Congenital segmental dilatation of the colon in a newborn: a radiologic perspective of an unusual entity.

A newborn with congenital segmental dilatation of the intestine affecting the colon is presented. This rare condition, unrelated to Hirschsprung's disease, may affect any portion of the bowel and is characterized by focal dilatation of a segment of bowel flanked by normal proximal and distal bowel. While reported in the surgical literature, congenital segmental dilatation of the intestine has not been reported in the pediatric radiology literature even though pediatric radiologists may be the first to encounter imaging suggesting the diagnosis. We therefore present the characteristic imaging findings, including abdominal radiographs and images from a contrast enema, and discuss the clinical presentation, pathology findings, associations, treatment, and prognosis of congenital segmental dilatation of the intestine to increase awareness of this unusual diagnosis.

Magnetic resonance imaging following the demonstration of a normal common bile duct on ultrasound in children with suspected choledocholithiasis: what is the benefit?

BACKGROUND: The role of MRI in evaluating children with an in situ gallbladder and suspected choledocholithiasis following a negative or inconclusive US is unclear. OBJECTIVE: To determine whether MRI benefits children with suspected choledocholithiasis and a normal common bile duct (CBD) without stones on US. MATERIALS AND METHODS: We conducted a retrospective 10-year review of paired US and MRI (within 10 days) in children 18 years or younger with suspected choledocholithiasis. With MRI as a reference standard, two reviewers independently evaluated the images for CBD diameter, choledocholithiasis, cholelithiasis and pancreatic edema. Serum lipase was recorded. We calculated exact binomial confidence limits for test positive predictive values (PPVs) and negative predictive values (NPVs) using R library epiR. RESULTS: Of 87 patients (46 female, 41 male; mean age 14 years, standard deviation [SD] 4.6 years; mean interval between US and MRI 1.6 days, SD 1.8 days), 55% (48/87) had true-negative US, without CBD dilation/stones confirmed on MRI; 5% (4/87) had false-positive US showing CBD dilatation without stones, not confirmed on MRI; 33% (29/87) had true-positive US, with MRI confirming CBD dilatation; and 7% (6/87) had false-negative US, where MRI revealed CBD stones without dilatation (2 patients) and CBD dilatation with or without stones (4 patients). Patients with false-negative US had persistent or worsening symptoms, pancreatitis or SCD. The overall US false-negative rate was 17% (6/35). Normal-caliber CBD on US without stones had an NPV of 89% (48/54, 95% confidence interval: 0.77-0.96). CONCLUSION: MRI adds little information in children with a sonographically normal CBD except in the setting of pancreatitis or worsening clinical symptoms. Further evaluation is warranted in children with elevated risk of stone disease.

Imaging findings in acute pediatric coronavirus disease 2019 (COVID-19) pneumonia and multisystem inflammatory syndrome in children (MIS-C).

The two primary manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in children are acute coronavirus disease 2019 (COVID-19) pneumonia and multisystem inflammatory syndrome (MIS-C). While most pediatric cases of acute COVID-19 disease are mild or asymptomatic, some children are at risk for developing severe pneumonia. In MIS-C, children present a few weeks after SARS-CoV-2 exposure with a febrile illness that can rapidly progress to shock and multiorgan dysfunction. In both diseases, the clinical and laboratory findings can be nonspecific and present a diagnostic challenge. Thoracic imaging is commonly obtained to assist with initial workup, assessment of disease progression, and guidance of therapy. This paper reviews the radiologic findings of acute COVID-19 pneumonia and MIS-C, highlights the key distinctions between the entities, and summarizes our understanding of the role of imaging in managing SARS-CoV-2-related illness in children.

Imaging Findings in Multisystem Inflammatory Syndrome in Children (MIS-C) Associated With Coronavirus Disease (COVID-19).

