Factors affecting high cumulative radiation exposure from paediatric computed tomography.

PURPOSE: To estimate occurrence rate of high cumulative radiation exposure from paediatric computed tomography (CT), and to determine influential factors on high-dose inclination. MATERIAL AND METHODS: Patients below 18 years old receiving at least 50 mSv of a cumulative dose during a 5-year period in a tertiary care centre were retrospectively enrolled. Individual patient characteristics, diagnoses, frequency of exa-minations, scanner sites, designated scans, and effective doses were recorded. Collective doses were compared among groups of the diagnoses and scanner sites, and regression analyses were applied. RESULTS: Of 2771 patients, 3.2% received individual cumulative doses between 50 and 303 mSv (median, 74 mSv). Frequency of examinations ranged from 1 to 13 times (median, 4 times) per patient. About 70% of the patients had oncological illness. Radiation was predominantly high in a CT simulator that could contribute the percentage of collective dose to twice that of examinations owing to higher scanning parts and CT dose index. Some scanner sites used higher acquisition phases. Regression analysis showed that the number of scanning parts and phases significantly influenced the cumulative dose inclination (p < 0.05) while frequent examinations did not. CONCLUSIONS: There was a low occurrence of paediatrics with high dose accumulation. Significant factors affecting potentially high exposure were customized CT protocols in the specific scanners.

Clinical Features and Survival Outcomes of Invasive Aspergillosis in Pediatric Patients at a Medical School in Thailand.

BACKGROUND: Invasive aspergillosis (IA) is a severe infection in immunocompromised patients. Recently, serum galactomannan has been widely used for diagnosis and voriconazole as an antifungal agent. The objective of this study is to describe clinical features and survival outcomes of IA. MATERIAL AND METHOD: A retrospective chart review of IA in patients younger than 18 years old at King Chulalongkorn Memorial Hospital, Thailand, was conducted. Clinical definitions were based on criteria oft he European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) 2008. RESULTS: Between January 2006 and December 2012, 40 cases of invasive aspergillosis were identified, classified as proven (8 patients, 20%), probable (28, 70%), and possible IA (4, 10%). Median age of patients was 10 years (range, 42 days-17 years). The most common underlying disease was hematologic malignancy (60%). The major risk factor was neutropenia (65%) with median duration of 21 days (range, 4-58 days). The most common site of infection was in the lungs (80%). The most common computed tomography chest finding was nodules (71%). An air crescent sign was seen only in 11% and a halo sign was found only in 7% of patients. Serum galactomannan was positive in 78% of patients with median value of 1.34 (range 0.5-5.6). Only seven patients (17%) had microbiological confirmation, of which were Aspergillus flavus (4 cases) and Aspergillus fumigates (3 cases). Antifungal therapy included voriconazole (23 patients, 58%), amphotericin B (12, 30%), liposomal amphotericin B (3, 8%), caspofungin (1, 2%) and itraconazole (1, 2%). Two deaths related to angioinvasive complications of aspergillosis (pulmonary hemorrhage and rupture mycotic aneurysm) were reported The 3-month and 12- month survival rates after diagnosed IA were 73.7% and 56.7%, respectively. The major cause of death was new episode of sepsis found in 11 cases (52%). CONCLUSION: The 1-year survival rate was poor; however, cause of death is related to complications of the immunocompromised state not from IA.

Survey of pediatric MDCT radiation dose from university hospitals in Thailand: a preliminary for national dose survey.

BACKGROUND: Increasing pediatric CT usage worldwide needs the optimization of CT protocol examination. Although there are previous published dose reference level (DRL) values, the local DRLs should be established to guide for clinical practice and monitor the CT radiation. PURPOSE: To determine the multidetector CT (MDCT) radiation dose in children in three university hospitals in Thailand in four age groups using the CT dose index (CTDI) and dose length product (DLP). MATERIAL AND METHODS: A retrospective review of CT dosimetry in pediatric patients (<15 years of age) who had undergone head, chest, and abdominal MDCT in three major university hospitals in Thailand was performed. Volume CTDI (CTDI(vol)) and DLP were recorded, categorized into four age groups: <1 year, 1-< 5 years, 5-<10 years, and 10-<15 years in each scanner. Range, mean, and third quartile values were compared with the national reference dose levels for CT in pediatric patients from the UK and Switzerland according to International Commission on Radiological Protection (ICRP) recommendation. Results Per age group, the third quartile values for brain, chest, and abdominal CTs were, respectively, in terms of CTDI(vol): 25, 30, 40, and 45 mGy; 4.5, 5.7, 10, and 15.6 mGy; 8.5, 9, 14, and 17 mGy; and in terms of DLP: 400, 570, 610, and 800 mGy cm; 80, 140, 305, and 470 mGy cm; and 190, 275, 560,765 mGy cm. CONCLUSION: This preliminary national dose survey for pediatric CT in Thailand found that the majority of CTDI(vol) and DLP values in brain, chest, and abdominal CTs were still below the diagnostic reference levels (DRLs) from the UK and Switzerland regarding to ICRP recommendation.

