram. Five (0.13%) of these infants were lost to follow-up; 52 subsequently had normal follow-up imaging; 49 had a low conus without other signs of tethering; 18 had a fatty filum; 2 had decreased conus motion; 2 had both a low conus and a fatty filum. None of these infants underwent surgery. Only the remaining 5/3,884 (0.13%) infants underwent surgical intervention (95% CI: 0–0.27%), and 4/5 were found to have a tethered cord intraoperatively. The risk of significant spinal malformations in asymptomatic, healthy infants with an isolated simple sacral dimple is exceedingly low.

Objective The normal diameter of the extrahepatic bile duct (EHD) in children has been poorly studied. Prior studies have enrolled small subject numbers, have studied only specific pediatric age groups, or have potential bias due to loosely defined exclusion criteria. We sought to establish parameters for the normal diameter of the EHD in children from birth to late adolescence, including premature infants. Methods A 12½-month institutional review board-approved, Health Insurance Portability and Accountability Act-compliant, retrospective chart review of all transabdominal ultrasounds performed on children (younger than 18 years) was conducted at a single pediatric tertiary referral center. Exclusion criteria included a past medical history of any pancreaticobiliary or hepatology disorder. New abnormal findings related to the liver, biliary system, or pancreas were also excluded. Recorded EHD measurements from review of the radiology reports were compiled. Estimated mean and 95% prediction intervals of EHD were calculated and reported for 6 nonoverlapping pediatric age groups. Results A total of 1016 ultrasounds on unique patients were included within the study. Estimated mean values and calculated 95% prediction intervals (in parentheses) for the diameter of the EHD were prematurity, 0.7 (0.3-1.7) mm; 0 to 2 months, 1.0 (0.4-2.3) mm; 3 to 11 months, 1.2 (0.5-2.9) mm; 1 to 4 years, 1.4 (0.6-3.3) mm; 5 to 12 years, 1.9 (0.8-4.3) mm; 13 to 17 years, 2.3 (1.0-5.2) mm. Conclusions Our derived data of normal predicted parameters of the EHD diameter in children of all age groups will help guide clinicians in identifying those patients outside the norm that may benefit from additional testing.

The purpose of this article is to determine the reliability of sonographic renal length measurements compared with measurements obtained from helical CT multiplanar reformat images and compared with standard renal growth curves.A retrospective review was performed of 76 subjects who underwent both renal ultrasound and abdominal CT within 2 weeks of one another. Renal lengths were measured using oblique coronal reformat images of helically acquired CT data by two observers on two occasions. Intraobserver and interobserver error for these measurements were calculated. Ultrasound renal length measurements were compared with CT measurements. Measurement variation was compared with standard renal growth curves.The mean (± SD) of the absolute value of interobserver error of CT measurements was 0.9 ± 0.8 mm. Compared with CT, individual ultrasound measurements underestimated renal length by 1.5 ± 5.6 mm on average, with a 95% CI of -12.5 to 9.5 mm. When the maximum of three ultrasound renal length measurements was used, the SD was 4.7 mm, with a 95% CI of -8.2 to 10.1 mm of the reported renal length. This corresponds to greater or less than 3.3 years of normal renal growth.Lack of renal growth can be asserted only when renal length falls below the growth curve, taking into account the corresponding measurement error limits, which we found to be greater or less than 9.3 mm. If the follow-up measurement falls within these limits, one should not infer lack of appropriate renal growth, even if the renal length measurement decreases or remains unchanged for up to 3 years.