BACKGROUND. A multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease (COVID-19) has recently been described. OBJECTIVE. The purpose of our study was to evaluate the imaging findings of MIS-C associated with COVID-19. METHODS. Imaging studies and medical records of patients (age range, 0-20 years) admitted with MIS-C between April 22 and May 21, 2020, were retrospectively reviewed. Thoracic imaging studies were evaluated for parenchymal, mediastinal and hilar, and cardiovascular abnormalities. Abdominal imaging studies were evaluated for abnormalities of solid viscera, hollow viscera, and the peritoneum as well as the mesentery and retroperitoneum. Studies were reviewed independently by two radiologists, and disagreements were resolved by a third senior radiologist. RESULTS. Sixteen patients (10 male and six female patients; age range, 20 months-20 years) were included in this study. All 16 patients presented with fever. Other presenting signs and symptoms included the following: vomiting (12/16, 75%), abdominal pain (11/16, 69%), rash (10/16, 63%), conjunctivitis (8/16, 50%), diarrhea (7/16, 44%), headache (6/16, 38%), and sore throat (5/16, 31%). Shortness of breath and cough were each present in one patient. Chest radiography showed cardiomegaly (10/16, 63%), congestive heart failure or cardiogenic pulmonary edema (9/16, 56%), atelectasis (9/16, 56%), pleural effusions (7/16, 44%), acute respiratory distress syndrome (2/16, 13%), and pneumonia (1/16, 6%). Eight patients (50%) were evaluated for pulmonary embolism (PE) (six [75%] by CT angiography [CTA] and two [25%] by ventilation-perfusion scintigraphy). In two of the eight patients (25%), CTA showed a segmental PE. Abdominal imaging findings (ultrasound, CT, and radiography) included small-volume ascites (6/16, 38%), hepatomegaly (6/16, 38%), echogenic kidneys (5/16, 31%), bowel wall thickening (3/16, 19%), gallbladder wall thickening (3/16, 19%), mesenteric lymphadenopathy (2/16, 13%), splenomegaly (1/16, 6%), and bladder wall thickening (1/16, 6%). The frequencies of findings based on all the reviewed modalities were as follows: cardiomegaly (12/16, 75%), pleural effusion (10/16, 63%), and atelectasis (10/16, 63%). Absolute interobserver agreement was 0.69-1 for thoracic findings and 0.17-1 for abdominal findings. Fifteen patients (94%) were discharged from the hospital (length of hospital stay: range, 3-20 days), and one patient remained in the hospital at the end of the study period. There were no mortalities. CONCLUSION. MIS-C associated with COVID-19 is characterized predominantly by cardiovascular abnormalities, although solid visceral organ, gallbladder, and bowel abnormalities as well as ascites are also seen, reflecting a multisystemic inflammatory process. CLINICAL IMPACT. The constellation of imaging findings in the setting of COVID-19 may alert radiologists to the diagnosis of MIS-C before rapid deterioration of patients.

Delayed sternal ossification in congenital heart disease: incidence using computed tomography.

BACKGROUND: While congenital heart disease (CHD) is known to be associated with sternal abnormalities, its association with absent sternal ossification is less well known. The literature is sparse and based on radiographs. OBJECTIVE: To quantify delayed sternal ossification in CHD using computed tomography (CT). MATERIALS AND METHODS: An imaging database search identified children with complex CHD and controls younger than 3 years of age who underwent chest CT from 2010 to 2019. Records were reviewed for demographics, CHD type and other pertinent history. Images were reviewed for manubrial or sternal segment ossification. Controls consisted of children undergoing chest CT for noncardiac reasons. Statistical analyses were conducted using a significance threshold of 0.05. RESULTS: Fifty-nine children had complex CHD (mean age: 9.4 months); 36 (61.0%) had cyanotic CHD. There were 189 controls (mean age: 17.9 months). Delayed sternal ossification was present in 7 children (11.9%) in the study group; 6 had cyanotic heart disease (85.7%). Patterns of ossification included manubrium only; manubrium and first sternal segment; first and second sternal segments; and manubrium, first segment and hypoplastic second segment. Three controls (1.6%) had sternal ossification delay, all with manubrial ossification only. Delayed sternal ossification was more prevalent in the study group than in the controls (P=0.002). Compared to the controls, a higher incidence of delayed sternal ossification was seen in children with cyanotic CHD (P<0.001) but not acyanotic CHD (P=0.37). CONCLUSION: Delayed sternal ossification occurs in children with CHD, particularly cyanotic forms, and requires no additional work-up.

Bladder prolapse through a patent urachus presenting as an umbilical mass in the newborn: characteristic prenatal sonographic findings and the diagnostic benefit of postnatal cystography.

