The beauty of pediatric musculoskeletal ultrasound.

Ultrasound is a powerful technique in pediatric imaging and musculoskeletal (MSK) imaging in many specific clinical scenarios. This article will feature some common and less common spot diagnoses in pediatric musculoskeletal ultrasound.Cases were collected by members of the Educational Committee of the ESSR (European Society of musculoSkeletal Radiology) and the Pediatric Subcommittee of the ESSR with expertise in musculoskeletal ultrasound.Fifteen clinical entities are discussed based on the features that allow diagnosis by ultrasound.Clinical history, location, and ultrasound appearance are the keys to spot diagnoses when performing pediatric musculoskeletal ultrasound. · Ultrasound in pediatric musculoskeletal imaging can achieve a diagnosis in specific clinical settings.. · Clinical history, location, and ultrasound appearance are keys to spot diagnoses.. · Knowledge of spot diagnoses in pediatric musculoskeletal ultrasound facilitates daily clinical practice..

The European Diploma in Musculoskeletal Radiology; Past, Present, and Future.

As per recommendations from the European Society of Radiology and the European Union of Medical Specialists, upon completion of level 3 radiology training, an objective assessment of the attained standards, aligned with national customs and practices, should take place. A subspecialty exam should ideally be an integral part of the training completion process. Among 10 of 13 European subspecialty societies currently offering a European subspecialty diploma, the European Society of Musculoskeletal Radiology (ESSR) diploma program was formally introduced by the ESSR in 2003. This article describes the evolution of the ESSR diploma, encompassing the current diploma program, validation procedures, endorsements, and future perspectives. Additionally, insights from a brief survey among ESSR diploma holders is shared, offering valuable tips for prospective candidates aiming to navigate the examination process successfully.

Imaging of Peripheral Nerves: AJR Expert Panel Narrative Review.

Peripheral nerve imaging provides information that can be critical to the diagnosis, staging, and management of peripheral neuropathies. MRI and ultrasound are the imaging modalities of choice for clinical evaluation of the peripheral nerves given their high soft tissue contrast and high resolution, respectively. This AJR Expert Panel Narrative Review describes MRI- and ultrasound-based techniques for peripheral nerve imaging; highlights considerations for imaging in the settings of trauma, entrapment syndromes, diffuse inflammatory neuropathies, and tumor; and discusses image-guided nerve interventions, focusing on nerve blocks and ablation.

Comparison of efficacy of ultrasound-guided platelet rich plasma injection versus dry needling in lateral epicondylitis-a randomised controlled trial.

PURPOSE: To assess whether Ultrasound guided dry needling is adequate for both common extensor tendon tears and tendinosis or whether ultrasound guided platelet rich plasma (PRP) has a superior outcome when compared to dry needling when there are tears of the common extensor tendon. MATERIALS AND METHODS: This is a single-centre, single-blinded, randomised controlled trial conducted between November 2018 and April 2020. 40 patients diagnosed with lateral epicondylitis based on clinical and sonographic features and having comparable baseline characteristics were randomly assigned to the two study groups (dry needling and PRP). Inclusion criteria were patients aged 20 years or more who were symptomatic for at least 3 months with sonographic evidence of lateral epicondylitis. Exclusion criteria were complete tear of common extensor tendon confirmed on ultrasound and presence of other associated diseases like osteoarthritis of shoulder and elbow. RESULTS: There was significant improvement in the visual analogue scale pain score in PRP group compared to the dry needling group at 9 months. However, this difference was not evident at 3 and 6 months follow-up. Mean improvement in common extensor tendon thickness in PRP group (5.1 mm at 3 months and 4.3 mm at 6 months) was slightly better than dry needling (4.4 mm at 3 months and 4.0 mm at 6 months). There was no difference in tear (if present) healing between both groups at 3 months. However at 6 months follow up, PRP demonstrated significant (mean-2.5) healing in tear compared to dry needling (mean-3.1). CONCLUSION: Two injections of Ultrasound guided PRP are more beneficial non operative treatment compared to ultrasound guided dry needling, in lateral epicondylitis.

Diagnostic accuracy of ultrasound versus X-ray for distal forearm fractures in children and adolescents: a systematic review and meta-analysis.