Objective To determine the interrater reliability (IRR) of lung ultrasonography (LUS) and chest radiography (CXR) and evaluate the accuracy of LUS compared with CXR for detecting pediatric pneumonia compared with chest computed tomography (CT) scan. Study design This was a prospective cohort study of children aged 3 months to 18 years with a CXR and LUS performed between May 1, 2012, and January 31, 2014 with or without a clinical diagnosis of pneumonia. Four pediatric radiologists blinded to clinical information reported findings for the CXR and LUS images. IRR was estimated for 50 LUS and CXR images. The main outcome was the finding from CT ordered clinically or the probability of the CT finding for patients clinically requiring CT. Two radiologists reviewed CT scans to determine an overall finding. Latent class analysis was used to evaluate the sensitivity and specificity for findings (eg, consolidation) for LUS and CXR compared with CT. Results Of the 132 patients in the cohort, 36 (27%) had CT performed for a clinical reason. Pneumonia was clinically documented in 47 patients (36%). The IRR for lung consolidation was 0.55 (95% CI, 0.40-0.70) for LUS and 0.36 (95% CI, 0.21-0.51) for CXR. The sensitivity for detecting consolidation, interstitial disease, and pleural effusion was statistically similar for LUS and CXR compared with CT; however, specificity was higher for CXR. The negative predictive value was similar for CXR and LUS. Conclusions LUS has a sufficiently high IRR for detection of consolidation. Compared with CT, LUS and CXR have similar sensitivity, but CXR is more specific for findings indicating pneumonia.

Cecal volvulus is an acute surgical condition that is extremely rare in children, with a mortality rate of up to 40%. The clinical symptoms are often non-specific, and pediatric patients frequently have neurological deficits with associated communication difficulties, making the clinical diagnosis extremely challenging. Conventional radiographic imaging studies play a key role in the prospective diagnosis in children. We report a rare case of cecal volvulus in a 12-year-old boy who was diagnosed pre-operatively by abdominal radiographs and a contrast enema.

A clinical study of early onset scoliosis (EOS) patients following implantation of magnetically controlled growing rods (MCGRs) demonstrated that increases in rod length were lower than programmed. Tissue depth, but not prior spine instrumentation, affected increases in rod length.

A true hermaphrodite is an individual who is found to have both testicular and ovarian tissue; ovotestes is the most common gonad. True hermaphroditism is a rare intersex disorder reported in less than 500 patients. This patient population typically presents with ambiguous genitalia, hypospadius, and often an associated bifid scrotum; 90% go on to develop gynecomastia. Although some patients are diagnosed in the newborn period, only 20% are diagnosed prior to the age of 5 years. In this case report, the authors describe these classic findings and the use of advanced ultrasound technology, which contributed to this rare diagnosis.

The spleen in infants and children is commonly involved in a variety of pathologic processes. Some of these processes cause isolated splenic disease, whereas others involve the spleen as part of a systemic illness. To facilitate differential diagnosis of splenic abnormalities, a pattern-oriented approach to the imaging evaluation of the pediatric spleen was developed. With this approach, splenic anomalies are categorized as anomalies of splenic shape (clefts, notches, lobules), location (eg, wandering spleen), number (polysplenia, asplenia), or size (splenomegaly, splenic atrophy); solitary lesions (eg, cysts, lymphangiomas, hemangiomas, hamartomas); multiple focal lesions (eg, trauma, infection and inflammation, neoplasms, storage disorders); and diffuse disease without focal lesions (eg, infarction, heavy metal deposition, hemangioendotheliomas, peliosis). A variety of imaging modalities can be used in splenic assessment, including computed tomography, magnetic resonance imaging, ultrasound, and technetium-99m scintigraphy. The imaging appearance of the pediatric spleen depends on the patient's age and the modality used; however, familiarity with the spectrum of radiologic patterns of splenic involvement will facilitate correct diagnosis and prompt treatment.

