Association of Time Since Diagnosis of Pediatric Ileocolic Intussusception With Success of Attempted Reduction: Analysis in 1065 Patients.

BACKGROUND: Radiologists generally treat pediatric ileocolic intussusceptions emergently given potential worse outcomes from delayed reduction attempts. However, relevant literature is conflicting. OBJECTIVE: To identify factors associated with successful image-guided ileocolic intussusception reduction in children, with attention to the time interval since diagnosis. METHODS: This retrospective study included patients <6 years old who underwent attempted image-guided enema reduction of ileocolic intussusception between May 2009 and July 2023. Patients were separated into two groups: those presenting directly to the institution (nontransferred patients, who all underwent attempted reduction <8 hours after ultrasound diagnosis), and those transferred from outside facilities. EHR data were extracted. Each patient's first image-guided reduction attempt was classified as successful or unsuccessful. Univariable and multivariable analyses were performed. RESULTS: The study included 1065 patients (649 male, 416 female; mean age, 18.1 months; age range, 2.2-71.0 months; 793 nontransferred and 272 transferred patients). In nontransferred patients, the mean interval between ultrasound diagnosis and reduction attempt was 150.8 minutes; in transferred patients, the mean interval between outside facility advanced imaging and reduction attempt was 460.1 minutes (p<.001). Successful reduction occurred in 84.6% and 81.6% of nontransferred and transferred patients, respectively (p=.25). In nontransferred patients, success occurred in 85.6% of attempts <2 hours after diagnosis versus 84.0% of attempts 2-<8 hours after diagnosis (p=.54); the mean interval from diagnosis to attempted reduction was 149.7 minutes and 156.8 minutes for successful and unsuccessful attempts, respectively (p=.53). In multivariable analysis, factors showing independent associations with success were proximal intussusception location (OR=3.63, p<.001) and absence of high-risk ultrasound findings (OR=2.57, p<.001); success was not independently associated with age, sex, bloody stools, reduction method, or time since diagnosis <2 hours (p>.05). In transferred patients, the mean interval from outside advanced imaging to attempted reduction was 463.1 minutes and 440.2 minutes for successful and unsuccessful attempts, respectively (p=.74). CONCLUSION: Intussusception reduction may not require completion emergently (within 2 hours after diagnosis), but potentially may be safely performed on an urgent basis (within 8 hours). CLINICAL IMPACT: The findings have implications for determining the standard of care, including criteria for oncall activation of radiologic resources, in pediatric intussusception management.

MRI diagnostic performance and strategies for identifying retears in treated pediatric discoid and non-discoid lateral meniscal repairs.

Magnetic resonance imaging (MRI) plays a role in assessing retears of previously treated lateral menisci (LM). We aim to characterize the rate and pattern of arthroscopically confirmed LM retears in children with and without discoid morphology. 288 patients (312 knees) who underwent arthroscopic repair of isolated LM tears between 2018 and 2023 were identified. 20 patients (21 knees) had arthroscopically confirmed isolated LM retear. This included 11 retears of discoid lateral meniscus (DLM) and 10 retears of non-DLM. MRI correctly identified retear in 81.8% of DLM cases (n = 9) and 100% of non-DLM cases (overall 90.5%, P = 0.476). 78% of DLM cases (n = 7) had residual discoid elements. MRI is highly accurate in diagnosing retears in isolated LM injuries (90.5%). We suggest that the radiological approach to assessing meniscal retears can be similarly applied to treated discoid and non-discoid menisci. However, special attention to residual discoid elements is crucial in previously treated DLMs.

Investigating the Bone Bruise Patterns in Pediatric Patients With Contact and Noncontact Acute Anterior Cruciate Ligament Tears: A Multicenter Study.

