High-resolution inspiratory and expiratory CT in older children and adults with bronchopulmonary dysplasia.

OBJECTIVE: The objective of this study is to correlate high-resolution inspiratory and expiratory CT findings with pulmonary function results in older children and adults who have bronchopulmonary dysplasia. SUBJECTS AND METHODS: High-resolution inspiratory and expiratory CT of the thorax was performed prospectively on 26 patients (16 male, 10 female) with a clinical history of bronchopulmonary dysplasia. The median age was 10 years old (range, 5-18 years). High-resolution CT during inspiration was scored for areas of decreased density and evidence of interstitial lung disease; expiratory CT was scored for air trapping. Findings were correlated with pulmonary function measurements and clinical history. RESULTS: Twenty-four (92%) of the 26 patients had abnormal CT findings. Of these 24, 22 had reticular opacities and 18 had areas of architectural distortion. Twenty patients had areas of relatively decreased density. In 24 patients, air trapping was seen on expiratory CT. Abnormal pulmonary function correlated significantly (p < .05) with abnormal decreases in density, air trapping on expiratory CT, and architectural distortion. CONCLUSION: Abnormal findings on inspiratory and expiratory high-resolution CT of older children with bronchopulmonary dysplasia include scarring and air trapping with architectural distortion. The correlation between these findings and physiologic evidence of air trapping and obstructive lung disease was statistically significant.

Emotion and memory: Children's long-term remembering, forgetting, and suggestibility.

Children's memories for an experienced and a never-experienced medical procedure were examined. Three- to 13-year-olds were questioned about a voiding cystourethrogram fluoroscopy (VCUG) they endured between 2 and 6 years of age. Children 4 years or older at VCUG were more accurate than children younger than 4 at VCUG. Longer delays were associated with providing fewer units of correct information but not with more inaccuracies. Parental avoidant attachment style was related to increased errors in children's VCUG memory. Children were more likely to assent to the false medical procedure when it was alluded to briefly than when described in detail, and false assents were related to fewer "do-not-know" responses about the VCUG. Results have implications for childhood amnesia, stress and memory, individual differences, and eyewitness testimony.

Ultrasound and MR imaging of fibromatosis colli (sternomastoid tumor of infancy).

The sonographic and CT findings of fibromatosis colli (sternomastoid tumor of infancy) have been described, but the MRI appearance has been reported in only one case in which the mass resolved over time. This case describes the detailed MRI findings in a biopsy-proven case of fibromatosis colli; the signal intensity of the mass on T2-weighted images was slightly less than on gradient-recalled T1-weighted images, consistent with the presence of some fibrous tissue within the muscle mass. The involved portion of the muscle was better defined on MRI than sonography. MRI was helpful in demonstrating the signal characteristics of the mass; localizing the mass to within the sternocleidomastoid muscle; and demonstrating clear surrounding fascial planes with lack of associated lymphadenopathy, airway compression, vascular encasement, bone involvement or intracranial/intraspinal extension associated with other neck masses.

Osteogenesis imperfecta: a review.

The wide spectra of the clinical features, classification, genetics and imaging features of osteogenesis imperfecta (OI) are discussed, especially in the context of distinguishing the condition from child abuse. A broad general knowledge of the clinical and genetic aspects of the disease, as well as the imaging features of OI, is required for radiologists to knowledgeably provide the proper diagnosis and to participate responsibly in a team approach with geneticists, clinicians, lawyers and child protection services. There are 4 major types of OI, ranging from mild to severe. The diagnosis is made from clinical, genetic and radiographic features. The complications of OI and the use of bone mineral density measurements, collagen analysis and prenatal ultrasonography are presented. Their clinical relevance to the diagnosis of OI are discussed. Skin biopsy for collagen analysis may be needed to aid in the diagnosis in confusing or mild cases. It is important to distinguish OI from child abuse in order to protect an abused child or to avoid an improper accusation of child abuse in a child with obvious OI.

Imaging findings in patients with-right lower quadrant pain: alternative diagnoses to appendicitis.

Patients with right lower quadrant (RLQ) pain referred for imaging studies with a clinical diagnosis of appendicitis may have other pathologic conditions mimicking appendicitis. Appropriate diagnostic imaging may establish other specific diagnoses and thereby play a significant role in determining proper medical or surgical treatment. In this pictorial essay, we present a spectrum of imaging findings in patients whose clinical features were suggestive of appendicitis, but the diagnoses of a broad spectrum of other diseases were established with the imaging studies. The differential diagnoses of diseases mimicking appendicitis are reviewed.

Effects of finasteride, a type 2 5-alpha reductase inhibitor, on fetal development in the rhesus monkey (Macaca mulatta).

