RESUMO
OBJECTIVES: Our aim is to describe the radiologic characteristics of rib fractures in clinically diagnosed cases of child abuse and suggest a complementary imaging for radiographically occult injuries in highly suspicious cases of child abuse. METHODS: Retrospective analysis of initial and follow-up skeletal surveys and computed tomography (CT) scans of 16 patients younger than 12 months were reviewed after obtaining approval from our institutional review board. The number, location, displacement, and age of the rib fractures were recorded. RESULTS: Out of a total 105 rib fractures, 84% (87/105) were detected on the initial skeletal survey. Seventeen percent (18/105) were seen only after follow-up imaging, more than half of which (11/18) were detected on a subsequent CT. Majority of the fractures were posterior (43%) and anterior (30%) in location. An overwhelming majority (96%) of the fractures are nondisplaced. CONCLUSIONS: Seventeen percent of rib fractures analyzed in the study were not documented on the initial skeletal survey. Majority of fractures are nondisplaced and located posteriorly or anteriorly, areas that are often difficult to assess especially in the acute stage. The CT scan is more sensitive in evaluating these types of fractures. Low-dose chest CT can be an important imaging modality for suspicious cases of child abuse when initial radiographic findings are inconclusive.
Assuntos
Maus-Tratos Infantis/diagnóstico , Fraturas das Costelas/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Feminino , Seguimentos , Humanos , Lactente , Masculino , Estudos RetrospectivosRESUMO
OBJECTIVE: To characterize regional differences in brain water distribution and content during diabetic ketoacidosis (DKA) in children and determine whether these differences correlate with regional vascular supply. STUDY DESIGN: We compared changes in brain water distribution and water content in different brain regions during DKA by analyzing magnetic resonance diffusion weighted imaging data collected during DKA and after recovery in 45 children (<18 years of age). We measured the apparent diffusion coefficient (ADC) of water in the frontal and occipital cortex, basal ganglia, thalamus, hippocampus, and medulla. Brain water content was also measured in a subset of patients. RESULTS: ADC values were elevated (suggesting vasogenic cerebral edema) in the frontal cortex, basal ganglia, thalamus, and hippocampus during DKA. In contrast, ADC values in the medulla and the occipital cortex were not increased during DKA, and ADC changes in the medulla tended to be negatively correlated with other regions. Regions supplied by the anterior/middle cerebral artery circulation had greater elevations in both ADC and brain water content during DKA compared with regions supplied by the posterior cerebral artery circulation. CONCLUSIONS: ADC changes during DKA in the brainstem contrast with those of other brain regions, and changes in both ADC and brain water content during DKA vary according to regional vascular supply. These data suggest that brainstem blood flow might possibly be reduced during DKA concurrent with hyperemia in other brain regions.