BACKGROUND: In adults with anterior cruciate ligament (ACL) tears, bone bruises on magnetic resonance imaging (MRI) scans provide insight into the underlying mechanism of injury. There is a paucity of literature that has investigated these relationships in children with ACL tears. PURPOSE: To examine and compare the number and location of bone bruises between contact and noncontact ACL tears in pediatric patients. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Boys ≤14 years and girls ≤12 years of age who underwent primary ACL reconstruction surgery between 2018 and 2022 were identified at 3 separate institutions. Eligibility criteria required detailed documentation of the mechanism of injury and MRI performed within 30 days of the initial ACL tear. Patients with congenital lower extremity abnormalities, concomitant fractures, injuries to the posterolateral corner and/or posterior cruciate ligament, previous ipsilateral knee injuries or surgeries, or closed physes evident on MRI scans were excluded. Patients were stratified into 2 groups based on a contact or noncontact mechanism of injury. Preoperative MRI scans were retrospectively reviewed for the presence of bone bruises in the coronal and sagittal planes using fat-suppressed T2-weighted images and a grid-based mapping technique of the tibiofemoral joint. RESULTS: A total of 109 patients were included, with 76 (69.7%) patients sustaining noncontact injuries and 33 (30.3%) patients sustaining contact injuries. There were no significant differences between the contact and noncontact groups in terms of age (11.8 ± 2.0 vs 12.4 ± 1.3 years; P = .12), male sex (90.9% vs 88.2%; P > .99), time from initial injury to MRI (10.3 ± 8.1 vs 10.4 ± 8.9 days; P = .84), the presence of a concomitant medial meniscus tear (18.2% vs 14.5%; P = .62) or lateral meniscus tear (69.7% vs 52.6%; P = .097), and sport-related injuries (82.9% vs 81.8%; P = .89). No significant differences were observed in the frequency of combined lateral tibiofemoral (lateral femoral condyle + lateral tibial plateau) bone bruises (87.9% contact vs 78.9% noncontact; P = .41) or combined medial tibiofemoral (medial femoral condyle [MFC] + medial tibial plateau) bone bruises (54.5% contact vs 35.5% noncontact; P = .064). Patients with contact ACL tears were significantly more likely to have centrally located MFC bruising (odds ratio, 4.3; 95% CI, 1.6-11; P = .0038) and less likely to have bruising on the anterior aspect of the lateral tibial plateau (odds ratio, 0.27; 95% CI, 0.097-0.76; P = .013). CONCLUSION: Children with contact ACL tears were 4 times more likely to present with centrally located MFC bone bruises on preoperative MRI scans compared with children who sustained noncontact ACL tears. Future studies should investigate the relationship between these bone bruise patterns and the potential risk of articular cartilage damage in pediatric patients with contact ACL tears.

Congenital and Traumatic Conditions of the Pediatric Hand: Overview for the Radiologist.

Alignment, longitudinal growth, and function of the musculoskeletal unit of the pediatric hand is complex due to the combination of open growth plates, ossification variations, and their relationship with finger tendinous and ligamentous attachments. This review presents the basics of normal development, acquired and congenital variations, and traumatic conditions of the pediatric hand from the perspective of the pediatric musculoskeletal radiologist and hand surgeon. This multimodality imaging article focuses on non-oncologic and non-rheumatologic conditions of the pediatric hand, inclusive of fingers, thumb, and metacarpal bones.

Percent Final Height Is a Novel Method That Identifies Differences Between the Rate of Development in American Children of Different Races.

INTRODUCTION: The Greulich & Pyle (G&P) Radiographic Atlas of Skeletal Development uses hand x-rays obtained between 1926 and 1942 on children of Caucasian ancestry. Our study uses modern Caucasian, Black, Hispanic, and Asian children to investigate patterns of development as a function of percent final height (PFH). METHODS: A retrospective review, at a single institution, was conducted using children who received a hand x-ray, a height measurement taken within 60 days of that x-ray, and a final height. BA and CA were compared between races. PFH was calculated by dividing height at the time of the x-ray by their final height. To further evaluate differences between races in CA or BA, PFH was then modeled as a function of CA or BA using a fifth-degree polynomial regression, and mean ages at the 85th PFH were compared. Patients were then divided into Sanders stages 1, 2-4, and 5-8 and the mean PFH, CA, and BA of the Asian, Black, and Hispanic children were compared with the White children using Student t test. P values less than 0.05 were considered significant. RESULTS: We studied 498 patients, including 53 Asian, 83 Black, 190 Hispanic, and 172 White patients. Mean BA was significantly greater than CA in Black males (1.27 y) and females (1.36 y), Hispanic males (1.12 y) and females (1.29 y), and White females (0.74 y). Hispanic and Black patients were significantly more advanced in BA than White patients ( P <0.001). At the 85th PFH, White and Hispanic males were older than Black males by at least 7 months ( P <0.001), and White females were significantly older than Hispanic females by 6.4 months ( P <0.001). At 85th PFH for males, Hispanic and Black males had greater BA than White males by at least 5 months ( P <0.001), and Asian females had a greater BA than Black females by at least 5 months ( P <0.001). Compared with White children, Hispanic children were significantly younger at Sanders 2-4 than White children, and Black children were skeletally older at Sanders 5-8. CONCLUSIONS: BA was greater than CA by ≥1 year in Black and Hispanic children, and that these children had a significantly greater BA than their White counterparts. Black males and Hispanic females reached their 85th PFH at younger ages, and Hispanic males and Asian females were the most skeletally mature at their 85th PFH. Our results suggest that BA and CA may vary as a function of race, and further studies evaluating growth via the 85th PFH may be necessary. LEVEL OF EVIDENCE: Therapeutic Study - Level IV.