In genetic male fetuses, dihydrotestosterone (DHT) plays an important role in normal prostatic and external genital differentiation. The enzyme steroid 5-alpha reductase (5 alpha R) catalyzes the conversion of testosterone (T) to DHT. The importance of 5 alpha R in sexual differentiation is evident from the study of human genetic males who congenitally lack this enzyme and consequently develop ambiguous genitalia. These individuals are specifically deficient in the type 2 isozyme, whereas the normal type 1 isozyme activity has been found. The purpose of this study was to determine 1) the suitability of the rhesus monkey for testing the safety of 5 alpha R inhibitors when administered during pregnancy and 2) the potential risk of administering a known type 2 5 alpha R inhibitor, finasteride, during the critical period of internal and external genital differentiation in rhesus monkeys. In vitro studies were also performed on selected rhesus monkey tissues to determine the distribution of the 5 alpha R isozymes. Gravid monkeys were treated once daily from gestational days (GD) 20 to 100. Sonographic monitoring was performed during the course of gestation to monitor viability, growth, and organ system development. Detailed fetal evaluations for developmental abnormalities were performed at term (GD 152 +/- 2). A group of 13 pregnant monkeys ("positive control") were given a high oral dose (2 mg/kg/day) of finasteride to demonstrate that inhibiting type 2 5 alpha R results in specific external genital abnormalities in male fetuses. Thirty-two pregnant monkeys were administered an intravenous (i.v.) formulation of finasteride at doses of 8, 80, or 800 ng/day. The highest i.v. dose selected was at least 60-750 times the semen levels of finasteride in man given orally 5 or 1 mg/day, respectively. Seventeen vehicle-control pregnant monkeys were also included. Administration of a high oral dose (2 mg/kg/day) of finasteride resulted in external genital abnormalities characterized by hypospadias, preputial adhesions to the glans, a small underdeveloped scrotum, a small penis, and a prominent midline raphe in male fetuses; however, no developmental abnormalities were seen in female fetuses. Similarly, no abnormalities were observed in either male or female fetuses of mothers given iv doses (8, 80, or 800 ng/day) of finasteride during pregnancy. The in utero sonographic findings in fetuses correlated with the gross findings at term. These studies have shown that external genital abnormalities can be produced in male monkey fetuses when exposed to a high oral dose (2 mg/kg/day) of finasteride, whereas no abnormalities were observed in fetuses exposed to the i.v. formulation of finasteride. Detailed in vitro studies demonstrated that the rhesus monkey also has two 5 alpha R isozymes (types 1 and 2) with a tissue distribution similar to that seen in man and, furthermore, that finasteride is a potent, mechanism-based inhibitor with selectivity for both human and rhesus type 2 5 alpha R. These studies have demonstrated that the monkey is a suitable model for assessing the safety of 5 alpha R inhibitors administered during pregnancy.

Non-accidental injury: confusion with temporary brittle bone disease and mild osteogenesis imperfecta.

Accurate diagnosis of non-accidental injury (NAI) can be reached in the majority of cases by careful appraisal of the social and family history, combined with painstaking clinical roentgenographic and other imaging evaluations. Careful review of the scientific literature clearly indicates that collagen analysis to exclude mild forms of osteogenesis imperfecta, especially type IV, is recommended only in rare cases in which diagnosis of NAI remains in doubt even after thorough evaluation by experienced radiologists and/or other physicians. Until clinical research scientifically establishes the existence of temporary brittle bone disease, it should remain strictly a hypothetical entity and not an acceptable medical diagnosis.

Bone age in children of diverse ethnicity.

OBJECTIVE: Determination of skeletal or bone age is often used in pediatrics and orthopedics. The most commonly used bone age standards in the United States, those published by Greulich and Pyle, were derived from white children of the upper socioeconomic class in 1931-1942. We examined whether these standards apply to the current assessment of bone age in children of diverse ethnicity. MATERIALS AND METHODS: Hand radiographs of children less than 19 years old at our institution were evaluated for bone age using the standards of Greulich and Pyle. Differences between bone age and chronologic age were calculated, and the mean differences were compared among subgroups of children on the basis of sex, age, and ethnicity. RESULTS: In Asian and white girls, bone age approximated chronologic age throughout childhood, with the only significant discrepancy being in adolescent white girls, in whom bone age exceeded chronologic age by an average of 4 months. In black girls, bone age exceeded chronologic age except during middle childhood. In late childhood and adolescence, bone age exceeded chronologic age by approximately 10 months. In Hispanic adolescent girls, bone age exceeded chronologic age by nearly 9 months. In black adolescent boys, bone age exceeded chronologic age by 5 months, with no significant discrepancies between bone age and chronologic age at other ages. In white preadolescent boys, bone age lagged behind chronologic age to a statistically significant degree, ranging from approximately 4 to 8 months. Preadolescent Asian boys also showed significant delays in bone age, particularly in middle childhood, when bone age lagged behind chronologic age by nearly 15 months. In adolescent Asian boys, bone age exceeded chronologic age by 9 months 15 days. In adolescent Hispanic boys, bone age exceeded chronologic age by 11 months 15 days. In younger Hispanic boys, delays in bone age occurred but were significant only in early childhood (4-month delay). CONCLUSION: Using the standards of Greulich and Pyle to determine bone age must be done with reservations, particularly in black and Hispanic girls and in Asian and Hispanic boys in late childhood and adolescence, when bone age may exceed chronologic age by 9 months to 11 months 15 days.

