Fever at Time of Leukemia Diagnosis in Children: Predictor of Bloodstream Infection or Catheter Removal?

PURPOSE: To assess the incidence of fever at diagnosis in children with leukemia and determine if fever at diagnosis is a predictor of bloodstream infection (BSI) or central venous access device (CVAD) removal for infection either within the first 30 days or between 30 and 90 days after CVAD insertion. MATERIALS AND METHODS: One hundred fifty-one patients with acute leukemia (July 1, 2018, to December 31, 2020) who underwent a CVAD insertion within 2 weeks of diagnosis were included. Patient data included demographic characteristics, fever at diagnosis, CVAD type, antibiotics before and/or on the day of CVAD insertion, BSI incidence, BSI rates per 1,000 catheter days, and need for catheter removal after CVAD insertion within 30 days and between 30 and 90 days. RESULTS: Patients with fever at diagnosis had a significantly higher incidence of BSI within the first 30 days after CVAD insertion (17/23) than that among patients without fever (6/23) (P = .046) at diagnosis. No statistically significant difference was observed in the incidence of BSI between 30 and 90 days after CVAD insertion between patients with fever (5/11) and those without fever at diagnosis (6/11) (P = .519). Fever at diagnosis was not a predictor of CVAD removal within 30 days (9 patients required CVAD removal; 7/9 had fever and 2/9 had no fever) (P = .181) or between 30 and 90 days (4 patients required CVAD removal; 1/4 had fever and 3/4 had no fever at diagnosis) (P = .343) after insertion. CONCLUSIONS: Fever at diagnosis in patients with leukemia is not a predictor of CVAD removal for infection.

Pediatric liver cirrhosis interventional procedures: from biopsy to transjugular intrahepatic portosystemic shunt.

Cirrhosis is a complex diffuse process whereby the architecture of the liver is replaced by abnormal nodules because of the presence of fibrosis. Several pediatric diseases such as extrahepatic portal vein obstruction, biliary atresia, alpha-1-antitrypsin deficit and autoimmune hepatitis can lead to cirrhosis and portal hypertension in children. In this article the authors describe interventional radiology procedures that can facilitate the diagnosis and treatment of diseases associated with liver cirrhosis and portal hypertension in the pediatric population. These procedures include image-guided liver biopsy, mesenteric-intrahepatic left portal vein shunts, balloon-occluded retrograde transvenous obliteration, transjugular intrahepatic portosystemic shunts and splenic embolization.

Utility of balanced steady-state field precession sequence in the evaluation of retinal and subdural hemorrhages in patients with abusive head trauma.

Abusive head trauma is the leading cause of physical child abuse deaths in children under 5 years of age in the United States. To evaluate suspected child abuse, radiologic studies are typically the first to identify hallmark findings of abusive head trauma including intracranial hemorrhage, cerebral edema, and ischemic injury. Prompt evaluation and diagnosis are necessary as findings may change rapidly. Current imaging recommendations include brain magnetic resonance imaging with the addition of a susceptibility weighted imaging (SWI) sequence which can detect additional findings that suggest abusive head trauma including cortical venous injury and retinal hemorrhages. However, SWI is limited due to blooming artifacts and artifacts from the adjacent skull vault or retroorbital fat, which can affect the evaluation of retinal, subdural, and subarachnoid hemorrhages. This work explores the utility of the high-resolution, heavily T2 weighted balanced steady-state field precession (bSSFP) sequence to identify and characterize retinal hemorrhage and cerebral cortical venous injury in children with abusive head trauma. The bSSFP sequence provides distinct anatomical images to improve the identification of retinal hemorrhage and cortical venous injury.

A Model of Care Optimized for Marginalized Remote Population Unravels Migration Pattern in India.

