Assessment of interpretation of paediatric skeletal radiographs in the emergency room.

AIM: To assess the performance of paediatric skeletal radiography interpretation in the emergency department. MATERIALS AND METHODS: In a large paediatric referral centre, data from trauma patients with initially misdiagnosed skeletal radiography was collected from October 2014 to June 2015. Data analysis focused on demographic data, region of the injury and clinical consequences as well as outcome of treatment. RESULTS: In 125 of 2,316 patients aged from 1-17 years an initial misdiagnosis was documented (5.4%). Misdiagnosis was detected and corrected the next day in a routine review attended by an experienced paediatric radiologist. False-negative interpretation (missed fracture) was found in 62 and false-positive (overdiagnosis) interpretation in 63 patients. The highest error rate was found in elbow radiography (12%) followed by wrist (8%), fingers (4.5%), metacarpus (4.2%), and toes (3.5%). The most frequently missed fracture was supracondylar elbow fracture (n=12). In case of initially missed fractures treatment was adjusted delayed the next day. In none of these patients, were repositioning or open surgical procedures necessary. No misdiagnosis resulted in additional morbidity. CONCLUSION: Misinterpretation of paediatric skeletal radiography by paediatric emergency physicians occurred frequently. The majority of diagnostic errors occurred in a few regions. None of these misdiagnoses negatively affected patients' health. A routine review by an experienced paediatric radiologist is mandatory, but may suffice the next day.

Early postnatal diagnosis of Costello syndrome.

Costello syndrome is a rare congenital disease with typical craniofacial and musculoskeletal features, cutaneous lesions, cardiac defects and cancer susceptibility. Affected patients show severe feeding difficulties for the first years of life and developmental delay. We present the case of a patient, in whom fetal tachycardia, polyhdramnios and physical characteristics led to an early diagnosis of Costello syndrome. Based on this patient we describe challenges and problems of therapeutic management of infants with Costello syndrome.

Necrotizing enterocolitis after open cardiac surgery for congenital heart defects--a serious threat.

Neonates with congenital heart disease are at risk to develop necrotizing enterocolitis (NEC). Especially in the postoperative period after correction of a congenital heart defect this intestinal inflammatory disease can be a potentially life-threatening complication. The purpose of this case series is to define the specific features of NEC in the postoperative situation, with emphasis on diagnostic difficulties.Medical records of neonates developing severe NEC in the postoperative period after surgical correction of a congenital heart defect from 2008 to 2011 were reviewed and compared.7 neonates with NEC after surgical correction of a congenital heart defect were identified. In all 7 patients typical radiologic findings of NEC were missing. Diagnosis was late in all 7 cases; 5 patients already had intestinal perforation. In 3 patients NEC successfully managed before surgical correction of the congenital heart defect dramatically relapsed in the postoperative period. 2 patients showed intestinal mucormycosis, an entity not clearly differentiated from NEC. Due to progressed disease at diagnosis all patients required extensive surgical procedures; 2 of them subsequently died.In the postoperative situation after surgical correction of a congenital heart defect diagnosis of NEC might be challenging. The general condition of these children complicates clinical examination and characteristic radiologic signs are absent. Late diagnosis and exclusive pathogens cause high morbidity and mortality.

[Closing gastroschisis: a distinct entity with high morbidity and mortality]. / Closing Gastroschisis: eine Sonderform der Gastroschisis mit hoher Morbidität und Mortalität.