MR imaging spectrum of adolescent pubic symphyseal injuries/athletic pubalgia.

BACKGROUND: Magnetic resonance imaging (MRI) findings associated with athletic pubalgia are well documented in the adult literature. OBJECTIVE: To describe the spectrum of MRI findings in adolescents with pubic symphyseal injuries/athletic pubalgia. MATERIALS AND METHODS: This is an institutional review board approved, retrospective study of all patients < 18 years who were referred for MRI, over the last 10 years. Two pediatric musculoskeletal radiologists evaluated the MRI in consensus for the following findings: Chronic Salter-Harris (SH)-I equivalent fracture or asymmetric parasymphyseal ossific fraying, non-retractile muscular tear or retraction, and edema of the aponeurosis and arcuate ligament. Radiographs were also reviewed for Risser stage. RESULTS: Fifteen patients were identified (100% male, median age 17 years, IQR 16-17.6). Most patients (14/15, 93%) had either asymmetric parasymphyseal ossific fraying (4/15, 27%) or chronic SH-1 equivalent fracture (10/15, 67%) of the pubic symphysis, and all patients (15/15, 100%) had aponeurotic and arcuate ligament edema. Few patients had rectus abdominis muscular retraction (2/15, 13%), non-retractile muscular tear of the rectus abdominis (2/15, 13%), and/or adductor muscle (4/15, 27%). Risser stage was as follows: stages 0 (13%), 3 (7%), 4 (47%), and 5 (33%). The injuries in our limited data set were independent of skeletal maturity with no statistically significant association between any of the MRI findings and Risser stage. CONCLUSION: The MR imaging spectrum of adolescent athletic pubalgia differs from the described findings in adults due to skeletal immaturity. The cleft sign described in adults manifests in adolescents as asymmetric parasymphyseal ossific fraying and chronic SH-1 equivalent fractures.

Gartland classification concordance of supracondylar fractures among pediatric emergency medicine physicians, radiologists, and orthopedic surgeons.

BACKGROUND: The modified Gartland classification is the most widely accepted grading method of supracondylar humeral fractures among orthopedic surgeons and is relevant to identifying fractures that may require surgery. OBJECTIVE: To assess the interobserver reliability of the modified Gartland classification among pediatric radiologists, pediatric orthopedic surgeons, and pediatric emergency medicine physicians. MATERIALS AND METHODS: Elbow radiographs for 100 children with supracondylar humeral fractures were retrospectively independently graded by two pediatric radiologists, two pediatric orthopedic surgeons, and two pediatric emergency medicine physicians using the modified Gartland classification. A third grader of the same subspecialty served as a tie-breaker as needed to reach consensus. Readers were blinded to one another and to the medical record. The modified Gartland grade documented in the medical record by the treating orthopedic provider was used as the reference standard. Interobserver agreement was assessed using kappa statistics. RESULTS: There was substantial interobserver agreement (kappa = 0.77 [95% CI, 0.69-0.85]) on consensus fracture grade between the three subspecialties. Similarly, when discriminating between Gartland type I and higher fracture grades, there was substantial interobserver agreement between specialties (kappa = 0.77 [95% CI, 0.66-0.89]). The grade assigned by pediatric radiologists differed from the reference standard on 15 occasions, pediatric emergency medicine differed on 19 occasions, and pediatric orthopedics differed on 9 occasions. CONCLUSION: The modified Gartland classification for supracondylar humeral fractures is reproducible among pediatric emergency medicine physicians, radiologists, and orthopedic surgeons.

Clinical impact of diagnostic image-guided injections for musculoskeletal pain work-up in adolescent and adult patients at a children's hospital: initial results.

