CT of Normal Developmental and Variant Anatomy of the Pediatric Skull: Distinguishing Trauma from Normality.

The use of computed tomography (CT) in clinical practice has been increasing rapidly, with the number of CT examinations performed in adults and children rising by 10% per year in England. Because the radiology community strives to reduce the radiation dose associated with pediatric examinations, external factors, including guidelines for pediatric head injury, are raising expectations for use of cranial CT in the pediatric population. Thus, radiologists are increasingly likely to encounter pediatric head CT examinations in daily practice. The variable appearance of cranial sutures at different ages can be confusing for inexperienced readers of radiologic images. The evolution of multidetector CT with thin-section acquisition increases the clarity of some of these sutures, which may be misinterpreted as fractures. Familiarity with the normal anatomy of the pediatric skull, how it changes with age, and normal variants can assist in translating the increased resolution of multidetector CT into more accurate detection of fractures and confident determination of normality, thereby reducing prolonged hospitalization of children with normal developmental structures that have been misinterpreted as fractures. More important, the potential morbidity and mortality related to false-negative interpretation of fractures as normal sutures may be avoided. The authors describe the normal anatomy of all standard pediatric sutures, common variants, and sutural mimics, thereby providing an accurate and safe framework for CT evaluation of skull trauma in pediatric patients.

UK intussusception audit: a national survey of practice and audit of reduction rates.

AIM: To define current UK reduction practice and the reductions rates achieved. MATERIALS AND METHODS: Electronic surveys were sent to radiologists at 26 UK centres. This assessed methods of reduction, equipment, personnel, and protocol usage. Standardized audit proforma were also sent to evaluate all reductions performed in 2011. RESULTS: Twenty-two of 26 centres (85%) replied. All used air enema under fluoroscopic guidance. Equipment was not standardized but could be broadly categorized into hand-pumped air-supply systems (seven centres) and pressurized air systems (15 centres). Seventeen centres followed a protocol based on British Society of Paediatric Radiologists (BSPR) guidelines. In 21 of the 22 centres a consultant paediatric radiologist led reductions and only 12 centres reported a surgeon being present. Three hundred and ten cases were reported across 22 centres. Cases per centre ranged from 0-31 (median 14). Reduction rates varied from 38-90% (median 71%). The overall perforation rate was 2.5%. Caseload did not significantly correlate with reduction rate, and there was no significant difference between the two types of equipment used. Median reduction rates were 15% higher in centres with a surgeon present at reduction (p < 0.05). CONCLUSION: Intussusception care in the UK lacks standardization of equipment and personnel involved. National reduction rates are lower than in current international literature. Improved standardization may lead to an improvement in reduction rates and a surgeon should always be present at reduction.

Air enema reduction of intussusception: a registrar-led, protocol-driven service is safe and effective.

PURPOSE: In the UK, air enema reduction of intussusception is predominantly performed by consultant radiologists. At our institution, it is usually performed by a team involving radiology and surgical registrars. The purpose of this study was to assess who performs air enemas in the UK and the efficacy and safety of our registrar-led service. METHODS: A telephone survey of paediatric surgical centres in the UK was performed asking who performs air enema in these institutions. Following this, a retrospective review of all air enemas at our institution between January 2005 and 2011 was performed. Cases were identified from radiology databases and reviewed for grade of radiologist, perforation and outcome. RESULTS: At all 25 centres, consultant radiologists performed air enemas. At our institution 145 enemas were performed in 6 years. 141 were analysed (54 girls, 87 boys). Median age was 9 months (range 3-107 months). 82 % were performed by the registrar-only team. Over 6 years the registrar-led reduction rate was 77.5 % and in the last 3 years 84 %. The perforation rate was 0.9 %. CONCLUSION: A paediatric surgical registrar-led service for air enema reduction can be safe and effective ensuring a team approach is adopted, equipment is efficient and a strict protocol is applied.

When should pelvic sentinel lymph nodes be harvested in patients with malignant melanoma?

