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.

Safety and Effectiveness of Sclerotherapy for Nonparasitic Splenic Cysts: A Systematic Review and Meta-Analysis.

PURPOSE: To assess the reported safety and effectiveness of sclerotherapy for the treatment of nonparasitic splenic cysts through a systematic review and meta-analysis. MATERIALS AND METHODS: A systematic search of PubMed MEDLINE, Embase, Web of Science, and the Cochrane Library through July 2023 was performed. Studies including at least 5 patients reporting percutaneous sclerotherapy of nonparasitic splenic cysts, initial and posttreatment cyst size, clinical symptoms as well as adverse events (AEs), and recurrence rates were included. A 0-8-point scale for case reports and case series was used to assess bias. Data were analyzed using random-effects meta-analysis. RESULTS: Twenty-three of 833 citations were selected for full-text assessment, and 7 studies were included for a total of 99 patients. The methodological quality of the studies included scored 3-7. Composite analysis demonstrated 38% (95% CI, 23%-55%) rate of recurrence after treatment with significant heterogeneity; however, when assessed for a cyst size of <8 cm, recurrence dropped to 7% (95% CI, 2%-20%). Residual symptoms after treatment completion were present in 17% (95% CI, 7%-33%). Intraprocedural and postprocedural AE rates were 6% (95% CI, 3%-13%) and 6% (95% CI, 3%-12%) respectively. CONCLUSIONS: Sclerotherapy of splenic cysts seemed to be safe, with a high rate of recurrence for cysts ≥8 cm.

Findings in percutaneous trans-hepatic cholecysto-cholangiography in neonates and infants presenting with conjugated hyperbilirubinemia: emphasis on differential diagnosis and cholangiographic patterns.

BACKGROUND: Biliary atresia (BA) is one of the causes of conjugated hyperbilirubinemia in infants which if untreated leads to end-stage liver disease and death. Percutaneous Trans-hepatic Cholecysto-Cholangiography (PTCC) is a minimally invasive study which can be utilized in the diagnostic work-up of these patients. This study's purpose is to describe the experience with PTCC in neonates, the imaging findings encountered, and the abnormal patterns which warrant further investigation. METHODS: A 16-year single-center retrospective study of patients with persistent neonatal cholestasis (suspected BA) undergoing PTCC. Patient demographics, laboratory values, PTCC images, pathology and surgical reports were reviewed. RESULTS: 73 patients underwent PTCC (68% male, mean age 8.7 weeks, mean weight 4.0 Kg). The majority of studies were normal (55%). Abnormal patterns were identified in 33 cases, 79% were diagnosed with BA and 12% with Alagille syndrome. Non-opacification of the common hepatic duct with a narrowed common bile duct (42%) and isolated small gallbladder (38%) were the most common patterns in BA. CONCLUSION: PTCC is a minimally invasive study in the diagnostic work-up of infants presenting with conjugated hyperbilirubinemia (suspected BA). Further invasive investigations or surgery can be avoided when results are normal.

Local reference and achievable dose levels for vascular and enterostomy access procedures in pediatric interventional radiology.

BACKGROUND: Knowledge of radiation quantities delivered in routine practice is an essential responsibility of a pediatric interventional radiology department. OBJECTIVE: To review radiation indices in frequently performed vascular and enterostomy access procedures at a quaternary pediatric hospital to formulate dosimetric reference levels and achievable levels. MATERIALS AND METHODS: A retrospective review of patient demographics, procedure information and quantitative dose metrics over a 2-year period was performed. Dosimetric details for common procedures (central line insertions, gastrostomy/gastrojejunostomy insertions and maintenance) were evaluated, correlated with demographic data and stratified across five weight groups (0-5 kg, 5-15 kg, 15-30 kg, 30-50 kg, 50-80 kg). Achievable (50th percentile) and reference (75th percentile) levels with confidence intervals were established for each procedure. RESULTS: Within the evaluation period, 3,165 studies satisfied the inclusion criteria. Five were classified as device insertions (peripherally inserted central catheter, n=1,145; port-a-catheter, n=321; central venous line, n=285; gastrostomy-tube [G-tube], n=262, and gastrojejunostomy-tube [GJ-tube], n=66), and two were classified as maintenance procedures (G-tube, n=358, and GJ-tube, n=728, checks, exchanges and reinsertions). Representative reference and achievable levels were calculated for each procedure category and weight group. CONCLUSION: This work highlights the creation of local reference and achievable levels for common pediatric interventional procedures. These data establish a dosimetric reference to understand the quantity of radiation routinely applied, allowing for improved relative radiation risk assessment and enriched communication to interventionalists, health care providers, parents and patients.