OBJECTIVE: To assess the clinical impact of diagnostic musculoskeletal (MSK) injections on treatment decision-making in adolescent and adult patients at a children's hospital. MATERIALS AND METHODS: Retrospective study in patients who underwent diagnostic MSK injections by fluoroscopy or ultrasound (US) between 8/2020 and 3/2023 at a children's hospital. Patients received ropivacaine and triamcinolone acetonide at pain site, reporting quantitative FACES pain score prior to, immediately following, and 2-3 days following injection. Impact on patient care was subsequently assessed. RESULTS: A total of 109 diagnostic fluoroscopic or US MSK injection referrals (mean: 17.6 years old) were included, most commonly hip (76.2%), ankle (9.2%), and iliopsoas tendon sheath (8.3%). Pain improvement occurred in 89.0% immediately and 67.9% 2-3 days after MSK injection, with net 84.4% exhibiting improvement based on pain scores and clinical exams. When there was pain improvement at the site of injection, there was a statistically higher incidence of operative intervention or additional therapeutic injections compared with the cohort that did not have symptom improvement (88% versus 35.3%, P < 0.0001). For the 15.6% (N = 17) of referrals that did not have pain improvement, 17.6% (n = 3) ultimately had an operative intervention at a separate site from the diagnostic injection, as an alternative etiology for the pain was found. CONCLUSION: Image-guided MSK injections play an important role in the management of musculoskeletal disorders. 84.4% of referrals experienced symptom relief, improving confidence for treatment decision-making. Importantly, 15.6% of patients were found to have an alternative etiology for symptoms, altering management altogether.

How Reliable Is the Measurement of the Lateral Center Edge Angle on Scoliosis Radiographs for Detecting Acetabular Dysplasia?

PURPOSE: Hip dysplasia reportedly occurs in up to 12% of the general population and may be higher in patients with adolescent idiopathic scoliosis (AIS). When using lateral center edge angle (LCEA) measurements to help identify hip dysplasia, it is uncertain if this measurement can be performed reliably on scoliosis radiographs due to parallax. The purpose of this study is to evaluate the reliability of measuring LCEA on scoliosis radiographs compared with standard pelvis radiographs. METHODS: This study evaluated 40 hips on 20 patients (mean age 12.5 years ± 3.1; 50% Female) who received PA scoliosis radiographs and AP pelvis radiographs within 1 year of each other. Review was performed by 4 pediatric radiologists (2 general, 2 MSK), 2 pediatric orthopaedic surgeons, and 1 research fellow. Radiographic measurement of the LCEA for each hip was first performed on the scoliosis radiograph. After a minimum of 3 days, the LCEA was measured on a pelvis radiograph of the same individual obtained within 1 year of the scoliosis radiograph. Pearson coefficient was used to measure agreement between scoliosis and pelvis radiograph measurements. Intraclass correlation coefficient (ICC) was used to evaluate intraobserver and interobserver agreement. ICC values <0.5 were classified as poor reliability, 0.5 to 0.75 were classified moderate, 0.75 to 0.90 were classified good, and >0.9 indicated excellent reliability. RESULTS: The mean difference between scoliosis and pelvis radiographs was 54 ± 79 days. There was good-to-excellent interobserver agreement on LCEA measurements made between readers on scoliosis radiographs (ICC: 0.94, 95% CI: 0.90-0.96, P <0.001) and pelvis radiographs (ICC: 0.91, 95% CI: 0.83-0.95, P <0.001), and moderate-to-excellent intraobserver agreement for scoliosis radiographs (ICC range: 0.68 to 0.98; P <0.001) and pelvis radiographs (ICC range: 0.62 to 0.96; P <0.001). There was a strong correlation between LCEA measurements made on scoliosis and pelvis radiographs ( r2 =0.66, P <0.001), and the intermodality agreement between scoliosis and pelvis radiograph LCEA measurements were moderate to good (ICC range: 0.68 to 0.89, P <0.001). CONCLUSIONS: Overall, there was good-to-excellent agreement between readers on scoliosis and pelvis radiographs, respectively, and moderate-to-excellent intraobserver agreement between LCEA measurements made on scoliosis radiographs and pelvis radiographs, respectively. LCEA measurements made on scoliosis radiographs strongly correlated to the measurements made on pelvis radiographs, and the intermodality ICC was also considered moderate to good. Dedicated pelvis radiographs may not be necessary during scoliosis workup and follow-up surveillance, thereby decreasing radiation exposure, cost, and improving patient care workflow. LEVEL OF EVIDENCE: Level IV-diagnostic study.

The Gartland classification for expediting supracondylar humerus fracture triage: a collaborative approach to structured reporting between pediatric radiologists and orthopedists.