Bladder prolapse through a patent urachus is rare. We present a newborn with an unusual exophytic, erythematous umbilical mass. Voiding cystography readily demonstrated continuity of the bladder dome with the umbilical mass, confirming bladder prolapse through a patent urachus. The diagnosis of bladder prolapse was rapidly made in a second newborn with similar imaging and clinical findings and confirmed by cystography. We discuss the embryology of this condition including the association with a vesico-allantoic cyst in utero. Pre- and postnatal images are presented. The use of cystography in diagnosis is emphasized.

Feasibility study of a novel portable digital radiography system modified for fluoroscopy in the neonatal intensive care unit.

BACKGROUND: A portable radiographic system capable of fluoroscopic imaging in the neonatal intensive care unit (NICU) potentially benefits critically ill neonates by eliminating the need to transport them to a fluoroscopy suite. OBJECTIVE: To evaluate whether a portable bedside fluoroscopy system in the NICU can deliver comparable image quality at a similar dose rate to a standard system in a fluoroscopy suite. MATERIALS AND METHODS: In phase A, 20 patients <3 years of age and scheduled to undergo upper gastrointestinal series (upper GI) or voiding cystourethrograms (VCUG) in the radiology fluoroscopy suite were recruited to evaluate a portable fluoroscopic unit. A modified portable radiographic system with a cassette-sized detector and an in-room fluoroscopy system were sequentially used in the same examination. Four radiologists compared the image quality of 20 images from each system using the Radlex score (1-4) for five image quality attributes. The radiation dose rates for the portable and in-suite systems were collected. In phase B, fluoroscopy studies were performed in 5 neonates in the NICU and compared to the 20 previous neonatal studies performed in the department. Clinical workflow, examination time, fluoroscopy time, scattered radiation dose and patient radiation dose were evaluated. RESULTS: In phase A, average dose rates for in-room and portable systems were equivalent, (0.322 mGy/min and 0.320 mGy/min, respectively). Reader-averaged Radlex scores for in-room and portable systems were statistically significantly greater (P<0.05) for all attributes on the portable system except for image contrast. In phase B, scattered radiation from the average fluoroscopy time (26 s) was equivalent to the scattered radiation of 2.6 portable neonatal chest radiographs. Procedure time and diagnostic quality were deemed equivalent. The average dose rate in the NICU with the portable system was 0.21 mGy/min compared to 0.29 mGy/min for the in-room system. CONCLUSION: The portable fluoroscopy unit is capable of providing comparable image quality at equivalent dose levels to an in-room system for neonates with minimal risks to the staff and other patients in the NICU.

COVID-19 in pediatric patients: a case series from the Bronx, NY.

BACKGROUND: Coronavirus disease 2019 (COVID-19) primarily affects adults, with a lower incidence in children. OBJECTIVE: To report our experience with critically ill children with COVID-19. MATERIALS AND METHODS: We reviewed the medical records of children with COVID-19 who were admitted Feb. 25 to May 1, 2020. We reviewed patient demographics, symptoms, comorbidities, requirement for respiratory support, evidence of acute myocardial injury, and chest radiographs. RESULTS: The study included 19 children and adolescents (ages 2 months to 18 years, median 8 years; 10 males, 9 females; 18 COVID-19-positive, 1 COVID-19-negative with positive exposure). Presenting symptoms included fever (89%), cough (68%), respiratory distress (68%) and vomiting/diarrhea (47%). Comorbidities were present in 12 (63%). Fourteen required intensive care; eight required intubation. Two children died. Five patients developed acute myocarditis (median age 7 years); in all five, chest radiographs were notable for cardiomegaly and pulmonary congestion or interstitial edema. Of these five, one (age 18 years), who had underlying hypertension and obesity, developed multifocal pneumonia and renal failure. The other four were previously healthy; three (ages 5 years, 7 years, 8 years) were subsequently diagnosed with multisystemic inflammatory syndrome in children (MIS-C); one developed pulmonary opacities consistent with adult respiratory distress syndrome, three (60%) had no parenchymal pulmonary opacities. Fourteen patients (median 13 years), most with comorbidities, had no acute myocardial injury. Chest radiographs in 13 (93%) demonstrated parenchymal lung disease with a predominant perihilar and basilar distribution. CONCLUSION: Myocarditis without pulmonary disease occurred in children in their first decade as a component of MIS-C, a newly described syndrome of multisystemic inflammation requiring further investigation. Pulmonary disease dominated the radiographic features of COVID-19-positive adolescents in their second decade in whom radiographs demonstrated predominantly perihilar and basilar distribution of lung opacities.