BACKGROUND AND AIMS: Access to basic health needs remains a challenge for most of world's population. In this study, we developed a care model for preventive and disease-specific health care for an extremely remote and marginalized population in Arunachal Pradesh, the northeasternmost state of India. APPROACH AND RESULTS: We performed patient screenings, performed interviews, and obtained blood samples in remote villages of Arunachal Pradesh through a tablet-based data collection application, which was later synced to a cloud database for storage. Positive cases of hepatitis B virus (HBV) were confirmed and genotyped in our central laboratory. The blood tests performed included liver function tests, HBV serologies, and HBV genotyping. HBV vaccination was provided as appropriate. A total of 11,818 participants were interviewed, 11,572 samples collected, and 5,176 participants vaccinated from the 5 westernmost districts in Arunachal Pradesh. The overall hepatitis B surface antigen (HBsAg) prevalence was found to be 3.6% (n = 419). In total, 34.6% were hepatitis B e antigen positive (n = 145) and 25.5% had HBV DNA levels greater than 20,000 IU/mL (n = 107). Genotypic analysis showed that many patients were infected with HBV C/D recombinants. Certain tribes showed high seroprevalence, with rates of 9.8% and 6.3% in the Miji and Nishi tribes, respectively. The prevalence of HBsAg in individuals who reported medical injections was 3.5%, lower than the overall prevalence of HBV. CONCLUSIONS: Our unique, simplistic model of care was able to link a highly resource-limited population to screening, preventive vaccination, follow-up therapeutic care, and molecular epidemiology to define the migratory nature of the population and disease using an electronic platform. This model of care can be applied to other similar settings globally.

Pediatric interventional radiology workforce in North America: a descriptive analysis of demographics, educational backgrounds and scholarly activities.

BACKGROUND: Pediatric interventional radiology has grown as an advanced subspecialty with increased demand, number and complexity of cases, and number of pediatric institutions offering a pediatric interventional radiology service. Despite the overall increase in the number of pediatric interventionalists over the past two decades, there is a heterogeneity in their academic backgrounds and a lack of uniform training pathways. OBJECTIVE: To analyze the demographics, academic backgrounds and scholarly activities of pediatric interventionalists across the United States (U.S.) and Canada. MATERIALS AND METHODS: A list of all members of the Society for Pediatric Interventional Radiology was obtained and pediatric interventionalists at academic and private practice institutions in the U.S. and Canada were included. Publicly available online sources were used to gather demographic and educational information about each pediatric interventionalist, which included the online curriculum vitae, the HealthGrades.com and Doximity.com websites, and Elsevier's Scopus database. Demographic and educational data including age, gender, educational background, additional degrees, academic rank, previous leadership positions, and metrics of scholarly activities were recorded. Fellowships in diagnostic pediatric radiology, adult interventional radiology and/or pediatric interventional radiology were recorded. Mann-Whitney U tests and Kruskal-Wallis tests were used to compare differences between groups. RESULTS: One hundred and twenty-five pediatric interventionalists were included, of whom 24 (19.2%) were female. The mean age was 48.6 years (standard deviation [SD]: 10.6, median: 45 years, range: 36-82 years). There was no statistical difference between median age for male versus female pediatric interventionalists (44.5 years vs. 45 years, P=0.89). A majority of pediatric interventionalists were American medical school graduates (96, 76.8%), while 29 (23.2%) were international medical graduates. Eighty-three percent (104) of the pediatric interventionalists completed diagnostic radiology residency training in the U.S., most commonly at the University of Cincinnati in Ohio (6.4%) and Washington University in St. Louis, MO (5.6%). Among fellowship training, pediatric interventionalists completed a pediatric radiology fellowship (61.6%), adult interventional radiology fellowship (40%) and/or a dedicated pediatric interventional radiology fellowship (57.6%). The mean±SD (median) publications, citations and Hirsch index (h-index) for pediatric interventionalists were 32±45 (12), 68±1,317 (120) and 9±10 (5), respectively. There was a statistically higher number of publications, citations and h-index with increasing academic rank at the assistant, associate and professor levels (P<0.001 for all groups). International medical graduate pediatric interventionalists had a higher, but not statistically significant, median publication count (26 vs. 11, P=0.0.25), citation count (236 vs. 93, P=0.36) and h-index (9.0 vs. 5, P=0.24) compared to pediatric interventional radiologists from American medical schools. CONCLUSION: Pediatric interventionalists in North America are predominantly male, with about a quarter having graduated from international medical schools. Pediatric radiology fellowship, followed by pediatric interventional radiology fellowship, was the most frequently pursued training pathway.