BACKGROUND: The modified Gartland classification is an important tool for evaluation of pediatric supracondylar humerus fractures (SCHF) because it can direct treatment decisions. Gartland type I can be managed outpatient, while emergent surgical consult occurs with type II and III. This study assesses the interobserver reliability of the Gartland classification between pediatric radiologists and orthopedic providers. METHODS: A retrospective review of 320 children diagnosed with a SCHF at a single tertiary children's hospital during 2022 was conducted. The Gartland classification documented in the radiographic report by a pediatric radiologist and the classification documented in the first encounter with an orthopedic provider was collected. Kappa value was used to assess interobserver reliability of classifications between radiologists and orthopedic providers. A second group of 76 Gartland type I SCHF from 2015, prior to our institution's implementation of structured reporting, was reviewed for comparison of unnecessary orthopedic consults at initial presentation. RESULTS: The Gartland classification has excellent interobserver reliability between radiologists and orthopedic providers with 90 % (289/320) agreement and kappa of 0.854 (confidence interval: 0.805-0.903). The most frequent disagreement that occurred was fractures classified as type II by radiology and type III by orthopedics. There were similar rates of consults for the 2015 and 2022 cohorts (p = 0.26). CONCLUSION: The Gartland classification system is a reliable and effective tool for communication between radiologists and orthopedic providers. Implementing a structured reporting system has the potential to improve triage efficiency for SCHF.

[Long-term outcomes of intravascular ultrasound-guided drug-eluting stents implantation in patients with acute coronary syndrome: ULTIMATE ACS subgroup].

Objective: To explore the long-term effects of intravascular ultrasound (IVUS) guidance on patients with acute coronary syndrome (ACS) undergoing drug-eluting stents (DES) implantation. Methods: Data used in this study derived from ULTIMATE trial, which was a prospective, multicenter, randomized study. A total of 1 448 all-comer patients were enrolled between 2014 August and 2017 May. Primary endpoint of this study was target vessel failure (TVF) at 3 years, including cardiac death, target-vessel-related myocardial infarction, and clinically-driven target vessel revascularization. Results: ACS was present in 1 136 (78.5%) patients, and 3-year clinical follow-up was available in 1 423 patients (98.3%). TVF in the ACS group was 9.6% (109/1 136), which was significantly higher than 4.5% (14/312) in the non-ACS group (log-rank P=0.005). There were 109 TVFs in the ACS patients, with 7.6% (43/569) TVFs in the IVUS group and 11.6% (66/567) TVFs in the angiography group (log-rank P=0.019). Moreover, patients with optimal IVUS guidance were associated with a lower risk of 3-year TVF compared to those with suboptimal IVUS results (5.4% (16/296) vs. 9.9% (27/273),log-rank P=0.041). Conclusions: This ULTIMATE-ACS subgroup analysis showed that ACS patients undergoing DES implantation were associated with a higher risk of 3-year TVF. More importantly, the risk of TVF could be significantly decreased through IVUS guidance in patients with ACS, especially in those who had an IVUS-defined optimal procedure.

Musculoskeletal injections for palliative treatment of neuromuscular hip dysplasia patients: how I do it.

This review describes our institution's standardized technique as well as potential pitfalls for therapeutic steroid injections in children with symptomatic neuromuscular hip dysplasia. Symptomatic, painful neuromuscular hip dysplasia can dramatically affect quality of life. Steroid injections are used to identify the source of perceived pain, temporarily treat pain while awaiting surgical intervention, or for therapeutic management for nonoperative hip joints.

Medial meniscal posterior horn tears and ramp lesions in pediatric patients: lessons learned.

Meniscal injuries are increasingly reported in pediatric patients due to early sports participation and are commonly encountered during anterior cruciate ligament reconstruction. Preoperative identification of meniscal tears is crucial, particularly when involving the posteromedial meniscocapsular junction (ramp lesion). MRI plays an important role in detecting this particular type of meniscal injury. Consequently, pediatric radiologists should be aware of particular MRI findings related to ramp lesions including the presence of a medial meniscal tear, peripheral meniscal irregularity, meniscocapsular junctional fluid-like signal intensity, and capsular ligament tears. Thus, we illustrate the lessons we have learned from our institutional multidisciplinary arthroscopic-MR correlation conference for retrospectively identified posterior horn medial meniscal tears and ramp lesions.

How Often Do Patients Presenting With Severe Adolescent Idiopathic Scoliosis Have Underlying Hip Dysplasia?

