Defensive fungal symbiosis on insect hindlegs.

Tympanal organs as "insect ears" have evolved repeatedly. Dinidorid stinkbugs were reported to possess a conspicuous tympanal organ on female's hindlegs. Here we report an unexpected discovery that the stinkbug's "tympanal organ" is actually a novel symbiotic organ. The stinkbug's "tympanum" is not membranous but a porous cuticle, where each pore connects to glandular secretory cells. In reproductive females, the hindleg organ is covered with fungal hyphae growing out of the pores. Upon oviposition, the females skillfully transfer the fungi from the organ to the eggs. The eggs are quickly covered with hyphae and physically protected against wasp parasitism. The fungi are mostly benign Cordycipitaceae entomopathogens and show considerable diversity among insect individuals and populations, indicating environmental acquisition of specific fungal associates. These results uncover a novel external fungal symbiosis in which host's elaborate morphological, physiological and behavioral specializations underpin the selective recruitment of benign entomopathogens for a defensive purpose.

Ultrasonography for the Detection of Osteomyelitis in Pediatric Patients With Soft Tissue Infection: A Pilot Study.

OBJECTIVES: To demonstrate the usefulness of ultrasonography for differentiating soft tissue infections with or without osteomyelitis in pediatric patients who underwent ultrasonography and subsequent magnetic resonance imaging (MRI). METHODS: Twenty-three patients were classified into 2 groups: 12 patients with and 11 patients without osteomyelitis based on MRI. Osteomyelitis using ultrasound is characterized by the presence of bone cortex irregularity and/or subperiosteal abscess formation. The diagnostic performance of ultrasonography for detecting osteomyelitis and subperiosteal abscess formation was compared with that of MRI. Diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were calculated with 95% confidence intervals (CIs). RESULTS: Of 12 osteomyelitis cases, 11 had abnormal bone marrow enhancement (one residual case did not undergo contrast enhancement study) and 5 had subperiosteal abscesses. The diagnostic accuracy of ultrasonography for osteomyelitis was 82.6% (number of correct diagnosis of osteomyelitis/total number = 19/23; 95% CI, 61.2-95.0) and for detecting periosteal abscess was 95.7% (number of correct diagnosis of periosteal abscess/total number = 22/23; 95% CI, 78.1-99.9), respectively. The sensitivity and specificity of ultrasonography for detecting osteomyelitis were 66.7% (95% CI, 34.9-90.1) and 100% (95% CI, 71.5-100), respectively. The sensitivity and specificity of ultrasonography for detecting periosteal abscess were 80% (95% CI, 28.4-99.5), and 100% (95% CI, 81.5-100), respectively. One-third of osteomyelitis cases could not be detected using ultrasonography. CONCLUSIONS: Ultrasonography may be useful for diagnosing osteomyelitis in pediatric patients; however, the technique appears limited by low sensitivity. However, it is more accurate for diagnosis of periosteal abscess in these patients.

Clinical audit of ultrasonography for detecting sialoliths in the submandibular gland in paediatric patients: A comparison to computed tomography and magnetic resonance imaging.

Objectives: To compare the performance of ultrasonography with magnetic resonance imaging (MRI) and computed tomography (CT) for detecting submandibular sialoliths. Methods: Thirteen patients with suspected submandibular sialoliths who underwent ultrasonography and CT or MRI were included. Sialoliths were diagnosed using CT (11 cases) or MRI (two cases). The submandibular duct was classified into distal and proximal ducts based on the point around the mylohyoid muscle. Sialoliths located in the proximal duct were difficult to differentiate from those located within the submandibular gland (SMG). Therefore, the location of the sialoliths was classified as follows: within the SMG/proximal duct and within the distal duct. The ultrasound results were compared with CT/MRI results. Results: Of the 13 patients included, two had sialoliths in both the SMG/proximal duct and the distal duct, three had sialoliths in the SMG/proximal duct, and five had sialoliths in the distal duct on CT or MRI. In this small cohort, all five sialoliths in the SMG/proximal duct were detected by ultrasoonography; however, of the seven cases with sialoliths located in the distal duct, only three could be detected by ultrasonography. Conclusions: The incidence of sialoliths in the distal duct was higher than that in the SMG/proximal duct. Ultrasonography showed a good performance compared with CT/MRI in the SMG/proximal duct but not in the distal duct.