To determine the radiographic appearance and features of corrosion in U.S. coins exposed to gastric acid.Six U.S. copper-based pre-1982 pennies, 12 zinc-based post-1982 pennies, a quarter, a nickel, and a dime were exposed to postprandial concentrations of gastric acid (0.15N HCl) for 7 days, and radiographs were obtained daily. Half the zinc-based coins were scraped to disrupt their copper coating. Coins were weighed at the start and completion of the study.Post-1982 zinc-based pennies developed radiolucent corrosive changes within 24 hours. Erosions on the coins became more apparent over time. Frank holes were present on day 2. The weights of these coins decreased 5%-8% during the study. Pre-1982 copper pennies and "silver-colored" coins showed no change on radiographs over 7 days.Unexpected radiolucent corrosions may develop in post-1982 zinc alloy pennies when retained in the stomach. Coins have long been considered innocuous foreign bodies in the gastrointestinal tracts of children. However, because of the potential for ulceration and zinc-related morbidity, closer clinical and radiographic observation is warranted. Coins with scalloped edges or holes should be endoscopically removed, as they have likely been retained longer than 1 or 2 days.

To evaluate the frequency of anterior chest wall variations in children.The computed tomographic (CT) images of 200 consecutive infants and children (114 boys and 86 girls; mean age, 10.5 years; age range, 3 months to 19 years) who underwent chest CT during a 20-month period were evaluated for chest wall variations. Children who had undergone chest wall surgery or were suspected of having a chest wall abnormality were excluded. The frequency of chest wall anomalies was compared with age and sex (Fisher exact test).The CT scans of 65 children (33%) depicted one or more variations in the anterior chest wall: titled sternum (n = 29), prominent convexity of anterior rib or costal cartilage (n = 19), prominent asymmetric costal cartilage (n = 20), well-defined paracostal subcutaneous nodule (n = 4), mild pectus excavatum (n = 4), or mild pectus carinatum (n = 4). The frequency of these findings did not vary significantly with age (P = .96) or sex (P = .36).Variations in the anterior chest wall are common, occurring in one-third of children, and should be considered normal. These asymptomatic variations should not be considered alarming when palpated at physical examination.

who had PET scans to evaluate CNS disease. These two patients illustrate normal variability of FDG uptake in pediatric chest. A, 1-year-old girl with developmental delay after neonatal encephalitis. Note normal FDG accumulation, which is intense in heart and more mild in thymus (arrow) in inverted “V’ configuration. B, 5-year-old autistic boy with less intense FDG uptake in thymus (arrow), but more intense uptake in lymphoid tissues in neck (arrowhead).

OBJECTIVE: Our intent was to describe the range of postoperative sonographic appearances of the bladder after endoscopic incision of ureteroceles. CONCLUSION: Preoperative and postoperative sonographic examinations of the bladder were reviewed in 14 patients (15 ureteroceles) who underwent endoscopic ureterocele incision. Five different appearances of the ureterovesical junction after endoscopic incision were found: a pseudomass (5/15), focal mucosal thickening (3/15), residual ureterocele with decrease in size (3/15), persistent unchanged ureterocele (1/15), and no residual abnormality (3/15). The most common postoperative sonographic appearance associated with development of vesicoureteral reflux was a mucosal pseudomass (4/6). The other bladder sonographic appearances had no correlation with development of reflux, degree of hydronephrosis, or success of the surgery.

In today’s practice of pediatric urology, imaging of the abnormal urinary tract usually begins in utero, as a result of abnormal findings on a screening prenatal ultrasound (US) examination. Many abnormal fetuses are then imaged by fetal MRI, where available, for genetic counseling or in those centers where fetal surgeons can intervene prenatally. In the newborn period, imaging is performed with as little radiation exposure as is reasonably achievable (ALARA). Usually, this is easily achieved since the mainstay of imaging the newborn urinary tract is US. Voiding cystourethrography (VCUG) and radionuclide renography, with or without a diuretic, are relatively low-radiation-dose techniques when modified for pediatric patients and are utilized for specific indications. Sometimes neonatal magnetic resonance imaging (MRI) can be very helpful to further evaluate complex urinary tract anomalies but is not used unless other techniques are insufficient to define the abnormality or to evaluate extent of disease, such as in neonatal neoplasms.

