Role of Shear Wave Elastography of Thyroid Gland in Children With Newly Diagnosed Hashimoto's Thyroiditis: Preliminary Study.

OBJECTIVES: The data on the use of shear wave elastography (SWE) in children with thyroid disorders is limited. We aimed to assess the role of SWE in the evaluation of the thyroid gland in children newly diagnosed with Hashimoto's thyroiditis (HT). METHODS: The thyroid gland was evaluated in 18 children (5 boys and 13 girls, age range: 5-12 years) with newly diagnosed HT and 27 (21 boys and 6 girls, age range: 4-12 years) healthy controls using grayscale ultrasound followed by SWE. The values of SWE (in kPa) were compared between cases and controls and were also correlated with various demographic variables and serum thyroid hormone concentrations. RESULTS: The overall median of SWE values in cases and controls was 20.6 kPa (IQR = 19.16-26.94) and 10.7 kPa (IQR = 9.9-16.32), respectively, and the difference was statistically significant (W = 438.5, P < .001). There was a moderate positive correlation between serum triiodothyronine concentrations and SWE (ρ = 0.57, P = .016) and a moderate negative correlation between serum thyroid stimulating hormone concentrations and SWE (ρ = -0.54, P = .020). A significant difference (W = 61.0, P = .003) was also seen in median SWE of the thyroid gland between boys (median: 29.63 kPa, IQR = 27.53-32.88) and girls (median: 19.43 kPa, IQR = 18.88-21.32). CONCLUSION: There is a significant difference between SWE values of thyroid in normal children and children with newly diagnosed HT. Hence, SWE may be used as a noninvasive imaging technique in distinguishing normal and abnormal thyroid gland at an early stage. We suggest larger studies to confirm our preliminary findings of SWE in pediatric HT.

Evaluation of coronary arteries in congenital heart disease in children: diagnostic comparison of electrocardiogram-gated and non-electro-cardiogram-gated computed tomography cardiac angiography.

Purpose: To compare the visualization and anatomy of coronary arteries in children (≤ 2 years) with congenital heart disease (CHD) on non-electrocardiogram (ECG)-gated and ECG-gated computed tomography angiography (CTA). Material and methods: In this retrospective study, approved by the Ethics Committee of our institute, evaluation of coronary arteries in CHD was performed in 40 children on non-ECG-gated CTA and in 42 children on ECG-gated CTA. The origin and course of the right coronary artery (RCA), left main coronary artery (LMCA), left anterior descending (LAD) artery, and left circumflex (LCX) artery were evaluated by 2 paediatric radiologists independently. Results: ECG-gated CT scans yielded increased (additional) visualization of all the coronary arteries, when compared to non-ECG-gated CT scans. The RCA, LMCA, LAD artery, and LCX artery were visualized in 47.5%, 62.5%, 55%, and 32.5% of children, respectively, on non-ECG-gated studies, while they were visualized in 64.3%, 92.8%, 80.9%, and 62% children, respectively, on ECG-gated studies. The coronary artery anatomical variations were also supplementarily detected more in the ECG-gated group (23.8%) than in the non-ECG gated group (2.5%). Conclusions: ECG-gated CT cardiac angiography studies yield enhanced diagnostic outcomes for the evaluation of the coronary arteries in comparison to non-ECG-gated studies.

Model-based iterative reconstruction in paediatric head computed tomography: a pilot study on dose reduction in children.

PURPOSE: To evaluate the potential of model-based iterative reconstruction (MBIR) on dose reduction and image quality in children undergoing computed tomography (CT) head examinations. MATERIAL AND METHODS: This prospective study was approved by the institutional ethics committee. A total of 88 children (age range of 5 to 16 years) with a history of seizures underwent contrast-enhanced CT scan. Forty-one children underwent CT study according to the MBIR technique, while 47 children underwent CT of the head with the non-MBIR protocol. Images were reviewed by 2 blinded paediatric radiologists in a random order. Mean dose-length product, CT dose index (CTDI) volume, and mean effective dose were recorded for both groups. Image quality, image noise, and diagnostic acceptability of 2 image sets were also recorded. RESULTS: In the MBIR group, the mean dose-length product was reduced by 79.8%; the mean CTDI volume was reduced by 88.5%, while the mean effective dose was reduced by 81% when compared to the non-MBIR group. No significant difference was seen in diagnostic acceptability, image noise, and image quality between the 2 groups. CONCLUSIONS: MBIR technique is highly effective in reducing radiation dose in paediatric head CT examinations without any significant difference in image quality, image noise, and diagnostic acceptability.

