Immediate chest radiograph interpretation by radiographers improves patient safety related to nasogastric feeding tube placement in children.

BACKGROUND: Despite the publication of a national patient safety alert in 2016, inadvertent feeding through misplaced nasogastric tubes continues to occur, either through failure to review the radiograph, misinterpretation of it, or failure to communicate the results. OBJECTIVE: The objectives were to determine whether training in a new pathway introduced to avoid these "never events" was followed and whether radiographer comments and prompt communication of results could reduce risk and improve patient safety in relation to nasogastric tube placement in children. MATERIALS AND METHODS: Following radiographer training in interpretation of nasogastric tube position and use of a commenting proforma and communication pathway, we reviewed all radiographs obtained to check nasogastric tubes performed over a 13-month period in children 0-16 years of age. Then we assessed accuracy of the radiographer comments, adherence to the pathway, and any practice change in children with misplaced nasogastric tubes. RESULTS: We reviewed 282 nasogastric tube check radiographs. For 262 radiographs (92.9%) the pathway was followed correctly. Of the total 282 radiographs, 240 (85%) were immediately reported using the standardised commenting proforma, and 235 radiographer comments were affirmed by the radiologist (97% accuracy, confidence interval 0.95-0.99). Of the immediately reported radiographs, 213 (88.8%) nasogastric tubes were considered to be safe for use. Four (1.7%) of the immediately reported nasogastric tubes were misplaced in a bronchus, and the report communicated to the clinical team resulted in removal or re-siting of the tubes. CONCLUSION: Nasogastric tube check radiographs in children can be reported accurately by radiographers trained in their interpretation and the results promptly communicated to clinical staff, improving safety in relation to nasogastric tube placement in children.

Whole-body MRI in the diagnosis of paediatric CNO/CRMO.

Chronic recurrent multifocal osteomyelitis (CRMO) is an auto-inflammatory disorder affecting the skeleton of children and adolescents. Whole-body MRI (WBMRI) is key in the diagnosis and follow-up of CRMO. Imaging protocols should include sagittal short Tau inversion recovery of the spine, imaging of the hands and feet, and T1 images for distinguishing normal bone marrow. CRMO lesions can be metaphyseal, epiphyseal and physeal-potentially causing growth disturbance and deformity. Spinal lesions are common, important and can cause vertebral collapse. Lesion patterns include multifocal tibial and pauci-focal patterns that follow a predictable presentation and course of disease. Common pitfalls of WBMRI include haematopoietic marrow signal, metaphyseal signal early on in bisphosphonate therapy and normal high T2 signal in the hands and feet. Pictorial reporting assists in recording lesions and follow-up over time. The purpose of this paper is to review the different WBMRI protocols, imaging findings, lesion patterns and common pitfalls in children with CRMO.

Introduction of a novel magnetic resonance imaging-based scoring system for assessing disease activity in children with juvenile dermatomyositis.

Objectives: We aimed to develop and assess the reliability of a novel MRI-based scoring system for reporting the severity of MRI findings in children with suspected JDM. Methods: Nine consultant paediatric radiologists independently assessed and scored 40 axial and 30 coronal thigh MR images of children with suspected JDM on two occasions using the juvenile dermatomyositis magnetic resonance Imaging Score (JIS). JIS was calculated for both reads for each plane and each limb, with possible scores ranging from 0 (normal) to 100 (severe). Inter- and intraobserver agreement was calculated using the intraclass correlation coefficient (ICC) and two- and one-way random effects models, respectively. Bland-Altman plots of the difference in JIS against the average JIS were also produced for each rater. Results: Overall, the interobserver reliability and agreement was good-for axial images, JIS ranged from 46.8 to 61.0 [ICC = 0.88 (95% CI: 0.82, 0.92)] for the left limb and 47.9-61.4 [ICC = 0.87 (95% CI: 0.81, 0.92)] for the right limb. For coronal images, JIS ranged from 56.7 to 65.1 [ICC = 0.90 (95% CI: 0.85, 0.95)] for the left limb and 55.7 to 66.8 [ICC = 0.90 (95% CI: 0.84, 0.94)] for the right limb. The intraobserver reliability and agreement was good, with ICC ranging from 0.90 to 0.94. Conclusion: JIS is a semi-objective scoring system with potential to serve as a reliable biomarker of disease severity and response to therapeutic interventions in children with JDM.