Assuntos
Água Corporal/metabolismo , Encéfalo/metabolismo , Cetoacidose Diabética/metabolismo , Adolescente , Água Corporal/diagnóstico por imagem , Encéfalo/irrigação sanguínea , Encéfalo/diagnóstico por imagem , Criança , Imagem de Difusão por Ressonância Magnética , HumanosRESUMO
Importance: The utility of the focused assessment with sonography for trauma (FAST) examination in children is unknown. Objective: To determine if the FAST examination during initial evaluation of injured children improves clinical care. Design, Setting, and Participants: A randomized clinical trial (April 2012-May 2015) that involved 975 hemodynamically stable children and adolescents younger than 18 years treated for blunt torso trauma at the University of California, Davis Medical Center, a level I trauma center. Interventions: Patients were randomly assigned to a standard trauma evaluation with the FAST examination by the treating ED physician or a standard trauma evaluation alone. Main Outcomes and Measures: Coprimary outcomes were rate of abdominal computed tomographic (CT) scans in the ED, missed intra-abdominal injuries, ED length of stay, and hospital charges. Results: Among the 925 patients who were randomized (mean [SD] age, 9.7 [5.3] years; 575 males [62%]), all completed the study. A total of 50 patients (5.4%, 95% CI, 4.0% to 7.1%) were diagnosed with intra-abdominal injuries, including 40 (80%; 95% CI, 66% to 90%) who had intraperitoneal fluid found on an abdominal CT scan, and 9 patients (0.97%; 95% CI, 0.44% to 1.8%) underwent laparotomy. The proportion of patients with abdominal CT scans was 241 of 460 (52.4%) in the FAST group and 254 of 465 (54.6%) in the standard care-only group (difference, -2.2%; 95% CI, -8.7% to 4.2%). One case of missed intra-abdominal injury occurred in a patient in the FAST group and none in the control group (difference, 0.2%; 95% CI, -0.6% to 1.2%). The mean ED length of stay was 6.03 hours in the FAST group and 6.07 hours in the standard care-only group (difference, -0.04 hours; 95% CI, -0.47 to 0.40 hours). Median hospital charges were $46â¯415 in the FAST group and $47â¯759 in the standard care-only group (difference, -$1180; 95% CI, -$6651 to $4291). Conclusions and Relevance: Among hemodynamically stable children treated in an ED following blunt torso trauma, the use of FAST compared with standard care only did not improve clinical care, including use of resources; ED length of stay; missed intra-abdominal injuries; or hospital charges. These findings do not support the routine use of FAST in this setting. Trial Registration: clinicaltrials.gov Identifier: NCT01540318.
Assuntos
Traumatismos Abdominais/diagnóstico por imagem , Preços Hospitalares , Tomografia Computadorizada por Raios X , Ultrassonografia , Ferimentos não Penetrantes/diagnóstico por imagem , Traumatismos Abdominais/economia , Traumatismos Abdominais/etiologia , Traumatismos Abdominais/cirurgia , Adolescente , California , Criança , Pré-Escolar , Serviço Hospitalar de Emergência/economia , Reações Falso-Negativas , Feminino , Recursos em Saúde/economia , Recursos em Saúde/estatística & dados numéricos , Humanos , Laparotomia , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Tomografia Computadorizada por Raios X/economia , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Centros de Traumatologia/economia , Resultado do Tratamento , Ultrassonografia/economia , Ultrassonografia/estatística & dados numéricosRESUMO
STUDY OBJECTIVE: We describe presentations and outcomes of children with basilar skull fractures in the emergency department (ED) after blunt head trauma. METHODS: This was a secondary analysis of an observational cohort of children with blunt head trauma. Basilar skull fracture was defined as physical examination signs of basilar skull fracture without basilar skull fracture on computed tomography (CT), or basilar skull fracture on CT regardless of physical examination signs of basilar skull fracture. Other definitions included isolated basilar skull fracture (physical examination signs of basilar skull fracture or basilar skull fracture on CT with no other intracranial injuries on CT) and acute adverse outcomes (death, neurosurgery, intubation for >24 hours, and hospitalization for ≥2 nights with intracranial injury on CT). RESULTS: Of 42,958 patients, 558 (1.3%) had physical examination signs of basilar skull fracture, basilar skull fractures on CT, or both. Of the 525 (94.1%) CT-imaged patients, 162 (30.9%) had basilar skull fracture on CT alone, and 104 (19.8%) had both physical examination signs of basilar skull fracture and basilar skull fracture on CT; 269 patients (51.2%) had intracranial injuries other than basilar skull fracture on CT. Of the 363 (91.7%) CT-imaged patients with physical examination signs of basilar skull fracture, 104 (28.7%) had basilar skull fracture on CT. Of 266 patients with basilar skull fracture on CT, 104 (39.1%) also had physical examination signs of basilar skull fracture. Of the 256 CT-imaged patients who had isolated basilar skull fracture, none had acute adverse outcomes (0%; 95% confidence interval 0% to 1.4%), including none (0%; 95% confidence interval 0% to 6.1%) of 59 with isolated basilar skull fractures on CT. CONCLUSION: Approximately 1% of children with blunt head trauma have physical examination signs of basilar skull fracture or basilar skull fracture on CT. The latter increases the risk of acute adverse outcomes more than physical examination signs of basilar skull fracture. A CT scan is needed to adequately stratify the risk of acute adverse outcomes for these children. Children with isolated basilar skull fractures are at low risk for acute adverse outcomes and, if neurologically normal after CT and observation, are candidates for ED discharge.