Anterolateral thigh measurements by ultrasound in neonates and young infants to ensure safe intramuscular injections during vaccination in low- and middle-income countries.

BACKGROUND: Use of same length needle for intramuscularly administered vaccines had been reported to cause under-and over-penetration among infants due to their different body weights and underlying variations in the fat and muscle thickness. Normative data regarding thigh compartment thickness are, however, lacking among neonates and infants aged ≤12 weeks particularly in low- and middle-incoming countries with high burden of low birth weight/growth restricted infants. METHODS: Present study investigated skin to muscle and skin to bone (STBD) distances of anterolateral thigh of babies (n = 300) aged ≤12 weeks (1-80 days) with different weight groups (<3 kg, 3-4 kg and >4 kg) by ultrasonography during their intramuscular vaccinations. RESULTS: Overall, mean [standard deviation (SD)] STBD was 17.04 (2.66) mm with range of 10.60-23.30 mm. Stratifying by current body weight, mean (SD) STBD in infants weighing less than 3 kg was 14.39 (1.23) mm. For infants weighing between 3-4 kg and >4 kg, the mean (SD) STBD were 16.69 (1.43) mm and 17.04 (2.66) mm, respectively. Estimated safety (no risk of over-penetration) of 16 mm was observed in 57.33% (172) infants whereas 25 mm needle had 100% over-penetration risk in the study cohort. Current body weight of infants was a significant predictor of safe injection [area under the receiver operating characteristic (ROC) curve 0.95; 95% CI 0.92-0.97]. CONCLUSIONS: Our study offers objective normative measurements of anterolateral thigh for safe intramuscular vaccination in young infants especially for low birth weight and growth restricted infants in low- and middle-income countries.

Canine Distemper Virus in Asiatic Lions of Gujarat State, India.

In September 2018, an epizootic infection caused by canine distemper virus emerged in an Asiatic lion population in India. We detected the virus in samples from 68 lions and 6 leopards by reverse transcription PCR. Whole-genome sequencing analysis demonstrated the virus strain is similar to the proposed India-1/Asia-5 strain.

Invasive Fungal Disease in Pediatric Acute Leukemia in the Nontransplant Setting: 8 Years' Experience From a Tertiary Care Center in North India.

BACKGROUND/AIM: The aim of this article is to study the spectrum, changing prevalence, and predictors for mortality of invasive fungal disease (IFD) in pediatric leukemia in a resource-limited setting. OBSERVATIONS: Prevalence was 7% (proven, 69%; probable, 16.4%; possible, 14.6%) and did not differ between acute lymphoblastic leukemia and acute myeloid leukemia. Lungs were frequently involved (46%). Aspergillus was the commonest fungus (47%). Visceral abscesses were frequent with candidiasis as compared with invasive molds (P=0.016). IFD resulted in a prolonged admission (mean, 12.6±2 d; P=0.014) and death (44%) (Aspergillus, 50%; Candida, 50%; Mucor, 34%). Diagnosis of acute myeloid leukemia predicted mortality (P=0.03). CONCLUSIONS: IFD was an important cause of treatment related mortality in pediatric leukemia (odds ratio, 8.39). Protocolled use of computed tomography-chest and galactomannan-assay aided diagnosis (P<0.05).

Orbital Mass in a Child With Acute Lymphoblastic Leukemia: A Case Report and Review of the Literature.

Acute lymphoblastic leukemia arising from lymphoid precursor cells of the bone marrow, the lymphoreticular system, and the soft tissue can present with medullary and extramedullary involvement. Extramedullary involvement has the propensity to affect a multitude of organs. Presentation with proptosis secondary to orbital mass in childhood acute lymphoblastic leukemia (ALL) is very rare. We report a child with pre-B cell ALL with an extramedullary soft tissue mass involving both orbits presenting with proptosis, and give a brief overview of the literature about this unusual entity. Rapid investigation and timely initiation of treatment are needed to salvage the eye and the vision. Orbital involvement is considered to confer a poorer prognosis to children with ALL.