Purpose: We evaluated the use of renal ultrasound for monitoring pyelocaliectasis after pyeloplasty in children.Materials and Methods: Changes in pyelocaliceal dilatation following pyeloplasty were assessed by serial ultrasound. Of 104 children 0 to 12 years old who underwent pyeloplasty between 1982 and 1992, 44 (47 renal units) were monitored with serial ultrasound for at least 2 years (range 2 to 9, mean 3.8). Patient ages at pyeloplasty were 0 to 3 months (17), 4 to 12 months (8), 1 to 6 years (13) and 7 to 12 years (6). Preoperative and postoperative ultrasound was reviewed by a single pediatric radiologist blinded to the date of surgery. The degree of pyelocaliectasis was graded as 0 to 4 according to the classification of the Society for Fetal Urology.Results: Preoperative ultrasound revealed grade 4 pyelocaliectasis in 26 kidneys (55 percent) and grade 3 disease in 21 (45 percent). Grade was the same or worse 1 month after pyeloplasty in the majority of kidneys (92 percent) studied at this...

Rationale and Objectives. We examined whether the intravenous (IV) Doppler ultrasound contrast agent SHU 508 would improve the detection of reduced perfusion of rabbit testes when normal flow was otherwise difficult to detect. Methods. Seventeen anesthetized prepubertal rabbits underwent ran dom unilateral spermatic cord ligation and a contralateral sham operation. Immediate, blinded, and systematic color Doppler examination of each pair of testes was recorded before and after IV administration of 1 ml (300 mg) SHU 508, a gas-containing microparticle. Recorded examinations were reviewed by two pediatric radiologists who were unaware of experimental conditions and who graded intratesticular flow. Results. For 34 pairs of observations (17 animals × 2 observers), intratesticular flow was absent in the sham-operated testes in 18 precontrast and two postcontrast images. The false-positive rate in this group decreased from 53% to 6%. This improvement in the detection of normal blood flow was statistically significant. The absence of flow in the ischemic testis was not significantly different before or after contrast agent administration. Conclusion. IV SHU 508 enhances color Doppler ultrasound detection of flow not otherwise evident in prepubertal rabbit testes. Doppler ultra-sound contrast agents may be used in a setting of suspected torsion when routine Doppler sonography is indeterminate.

In 1960 Van Wyk and Grumbach described a syndrome of juvenile hypothyroidism, precocious puberty and ovarian enlargement. These findings undergo complete regression with thyroid hormone replacement therapy. This diagnosis can be made on the basis of imaging findings and thyroid function analysis, avoiding surgery.To relate the distinctive clinical and imaging features and putative pathophysiological mechanism of a series of patients with Van Wyk and Grumbach syndrome (VWGS).Patients with VWGS diagnosed at two large children's hospitals over a 6-year period beginning in 1999 were retrospectively reviewed. A literature review was also conducted.Five female patients were diagnosed with cystic ovarian enlargement and hypothyroidism at ages ranging from 9 to 17 years. Isosexual precocious puberty was found in prepubescent patients. Associated findings included delayed bone age, ascites, and pleural and pericardial effusions. Ovarian cyst involution occurred following treatment of the hypothyroidism.The association of primary hypothyroidism with cystic ovarian enlargement and precocious puberty is important to recognize. In the absence of suspected ovarian torsion, surgery is unnecessary, as cyst regression occurs after appropriate thyroid hormone replacement. Noncompliance with hormone replacement therapy should be considered when cystic ovarian enlargement is noted in patients with a history of hypothyroidism.