Assuntos
Traumatismos Cranianos Fechados/diagnóstico , Fratura da Base do Crânio/diagnóstico , Adolescente , Criança , Pré-Escolar , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Escala de Coma de Glasgow , Traumatismos Cranianos Fechados/diagnóstico por imagem , Traumatismos Cranianos Fechados/terapia , Humanos , Masculino , Fratura da Base do Crânio/diagnóstico por imagem , Fratura da Base do Crânio/terapia , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
STUDY OBJECTIVE: We compare test characteristics of abdominal computed tomography (CT) with and without oral contrast for identifying intra-abdominal injuries. METHODS: This was a planned subanalysis of a prospective, multicenter study of children (<18 years) with blunt torso trauma. Children imaged in the emergency department with abdominal CT using intravenous contrast were eligible. Oral contrast use was based on the participating centers' guidelines and discretions. Clinical courses were followed to identify patients with intra-abdominal injuries. Abdominal CTs were considered positive for intra-abdominal injury if a specific intra-abdominal injury was identified and considered abnormal if any findings suggestive of intra-abdominal injury were identified on the CT. RESULTS: A total of 12,044 patients were enrolled, with 5,276 undergoing abdominal CT with intravenous contrast. Of the 4,987 CTs (95%) with documented use or nonuse of oral contrast, 1,010 (20%) were with and 3,977 (80%) were without oral contrast; 686 patients (14%) had intra-abdominal injuries, including 127 CTs (19%) with and 559 (81%) without oral contrast. The sensitivity in the detection of any intra-abdominal injury in the oral contrast versus no oral contrast groups was sensitivitycontrast 99.2% (95% confidence interval [CI] 95.7% to 100.0%) versus sensitivityno contrast 97.7% (95% CI 96.1% to 98.8%), difference 1.5% (95% CI -0.4% to 3.5%). The specificity of the oral contrast versus no oral contrast groups was specificitycontrast 84.7% (95% CI 82.2% to 87.0%) versus specificityno contrast 80.8% (95% CI 79.4% to 82.1%), difference 4.0% (95% CI 1.3% to 6.7%). CONCLUSION: Oral contrast is still used in a substantial portion of children undergoing abdominal CT after blunt torso trauma. With the exception of a slightly better specificity, test characteristics for detecting intra-abdominal injury were similar between CT with and without oral contrast.
Assuntos
Traumatismos Abdominais/diagnóstico por imagem , Meios de Contraste/efeitos adversos , Radiografia Abdominal/métodos , Tomografia Computadorizada por Raios X/métodos , Ferimentos não Penetrantes/diagnóstico por imagem , Administração Intravenosa , Administração Oral , Adolescente , Criança , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Estudos Prospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Intussusception is a common pediatric abdominal emergency, treated with image-guided reduction. Available techniques include fluoroscopic and ultrasonographic monitoring of liquid and air. OBJECTIVE: The purpose of this study was to determine current practices and establish trends by comparing our findings with reports of previous surveys. MATERIALS AND METHODS: This study is based on an e-mail survey sent to all 1,538 members of the Society for Pediatric Radiology. It included questions about demographics, presence of parents/surgeon during procedure, patient selection/preparation, use of sedation, preferred methods of reduction and technical details, approach to unsuccessful reduction, and self-reported incidence of success/perforation. RESULTS: The 456 respondents (30%) reported attempting 3,834 reductions in the preceding 12 months. Of these, 96% use fluoroscopy and 4% use US guidance for reduction; 78% use air, 20% prefer fluid; 75% require intravenous access; 63% expect a surgeon to be present in hospital; 93% do not sedate. Although inflating a rectal balloon is controversial, 39% do so, and 50% employ a pressure-release valve. Seventy-two percent attempt reductions three times in the same position. In case of unsuccessful reductions, 64% wait and re-attempt later, 19% apply manual pressure, and 15% try again in left decubitus position. About 20% reattempt reduction after waiting 2 h or more. CONCLUSION: By providing a better understanding of both trends in and diversity of current practice, we hope to increase the confidence with which the individual practitioner will approach each case.