Ultrasound for the evaluation of the urethra in pediatric patients.

Urethral lesions in pediatric patients can be visualized using ultrasonography. Therefore, sonographers and physicians should be familiar with the technique.

Ultrasonographic Findings of Catheter-Related Bloodstream Infection in Pediatric Patients.

BACKGROUND: Catheter removal is essential for treating catheter-related bloodstream infection (CRBSI); however, clinicians are sometimes hesitant to remove catheters in pediatric patients due to the difficulty of securing vascular access. Confirming the diagnosis of CRBSI is important to justify catheter removal. The purpose of this study was to describe the sonographic findings of CRBSI. MATERIALS AND METHODS: We included patients with a central venous catheter (CVC) or peripherally inserted central catheter (PICC) who had a positive blood culture and underwent ultrasound. The patients were classified as with or without CRBSI. Sonographic findings, such as the presence/absence of thrombus, venous wall thickening, hyperechogenicity, and fluid collection around the vein were compared using Fisher's exact test. RESULTS: Of the 58 patients, 38 (66%) were diagnosed with CRBSI. The presence of thrombus (19/38 vs 3/20, P = .011); and hyperechogenicity around the vein (14/38 vs 2/20, P = .035) differed significantly, but There was no significant difference in the presence of venous wall thickening (10/38 vs 1/20, P = .077), and fluid collection around the vein (5/38 vs 0/20, P = .153), did not differ significantly in patients with and without CRBSI, respectively. One-third of patients with CRBSI, including 11 (42.3%) patients with CVC, and 2 (16.7%) patients with PICC, did not have abnormal sonographic findings. CONCLUSION: Ultrasound findings are useful for diagnosing CRBSI. However, the sensitivity of sonographic findings is low and abnormal sonographic findings are sometimes absent in children with CRBSI; therefore, physicians should not rule out CRBSI based on normal sonographic findings, especially in patients a CVC and a positive blood culture.

Point-of-care ultrasonography for the diagnosis and manual detorsion of testicular torsion.

Testicular torsion is a urological emergency caused by the loss of testicular tissue due to ischemic damage. Rapid diagnosis and urgent treatment play a crucial role in the management of testicular torsion. Manual detorsion can be performed at the bedside, thereby reducing the duration of ischemia. Recent studies have reported the use of point-of-care ultrasonography for diagnosing testicular torsion; however, no review article has focused on the ultrasonographic findings pertaining to manual detorsion. This review describes the diagnosis of testicular torsion and the ultrasonographic indications for manual detorsion. Spermatic cord twisting or the whirlpool sign, absence of or decreased blood flow within the affected testis, abnormal testicular axis, abnormal echogenicity, and enlargement of the affected testis and epididymis due to ischemia are the sonographic findings associated with testicular torsion. The following findings are considered indications for manual detorsion: direction of testicular torsion, i.e., inner or outer direction (ultrasonographic accuracy of 70%), and the degree of spermatic cord twist. The following sonographic findings are used to determine whether the treatment was successful: presence of the whirlpool sign and the degree and extent of perfusion of the affected testis. Misdiagnosis of the direction of manual detorsion, a high degree of spermatic cord twisting and insufficient detorsion, testicular compartment syndrome, and testicular necrosis were found to result in treatment failure. The success of manual detorsion is determined based on the symptoms and sonographic findings. Subsequent surgical exploration is recommended in all cases, regardless of the success of manual detorsion.

Assessing the Usefulness of Ultrasonography for the Diagnosis and Evaluation of Intra-Orbital Lesions in Pediatric Patients: A Retrospective Analysis.

