Real-time x-ray abnormality alerts for emergency departments using a radiographer comment model - a multisite pilot study.

INTRODUCTION: The timely communication of clinically significant image appearances to Emergency Department (ED) referrers is necessary for optimum patient care. Australian reliance on verbal communication only is time-limited, open to misinterpretation and lacks transparency. A combined radiographer alert and comment model was designed to reliably communicate image abnormalities to ED referrers in real-time. METHODS: A multidisciplinary steering group designed the model for all ED general imaging. Protocols were developed to document radiographer comments (critical, urgent and clinically significant) in patients' medical records. Critical findings were communicated directly to ED. Five NSW hospitals varying in size, complexity and population demographics piloted the model between three to twelve months during 2021-2022. Site auditors compared comments with the radiology report and designated each as True Positive (TP), False Positive (FP), indeterminate and clinically significant. Indeterminate cases were analysed by an external radiologist. Inter-observer consensus was obtained for all classifications via two independent auditors. The Positive Predictive Value (PPV), or precision of the comment, was calculated for each site. RESULTS: Radiographers (n = 69) provided comments for 1102 cases. The pooled average PPV for TP was 0.96; (0.947-0.971; 95% CI). The weighted mean error (FP comments) was 3.9%; (2.9% - 5.3%.; 95% CI). CONCLUSION: The Radiographer Comment model provided consistent levels of commenting precision and reproducibility across a range of sites with a pooled average PPV (0.96). The False Positive rate or weighted mean error (FP) of 3.9% (2.9% - 5.3%.; 95% CI) was low. IMPLICATIONS FOR FUTURE PRACTICE: A strategic, interprofessional approach in the implementation of an image alert combined with a Radiographer Comment can be adapted across a variety of hospital settings for ED and other departments.

The multi-disciplinary management of complex congenital and acquired tracheo-oesophageal fistulae.

AIM OF THE STUDY: Complex tracheo-oesophageal fistulae (TOF) are rare congenital or acquired conditions in children. We discuss here a multidisciplinary (MDT) approach adopted over the past 5 years. METHODS: We retrospectively collected data on all patients with recurrent or acquired TOF managed at a single institution. All cases were investigated with neck and thorax CT scan. Other investigations included flexible bronchoscopy and bronchogram (B&B), microlaryngobronchoscopy (MLB) and oesophagoscopy. All cases were subsequently discussed in an MDT meeting on an emergent basis if necessary. MAIN RESULTS: 14 patients were referred during this study period of which half had a congenital aetiology and the other half were acquired. The latter included button battery ingestions (5/7) and iatrogenic injuries during oesophageal atresia (OA) repair. Surgical repair was performed on cardiac bypass in 3/7 cases of recurrent congenital fistulae and all cases of acquired fistulae. Post-operatively, 9/14 (64%) patients suffered complications including anastomotic leak (1), bilateral vocal cord paresis (1), further recurrence (1), and mortality (1). Ten patients continue to receive surgical input encompassing tracheal/oesophageal stents and dilatations. CONCLUSIONS: MDT approach to complex cases is becoming increasingly common across all specialties and is important in making decisions in these difficult cases. The benefits include shared experience of rare cases and full access to multidisciplinary expertise.

Double-blind randomized clinical trial of percutaneous endoscopic gastrostomy versus radiologically inserted gastrostomy in children.

BACKGROUND: The aim of this RCT was to determine whether radiologically inserted gastrostomy (RIG) in children is associated with more complications than percutaneous endoscopic gastrostomy (PEG). METHODS: Children at a single tertiary children's hospital requiring a primary gastrostomy were randomized to PEG or RIG. Patients were followed by assessors blinded to the insertion method. Complications were recorded, assigned a severity score, and analysed by zero-inflated Poisson regression analysis on an intention-to-treat basis, adjusting for length of follow-up. RESULTS: Over a 3-year period, 214 children were randomized (PEG, 107; RIG, 107), of whom 100 received PEG and 96 RIG. There was no significant difference in the number of complications between PEG and RIG groups (P = 0·875), or in the complication score: patients undergoing RIG had a 1·04 (95 per cent c.i. 0·89 to 1·21) times higher complication score than those who underwent PEG (P = 0·597). Only age had an independent significant effect on complication score, with older patients having a 0·97 (0·95 to 1·00) times lower complication score per year. CONCLUSION: PEG and RIG are both safe methods of gastrostomy insertion with a low rate of major complications. Registration number: NCT01920438 ( http://www.clinicaltrials.gov).