Assuntos
Pesquisas sobre Atenção à Saúde/estatística & dados numéricos , Intestinos/diagnóstico por imagem , Intussuscepção/cirurgia , Radiografia Intervencionista , Ultrassonografia de Intervenção , Criança , Feminino , Fluoroscopia , Humanos , Intestinos/cirurgia , Intussuscepção/diagnóstico por imagem , Masculino , Monitorização IntraoperatóriaRESUMO
The purpose of this study was to determine the value of follow-up barium esophogram in diagnosing esophageal injury or leak if the initial water-soluble contrast examination of the esophagus is normal. An institutional review board (IRB)-approved retrospective review of all pediatric patients less than 18 years old referred to the radiology department for evaluation of esophageal injury or leak was performed for a 9-year period from 2005 to 2014. The majority of patients had unexplained pneumomediastinum, chest trauma (gunshot or puncture wound), or foreign body ingestion as the reason for the referral. Forty-nine patients (age range 10 days to 17 years) underwent an initial water-soluble esophogram immediately followed by a barium esophogram. Forty-six studies were negative on both water-soluble contrast and barium studies. Two studies were both positive on the initial water-soluble contrast and subsequent barium studies. A single study showed the esophageal leak only in the water-soluble study, with the follow-up barium exam being normal. The result of this study indicates that a single-contrast water-soluble esophogram alone is sensitive in the diagnosis of esophageal injury or leak. It has a 100 % sensitivity and negative predictive value. A follow-up barium esophogram only increases the study time and radiation dose to the patient.
Assuntos
Perfuração Esofágica/diagnóstico por imagem , Esôfago/diagnóstico por imagem , Esôfago/lesões , Extravasamento de Materiais Terapêuticos e Diagnósticos/diagnóstico por imagem , Adolescente , Sulfato de Bário , Criança , Pré-Escolar , Meios de Contraste , Humanos , Lactente , Recém-Nascido , Radiografia , Estudos Retrospectivos , Ácidos Tri-IodobenzoicosRESUMO
Prospective studies of infants at risk for autism spectrum disorder have provided important clues about the early behavioural symptoms of autism spectrum disorder. Diagnosis of autism spectrum disorder, however, is not currently made until at least 18 months of age. There is substantially less research on potential brain-based differences in the period between 6 and 12 months of age. Our objective in the current study was to use magnetic resonance imaging to identify any consistently observable brain anomalies in 6-9 month old infants who would later develop autism spectrum disorder. We conducted a prospective infant sibling study with longitudinal magnetic resonance imaging scans at three time points (6-9, 12-15, and 18-24 months of age), in conjunction with intensive behavioural assessments. Fifty-five infants (33 'high-risk' infants having an older sibling with autism spectrum disorder and 22 'low-risk' infants having no relatives with autism spectrum disorder) were imaged at 6-9 months; 43 of these (27 high-risk and 16 low-risk) were imaged at 12-15 months; and 42 (26 high-risk and 16 low-risk) were imaged again at 18-24 months. Infants were classified as meeting criteria for autism spectrum disorder, other developmental delays, or typical development at 24 months or later (mean age at outcome: 32.5 months). Compared with the other two groups, infants who developed autism spectrum disorder (n = 10) had significantly greater extra-axial fluid at 6-9 months, which persisted and remained elevated at 12-15 and 18-24 months. Extra-axial fluid is characterized by excessive cerebrospinal fluid in the subarachnoid space, particularly over the frontal lobes. The amount of extra-axial fluid detected as early as 6 months was predictive of more severe autism spectrum disorder symptoms at the time of outcome. Infants who developed autism spectrum disorder also had significantly larger total cerebral volumes at both 12-15 and 18-24 months of age. This is the first magnetic resonance imaging study to prospectively evaluate brain growth trajectories from infancy in children who develop autism spectrum disorder. The presence of excessive extra-axial fluid detected as early as 6 months and the lack of resolution by 24 months is a hitherto unreported brain anomaly in infants who later develop autism spectrum disorder. This is also the first magnetic resonance imaging evidence of brain enlargement in autism before age 2. These findings raise the potential for the use of structural magnetic resonance imaging to aid in the early detection of children at risk for autism spectrum disorder or other neurodevelopmental disorders.