Venous injury in pediatric abusive head trauma: a pictorial review.

Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. An intracranial pathology can exist even in the setting of a normal physical exam. A delay in the diagnosis of AHT can have serious life-threatening consequences for the child and increases the potential the child will be abused again. In this article, we review the traumatic subdural hematoma as well as various morpho-structural patterns of shearing injuries and thrombosis of intracranial bridging veins. This work serves as a summary of patterns of imaging features of intracranial venous injury in AHT, as described in the literature, to facilitate familiarity and early detection of abusive head trauma in the pediatric population. Essentially, in AHT there is a traumatic injury to the bridging vein with either partial or complete tear. This can secondarily result in thrombosis at the terminal end of the bridging vein with blood clots adjacent to the bridging vein.

Successful percutaneous transhepatic recanalization of a completely obstructed hepatico-jejunal anastomosis in a child with liver transplantation: Unusual employment of the transseptal puncture system.

Stenosis of the HJ is a common complication of pediatric split LT with high morbidity and possible evolution to secondary biliary cirrhosis and re-transplantation if not treated. Because the endoscopy is generally infeasible in the Roux-en-Y, percutaneous interventional radiology management is usually the safest and most effective approach to avoid surgical revision of a stenotic bilio-enteric anastomosis. We present the case of a child with acute onset of cholestasis 7 months after left lateral segment partial LT due to occlusion of the HJ. The biliary stricture was found to be non-crossable with conventional interventional radiological techniques. The obstruction was resolved creating a new bilio-digestive communication via percutaneous transhepatic approach using the TPS. This device is usually employed by the interventional cardiologist to perform some procedures requiring the direct access to the left atrium through interatrial septal puncture. In conclusion, percutaneous transhepatic recanalization of the hepato-jejuno anastomosis is a rare but feasible and valuable procedure alternative to the surgical resolution even in small infants. Although few cases have been reported in literature, it has to be considered an additional treatment option when the conventional approaches fail.

Lissencephaly and Advanced-Stage Congenital Cytomegalovirus Infection in a Neonate.

This case report investigates the management of a 24-week-old neonate with congenital cytomegalovirus (CMV) infection and its sequelae, including severe intrauterine growth restriction, thrombocytopenia, and brain anomalies, ultimately progressing to lissencephaly. The diagnostic challenges included delayed clinical suspicion of congenital CMV, which was not identified until after delivery through CMV DNA polymerase chain reaction, and differentiating its symptoms from other potential causes of the neonate's condition. Aggressive interventions included antibiotics, antiviral therapy with ganciclovir, and supportive measures such as intubation, CPR, respiratory support, blood transfusions, and management of coagulopathy. Despite these efforts, the patient deteriorated due to progressive hypoperfusion, hypoxemic cardiorespiratory failure, and disseminated intravascular coagulopathy. Due to the poor prognosis and extent of multiorgan damage, support was withdrawn per parental consent. This case highlights the complications encountered when managing an advanced-stage neonatal CMV infection and emphasizes the importance of a multidisciplinary and holistic approach to guide diagnosis and treatment.

Candida parapsilosis in Late Prosthetic Joint Infections Among Immunocompetent Patients: A Case Series.

Introduction: Fungal prosthetic joint infections (PJIs) are very rare in immunocompetent patients. PJI can present either early, delayed, or as late chronic infections. Diagnosis of fungal PJI presenting late is challenging due to the difficulty in isolation as well as the clinical presentation very similar to an aseptic loosening. There are no clear guidelines regarding the management of these patients. Case Report: We present five cases of Candida parapsilosis PJI presenting as late chronic infections. All five patients were culture-negative preoperatively, immunocompetent, and with good soft-tissue condition. There were three infected knee prostheses and two infected hip hemiarthroplasty. All of them were treated with extensive debridement, meticulous sampling, and extended culture. We treated all of them with long-term antifungals without any disease reactivation or recurrence till the last follow-up. Conclusion: Fungal infection should be suspected in immunocompetent patients presenting early with features of aseptic loosening but without typical signs of periprosthetic infection. Revision with long-term suppressive therapy can give good results in these patients.