Fostering research in pediatric interventional radiology: needs assessment and suggestions for support.

BACKGROUND: Due to the rarity of pediatric diseases, collaborative research is the key to maximizing the impact of research studies. A research needs assessment survey was created to support initiatives to foster pediatric interventional radiology research. OBJECTIVE: To assess the status of pediatric interventional radiology research, identify perceived barriers, obtain community input on areas of research/education/support, and create metrics for evaluating changes/responses to programmatic initiatives. MATERIALS AND METHODS: A survey link was sent to approximately 275 members of the Society for Pediatric Interventional Radiology (SPIR) between May and October 2020. Data was collected using a web-based interface. Data collected included practice setting, clinical role, research experience, research barriers, and suggestions for future initiatives. RESULTS: Fifty-nine surveys were analyzed with a staff physician survey response rate of 28% (56/198). A wide range of practice sizes from 15 countries were represented. Respondents were predominantly staff physicians (95%; 56/59) with an average of 11 years (range: 1-25 years) of clinical experience working at academic or freestanding children's hospitals. A total of 100% (59/59) had research experience, and 70% (41/58) had published research with a mean of 30 peer-reviewed publications (range: 1-200). For job security, 56% (33/59) of respondents were expected or required to publish, but only 19% (11/58) had research support staff, and 42% (25/59) had protected research time, but of those, 36% (9/25) got the time "sometimes or never." Lack of support staff, established collaborative processes, and education were identified as top barriers to performing research. CONCLUSIONS: The needs assessment survey demonstrated active research output despite several identified barriers. There is a widespread interest within the pediatric interventional radiology community for collaborative research.

Turning down the heat: The case for mild hyperthermia and thermosensitive liposomes.

"A single disappointing study does not mean an end to the future of ThermoDox®", writes Michael Tardugno (CEO of Celsion Corporation), after announcing the termination of Celsion's second Phase III clinical trial. The OPTIMA trial, as it was known, evaluated their thermosensitive liposome (TSL) formulation of doxorubicin (ThermoDox®) in combination with radiofrequency ablation for the treatment of hepatocellular carcinoma (HCC). The purpose of this perspective is to review the case of ThermoDox and to address questions related to its clinical translation. Specifically, what has prevented the clinical translation of this once highly regarded breakthrough technology? Is this the end of TSLs? What can we learn from the challenges faced in the clinical development of this multi-modal therapy? As formulation scientists working in the field, we continue to believe that heat-triggered drug delivery platforms have tremendous potential as chemotherapy. Herein, we highlight potential limitations in the design of many of the Thermodox clinical trials, and we propose that despite these setbacks, TSLs have the potential to become an effective component of cancer therapy.

Active 2D-DNA Fingerprinting of WirelessHART Adapters to Ensure Operational Integrity in Industrial Systems.

The need for reliable communications in industrial systems becomes more evident as industries strive to increase reliance on automation. This trend has sustained the adoption of WirelessHART communications as a key enabling technology and its operational integrity must be ensured. This paper focuses on demonstrating pre-deployment counterfeit detection using active 2D Distinct Native Attribute (2D-DNA) fingerprinting. Counterfeit detection is demonstrated using experimentally collected signals from eight commercial WirelessHART adapters. Adapter fingerprints are used to train 56 Multiple Discriminant Analysis (MDA) models with each representing five authentic network devices. The three non-modeled devices are introduced as counterfeits and a total of 840 individual authentic (modeled) versus counterfeit (non-modeled) ID verification assessments performed. Counterfeit detection is performed on a fingerprint-by-fingerprint basis with best case per-device Counterfeit Detection Rate (%CDR) estimates including 87.6% < %CDR < 99.9% and yielding an average cross-device %CDR ≈ 92.5%. This full-dimensional feature set performance was echoed by dimensionally reduced feature set performance that included per-device 87.0% < %CDR < 99.7% and average cross-device %CDR ≈ 91.4% using only 18-of-291 features­the demonstrated %CDR > 90% with an approximate 92% reduction in the number of fingerprint features is sufficiently promising for small-scale network applications and warrants further consideration.

