The Evaluation of Palpable Thigh Nodularity in Vaccination-age Children - Differentiating Vaccination Granulomas from Other Causes.

Palpable thigh nodularity is a relatively frequent indication for imaging of vaccination-age children, with patients often referred by their community physician or general practitioner. Ultrasound (US) is the imaging modality of choice to delineate the abnormality, and we present a number of characteristic findings that permit the radiologist and pediatrician to accurately identify the cause. A retrospective review was performed at the largest children's hospital in a European country between 2015 and 2017 over a 30-month period. A search was performed of the hospital's Picture Archiving and Communication System (PACS) for all children referred for a soft-tissue, upper limb, or lower limb US between January 2015 and July 2017. The findings were collated and stored in a spreadsheet. Nine patients were identified who developed subcutaneous nodules in the thigh at some point during their childhood vaccination schedule. Three of these patients had clinical histories strongly suggestive of a diagnosis of abscess or foreign body. The remaining six patients were selected for more in-depth analysis. Four of these patients had US features consistent with vaccination granuloma. Two patients were ultimately diagnosed with venolymphatic malformations. Palpable thigh nodularity in a child of vaccination age is encountered with a reasonable frequency. When encountered, granulomas tend to be located within the subcutaneous tissues, and we postulate that this is due to erroneous administration of a vaccine into the subcutis rather than into the muscle.

Multicystic Encephalomalacia: The Neuropathology of Systemic Neonatal Parechovirus Infection.

The Neuropathology of Human Parechovirus (HPeV) is not widely described due to the relatively recent discovery of the virus combined with a limited number of autopsy case reports. We report the case of an infant boy born at 38 weeks who, six days after birth, presented with fever and severe neurological dysfunction. Human Parechovirus Type 3 (HPeV3) RNA was detected in his cerebrospinal fluid (CSF) and blood. He died five days after his initial presentation. Neuropathologic examination demonstrated multicystic encephalomalacia (ME). This case report confirms that white matter pathology is dominant in HPeV3 infection. A unique feature, of HPeV encephalomalacia is absence of CSF pleocytosis and minimal inflammation in the meninges. The findings permit comment on the pathogenesis of brain injury by this virus.

Cardiac strangulation causing refractory cardiac arrest during elective pacemaker revision: a cautionary tale.

We describe a previously asymptomatic 7-year-old girl with a sudden cardiac arrest during elective pacemaker revision. Later imaging identified epicardial pacemaker lead strangulation of the left anterior descending and left circumflex coronary arteries. Anaesthetic induction led to a reduction in myocardial perfusion, precipitating the arrest. Extreme care should be taken during anaesthesia if cardiac strangulation is suspected.

Accuracy of ultrasound in measurement of the pediatric cricothyroid membrane.

BACKGROUND: Emergency front of neck airway is a recommended airway rescue strategy in children over 1 year old. Surgical tracheostomy is advocated as the first-line technique, but in the absence of an ear, nose and throat surgeon cricothyroidotomy or tracheostomy is proposed. Recent research shows that clinical identification of the cricothyroid membrane is frequently inaccurate in older children and adults and has prompted investigation of ultrasound as a potential clinical tool for emergency front of neck airway. Advance knowledge of the dimensions of the pediatric cricothyroid membrane may assist clinicians in determining the feasibility of emergency front of neck airway, optimum technique, and equipment. AIMS: The aim of this study was to assess the accuracy of ultrasound-assisted pediatric cricothyroid membrane localization and dimension measurement using magnetic resonance imaging as the reference standard. METHODS: After structured training, two pediatric anesthesiology trainees used ultrasound to identify and measure the dimensions of the cricothyroid membrane in pediatric patients undergoing elective magnetic resonance imaging of the head and neck under general anesthesia. A pediatric radiologist reviewed the corresponding magnetic resonance imaging scans and measured the height of the cricothyroid membrane. The accuracy of the cricothyroid membrane height as measured by ultrasound was compared to that measured by magnetic resonance imaging. RESULTS: Twenty-two patients were included in the study. The cricothyroid membrane was accurately identified by ultrasound in all cases. The correlation coefficient for cricothyroid membrane height measured by ultrasound and that measured by magnetic resonance imaging was 0.98 (95% C.I 0.95-0.99, P < 0.0001). The bias was -0.16 mm and the precision was 0.19 mm. All differences were within the a priori limits of agreement. The 95% limits of agreement were -0.54 to 0.22 mm. CONCLUSION: Ultrasound can be used to accurately identify and measure cricothyroid membrane height in pediatric patients. This approach could have clinical and research utility.

