Correlation between ultrasonic and radiographic imaging of developmental dysplasia of the hip.

PURPOSE: The correlation between the degree of developmental hip dysplasia (DDH) measured on ultrasound images compared with that measured on radiographs is not clear. Most studies have compared ultrasonography (US) and radiographic images made at different times of follow-up. In this study the correlation between US images and radiographs of the hip made on the same day was evaluated. METHODS: US images and radiographs of both hips of 74 infants, who were treated for stable DDH, were reviewed in a retrospective study. Only infants who had an US examination and a radiograph on the same day were included. RESULTS: The correlation between α-angle of Graf and femoral head coverage on US was strong (p ≤ 0.0001). Weak correlations were found between the acetabular index of Tönnis on radiographs and α-angle of Graf on US (p = 0.049) and between acetabular index of Tönnis on radiographs and femoral head coverage of Morin on US (p = 0.100). CONCLUSION: This study reports on the correlation between US and radiographic imaging outcomes, both made on the same day in patients for treatment and follow-up of DDH. LEVEL OF EVIDENCE: IV.

Diagnostic accuracy of point-of-care ultrasound for evaluation of early blood-induced joint changes: Comparison with MRI.

INTRODUCTION: Recurrent joint bleeding is the hallmark of haemophilia. Synovial hypertrophy observed with Magnetic Resonance Imaging (MRI) is associated with an increased risk of future joint bleeding. AIM: The aim of this study was to investigate whether point-of-care ultrasound (POC-US) is an accurate alternative for MRI for the detection of early joint changes. METHODS: In this single centre diagnostic accuracy study, bilateral knees and ankles of haemophilia patients with no or minimal arthropathy on X-rays were scanned using POC-US and 3 Tesla MRI. POC-US was performed by 1 medical doctor, blinded for MRI, according to the "Haemophilia Early Arthropathy Detection with Ultrasound" (HEAD-US) protocol. MRIs were independently scored by 2 radiologists, blinded for clinical data and ultrasound results. Diagnostic accuracy parameters were calculated with 95% confidence intervals (CI). RESULTS: Knees and ankles of 24 haemophilia patients (96 joints), aged 18-34, were studied. Synovial hypertrophy on MRI was observed in 20% of joints. POC-US for synovial tissue was correct (overall accuracy) in 97% (CI: 91-99) with a positive predictive value of 94% (CI: 73-100) and a negative predictive value of 97% (CI: 91-100). The overall accuracy of POC-US for cartilage abnormalities was 91% (CI: 83-96) and for bone surface irregularities 97% (CI: 91-99). CONCLUSION: POC-US could accurately assess synovial hypertrophy, bone surface irregularities and cartilage abnormalities in haemophilia patients with limited joint disease. As POC-US is an accurate and available alternative for MRI, it can be used for routine evaluation of early joint changes.

The don't know option in progress testing.

Formula scoring (FS) is the use of a don't know option (DKO) with subtraction of points for wrong answers. Its effect on construct validity and reliability of progress test scores, is subject of discussion. Choosing a DKO may not only be affected by knowledge level, but also by risk taking tendency, and may thus introduce construct-irrelevant variance into the knowledge measurement. On the other hand, FS may result in more reliable test scores. To evaluate the impact of FS on construct validity and reliability of progress test scores, a progress test for radiology residents was divided into two tests of 100 parallel items (A and B). Each test had a FS and a number-right (NR) version, A-FS, B-FS, A-NR, and B-NR. Participants (337) were randomly divided into two groups. One group took test A-FS followed by B-NR, and the second group test B-FS followed by A-NR. Evidence for impaired construct validity was sought in a hierarchical regression analysis by investigating how much of the participants' FS-score variance was explained by the DKO-score, compared to the contribution of the knowledge level (NR-score), while controlling for Group, Gender, and Training length. Cronbach's alpha was used to estimate NR and FS-score reliability per year group. NR score was found to explain 27 % of the variance of FS [F(1,332) = 219.2, p < 0.0005], DKO-score, and the interaction of DKO and Gender were found to explain 8 % [F(2,330) = 41.5, p < 0.0005], and the interaction of DKO and NR 1.6 % [F(1,329) = 16.6, p < 0.0005], supporting our hypothesis that FS introduces construct-irrelevant variance into the knowledge measurement. However, NR-scores showed considerably lower reliabilities than FS-scores (mean year-test group Cronbach's alphas were 0.62 and 0.74, respectively). Decisions about FS with progress tests should be a careful trade-off between systematic and random measurement error.