Tissue-Engineered Tracheal Replacement in a Child: A 4-Year Follow-Up Study.

In 2010, a tissue-engineered trachea was transplanted into a 10-year-old child using a decellularized deceased donor trachea repopulated with the recipient's respiratory epithelium and mesenchymal stromal cells. We report the child's clinical progress, tracheal epithelialization and costs over the 4 years. A chronology of events was derived from clinical notes and costs determined using reference costs per procedure. Serial tracheoscopy images, lung function tests and anti-HLA blood samples were compared. Epithelial morphology and T cell, Ki67 and cleaved caspase 3 activity were examined. Computational fluid dynamic simulations determined flow, velocity and airway pressure drops. After the first year following transplantation, the number of interventions fell and the child is currently clinically well and continues in education. Endoscopy demonstrated a complete mucosal lining at 15 months, despite retention of a stent. Histocytology indicates a differentiated respiratory layer and no abnormal immune activity. Computational fluid dynamic analysis demonstrated increased velocity and pressure drops around a distal tracheal narrowing. Cross-sectional area analysis showed restriction of growth within an area of in-stent stenosis. This report demonstrates the long-term viability of a decellularized tissue-engineered trachea within a child. Further research is needed to develop bioengineered pediatric tracheal replacements with lower morbidity, better biomechanics and lower costs.

Bronchomegaly as a complication of fetal endoscopic tracheal occlusion. A caution and a possible solution.

Fetal medicine is developing rapidly and aims to improve the outcome for fetuses with congenital anomalies. Fetal endoscopic tracheal occlusion (FETO) has been developed for fetuses with congenital diaphragmatic hernia to counterbalance the compression of the lung by the abdominal viscera, preserving the pulmonary maturation. Because the perinatal morbidity and mortality of patients treated with FETO have decreased, new complications are emerging in the older survivors. Tracheomegaly has been reported to be a late complication of FETO, sometimes requiring tracheostomy. We report a case of bronchial dilatation after FETO and suggest an alternative surgical treatment.

Paediatric interventional oncology.

As is often the case with developments in interventional radiology (IR), widespread adoption of the newer techniques of interventional oncology has taken longer in paediatric than in adult practice. The three main applications of IR techniques in children with cancer are biopsy, regional therapy and supportive care (including the treatment of complications), and these are considered separately.

Management and outcome of vein of Galen malformation.

OBJECTIVE: To describe our experience of treating children with vein of Galen aneurysmal malformation (VGM) in a single UK centre between 2003 and 2008. METHOD: Retrospective review of case notes and neuroimaging. RESULTS: 33 children were seen (26 neonates, seven infants), of whom 28 underwent endovascular treatment. Four were not offered treatment as they had evidence of severe diffuse brain injury at presentation; treatment was deferred in another who subsequently died. Seven children died (two of whom had endovascular treatment). Of the survivors (all treated), 13 (39%) are neurodevelopmentally intact, seven (21%) have mild neurodevelopmental impairment and the remaining six (18%) have significant neurological impairment. The authors were not able to identify clinical or radiological parameters which strongly predicted outcome. Of note, two children with initially low Bicêtre scores were neurologically intact after successful embolisation. CONCLUSION: The outlook for children with VGM is significantly better since the advent of endovascular treatment. Decisions about the appropriateness and timing of treatment should be taken by an experienced multidisciplinary team.

Neonatal mycotic internal iliac aneurysm due to methicillin-resistant Staphylococcus aureus (MRSA) septicaemia successfully treated by coil embolisation.