Sonographic features of umbilical catheter-related complications.

Umbilical catheters are commonly used in the neonatal period for blood sampling or for administering medication or parenteral nutrition. The position of the catheter is usually confirmed with radiography. However, many complications associated with the use of umbilical catheters, such as liver collections from extravasation or vascular thrombosis, are not apparent on radiographs but can be easily diagnosed with ultrasound. This pictorial review illustrates the sonographic findings of complications that should be excluded in the sick neonate with an indwelling catheter.

Bowing fracture of the inferior angle of the scapula, a difficult diagnosis.

A 4-year-old boy presented with swelling over the inferior tip of the scapula and an unclear history. Initial radiographic findings were concerning for an aggressive lesion. This case highlights how a multimodality imaging approach was used to relieve uncertainty by diagnosing a paediatric bowing type fracture of the scapular tip.

Primary hypertrophic osteoarthropathy: ultrasound and MRI findings.

Primary hypertrophic osteoarthropathy is a rare genetic disorder related to failures in prostaglandin metabolism. Patients present with joint pain, limb enlargement, skin thickening and finger clubbing. Radiographs show characteristic periosteal reaction and thickening along the long bones. We present MRI and US findings in a child with the condition. Ultrasound showed echogenic tissue surrounding the long bones, presumably reflecting oedema and inflammatory tissue. Doppler sonograms demonstrated increased vascularity on the surface of some superficial bony structures.

Delayed presentation of a caecal haematoma initially managed as appendicitis.

A 15-year-old boy with caecal haematoma required a right hemicolectomy due to development of small bowel obstruction and near caecal perforation having presented several days after an episode of minor trauma. The position of the caecum between intraperitoneal and extraperitoneal bowel requires special treatment considerations. This is a unique case in an adolescent because caecal haematoma usually presents acutely with abdominal pain.

Renal lymphangiomatosis, interrupted IVC with persistent primitive hepatic venous plexus and multiple anomalous venous channels: parts of an overlap syndrome?

A 5-year-old girl with cutis marmorata telangiectasia congenita (CMTC) and congenital glaucoma, who had previously presented with seizures, transient hemiplegia, upper gastrointestinal bleeding and hemihypertrophy, developed a large pleural effusion. Subsequent imaging revealed renal lymphangiomatosis, multiple anomalous intra-abdominal venous channels, an interrupted inferior vena cava with a persistent primitive hepatic venous plexus (PPHVP) and meningeal angiomas. To the best of our knowledge, the CT findings of PPHVP and the combination of the demonstrated abnormalities have not been previously reported. They may represent an overlap syndrome of CMTC, Sturge-Weber syndrome and Klippel-Trenaunay syndrome. The complexity and degree of overlap highlights the importance of an accurate clinical and anatomical description and good communication among clinicians.

US and MRI of a pharyngeal hairy polyp with pathological correlation.

Hairy polyps are uncommon developmental malformations of the oropharynx. They are frequently pedunculated and can cause respiratory distress in the neonate. Hairy polyps are usually diagnosed with MRI but can be well seen at US. To our knowledge, the sonographic features have not been previously reported.

Sonography of renal venous thrombosis in neonates and infants: can we predict outcome?

BACKGROUND: The relationship between sonographic features of renal venous thrombosis (RVT) and outcome has not been described in a large series of patients. OBJECTIVE: To analyze sonographic findings of RVT and their evolution in a large series of patients and to attempt to identify features that might predict outcome. MATERIALS AND METHODS: Retrospective analysis of sonograms and medical records of neonates and infants diagnosed with RVT during the period 1998-2007. RESULTS: Of 22 children (mean age: 3 days; age range: 0-107 days), RVT was bilateral in 12. Of 34 affected kidneys, thrombus in the main renal vein was seen in 17 and typical RVT sonographic findings without main renal vein thrombus were seen in the remaining 17. All children had US follow-up (range: 0.6-97.2 months). Three children with bilateral RVT died. Nine kidneys atrophied. Imaging findings associated with subsequent kidney atrophy included markedly reduced perfusion at diagnosis, subcapsular collections, patchy cortical echotexture and profoundly hypoechoic and irregular renal pyramids. Six patients (eight kidneys) presented with renal calcifications on initial sonogram before 7 days of life, suggesting antenatal RVT. CONCLUSION: Sonography is useful in neonatal and early infant RVT and might help predict renal atrophy. Antenatal RVT appears to be relatively common.