Sonographic differential diagnosis of right lower quadrant pain other than appendicitis.

Most patients presenting with right lower quadrant pain are clinically suspected to have acute appendicitis. However, sonographic findings other than appendicitis are detected in patients who are referred for ultrasound to rule out appendicitis. This pictorial essay delineates a number of unsuspected pathological conditions revealed by ultrasound examination of the right lower quadrant that do not involve the appendix but closely mimic acute appendicitis. Imaging studies play a significant role in preoperative diagnosis and determination of proper treatment. The patient can undergo triage for proper further workup and surgical versus nonsurgical management. Acute appendicitis initially was considered on clinical presentation in all of our patients. The correct diagnosis of other pathological conditions was made on the basis of sonographic findings.

Large intrathoracic tumors in children: imaging findings.

Massive benign or malignant thoracic tumors in children may arise from the chest wall, pleura, lung parenchyma, or mediastinum and may be primary or secondary. On initial chest radiographs, these masses usually appear as an opaque hemithorax or an obvious large opaque mass. If the site of origin of the intrathoracic tumor can be determined, the differential diagnosis may be based on the location of the tumor, the age of the patient, and distinguishing imaging features. The purpose of this essay is to illustrate imaging findings of large intrathoracic masses that cause an opaque hemithorax on initial chest radiographs. Chest wall masses that do not grow primarily intrathoracically are not included in this discussion.

Ulcerative type of colitis associated with the use of high strength pancreatic enzyme supplements in cystic fibrosis.

A 2 1/2-year-old girl with cystic fibrosis, who presented with hematochezia, developed an inflammatory ulcerative type of colitis with mild interstitial fibrosis and colonic narrowing while being treated with high strength pancreatic enzyme supplements. Findings of contrast enema, endoscopy, and colonic biopsy are described. The spectrum of colonic disease associated with the use of high strength pancreatic enzyme supplements in cystic fibrosis patients is discussed.

Abdominal tuberculosis in children.

Four boys with abdominal tuberculosis, one of whom had acquired immunodeficiency syndrome, are presented. Abdominal imaging findings on plain radiography, ultrasonography, computed tomography, and gastrointestinal contrast studies included tuberculous peritonitis and ascites in all patients, tuberculous adenopathy in two, gastrointestinal tuberculosis in two, and omental tuberculosis in two. The radiographic features particularly characteristic of abdominal tuberculosis were: (1) low attenuating adenopathy with rim enhancement, (2) omental or ileocecal inflammatory mass, (3) high density ascites, and (4) gastrointestinal enteritis involving the ileocecal region. All patients had acid-fast bacilli identified in cultures of bodily fluids and/or pathologic specimens and three patients had cultures positive for Mycobacterium tuberculosis. The patient with a negative culture had a positive PPD skin test and a surgical specimen showing caseating granulomata and acid-fast bacilli in the omentum. The radiologist must maintain a high degree of suspicion for abdominal tuberculosis particularly in normal or immunosuppressed children with acquired immunodeficiency syndrome. Fine needle aspiration and biopsy of abdominal adenopathy, inflammatory mass or ascites may be necessary for diagnosis.

CT, MRI, and color Doppler ultrasound correlation of pancreatoblastoma: a case report.

Pancreatic neoplasms in childhood are rare but should be considered in the differential diagnosis of masses in the region of the lesser sac. A case of pancreatoblastoma in a 3 1/2-year-old boy is presented. The patient was studied with US, CT, and MR imaging.

Pelvic injuries in child abuse.

Three cases of child abuse are described in which pelvic injuries were prominent findings on radiologic examination: Two patients had pelvic fractures, and one was found to have heterotopic ossification of the soft tissues of the pelvis and thighs corresponding to extensive bruising in the pubic, genital, buttock, and thigh areas, resulting from physical and sexual abuse. These represent uncommon radiographic findings. Skeletal survey in cases of suspected child abuse should include the entire pelvis, and special attention should be paid to the ischiopubic rami the most common site of these rare pelvic injuries.

Three pediatric patients with extension of prostatic embryonal rhabdomyosarcoma anterior to the bladder into the space of Retzius.

Invasive embryonal rhabdomyosarcoma of the prostate often extends superiorly into the bladder base requiring partial cystectomy as part of excision of the primary tumor. Three patients were studied with ultrasonography CT and MRI and showed the extension of the tumor superiorly and anterior to the bladder in the prevesical space of Retzius. Complete excision with bladder sparing was successful in two of the patients. The imaging of pelvic tumors in children (although well studied with ultrasonography, CT) is helped by MRI in the sagittal plane and/or lateral films of intravenous pyelograms and cystograms to establish the relation of the tumor to the bladder.

Esophageal perforation by a tooth in child abuse.

A unique case of child abuse in a six-year-old Hispanic girl is reported. In this case, a tooth avulsed and swallowed during an episode of physical abuse and/or sexual abuse, caused an esophageal perforation resulting in a retropharyngeal abscess and mediastinal abscess containing the tooth. Although traumatic esophageal injuries in child abuse have occurred, the presence of a tooth within the mediastinal abscess is an unique manifestation of child abuse.