Clinical application of three-dimensional printing to the management of complex univentricular hearts with abnormal systemic or pulmonary venous drainage.

In recent years, three-dimensional printing has demonstrated reliable reproducibility of several organs including hearts with complex congenital cardiac anomalies. This represents the next step in advanced image processing and can be used to plan surgical repair. In this study, we describe three children with complex univentricular hearts and abnormal systemic or pulmonary venous drainage, in whom three-dimensional printed models based on CT data assisted with preoperative planning. For two children, after group discussion and examination of the models, a decision was made not to proceed with surgery. We extend the current clinical experience with three-dimensional printed modelling and discuss the benefits of such models in the setting of managing complex surgical problems in children with univentricular circulation and abnormal systemic or pulmonary venous drainage.

Quality of pediatric abdominal CT scans performed at a dedicated children's hospital and its referring institutions: a multifactorial evaluation.

BACKGROUND: Pediatric patients requiring transfer to a dedicated children's hospital from an outside institution may undergo CT imaging as part of their evaluation. Whether this imaging is performed prior to or after transfer has been shown to impact the radiation dose imparted to the patient. Other quality variables could also be affected by the pediatric experience and expertise of the scanning institution. OBJECTIVE: To identify differences in quality between abdominal CT scans and reports performed at a dedicated children's hospital, and those performed at referring institutions. MATERIALS AND METHODS: Fifty consecutive pediatric abdominal CT scans performed at outside institutions were matched (for age, gender and indication) with 50 CT scans performed at a dedicated freestanding children's hospital. We analyzed the scans for technical parameters, report findings, correlation with final clinical diagnosis, and clinical utility. Technical evaluation included use of intravenous and oral contrast agents, anatomical coverage, number of scan phases and size-specific dose estimate (SSDE) for each scan. Outside institution scans were re-reported when the child was admitted to the children's hospital; they were also re-interpreted for this study by children's hospital radiologists who were provided with only the referral information given in the outside institution's report. Anonymized original outside institutional reports and children's hospital admission re-reports were analyzed by two emergency medicine physicians for ease of understanding, degree to which the clinical question was answered, and level of confidence in the report. RESULTS: Mean SSDE was lower (8.68) for children's hospital scans, as compared to outside institution scans (13.29, P = 0.03). Concordance with final clinical diagnosis was significantly lower for original outside institution reports (38/48, 79%) than for both the admission and study children's hospital reports (48/50, 96%; P = 0.005). Children's hospital admission reports were rated higher than outside institution reports for completeness, ease of understanding, answering of clinical question, and level of confidence of the report (P < 0.001). CONCLUSION: Pediatric abdominal CT scans performed and interpreted at a dedicated children's hospital are associated with higher technical quality, lower radiation dose and a more clinically useful report than those performed at referring institutions.

Percutaneous embolization of a chylous leak from thoracic duct injury in a child.

Postoperative chylous leak may result from thoracic duct injury during surgical procedures in the chest or neck and can be successfully treated with percutaneous embolization. We report the case of a child with persistent chylothorax and chyloperitoneum following multivisceral transplantation, which was performed due to unresectable inflammatory myofibroblastic tumor of the retroperitoneum. Intranodal lymphangiography was used to demonstrate the site of chylous leak from the lower segment of the thoracic duct and the leak resolved within days following percutaneous embolization of the thoracic duct.

Life-threatening rupture of a renal angiomyolipoma in a patient taking over-the-counter horse chestnut seed extract.