A 12-day-old term male neonate presented with septic arthritis, multiple skin and intrabdominal abscesses and a mycotic aneurysm of the right internal iliac artery. He was diagnosed as having methicillin resistant staphylococcus aureus (MRSA) septicaemia and deemed unsuitable for surgical treatment of the aneurysm. Coil embolisation of the internal iliac artery was performed, followed by a successful recovery and with no evidence of residual or recurrent infection. The authors describe a method of treating internal iliac mycotic aneurysms in high-risk patients by endovascular means, which we believe has not been attempted in this precise scenario before.

Successful resection of a congenital superior mesenteric arteriovenous malformation.

A 15-month-old male presented with severe gastrointestinal bleeding and heart failure. Imaging revealed a superior mesenteric artery arteriovenous malformation, associated with a congenital portosystemic shunt. The heart failure was cured by resection of the arteriovenous malformation.

MR imaging of the brain in patients cured of acute lymphoblastic leukemia--the value of gradient echo imaging.

BACKGROUND AND PURPOSE: Hemosiderin and white matter lesions are 2 of the most common neurologic complications found on MR imaging that may be related to cranial irradiation and intrathecal methotrexate (MTX) therapy in childhood acute lymphoblastic leukemia (ALL). We evaluated the brains of patients previously treated for ALL with cranial irradiation and intrathecal MTX with MR imaging and tested the hypothesis that these patients have more MR evidence of central nervous system (CNS) injury than control patients who are in complete remission following systemic chemotherapy without cranial irradiation. METHODS AND MATERIALS: ALL patients recruited from a pediatric cancer center data base were examined at 1.5T by using T1-weighted, T2-weighted, gradient echo (GE), and fluid-attenuated inversion recovery sequences. Patients treated in childhood for solid extracranial neoplasms were used as controls. RESULTS: Lesions consistent with old hemorrhage were detected in 23 (55%) of the ALL patients and in none of the control patients (P <.001). Of the 62 hemorrhages detected on the GE images, only 9 (15%) were shown on T2-weighted images. White matter abnormalities were found in 2 ALL patients (5%) and one control patient (5%). Old infarcts were seen in 2 ALL patients (10%). CONCLUSION: Cerebral hemorrhages related to radiation-induced vascular malformations, most of which are asymptomatic, are much more common in survivors of childhood ALL than previously thought. GE sequencing is more sensitive in detecting hemorrhagic lesions than T2-weighted sequencing and is to be included in imaging protocols for follow-up study of patients after cerebral radiation therapy.

Computed tomography versus bronchography in the diagnosis and management of tracheobronchomalacia in ventilator dependent infants.

AIM: To assess the relative accuracy of dynamic spiral computed tomography (CT) compared with tracheobronchography, in a population of ventilator dependent infants with suspected tracheobroncho-malacia (TBM). SETTING: Paediatric intensive care unit in a tertiary teaching hospital. PATIENTS AND METHODS: Infants referred for investigation and management of ventilator dependence and suspected of having TBM were recruited into the study. Tracheobronchography and CT were performed during the same admission by different investigators who were blinded to the results of the other investigation. The study was approved by the hospital research ethics committee, and signed parental consent was obtained. RESULTS: Sixteen infants were recruited into the study. Fifteen had been born prematurely, and five had cardiovascular malformations. In 10 patients there was good or partial correlation between the two investigations, but in six patients there was poor or no correlation. Bronchography consistently showed more dynamic abnormalities, although CT picked up an unsuspected double aortic arch. Radiation doses were 0.27-2.47 mSv with bronchography and 0.86-10.67 mSv with CT. CONCLUSIONS: Bronchography was a better investigation for diagnosing TBM and in determining opening pressures. Spiral CT is unreliable in the assessment of TBM in ventilator dependent infants. In addition, radiation doses were considerably higher with CT.

Imaging findings of paediatric oncology patients presenting with acute neurological symptoms.