OBJECTIVES: To assess the usefulness of ultrasonography in the diagnosis and evaluation of extraocular intra-orbital lesions in pediatric patients. METHODS: Twenty-three pediatric patients with intra-orbital lesions who underwent both ultrasound and computed tomography/magnetic resonance imaging (CT/MRI) were included. The following parameters were evaluated using ultrasound: 1) lesion detection rate (presence or absence of lesions), 2) lesion characteristics, 3) lesion location (extraconal or intraconal), and 4) the lesion longest linear dimensions, and these were compared using Fisher's exact test and Mann-Whitney U test. RESULTS: Two lesions could not be detected using ultrasound; in the other 21 cases, the lesion characteristics diagnosed by ultrasound were correct. Diagnostic accuracy of detection and characteristics assessment using ultrasound were 91.3% and 91.3%, respectively. The lesion location was not significantly different between the two groups (intraconal/extraconal in those detected using ultrasound versus those in the absence on ultrasound = 7/14 versus 0/2, P > .999); however, in two cases that were not detected on ultrasound, the lesions were located at extraconal. Lesions that were small in longest linear dimensions on CT/MRI were not detected using ultrasound (the longest linear dimensions in lesions detected using ultrasound versus that in the absence of ultrasound: 29.5 ± 8.2 [range, 13-46] versus 10 and 11 mm, P = .043). CONCLUSIONS: Ultrasonography proved to be useful for visualizing and evaluating intra-orbital lesions except for lesions that were relatively small in size. Therefore, although ultrasound could not detect lesions located behind bone and bone invasion, it could be used for diagnosing and selecting treatment strategies for intra-orbital lesions.

Sonographic Findings of Cervical Chondrocutaneous Branchial Remnants-A Comparison With Dermal Lesions/Cysts and a Literature Review: A Pilot Study.

OBJECTIVES: Cervical chondrocutaneous branchial remnants (CCBRs) and dermal lesions, such as epidermoid cysts or brachial anomalies, including lateral cervical cysts/sinuses or dermal sinuses of anterior chest lesions, are usually located at the lower neck at the anterior or posterior border of the sternocleidomastoid muscle (SCM). We aimed to demonstrate the usefulness of ultrasonography in the differential diagnosis and evaluation of CCBRs. METHODS: We evaluated 22 lesions of 20 pediatric patients, classified into CCBR and dermal lesion groups. We used Fisher's exact test to evaluate differences between these groups in terms of lesion shape (low-echoic mass- or tubular-like), whether the lesion was adjacent to/in contact with the SCM or not, and the presence or absence of a concave SCM caused by the lesion. RESULTS: Of the 22 lesions, 8 were CCBRs, and 14 were dermal lesions. We found a significant difference in the presence/absence of adjacency to or contact with the SCM (presence/absence of adjacency to or contact with the SCM in CCBRs vs that in dermal lesions: 6/2 vs 1/13, P = .002) and presence/absence of lesion-induced concavity of the SCM (presence/absence of lesion-induced concavity of the SCM in CCBRs vs that in dermal lesions: 3/5 vs 0/14, P = .036). The lesion shape (low-echoic mass-like/tubular-like lesions) did not significantly differ between the two study groups (low-echoic mass-like/tubular-like lesions in CCBRs vs that in dermal lesions: 5/3 vs 11/6, P = .624). CONCLUSIONS: CCBRs have a strong association with the SCM. These sonographic findings may be useful in the differential diagnosis of dermal cervical lesions.

Complete Remission of Renal Scarring in Follow-Up DMSA Renal Scintigraphy After Urinary Tract Infection.

Our study aimed to investigate the association between the characteristics of patients/images and complete remission of renal scarring shown in the first chronic phase Technetium-99m dimercaptosuccinic acid (DMSA) renal scintigraphy images in children with urinary tract infection (UTI). Fifty children, who underwent the chronic phase of DMSA scintigraphy more than twice following UTI diagnosis and had renal scarring in the first chronic phase DMSA renal scintigraphy, were enrolled. They were classified into 2 groups: with and without complete remission of renal scarring on the second chronic phase DMSA renal scintigraphy. Renal scarring was classified into 3 grades based on severity per the image findings. Seven cases had complete remission from renal scarring. There were significant differences in age and severity. Renal scarring might be completely reversed in young children without severe findings on DMSA renal scintigraphy. Additional chronic phase examination may aid in follow-up completion and patients' peace of mind.