Management of Intussusception in the Pediatric Emergency Department: Risk Factors for Recurrence.

BACKGROUND: The standard treatment for intussusception is air reduction enema (ARE) with inpatient observation for 24 to 48 hours to monitor for recurrence. More recent but limited observations suggest that patients who have undergone successful ARE can safely be discharged after 4 to 6 hours of observation. Our primary objective was to identify risk factors associated with early recurrence. Our secondary objectives included validating risk criteria from prior studies and identifying risk factors for ARE failures. DESIGN/METHODS: A retrospective cohort study of children discharged from a large urban quaternary hospital with a final diagnosis of intussusception (International Classification of Diseases, Ninth Revision, code 560.0) or who underwent ARE from 2005 to 2015 was identified. Demographic data, radiology images, and clinical course were recorded. Repeat visits, cases with incomplete medical records, and those with incorrect diagnoses were excluded. RESULTS: A total of 250 cases were identified. Two hundred cases were included for analysis. Fifty were excluded. Of the 163 who had successful reduction with ARE, 22 patients (13.5%) recurred, and 12 (7.3%) recurred within 48 hours. Fever (odds ratio, 4.25; P = 0.04; 95% confidence interval, 1.04-17.3) and female sex (odds ratio, 7.94; P = 0.01; 95% confidence interval, 1.82-34.6) were independently associated with early recurrence. No radiologic features were associated with early recurrence. CONCLUSIONS: Early recurrence after successful ARE was low, although more frequent in girls and in those with fever over 100.4°F. We therefore advocate for prospective studies to validate these risk criteria to identify patients who are at low risk for early recurrence and may qualify for early discharge from the emergency department.

Effect of radiologist pregnancy on the performance of pediatric fluoroscopic studies: a survey of Society for Pediatric Radiology members.

BACKGROUND: To our knowledge, the fluoroscopic practice patterns of pregnant diagnostic radiologists have not been documented. OBJECTIVE: To describe the fluoroscopic practice patterns during pregnancy among members of the Society for Pediatric Radiology (SPR) and potential impact on career and professional relationships. MATERIALS AND METHODS: After approval from the SPR, we sent all 1,847 SPR members an email link to an anonymous online survey that queried how pregnancy affects a practicing radiologist who performs fluoroscopy. RESULTS: Of the 398 responses (65% female, 35% male), most female respondents (78%) reported having been pregnant while practicing radiology and the majority (85%) performed fluoroscopy during pregnancy. Most performed fluoroscopy during all three trimesters (first 78%, second 90%, third 87%) and the majority (81%) used double-lead. Forty-six percent indicated that their fluoroscopic responsibilities during pregnancy were stressful. Of those who opted to perform fewer fluoroscopy studies, 20% indicated that it impacted negatively on their career or professional relationships. After witnessing a pregnant co-worker perform fewer fluoroscopic studies, 11% (4% male; 16% female; P<0.05) of respondents observed a subsequent negative impact on the co-worker's career or professional relationships. CONCLUSION: The majority of responding female SPR members had performed fluoroscopy during pregnancy and most performed fluoroscopy during their entire pregnancy with double-lead. Differences between self-reported adversity and observed adversity of performing less fluoroscopy during pregnancy speak to the lack of awareness of the issues, particularly among male colleagues. A clear policy with regard to performing fluoroscopy during pregnancy for all radiologists in every department is necessary.

Radiation dose monitoring in pediatric fluoroscopy: comparison of fluoroscopy time and dose-area product thresholds for identifying high-exposure cases.