Clinical Profile, Complications and Trends of Ocular Anaesthesia in a Multi-tier Ophthalmology Network in India: An Eight-Year Experience.

INTRODUCTION: To describe the clinical profile, complications and trends of ocular anaesthesia in a multi-tier ophthalmology network in India. METHODS: This retrospective hospital-based study included 417,622 patients presenting between January 2013 and December 2020. Patients who were administered either topical, local or general anaesthesia for ocular surgery in at least one eye were included as cases. The data were collected using an electronic medical record system. RESULTS: Among the 417,622 patients, local anaesthesia was administered to 280,638, (67.2%) patients and was the most commonly administered type followed by topical anaesthesia in 84,117 (20.14%) patients. The most common complication encountered in administering local anaesthesia was retrobulbar haemorrhage in 103 (0.037%) patients followed by lid haematoma in 49 (0.017%) patients. Tooth damage occurred in 40 (0.076%) patients followed by delayed recovery in 30 (0.057%) patients during general anaesthesia. The trend of local anaesthesia decreased (83.48% vs 53.36%), whereas the trend of topical anaesthesia increased (8.61% vs 32.42%) over the study period. CONCLUSION: There is a notable trend towards the adoption of less invasive anaesthetic methods, particularly in common surgeries such as cataract, intravitreal injection, and vitreoretinal surgery. However, despite this trend, a significant proportion of oculoplastic/orbital surgeries, trauma, and strabismus surgeries continue to be performed under general anaesthesia. These observations underscore the ongoing evolution of ocular anaesthesia practices, reflecting advancements in surgical techniques and patient preferences.

Glaucoma awareness, anxiety and its impact on patients undergoing visual field testing and optical coherence tomography.

PURPOSE: To assess the effect of Glaucoma awareness, knowledge, and anxiety on patients under visual field analysis by Humphrey's visual field analyzer (HFA) and optical coherence tomography(OCT). METHODS: This prospective comparative cohort study included glaucoma patients undergoing HFA (Group A)(n = 150) and OCT(Group B) (n = 150). Each group consisted of 75 newly diagnosed patients and 75 patients who were on follow-up. Participants completed State trait anxiety inventory form Y2(STAI) before and after the test to assess pre-test and intra-test anxiety. Another validated and structured questionnaire was used to assess patient awareness and knowledge of glaucoma. Anxiety scores were used to make correlations and comparisons between the two groups and also against visual field reliability indices. The impact of awareness on anxiety scores and its correlation with reliability indices were also determined. RESULTS: Overall pretest and intratest anxiety scores in patients undergoing HFA were 52.39(9.5) and 52.45(8.6)and OCT 53.04(8.0) and 53.83(8.2) respectively.Pretest anxiety was less in follow-up patients of both groups(Group A-51.04,Group B-52.72).There was no statistically significant difference between the groups(pretest p = 0.52,Intratest p = 0.15). Anxiety score was found to be significantly high in female participants(54.07,p = 0.01)and those without awareness(p < 0.001). Patients with education of graduation and above in group B had significantly lower anxiety scores(p = 0.007). CONCLUSION: Anxiety levels induced by both diagnostic modalities HFA and OCT appear to be similar and it does not affect the reliability indices.Anxiety score was higher in female participants and participants lacking disease awareness.

One-year outcomes of rate versus rhythm control of atrial fibrillation in the Kerala-AF Registry.