The 5-Year EFS of Multisystem LCH With Risk-Organ Involvement Is Suboptimal: A Single-center Experience From India.

The study describes an 8-year experience of a single center in managing patients with langerhans cell histiocytosis on the basis of the langerhans cell histiocytosis-III platform. A retrospective case-file review of children diagnosed during 2006 to 2013 was performed. Group 1 (multisystem with risk-organ involvement) patients received an initial treatment of 6 to 12 weeks, followed by continuation treatment to complete 12 months. Drugs included vinblastine, prednisolone, and 6-mercaptopurine. Group 2 (multisystem without risk-organ involvement) patients received a similar treatment, except for 6-mercaptopurine. Group 3 (single-system/multifocal bone disease) patients were treated for a duration of 6 months. Forty-nine patients were treated: 24 (49%), 14 (28.6%), and 11 (22.4%) in groups 1, 2, and 3, respectively. The mean age at diagnosis was 31.6 ± 28.4 months (range, 4 to 120 mo). Five patients abandoned treatment. There were 7 deaths, all in group 1. All patients who died had either a partial response or progressive disease after induction (P=0.000). Among patients with liver involvement, those with sclerosing cholangitis had a greater mortality (P=0.007). A relapse was observed in 12 (24.5%) patients. The frequency of relapse was not different in the 3 groups (P=0.833). The 5-year event-free survival in groups 1, 2, and 3 was 29.3 ± 10%, 58.9 ± 14.6%, and 69.3 ± 15%, respectively (P=0.019). The 5-year overall survival was 100% in groups 2/3 and 68.9 ± 9.8% in group 1 (P=0.011).

Omental infarction: An unusual cause of right iliac fossa pain in children.

Omental infarction is an uncommon cause of acute abdomen in the pediatric population. We report a case of a 4-year-old male child with right iliac fossa pain. The final diagnosis was made on ultrasound and computed tomography findings. This entity needs to be differentiated from acute conditions like appendicitis, avoiding surgery.

A snapshot of microbial communities from the Kutch: one of the largest salt deserts in the World.

Here we present the first report on the taxonomic diversity of the microbial communities of the saline desert of the Great Rann of Kutch, Gujarat, India, using a metagenomic approach. Seven samples, differing in salinity levels and covering different seasons, were analysed to investigate the dynamics of microbial communities in relation to salinity and season. Metagenomic data generated using whole metagenome sequencing revealed that despite its very high salinity (4.11-30.79 %), the saline desert's microbiota had a rich microbial diversity that included all major phyla. Notably, 67 archaeal genera, representing more than 60 % of all known archaeal genera, were present in this ecosystem. A strong positive correlation (0.85) was observed between the presence of the extremely halophilic bacterium Salinibacter and salinity level. Taxonomic and functional comparisons of the saline desert metagenome with those of other publicly available metagenomes (i.e. sea, hypersaline lagoon, solar saltern, brine, hot desert) was carried out. The microbial community of the Kutch was found to be unique yet more similar to the sea biomes followed by hypersaline lagoon.

Thromboembolic complications in childhood nephrotic syndrome: a clinical profile.

BACKGROUND: Thromboembolism is a rare life-threatening complication of childhood nephrotic syndrome. METHODS: We present the clinical profile and outcome of 34 children with 35 events of thromboembolic complications with nephrotic syndrome. RESULTS: Cerebral venous thrombosis (CVT) was the commonest complication seen in 11 (31.4 %) children followed by pulmonary thromboembolism and deep venous thrombosis in 9 (25.7 %) and 6 (16.6 %) children, respectively. Arterial thrombosis resulting in central nervous system infarcts was observed in 7 (20 %) children and 2 children had thrombosis of the peripheral arteries. Episodes were equal in steroid-resistant nephrotic syndrome and steroid-dependent nephrotic syndrome groups. Most of the thromboembolic complications occurred with relapse but 11.4 % of children developed intracranial thrombosis during remission. The most sensitive symptom of CVT was persistent headache while unexplained respiratory distress and hypoxemia pointed towards pulmonary thromboembolism. Hypoalbuminemia was seen in 82.8 % of children, while concurrent infection was seen in 31.4 %. Coexistence of genetic prothrombotic condition was identified and merits evaluation. Early heparin therapy followed by oral anticoagulants resulted in complete recovery in 91.1 % of children. Death occurred in 3 (8.5 %) children and autopsy revealed pulmonary thromboembolism in 2 children. CONCLUSION: Venous and arterial thrombotic complications can occur in children with nephrotic syndrome. A high index of suspicion is required as the clinical features may be subtle. Neuroimaging and angiographic techniques help in confirming diagnosis. Early aggressive heparin therapy followed by oral anticoagulants is necessary for a favorable outcome.