PURPOSE: We correlate severe bowel damage in gastroschisis to the rare intrauterine event of narrowing of the abdominal wall around the protruding intestines. We describe this "closing gastroschisis" as a distinct entity. Prenatal ultrasound findings as gastric or bowel dilation were compared to the postnatal findings in order to find markers for an early in utero diagnosis of closing gastroschisis. Early diagnosis could prompt timely delivery to save the compromised bowel and avoid short gut syndrome. MATERIALS AND METHODS: We documented the pre- and postnatal course of our patients with gastroschisis from 2007 to 2009.  Closing gastroschisis was suspected antenatally and confirmed postnatally. We identified 5 out of 18 patients showing closure of the abdominal wall with varying degrees of bowel damage. Prenatal ultrasound findings were correlated to the postnatally confirmed extent of intestinal damage. RESULTS: We could not find consistent ultrasound markers for prenatal diagnosis of closing gastroschisis. In prenatal ultrasound three patients presented significant gastric dilation and then experienced severe courses postnatally due to segmental gut necrosis. One of these three died and the other two developed short gut syndrome. In one case progressive intraabdominal loop dilation with simultaneous shrinking of the extraabdominal loops occurred corresponding to closing gastroschisis with segmental midgut necrosis. CONCLUSION: Closing gastroschisis must be seen as a special form of gastroschisis. Extended intestinal damage is often life-threatening. In longitudinal observation dynamics of fetal ultrasound findings can lead to the diagnosis of closing gastroschisis. Progressive intraabdominal loop dilation is always highly suspicious and must lead to close follow-up and timely delivery.

[Hepatic artery pseudoaneurysm following blunt abdominal injury]. / Arterielles Pseudoaneurysma der Leber nach stumpfem Bauchtrauma.

Posttraumatic hepatic artery pseudoaneurysms are a rare but life-threatening complication of blunt abdominal trauma with liver damage. We report the case of a child who developed a pseudoaneurysm of the right hepatic artery after a bicycle accident with central liver rupture. After an episode of hemodynamically relevant hemobilia due to delayed bleeding, the asymptomatic pseudoaneurysm was diagnosed coincidentally by ultrasound. Because of the progression in size angiographic coiling was performed and led to thrombotic occlusion of the pseudoaneurysm. After a symptom-free period of 1 month the child required surgery because of acute cholecystitis.

Therapeutic step-up strategy for management of hereditary pancreatitis in children.

BACKGROUND/PURPOSE: Various different regimes exist for the treatment of hereditary pancreatitis in childhood. Here, we propose a therapeutic pathway with emphasis on endoscopic and surgical procedures. METHODS: From 2006 to 2013, 12 patients with a diagnosis of hereditary pancreatitis were prospectively included in a therapeutic step-up schema. The treatment outcome was evaluated and correlated to aetiological factors and pathoanatomic findings. RESULTS: After diagnostic work-up (laboratory data, ultrasound examination, magnetic resonance cholangiopancreatography and genetic testing), all 12 patients underwent early endoscopic retrograde cholangiopancreatography (ERCP), which was successfully performed in ten children. Obstructive pancreatitis was found in eight children, and required sphincterotomy, dilation and stenting for 12 months. In two children with unsuccessful ERCP, open surgical drainage procedures were performed. After a mean follow-up of 32 months all children are free of recurrence of pancreatitis without any impairment of everyday activities. CONCLUSIONS: For children with hereditary pancreatitis, a therapeutic step plan with early ERCP and open surgical drainage procedures in case of impossible or insufficient endoscopic treatment prevents recurring pancreatitis and offers a normal quality of life without any major complications.

Amplitude degradation of time-reversed pulses in nonlinear absorbing thermoviscous fluids.

The linear wave equation in a lossless medium is time reversible, i.e., every solution p(x, t) has a temporal mirror solution p(x, -t). Analysis shows that time reversal also holds for the lossless nonlinear wave equation. In both cases, time-reversal invariance is violated when losses are present. For nonlinear propagation loses cannot normally be ignored; they are necessary to prevent the occurrence of multivalued waveforms. Further analysis of the nonlinear wave equation shows that amplification of a time-reversed pulse at the array elements also leads to a violation of time reversal even for lossless nonlinear acoustics. Numerical simulations are used to illustrate the effect of nonlinearity on the ability of a time-reversal system to effectively focus on a target in an absorbing fluid medium. We consider both the amplitude and arrival time of retrodirected pulses. The numerical results confirm that both shock generation (with the accompanying absorption) and amplification at the array, adversely affect the ability of a time-reversal system to form strong retrodirective sound fields.