PURPOSE: Utilizing ultrasound for the detection of distal forearm fractures in children presents a potential safe and radiation-free alternative compared to X-ray. METHODS: A systematic review was undertaken to compare the diagnostic accuracy of ultrasound in detecting distal forearm fractures in children with X-ray imaging within the period spanning January 2010 to August 2023. The electronic databases MEDLINE and Cochrane CENTRAL were utilized for data retrieval. The QUADAS-2 tool was employed to assess the quality of the included studies. Subsequent statistical analysis was performed to calculate pooled sensitivity and specificity, positive and negative likelihood ratios, as well as the diagnostic odds ratio. RESULTS: Our meta-analysis included seventeen studies, encompassing a total of 2003 patients, 2546 ultrasound scans, and 1203 fracture cases as identified by the reference test (X-ray). The pooled sensitivity and specificity were 0.96 (95% CI: 0.93-0.98) and 0.96 (95% CI: 0.89-0.98), respectively. The positive likelihood ratio was 13.40 (95% CI: 7.97-21.50), the negative likelihood ratio was 0.06 (95% CI: 0.04-0.1), and the pooled diagnostic odds ratio was 209 (95% CI: 92.20-412.00). Our statistical analysis revealed low heterogeneity within our studied cohort. CONCLUSIONS: Our study indicates that ultrasound exhibits exceptionally high accuracy in the detection of distal forearm fractures in children and adolescents. It can be employed safely to either confirm or rule out a fracture, thus circumventing the need for potentially harmful radiation exposure in this vulnerable population. Future research endeavors should focus on establishing a universally accepted protocol for training and scanning methods to standardize practices and eliminate disparities in diagnostic procedures.

Spinal accessory nerve anatomy in the posterior cervical triangle: A systematic review with meta-analysis.

This study aimed to investigate the anatomy of the spinal accessory nerve (SAN) in the posterior cervical triangle, especially in relation to adjacent anatomical landmarks, along with a systematic review of the current literature with a meta-analysis of the data. Overall, 22 cadaveric and three prospective intraoperative studies, with a total of 1346 heminecks, were included in the analysis. The major landmarks relevant to the entry of the SAN at the posterior border of the SCM muscle (PBSCM) were found to be the mastoid apex, the great auricular point (GAP), the nerve point (NP), and the point where the PBSCM meets the upper border of the clavicle. The SAN was reported to enter the posterior cervical triangle above GAP in 100% of cases and above NP in most cases (97.5%). The mean length of the SAN along its course from the entry point to its exit point from the posterior triangle of the neck was 4.07 ± 1.13 cm. The SAN mainly gave off 1 or 2 branches (32.5% and 31%, respectively) and received either no branches or one branch in most cases (58% and 23%, respectively) from the cervical plexus during its course in the posterior cervical triangle. The major landmarks relevant to the entry of the SAN at the anterior border of the TPZ muscle (ABTPZ) were found to be the point where the ABTPZ meets the upper border of the clavicle and the midpoint of the clavicle, along with the mastoid apex, the acromion, and the transverse distance of the SAN exit point to the PBSCM. The results of the present meta-analysis will be helpful to surgeons operating in the posterior cervical triangle, aiding the avoidance of the iatrogenic injury of the SAN.

Ultrasound-guided median nerve hydrodissection of pronator teres syndrome: a case report and a literature review.

Aim of the study: To describe the sonographic appearance of pronator teres syndrome and the role of ultrasound-guided hydrodissection for its management. Case description: Pronator teres syndrome is a well-known compressive neuropathy of the median nerve between the two heads of pronator teres. However, the clinical presentation of this syndrome can be indolent with vague pain at the proximal volar forearm leading to a delay in diagnosis. We describe our experience in the management of pronator teres syndrome in a healthy young badminton player with ultrasound-guided median nerve hydrodissection. We highlight the clinical presentation, the role of dynamic Ultrasound scan (USS) in the diagnosis and effective treatment of pronator teres syndrome. Conclusions: In conclusion, managing PTS can be challenging, and this case highlights the importance of ultrasound-guided hydrodissection, when conservative measures have failed to improve the symptoms. Further studies are required to assess and compare the long-term outcomes of these interventions.

Median nerve versus flexor tendons: visualization of median nerve level changes in the proximal carpal tunnel during wrist movement with dynamic high-resolution ultrasound.