BACKGROUND: Fluoroscopy time has been used as a surrogate for radiation dose monitoring in pediatric fluoroscopy; however it does not account for factors such as magnification or collimation. Dose-area product (DAP) is a more accurate measure of radiation exposure but its dependence on patient weight and body-part thickness is a challenge in children of varying ages. OBJECTIVE: To determine whether fluoroscopy time and DAP produce concurrent results when they are used to identify high-exposure cases, and to establish radiation dose thresholds for our institution. MATERIALS AND METHODS: During a 2-year period we prospectively monitored pediatric fluoroscopy studies performed at the Children's Hospital at Montefiore. We recorded study type, fluoroscopy time, DAP, patient age, weight and height. We then calculated 90th percentile fluoroscopy time and DAP thresholds for weight and age. RESULTS: We evaluated 1,011 cases (453 upper gastrointestinal [UGI] series, 266 voiding cystourethrograms [VCUGs], 120 contrast enemas, 108 speech studies, and 64 esophagrams). Fluoroscopy time demonstrated moderate correlation with DAP (rs=0.45, P<0.001, Spearman rank). DAP strongly correlated with patient weight (rs=0.71, P<0.001) and age (rs=0.70, P<0.001). Concordance of cases exceeding 90th percentile thresholds for fluoroscopy time and DAP were κ=0.27 for UGI series and κ=0.49 for VCUG for weight-based cutoffs, and κ=0.36 for UGI series and κ=0.40 for VCUG for age-based cutoffs. CONCLUSION: The limited correlation of fluoroscopy time with DAP suggests these methods are not equivalent for dose monitoring. However, the strong correlation of DAP with patient weight and age presents a challenge for establishing DAP thresholds in children, who range widely in size. Despite controlling for weight or age, there was limited overlap of cases exceeding the 90th percentile threshold for fluoroscopy time and DAP. This further reinforces the non-overlapping outcome of these two methods and indicates that fluoroscopy time might be inadequate for dose monitoring.

Identification of clinical parameters to increase the diagnostic yield of the non-emergent upper gastrointestinal series in pediatric outpatients.

BACKGROUND: Outpatient, non-emergent upper gastrointestinal (GI) series are frequently requested in children with no surgical history who have nonspecific symptoms such as abdominal pain, failure to thrive and vomiting. The positive yield of an upper GI series in these patients, and, thus, its utility, has not been studied. OBJECTIVES: We evaluated the incidence of positive upper GI findings in children without a history of GI pathology or abdominal surgery in order to identify clinical indications associated with a greater diagnostic yield. MATERIALS AND METHODS: Findings of upper GI series performed between October 2015 and October 2017 in three institutions in children younger than 18 years of age were retrospectively reviewed. The upper GI series protocol for each institution was also reviewed. Children with a medical or surgical GI history, children with insufficient history in the chart and those with an incomplete upper GI series were excluded from the study. Exam indications, patient demographics and clinical history were obtained from the electronic medical records. RESULTS: Of 1,267 children who underwent outpatient upper GI series, 720 (median age: 2 years) had no GI history and were included in the study. The most common indications were non-bilious vomiting (62%), reflux symptoms (28%) and abdominal pain (20%). Upper GI series were normal in 605/720 cases (84%), including 25/26 children with reported bilious emesis. Of the 115 positive studies, 78 (68%) showed only gastroesophageal reflux (GER) (median age: 11 months). Of the remaining 37 studies, 19 demonstrated esophageal findings. One case of malrotation without midgut volvulus was identified in a patient who presented with dysphagia and reflux symptoms. Using a multinomial logistic regression model and adjusting for other variables, reflux symptoms and younger patient age were independent predictors of GER on upper GI series (relative risk ratios of 2.2 and 0.9, respectively). Dysphagia and/or foreign body sensation and older patient age were independent predictors of the presence of esophageal findings (relative risk ratios of 3.3 and 1.1, respectively). CONCLUSION: The yield of routine upper GI series in children with nonspecific symptoms, such as abdominal pain and vomiting, and no surgical history is low. Diagnostic yield was improved in older children and in those complaining of dysphagia and/or foreign body sensation. Routine upper GI series should be avoided in clinically well children with symptoms only of uncomplicated GER and no significant GI history. In children with a history of dysphagia and/or foreign body sensation, an esophagram/barium swallow can suffice.

Primary hyperoxaluria: spectrum of clinical and imaging findings.

Primary hyperoxaluria is a rare autosomal recessive inborn error of metabolism with three known subtypes. In primary hyperoxaluria type 1, the most common of the subtypes, a deficiency in the hepatic enzymes responsible for the metabolism of glycoxylate to glycine, leads to excessive levels of glyoxylate, which is converted to oxalate. The resultant elevation in serum and urinary oxalate that characterizes primary hyperoxaluria leads to calcium oxalate crystal deposition in multiple organ systems (oxalosis). We review the genetics, pathogenesis, variable clinical presentation and course of this disease as well as its treatment. Emphasis is placed on the characteristic imaging findings before and after definitive treatment with combined liver and renal transplantation.

Ovary preservation in the treatment of childhood Meigs syndrome.