Assuntos
Encéfalo/crescimento & desenvolvimento , Encéfalo/patologia , Transtornos Globais do Desenvolvimento Infantil/líquido cefalorraquidiano , Transtornos Globais do Desenvolvimento Infantil/complicações , Deficiências do Desenvolvimento/patologia , Fatores Etários , Pré-Escolar , Deficiências do Desenvolvimento/líquido cefalorraquidiano , Feminino , Lateralidade Funcional , Cabeça/patologia , Humanos , Processamento de Imagem Assistida por Computador , Lactente , Estudos Longitudinais , Imageamento por Ressonância Magnética , Masculino , Fatores de TempoRESUMO
Although Wilms tumor is the most common renal malignancy in children, the differential diagnosis is extensive and includes both malignant and benign disorders. We present a simple mnemonic-WARM N COLD, to aid in remembering these diverse tumors. Imaging clues including age of the patient, associated disease or syndrome as well as salient imaging characteristics such as bilaterality, and type or presence of metastasis are also presented and can help differentiate between these renal tumors of childhood.
Assuntos
Diagnóstico por Imagem , Neoplasias Renais/diagnóstico , Criança , Pré-Escolar , Diagnóstico Diferencial , Humanos , Lactente , Neoplasias Renais/patologia , Memória , Tumor de Wilms/diagnóstico , Tumor de Wilms/patologiaRESUMO
STUDY OBJECTIVE: We compare the prevalence of clinically important traumatic brain injuries and the use of cranial computed tomography (CT) in children with minor blunt head trauma with and without ventricular shunts. METHODS: We performed a secondary analysis of a prospective observational cohort study of children with blunt head trauma presenting to a participating Pediatric Emergency Care Applied Research Network emergency department. For children with Glasgow Coma Scale (GCS) scores greater than or equal to 14, we compared the rates of clinically important traumatic brain injuries (defined as a traumatic brain injury resulting in death, neurosurgical intervention, intubation for more than 24 hours, or hospital admission for at least 2 nights for management of traumatic brain injury in association with positive CT scan) and use of cranial CT for children with and without ventricular shunts. RESULTS: Of the 39,732 children with blunt head trauma and GCS scores greater than or equal to 14, we identified 98 (0.2%) children with ventricular shunts. Children with ventricular shunts had more frequent CT use: (45/98 [46%] with shunts versus 13,858/39,634 [35%] without; difference 11%; 95% confidence interval 1% to 21%) but a similar rate of clinically important traumatic brain injuries (1/98 [1%] with shunts versus 346/39,619 [0.9%] without; difference 0.1%; 95% confidence interval -0.3% to 5%). The one child with a ventricular shunt who had a clinically important traumatic brain injury had a known chronic subdural hematoma that was larger after the head trauma compared with previous CT; the child underwent hematoma evacuation. CONCLUSION: Children with ventricular shunts had higher CT use with similar rates of clinically important traumatic brain injuries after minor blunt head trauma compared with children without ventricular shunts.