Point-of-Care Ultrasound for Mimicker Lesions of Incarcerated Inguinal Hernia.

Inguinal hernia is the most common surgical disease in pediatric patients, and urgent intervention such as manual reduction is needed for incarcerated inguinal hernia. Torsion of undescended testes, inguinal herniated ovarian torsion, and purulent lymphadenitis are mimickers of this condition. If these mimicker lesions are misdiagnosed as incarcerated inguinal hernia, manual reduction usually fails, and edematous and erythematous changes may occur in these mimicker lesions due to manual reduction. For physicians in the emergency department, prompt decisions and familiarity with the sonographic appearance of different contents within an inguinal hernia are important to accurately diagnose these mimickers. In this case series, we present sonographic images of a typical case of incarcerated inguinal hernia (an 11-month-old male with right incarcerated inguinal hernia) and three cases of mimicker lesions (a 7-month-old female with herniated ovarian torsion, a 7-year-old boy with undescended testicular torsion, and a 2-month-old male with purulent lymphadenitis). The incidence of incarcerated inguinal hernia is reported to be higher in males (80%), on the right side (60%), and in infants and toddlers. This information is important for diagnosing mimicker lesions. In addition, to prevent manual reduction in mimicker diseases, point-of-care ultrasound before manual reduction in suspected cases of incarcerated inguinal hernia is important.

Useful sonographic findings for diagnosing dermal metastases of rhabdomyosarcoma.

Rhabdomyosarcoma developing in deep locations, such as the genitourinary tract, and perianal and perineal regions, symptoms may be obscure. Dermal rhabdomyosarcoma metastases may be first symptom of that and those arise in the subcutaneous fat tissue, presenting as a high echoic area surrounded by a low echoic area, accompanied by a high echoic peripheral area. These sonographic findings might indicate an aggressive malignant disease, and that would be useful to differentiate from other dermal lesions.

Association between the dynamic movement of hyperechoic foci and patients'/sonographic outcomes among pediatric patients with portal venous gas following a cardiac event.

OBJECTIVES: To demonstrate the association between the dynamic movements of hyperechoic foci in portal venous gas (PVG) and patients'/sonographic outcomes after congenital heart disease or cardiac events. METHODS: Thirty-one pediatric patients requiring management of congenital heart diseases or cardiac events who had PVG on ultrasound were included in this retrospective study. The patient outcome was prognosis: dead or alive. The sonographic outcome was recovery from PVG, measured as days from PVG detection to when it diminished on ultrasound. The following sonographic findings of hyperechoic foci in PVG were compared between patients: detection within the mesenteric vein, having to-and-fro movements within the intrahepatic portal vein, distribution (left segment or both left and right segments) and shape (line or punctate) in the liver, and detection within the portal and hepatic veins. Comparisons were made using Fisher's exact/Mann-Whitney U test. RESULTS: Four patients died without having recovered from PVG. A significant difference was observed in terms of the to-and-fro movement (with/without to-and-fro movement in dead vs. alive patients: 3/1 vs. 1/26, respectively; P = 0.003). Furthermore, a significant difference in sonographic outcomes was observed regarding patients with/without hyperechoic foci within the mesenteric vein (days with vs. without this finding: 2.0 ± 1.24(1-5) vs.1 ± 0(1), respectively; P = 0.011). CONCLUSIONS: In our small limited cohort, when PVG was visualized on ultrasound, close evaluation of the dynamic movement of hyperechoic foci, especially their to-and-fro movement within the intrahepatic portal vein and detection of hyperechoic foci within the mesenteric vein, were useful in predicting patients' outcomes and the time to PVG diminishment.

Association between the imaging characteristics of renal abscess and vesicoureteral reflux.