Considerations for Radio Frequency Fingerprinting across Multiple Frequency Channels.

Radio Frequency Fingerprinting (RFF) is often proposed as an authentication mechanism for wireless device security, but application of existing techniques in multi-channel scenarios is limited because prior models were created and evaluated using bursts from a single frequency channel without considering the effects of multi-channel operation. Our research evaluated the multi-channel performance of four single-channel models with increasing complexity, to include a simple discriminant analysis model and three neural networks. Performance characterization using the multi-class Matthews Correlation Coefficient (MCC) revealed that using frequency channels other than those used to train the models can lead to a deterioration in performance from MCC > 0.9 (excellent) down to MCC < 0.05 (random guess), indicating that single-channel models may not maintain performance across all channels used by the transmitter in realistic operation. We proposed a training data selection technique to create multi-channel models which outperform single-channel models, improving the cross-channel average MCC from 0.657 to 0.957 and achieving frequency channel-agnostic performance. When evaluated in the presence of noise, multi-channel discriminant analysis models showed reduced performance, but multi-channel neural networks maintained or surpassed single-channel neural network model performance, indicating additional robustness of multi-channel neural networks in the presence of noise.

Image-guided chest tube drainage in the management of chylothorax post cardiac surgery in children: a single-center case series.

BACKGROUND: In children, chylothorax post cardiac surgery can be difficult to treat, may run a protracted course, and remains a source of morbidity and mortality. OBJECTIVE: To analyze the experience with percutaneous image-guided chest-tube drainage in the management of post-cardiac-surgery chylothoraces in children. MATERIALS AND METHODS: We conducted a single-center retrospective case series of 37 post-cardiac-surgery chylothoraces in 34 children (20 boys; 59%), requiring 48 drainage procedures with placement of 53 image-guided chest tubes over the time period 2004 to 2015. We analyzed clinical and procedural details, adverse events and outcomes. Median age was 0.6 years, median weight 7.2 kg. RESULTS: Attempted treatments of chylothoraces prior to image-guided chest tubes included dietary restrictions (32/37, 86%), octreotide (12/37, 32%), steroids (7/37, 19%) and thoracic duct ligation (5/37, 14%). Image-guided chest tubes (n=43/53, 81%) were single unilateral in 29 children, bilateral in 4 (n=8/53, 15%), and there were two ipsilateral tubes in one (2/53, 4%). Effusions were isolated, walled-off, in 33/53 (62%). In 20/48 procedures (42%) effusions were septated/complex. The mean drainage through image-guided chest tubes was 17.3 mL/kg in the first 24 h, and 13.4 mL/kg/day from diagnosis to chest tube removal; total mean drainage from all chest tubes was 19.6 mL/kg/day. Nine major and 27 minor maintenance procedures were required during 1,207 tube-days (rate: 30 maintenance/1,000 tube-days). Median tube dwell time was 21 days (range 4-57 days). There were eight mild adverse events, three moderate adverse events and no severe adverse events related to image-guided chest tubes. Radiologic resolution was achieved in 26/37 (70%). Twenty-three children (68%) survived to discharge; 11 children (32%) died from underlying cardiac disease. CONCLUSION: Management of chylothorax post-cardiac-surgery in children is multidisciplinary, requiring concomitant multipronged approaches, often through a protracted course. Multiple image-guided chest tube drainages can help achieve resolution with few complications. Interventional radiology involvement in tube care and maintenance is required. Overall, mortality remains high.

Use of Tissue Plasminogen Activator in Abdominal Abscesses in Children-A Single-Center Randomized Control Trial.

PURPOSE: To establish the efficacy of once-per-day intracavitary tissue plasminogen activator (tPA) in the treatment of pediatric intra-abdominal abscesses. METHODS: A single-center prospective, double-blinded, randomized controlled trial of the use of intracavitary tPA in abdominal abscesses in children. Patients were randomized to either tPA-treatment or saline-treatment groups. Primary outcome was drainage catheter dwell (hours). Secondary outcomes were length of hospital stay, times to discharge, clinical and sonographic resolution, and adverse events (AEs). RESULTS: Twenty-eight children were randomized to either group (n = 14 each). Demographics between groups were not significantly different (age P = .28; weight P = .40; gender P = .44). There were significantly more abscesses in the tPA-treated group (P = .03). Abscesses were secondary to perforated appendicitis (n = 25) or postappendectomy (n = 3). Thirty-four abscesses were drained, 4 aspirated, 3 neither drained/aspirated. There was no significant difference in number of drains (P = .14), drain size (P = .19), primary outcome (P = .077), or secondary outcomes found. No procedural or intervention drug-related AEs occurred. No patient in the saline-treated group required to be switched/treated with tPA. CONCLUSION: No significant difference in the length of catheter dwell time, procedure time to discharge, or time to resolution was found. Intracavitary tPA was not associated with morbidity or mortality. The results neither support nor negate routine use of tPA in the drainage of intra-abdominal abscess in children. It is possible that a multicentre study with a larger number of patients may answer this question more definitively.