BACKGROUND: Preoperative lymphoscintigraphy for sentinel node biopsy (SNB) combined with intra-operative gamma-probe detection often identifies nodes within the pelvis. This study investigates the role of pelvic SNB harvest. METHODS: Retrospective review of eighty-two stage I/II melanoma patients with primary tumour on the lower limb and trunk who underwent groin SNB, either inguinal or pelvic or both, over a three year period. RESULTS: Of the 82 patients, 19 had positive SNBs (24%), all of which were inguinal nodes. None of the 11 patients with pelvic nodes removed had a positive pelvic node. The median follow-up period was 18 months (SD: 10.8; range: 8-43). Although the complication rate was higher following pelvic SNB, the difference was not statistically significant (p > 0.5). The average operative time for an inguinal SNB was 92 min, and increased significantly to 134 min for a pelvic SNB (p < 0.0001). Lymphoscintigraphy of trunk and thigh melanomas identified individual tracks to be leading directly from the tumour to a pelvic node(s). However, when the primary tumour was located at or below the knee, pelvic nodes identified by lymphoscintigraphy appeared to be second level nodes. CONCLUSION: A lymphoscintigraphy protocol that includes dynamic images obtained in frequent intervals following injection of the radiotracer combined with thorough preoperative analysis of the lymphoscintigraphy scans and effective communication between the radiologist and the surgeon allows accurate identification of the primary tracks and prevent unnecessary harvest of second echelon pelvic lymph nodes. In patients with significant co-morbidities due consideration is required before harvesting pelvic sentinel nodes.

Predicting the weight gain required for recovery from anorexia nervosa with pelvic ultrasonography: an evidence-based approach.

Target weights are an arbitrary means of determining return to physical health in patients with anorexia nervosa (AN) and lack reliability and validity. Transabdominal pelvic ultrasound scanning (U/S) offers a more objective method of ascertaining physical well being by the ability to determine reproductive maturity. This study aimed to explore the correlations between the maturity grading on pelvic U/S and weight for height (WfH) ratios and body mass index (BMI) percentiles. Ultrasound studies were performed in 72 female adolescents (aged 11-17 years at intake) with AN. Scans were graded for maturity using published parameters of pelvic maturity and compared with the patient's WfH ratio and BMI percentile. In our sample was a wide variation of WfH ratios and BMI percentiles at each grade of maturity. This supports the view that arbitrary targets for weight, WfH ratio or BMI percentile are likely to be unnecessarily high for some patients and too low for others. We recommend that targets be based upon baseline pelvic U/S grading and follow-up scanning.

Pelvic ultrasonography in anorexia nervosa: what the clinician should ask the radiologist and how to use the information provided.

Pelvic ultrasonography is generally regarded as the gold standard for determination of pelvic maturity and hence the need for further weight gain in patients with anorexia nervosa. Many clinicians, however, have limited knowledge of this technique. Here, we describe the use of pelvic ultrasonography in anorexia nervosa and present an algorithm to assist the clinician, both with what questions to ask from the radiologist, and how to use the information provided to determine the morphology and hence maturity of the pelvic organs. We then show how this information can be used to assign the level of pelvic maturity a grade from 1 to 5. Finally, we demonstrate use of this system in two patients who progressively gained weight until pelvic maturity was achieved.

Is there increased risk of local and in-transit recurrence following sentinel lymph node biopsy?

Recent publications have suggested that sentinel lymph node biopsy (SLNB) and completion lymphadenectomy (CLND) increase the rate of local and in-transit disease up to 23% in sentinel node positive group of patients with cutaneous melanoma. This retrospective study combined the data from two national centres on local and in-transit disease in 972 melanoma patients who underwent SLNB procedure over 6.5 years period. In total, 77 patients (7.9%) developed loco-regional recurrence: 41 (4.2%) local recurrence only and 36 patients (3.7%) in-transit metastases during a mean follow-up of 42 months. Patients with positive sentinel lymph node were three times more likely to develop loco-regional metastases than those with no nodal disease (17 vs. 5.6%). Over one third of all recurrences developed following excision of thick (Breslow thickness over 4mm) primary tumours. In both centres age and Breslow thickness were found to be significantly higher in the recurrence group (p<0.001 for both). This study revealed a strong association between increased risk of loco-regional metastases and aggressive tumour biology and adverse patients factors. No conclusive evidence was found to support an increased incidence in patients undergoing SLNB and CLND compared to that published for patients undergoing wide local excision alone.