Aim: The purpose of this prospective ultrasound study was to document dorso-palmar (vertical) displacement of the median nerve in relation to the superficial flexor tendons at the level of the carpal tunnel. Furthermore, the gliding patterns of the median nerve were characterized. The presence of vertical gliding was intended to serve as an additional bio-kinematic parameter of median nerve movement, and will be referred to as a 'level change'. Material and methods: In this study, a total of 32 healthy young individuals underwent dynamic high-resolution ultrasound examinations of both wrists. The neutral position, and maximum flexion and extension of the wrist had to be reached in active and passive movement. The gliding patterns were determined in relation to the superficial flexor tendons. When no vertical nerve gliding was observed, it was characterized as 'no level change'. Results: The presence of a level change prevailed in the healthy young cohort and was observed in 84% (27/32) of individuals during wrist flexion. The following gliding pattern was distinctively the most common: gliding of the entire nerve in between the flexor tendons in active but not in passive movement of the right and left wrists (13/27; 48%). The extent of vertical displacement was found to be associated with the gliding pattern (Kruskal-Wallis test). Conclusions: Movement in the carpal tunnel allows the median nerve to adapt to biomechanical stress. Dynamic ultrasound can demonstrate median nerve level changes in response to wrist movements. Furthermore, a typical gliding pattern was characterized. The presence of level change and gliding patterns were proposed as additional movement parameters during wrist flexion in healthy individuals.

Ultrasound morphometry of the cervical vagus nerve for daily clinical practice: Reference values for cross sectional area and fascicle count.

INTRODUCTION: High resolution ultrasound (US) of the cervical vagus nerve (CVN) is clinically relevant in the diagnostic workup and during neurostimulation therapy of several neurologic diseases. This prospective study aims to provide reference data of the cross-sectional area (CSA) and fascicle count of the normal CVN and to investigate their possible association with anthropometric data in a large cohort of patients. METHODS: A total of 657 CVNs in 330 individuals without history of neurological disease were examined using US (7-15Mhz). The CVN fascicle count and CSA inside the hyperechoic epineurium at the level of the thyroid lobes were measured. Three CSA measurements were performed to calculate the mean value. Anthropometric data were recorded. RESULTS: The mean fascicle count was 2.4 ± 1.1 (right) and 2 ± 1 (left) (paired t- test, p < 0.001). Two CVN patterns were identified: A single hypoechoic fascicular structure (26.2 % right, 36.3 % left) and a honeycomb structure of 2-6 discrete fascicles (72.3 % right, 63.7 % left). Right CVN mean CSA was larger compared to left (2.3 ± 1 mm2 and 1.8 ± 0.8 mm2 respectively, t-test, p-0.000). There was no difference in the CSA values between sex and no correlation to age or height. A positive correlation between the CSA and weight and BMI was found (Pearson's correlation, p = 0.01 right and p = 0.05 left). CONCLUSION: The right CVN has larger CSA and contains more fascicles than the left. CVN is usually mono- or oligo-fascicular with a honeycomb appearance. The CSA increased with increasing BMI but no age and sex specific differences were noted.

Nerve entrapment syndromes: detection by ultrasound.

Nerve entrapment syndromes are commonly encountered in clinical practice. Accurate diagnosis and management require a knowledge of peripheral neuroanatomy and the recognition of key clinical symptoms and findings. Nerve entrapment syndromes are frequently associated with structural abnormalities of the affected nerve. Therefore, imaging allows the evaluation of the cause, severity, and etiology of the entrapment. High-resolution ultrasonography can depict early and chronic morphological changes within the entire nerve course and is therefore an ideal modality for diagnosing various nerve entrapment syndromes in different regions. This review article presents some of the most common types of nerve entrapment, with special focus on ultrasound imaging and key findings.

Investigation of Real-Time Diagnostic Ultrasound as a Means of Biofeedback Training in Transversus Abdominus Re-Education of Patients with Non-Specific Low Back Pain: A Prospective Randomized Controlled Pilot Study.

Background: It is believed that ultrasound-guided imaging of activation/contraction of the deep abdominal muscles (such as transervsus abdominis) is useful for assisting deep muscle re-education, which is often dysfunctional in non-specific low back pain (NSLBP). Thus, this pilot study aimed to evaluate the use of real-time ultrasound (US) as a feedback device for transverse abdominis (TrA) activation/contraction during an exercise program in chronic NSLBP patients. Methods: Twenty-three chronic NSLBP patients were recruited and randomly assigned to a US-guided (n = 12, 8 women, 47.6 ± 2.55 years) or control group (n = 11, 9 women, 46.9 ± 4.29 years). The same motor control-based exercise program was applied to both groups. All patients received physiotherapy twice per week for seven weeks. Outcome measures, tested at baseline and post-intervention, included Numeric Pain Rating Scale, TrA activation level (measured through a pressure biofeedback unit-based developed protocol), seven established motor control tests, Roland-Morris Disability Questionnaire and Hospital Anxiety and Depression Scale. Results: For each group, all outcome variables yielded statistical differences post-intervention (p < 0.05), indicating significant improvements. However, there were no significant group x time interactions for any of the outcomes (p > 0.05), thus, indicating no superiority of the US-guided group over the control. Conclusions: The addition of US as a visual feedback device for TrA re-education during a motor control exercise program was not proven superior to traditional physiotherapy.