Assuntos
Lesões Encefálicas/etiologia , Derivações do Líquido Cefalorraquidiano/efeitos adversos , Traumatismos Cranianos Fechados/complicações , Lesões Encefálicas/epidemiologia , Pré-Escolar , Escala de Coma de Glasgow , Traumatismos Cranianos Fechados/diagnóstico por imagem , Humanos , Lactente , Neuroimagem , Prevalência , Estudos Prospectivos , Tomografia Computadorizada por Raios XRESUMO
STUDY OBJECTIVE: We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. METHODS: We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. RESULTS: We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). CONCLUSION: A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.
Assuntos
Apendicite/diagnóstico , Técnicas de Apoio para a Decisão , Feminino , Humanos , MasculinoRESUMO
BACKGROUND: Skeletal surveys for non-accidental trauma (NAT) include lateral spinal and pelvic views, which have a significant radiation dose. OBJECTIVE: To determine whether pelvic and lateral spinal radiographs should routinely be performed during initial bone surveys for suspected NAT. MATERIALS AND METHODS: The radiology database was queried for the period May 2005 to May 2011 using CPT codes for skeletal surveys for suspected NAT. Studies performed for skeletal dysplasia and follow-up surveys were excluded. Initial skeletal surveys were reviewed to identify fractures present, including those identified only on lateral spinal and/or pelvic radiographs. Clinical information and MR imaging was reviewed for the single patient with vertebral compression deformities. RESULTS: Of the 530 children, 223 (42.1%) had rib and extremity fractures suspicious for NAT. No fractures were identified solely on pelvic radiographs. Only one child (<0.2%) had vertebral compression deformities identified on a lateral spinal radiograph. This infant had rib and extremity fractures and was clinically paraplegic. MR imaging confirmed the vertebral body fractures. CONCLUSION: Since no fractures were identified solely on pelvic radiographs and on lateral spinal radiographs in children without evidence of NAT, nor in nearly all with evidence of NAT, inclusion of these views in the initial evaluation of children for suspected NAT may not be warranted.
Assuntos
Maus-Tratos Infantis/diagnóstico , Maus-Tratos Infantis/estatística & dados numéricos , Fraturas Ósseas/diagnóstico por imagem , Fraturas Ósseas/epidemiologia , Doses de Radiação , Proteção Radiológica/estatística & dados numéricos , Intensificação de Imagem Radiográfica/métodos , Acidentes , California/epidemiologia , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pelve/diagnóstico por imagem , Prevalência , Proteção Radiológica/métodos , Radiografia/estatística & dados numéricos , Reprodutibilidade dos Testes , Medição de Risco , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Men on active surveillance for clinical stage I nonseminomatous germ cell tumor (NSGCT) undergo frequent computed tomography imaging to avoid delayed detection of disease. Irradiation from frequent imaging and chemotherapy upon progression may place patients at increased risk of a second malignancy. In this study, the authors sought to identify such an increased risk among men who chose initial surveillance for NSGCT. METHODS: The authors utilized data from the Surveillance, Epidemiology and End Results Program and stratified the cohort based on whether they underwent retroperitoneal lymph node dissection (RPLND). A propensity-score model was used to adjust for covariates, and a competing-risks regression analysis was performed to estimate cumulative incidence rates of second malignancy. Incidence risk ratios were predicted by using the cumulative incidence rates per 10,000 patients. RESULTS: There was no statistically significant increase in the incidence of a secondary malignancy for the entire cohort of testicular cancer survivors. However, when the analysis was restricted to patients with clinical stage I NSGCT, nonsurgical management only in those aged >45 years was an independent predictor of developing a second malignancy. For every 10,000 patients with stage I NSGCT who chose to forego RPLND, an absolute excess incidence of 22, 52, and 73 secondary malignancies would be diagnosed at 5 years, 10 years, and 15 years, respectively. CONCLUSIONS: The current results indicated that patients aged >45 years who forego RPLND for T1 or T2 clinical stage I NSGCT are more likely to develop a second malignancy than those who do undergo RPLND. Nonsurgical management of NSGCT may be associated with more long-term health risks than primary RPLND.