BACKGROUND: Alternative medical therapies are increasingly being prescribed due to their good safety profile and perceived limited side effects. They are often unregulated and prescribed over the counter. One such medication is horse chestnut seed extract (HCSE), which is used for the treatment of chronic venous insufficiency and is known to affect blood coagulation. Angiomyolipoma (AML) is a benign fat-containing mesenchymal tumor of the kidney. It is often found incidentally and in most cases can be managed conservatively. Rupture of the kidney with hemorrhage is a well-known complication that may be serious and life-threatening. Known risk factors for hemorrhage include anticoagulation as well as pregnancy, increased size of the lesion, high lesion vascularity, and aneurysm formation within the tumor. OBJECTIVES: The aim is to raise awareness of potential HCSE-induced anticoagulation, including, as in the case presented, acute renal AML hemorrhage. CASE REPORT: The case of a patient taking HCSE for venous insufficiency is presented. The patient suffered a life-threatening rupture of the kidney in the presence of known renal AML. She underwent emergency embolization with a successful outcome. Because HCSE-containing products are thought to be generally safe in the treatment of chronic venous insufficiency, it is important to be mindful of their potential anticoagulant properties and, therefore, their relative contraindication both in patients taking other anticoagulants and those with known renal AML. CONCLUSION: We demonstrate a potentially life-threatening association between HSCE-containing products and renal AML, highlighting the risk associated with HSCE-induced anticoagulation.

PHACE syndrome: MRI of intracerebral vascular anomalies and clinical findings in a series of 12 patients.

BACKGROUND: PHACE (posterior fossa defects, haemangioma, arterial anomalies, coarctation of the aorta and cardiac defects, eye abnormalities) syndrome describes a constellation of abnormalities that can occur in association with segmental craniofacial infantile haemangioma. OBJECTIVE: To report the spectrum of clinical and imaging abnormalities seen in a cohort of children. MATERIALS AND METHODS: A retrospective review of the clinical and imaging records of all patients diagnosed with PHACE syndrome between 1998 and 2009 was performed. Information sought included patient demographics, craniofacial segments involved, imaging findings and other extracutaneous abnormalities. RESULTS: Twelve patients were diagnosed with PHACE syndrome over 11 years. All patients had a segmental craniofacial haemangioma. Involved facial segments, in order of frequency, were frontotemporal (12), maxillary (8), mandibular (5) and frontonasal (1). The most common extracutaneous abnormalities were neurovascular anomalies (10), with many patients having multiple anomalies. The spectrum of arterial anomalies ranged from hypoplasia (9) to ectasia (3), anomalous origin/course (2) and persistent fetal anastomosis (2). Other anomalies found included cardiac anomalies (3), coarctation of the aorta (2), posterior fossa malformations (1) and sternal region anomalies (1). CONCLUSION: Intracranial anomalies are the most common extracutaneous feature of PHACE syndrome. The contribution of the radiologist in the recognition of such anomalies is important for the diagnosis of PHACE syndrome.

Geographic origin of publications in radiological journals as a function of GDP and percentage of GDP spent on research.

RATIONALE AND OBJECTIVES: The aim of this study was to examine the geographic origin of publications in the highest impacting radiology journals and to examine the link between the percentage of gross domestic product (GDP) spent on research by a country and the output of radiology publications. MATERIALS AND METHODS: The five highest impacting general radiology journals (according to the ISI Web of Knowledge database) were selected over a 6-year period from January 2002 to December 2007. Publications were totaled according to the country of the corresponding author. Publications (total and corrected for population size) were assessed according to the GDP of a given country and the percentage of GDP spent on research in that country. Correlation was determined using Spearman's rank. RESULTS: In total, 10,925 papers were identified. The top 10 nations produced 83.9% of the total number of papers. The United States was the most prolific country, with 41.7% of the total. The second-ranked and third-ranked countries were Germany (11.6%) and Japan (6.7%). Corrected for GDP, smaller European countries outperformed larger nations. Switzerland (0.925 publications per billion of GDP), Austria (0.694 publications per billion of GDP), and Belgium (0.648 publications per billion of GDP) produced the most papers per billion of GDP. When corrected for percentage of GDP spent on research, European countries again ranked highest, with Greece, Turkey, and Belgium having the best ratios. The percentage of GDP spent on research was positively correlated with the number of publications in high-ranking radiology journals (r = 0.603, P < .001). CONCLUSIONS: The United States is the most productive country in absolute number of publications. The flaws of using population size to compare publication output are clear, and a comparison using GDP and the percentage of GDP spent on research may give more meaningful results. When GDP is taken into consideration, smaller European countries are more productive. The importance of investment in radiologic research is emphasized by the association between increased funding of research and the number of publications in high-impacting radiology journals.