Ultrasound of the adrenal gland in children.

Ultrasound is the modality of choice in the evaluation of neonates and young children with suspected adrenal lesions including adrenal haemorrhage and congenital adrenal hyperplasia. It is also the initial imaging modality in children presenting with an upper abdominal mass, which may be adrenal in origin. Topic discussion: This paper shows adrenal anatomy and demonstrates how the sonographic features change with age. It reviews the imaging features of congenital adrenal lesions, as well as benign and malignant conditions affecting the adrenal gland in childhood. Discussion and Conclusion: Ultrasound is a useful primary imaging modality in the assessment of the adrenal gland in children. Knowledge of the changes of the adrenal gland with age is important when assessing the adrenal gland. Ultrasound is also useful for assessing abdominal masses. However, it cannot differentiate adrenal masses, therefore correlation with biochemical findings, multimodality imaging, and histology is usually required.

Surgical management of symptomatic osteonecrosis and utility of core decompression of the femoral head in young people with acute lymphoblastic leukaemia recruited into UKALL 2003.

AIMS: Osteonecrosis (ON) can cause considerable morbidity in young people who undergo treatment for acute lymphoblastic leukaemia (ALL). The aims of this study were to determine the operations undertaken for ON in this population in the UK, along with the timing of these operations and any sequential procedures that are used in different joints. We also explored the outcomes of those patients treated by core decompression (CD), and compared this with conservative management, in both the pre- or post-collapse stages of ON. METHODS: UK treatment centres were contacted to obtain details regarding surgical interventions and long-term outcomes for patients who were treated for ALL and who developed ON in UKALL 2003 (the national leukaemia study which recruited patients aged 1 to 24 years at diagnosis of ALL between 2003 and 2011). Imaging of patients with ON affecting the femoral head was requested and was used to score all lesions, with subsequent imaging used to determine the final grade. Kaplan-Meier failure time plots were used to compare the use of CD with non surgical management. RESULTS: Detailed information was received for 85 patients who had developed ON during the course of their ALL treatment. A total of 206 joints were affected by ON. Of all joints affected by ON, 21% required arthroplasty, and 43% of all hips affected went on to be replaced. CD was performed in 30% of hips affected by ON. The majority of the hips were grade 4 or 5 at initial diagnosis of ON. There was no significant difference in time to joint collapse between those joints in which CD was performed, compared with no joint-preserving surgical intervention. CONCLUSION: There is a high incidence of surgery in young people who have received treatment for ALL and who have developed ON. Our results suggest that CD of the femoral head in this group of patients does not delay or improve the rates of femoral head survival. Cite this article: Bone Joint J 2021;103-B(3):589-596.

Sonography of musculoskeletal infection in children.

Musculoskeletal infection, especially in young children, often presents with non-specific clinical signs and symptoms necessitating early imaging to identify the source of infection. While MRI is the investigation of choice to demonstrate bone infection, it is expensive and often requires a general anaesthetic in the young child. Ultrasound can be a useful tool in the initial assessment due to its easy availability and portable equipment. It does not involve ionising radiation and is used to guide aspiration and drainage procedures. This review explains sonographic features of septic arthritis, osteomyelitis, pyomyositis and soft tissue infection in children and highlights advantages and limitations of sonography when assessing the child with suspected musculoskeletal infection.

Imaging for detection of osteomyelitis in people with diabetic foot ulcers: A systematic review and meta-analysis.