Hemodialysis Catheters in Infants: A Retrospective Single-Center Cohort Study.

PURPOSE: Evaluate technical aspects and outcomes of insertion/maintenance of hemodialysis (HD) central venous catheter (CVC) during infancy. MATERIALS AND METHODS: Single-center retrospective study of 29 infants who underwent 49 HD-CVC insertions between 2002 and 2016. Demographics, procedural, and post-procedural details, interventional radiology (IR) maintenance procedures, technical modifications, complications, and outcomes were evaluated. Technical adjustments during HD-CVC placement to adapt catheter length to patient size were labeled "modifications." CVCs requiring return visit to IR were called IR-maintenance procedures. Mean age and weight at HD-CVC insertion were 117 days and 4.9 kg. RESULTS: Of the 29 patients, 13 (45%) required renal-replacement-therapy (RRT) as neonates, 10 (34%) commenced RRT with peritoneal dialysis (PD), and 19 (66%) with HD. Fifteen nontunneled and 34 tunneled HD-CVCs were inserted while patients were ≤1 year. Technical modifications were required placing 25/49 (51%) HD-CVCs: 5/15 (33%) nontunneled and 20/34 (59%) tunneled catheters (P = .08). Patients underwent ≤6 dialysis-cycles/patient during infancy (mean 2.3), and a mean of 4.1 and 49 HD-sessions/catheter for nontunneled and tunneled HD-CVCs, respectively. Mean primary and secondary device service, and total access site intervals for tunneled HD-CVCs were 75, 115, and 201 days, respectively. A total of 26 of 49 (53%) patients required IR-maintenance procedures. Nontunneled lines had greater catheter-related bloodstream infections per 1,000 catheter-days than tunneled HD-CVCs (9.25 vs. 0.85/1,000 catheter days; P = .02). Nineteen patients (65%) survived over 1 year. At final evaluation (December 2017): 8/19 survived transplantation, 5/19 remained on RRT, 2/19 completely recovered, 1/19 lost to follow-up, and 3 died at 1.3, 2, and 10 years. CONCLUSIONS: Placement/maintenance of HD-CVCs in infants pose specific challenges, requiring insertion modifications, and IR-maintenance procedures to maintain function.

Percutaneous removal of biliary stones post-liver transplant in a pediatric patient: Case report and review of the literature.

This case report describes an 8-year-old girl who underwent a segmental LT for a primary diagnosis of citrullinemia at the age of 12 months. She presented with cholangitis secondary to stenosis of the biliary-enteric anastomosis. MRI revealed dilatation of intrahepatic bile ducts associated with multiple stones. An endoscopic approach failed to decompress the bile ducts and remove the stones. A percutaneous approach was then undertaken. After placement of a temporary external biliary drain for 12 days, a 26 French sheath was placed to access the bile ducts. Using a 14Fr flexible cystoscope, 80%-90% of the biliary stones were removed. This was followed by antegrade balloon dilatation of the biliary-enteric anastomosis. Two months later, the procedure was repeated, resulting in complete clearance of the biliary stones. An internal-external biliary drain was maintained in placed for 10 months. The patient has been asymptomatic, with no evidence of stone recurrence for 13 months after drain removal. Percutaneous biliary stone removal is commonly performed in adults with non-transplanted livers, especially in complex cases, and has also been shown to be successful in the pediatric population. However, it is rarely reported in transplanted livers in adults, and to the best of our knowledge, no pediatric cases have been reported. This case illustrates that this technique can be successfully utilized in pediatric LT patients.

Trends in Use of Electronic Health Records in Pediatric Office Settings.