Background: There is ongoing debate around rate versus rhythm control strategies for managing atrial fibrillation (AF), however, much of the data comes from Western cohorts. Kerala-AF represents the largest prospective AF cohort study from the Indian subcontinent. Objectives: To compare 12-month outcomes between rate and rhythm control strategies. Methods: Patients aged ≥18 years with non-transient AF were recruited from 53 hospitals across Kerala. Patients were stratified by rate or rhythm control. The primary outcome was a composite of all-cause mortality, arterial thromboembolism, acute coronary syndrome or hospitalization due to heart failure or arrhythmia at 12 months. Secondary outcomes included bleeding events and individual components of the primary. Predictors of the composite outcome were analysed by logistic regression. Results: A total of 2901 patients (mean age 64.6 years, 51% female) were included (2464 rate control, 437 rhythm control). Rates of the primary composite outcome did not differ between groups (29.7% vs 30.0%; p = .955), nor did any component of the primary. Bleeding outcomes were also similar (1.6% vs 1.9%; p = .848). Independent predictors of the primary composite outcome were older age (aOR 1.01; p = .013), BMI <18 (aOR 1.51; p = .025), permanent AF (aOR 0.78; p = .010), HFpEF (aOR 1.40; p = .023), HFrEF (aOR 1.39; p = .004), chronic kidney disease (aOR 1.36; p < .001), and prior thromboembolism (aOR 1.31; p = .014). Conclusion: In the Kerala-AF registry, 12-month outcomes did not differ between rate and rhythm control cohorts.

Fibrolipomatous hamartoma of the median nerve in a child with carpal tunnel syndrome: imaging findings and literature review.

Fibrolipomatous hamartoma of the median nerve is an uncommon benign tumour of the childhood, which usually manifests in adolescents or adulthood with signs of compressive neuropathy at wrist. Symptomatic tumour is unusual in children below 5 years age and can be underdiagnosed. Magnetic resonance imaging provides pathognomonic features for the diagnosis, obviating the need for biopsy. Although standard ultrasonography is frequently the first-line imaging approach in the evaluation of soft-tissue masses, sonographic findings of this lesion are less frequently reported and have to be kept in mind by radiologist. We report the unusual case of carpal tunnel syndrome secondary to fibrolipomatous hamartoma of the median nerve in a 4-year-old child successfully treated with surgical carpal tunnel release.

A 15-Year Analysis of International Medical Graduates Matching Into Diagnostic Radiology Residency Programs in the United States.

RATIONALE AND OBJECTIVES: To analyze the trends in international medical graduates (IMGs) matching into diagnostic radiology residency programs in the United States (US). MATERIALS AND METHODS: The National Resident Match Program data was accessed for years 2005-2020 and diagnostic radiology residency-specific data was extracted for US MD, osteopathic (DO), and IMG applicants. IMGs were categorized into US-citizen IMGs and non-US citizen IMGs per the National Residency Match Program. Variables collected for each year included the number of positions, number of applicants in each group, positions filled/unfilled, and fill rate of each group. Additional data for some years included USMLE Step 1 score, United States Medical Licensing Examination (USMLE) Step 2 clinical knowledge (CK) score, number of research experiences, number of abstracts/publications, and additional degrees obtained. Trends were analyzed using simple linear regression model and p value <0.05 was considered significant. RESULTS: The number of diagnostic radiology residency programs increased from 203 (2006) to 212 (2020). The total number of diagnostic radiology residency positions increased from 1011 (2006) to 1113 (2020), with the peak of 1145 in 2014. The overall "match rate," that is, proportion of positions filled to positions available, increased from 96.4% (2006) to 97.3% (2020), with a brief decline to 86.7% in 2015. Among the filled positions, the proportion filled by US medical school graduates significantly declined from 89.7% (2006) to 69.2% (2020) (p < 0.001), and the proportion of positions filled by osteopathic seniors and graduates significantly increased from 2.2% (2006) to 15.1% (2020; p < 0.001). The proportion of US IMGs increased from 3.2% (2006) to 5.4% (2020), while the proportion of non-US IMGs increased from 4.4% (2006) to 9.4% (2020), with overall IMG match rate increased significantly from 7.6% to 14.9% (p = 0.009). The mean Step 1 scores of US IMGs and non-US IMGs were 238 and 237.3, and the mean Step 2 CK scores were 241.67 and 241, respectively. Cumulatively over the study period, a total of 736 US IMGs and 1051 non-US IMGs have matched into diagnostic radiology residency. CONCLUSION: There is an increasing proportion of IMGs, especially the non-US citizen IMGs, matching into US radiology residency programs in the last decade. Diagnostic radiology remains a competitive specialty evidenced by average USMLE scores higher than national average and research experiences of matched candidates.

Case report: Bilateral pleural effusion secondary to late migration of a tunneled central venous catheter in a patient affected by high risk neuroblastoma.

