Of oranges and lemons: you are what you eat.

A young boy presented with increasing lower limb pain and swelling for a month. At the time of his hospitalisation, he was unable to walk. We report the patient's clinical journey with clinical commentary throughout, highlighting the importance that uncommon diseases may be diagnosed with a high index of suspicion and thorough history taking.

Current Role of Conventional Radiography of Sacroiliac Joints in Adults and Juveniles with Suspected Axial Spondyloarthritis: Opinion from the ESSR Arthritis and Pediatric Subcommittees.

This opinion article by the European Society of Musculoskeletal Radiology Arthritis and Pediatric Subcommittees discusses the current use of conventional radiography (CR) of the sacroiliac joints in adults and juveniles with suspected axial spondyloarthritis (axSpA). The strengths and limitations of CR compared with magnetic resonance imaging (MRI) and computed tomography (CT) are presented.Based on the current literature and expert opinions, the subcommittees recognize the superior sensitivity of MRI to detect early sacroiliitis. In adults, supplementary pelvic radiography, low-dose CT, or synthetic CT may be needed to evaluate differential diagnoses. CR remains the method of choice to detect structural changes in patients with suspected late-stage axSpA or established disease and in patients with suspected concomitant hip or pubic symphysis involvement. In children, MRI is the imaging modality of choice because it can detect active as well as structural changes and is radiation free.

Can the Third Part of Duodenum Behind SMA Be Detected With Confidence on CT as a Proposed Mechanism for Imaging Suspected Malrotation in Children? A Preliminary Proof of Concept Study.

AIM: The aims of this study were to determine frequency and reliability of computed tomography (CT) detection of anatomic landmarks for imaging suspected midgut malrotation in infants and children, and to calculate an estimated effective dose of an upper abdominal CT scan in our patient population. MATERIALS AND METHODS: Fifty consecutive pediatric patients who underwent a CT scan that included their upper abdomen between August 2016 and February 2018 were included. Four pediatric radiology consultants independently reviewed CT scans for detection of the third part of the duodenum and defined their confidence level of this through identification of continuity with the pyloric antrum, D1, D2, and D4 components of the duodenum, as well as the duodenojejunal flexure.Interobserver variability was assessed using Fleiss κ for agreement. A dose estimate, per scan, was calculated using the scanner dose-length product and published conversion factors by Deak. RESULTS: Thirty patients were boys. The average age was 7.5 ± 5.4 years (6 days to 16 years). The D3 segment was definitely identified in 70% of scans, with 68% to 73%, moderate agreement between the readers and a Fleiss κ of 0.47 to 0.52. The DJ flexure was definitely identified in only 30.5% cases, with 35%, poor agreement between readers (Fleiss κ of 0.03). The average estimated dose for a targeted CT scan of the abdomen was 0.9 mSv (0.04-2.4 mSv). CONCLUSIONS: The third part of the duodenum, which is integral in excluding malrotation on cross-sectional studies, was "definitely" identified in 70% of CT scans of children in our study, with 68% to 73% agreement between the readers and a Fleiss κ of 0.47 to 0.52.These preliminary proof of concept results demonstrating a combination of a comparable CT dose in relation to upper gastrointestinal contrast studies and an acceptable number of cases delineating the third part of the duodenum with moderate agreement are a first step in suggesting low-dose CT for an imaging diagnosis of malrotation. Malrotation can be excluded in cases where D3 is well demonstrated in the normal position, which negates the need to automatically refer children with bilious emesis to specialist centers for upper gastrointestinal contrast studies.

Artificial intelligence for interpretation of segments of whole body MRI in CNO: pilot study comparing radiologists versus machine learning algorithm.