Anatomical Variants of the Upper Limb Nerves: Clinical and Preoperative Relevance.

Profound knowledge of nerve variations is essential for clinical practice. It is crucial for interpreting the large variability of a patient's clinical presentation and the different mechanisms of nerve injury. Awareness of nerve variations facilitates surgical safety and efficacy. Clinically significant anatomical variations can be classified into two main groups: variability in the course of the nerve and variability of structures surrounding the nerve. In this review article we focus on the most common nerve variants of the upper extremity and their clinical relevance.

The Beauty of Musculoskeletal Ultrasound: Spot Diagnoses.

INTRODUCTION: Ultrasound is a powerful technique in musculoskeletal (MSK) imaging, and it can replace MR imaging in many specific clinical scenarios. This article will feature some common and less common spot diagnoses in musculoskeletal ultrasound. SPOT DIAGNOSIS: Cases were collected by members of the Educational Committee of the ESSR ( European Society of Musculoskeletal Radiology) with expertise in musculoskeletal ultrasound. Sixteen clinical entities are discussed based on the features that allow US spot diagnosis. CONCLUSION: Clinical history, location, and ultrasound appearance are the keys to spot diagnoses when performing musculoskeletal ultrasound. KEY POINTS: · Musculoskeletal ultrasound can be the primary and only modality in common spot diagnoses in specific clinical settings.. · Clinical history, location, and ultrasound appearance are keys to spot diagnoses.. · Knowledge of spot diagnoses in musculoskeletal ultrasound facilitates daily clinical practice.. CITATION FORMAT: · Drakonaki EE, Martinoli C, Vanhoenacker FM et al. The Beauty of Musculoskeletal Ultrasound: Spot Diagnoses. Fortschr Röntgenstr 2023; 195: 385 - 392.

Sonoanatomy of the ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves: a practical guide for US-guided injections.

The ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves are the major sensory nerves that may be involved in chronic groin and genital pain with a significant impact on the quality of life of patients. The diagnosis remains clinical, and US-guided diagnostic injections using an anesthetic may aid in confirming the clinical suspicion. The anatomy of the peripheral nerves can be successfully studied using imaging. High-resolution ultrasound is increasingly used in the clinical setting for visualizing small peripheral nerves, and magnetic resonance imaging provides an anatomical overview of the relationship between small nerves and surrounding structures. In this pictorial assay, we review the anatomy and clinical relevance of the ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves. We summarize the various techniques for ultrasound identification, and present the ultrasound-guided infiltration techniques for injecting the ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves. Corresponding magnetic resonance images and clinical photos of the probe placement technique are provided for anatomical correlation. This paper is aimed to serve as a practical technical guide for physicians to familiarize themselves with the ultrasound anatomy of the major inguinal sensory nerves and to enable successful ultrasound identification and ultrasound-guided diagnostic or therapeutic infiltrations for pain management of the ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VII, nerves of the lower limb.

OBJECTIVES: To perform a Delphi-based consensus on published evidence on image-guided interventional procedures for peripheral nerves of the lower limb (excluding Morton's neuroma) and provide clinical indications. METHODS: We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around peripheral nerves in the lower limb (excluding Morton's neuroma) to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper. RESULTS: Nine statements on image-guided interventional procedures for peripheral nerves of the lower limb have been drafted. All of them received strong consensus. Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. CONCLUSION: Despite the promising results reported by published papers on image-guided interventional procedures for peripheral nerves of the lower limb, there is still a lack of evidence on the efficacy of most procedures. KEY POINTS: • Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. • US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. • US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. The volume of local anesthetic affects the size of the blocked sensory area.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VI, foot and ankle.

OBJECTIVES: Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region. METHODS: We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around foot and ankle in order to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper that was shared with all panel members for final approval. RESULTS: A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement. CONCLUSION: According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton's neuroma, particularly using platelet-rich plasma and corticosteroids, respectively. KEY POINTS: • The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle. • Strong consensus was obtained for all statements. • The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton's neuroma and PRP for plantar fasciitis.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part V, knee.

