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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.
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OBJECTIVE: To evaluate associations between neurologic outcomes and early measurements of basal ganglia (BG) and thalamic (Th) perfusion using color Doppler ultrasonography (CDUS) in infants with hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN: Prospective study of infants with mild (n = 18), moderate (n = 17), and severe HIE (n = 14) and controls (n = 17). Infants with moderate-severe HIE received therapeutic hypothermia (TH). CDUS was performed at 24-36 hours and brain magnetic resonance imaging (MRI) at a median of 10 days. Development was followed through 2.5-5 years. The primary outcome was the association between BG and Th perfusion and brain MRI injury. Secondary analyses focused on associations between perfusion measurements and admission neurologic examinations, MRI scores in infants treated with TH, and motor and sensory disability, or death. An exploratory analysis assessed the accuracy of BG and Th perfusion to predict brain MRI injury in infants treated with TH. RESULTS: Increased BG and Th perfusion on CDUS was observed in infants with severe MRI scores and those with significant motor and neurosensory disability or death through 2.5-5 years (P < .05). Infants with severe HIE showed increased BG and Th perfusion (P < .005) compared with infants with moderate HIE. No differences were identified between the between the control and mild HIE groups. Th perfusion ≥0.237 cm/second (Area under the curve of 0.824) correctly classified 80% of infants with severe MRI scores. CONCLUSIONS: Early dynamic CDUS of the BG and Th is a potential biomarker of severe brain injury in infants with HIE and may be a useful adjunct to currently used assessments.
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Gânglios da Base , Hipotermia Induzida , Hipóxia-Isquemia Encefálica , Imageamento por Ressonância Magnética , Tálamo , Ultrassonografia Doppler em Cores , Humanos , Gânglios da Base/diagnóstico por imagem , Hipóxia-Isquemia Encefálica/diagnóstico por imagem , Hipóxia-Isquemia Encefálica/terapia , Estudos Prospectivos , Masculino , Feminino , Ultrassonografia Doppler em Cores/métodos , Recém-Nascido , Imageamento por Ressonância Magnética/métodos , Tálamo/diagnóstico por imagem , Lactente , Lesões Encefálicas/diagnóstico por imagemRESUMO
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.
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Espondiloartrite Axial , Sacroileíte , Espondilartrite , Humanos , Adulto , Criança , Articulação Sacroilíaca/diagnóstico por imagem , Espondilartrite/diagnóstico por imagem , Espondilartrite/patologia , Radiografia , Sacroileíte/diagnóstico por imagem , Sacroileíte/patologia , Imageamento por Ressonância Magnética/métodosRESUMO
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.
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Duodeno , Tomografia Computadorizada por Raios X , Criança , Pré-Escolar , Estudos Transversais , Duodeno/diagnóstico por imagem , Feminino , Humanos , Lactente , Masculino , Estudo de Prova de Conceito , Reprodutibilidade dos TestesRESUMO
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.
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Fêmur/diagnóstico por imagem , Interpretação de Imagem Assistida por Computador/métodos , Aprendizado de Máquina , Osteíte/diagnóstico por imagem , Radiologistas , Tíbia/diagnóstico por imagem , Imagem Corporal Total , Adolescente , Inteligência Artificial , Conservadores da Densidade Óssea/uso terapêutico , Doença Crônica , Progressão da Doença , Humanos , Imageamento por Ressonância Magnética , Osteíte/tratamento farmacológico , Pamidronato/uso terapêutico , Projetos Piloto , Sensibilidade e Especificidade , Máquina de Vetores de Suporte , Resultado do TratamentoRESUMO
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.
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Imageamento por Ressonância Magnética/métodos , Neurofibromatose 1/diagnóstico por imagem , Glioma do Nervo Óptico/diagnóstico por imagem , Criança , Pré-Escolar , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Estudos RetrospectivosRESUMO
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.
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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.
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Imagem de Difusão por Ressonância Magnética/métodos , Sacroileíte/diagnóstico por imagem , Adolescente , Criança , Meios de Contraste , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos , Adulto JovemRESUMO
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.
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Força Compressiva , Fixadores Externos , Modelos Anatômicos , Poliuretanos , Tíbia , Fraturas da Tíbia/cirurgia , Desenho de EquipamentoRESUMO
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.
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Força Compressiva , Fixadores Externos , Modelos Anatômicos , Poliuretanos , Tíbia , Fraturas da Tíbia/cirurgia , Desenho de EquipamentoRESUMO
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
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Cães , Bactérias , Categute , Cães , Suturas , Tensão Superficial , Vagina/microbiologiaRESUMO
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
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Cicatrização , Cães , Suturas , Ar , InsuflaçãoRESUMO
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