Adnexal torsion is rare, and symptoms are nonspecific. Clinicians often rely on US examinations to evaluate girls with abdominal or pelvic pain.To determine which sonographic findings can predict adnexal torsion by comparing pediatric and adolescent patients with surgically confirmed torsion (cases) to those without torsion (controls).Cases and controls were identified retrospectively by searching 7 years of medical record and radiology databases. An adnexal ratio was calculated as the volume of the affected adnexa divided by the volume of the unaffected adnexa.We identified 61 menarchal subjects: 33 cases and 28 controls. Adnexal volume was larger in cases than in controls (185 vs. 37.8 ml, P0.001). A volume of75 ml was more common in cases than in controls (64 vs. 15%, P0.001). No cases had an adnexal volume of20 ml (P0.001). The adnexal ratio was larger in cases than in controls (16.1 vs. 6.7, P0.001). An adnexal ratio of15 was seen in 40% of cases and in no controls (P = 0.08). Doppler US results were not predictive of torsion.An adnexal volume of20 ml is strong evidence against adnexal torsion in menarchal females. In this age group, the diagnosis of torsion cannot be established by US examination alone.

We report the case of an immunocompromised 15-year-old boy who presented with symptoms mimicking an "acute abdomen" related to necrotizing myofasciitis of the anterior abdominal wall. CT demonstrated the abdominal wall process as the cause of the patient's symptoms and sonographically guided aspiration confirmed the diagnosis. Despite prompt diagnosis and aggressive surgical debridement, the infection continued to progress and the patient died within 24 h of presentation.

Since the development of fast imaging sequences, MR has proved to be a helpful tool in the evaluation of fetal pathology. Because of the high water content of fetal tissues and pathology, hydrography imaging (MR fetography) can provide additional diagnostic information. To demonstrate the benefit of MR fetography in fetal imaging. From 2004 to 2005, 126 fetal MR examinations were performed for evaluation of an abnormality depicted on an antenatal sonogram. Single-shot fast spin-echo MR imaging and MR fetography were performed through the area of fetal pathology. The two studies were retrospectively compared. The primary diagnosis was not changed with the addition of MR fetography. New findings, particularly in the kidneys and spine, were identified in 9% of the patients. When fetal pathology was of high water content (80% patients), the MR fetography imaging increased diagnostic confidence. In 11% of the patients, those with cardiovascular or low water pathology, the MR fetography was not beneficial. The mainstay of fetal imaging is currently the HASTE and SSFSE sequences. However, MR fetography is an excellent adjunct that highlights fetal pathology by reinforcing the diagnosis, identifying additional findings, and providing high-contrast high-resolution images that are helpful when counseling clinicians and patients.

Twin-twin transfusion syndrome (TTTS) is a complication of monochorionic/diamniotic twin pregnancies. An imbalance of blood flow occurs through placental anastomoses, causing potentially significant morbidity and mortality in both twins. Although the sonographic findings of TTTS are well documented, we believe that MR imaging is a valuable adjunct.We describe the fetal MR imaging findings associated with TTTS.From 2003 to 2005, 37 consecutive MR imaging studies were performed on multiple-gestation pregnancies. Of the 37, 25 were consistent with TTTS, correlated and confirmed by sonographic criteria. MR fetal abnormalities were documented.Cerebral ischemia, which could not be demonstrated by sonography, was delineated well by MR imaging. New findings noted on fetal MR imaging were enlargement of cerebral venous sinuses in both twins, dilatation of the renal collecting system in the recipient, lung lesions in the recipient and cerebral malformations in the donor.MR imaging is an important adjunct in TTTS imaging. Its benefit over sonography is its clear definition of cerebral pathology, which is important for intervention and counseling. The new findings, particularly in the urinary tract and cerebral venous sinuses, also help support the diagnosis of TTTS and might reveal additional consequences of the altered hemodynamics that occur in TTTS.