Sensitivity and specificity of using pelvic ultrasonographic parameters combined with basal gonadotropin levels to diagnose central precocious puberty in Thai girls.

Background: The criterion standard gonadotropin-releasing hormone (GnRH) stimulation tests to diagnose central precocious puberty (CPP) are time-consuming, inconvenient, and expensive. Objectives: To determine predictive cut-off values codetermined by ultrasonographic parameters and basal gonadotropin levels in girls with premature sexual development and compare them results of criterion standard tests in a study of diagnostic accuracy. Methods: Retrospective review of hormonal investigations and ultrasonographic uterine and ovarian parameters in a consecutive sample of girls at a single center, tertiary care hospital in Bangkok, Thailand. Results: We separated data from 68 girls (age range 2-12 years) into 2 groups based on their response to a GnRH analogue agonist stimulation test. A "prepubertal response" group included girls with premature thelarche and thelarche variants (n = 18, 6.37 ± 1.77 years) and a "pubertal response" group, including girls with CPP (n = 50, 8.46 ± 1.46 years); excluding patients with pathological causes (n = 0). The basal level of luteinizing hormone (LH) had the largest area under receiver operating characteristic curves (AUC) of 0.84; 95% confidence interval [CI] 0.74-0.93) compared with basal levels of follicle stimulating hormone (AUC 0.77; 95% CI 0.64-0.90) or estradiol (0.70; 95% CI 0.56-0.85). An optimal cut-off of 0.25 IU/L LH was related to a pubertal response to GnRH analogue agonist stimulation tests with 75.0% sensitivity, 88.9% specificity, 94.7% positive predictive value (PPV), and 57.1% negative predictive value. Uterine and ovarian cut-off volumes of 3.5 cm3 and 1.5 cm3 were related to a pubertal response with 88.6% and 76.2% PPV, respectively. A uterine width cut-off of 1.7 cm combined with a basal LH cut-off of 0.25 IU/L increased specificity and PPV to 100%. Conclusion: Combining uterine and ovarian ultrasonographic parameters with basal gonadotropin levels, especially uterine width and basal LH level, appears useful for diagnosis of CPP.

Common pitfalls and mistakes in pediatric ultrasound.

There are many errors and pitfalls that are commonly encountered during ultrasound examinations. In normal ultrasound, pitfalls may arise from anatomic or physiologic variants of pediatric anatomy, settings, artifacts, patient conditions, operator misunderstanding, or inexperienced performance. In limited field and point-of-care ultrasound, common errors are usually due to limited access, misdiagnosis as a result of wrong timing, unsuitable patient conditions, limited transducer options, satisfaction of search, and unfamiliarity with pediatric sonography. Knowledge of these pitfalls helps improve a physician's performance and diagnosis.

Nonalcoholic fatty liver disease and hepatic fibrosis among perinatally HIV-monoinfected Asian adolescents receiving antiretroviral therapy.

To assess and compare the prevalence of persistent hepatic abnormalities, including nonalcoholic fatty liver disease (NAFLD) and/or hepatic fibrosis, among perinatally HIV-monoinfected Asian adolescents with history of abnormal hepatic enzymes to those without, using noninvasive diagnostic tools. A multicenter cohort study was conducted in Thailand and Indonesia. Adolescents aged 10-25 years who were on antiretroviral treatment (ART), had virologic suppression (HIV RNA<400 copies/mL within the past 6 months), and had no history of chronic hepatitis B/C infection were enrolled. Participants were pre-classified into 2 subgroups (1:1 ratio) as participants with history of elevated versus normal aminotransferase enzymes. NAFLD was defined as hepatic steatosis (any severity) evaluated by liver ultrasonography. Significant hepatic fibrosis was defined as liver stiffness ≥7.4 kPa evaluated by transient elastography. Participants who met the criteria for protocol-defined NAFLD and/or hepatic fibrosis were re-assessed to evaluate disease progression (persistent versus transient hepatic abnormalities) at one year later. Of 120 participants, 62 (51.7%) were male, 7 (5.8%) had central obesity, and 19 (15.8%) had insulin resistance (homeostasis model assessment of insulin resistance [HOMA-IR] >3.16). At enrollment, the median age and duration of ART (IQR) were 17.0 (14.6-19.2) years and 10.5 (7.1-12.0) years, respectively. Persistent hepatic abnormalities were identified in 5/60 participants listed in the group having history of elevated aminotransferases, corresponding to the prevalence of 8.3% (95% CI: 2.8-18.4%), whereas none (0/60) were among the group having history of normal hepatic enzymes. All 5 participants had persistent aminotransferase elevation (≥2 episodes within the past 12 months). Baseline alanine aminotransferase (ALT) >30 U/L (adjusted odds ratio [aOR]: 29.1; 95% CI: 1.7-511.8), and HOMA-IR >3.16 (aOR: 17.9; 95% CI: 1.1-289.7) were independently associated with persistent hepatic abnormalities. Among perinatally HIV-monoinfected Asian adolescents with history of elevated aminotransferase enzymes, persistent hepatic abnormalities are not uncommon. Screening for liver complications by noninvasive diagnostic tools might be considered in at risk individuals, including those with persistent ALT elevation and insulin resistance.