OBJECTIVES: To determine the prevalence and functionalities of electronic health records (EHRs) and pediatricians' perceptions of EHRs. STUDY DESIGN: An 8-page self-administered questionnaire sent to 1619 randomly selected nonretired US American Academy of Pediatrics members in 2016 was completed by 709 (43.8%). Responses were compared with surveys in 2009 and 2012. RESULTS: The percent of pediatricians who were using EHRs increased from 58% in 2009 and 79% in 2012 to 94% in 2016. Those with fully functional EHRs, including pediatric functionality, more than doubled from 8.2% in 2012 to 16.9% in 2016 (P = .01). Fully functional EHRs lacking pediatric functionality increased slightly from 7.8% to 11.1% (P = .3), and the percentage of pediatricians with basic EHRs remained stable (30.4% to 31.0%; P < .3). The percentage of pediatricians who lacked basic EHR functionality or who reported no EHR decreased (from 53.6% to 41.0%; P < .001). On average, pediatricians spent 3.4 hours per day documenting care. CONCLUSIONS: Although the adoption of EHRs has increased, >80% of pediatricians are working with EHRs that lack optimal functionality and 41% of pediatricians are not using EHRs with even basic functionality. EHRs lacking pediatric functionality impact the health of children through increased medical errors, missed diagnoses, lack of adherence to guidelines, and reduced availability of child-specific information. The pediatric certification outlined in the 21st Century Cures Act may result in improved EHR products for pediatricians.

Experience with Compressed Gelfoam Plugs in Children during Liver Biopsies and Other IR Procedures: A Retrospective Single-Center Case Series.

PURPOSE: To analyze the experience using compressed gelfoam plugs (CGPs) in children during liver biopsies and other interventional procedures. MATERIALS AND METHODS: This was a single-center, retrospective, consecutive case series of 477 various pediatric interventional radiology procedures using CGPs (January 2012 to December 2016) performed on 397 children (209 males, 188 females; median age, 7 years [range, 9 days-17.8 years]; median weight, 18 kg [range, 2.7-141 kg]). Of 477 procedures, most (n = 371) were liver biopsies, 98 were biopsies of other organs, and 8 were non-biopsy procedures. Analysis focused on liver biopsies. RESULTS: Of liver biopsies, a median of 2 CGPs were used per procedure, and the mean drop in hemoglobin was -0.36 g/dl (-3.0% change). Thirty-seven mild, 8 moderate, 2 severe, and 1 life-threatening (an anaphylaxis to CGP) adverse events (AEs) occurred. Analysis of liver biopsies with AEs showed significant association between number of passes, cores, and focal-type lesions (unadjusted logistic regression: P = .007, P = .022, P = .028, respectively) and age, weight, and number of passes (adjusted multiple logistic regression: P = .006, P = .032, P = .046, respectively). Technical problems relating to CGP deployment were noted in 5 (1%), without any AEs. CONCLUSIONS: CGPs were used in a wide variety of procedures and organs in children. There was 1 life-threatening AE resulting from the rare risk of anaphylaxis caused by the gelfoam-containing plug. After liver biopsies, transfusion was required in 2/371 (0.5%) procedures, 1 related to pre-biopsy anemia (0.25%).

Use of the Transrectal Ultrasound Probe in Aspiration and Drainage in Pediatric Patients: A Retrospective Observational Study.

PURPOSE: To retrospectively evaluate the safety and efficacy of transrectal ultrasound (TRUS) probe use for aspiration and drainage of pelvic abscesses in children. MATERIALS AND METHODS: Patient demographics, procedural details, technical success, safety, and clinical course of TRUS procedures were retrospectively analyzed. Between 2007 and 2016, 118 TRUS-guided procedures were performed in 115 children (60 males, 55 females); median age was 12.4 years (range, 2.4-17.9 years) and median weight was 45 kg (range, 12.6-112 kg). Ten children were 5 years of age or younger. RESULTS: In total, 113/118 procedures were performed under general anesthesia. The rectum accommodated the probe and needle guide without resistance in all children (technical feasibility, 100%). Abscesses were anterior to the rectum in 116/118 and posterior in 2/118. One hundred twelve collections were drained, 4 were aspirated, and 2 procedures were aborted, both subsequently successfully drained (2 and 3 days later). One patient underwent repeat drainage after 28 months. No major complications were reported. Median times to temperature normalization was 0 days (mean, 1.2; range, 0-13 days), catheter dwell time 5 days (mean, 6; range, 2-21 days), drain removal to discharge 1 day (mean, 2; range, 0-41 days), and follow-up 117 days (mean, 195; range, 5-2,690 days). CONCLUSIONS: TRUS-guided drainage using the TRUS probe and needle guide is a safe and effective method for aspiration and drainage of pelvic abscesses in children as young as 2 years.