Paediatric oncology patients are prone to central nervous system (CNS) complications due to multiple factors including disorders of the blood cell counts (which include neutropenia, thrombocytopenia or hyperleukocytosis), immunosuppression, neurotoxicity of the treatment, CNS dysfunction due to failure of other organ systems, disease progression of the primary malignancy or metastases. Imaging plays an important role in the management of paediatric oncology patients presenting with acute neurological symptoms. This pictorial review is from our institutional experience on imaging children who are under the care of the Child Cancer Centre. The review consists of a spectrum of neurological complications in paediatric oncology patients. The complications can be classified as (1) cerebrovascular complications, (2) treatment-elated complications, (3) opportunistic infections and (4) tumoural involvement of the CNS. Computed tomography (CT) is the initial choice of investigation, which is easily available and helps to exclude major intracranial abnormality such as haemorrhage. If the CT is negative, magnetic resonance imaging (MRI) should be performed, which is more sensitive for detection of CNS lesions.

Embolisation of a renal artery pseudoaneurysm in a patient with renal malrotation and chronic aortic dissection.

INTRODUCTION: Renal artery pseudoaneurysms may arise as a complication of percutaneous nephrolithotomy (PCNL). Prompt recognition and treatment is essential to arrest haemorrhage which may be life threatening. CLINICAL PICTURE: A patient with chronic aortic dissection and malrotated right kidney underwent PCNL for right renal calculus. He developed delayed gross haematuria. TREATMENT: Angiography showed a pseudoaneurysm arising from one of two right renal arteries, which in turn arose from the false lumen of the aortic dissection. The supplying artery was successfully embolised. CONCLUSION: Renal artery pseudoaneurysms can be successfully treated with prompt angiography and embolisation, even in the presence of renal malrotation and aortic dissection.

Sellar and suprasellar medulloepithelioma.

Medulloepithelioma is a rare tumour with a very poor prognosis. The most frequent site in the central nervous system is the cerebral hemispheres. Appearances on MRI are very variable, possibly reflecting the divergent forms of differentiation seen at histological examination. We report a rare case of sellar and suprasellar medulloepithelioma in a 2-year-old boy and discuss the imaging, differential diagnosis and pathologic findings.

Imaging features of pancreatoblastoma.

BACKGROUND: Pancreatoblastoma is a rare tumour of childhood. Reports of the imaging appearances are limited. OBJECTIVE: To define the imaging features of pancreatoblastoma by analysis of four previously unreported cases and review of the literature. MATERIALS AND METHODS: Findings at CT (n = 4), US (n = 3) and MRI (n = 2) were retrospectively reviewed in four patients with pancreatoblastoma. A Medline search was performed to identify relevant literature. RESULTS: Pancreatoblastoma arises most frequently in the body and/or tail, or involves the entire pancreas. Ultrasonography, CT and MRI show variable imaging features, but should in most cases permit preoperative distinction of pancreatoblastoma from other tumours that occur in this region in infancy and childhood. Detection of metastases in the liver, lymph nodes and peritoneal cavity is not significantly better with any one of these three modalities. CONCLUSION: Preoperative imaging with US, CT and/or MRI will usually suggest a correct diagnosis of pancreatoblastoma. Contrary to previous reports, the tumour arises in the pancreatic head in a minority of cases.

Long-term cerebral metabolite changes on proton magnetic resonance spectroscopy in patients cured of acute lymphoblastic leukemia with previous intrathecal methotrexate and cranial irradiation prophylaxis.

PURPOSE: To evaluate the long-term brain metabolite changes on (1)H-MRS in acute lymphoblastic leukemia (ALL) patients who had intrathecal methotrexate (ITMTX) and cranial irradiation (CRT) for central nervous system (CNS) prophylaxis against CNS relapse. METHODS AND MATERIALS: Thirty-seven ALL patients (12 females, 25 males) with history of ITMTX and CRT for CNS prophylaxis were studied. Age ranges at the time of diagnosis and at magnetic resonance examination were 0.8-13 years and 12-27 years, respectively. The interval since diagnosis was 5.6-19 years. T2-weighted and gradient-recalled echo (GRE) magnetic resonance imaging (MRI) and proton magnetic resonance spectroscopy ((1)H-MRS) were performed to assess brain injury. RESULTS: On MRI, 3 leukoencephalopathy (LEP) and 1 infarct were detected. Twenty-two patients had evidence of hemosiderin. On (1)H-MRS no statistically significant difference in choline (Cho)/creatine (Cr) and N-acetylaspartate (NAA)/Cr was associated with LEP. A lower Cho/Cr (p = 0.006) and NAA/Cr (p = 0.078) was observed in brains with hemosiderin. Linear-regression analysis showed no statistically significant relationship between NAA/Cr or Cho/Cr with age at diagnosis, but there was a statistically significant decreasing trend of NAA/Cr and Cho/Cr with the interval since diagnosis. CONCLUSION: Long-term brain injury in ALL survivors after CNS prophylaxis with ITMTX and CRT was reflected by decreasing NAA/Cr and Cho/Cr with the interval since diagnosis. The lower Cho/Cr associated with hemosiderin but not LEP suggested a different pathophysiology for these brain lesions.