Background: Radiopharmaceutical uptake of [18F]2-deoxy-2-glucose (FDG) in brown adipose tissue is noted on 15–20% of positron emission tomography (PET) scans in children and adolescents. One report suggests that moderate-dose oral diazepam can partly or completely block FDG uptake in brown adipose tissue. Objective: To determine whether [18F]FDG uptake in brown adipose tissue can be adequately blocked by pre-medication other than moderate-dose oral diazepam. Materials and methods: One hundred and eighteen [18F]FDG PET body imaging studies were performed in 69 pediatric patients with a variety of solid tumors. The mean age at the time of imaging was 12.9 years (range 1.2–22.6 years), and 33 studies were performed in patients younger than 10 years old. Seventy-six were performed in boys and 42 in girls. Patients were imaged using a dedicated PET camera. Pre-medication was given in 88 studies: 45 received intravenous fentanyl (0.75–1.0 μg/kg), 34 received low-dose oral diazepam (0.06 mg/kg) and 9 received moderate-dose oral diazepam (0.10 mg/kg). Thirty patients received no pre-medication, 7 of whom were known to have received opiates for pain during the 12 h before the study. Six body regions in the neck and chest were reviewed for [18F]FDG uptake in brown adipose tissue. Uptake of FDG in brown fat was visually graded: 0 for no FDG uptake, 1 for low-grade uptake, 2 for moderate uptake, and 3 for intense uptake. Visual grades 2 and 3 were considered to interfere potentially with image interpretation in the neck and chest. Data were analyzed by multivariate regression using a Poisson distribution. Results: [18F]FDG uptake in brown adipose tissue was most often seen in the lateral neck region and superior and lateral to the lungs (in 36 and 39 studies, respectively). Uptake was also seen near the costovertebral junctions (15 studies), in the superior and central neck in 7 studies and in the anterior mediastinum in 2. Brown adipose tissue uptake was thought to interfere potentially with image interpretation (visual grades 2 and 3) in 19 studies—in 6 of 23 (26.1%) studies after no pre-medication and no opiates for pain, in 10 of 34 (29.4%) after low-dose oral diazepam, in 0 of 9 (0%) after moderate-dose oral diazepam, in 3 of 45 (6.7%) after intravenous fentanyl, and in 0 of 7 (0%) after opiates prescribed for pain. Intravenous fentanyl reduced the grade of brown adipose tissue compared to no drug (P=0.0039) and low-dose diazepam (P=0.0024). Low-dose diazepam had no effect when compared to no drug (P=0.984). There were inadequate data for statistical testing of moderate-dose valium and opiates prescribed for pain. Children younger than 10 years had lower uptake grades (P=0.019) than those older than 10 years. Summary: The frequency of interfering [18F]FDG uptake in brown adipose tissue is reduced by intravenous fentanyl pre-medication, which appears to be an effective alternative to the existing standard pre-medication, moderate-dose oral diazepam.

Purpose: Conflicting data exist concerning optimal timing for initial postnatal ultrasound in newborns with prenatal hydronephrosis. To determine whether timing significantly affects the accuracy of postnatal ultrasound, we conducted a prospective study comparing ultrasound within 48 hours of birth and at 7 to 10 days of life.Materials and Methods: A total of 21 consecutive newborns with prenatal hydronephrosis were enrolled in 14 months. Prenatal hydronephrosis was defined as a pelvic diameter 4 mm. or greater before 33 weeks and 8 mm. or greater beginning at 33 weeks of gestation. Postnatal hydronephrosis was assessed using the Society for Fetal Urology grading system. Patients were subsequently followed with serial ultrasound and adjunctive imaging studies.Results: Of the 32 evaluable renal units a majority had a change in the degree of hydronephrosis between the first and second ultrasound. An increase in hydronephrosis was found in 14 (44%) renal units with an increase of 2 or greater grades ...