BACKGROUND: To initiate the development of a machine learning algorithm capable of comparing segments of pre and post pamidronate whole body MRI scans to assess treatment response and to compare the results of this algorithm with the analysis of a panel of paediatric radiologists. METHODS: Whole body MRI of patients under the age of 16 diagnosed with CNO and treated with pamidronate at a tertiary referral paediatric hospital in United Kingdom between 2005 and 2017 were reviewed. Pre and post pamidronate images of the commonest sites of involvement (distal femur and proximal tibia) were manually selected (n = 45). A machine learning algorithm was developed and tested to assess treatment effectiveness by comparing pre and post pamidronate scans. The results of this algorithm were compared with the results of a panel of radiologists (ground truth). RESULTS: When tested initially the machine algorithm predicted 4/7 (57.1%) examples correctly in the multi class model, and 5/7 (71.4%) correctly in the binary group. However when compared to the ground truth, the machine model was able to classify only 33.3% of the samples correctly but had a sensitivity of 100% in detecting improvement or worsening of disease. CONCLUSION: The machine learning could detect new lesions or resolution of a lesion with good sensitivity but failed to classify stable disease accurately. However, further validation on larger datasets are required to improve the specificity and accuracy of the machine model.

Neurofibromatosis Type 1: Description of a Novel Diagnostic Scoring System in Pediatric Optic Nerve Glioma.

OBJECTIVE: Neurofibromatosis type 1 (NF1) is a multisystemic genetic disease in which patients develop benign tumors including optic nerve gliomas (ONG). Optic nerve thickening and tortuosity are radiologic markers of tumors but can also be present in children with NF1 who do not have gliomas, thus complicating screening and diagnosis. We undertook this study to retrospectively determine quantitative and qualitative diagnostic criteria using MRI of the orbits for ONG in children with NF1. MATERIALS AND METHODS: MR images of the orbits obtained from 2003 to 2016 for children with and without NF1 were reviewed. Optic nerves were divided into three groups: NF1 with glioma (n = 71 nerves), NF1 without glioma (n = 151 nerves), and healthy control subjects (n = 66 nerves). The diameter of each nerve was measured at multiple locations. Two radiologists assessed tortuosity using validated criteria, and subarachnoid dilatation was quantified. Last, a composite score using both optic nerve diameter and tortuosity was proposed. RESULTS: The mean diameter of the optic nerve was significantly larger in patients with NF1 with glioma compared with those with NF1 without glioma and with control subjects at all locations. Maximal nerve diameter greater than 2 SD above the mean maximal diameter for control nerves was considered abnormally enlarged. The tortuosity parameters were all significantly associated with ONG compared with absence of ONG in NF1. A scoring system derived from these data were highly reliable in differentiating ONG from absence of ONG in NF1. CONCLUSION: The radiologic diagnosis of ONG in patients with NF1 is challenging. The scoring systems we describe provide a framework for simple radiologic criteria for ONG in these patients.

Correction to: Magnetic resonance imaging of sacroiliitis in children: frequency of findings and interobserver reliability.

The original version of this article contained an error. Under the heading 'Limitations', the sentence 'Another limitation was the decision to exclude one reader from interobserver analysis.

Magnetic resonance imaging of sacroiliitis in children: frequency of findings and interobserver reliability.

BACKGROUND: Clinicians increasingly rely on imaging in juvenile idiopathic arthritis (JIA) to identify sacroiliitis and guide treatment. However, there is limited evidence about magnetic resonance imaging (MRI) for sacroiliitis in children, and interobserver reliability is variable. OBJECTIVE: Identify the frequency of MRI findings in children with suspected sacroiliitis, calculate inter-reporter reliability and assess the value of diffusion-weighted imaging and contrast-enhanced sequences. MATERIALS AND METHODS: We retrospectively reviewed 3 years of sacroiliac joint MRI records for suspected sacroiliitis in patients <21 years at a United Kingdom tertiary referral paediatric hospital. Five radiologists (panel of three radiologists and two independent radiologists) reviewed all MRI examinations using a pictorial checklist to identify oedema, effusions, diffusion-weighted signal abnormality, enhancement, erosions and sclerosis. The frequency of panel findings was reported. Interobserver agreement was calculated using the Cohen kappa coefficient. RESULTS: An MRI diagnosis of sacroiliitis was made in 12 of 99 examinations (12%). The findings in all scans included oedema (9%), erosions (8%), diffusion-weighted signal abnormality (6%), abnormal enhancement (6%) and effusion (4%). All scans with abnormal contrast enhancement had other MRI features of sacroiliitis. Interobserver agreement was slight to moderate. CONCLUSION: Oedema and erosions were the most common findings. Inter-reporter reliability was variable with at best moderate agreement for the presence of sacroiliitis and erosions. The use of contrast enhancement for diagnosing sacroiliitis in children with JIA may be questionable.