Vesicoureteric reflux and renal scarring in Chinese children.

Vesicoureteric reflux (VUR) and renal scarring are commonly found in children with urinary tract infection (UTI). The prevalence of VUR and scarring may vary between racial groups. There are no published data on the prevalence of VUR and scarring in Chinese children with UTI. A retrospective, single-institution study was made of Hong Kong Chinese children aged less than 5 years with a documented UTI investigated by both micturating cystourethrography and dimercaptosuccinic acid scintigraphy. VUR was identified in 39% of 93 Chinese children with UTI. Renal scarring was present in 28% of boys, which is comparable with published data on Western children. Scarring appears to be less common in Chinese girls with UTI (11%) than in Western girls (30-38% from published data), and its severity is poorly related to VUR grade. There is a significant dependency relationship between grade of VUR and degree of scarring in Chinese boys (p < 0.05). In conclusion, renal scarring appears to be relatively uncommon in Chinese girls. The correlation between grade of VUR and degree of scarring in Chinese boys suggests a relationship, but provides no evidence about the direction of causation.

Alveolar soft-part sarcoma: a rare soft-tissue malignancy with distinctive clinical and radiological features.

Alveolar soft-part sarcoma (ASPS) is a rare tumour. Certain distinctive clinical and radiological features suggest the correct diagnosis. There is moderate predilection for young women. ASPS almost always arises in skeletal muscle and occurs most frequently in the lower limbs. There is often a long clinical history and a large mass at presentation. Two young females with ASPS presented with very vascular tumours in the thigh, with prominent intra- and extra-tumoural blood vessels. The imaging findings and the existing literature are reviewed.

Acute elbow trauma in children: spectrum of injury revealed by MR imaging not apparent on radiographs.

OBJECTIVE: The objective of this study is to evaluate the frequency and significance of unrecognized bone or soft-tissue injury in pediatric patients with elbow trauma assessed with radiographs alone. SUBJECTS AND METHODS: Fifty children (32 boys and 18 girls; mean age, 7.3 years; age range, 2-12 years) with acute elbow trauma were examined with radiography and MR imaging. Radiographs were categorized into those showing normal findings, an effusion, an equivocal fracture, or an unequivocal fracture. MR examinations were assessed for an effusion, fracture, transphyseal fracture extension, physeal injury, bone bruising, and ligament or muscle injury. Average clinical follow-up was 1.6 years (range, 6-28 months) after injury. RESULTS: Radiographs showed normal findings in seven children (14%), an effusion only in 17 children (34%), and an unequivocal or equivocal fracture in 26 children (52%). MR imaging showed an effusion in 48 children (96%); unequivocal fracture in 37 children (74%), including transphyseal fracture in seven children (14%) and other physeal injury in three children (6%); bone bruising in 45 children (90%); ligament injury in six children (14%); and muscle injury in 19 children (38%). A less severe spectrum of injury occurred in children with normal findings on radiographs than in those with an effusion or fracture seen on radiography. Follow-up radiographs did not help in the detection of radiographically occult fractures. MR findings had no appreciable effect on patient treatment and no value in predicting duration of convalescence or clinical outcome at an average of 1.6 years after injury. CONCLUSION: In children with elbow trauma, MR imaging reveals a broad spectrum of bone and soft-tissue injury beyond that recognizable radiographically. However, the additional information afforded by MR imaging has little bearing on treatment or clinical outcome.