Tracheobronchial abnormalities on computed tomography angiography in children with congenital heart disease.

OBJECTIVES: To evaluate the assortment of tracheobronchial abnormalities on computed tomography angiography (CTA) in children with congenital heart disease (CHD). METHODS: In this study approved by the Institute ethics committee, CTA studies of 182 children (age range: 2 days-8 years) with CHD, performed from July 2021 to March 2023 were analyzed. Two pediatric radiologists independently assessed the tracheobronchial airways (from the trachea to lobar bronchi) for developmental and branching anomalies and airway compromise (narrowing). In cases which demonstrated airway compromise, the extent and the cause of airway narrowing were evaluated, and the etiology were divided into extrinsic and intrinsic causes. Interobserver agreement between the two radiologists was calculated using kappa statistics. RESULTS: One hundred children demonstrated normal airway anatomy and no luminal narrowing. Airway narrowing was observed in 63 (34.6%) children (κ: 0.954), and developmental airway anomalies were seen in 32 (17.5%) children (κ: 0.935). Of the 63 children with airway narrowing, 47 (25.8%) children had extrinsic cause for narrowing, 11 (6%) children had intrinsic causes for narrowing, and 5 (2.7%) children had both intrinsic and extrinsic causes attributing to airway compromise. Significant airway narrowing (>50% reduction) was seen in 35 (19.2%) children (κ: 0.945). CONCLUSION: Tracheobronchial airway abnormalities are frequently associated in children with CHD and need to be appraised preoperatively. Cross-sectional imaging with CTA provides excellent information on tracheobronchial airway anatomy and caliber as well as delineates the possible etiology of airway narrowing, thus accurately diagnosing airway anomalies.

Complete mitogenome of Asiatic lion resolves phylogenetic status within Panthera.

BACKGROUND: The origin, evolution and speciation of the lion, has been subject of interest, debate and study. The present surviving lions of the genus Panthera comprise of eight sub-species inclusive of Asiatic lion Panthera leo persica of India's Gir forest. Except for the Asiatic lion, the other seven subspecies are found in different parts of Africa. There have been different opinions regarding the phylogenetic status of Panthera leo, as well as classifying lions of different geographic regions into subspecies and races. In the present study, mitogenome sequence of P. leo persica deduced, using Ion Torrent PGM to assess phylogeny and evolution which may play an increasingly important role in conservation biology. RESULTS: The mtDNA sequence of P. leo persica is 17,057 bp in length with 40.8% GC content. Annotation of mitogenome revealed total 37 genes, including 13 protein coding, 2 rRNA and 22 tRNA. Phylogenetic analysis based on whole mitogenome, suggests Panthera pardus as a neighbouring species to P. leo with species divergence at ~2.96 mya. CONCLUSION: This work presents first report on complete mitogenome of Panthera leo persica. It sheds light on the phylogenetic and evolutionary status within and across Felidae members. The result compared and evaluated with earlier reports of Felidae shows alteration of phylogenetic status and species evolution. This study may provide information on genetic diversity and population stability.

Pulmonary nodules with central cavitation in a young child.

Autopsy findings of a young boy presenting with high-grade fever,cough, and respiratory distress and with a family history of tuberculosis are described.

Epidemiology, Clinical Profile, Intensive Care Needs and Outcome in Children with SARS-CoV-2 Infection Admitted to a Tertiary Hospital During the First and Second Waves of the COVID-19 Pandemic in India.

