Improving On-Time Starts for Pediatric Cardiac MRI.

PURPOSE: Delayed start times for cardiac MRI examinations have resulted in longer patient fasts, extended wait times, and poor synchronization of anesthesia induction and contrast administration. The aim of this work was to improve on-time start rates from an initial baseline of 10%. METHODS: A multidisciplinary team comprising members of the cardiac and radiology services used the Realizing Improvement Through Team Empowerment methodology to target the root causes of the delays and enhance workflow. The main factors identified as contributing to examination delays were late patient arrival, variations in patient preparation time, unavailability of equipment, and inefficient scheduling processes. RESULTS: The implementation of various interventions, such as the use of standardized appointment scripts, ensuring timely patient preparation, and ensuring the availability of equipment when required, resulted in an increase in on-time start rates for cardiac MRI examinations to 34%. CONCLUSIONS: The study's systematic approach proved to be valuable in both understanding and resolving the identified problems. Through the continuous application of plan-do-study-act cycles, the authors effectively pinpointed obstacles and tested multiple potential measures to overcome them. This approach made it possible to comprehend the issue and to implement targeted interventions to address it.

Establishing a magnetic resonance safety program.

Establishing a magnetic resonance (MR) safety program is crucial to ensuring the safe MR imaging of pediatric patients. The organizational structure includes a core safety council and broader safety committee comprising all key stakeholders. These groups work in synchrony to establish a strong culture of safety; create and maintain policies and procedures; implement device regulations for entry into the MR setting; construct MR safety zones; address intraoperative MR concerns; guarantee safe scanning parameters, including complying with specific absorption rate limitations; adhere to national regulatory body guidelines; and ensure appropriate communication among all parties in the MR environment. Perspectives on the duties of the safety council members provide important insight into the organization of program oversite. Ultimately, the collective dedication and vigilance of all MR staff are crucial to the success of a safety program.

Contrast Extravasation using Power Injectors for Contrast-Enhanced Computed Tomography in Children: Frequency and Injury Severity.

PURPOSE: To evaluate the safety of power injectors for contrast-enhanced computed tomography (CT) in children, namely: the prevalence and injury severity of contrast extravasations related to power injectors and the factors associated with these events. METHODS: The need to obtain informed consent was waived for this HIPAA-compliant and IRB approved retrospective study. Around 2429 contrast-enhanced CT performed with a power injector were identified during a 3-year period. Data collected included patient demographic, power injector, and contrast agent information. The patients' symptoms, severity of injury and treatment with contrast extravasation were recorded. Around 1496 cases (823 boys, 673 girls) were included in the analysis. Independent-sample t test and Chi-square were used. For a sub-analysis using the extravasation cases, nonparametric tests were used. RESULTS: The mean age was 9.5 ± 6.1 years. The most common access site, catheter site, and contrast agent used were the antecubital fossa, 22 gauge and Iohexol. The mean peak pressure was 68.9 ± 62.3 psi and the flow rate was 1.7 ± 0.9 mL/s. Eighteen cases of contrast extravasation were identified with a mean age of 11.2 ± 6.2 years. There were seven mild, six moderate, and five severe. Cases with extravasation had significantly higher peak pressure (p < 0.001) and flow rate (p < 0.001) compared to those without extravasation. Patients who received Iohexol-350 had significantly more contrast extravasation compared to those who used Iohexol-300 (p = 0.03). However, after post-hoc correction, only peak pressure (p < 0.01) and flow rate (p = 0.01) remained significant. CONCLUSION: The use of power injectors in children undergoing contrast-enhanced CT is associated with a low rate of extravasation and of long-term injury.

Dual-energy compared to single-energy CT in pediatric imaging: a phantom study for DECT clinical guidance.

BACKGROUND: Dual-energy CT technology is available on scanners from several vendors and offers significant advantages over classic single-energy CT technology in multiple clinical applications. Many studies have detailed dual-energy CT applications in adults and several have evaluated the relative radiation dose performance of dual-energy CT in adult imaging. However, little has been published on dual-energy CT imaging in the pediatric population, and the relative dose performance of dual-energy CT imaging in the pediatric population is not well described. OBJECTIVE: When evaluating dual-energy CT technology for implementation into a routine clinical pediatric imaging practice, the radiation dose implications must be considered, and when comparing relative CT dose performance, image quality must also be evaluated. Therefore the purpose of this study is to develop dual-energy CT scan protocols based on our optimized single-energy scan protocols and compare the dose. MATERIALS AND METHODS: We scanned the head, chest and abdomen regions of pediatric-size anthropomorphic phantoms with contrast inserts, using our optimized single-energy clinical imaging protocols on a Siemens Flash® CT scanner. We then scanned the phantoms in dual-energy mode using matching image-quality reference settings. The effective CT dose index volume (CTDIvol) of the scans was used as a surrogate for relative dose in comparing the single- and dual-energy scans. Additionally, we evaluated image quality using visual assessment and contrast-to-noise ratio. RESULTS: Dual-energy CT scans of the head and abdomen were dose-neutral for all three phantoms. Dual-energy CT scans of the chest showed a relative dose increase over the single-energy scan for 1- and 5-year-old child-based age-equivalent phantoms, ranging 11-20%. Quantitative analysis of image quality showed no statistically significant difference in image quality between the single-energy and dual-energy scans. There was no clinically significant difference in image quality by visual assessment. CONCLUSION: Dual-energy CT is dose-neutral in imaging the head and abdomen in children. It is not dose-neutral in chest imaging of very small children. With a better understanding of the dose consequences of converting single-energy protocols to dual-energy protocols we can begin to implement clinical dual-energy CT and utilize its unique capabilities in pediatric imaging.