OBJECTIVES: Interventional procedures around the knee are widely adopted for treating different musculoskeletal conditions. A panel of experts from the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the existing literature to assess the evidence on image-guided musculoskeletal interventional procedures around the knee, with the goal of highlighting some controversies associated with these procedures, specifically the role of imaging guidance, as well as the efficacy of the medications routinely injected. METHODS: We report the results of a Delphi-based consensus of 53 experts in musculoskeletal radiology, who reviewed the published literature for evidence on image-guided interventional procedures around the knee to derive a list of pertinent clinical indications. RESULTS: A list of 10 statements about clinical indications of image-guided procedures around the knee was created by a Delphi-based consensus. Only two of them had the highest level of evidence; all of them received 100% consensus. CONCLUSIONS: Ultrasonography guidance is strongly recommended for intra-articular and patellar tendinopathy procedures to ensure the precision and efficacy of these treatments. Prospective randomized studies remain warranted to better understand the role of imaging guidance and assess some of the medications used for interventional procedures around the knee. KEY POINTS: • A list of 10 evidence-based statements on clinical indications of image-guided interventional procedures around the knee was produced by an expert panel of the ESSR. • Strong consensus with 100% agreement was obtained for all statements. • Two statements reached the highest level of evidence, allowing us to strongly recommend the use of ultrasonography to guide intra-articular and patellar tendon procedures to ensure higher accuracy and efficacy of these treatments.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part IV, hip.

OBJECTIVES: Image-guided musculoskeletal interventional procedures around the hip are widely used in daily clinical practice. The need for clarity concerning the actual added value of imaging guidance and types of medications to be offered led the Ultrasound and the Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) to promote, with the support of its Research Committee, a collaborative project to review the published literature on image-guided musculoskeletal interventional procedures in the lower limb in order to derive a list of clinical indications. METHODS: In this article, we report the results of a Delphi-based consensus of 53 experts who reviewed the published literature for evidence on image-guided interventional procedures offered in the joint and soft tissues around the hip in order of their clinical indications. RESULTS: Ten statements concerning image-guided treatment procedures around the hip have been collected by the panel of ESSR experts. CONCLUSIONS: This work highlighted that there is still low evidence in the existing literature on some of these interventional procedures. Further large prospective randomized trials are essential to better confirm the benefits and objectively clarify the role of imaging to guide musculoskeletal interventional procedures around the hip. KEY POINTS: • Expert consensus produced a list of 10 evidence-based statements on clinical indications of image-guided interventional procedures around the hip. • The highest level of evidence was only reached for one statement. • Strong consensus was obtained for all statements.

Frailty and chronic respiratory disease: the need for a multidisciplinary care model.

BACKGROUND: Frailty is a state of increased vulnerability to various health stressors but little information is summarized about frailty in patients with specific chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), and asthma. OBJECTIVE: We aimed to describe the burden of frailty on patients with chronic respiratory disorders and to discuss the need for multidisciplinary care services. METHODS: PubMed and Cochrane Central databases were systematically reviewed for studies reporting outcomes associated with frailty in COPD, IPF, and asthma. Electronic databases were searched for relevant articles published in English from 2010 up to July 2020. Appraisal was carried out based on the Hierarchy of Evidence Rating System and the GRADE guidelines. RESULTS: A total of 31 articles met all inclusion criteria with 24 of them at level IV, 1 at level V, and 6 at level VI. Frailty is likely to negatively affect quality of life and to increase the risk of mortality, especially in elderly with COPD, IPF and asthma. Each disease has a particular effect on the balance between health status, respiratory impairment and frailty. A greater understanding of frailty phenotype across different ages, as well as in a range of long-term conditions, is of great necessity in both clinical and research settings. Limited conformity was observed between different methodologies and nature of chronic diseases studied, leading to a further difficulty to extract homogeneous information. CONCLUSION: Literature shows that frailty is prevalent in COPD, IPF, and asthma, after adjusting for shared risk factors. Our findings suggest that frailty should be approached as an entity per se', in order to assess real mortality risk, alongside respiratory disease severity and the presence of comorbidities. Health care professionals need knowledge, skills and multidisciplinary collaboration to buffer the impact of frailty on everyday practice.

A case of incidental infantile gallbladder adenomyomatosis: an unusual US finding of uncertain clinical significance.

Adenomyomatosis of the gallbladder is defined as hypertrophy of the gallbladder mucosal epithelium that invaginates into a thickened muscularis propria, leading to the formation of intramural diverticula. It is typically considered a benign condition most commonly affecting adults and, rarely, children. In this case report, we present a case of gallbladder adenomyomatosis in a 3-month-old infant. The diagnosis was made incidentally on ultrasound examination of the abdomen, in an otherwise asymptomatic child with no laboratory test abnormalities and no underlying disease. The purpose of this case report is to make infantile adenomyomatosis and its implications known to clinicians, as the literature on this topic is limited. To the best of our knowledge, this is the youngest reported case of adenomyomatosis in the pediatric population.