INTRODUCTION: Renal abscesses are rare in pediatric populations. We aimed to highlight the differences in the computed tomography (CT) imaging characteristics of renal abscesses in patients with and without vesicoureteral reflux (VUR). MATERIALS AND METHODS: Thirteen children with renal abscesses were included and categorized into those with and without VUR. Blood and urine culture results were recorded as positive or negative. Imaging characteristics were recorded: with/without subcapsular fluid collection, with/without upper/lower pole involvement, and with single/multiple lesions in kidneys. Fisher's exact test was used for intergroup comparisons of the rate of positive pathogens and imaging characteristics. RESULTS: Nine patients had VUR (45.9%). Blood and urine culture were positive in two (15.4%) and seven cases (53.8%), respectively. There was no significant difference in the rate of pathogen-positive blood and urine cultures (blood culture positive/negative status with VUR vs. that without VUR = 2/7 vs. 0/4, p > 0.999, urine culture positive/negative status with VUR vs. that without VUR = 4/5 vs. 3/1, p = 0.559). The two groups differed significantly regarding subcapsular fluid collection presence (with/without subcapsular fluid collection with VUR vs. that without VUR = 9/0 vs 1/3, p = 0.014). There was no significant difference in upper/lower pole involvement (with/without involving upper/lower pole with VUR vs. that without VUR = 8/1 vs 2/2, p = 0.203). Patients with VUR were non-significantly more likely to have multiple lesions compared to those without VUR. CONCLUSIONS: VUR was associated with subcapsular fluid collection and possibly with multiple lesions, indicating the need for prompt detection of and specific treatment for VUR in cases with these findings.

Carnival Mask Sign on Bone Scan of Craniofacial Metastasis of Neuroblastoma.

A craniofacial mass may cause the first clinical symptoms of malignancy. In pediatric patients, neuroblastoma, Langerhans cell histiocytosis (LCH), and acute lymphoblastic leukemia (ALL) are the most common diseases initially manifesting with bone lesions, and bone scintigraphy is a useful modality to evaluate them. The purpose of this pictorial essay was to show the scintigraphy findings of the craniofacial bones in three patients, with neuroblastoma, ALL, and LCH, and to provide a useful scintigraphic sign to differentiate these diseases. In the bone scintigraphy of neuroblastoma with craniofacial bone metastases, strong tracer uptake was evident, resembling a carnival mask. In contrast, in the two cases with LCH and ALL involving the craniofacial bones, the tracer uptake was lower than in neuroblastoma and with different distributions. Bone metastases of neuroblastoma usually occur in the periorbital craniofacial bones, and these metastases may be locally aggressive, destroying the bones; which show stronger uptake than other cranial bones. LCH is associated with varying degrees of disease activity, and its bone imaging findings differ based on its activity. Therefore, these lesions present low uptake in bone scintigraphy, showing as "cold spots". Therefore, LCH scintigraphy of the craniofacial bones does not resemble a carnival mask. The bone marrow infiltration by leukemic cells usually shows as diffuse bone marrow. Therefore, in bone scintigraphy of leukemia, the tracer uptake in the periorbital craniofacial bones is similar to other cranial bones, not presenting as a carnival mask. In conclusion, bone scintigraphy to evaluate malignant craniofacial lesions could provide useful differential diagnostic information.

Evaluating the one-time chair stand test for predicting the coronavirus disease severity in patients during hospital admission: a cohort study in Japan.