Assuntos
Neoplasias Embrionárias de Células Germinativas/patologia , Segunda Neoplasia Primária/epidemiologia , Sobreviventes , Neoplasias Testiculares/patologia , Adolescente , Adulto , Humanos , Excisão de Linfonodo , Masculino , Pessoa de Meia-Idade , Neoplasias Embrionárias de Células Germinativas/cirurgia , Espaço Retroperitoneal/patologia , Risco , Neoplasias Testiculares/cirurgiaRESUMO
Neuroblastoma is an enigmatic disease entity; some tumors disappear spontaneously without any therapy, while others progress with a fatal outcome despite the implementation of maximal modern therapy. However, strong prognostic factors can accurately predict whether children have "good" or "bad" disease at diagnosis, and the clinical stage is currently the most significant and clinically relevant prognostic factor. Therefore, for an individual patient, proper staging is of paramount importance for risk assessment and selection of optimal treatment. In 2009, the International Neuroblastoma Risk Group (INRG) Project proposed a new staging system designed for tumor staging before any treatment, including surgery. Compared with the focus of the International Neuroblastoma Staging System, which is currently the most used, the focus has now shifted from surgicopathologic findings to imaging findings. The new INRG Staging System includes two stages of localized disease, which are dependent on whether image-defined risk factors (IDRFs) are or are not present. IDRFs are features detected with imaging at the time of diagnosis. The present consensus report was written by the INRG Imaging Committee to optimize imaging and staging and reduce interobserver variability. The rationales for using imaging methods (ultrasonography, magnetic resonance imaging, computed tomography, and scintigraphy), as well as technical guidelines, are described. Definitions of the terms recommended for assessing IDRFs are provided with examples. It is anticipated that the use of standardized nomenclature will contribute substantially to more uniform staging and thereby facilitate comparisons of clinical trials conducted in different parts of the world.
Assuntos
Neoplasias do Sistema Nervoso Central/diagnóstico , Neuroblastoma/diagnóstico , Criança , Diagnóstico por Imagem , Humanos , Metástase Neoplásica , Estadiamento de Neoplasias , Fatores de RiscoRESUMO
BACKGROUND: Residents should be exposed to adequate procedural volume to act independently upon completion of training. Informal inquiry led us to question whether residents encounter enough intussusception reductions to become comfortable with the procedure. OBJECTIVE: We sought to determine radiology residents' exposure to intussusception reductions, and whether their experiences vary by region or institution. MATERIALS AND METHODS: U.S. radiology residency program directors were asked to encourage their residents to complete a 12-question online survey describing characteristics of their pediatric radiology department, experiences with intussusception reduction, and confidence in their own ability to perform the procedure. RESULTS: Six hundred sixty-four residents responded during the study period. Of those, 308 (46.4%) had not experienced an intussusception reduction, and 228 (34%) had experienced only one or two. Twenty-two percent of fourth-year residents had never experienced an intussusception reduction, and 21% had experienced only one. Among second- through fourth-year residents, only 99 (18.3%) felt confident that they could competently reduce an intussusception (P < 0.0001), and 336 (62.2%) thought they would benefit from a computer-assisted training model simulating intussusception reduction (P < 0.0001). CONCLUSION: Radiology residents have limited opportunity to learn intussusception reduction and therefore lack confidence. Most think they would benefit from additional training with a computer-simulation model.