INTRODUCTION: Adolescent idiopathic scoliosis radiographic screening will often include the hips. The purpose of this study is to evaluate the prevalence of hip dysplasia by lateral center edge angle (LCEA) on scoliosis radiographs in patients presenting with severe range (>45 deg) idiopathic curves. METHODS: We reviewed 200 consecutive patients (400 hips) with idiopathic scoliosis with major coronal curves ≥45 degrees between October 2009 and October 2022. The presenting scoliosis radiograph PA were reviewed for the following variables: major coronal curve direction, coronal balance, and lateral center edge angles. An LCEA value ≤18 was considered dysplastic. To assess potential measurement variability related to parallax of the scoliosis radiographs, the intermodality intraclass correlation coefficient (ICC) was measured from a subset of 20 hip LCEA values from patients with both scoliosis and pelvis radiographs. RESULTS: A total of 200 patients [mean age: 13.6 (1.8) years; Female: 79%] were reviewed. The mean major curve (SD) was 58.6 degrees (11.4 deg). Overall 19% (37/200) patients or 11% (43/400) of hips had hip dysplasia. Of the dysplastic hips, 16% (6/43, P <0.001) were bilateral and 57% (21/43, P =0.04) were right sided. There was no association between dysplastic hip laterality and ipsilateral or contralateral coronal balance ( P =0.26) or curve direction ( P =0.49). The interobserver ICC for assessment of LCEA on scoliosis radiographs was 0.85, and the intermodality ICC between pelvic and scoliosis radiographs was 0.78. CONCLUSION: Hip dysplasia was present in 19% of patients presenting with large major curves, and many of these patients had right sided hip dysplasia. There was no association between hip dysplasia laterality and the patient's major curve direction or coronal balance. There was good intermodality reliability (ICC=0.78) between LCEA values in patients who had both scoliosis and pelvis radiographs, and good inter-rater reliability between raters. Radiographic interpretation of adolescent idiopathic scoliosis should focus not only on the description of the curve and ruling out underlying segmentation anomalies but should also include critical assessment of the hips to exclude co-existing hip dysplasia. LEVEL OF EVIDENCE: Therapeutic study-level IV.

Improved Identification of Adolescent Hip Dysplasia Using a Screening Method Based on Lateral Center Edge Angle Measurements.

BACKGROUND: In addition to the clinical exam, several quantitative measurement tools are performed on pelvic radiographs in the assessment of adolescent hip dysplasia at most dedicated pediatric hip preservation clinics, with the most commonly used measurement called the lateral center edge angle (LCEA). However, most pediatric radiologists do not use these quantitative measuring tools and instead make the diagnosis of adolescent hip dysplasia based on subjective review. OBJECTIVE: The purpose of this study is to determine the additive value of a measurement-based diagnosis of adolescent hip dysplasia using LCEA versus subjective radiographic interpretation by pediatric radiologists. METHODS: A review of pelvic radiographs for the binomial diagnosis of hip dysplasia was performed by four pediatric radiologists (two general, two musculoskeletal). The review included 97 pelvic AP radiographs (mean age 14.4 years [range 10-20 years], 81% female) for a total of 194 hips (58 cases of adolescent hip dysplasia and 136 normal) all of whom were evaluated in a tertiary care pediatric subspecialty hip preservation clinic. Subjective radiographic interpretation of each hip for a binomial diagnosis of hip dysplasia was performed. 2 weeks later and without knowledge of the subjective radiographic interpretation results, the same review was performed with LCEA measurement and a diagnosis of hip dysplasia made when LCEA angles were under 18 degrees. A comparison of sensitivity/specificity between methods per reader was conducted. A comparison of accuracy between methods for all readers combined was performed. RESULTS: For all four reviewers, the sensitivity of subjective versus LCEA measurement-based diagnosis of hip dysplasia was 54-67% (average 58%) versus 64-72% (average 67%), respectively, and specificity was 87-95% (average 90%) versus 89-94% (average 92%), respectively. All four readers demonstrated an intra-reader trend for improvement in the diagnosis of adolescent hip dysplasia after the addition of LCEA measurements but was only statistically significant in one of the four readers. The combined accuracy of all four readers for subjective and LCEA measurement-based interpretation was 81% and 85%, respectively with p = 0.006. CONCLUSION: Compared with subjective interpretation, LCEA measurements demonstrate increased diagnostic accuracy amongst pediatric radiologists for the correct diagnosis of adolescent hip dysplasia.