The significance of reflectance confocal microscopy in the assessment of solitary pink skin lesions.

BACKGROUND: Solitary pink lesions often manifest nondescript clinical and dermatoscopic primary morphologic features. The differential diagnosis for pink lesions tends, therefore, to be broad, ranging from inflammatory processes to malignancy. In vivo reflectance confocal microscopy (RCM) may help in the evaluation of pink lesions. OBJECTIVE: We sought to demonstrate the use of RCM as an adjunct to the bedside diagnosis of pink lesions. METHODS: We describe a series of patients with clinically and dermatoscopically equivocal pink lesions for which RCM examination allowed for a rapid and accurate diagnosis. All lesions were excised for histopathologic evaluation. Integrating the findings in the case series with a literature review, we present RCM diagnostic criteria for pink lesions. RESULTS: Lesions included basal cell carcinoma, squamous cell carcinoma, amelanotic melanoma, and inflamed seborrheic keratosis. RCM shows distinctive findings for each diagnostic entity when stratified by anatomic level into suprabasal epidermis, dermoepidermal junction, and papillary dermis. In the cases presented RCM allowed for a rapid and accurate noninvasive diagnosis. LIMITATIONS: The study is descriptive and does not test accuracy of RCM criteria in a prospective series of pink lesions. CONCLUSION: RCM may add useful diagnostic features to the clinical evaluation of solitary pink lesions.

Towards identification of hereditary DNA mismatch repair deficiency: sebaceous neoplasm warrants routine immunohistochemical screening regardless of patient's age or other clinical characteristics.

Although the significance of immunohistochemical detection of DNA mismatch repair proteins and/or microsatellite instability testing in identifying patients at risk for germline deficiency in DNA mismatch repair genes is well established in colorectal carcinomas, the proper use of such techniques in sebaceous neoplasms, another tumor type that has been implicated in patients with hereditary DNA mismatch repair deficiency, has not been clearly defined. In this study, we stratified a series of 27 patients with 1 or more sebaceous neoplasms based on the pattern of immunohistochemical expression of MLH1, MSH2, MSH6, and PMS2, and comparatively analyzed their clinical and pathologic characteristics, including tumor-infiltrating lymphocytes and peritumoral lymphocytic response as determined by immunohistochemical staining for CD3. The study tissue samples included 30 sebaceous carcinomas, 14 sebaceous adenomas, and 7 sebaceous hyperplasias, along with 8 concurrent nonsebaceous lesions from 6 patients. Overall, 12 of the 27 (44%) patients showed abnormal IHC staining with mismatch repair proteins in their sebaceous tumors, the most commonly seen abnormality being concurrent loss of MSH2 and MSH6 (8/12, 67%). Sebaceous adenomas and carcinomas occurring in the same patients showed an identical staining pattern, as did hereditary nonpolyposis colorectal cancer-related nonsebaceous tumors in the same patients. When compared with cases that had normal expression of the mismatch repair proteins, cases with abnormal expression tended to be younger (median age, 56.5 y vs. 68 y), more likely to involve sites outside the head and neck (9/12 vs. 0/15), and more likely to have synchronous or metachronous visceral malignancies (8/12 vs. 3/15) and a positive family history. Furthermore, sebaceous tumors with abnormal expression had significantly higher CD3-positive tumor-infiltrating lymphocytes and peritumoral lymphocytic response. Thus, all these factors (age less than 60 y, involvement of nonhead and neck sites, visceral malignancy, family history fulfilling at least Bethesda guidelines, and lymphocytic infiltration) bore informative value in predicting abnormal expression of DNA mismatch repair proteins. However, their sensitivity was only modest, being 58%, 75%, 67%, 78%, and 75%, respectively. On such a premise, given that sebaceous neoplasms are only infrequently encountered, and that immunohistochemistry is easily available and reasonably reliable, we recommend that, when there exists a desire to identify hereditary DNA mismatch repair deficiency, routine immunohistochemical detection of DNA mismatch repair proteins be performed in all sebaceous neoplasms regardless of patient's age or other clinical characteristics.