Diagnosis and subsequent US-guided percutaneous drainage of an adrenal abscess in a 5-week-old infant.

Adrenal abscess is an uncommon finding in neonates and young infants. It may have a fatal outcome if inadequately treated. This case report describes the successful diagnosis and treatment of a left-sided adrenal abscess in a 5-week-old girl. Abdominal US and antigranulocyte antibody-scintigraphy showed an encapsulated suprarenal mass with debris suspicious for an adrenal abscess. Treatment is generally surgical. In this case, however, we performed US-guided percutaneous drainage combined with intravenous antibiotic treatment. The child recovered fully.

Radiation exposure and mortality risk from CT and PET imaging of patients with malignant lymphoma.

OBJECTIVE: To quantify radiation exposure and mortality risk from computed tomography (CT) and positron emission tomography (PET) imaging with (18)F-fluorodeoxyglucose ((18)F-FDG) in patients with malignant lymphoma (Hodgkin's disease [HD] or non-Hodgkin's lymphoma [NHL]). METHODS: First, organ doses were assessed for a typical diagnostic work-up in children with HD and adults with NHL. Subsequently, life tables were constructed for assessment of radiation risks, also taking into account the disease-related mortality. RESULTS: In children with HD, cumulative effective dose from medical imaging ranged from 66 mSv (newborn) to 113 mSv (15 years old). In adults with NHL the cumulative effective dose from medical imaging was 97 mSv. Average fractions of radiation-induced deaths for children with HD [without correction for disease-related mortality in brackets] were 0.4% [0.6%] for boys and 0.7% [1.1%] for girls, and for adults with NHL 0.07% [0.28%] for men and 0.09% [0.37%] for women. CONCLUSION: Taking into account the disease-related reduction in life expectancy of patients with malignant lymphoma results in a higher overall mortality but substantial lower incidence of radiation induced deaths. The modest radiation risk that results from imaging with CT and (18)F-FDG PET can be considered as justified, but imaging should be performed with care, especially in children.

High-resolution computed tomography and pulmonary function in children with common variable immunodeficiency.

High-resolution computed tomography (HRCT) may be useful to monitor lung disease in children with common variable immunodeficiency disorder (CVID). We evaluated interobserver agreement and correlation with pulmonary function tests (PFTs) for automated quantification and visual scoring of air trapping and airway wall thickening on HRCT in paediatric CVID patients. In a cohort of 51 children with CVID, HRCT was analysed visually and automated for presence of air trapping and airway wall thickening. PFTs were expressed as % predicted. Disease duration, physician-diagnosed pneumonias and antibiotic prophylaxis were recorded. Interobserver agreement for automated airway wall thickening was good with an intra-class correlation coefficient of 0.88, compared with 0.51 for visual scoring. Presence of air trapping on HRCT correlated significantly with PFTs and disease duration, but was not associated with previous pneumonias. Airway wall thickening did not correlate significantly with PFTs or disease duration and was not associated with previous pneumonias or prophylactic antibiotic use. In children with CVID disorders, HRCT air trapping measurements are significantly correlated with PFTs and disease duration. Quantitative air trapping is a feasible and promising technique for small airway disease quantification that may be applied to monitor (silent) disease progression in CVID.

Pelvic rotation and tilt can cause misinterpretation of the acetabular index measured on radiographs.