Should isolated superolateral Hoffa's fat pad edema identified by MRI be reported or ignored in adolescent patients?

BACKGROUND AND OBJECTIVE: The presence of superolateral Hoffa's fat pad (SHFP) edema is associated with several morphometric measurements related to patellar alignment and trochlear morphology. Our aim is to evaluate management implications in adolescent patients with isolated superolateral Hoffa's fat pad edema on MRI. MATERIALS AND METHODS: Retrospective review of 117 adolescents with knee MRI (mean 14.8 years old) with isolated superolateral Hoffa's fat pad edema. Patients with edema were separated into two groups based on the number of MRI axial slices involved with edema: group 1 (G1) of 27 patients with 1 slice vs group 2 (G2) of 90 patients with 2 or more slices. A comparison control group was used (45 patients who had normal MRI knees). Data points included % referral for physical therapy (PT) or surgery, Hoffa's fat pad edema, tibial tubercle-trochlear groove (TT-TG) distance and lateral trochlear inclination (LTI) angle. Fisher's exact and independent t-tests, ANOVA and regression models were used for statistical analysis. RESULTS: There is statistically significant difference between Hoffa's fat pad edema patients and control regarding PT referral with G1: 70%, G2: 76%, and control: 53% (p = 0.03). There is statistically significant difference between these groups regarding TT-TG measurements with higher values in edema groups; G1: 11.9 mm±4.1, G2 13 mm ±4.1, and control 8.7 mm±3.6, (p = 0.001). There was a statistically significant association between edema and increased TT-TG distance (p = 0.001) but not LTI angle (p = 0.2). CONCLUSION: MRI identification of isolated superolateral Hoffa's fat pad edema is positively associated with TT-TG distance and its presence is associated with higher referral rates to physical therapy for patella maltracking.

Too hot to defend: a tale of salicylic acid.

Extreme temperatures threaten plant immunity by suppressing the salicylic acid (SA) biosynthesis via unknown mechanisms. Kim et al. demonstrated that suppression of the SA pathway and plant immunity can be rescued by optimised expression of two master immune regulator(s), advancing our prospects for better protecting plants in a warming climate.

[Outcomes at discharge of preterm infants born <34 weeks' gestation].

Objective: To investigate the incidence and trend of short-term outcomes among preterm infants born <34 weeks' gestation. Methods: A secondary analysis of data from the standardized database established by a multicenter cluster-randomized controlled study "reduction of infection in neonatal intensive care units (NICU) using the evidence-based practice for improving quality (REIN-EPIQ) study". This study was conducted in 25 tertiary NICU. A total of 27 192 infants with gestational age <34 weeks at birth and admitted to NICU within the first 7 days of life from May 2015 to April 2018 were enrolled. Infants with severe congenital malformation were excluded. Descriptive analyses were used to describe the mortality and major morbidities of preterm infants by gestational age groups and different admission year groups. Cochran-Armitage test and Jonckheere-Terpstra test were used to analyze the trend of incidences of mortality and morbidities in 3 study-years. Multiple Logistic regression model was constructed to analyze the differences of outcomes in 3 study-years adjusting for confounders. Results: A total of 27 192 preterm infants were enrolled with gestational age of (31.3±2.0) weeks at birth and weight of (1 617±415) g at birth. Overall, 9.5% (2 594/27 192) of infants were discharged against medical advice, and the overall mortality rate was 10.7% (2 907/27 192). Mortality for infants who received complete care was 4.7% (1 147/24 598), and mortality or any major morbidity was 26.2% (6 452/24 598). The incidences of moderate to severe bronchopulmonary dysplasia, sepsis, severe intraventricular hemorrhage or periventricular leukomalacia, proven necrotizing enterocolitis, and severe retinopathy of prematurity were 16.0% (4 342/27 192), 11.9% (3 225/27 192), 6.8% (1 641/24 206), 3.6% (939/25 762) and 1.5% (214/13 868), respectively. There was a decreasing of the overall mortality (P<0.001) during the 3 years. Also, the incidences for sepsis and severe retinopathy of prematurity both decreased (both P<0.001). However, there were no significant differences in the major morbidity in preterm infants who received complete care during the 3-year study period (P=0.230). After adjusting for confounders, infants admitted during the third study year showed significantly lower risk of overall mortality (adjust OR=0.62, 95%CI 0.55-0.69, P<0.001), mortality or major morbidity, moderate to severe bronchopulmonary dysplasia, sepsis and severe retinopathy of prematurity, compared to those admitted in the first study year (all P<0.05). Conclusions: From 2015 to 2018, the mortality and major morbidities among preterm infants in Chinese NICU decreased, but there is still space for further efforts. Further targeted quality improvement is needed to improve the overall outcome of preterm infants.