BACKGROUND: Osteomyelitis is an infection of the bone which can occur in people with diabetic foot ulcers. It can be diagnosed using X-rays, ultrasound, scintigraphy, magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT) and positron emission tomography (PET). OBJECTIVES: To review the evidence on the diagnostic accuracy of imaging tests to diagnose osteomyelitis in people with diabetic foot ulcers. METHODS: We conducted a systematic review and meta-analysis. MEDLINE, EMBASE and other databases were searched to July 2018. Risk of bias was evaluated. Diagnostic accuracy was estimated using bivariate meta-analyses. RESULTS: Thirty-six studies were included in the meta-analysis. Eight studies were at high risk of bias MRI had high diagnostic accuracy (22 studies: 96.4 % sensitivity (95 % CI 90.7-98.7); 83.8 % specificity (76.0-89.5)). PET scans also had high accuracy (6 studies: 84.3 % sensitivity (52.8-96.3); 92.8 % specificity (75.7-98.2)), and possibly also SPECT, but with few studies (3 studies: 95.6 % sensitivity (76.0-99.3); 55.1 % specificity (19.3-86.3)). Scintigraphy (17 studies: 84.2 % sensitivity (76.8-89.6); 67.7 % specificity (56.2-77.4)), and X-rays (16 studies: 61.9 % sensitivity (50.5-72.1); 78.3 % specificity (62.9-88.5)) had generally inferior diagnostic accuracy. CONCLUSIONS: MRI and PET both reliably diagnose osteomyelitis in diabetic foot ulcer patients. SPECT may also have good diagnostic accuracy, although evidence is limited. This review confirms most current guidelines, showing that MRI may be the preferable test in most cases, given its wider availability and the lack of potentially harmful ionising radiation.

The role of ultrasound as a problem-solving tool in the assessment of paediatric musculoskeletal injuries.

Musculoskeletal trauma in the paediatric population covers a wide range of injuries; although many overlap with their adult counterparts, others are exclusive to the immature skeletal system. Ultrasound is a versatile tool particularly suited to both the imaging of children and the dynamic assessment of musculoskeletal injuries. This pictorial review aims to discuss a range of injuries, focusing on those commonly encountered in children. We shall describe the muscle-tendon-bone complex and changes that occur with increasing skeletal maturity and how this affects the type of injury encountered.

Imaging tests for the detection of osteomyelitis: a systematic review.

BACKGROUND: Osteomyelitis is an infection of the bone. Medical imaging tests, such as radiography, ultrasound, magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT) and positron emission tomography (PET), are often used to diagnose osteomyelitis. OBJECTIVES: To systematically review the evidence on the diagnostic accuracy, inter-rater reliability and implementation of imaging tests to diagnose osteomyelitis. DATA SOURCES: We conducted a systematic review of imaging tests to diagnose osteomyelitis. We searched MEDLINE and other databases from inception to July 2018. REVIEW METHODS: Risk of bias was assessed with QUADAS-2 [quality assessment of diagnostic accuracy studies (version 2)]. Diagnostic accuracy was assessed using bivariate regression models. Imaging tests were compared. Subgroup analyses were performed based on the location and nature of the suspected osteomyelitis. Studies of children, inter-rater reliability and implementation outcomes were synthesised narratively. RESULTS: Eighty-one studies were included (diagnostic accuracy: 77 studies; inter-rater reliability: 11 studies; implementation: one study; some studies were included in two reviews). One-quarter of diagnostic accuracy studies were rated as being at a high risk of bias. In adults, MRI had high diagnostic accuracy [95.6% sensitivity, 95% confidence interval (CI) 92.4% to 97.5%; 80.7% specificity, 95% CI 70.8% to 87.8%]. PET also had high accuracy (85.1% sensitivity, 95% CI 71.5% to 92.9%; 92.8% specificity, 95% CI 83.0% to 97.1%), as did SPECT (95.1% sensitivity, 95% CI 87.8% to 98.1%; 82.0% specificity, 95% CI 61.5% to 92.8%). There was similar diagnostic performance with MRI, PET and SPECT. Scintigraphy (83.6% sensitivity, 95% CI 71.8% to 91.1%; 70.6% specificity, 57.7% to 80.8%), computed tomography (69.7% sensitivity, 95% CI 40.1% to 88.7%; 90.2% specificity, 95% CI 57.6% to 98.4%) and radiography (70.4% sensitivity, 95% CI 61.6% to 77.8%; 81.5% specificity, 95% CI 69.6% to 89.5%) all had generally inferior diagnostic accuracy. Technetium-99m hexamethylpropyleneamine oxime white blood cell scintigraphy (87.3% sensitivity, 95% CI 75.1% to 94.0%; 94.7% specificity, 95% CI 84.9% to 98.3%) had higher diagnostic accuracy, similar to that of PET or MRI. There was no evidence that diagnostic accuracy varied by scan location or cause of osteomyelitis, although data on many scan locations were limited. Diagnostic accuracy in diabetic foot patients was similar to the overall results. Only three studies in children were identified; results were too limited to draw any conclusions. Eleven studies evaluated inter-rater reliability. MRI had acceptable inter-rater reliability. We found only one study on test implementation and no evidence on patient preferences or cost-effectiveness of imaging tests for osteomyelitis. LIMITATIONS: Most studies included < 50 participants and were poorly reported. There was limited evidence for children, ultrasonography and on clinical factors other than diagnostic accuracy. CONCLUSIONS: Osteomyelitis is reliably diagnosed by MRI, PET and SPECT. No clear reason to prefer one test over the other in terms of diagnostic accuracy was identified. The wider availability of MRI machines, and the fact that MRI does not expose patients to harmful ionising radiation, may mean that MRI is preferable in most cases. Diagnostic accuracy does not appear to vary with the potential cause of osteomyelitis or with the body part scanned. Considerable uncertainty remains over the diagnostic accuracy of imaging tests in children. Studies of diagnostic accuracy in children, particularly using MRI and ultrasound, are needed. STUDY REGISTRATION: This study is registered as PROSPERO CRD42017068511. FUNDING: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 61. See the NIHR Journals Library website for further project information.