OBJECTIVES: To compare the epidemiological, clinical profile, intensive care needs and outcome of children hospitalized with SARS-CoV-2 infection during the first and second waves of the pandemic. METHODS: This was a retrospective study of all children between 1 mo and 14 y, admitted to a dedicated COVID-19 hospital (DCH) during the first (1st June to 31st December 2020) and second waves (1st March to 30th June 2021). RESULTS: Of 217 children, 104 (48%) and 113 (52%) were admitted during the first and second waves respectively. One hundred fifty-two (70%) had incidentally detected SARS-CoV-2 infection, while 65 (30%) had symptomatic COVID-19. Comorbidities were noted in 137 (63%) children. Fifty-nine (27%) and 66 (30%) children required high-dependency unit (HDU) and ICU care respectively. Severity of infection and ICU needs were similar during both waves. High-flow oxygen (n = 5, 2%), noninvasive ventilation [CPAP (n = 34, 16%) and BiPAP (n = 8, 5%)] and invasive ventilation (n = 45, 21%) were respiratory support therapies needed. NIV use was more during the second wave (26% vs. 13%; p = 0.02). The median (IQR) length (days) of DCH stay among survivors was longer during the first wave [8 (6-10) vs. 5.5 (3-8); p = 0.0001]. CONCLUSIONS: Disease severity, associated comorbidities, PICU and organ support need and mortality were similar in the first and second waves of the pandemic. Children admitted during the second wave were younger, had higher proportion of NIV use and shorter length of COVID-19 hospital stay.

Whole-body MR imaging in evaluation of children with juvenile dermatomyositis.

PURPOSE: To evaluate the whole-body MRI (WBMRI) findings in children with juvenile dermatomyositis (JDM) and correlate them with clinical and laboratory results. METHOD: We conducted the present prospective study from October 2019 to September 2021. Thirty children (8.2 ± 3.88 years) with a diagnosis of JDM based on EULAR/ACR classification criteria underwent WBMRI using short tau inversion recovery, diffusion-weighted, and T1 modified DIXON (precontrast and postcontrast) sequences. WBMRI scans were analysed independently by two radiologists for abnormal signal intensity and enhancement in the different muscle groups. Radiological findings were correlated with clinical examination, muscle enzymes, and inflammatory markers. RESULTS: WBMRI revealed abnormal signal intensity and diffusion restriction, predominantly in the thigh (n = 21, 70 % children), calf (n = 18, 60 % children), and hip (n = 16, 53.3 % children) muscles. A significant positive correlation was observed between the serum total creatinine kinase and lactic dehydrogenaselevels, with altered signal intensity and diffusion restriction in the paraspinal and thigh muscles. Diffusion restriction in the hip and calf muscles also showed significant positive correlations with these enzymes. Significant positive correlations were detected between lower limb muscle strength and altered signal intensity and diffusion restriction in the thigh (p = 0.023) and calf (p = 0.002) muscles. Postcontrast images did not yield any additional useful information. CONCLUSIONS: WBMRI provided useful information in evaluation of the extent and distribution of findings in children with JDM. There were significant positive correlations between MRI findings and muscle enzymes and clinical examination results. The addition of contrast to the WBMRI protocol did not provide any additional advantage.

Role of abdominal sonography in the preoperative diagnosis of extrahepatic biliary atresia in infants younger than 90 days.

OBJECTIVE: The objective of our study was to prospectively assess the role of abdominal sonography in the preoperative diagnosis of extrahepatic biliary atresia (EHBA) in infants younger than 90 days. SUBJECTS AND METHODS: Sonography was performed in 99 infants younger than 90 days with conjugated hyperbilirubinemia (total bilirubin > 3 mg/dL, conjugated bilirubin > 20% of total) after 4 hours of fasting. They were evaluated for the "triangular cord" sign, the presence and morphology of the gallbladder, gallbladder contraction after oral feeding, the presence and diameter of the common bile duct (CBD), liver size and echotexture, spleen size, caliber of the right branch of the hepatic artery, and caliber of the right branch of the portal vein. The final diagnosis of EHBA was made on basis of surgery. The performance of sonography in the diagnosis of EHBA was evaluated. RESULTS: The study group was composed of 68 boys and 31 girls (age range, 13-89 days); of the 99 infants, 30 had EHBA. The triangular cord sign had a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 23.3%, 97.1%, 77.8%, and 74.4%, respectively. The gallbladder was not visualized in seven infants, all of whom had EHBA. The sensitivity, specificity, PPV, and NPV of an abnormal gallbladder were 83.3%%, 82.6%, 67.6%, and 91.9%, respectively, and for noncontraction of the gallbladder were 87%, 72.5%, 51.3%, and 94.3%, respectively. A nonvisualized CBD had a sensitivity, specificity, PPV, and NPV of 93.3%, 47.8%, 43.8%, and 94.3%, respectively. A negative triangular cord sign with normal gallbladder morphology had an NPV of 91.9% for excluding EHBA. CONCLUSION: Comprehensive sonographic evaluation can help in segregating infants at high risk of EHBA from those at low risk.