[The influence of the number of bars on the axial compressive strength of uniplanar external fixators in polyurethane tibia models]. / A influência do número de barras na resistência à compressão axial dos fixadores externos monoplanares em modelos de tíbias de poliuretano.

OBJECTIVE: This is an experimental study with the objective of analyses the increase of rigidity in synthetic tibia bones with external fixators, with single and double connecting rods and with stable and unstable fracture patterns. METHODS: The external fixators were used in the monoplanar, half pin configuration submitted to an axial compression load using the connecting bar in different patterns. Forty-eight similar models to the human tibia had been used. In all the models were left an interval of 0,5 cm between the fragments and were made cuts of 15 masculine and 45 masculine to simulate stable and unstable fracture patterns, respectively. The models had been divided in four groups in accordance with the cut (15 masculine and 45 masculine) and the number of metallic bars in assembly (1 and 2 bars). The study used the Instron testing machine which the models were submitted to the axial load until the fragments that were separated by a gap made full contact. RESULTS: The instability forces in the assembly with a double bar had been sufficiently superior to the forces with only one bar. It was still observed that the group with unstable fracture pattern and with only one connecting rod had a lesser variability compared with the other groups and presented more homogeneous results, with a minor average. CONCLUSION: The assembly with a double longitudinal connecting rod in the studied models is more stable than the others to stand compression load.

A influência do número de barras na resistência à compressão axial dos fixadores externos monoplanares em modelos de tíbias de poliuretano / The influence of the number of bars on the axial compressive strength of uniplanar external fixators in polyurethane tibia models

OBJETIVO: Analisar a resistência (rigidez) do sistema de fixação externa tubular uniplanar, com hastes de conexão única e dupla, com traços de fraturas estáveis e instáveis. MÉTODOS: Foram utilizados 48 modelos semelhantes à tíbia. Em todos foi deixado um intervalo de 0,5 cm entre os fragmentos e realizados cortes com angulações de 15º e 45º para simular fraturas estáveis e instáveis, respectivamente. Os modelos foram divididos em quatro grupos de acordo com o traço fraturário (15º e 45º) e o número de barras metálicas na montagem (1 e 2 barras). Os modelos de prova foram adaptados à uma máquina de testes Instron®, pelas suas extremidades, e submetidos à compressão axial até que os fragmentos tiveram contato total. Avaliou-se a força necessária para efetuar o completo contato dos fragmentos do modelo. RESULTADOS: As forças instabilizadoras na montagem do fixador com barra dupla foram bastante superiores às com barra única. Observou-se ainda que o grupo com barra única instável apresentou variabilidade muito menor que os demais grupos, ou seja, apresenta resultados mais homogêneos, além de ter apresentado a menor média. CONCLUSÃO: A montagem do fixador externo com uma haste longitudinal dupla nos modelos estudados é mais estável que as demais quando submetidas à uma força de compressão axial.

OBJECTIVE: This is an experimental study with the objective of analyses the increase of rigidity in synthetic tibia bones with external fixators, with single and double connecting rods and with stable and unstable fracture patterns. METHODS: The external fixators were used in the monoplanar, half pin configuration submitted to an axial compression load using the connecting bar in different patterns. Forty-eight similar models to the human tibia had been used. In all the models were left an interval of 0,5 cm between the fragments and were made cuts of 15º and 45º to simulate stable and unstable fracture patterns, respectively. The models had been divided in four groups in accordance with the cut (15º and 45º) and the number of metallic bars in assembly (1 and 2 bars). The study used the Instron® testing machine which the models were submitted to the axial load until the fragments that were separated by a gap made full contact. RESULTS: The instability forces in the assembly with a double bar had been sufficiently superior to the forces with only one bar. It was still observed that the group with unstable fracture pattern and with only one connecting rod had a lesser variability compared with the other groups and presented more homogeneous results, with a minor average. CONCLUSION: The assembly with a double longitudinal connecting rod in the studied models is more stable than the others to stand compression load.