BACKGROUND: Radiographic diagnosis and followup studies of developmental dysplasia of the hip are commonly performed by measuring the acetabular index on radiographs using Hilgenreiner's method. The outcome of the measurement, however, depends on the orientation of the subject's pelvis relative to the xray source. The influence of pelvic rotation and tilt on the measurement error has been evaluated separately but not in combination. QUESTIONS/PURPOSES: We asked whether (1) combinations of pelvic rotation and tilt introduced systematic error in acetabular index measurement in a reproducible way, and (2) ratios proposed to evaluate either pelvic rotation (R(rotation)) or pelvic tilt (R(tilt)) are influenced by pelvic tilt and rotation, respectively. METHODS: Radiographic measurements of the acetabular index, R(rotation), and R(tilt) were performed on digitally reconstructed radiographs of one high-resolution three-dimensional CT dataset with various combinations of pelvic rotation and tilt. RESULTS: For rotations and tilt up to 12°, the average systematic errors in the acetabular index varied from -8.8° to 4.5°. Negative and positive error values can be interpreted as underestimations and overestimations of the acetabular index, respectively. Errors in acetabular index measurements were acceptable for R(rotation) values between 1.0 and 2.0 and R(tilt) values between 1.1 and 1.8. CONCLUSIONS: To limit the systematic error in assessing the acetabular index caused by pelvic misalignment, we recommend only radiographs acquired with ± 4° rotation and ± 4° tilt be considered acceptable.

Modified Chrispin-Norman chest radiography score for cystic fibrosis: observer agreement and correlation with lung function.

OBJECTIVE: To test observer agreement and two strategies for possible improvement (consensus meeting and reference images) for the modified Chrispin-Norman score for children with cystic fibrosis (CF). METHODS: Before and after a consensus meeting and after developing reference images three observers scored sets of 25 chest radiographs from children with CF. Observer agreement was tested for line, ring, mottled and large soft shadows, for overinflation and for the composite modified Chrispin-Norman score. Correlation with lung function was assessed. RESULTS: Before the consensus meeting agreement between observers 1 and 2 was moderate-good, but with observer 3 agreement was poor-fair. Scores correlated significantly with spirometry for observers 1 and 2 (-0.72

Constipation in pediatric cystic fibrosis patients: an underestimated medical condition.

BACKGROUND: The aims of this study were to determine prevalence, risk factors and treatment of constipation in patients with Cystic Fibrosis (CF), as well as the diagnostic value of abdominal radiography. METHODS: A cohort of 214 pediatric CF patients was investigated. Furthermore, 106 abdominal radiographs of CF patients with or without constipation were independently assessed by three observers on two separate occasions using the Barr and Leech scores. RESULTS: The prevalence of constipation was 47%. Low total fat absorption and meconium ileus were independent risk factors for constipation in CF, while fiber and fluid intake were not associated. In CF patients the inter and intraobserver variabilities of the Barr and Leech scores were poor to moderate. CONCLUSION: Constipation is a significant medical issue in CF and was associated with low total fat absorption and a history of meconium ileus. Finally, abdominal radiography seems of little value in the regular follow-up of CF patients.

Grading of carotid artery stenosis with multidetector-row CT angiography: visual estimation or caliper measurements?

To assess the optimal method for grading carotid artery stenosis with computed tomographic angiography (CTA), we compared visual estimation to caliper measurements, and determined inter-observer variability and agreement relative to digital subtraction angiography (DSA). We included 46 patients with symptomatic carotid stenosis for whom CTA and DSA of 55 carotids was available. Stenosis quantification by CTA using visual estimation (CTA(VE)) (method 1) was compared with caliper measurements using subjectively optimized wide window settings (method 2) or predefined contrast-dependent narrow window settings (method 3). Measurements were independently performed by two radiologists and two residents. To determine accuracy and inter-observer variability, we calculated linear weighted kappa, performed a Bland-Altman analysis and calculated mean difference (bias) and standard deviation of differences (SDD). For inter-observer variability, kappa analysis was "very good" (0.85) for expert observers using CTA(VE) compared with "good" (0.61) for experts using DSA. Compared with DSA, method 1 led to overestimation (bias 5.8-8.0%, SDD 10.6-14.4), method 3 led to underestimation (bias -6.3 to -3.0%, SDD 13.0-18.1). Measurement variability between DSA and visual estimation on CTA (SDD 11.5) is close to the inter-observer variability of repeated measurements on DSA that we found in this study (SDD 11.6). For CTA of carotids, stenosis grading based on visual estimation provides better agreement to grading by DSA compared with stenosis grading based on caliper measurements.