Meigs syndrome, the combination of benign ovarian tumor, ascites, and pleural effusion, is present in a small percentage of ovarian fibromas and is infrequently reported in children. When associated with elevated CA-125 suspicion is raised for malignancy, often prompting aggressive surgical intervention. We present a case of childhood Meigs syndrome and review the relevant literature with emphasis on ovary preservation. Out of nine identified pediatric cases, one involved ovary sparing treatment and none recurred or progressed to malignancy. Our report highlights the importance of presurgical identification of Meigs syndrome in order to curtail salpingo-oophorectomy when feasible.

Yield of diagnostic tests in obese children with an elevated alanine aminotransferase.

AIM: Nonalcoholic fatty liver disease (NAFLD) is associated with obesity and affects roughly 10% of children. However, NAFLD is often diagnosed by exclusion - that is, obese children with an elevated alanine aminotransferase (ALT) are screened for other liver diseases in the absence of a biopsy. This testing is nonstandardized, and professional society recommendations differ. This study examines the yield of testing for disorders other than NAFLD in this patient population. METHODS: A retrospective study was performed in 120 obese, asymptomatic, noncholestatic children with an ALT ≥40 U/L and additional diagnostic testing. RESULTS: No patients were found to have Wilson's, hepatitis A, hepatitis B, hepatitis C, cytomegalovirus, alpha-1 antitrypsin deficiency, autoimmune hepatitis, celiac disease or Epstein-Barr virus. Only one patient (1/120) was identified with definite disease other than NAFLD, which was muscular dystrophy. The positive predictive value of a screening test was 5%, and the specificity was 97%. Of 70 children with an abdominal ultrasound, no significant abnormalities were identified. CONCLUSION: Extensive testing in asymptomatic, noncholestatic, obese children with an elevated ALT may be of limited diagnostic value and false-positive tests are likely. Large, prospective studies are needed to help focus the work up in this patient population.

Shwachman-Bodian-Diamond syndrome: metaphyseal chondrodysplasia in children with pancreatic insufficiency and neutropenia.

Shwachman-Bodian-Diamond syndrome (OMIM 260400) was identified in 1964 by pediatricians Harry Shwachman, a leader in cystic fibrosis, and Louis K. Diamond, a hematologist, along with pediatrician and morbid anatomist Martin Bodian. Initially the syndrome's clinical presentation included exocrine pancreatic insufficiency (lipomatous replacement of the pancreas) and neutropenia. In 1967 skeletal changes of metaphyseal chondrodysplasia were also described, completing the triad of findings; these abnormalities are present in all affected children and should be viewed as an integral feature of the syndrome, also called Shwachman-Diamond syndrome.

Efficacy of ultrasound elastography in detecting active myositis in children: can it replace MRI?

BACKGROUND: Juvenile idiopathic inflammatory myopathy is a rare yet potentially debilitating condition. MRI is used both for diagnosis and to assess response to treatment. No study has evaluated the performance of US elastography in the diagnosis of this condition in children. OBJECTIVE: To assess the performance of compression-strain US elastography in detecting active myositis in children with clinically confirmed juvenile idiopathic inflammatory myopathy and to compare its efficacy to MRI. MATERIALS AND METHODS: Children with juvenile idiopathic inflammatory myopathy underwent non-contrast MR imaging as well as compression-strain US elastography of the quadriceps muscles. Imaging findings from both modalities were compared to each other as well as to the clinical determination of active disease based on physical examination and laboratory data. Active myositis on MR was defined as increased muscle signal on T2-weighted images. Elastography images were defined as normal or abnormal based on a previously published numerical scale of muscle elastography in normal children. Muscle echogenicity was graded as normal or abnormal based on gray-scale sonographic images. RESULTS: Twenty-one studies were conducted in 18 pediatric patients (15 female, 3 male; age range 3-19 years). Active myositis was present on MRI in ten cases. There was a significant association between abnormal MRI and clinically active disease (P = 0.012). US elastography was abnormal in 4 of 10 cases with abnormal MRI and in 4 of 11 cases with normal MRI. There was no association between abnormal elastography and either MRI (P > 0.999) or clinically active disease (P > 0.999). Muscle echogenicity was normal in 11 patients; all 11 had normal elastography. Of the ten patients with increased muscle echogenicity, eight had abnormal elastography. There was a significant association between muscle echogenicity and US elastography (P < 0.001). The positive and negative predictive values for elastography in the determination of active myositis were 75% and 31%, respectively, with a sensitivity of 40% and specificity of 67%. CONCLUSION: Compression-strain US elastography does not accurately detect active myositis in children with juvenile idiopathic inflammatory myopathy and cannot replace MRI as the imaging standard for detecting myositis in these children. The association between abnormal US elastography and increased muscle echogenicity suggests that elastography is capable of detecting muscle derangement in patients with myositis; however further studies are required to determine the clinical significance of these findings.