[Comparison of clinical features between sporadic pancreatic neuroendocrine tumors and those associated with multiple endocrine neoplasia type 1].

Objective: To compare the clinical features of multiple endocrine adenoma type 1 (MEN-1) associated pancreatic neuroendocrine neoplasms (pNENs) as well as sporadic pNENs. Methods: The clinical data of 28 sporadic pNENs patients and 10 MEN-1-related pNENs patients admitted to the First Affiliated Hospital of Nanjing Medical University from January 2010 to June 2021 were collected. Meanwhile, by searching PubMed database and reviewing the clinical data of 20 foreign patients with MEN-1-related pNENs which were reported at the same time.Compare and analyze the similarities and differences between MEN1-associated pNENs and sporadic pNENs in clinical features, such as family history, blood tests, pathological diagnostic indicators, tumor grade, stage and metastasis, treatment and prognosis and so on. Results: A total of 58 pNENs patients were included, and there were 30 MEN1-related pNENs patients and 28 sporadic pNENs patients. Eighteen patients (60%) had a family history of MEN1-related pNENs, and the mean age of onset was (35.3±13.0)years. There were no patients (0) with family history of sporadic pNENs, and the mean age of onset was(55.3±13.4)years. In contrast, the differences in family history, age of onset and NSE were statistically significant(all P<0.05).Among the pathological diagnostic indicators, there were 19 patients (63.3%) with Grade G2 of MEN1-related pNENs, and 25 patients (83.3%) with somatostatin receptor 2(SSTR2) negative. In sporadic pNENs, there were 16 patients (57.1%) with Grade G2 and 9 patients (32.1%) with SSTR2 negative. The differences in pathological grade, immunohistochemistry (Chromogranin A, CD56, and somatostatin receptor 2, SSTR2) between the two groups were statistically significant(all P<0.05). In terms of tumor staging and metastasis, 21 patients with MEN-1-related pNENs had metastasis (70%) and 20 patients with stage Ⅰ and Ⅱ AJCC (71%) in all. Eight patients with sporadic pNENs had metastasis (26.7%) and 8 patients were with stage Ⅰ and Ⅱ AJCC (28.6%). By contrast, the differences in total metastasis rate, AJCC stage and distant metastasis between the two groups were statistically significant(all P<0.05). In terms of treatment and prognosis, there was no statistical significance in the differences between surgical treatment and prognosis (P>0.05), and the difference was also not statistically significant in survival rate between them (P>0.05). Conclusions: There are no significant differences between MEN1-related pNENs and sporadic pNENs in terms of treatment, prognosis, and survival rate, but there are significant differences in clinical features, pathological features and the staging and grading of tumors. The rate of tumor grade, stage and metastasis of sporadic pNENs is higher.

CT imaging of esophageal foreign bodies in children: a pictorial essay.

Foreign body (FB) ingestion is common in children, particularly from 6 months to 3 years of age. As young children may be unable to provide a clinical history and the ingestion is often unwitnessed, imaging plays an important role in diagnosis, predicting outcomes and detecting complications that require surgical intervention. Since 2015, our institution's diagnostic algorithm for suspected airway foreign bodies has included a noncontrast airway FB CT (FB-CT) with the z-axis coverage spanning from the larynx to the proximal segmental bronchi of the lower lung zones. The effective dose of radiation from this FB-CT airway protocol is typically less than 1 mSv, compared to an effective dose of just under 1 mSv to up to 3 mSv for a fluoroscopic esophagram in children under 10 years of age and 1-3 mSv for a routine pediatric CT chest. In using the FB-CT airway protocol at our institution, we observed that esophageal rather than airway FBs were sometimes encountered on these exams. However, the confidence among radiologists for definitively diagnosing an esophageal foreign body on noncontrast CT was variable. Consequently, we created a teaching module of positive cases for our group of 21 pediatric body radiologists to increase their diagnostic confidence. This pictorial essay illustrates our institutional experience and can help others to confidently diagnose esophageal foreign bodies using a dedicated CT foreign body imaging protocol. At a similar radiation dose to a fluoroscopic esophagram, CT provides the additional advantage of an expedited diagnosis without the need for a radiologist on site.