Neonatal cranial ultrasound versus MRI and neurodevelopmental outcome at school age in children born preterm.

AIM: To examine the correlation between neonatal cranial ultrasound and school age magnetic resonance imaging (MRI) and neurodevelopmental outcome. METHODS: In a prospective 2 year cohort study, 221 children (gestational age < or =32 weeks and/or birth weight < or =1500 g) participated at a median age of 8.1 years (inclusion percentage 78%). Conventional MRI, IQ (subtests of the WISC), and motor performance (Movement Assessment Battery for Children) at school age were primary outcome measurements. RESULTS: Overall, there was poor correspondence between ultrasound group classifications and MRI group classifications, except for the severe group (over 70% agreement). There was only a 1% chance of the children with a normal cranial ultrasound having a major lesion on MRI. Mean IQ (standard deviation) was significantly lower in children with major ultrasound or MRI lesions, but was also lower in children with minor lesions on MRI compared to children with a normal MRI (91+/-16, 100+/-13, 104+/-13 for major lesions, minor lesions, and normal MRI, respectively). Median total impairment score (TIS) was significantly higher in children with major lesions on ultrasound or MRI as well as in children with minor lesions on MRI (TIS 4.0 and 6.25 for normal and minor lesions on MRI, respectively; p<0.0001). CONCLUSIONS: A normal neonatal cranial ultrasound excluded a severe lesion on MRI in 99% of cases. MRI correlated more strongly with mean IQ and median TIS than ultrasound. Subtle white matter lesions are better detected with MRI which could explain the stronger correlation of MRI with IQ and motor performance.

Carotid stenosis and carotid plaque analysis relevant to carotid endarterectomy and stent-assisted angioplasty.

The primary objective of this cadaveric study was to review the morphological variations of the anatomy of the human carotid artery bifurcation relevant to carotid endarterectomy (CEA) and carotid artery stent-supported angioplasty (CSSA). We quantify carotid bifurcation plaque morphology. Results showed that the angle of deviation at the origin of the internal carotid artery (ICA), in relation to the common carotid artery (CCA), measured a mean of 21.8 degrees with a range from seven to 45 degrees. This anatomical finding is important for the interventionalist concerned with insertion of a carotid stent. The angle of the ICA origin may be an independent risk factor for early atherosclerotic changes at the ICA bulb. Carotid bifurcation plaque was observed in a small, random cohort of seven out of 13 cadavers, and contributed to a mean stenosis of 15.2% (range 5.0-34.8%). Plaque morphology (n = 7) showed haemorrhage (29%), superficial thrombosis (57%), calcification (71%), areas of focal necrosis (71%), neovascularisation (14%) and infiltrates (29%). Ulcerations were not detected. Although four out of 13 patients (31%) died of a cerebrovascular accident, the cause of cerebral apoplexy was thought not to be associated with the carotid bifurcation pathology. 'Re-boring' of occluding plaque, as in CEA, offers potential volumetric anatomical advantage over CSSA within the carotid bifurcation and bulb. In conclusion, precise and applied knowledge of carotid bifurcation anatomy is critical to reduce technical complications during CEA or CSSA. This information may reduce potential dangers of iatrogenic thrombo-embolism and ensuing neurologic deficits. Patients with low-grade carotid stenosis, evidence of focal plaque necrosis, are at risk of spontaneous plaque cap rupture, distal thromboembolism and stroke.

EVAR: critical applied aortic morphology relevant to type-II endoleaks following device enhancement in patients with abdominal aortic aneurysms.

Endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) is an established alternative option to conventional surgery for AAA, provided optimal anatomical morphology of the aneurysm sac, neck and outflow exists. In most documented series of EVAR, type-II endoleak occurrence is a universal procedural drawback. This is referred to as the Achilles heel of EVAR. This morphological study, addressing predominantly non-aneurysmal aortic anatomy, reveals the dyssynchronous origins of the renal ostia, ectopia of the superior mesenteric artery and median sacral artery, variations in the length of the infrarenal abdominal aorta, multiple mainstem renal arteries, and the presence of accessory renal arteries (in 13% of cadavers). Such potential vascular anomalies need careful consideration pre-operatively prior to EVAR. In a prospective, clinical study of EVAR in 163 patients over 60 months, using four different aortic stent devices, we demonstrated an intraprocedural type-II endoleak rate, before exclusion, of 3% (5/163). Most were related to patent lumbar arteries. An active policy of intraprocedural aneurysm pressure sac measurement and angiography was used to demonstrate type-I and type-II endoleaks, focusing on the applied anatomy of aortic side branches and variations. Selective intraprocedural coil embolisation and thrombin injection into the sac was utilised to thrombose persisting and large lumbar arteries that predisposed to retroleaks. We recorded a low incidence of persisting type-II endoleaks using this proactive treatment strategy by addressing variant aortic morphology and patent lumbar arteries during EVAR. One aneurysm-related death (0.6%) was observed due to late rupture after EVAR, and a single intraprocedural death was related to unpredictable aneurysm rupture. In conclusion, comprehensive anatomical knowledge of the abdominal aorta and its main collateral side branches, including variations, is a fundamental prerequisite if satisfactory and predictable results are to be achieved after EVAR, especially regarding prevention, diagnosis and treatment of type-II endoleaks. Intraprocedural aneurysm sac pressure monitoring, coil embolisation and the use of injection of thrombin into the aneurysm sac of selected patients is useful in reducing the incidence of post-EVAR type-II persisting endoleaks.

[Current validation of the Greulich and Pyle atlas for the determination of skeletal age]. / Hedendaagse validering van de atlas van Greulich en Pyle voor het bepalen van de skeletleeftijd.

The radiological atlas of Greulich and Pyle published in 1959 has been validated for the modern measurement of skeletal development in a population of white school-age children from Rotterdam. This is a useful study result. Although contemporary children grow to become much taller than in previous generations, this increased growth potential is apparently realised within the same time span.

The benefit of STent placement and blood pressure and lipid-lowering for the prevention of progression of renal dysfunction caused by Atherosclerotic ostial stenosis of the Renal artery. The STAR-study: rationale and study design.

BACKGROUND: Atherosclerotic renal artery stenosis (ARAS) is associated with progressive loss of renal function and is one of the most important causes of renal failure in the elderly. Current treatment includes restoration of the renal arterial lumen by endovascular stent placement. However, this treatment only affects damage caused by ARAS due to the stenosis and ensuing post-stenotic ischemia. ARAS patients have severe general vascular disease. Atherosclerosis and hypertension can also damage the kidney parenchyma causing renal failure. Medical treatment focuses on the latter. Lipid-lowering drugs (statins) could reduce renal failure progression and could reduce the overall high cardiovascular risk. The additional effect on preserving renal function of stent placement as compared to medical therapy alone is unknown. Therefore, the STAR-study aims to compare the effects of renal artery stent placement together with medication vs. medication alone on renal function in ARAS patients. METHOD: Patients with an ARAS of > or = 50% and renal failure (creatinine (Cr) clearance < 80 mL/min/1.73 m2) are randomly assigned to stent placement with medication or to medication alone. Medication consists of statins, anti-hypertensive drugs and antiplatelet therapy. Patients are followed for 2 yrs with extended follow-up to 5 yrs. The primary outcome of this study is a reduction in Cr clearance > 20% compared to baseline. This trial will include 140 patients.

Unilateral parenchymal haemorrhagic infarction in the preterm infant.

A unilateral parenchymal haemorrhage associated with a germinal matrix-intraventricular haemorrhage (GMH-IVH) is still an important problem in the preterm infant and especially in those who are very immature. This type of lesion is now considered mainly to be caused by impaired drainage of the veins in the periventricular white matter and is often referred to as a venous infarction. The risk factors and neonatal imaging findings, as well as neurodevelopmental outcome and imaging data in infancy, of this type of lesion differ from those found in children with bilateral periventricular leukomalacia. An effort should, therefore, always be made to make a distinction between these two types of lesions. In our experience it is possible to make this distinction in most cases, when performing both sequential ultrasonography as well as selective magnetic resonance imaging during the neonatal period.