Osteomyelitis is an infection of the bone and is treated with antibiotics. Left untreated, it can cause permanent damage and can lead to amputation. The best method to diagnose osteomyelitis is to take a bone sample (bone biopsy) but this is invasive and painful. Imaging may help target the best locations for biopsies or remove the need for a biopsy entirely. Several methods are available, including radiography, ultrasound, magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT) and positron emission tomography (PET). This project systematically reviewed the relevant literature to determine which tests are the most accurate and relevant for clinical practice. All types of patients and all types of osteomyelitis were reviewed. Studies were pooled using statistical methods (meta-analyses) to estimate the overall accuracy of the imaging tests. The review identified 81 studies and concluded that MRI, PET and SPECT all had similar accuracy, correctly identifying over 85% of people who did have osteomyelitis and over 80% of people who did not have osteomyelitis. Radiography and computed tomography were less accurate. Modern forms of scintigraphy have accuracy similar to PET or MRI. There was no evidence that the accuracy of the imaging tests was different depending on the cause of osteomyelitis or which body part was affected. In particular, diagnostic accuracy in people with diabetic foot ulcers was similar to other types of osteomyelitis in adults. There was not enough evidence about which tests are most accurate in children, so further studies in children are needed.

British OsteoNEcrosis Study (BONES) protocol: a prospective cohort study to examine the natural history of osteonecrosis in older children, teenagers and young adults with acute lymphoblastic leukaemia and lymphoblastic lymphoma.

INTRODUCTION: Osteonecrosis is a well-recognised treatment-related morbidity risk in patients diagnosed with acute lymphoblastic leukaemia (ALL) and lymphoblastic lymphoma (LBL), with a high rate of affected patients requiring surgical intervention. Patients may have asymptomatic changes on imaging studies that spontaneously regress, and little is known about the natural history of osteonecrotic changes seen. The main aim of the British OsteoNEcrosis Study (BONES) is to determine the incidence of symptomatic and asymptomatic osteonecrosis in the lower extremities of survivors of ALL or LBL diagnosed aged 10-24 years in the UK at different time points in their treatment. This study also aims to identify risk factors for progression and the development of symptomatic osteonecrosis in this population, as well as specific radiological features that predict for progression or regression in those with asymptomatic osteonecrosis METHODS AND ANALYSIS: BONES is a prospective, longitudinal cohort study based at principal treatment centres around the UK. Participants are patients aged 10-24 years diagnosed with ALL or LBL under standard criteria. Assessment for osteonecrosis will be within 4 weeks of diagnosis, at the end of delayed intensification and 1, 2 and 3 years after the start of maintenance therapy. Assessment will consist of MRI scans of the lower limbs and physiotherapy assessment. Clinical and biochemical data will be collected at each of the time points. Bone mineral density data and vertebral fracture assessment using dual-energy X-ray absorptiometry will be collected at diagnosis and annually for 3 years after diagnosis of malignancy. ETHICS AND DISSEMINATION: Ethical approval has been obtained through the Yorkshire and Humber Sheffield Research Ethics Committee (reference number: 16/YH/0206). Study results will be published on the study website, in peer-reviewed journals and presented at relevant conferences and via social media. TRIAL REGISTRATION NUMBER: NCT02598401; Pre-results.