Regression of a cervical spinal mass following highly active antiretroviral therapy (HAART) in child with advanced human immunodeficiency virus (HIV) disease.

This report documents a case of infiltrating cervical spinal mass, most likely a spinal tumor, in a girl with HIV infection that regressed following HAART and without treatment of the tumor or any anti-infectives.

Child abuse: radiographic findings at King Chulalongkorn Memorial Hospital.

OBJECTIVE: To describe radiographic findings in physically abused children. MATERIAL AND METHOD: The physically abused children diagnosed in King Chulalongkorn Memorial Hospital from 1998 to 2002 were retrospectively reviewed of medical records and radiographic imaging. RESULT: Eighteen of 30 physically abused children had positive radiographic findings and 15 of 18 were related to head injury. Subdural hematomas and skull fractures were the two most common findings found in 11 cases and 9 cases respectively. Seven of 11 cases of head injury had retinal hemorrhage. Fractures other than the skull were detected in 6 patients, located at the long bones, ribs and spines. The abused children with positive radiographic findings were more commonly found in younger infants and mucocutaneous lesions might be absent. CONCLUSION: Inflicted head injury was the most common radiographic findings in the present series. Shaking-impact mechanism was likely to play a significant role in this group of patients.

Potential of ultrasound in the pediatric chest.

Ultrasound (US) of chest, even with inherent limitations of the US beam and air, has been useful in many pediatric chest conditions. It has extended its role and is now widely used by many subspecialists in medicine. This review article will cover techniques, indications, and applications of chest US in neonates, infants and children, including also different common as well as some rare and modern aspects and applications, such as pleural effusion, pneumothorax, pulmonary lesions, mediastinum, diaphragm, and chest wall. Other related imaging modalities are also briefly discussed.

Aspiration cytology of mesenchymal hamartoma of the chest wall: a case report and literature review.

Mesenchymal hamartoma of the chest wall is a rare tumor-like lesion of infancy and childhood. The few available descriptions of the findings on fine needle aspiration list spindle-shaped cells and cartilage or chondromyxoid material as essential features for this diagnosis. An aggressive appearance on imaging studies and a lack of familiarity with this lesion, can lead the pathologist to misdiagnose the cytologic findings as malignancy. We reported a 5-month-old male presenting with a mass of the right chest wall progressively for 2 months. Radiologic studies showed a mixed solid and cystic mass originating from the third, fourth and fifth ribs, and a diagnosis of malignancy was favored. Fine needle aspiration recovered only spindle-shaped cells and a few multinucleated giant cells of osteoclast type. After a review of the imaging, a diagnosis of mesenchymal hamartoma of the chest wall was raised. This diagnosis was confirmed by pathologic examination of the subsequently resected mass. This is the sixth report of a mesenchymal hamartoma of the chest wall diagnosed by fine needle aspiration. This case illustrates that this diagnosis can be suspected in the absence of cartilage or chondromyxoid material, given appropriate clinical and radiologic findings.

Computed tomographic angiography (CTA) of major thoracic vessels in children--a pictorial assay on common findings also discussing CTA technique.

CTA plays an important role in evaluation of the major thoracic vessels in children. The purpose of this review is to describe the application of CTA in evaluation of the thoracic aorta, the pulmonary arteries and veins, and potential aortic-pulmonary collaterals. Indications, consideration, technical details of how to perform these investigations in children, restrictions and representative illustration are presented and discussed.

Xanthogranulomatous adrenalitis in a neonate: CT and US findings.

We report a 46-day-old female infant with xanthogranulomatous adrenalitis. Ultrasonography showed a complex, solid-cystic right suprarenal mass with poorly defined margins. Colour flow Doppler revealed the solid portion of the mass to be vascular. CT demonstrated a heterogeneous cystic and solid mass with some contrast enhancement in the inferior part of the lesion. There was compression of the adjacent upper pole of the right kidney and the lateral aspect of the inferior vena cava. The mass was completely removed; histological examination revealed xanthogranulomatous adrenalitis. At the time of this report she remained well 3 years following surgery.