Volvulus of the entire small bowel with normal bowel fixation simulating malrotation and midgut volvulus.

BACKGROUND: Midgut volvulus is a complication of malrotation of bowel and mesenteric malfixation. In contrast, primary volvulus of the small bowel is a distinctly different and rare entity characterized by torsion of the entire small bowel with normal mesenteric fixation. OBJECTIVE: To present the clinical and imaging findings in four infants with primary small bowel volvulus and normal bowel fixation in order to improve awareness of this entity among clinicians and radiologists and to discuss the potential etiologies of this entity to distinguish it from other causes of small bowel volvulus. MATERIALS AND METHODS: A retrospective review of imaging studies (two ultrasounds and four upper gastrointestinal series) in four infants (three full-term and one premature) from three institutions with surgically proven volvulus of the entire small bowel and normal bowel fixation were reviewed by three board-certified pediatric radiologists and correlated with clinical and surgical reports when available. RESULTS: The infants presented during the first week to 6 months of life and were acutely ill. The upper gastrointestinal series showed complete duodenal obstruction with beaking in one and partial duodenal obstruction in three. All studies were interpreted as highly suspicious for malrotation and midgut volvulus. Emergent laparotomy demonstrated primary small bowel volvulus with normal mesenteric fixation in all infants. The base of the small bowel mesentery was described by the operating surgeon as smaller than normal in one infant (case 3). There was no mesenteric defect or other abnormality predisposing to volvulus in the other three. In both infants who had abdominal US, a retroperitoneal position of the third portion of the duodenum was demonstrated. All infants survived. One infant required resection of the necrotic small bowel and currently has short gut syndrome, one has malabsorption and two were lost to follow-up. CONCLUSION: Primary small bowel volvulus with normal fixation is indistinguishable from malrotation with midgut volvulus in the acutely ill infant or child. Radiographic diagnosis can be difficult in patients with intermittent or incomplete small bowel volvulus without malrotation. In these patients, neither an upper gastrointestinal series demonstrating a normal position of the duodenojejunal junction nor the sonographic demonstration of a retromesenteric third portion of the duodenum excludes the diagnosis. In young infants, the clinical and imaging findings may mimic necrotizing enterocolitis. Sonography may be useful to evaluate the bowel for signs of bowel wall compromise or a whirlpool sign.

The impact of on-site attending radiologist overnight coverage on radiology resident learning: a preliminary assessment.

The objective of this study is to assess the impact of on-site attending radiologist overnight coverage on resident education during transition to 24/7 attending coverage. The study was exempted from IRB review. An anonymous survey was sent to 9 second year radiology residents who completed their first night call rotation (NC) with an attending radiologist (group 1) and 18 residents who completed their first NC prior to overnight attending coverage (group 2). This addressed anxiety level prior to NC, work pace, autonomy and confidence, and attending feedback, with responses graded on a five-point scale. Statistical analysis was performed using Spearman's rho correlation coefficient. Diagnostic Radiology In-Training (DXIT(TM)) exam scores were collected prior to and following completion of the NC rotation, and results were compared. Case volume before and after the transition was recorded. p value <0.05 indicated statistical significance. Eight out of nine residents in group 1 and 16 out of/18 residents in group 2 completed the survey. Group 1 was more likely to report working at a comfortable pace (p = 0.008) and receiving attending feedback (p = 0.004) than group 2. A non-significant trend towards reduced anxiety prior to NC was present in group 1 (p = 0.077). No difference in independence (p = 0.918), autonomy (p = 0.635), or confidence during (p = 0.431) or after NC (p = 1.00) was identified. DXIT(TM) scores were not significantly different between the two groups (p = 0.396). While overall case volume dictated by residents increased, fewer plain radiographs were dictated. Overnight attending coverage provides a more comfortable pace of study interpretation and increased attending feedback without decreasing resident independence or DXIT(TM) scores. Plain radiograph interpretation may need to be further emphasized.