Congenital hemolytic anemias frequently lead to severe hemolysis due to splenic sequestration of abnormal erythrocytes. 1 For children with hereditary spherocytosis (HS), a total splenectomy eliminates the main source of erythrocyte destruction. For children with other hemolytic anemias, a splenectomy eliminates splenic sequestration and reduces symptoms of hypersplenism. The use of total splenectomy in children is restricted by concern of overwhelming postsplenectomy sepsis. 2–5 In children less than 5 years of age, the risk of overwhelming postsplenectomy sepsis may be increased 60- to 100-fold compared to children who have not had a splenectomy. 4 Although the risk of overwhelming postsplenectomy sepsis is reduced by use of immunizations to Streptococcus pneumoniae, Meningococcus, and Haemophilus influenzae as well as postoperative antibiotic prophylaxis, its risk is never eliminated. 5 Moreover, concerns persist of incomplete protection by pneumococcal vaccinations, antibiotic resistance, and poor compliance with antibiotic prophylaxis. 5,6 For children with congenital hemolytic anemias, a partial splenectomy has been proposed as an alternative to total splenectomy, with the goal of removing enough spleen to gain a desired hematologic effect while preserving splenic immune function. 7–10 However, the use of partial splenectomy is limited because of technical difficulties and concerns of splenic regrowth. 7,8,11,12 Recently several groups have renewed an interest in partial splenectomy. 7–10 To assess the role of partial splenectomy in symptomatic children with various congenital hemolytic anemias, we have followed 25 children with various congenital hemolytic anemias who underwent partial splenectomy. We examined the effects of partial splenectomy on hemolysis, splenic phagocytic and immune function, and splenic regrowth. Our results suggest that partial splenectomy may be beneficial for a variety of congenital hemolytic anemias.

Conflicting data exist concerning optimal timing for initial postnatal ultrasound in newborns with prenatal hydronephrosis. To determine whether timing significantly affects the accuracy of postnatal ultrasound, we conducted a prospective study comparing ultrasound within 48 hours of birth and at 7 to 10 days of life.A total of 21 consecutive newborns with prenatal hydronephrosis were enrolled in 14 months. Prenatal hydronephrosis was defined as a pelvic diameter 4 mm. or greater before 33 weeks and 8 mm. or greater beginning at 33 weeks of gestation. Postnatal hydronephrosis was assessed using the Society for Fetal Urology grading system. Patients were subsequently followed with serial ultrasound and adjunctive imaging studies.Of the 32 evaluable renal units a majority had a change in the degree of hydronephrosis between the first and second ultrasound. An increase in hydronephrosis was found in 14 (44%) renal units with an increase of 2 or greater grades in 8 (25%). At a median followup of 15 months only 3 renal units had a persistent increase in hydronephrosis. None had greater than grade 2 hydronephrosis or required therapeutic intervention. A decrease in hydronephrosis between the first and second ultrasound was noted in 8 (25%) renal units. Seven renal units were excluded from analysis due to unequivocal obstruction, and none of these demonstrated a change between the 2 sonograms.The degree of hydronephrosis varied between scans performed in the first 48 hours and 7 to 10 days of life in most newborns. The initial ultrasound more commonly underestimated the degree of hydronephrosis but this difference was not clinically significant at further followup. We recommend initial postnatal sonogram at 7 to 10 days of life for routine prenatal hydronephrosis but earlier scans may be appropriate in select cases.

Cancer is second only to accidents as the leading cause of death in children younger than 15 years of age. Although the overall incidence of childhood cancers increased 10% between 1973 and 1991, mortality in these children showed an impressive decline of 42%. Moreover, the 5-year survival rate of childhood cancer patients for all sites combined increased from a staggering 30% in the early 1960s to almost 70% in the 1990s. 1, 2, 3

There is a high incidence of delayed sexual development and short stature during childhood in children with sickle cell anemia (SCA). We report a 15 year-old male with SCA who presented with significant short stature after a near death event (involving seizures and prolonged hypoxia). His evaluation showed growth hormone (GH) deficiency with low insulin-like growth factor-I (IGF-I), low IGF binding protein-3, and low GH response to stimulation. He was started on GH replacement with poor response in height gain although with normal response in terms of elongation of his arm span. Further studies showed premature closure of the epiphyses of the femora and tibiae bilaterally. This report demonstrates that children with SCA may present with growth failure not only due to nutritional and GH abnormalities but also due to abnormal growth plates, probably due to local anoxic events. Children with SCA should always have their arm span measured carefully.