Evaluation of implanted venous port-a-caths in children with medical complexity and neurologic impairment.

BACKGROUND: Children with medical complexity and associated neurologic impairment frequently face difficulties with venous access. Intermittently they require urgent intravenous administration of fluids and medication. OBJECTIVE: To analyze the use of implanted port-a-caths in children with medical complexity who have neurologic impairment and difficult venous access. MATERIALS AND METHODS: We performed a single-center observational study of port-a-caths placed by interventional radiologists in children with medical complexity with neurologic impairment. We analyzed peripheral intravenous access attempts, peripheral intravenous starts, peripheral intravenous complications, alternative temporary central venous access devices, port-a-cath insertions, catheter days, access days, port-a-cath-related complications, hospital admissions and emergency department visits. We compared the year pre port-a-cath to the year post port-a-cath. RESULTS: Twenty-one children with medical complexity with neurologic impairment (10 boys, 11 girls; median age 4.1 years; median weight 13.7 kg) underwent 26 port-a-cath insertions (median catheter days 787). In the year post port-a-cath compared to pre port-a-cath there was a highly significant reduction (P<0.001) in numbers of peripheral intravenous attempts, peripheral intravenous starts and skin punctures; and a significant reduction (P<0.05) in need for other devices, number of emergency department visits, emergency department visits resulting in hospital admissions, and total admissions. Adverse events were graded as mild (n=18), moderate (n=6) and severe (n=0). CONCLUSION: Port-a-cath placement in children with medical complexity with neurologic impairment significantly reduced all peripheral intravenous attempts, peripheral intravenous starts, skin punctures, total number of emergency department visits, visits culminating in admission, and total number of inpatient admissions. Advantages must be considered against potential port-a-cath-related adverse events.

Perforations associated with peripherally inserted central catheters in a neonatal population.

BACKGROUND: Peripherally inserted central catheters (PICCs) are increasingly used in neonates but perforations can result in devastating complications such as pericardial and pleural effusions. Identifying risk factors may guide surveillance and reduce morbidity and mortality. OBJECTIVE: To determine the risk factors for PICC perforation in neonates. MATERIALS AND METHODS: Retrospective case:control (1:2) study of neonates admitted between 2004-2014. Charts and imaging were reviewed for clinical and therapeutic risk factors. RESULTS: Among 3,454 PICCs, 15 cases of perforation (incidence 0.4%, 5 pericardial effusions, 10 pleural effusions) were matched to 30 controls, based on gestation and insertion date. Timing of perforations post-insertion was median 4 days for pericardial effusions and 21.5 days for pleural effusions. A risk factor for pericardial effusion was lower weight at PICC insertion compared with controls. There were no statistically significant differences between cases and controls in catheter material, insertion site, PICC size and lumen number. Among upper limb PICCs, pericardial effusions were associated with tip positions more proximal to the heart at insertion (P=0.005) and at perforation (P=0.008), compared with controls. Pleural effusions were associated with tip positions more distal from the heart at perforation (P=0.008). Within 48 h before perforation, high/medium risk infusions included total parenteral nutrition (100% cases vs. 56.7% controls, P=0.002) and vancomycin (60% cases vs. 23.3% controls, P=0.02). CONCLUSION: PICC-associated pericardial effusions and pleural effusions are rare but inherent risks and can occur at any time after insertion. Risk factors and etiologies are multifactorial, but PICC tip position may be a modifiable risk factor. To mitigate this risk, we have developed and disseminated guidelines for target PICC positions and routinely do radiographs to monitor PICCs for migration and malposition in our NICU. The increased knowledge of risk profiles from this study has helped focus surveillance efforts and facilitate early recognition and treatment.

Increased risk of symptomatic upper-extremity venous thrombosis with multiple peripherally inserted central catheter insertions in pediatric patients.