The insertion of long-term central venous catheters is a standard of care for children affected by malignancies, although it can be associated with life-threatening complications. The present paper reports an unusual mechanical complication related to the use of a long term tunneled central venous catheter in a pediatric oncologic patient. An 18 months old child, diagnosed with stage M high-risk retroperitoneal neuroblastoma, underwent ultrasound-guided placement of a 6 Fr bilumen long-term tunneled central venous catheter in the right internal jugular vein prior to the beginning of induction chemotherapy. The correct position of the distal tip of the catheter was confirmed by fluoroscopy. After 4 months of regular use of the device, the patient experienced neck swelling during high-dose chemotherapy infusion. A chest x-ray showed a dislocated catheter and bilateral pleural effusion. CT scan demonstrated the tip of the catheter rupturing the medial wall of the right jugular vein and entering the mediastinum; furthermore, pneumomediastinum, subcutaneous neck emphysema and bilateral pleural effusion were noticed and a thrombus was evident in the right jugular vein at the insertion in the brachiocephalic vein. The patient was then transferred to the Intensive Care Unit and bilateral thoracostomy tubes were placed urgently (500 mL of clear fluid were evacuated from pleural spaces). The dislocated catheter was removed electively on the following day under fluoroscopy. Despite ultrasound-guided placement and long-term uneventful use of the catheter, life-threatening central venous catheter-related mechanical complications can occur; the current case report emphasizes the importance of careful monitoring of patients with central venous catheters in order to quickly diagnose and treat potentially lethal complications.

Single-Stage Revision With Fluconazole Monotherapy in Fungal Prosthetic Knee Joint Infections.

Fungal prosthetic joint infection is rare, and two-stage revision is usually advocated. We present our experience with 2 cases of fungal prosthetic knee joint infection presenting 25 months and 3 years after index surgery. Both patients were managed with single-stage revision arthroplasty and fluconazole monotherapy. They remain asymptomatic with good knee society score after 2 years of follow-up. Preoperative workup of all aseptic loosening cases should include extended culture for fungal elements. Single-stage revision with antifungal therapy for 3 months gives good results in nonimmunocompromised patients with good soft-tissue envelope.

Basal Ganglia Disease Mimicking Acute Encephalitis Syndrome Among Infants of Bodo Tribe, Assam.

We conducted a review of hospital records of infants with acute encephalitis syndrome with bilateral symmetrical basal ganglia infarcts, between 2011-2015, at a single center in Assam. Thiamine (as part of multivitamin injection) was used in the treatment of 23 infants and not used in 27; Only 1 (3.7%) infant died in the former group and 20 infants (86.9%) died in the latter [RR (95% CI) 0.04 (0.006,0.29); P<0.001). Two infants on follow-up had normal development, both in the thiamine group. The study suggests the possibility of subclinical thiamine deficiency, mitochondrial diseases, or SLC19A3 gene mutation in this population.

Stenotrophomonas maltophilia as a rare cause of meningitis and ventriculoperitoneal shunt infection.

Stenotrophomonas maltophilia is an extremely rare pathogen responsible for ventriculoperitoneal shunt infection and meningitis. This young female patient with history of multiple shunt revisions in the past, came to us with shunt dysfunction and exposure of the ventriculoperitoneal shunt tube in the neck. The abdominal end of the shunt tube was seen migrating into the bowel during shunt revision. The cerebrospinal fluid analysis showed evidence of Stenotrophomonas maltophilia growth. This is the first reported case of Stenotrophomonas maltophilia meningitis associated with ventriculoperitoneal shunt migration into the bowel.

HIV-vacuolar myelopathy: an unusual early presentation in HIV.

Human immunodeficiency virus (HIV)-vacuolar myelopathy is a late presentation of HIV infection and rarely the presenting symptom. Treatment of HIV-vacuolar myelopathy involves anti-retroviral therapy, but neurological deficits are devastating if diagnosis is delayed. We present a rare case of a patient who presented with HIV-vacuolar myelopathy as the initial presentation in a case of newly diagnosed HIV. The case emphasizes the importance of a high index of suspicion and diagnosis for better outcomes in HIV-vacuolar myelopathy.