Two pediatric cases of primary cutaneous B-cell lymphoma and review of the literature.

Primary cutaneous lymphomas are rare in the pediatric population and most often represent mycosis fungoides or CD30+ lymphoproliferative disorders. Primary cutaneous B-cell lymphoma has rarely been reported in children, and in the past may have been mistaken for disseminated nodal disease or benign cutaneous lymphoid hyperplasias. We describe two cases of marginal zone primary cutaneous B-cell lymphoma in young males. Thus far both have been managed with local therapy. We review the literature of this rare malignancy.

Melanoma mimicking seborrheic keratosis: an error of perception precluding correct dermoscopic diagnosis.

Seborrheic keratosis is a common skin lesion that can usually be recognized either clinically or dermoscopically. However, melanomas mimicking seborrheic keratoses, as well as melanomas arising in association with seborrheic keratoses, have been described. We report the case of a patient with a lesion that initially revealed "classic" dermoscopic features of a seborrheic keratosis. However, during follow-up, changes in color developed within the center of the lesion that led the clinician to the correct diagnosis of melanoma. Upon retrospective evaluation of the baseline image of the lesion; the clinician was now able to "see" that which his brain could not appreciate on initial examination and to realize that the lesion had subtle features suspect for melanoma. This case represents a diagnostic pitfall due to errors in perception. Dermatologists should be cognizant of "errors in perception"; we suggest that a final dermoscopic judgment of a seborrheic keratosis be rendered by combining the gestalt diagnosis of the overall pattern, with deliberate dermoscopic analysis of all quadrants of the lesion.

Scrotal and penile papules and plaques as the initial manifestation of a cutaneous metastasis of adenocarcinoma of the prostate: case report and review of the literature.

Cutaneous metastasis of prostatic adenocarcinoma is a rare phenomenon. We present a 56-year-old African American man with metastatic disease in the skin and subcutis of the suprapubic and scrotal area 2 years after his initial diagnosis presenting as scrotal and penile edema and plaque like scrotal rash. We also review the literature on this subject.

Primary male neuroendocrine adenocarcinoma involving the nipple simulating Merkel cell carcinoma - a diagnostic pitfall.

Male breast cancer is a rare entity accounting for < 1% of all breast cancer cases in the United States, but with a rate that has been rising over the last 25 years. Nipple skin/subcutaneous tumors in men are even rarer. Likewise, true neuroendocrine carcinoma of the breast, defined as > 50% of tumor cells staining for either chromogranin or synaptophysin, is not a common entity, usually occurring in older women. We present the case of a 70-year-old man with a slowly growing nipple mass that had enlarged over the previous 1.5 years. The histology consisted of nests, trabeculae and sheets of basaloid cells with rare abortive gland formation and a pushing edge. The case was originally misdiagnosed as a Merkel cell carcinoma, based largely on histologic morphology. Strong staining for synaptophysin (in greater than 50% of cells), CD56, keratins AE1 : AE3 and Cam 5.2, as well as estrogen receptor and progesterone receptor was noted. Myoepithelial cells within in situ areas were identified using stains for calponin and 4A4, supporting a primary mammary duct origin. Additionally, a substantial portion of cells stained for Gross Cystic Disease Fluid Protein-15 (GCDFP-15), confirming some overlap with sweat duct differentiation. To the best of our knowledge, although reported in the male breast, no case of primary nipple neuroendocrine carcinoma in a male patient has been reported in the literature. The gender of the patient and association with the skin of the chest wall probably contributed to the original misdiagnosis of Merkel cell carcinoma in this patient.

Photo-distributed neutrophilic drug eruption and adult respiratory distress syndrome associated with antidepressant therapy.

Drug reactions are well-known complications of antidepressant therapy, often related to photosensitization. Herein is reported a singular case of antidepressant (amoxapine and citalopram) and anxiolytic related (perphenazine) photo-distributed neutrophilic dermatosis and adult respiratory distress syndrome (ARDS). The clinicopathologic findings displayed overlapping features with drug-induced Sweet's syndrome, acute generalized exanthematous pustulosis (AGEP), and so-called sterile neutrophilic folliculitis with perifollicular vasculopathy. Of the three medications, only amoxapine has been associated with AGEP. Treatment with high-dose systemic corticosteroids and cessation of drug therapy was followed by rapid resolution of the cutaneous eruption and respiratory distress. The possibility that neutrophil infiltration of the lung and/or accumulation of neutrophils in the skin and blood served as a source for reactive oxygen species, leading to lung injury and subsequent ARDS, is discussed.