A influência da microflora vaginal de cães na resistência tênsil dos fios cirúrgicos polipropilene, categute cromado, poliglecaprone 25 e glicomer 60 / The influence of vaginal flora in the tensile strenght the material sutures polypropilene, chromic gut, poliglecaprone 25 and clicomer 60

O objetivo desse estudo é analisar a influência da flora bacteriana vaginal na RESISTÊNCIA TÊNSIL DOS FIOS CIRÚRGICOS POLIPROPILENE, CATEGUTE CROMADO, POLIGLECAPRONE 25 E GLICOMER 60. AMOSTRAS DE CADA TIPO DE FIO FORAM INOCULADAS EM CULTURA deflora bacteriana vaginal e plasma animal e fêmeas Canis familiaris para avaliação quanto à resistência à tração linear, nos dias 1,, 3, 5, 7, 10 e 14 de incubação. Para a coleta da flora bacteriana inseriu-se swab vaginal estéril em vestíbulo e vagina distal. O material foi colocado em meio de transporte agar (Carry Blair - DIFCO), em um tubo de ensaio esterilizado, e encaminhado para o Laboratório de Microbiologia e Patologia Clínica Curitiba e posteriormente para medida da resist~encia t~ensil, para a Universidade de Wurzburg, Alemanha. Com base nos resultados, pode-se concluir que a flora bacteriana vaginal das f~emeas Canis familiaris não alterou a resist~encia tênsil em nenhum dos fios estudados

Estudo experimental comparativo da cicatrização de suturas em cornos uterinos de Canis familiaris, utilizando os fios de poliglactina 910 e poliglecaprone 25 / Experimental study of healing process of the uterine horns of Canis familiaris performed with poliglactina 910 and poliglecaprone 25

O objetivo deste trabalho é analisar experimentalmente, de modo prospectivo e randomizado, os aspectos de cicatrização de suturas realizadas em cornos uterinos de cães, comparando os fios poliglactina 910 (Vicry) e poliglecaprone 25 (Monocryl). Foram utilizados 18 fêmeas Canis familiaris, divididas em 3 grupos com 6 animais, para avaliação no 3º, 7º e 21º dia pós-operatório. Uma vez realizado o procedimento cirúrgico em ambos cornos uterinos e dado o período expectante, foram analisados: aspecto macroscópico, sob os testes "t Student", "Exato de Fisher", "Mann-Whitney" e, para análise de variância, o teste utilizado foi o "anova". Na análise dos parâmetros estudados, concluiu-se que o fio Vicryl e o fio Monocryl equipararam-se na realização da sutura cicatricial em cornos uterinos de fêmeas Canis familiaris

Estudo comparativo da cicatrizaçäo de suturas em trato genital da fêmea canis familiaris com uso de fios de polipropilene, categute cromado, poliglecaprone 25 e glicomer 60 / Comparative study of wound healing of sutures in female canis familiaris with material suture polypropilene, chromic gut, poliglecaprone 25 and glicomer 60

O presente estudo tem como objetivo comparar o processo de reparo em suturas de cornos uterinos e vagina da fêmea Canis Familiaris, realizadas com o fio monofilamentar absorvível de glicomer 60 (Monosyn), polipropilene (Prolene), POLIGLECAPRONE 25 (Monocryl) e categute cromado. Realizaram-se suturas nos cornos uterinos e vagina de 18 cadelas, com avaliaçäo após 3, 7 2 14 dias. Ao toque vaginal todos os fios foram palpáveis logo após as suturas e no dia 3 de P.O. A presença de bridas e aderências do corno uterino foi mais frequente com o categute cromado, porém sem significäncia estatística. Näo houve diferença estatística entre os grupos na determinaçäo da resistência à insuflaçäo de ar atmosférico e da tensäo radial das suturas dos cornos uterinos. No 3§ dia ocorreu maior necrose isquêmica com o glicomer 60 (p=0,0065) e a coaptaçäo das bordas de sutura na vagina esteve completa no 7§dia e, nos cornos uterinos, no 14§ dia na maioria dos fios estudados. Concluiu-se que o fio glicomer 60 equiparou-se aos demais fios do estudo nos primeiros 14 dias de pós-operatório de suturas realizadas em corno uterino e vagina de cadelas