BACKGROUND: This study aimed to understand whether the one-time chair stand test (CS-1) is useful for predicting the severity of coronavirus disease (COVID-19) in 101 patients admitted to the hospital with acute respiratory failure. METHODS: This single-centered, prospective observational cohort study enrolled 101 critically ill adult patients hospitalized with COVID-19 who underwent the CS-1 as a dynamic evaluation tool in clinical practice between late April 2020 and October 2021. Data on demographic characteristics, symptoms, laboratory values, computed tomography findings, and clinical course after admission were collected. Furthermore, the data was compared, and the association between the intubation and non-intubation groups was determined. We also calculated the cutoff point, area under the curve (AUC), and 95% confidence interval (CI) of the change in oxygen saturation (ΔSpO2) during the CS-1. RESULTS: Thirty-three out of 101 patients (33%) were intubated during hospitalization. There was no significant difference in the resting SpO2 (93.3% versus 95.2%, P = 0.22), but there was a significant difference in ΔSpO2 during the CS-1 between the intubation and non-intubation groups (10.8% versus 5.5%, P < 0.01). In addition, there was a significant correlation between hospitalization and ΔSpO2 during the CS-1 (ρ = 0.60, P < 0.01). The generated cutoff point was calculated as 9.5% (AUC = 0.94, 95% CI = 0.88-1.00). CONCLUSION: For COVID-19 patients with acute respiratory failure, the CS-1 performed on admission was useful for predicting the severity of COVID-19. Furthermore, the CS-1 can be utilized as a remote and simple evaluation parameter. Thus, it could have potential clinical applications in the future.

Prediction of testicular atrophy based on sonographic findings immediately after successful manual detorsion.

Purpose: To investigate and determine the sonographic findings obtained from manually distorted testes to predict testicular atrophy following manual detorsion. Materials and methods: Twenty-two patients who had been diagnosed with testicular torsion and undergone manual detorsion were included. These patients were classified according to the presence or absence of testicular atrophy. The duration of symptoms, presence or absence of hyperperfusion within the entire affected testis, and echogenicity (homogeneous or heterogeneous) within the affected testis were compared using the Mann-Whitney U-test or Fisher's exact test, as appropriate. Results: Testicular atrophy was detected in seven patients. There was a significant difference in the frequency of hyperperfusion within the entire affected testis (with atrophy [present/absent] vs. without atrophy [present/absent] = 0/7 vs. 8/7, P = 0.023) between patients with and without testicular atrophy. No significant differences in the duration of symptoms (with atrophy vs. without atrophy = 7 ± 3.3 h vs. 4.7 ± 3.6 h, P = 0.075) or frequency of echogenicity within the testis (with atrophy [heterogeneous/homogeneous] vs. without atrophy [heterogeneous/homogeneous] = 2/5 vs. 2/13, P = 0.565) were observed between the groups. Conclusions: This small cohort study suggests that the presence of hyperperfusion within the entire affected testis immediately after successful manual detorsion is useful in predicting the avoidance of testicular atrophy.

Incidence and diagnostic performance of ultrasound for perianal abscess or fistula-in-ano in pediatric patients with perianal inflammation.

OBJECTIVES: To describe the incidence and diagnostic performance of ultrasound for perianal abscess or fistula-in-ano in pediatric patients with perianal inflammation. METHODS: We included 45 patients with perianal inflammation who underwent ultrasonography. To demonstrate the diagnostic performance of ultrasound for fistula-in-ano, a definite diagnosis of perianal abscess, and fistula-in-ano was determined as that proven through magnetic resonance imaging (MRI) or computed tomography (CT). The absence or presence of perianal abscess and fistula-in-ano on ultrasonography was recorded. RESULTS: Among the 45 patients, on ultrasound, perianal abscess and fistula-in-ano were detected in 22 (48.9%) and 30 (68.2%) patients, respectively. Nine patients had MRI or CT and a definite diagnosis of perianal abscess or fistula-in-ano; accuracy, negative predictive value, and positive predictive value of ultrasound for perianal abscess were 77.8% (7/9; 95% confidence interval [CI]: 40.0%-97.1%), 66.7% (2/3; 95% CI: 9.4%-99.2%), 83.3% (5/6; 95% CI: 35.9%-99.6%), and those of fistula-in-ano were 100% (9/9; 95% CI: 66.4%-100%), 100% (8/8; 95% CI: 63.1%-100%), and 100% (1/1; 95% CI: 2.5%-100%), respectively. CONCLUSIONS: Perianal abscess and fistula-in-ano were detected by ultrasound in half of the patients with perianal inflammation. Accordingly, ultrasound has an acceptable diagnostic performance for perianal abscess and fistula-in-ano.