Diagnostic utility of MDCT in evaluation of persistent stridor in children: Large airway causes and benefit of additional findings.

OBJECTIVES: To assess the diagnostic utility of MDCT in the evaluation of persistent stridor in children for the underlying large airway causes and benefit of additional findings. METHODS: All consecutive pediatric patients who underwent MDCT for the evaluation of persistent stridor from December 2018 to February 2020 were included. Two pediatric radiologists independently reviewed MDCT studies for the presence of abnormalities at six large airway levels: (1) nasopharynx, (2) oropharynx, (3) glottis, (4) subglottis, (5) trachea, and (6) mainstem bronchi. In addition, studies were evaluated for the presence of non-airway abnormalities. Interobserver agreement between two reviewers was evaluated with kappa statistics. RESULTS: There were a total of 40 pediatric patients (age range: 1 day-4 years. MDCT detected large airway abnormalities in 20 (50%) out of 40 patients, including 4 (20%) in nasopharynx, 4 (20%) in glottis, 4 (20%) in trachea, 3 (15%) in subglottis, 3 (15%) in mainstem bronchi, and 2 (10%) in oropharynx. Non-airway abnormalities were seen in 13 (32.5%) children, including 9 (69%) in the lungs, 3 (23%) in the soft tissue, and 1 (8%) in the bone. The remaining 7 (17.5%) studies were normal. There was excellent interobserver agreement seen for detecting large airway and non-airway abnormalities (k > 0.90). CONCLUSION: MDCT has high diagnostic utility in diagnosing large airway causes of persistent stridor in children. It can also provide additional information regarding non-airway abnormalities. Therefore, MDCT has the potential to be utilized as a noninvasive problem-solving imaging modality in pediatric patients with persistent stridor.

Chest MRI as an emerging modality in the evaluation of empyema in children with specific indications: Pilot study.

OBJECTIVES: To assess the diagnostic role of chest magnetic resonance imaging (MRI) for evaluating empyema in children with specific indications. METHODS: Nineteen children (5-16 years) with a diagnosis of empyema were enrolled in this prospective study from January 2018 to February 2020. MRI and multidetector computed tomography (MDCT) of the chest was performed within 48 h of each other. Two pediatric radiologists independently evaluated the MRI and CT images for the presence of fluid and air in the pleural cavity, septations within the fluid, pleural thickening, pleural enhancement, drainage tube tip localization, consolidation, and lymphadenopathy. Kappa test of agreement was used to determine the agreement between the MRI and MDCT findings. Chance-corrected kappa statistics were used for calculating the interobserver variation. RESULTS: The kappa test showed almost perfect agreement (κ = 1) between MRI and MDCT for detecting fluid, pleural thickening, pleural enhancement, drainage tube tip localization, consolidation, and lymphadenopathy. Septations within the fluid were detected in 16 (84.2%) patients on MRI, and in 14 (73.7%) patients on MDCT. Almost perfect agreement (κ = 0.81-1.00) was seen for all the findings on CT and MRI between the two radiologists, except for pleural thickening for which a strong agreement (κ = 0.642) was observed. CONCLUSION: MRI is comparable to MDCT for the detection of various findings in children with empyema. MRI may be considered in lieu of CT, as a problem-solving tool and as a radiation-reducing endeavor in children with empyema, specifically, only where CT is required for preoperative planning and evaluation of complications.