BACKGROUND: Peripherally inserted central catheters (PICCs) are associated with superficial and deep venous thrombosis of the arm. OBJECTIVE: The purpose of this study was to analyze the sequelae of repeated upper limb PICC insertions in children, in terms of the frequency of upper limb thrombosis in this patient group. MATERIALS AND METHODS: The study population included all children who underwent their first successful arm PICC insertion between January 2010 and December 2015. We included subsequent ipsilateral arm PICCs in the analysis. Patients were followed until March 2016 or until any alternative central venous line insertion. For each PICC insertion, we collected demographic variables and line characteristics. We correlated all symptomatic deep and superficial thromboses of the arm with the PICC database. RESULTS: Applying inclusion and exclusion criteria, 2,180 PICCs remained for analysis. We identified first, second, third and fourth PICC insertions in the same arm in 1,955, 181, 38 and 6 patients, respectively. In total there were 57 upper body deep symptomatic thrombotic events. An increasing odds ratio was seen with higher numbers of PICC insertions, which was significant when comparing the first with the third and fourth PICC insertions in the same arm (odds ratio [OR] 6.00, 95% confidence interval [CI] 2.25-16.04, P=0.0004). Double-lumen PICCs were associated with a significantly higher risk of thrombosis than single lumen (OR 2.77, 95% CI 1.72-4.47, P=0.0003). CONCLUSION: Repetitive PICC insertions in the same arm are associated with an increased risk of symptomatic thrombosis. Double-lumen PICCs are associated with a higher risk of thrombosis compared to single-lumen lines.

Technique, Safety, and Yield of Bone Biopsies for Histomorphometry in Children.

PURPOSE: To evaluate image-guided bone biopsy for bone histomorphometry to assess osteoporosis in children with respect to safety and yield. MATERIALS AND METHODS: A single-center retrospective review was performed of 79 bone biopsies in 73 patients performed between 2007 and 2015. Biopsies of the iliac bone were performed under general anesthesia, after tetracycline labeling, using a Rochester needle (Medical Innovations International, Inc, Rochester, Minnesota). Ultrasound and fluoroscopic guidance were used in all procedures. Biopsy technique, technical success, safety, and histomorphometry results (complete, incomplete, none) were analyzed. RESULTS: There were 41 male patients (51.8%). Technical success was achieved in 76/79 (96%) procedures. Of 79 biopsies, 75 (95%) were uneventful. Unplanned overnight observation was required in 3 (minor SIR grade B), and prolonged hospital stay owing to hematoma causing nerve compression pain was required in 1 (major SIR grade D). Complete histomorphometric reports were obtained in 69 (87%) procedures, incomplete reports were obtained in 7 (9%), and no reports were obtained in 3(4%). Incomplete reports were insufficient to provide a definitive diagnosis or guide treatment. Histomorphometry impacted subsequent therapy in 69 (87%) biopsies. CONCLUSIONS: Image-guided bone biopsy for osteoporosis using the Rochester needle is a valuable and safe technique for establishing the diagnosis of osteoporosis and directing treatment based on histomorphometry results.

MR Lymphangiography in Children: Technique and Potential Applications.

The lymphatic system, an important component of the circulatory system with essential physiologic functions, can be affected by various disease processes. There has been a delay in the development of effective imaging methods for the lymphatic system due to its small size, which limits visualization as well as introduction of contrast material. Traditionally, the lymphatic system has been imaged by injecting contrast material or radiotracers into the feet or hands. This is not sufficient for assessment of the central conducting lymphatics (CCLs) (such as the thoracic duct or the cisterna chyli). Fluoroscopic intranodal lymphangiography with injection of oil-based contrast material into groin lymph nodes improves visualization of CCLs but is limited in practice owing to the use of radiation and the potential risk for paradoxical embolization in children with left-to-right shunt. Dynamic contrast material-enhanced (DCE) magnetic resonance (MR) lymphangiography, which is performed by injecting gadolinium-based contrast material into groin lymph nodes, overcomes these limitations. T2-weighted imaging plays a complementary role to DCE MR lymphangiography in the assessment of CCLs. DCE MR lymphangiography demonstrates preserved integrity or any abnormality of the CCLs (including blockage or leak). The technique has recently been used in evaluating pulmonary lymphatic perfusion syndrome in children with plastic bronchitis, neonatal lymphatic flow disorders, and nontraumatic chylothorax. It is useful in identification of the source of chylous ascites and contributes to understanding of the anatomy of lymphatic malformations. It is successfully used for planning of embolization of aberrant lymphatic channels in a variety of lymphatic flow disorders. This review discusses the anatomy and function of the lymphatic system, the evolution of imaging of the lymphatic system, and DCE MR lymphangiography technique and its applications in children. ©RSNA, 2017.