Combined ultrasound and fluoroscopy guided tunneled external lumbar drain placement in children.

External lumbar drain placement has been shown to be an efficacious and safe approach to managing various forms of intracranial hypertension in adult patients and children. The use of ultrasound guidance for lumbar punctures in young patients has been described however, but the modality is not routinely used for the placement of tunneled lumbar drains. In this report, two cases are presented that detail experience using ultrasound guidance for tunneled lumbar drains in children.

Spinal ultrasound after failed landmarked-based lumbar puncture: a single institutional experience.

BACKGROUND: The safety and efficacy of US-guided lumbar puncture in children has been described. In the pediatric setting, children are frequently referred to interventional radiology only after a failed landmark-based attempt. Routine pre-procedure US in these children is useful to determine a safe level for subarachnoid access and to optimize success. OBJECTIVE: To determine whether pre-procedure US improves technical success and safety of US-guided lumbar puncture. MATERIALS AND METHODS: We included 47 children. Inclusion criteria were urgent US-guided lumbar puncture in pediatric patients <18 years old. Exclusion criteria were non-urgent lumbar punctures, children referred without an antecedent landmark-based attempt, lumbar punctures performed with fluoroscopic guidance, and procedures performed prior to introducing the diagnostic approach in 2017. We did not evaluate data pertaining to successful landmark-based lumbar punctures performed without subsequent need for additional attempts. We recorded technical successes, adverse events and relevant abnormalities identified on pre-procedural US. RESULTS: Thirty-six US-guided lumbar punctures were performed with 100% technical success. Eleven children referred to interventional radiology did not undergo lumbar puncture because of unfavorable US findings or interval clinical improvement obviating the need for lumbar puncture. Thirty-six children underwent US evaluation of the thecal sac prior to potential intervention. Of these 36 with pre-procedural US studies, 12 demonstrated paucity of cerebrospinal fluid and 14 demonstrated an epidural hematoma. Fifteen children who underwent lumbar puncture had a "traumatic tap," classified as a mild adverse event. No moderate or severe adverse events were recorded. CONCLUSION: Limited spinal US following failed landmark-based lumbar punctures frequently identifies procedure-related complications and can augment patient selection for future image-guided lumbar punctures.

Doppler ultrasound predictors of transplant hepatic venous outflow obstruction in pediatric patients.

OBJECTIVE: To investigate Doppler US and catheter venogram correlates to improve detection of transplant HVOO and avoid unnecessary invasive imaging procedures. MATERIALS AND METHODS: A retrospective review was performed in all pediatric OLT patients undergoing catheter venography of the hepatic veins between 2007 and 2017 at a single large tertiary pediatric liver transplant institution. RESULTS: Forty-four transplant hepatic venograms in 32 OLT patients were included (mean 1.38, range 1-4 venograms per patient). All venograms were preceded by an independent Doppler US examination. Twenty-one (47.7%) venograms were performed for the investigation of suspected HVOO based on Doppler US alone, 19 (43.2%) were performed for TJLB without suspected HVOO, 4 (9.1%) were performed for both. Sixteen (36.3%) instances of >50% anastomotic stenosis were identified. Mean peak anastomotic velocities were 208 cm/s and 116 cm/s in the presence and absence of a >50% venographic stenosis, respectively (P < 0.004). In all cases where there was a monophasic waveform seen on Doppler US, there was a > 50% stenosis seen on hepatic vein venogram. In all cases where a triphasic waveform was seen on Doppler US, there was no stenosis seen on hepatic vein venogram. CONCLUSION: While a Doppler US velocity threshold providing both high sensitivity and specificity has yet to be identified, increasing peak anastomotic velocity and decreasing intrahepatic venous velocity correlate strongly with venographic outflow stenosis. The presence of a triphasic intrahepatic waveform provides good NPV.

Emergent embolization of a ruptured splenic artery aneurysm complicating Menkes disease.

We report a 7-year-old boy with Menkes disease complicated by rupture of a large splenic artery aneurysm. The aneurysm was successfully embolized with microcoils and n-butyl cyanoacrylate. Further angiographic evaluation revealed marked tortuosity of mesenteric and lower extremity vasculature, including the femoral arteries bilaterally, without aneurysm formation. The patient has since been evaluated annually with computed tomography angiography and there have been no additional vascular complications of his disease during 3-year follow up.

Development and Evaluation of a Web-Based Dermatology Teaching Tool for Preclinical Medical Students.

INTRODUCTION: There is growing interest in, and emphasis on, electronic teaching tools in medicine. Despite relevant testing on the United States Medical Licensing Examination (USMLE), American medical schools offer limited training in skin disorders. Teaching visual topics like dermatology in classroom formats is challenging. We hypothesized that an electronic module would enhance students' dermatology competency. METHODS: A self-directed, case-based module was created. To test its efficacy, 40 medical students were randomized to have module access (interventional group) or none (conventional group). Learning outcomes were compared using a multiple-choice exam, including questions relevant and irrelevant to the module. Outcomes included proportions of correctly answered module questions (module scores) and nonmodule questions (nonmodule scores). Difference scores were calculated: (module score) - (nonmodule score). Positive values indicated that knowledge of module questions surpassed that of nonmodule questions. If there were a training effect, the interventional group's difference score should exceed that of the conventional group. RESULTS: The interventional group scored significantly higher than did the conventional group on module questions-75% (interquartile range [IQR], 69-88) versus 50% (IQR, 38-63), p < .001-and nonmodule questions-85% (IQR, 69-92) versus 69% (IQR, 54-77), p = .02. The Hodges-Lehman median difference estimate of the training effect was 13.0 (95% confidence interval, 0.5-25.5). DISCUSSION: This e-module is effective at enhancing students' competency in dermatology while emphasizing detailed pathophysiology that prepares them for USMLE Step 1. A module-based curriculum may enhance learning in supplement to traditional teaching modalities.