Assuntos
Internato e Residência/estatística & dados numéricos , Intussuscepção/diagnóstico por imagem , Intussuscepção/prevenção & controle , Competência Profissional , Radiologia/educação , Radiologia/estatística & dados numéricos , Estudantes/estatística & dados numéricos , Adulto , California , Feminino , Humanos , Masculino , Radiografia , Adulto JovemRESUMO
BACKGROUND: Intussusception reduction allows young children to avoid surgery. However, graduating residents have had relatively little training in intussusception reduction and, for the most part, consider themselves ill-prepared to perform this procedure. OBJECTIVE: The goal of this study was to assess the extent of training in intussusception reduction during one year of a pediatric radiology fellowship and to determine whether graduating fellows consider themselves adequately trained in this technique. MATERIALS AND METHODS: Pediatric radiology fellows were surveyed during June 2010 and asked to characterize their fellowship, to indicate the number of intussusception reductions performed (both the total number and those performed with faculty oversight but without active faculty involvement), and to assess the adequacy of their training. RESULTS: There were 31 responses, representing almost 1/3 of current fellows. Pediatric radiology fellows perform on average 6.9 reductions, 3.8 of which are with faculty oversight but without active faculty involvement. Ninety percent consider themselves well-trained in the technique, whereas 10% are uncertain (none consider their training inadequate). CONCLUSION: Almost all pediatric radiology fellows consider their training in intussusception reduction to be adequate.
Assuntos
Intussuscepção/prevenção & controle , Pediatria , Competência Profissional , Radiologia , Bolsas de Estudo , Humanos , Intussuscepção/cirurgia , Pediatria/educação , Radiologia/educação , Inquéritos e QuestionáriosRESUMO
BACKGROUND: CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary. METHODS: We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission >or=2 nights). FINDINGS: We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations. INTERPRETATION: These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated. FUNDING: The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.
Assuntos
Lesões Encefálicas/etiologia , Traumatismos Craniocerebrais , Técnicas de Apoio para a Decisão , Medição de Risco/métodos , Tomografia Computadorizada por Raios X , Algoritmos , Fenômenos Biomecânicos , Lesões Encefálicas/diagnóstico por imagem , Lesões Encefálicas/mortalidade , Criança , Pré-Escolar , Traumatismos Craniocerebrais/complicações , Traumatismos Craniocerebrais/diagnóstico , Árvores de Decisões , Medicina de Emergência/métodos , Humanos , Intubação Intratraqueal/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Seleção de Pacientes , Pediatria/métodos , Valor Preditivo dos Testes , Estudos Prospectivos , Medição de Risco/normas , Fatores de Risco , Índice de Gravidade de Doença , Tomografia Computadorizada por Raios X/efeitos adversos , Tomografia Computadorizada por Raios X/estatística & dados numéricosRESUMO
PURPOSE: To evaluate which parameters may affect endothelial cell loss after Descemet membrane endothelial keratoplasty (DMEK) by comparing eyes in the low vs high quartile of endothelial cell loss over a follow-up period of 4 years. DESIGN: Retrospective cohort study. METHODS: Donor endothelial cell density (ECD) decline was evaluated for 351 eyes of 275 patients up to 4 years after DMEK for Fuchs endothelial corneal dystrophy (FECD). Eyes with a postoperative endothelial cell loss in the lower quartile at all available follow-up moments were assigned to Group 1 (n = 51) and those in the upper quartile to Group 2 (n = 42). Multinomial regression was used to assess which covariates were related to greater ECD decline. RESULTS: Mean endothelial cell loss as compared to preoperative donor ECD for the entire study group was 33 (±16)%, 36 (±17)%, and 52 (±18)% at 1, 6, and 48 months postoperatively. Endothelial cell loss of Group 1 was 12 (±7)%, 13 (±6)%, and 26 (±8)% at, respectively, 1, 6, and 48 months postoperatively, and 59 (±10)%, 64 (±9)%, and 75 (±5)% in Group 2. Partial graft detachment, donor death cause cardiovascular/stroke (vs cancer), postoperative complications other than graft detachment, and severity of preoperative FECD (all P < .01) showed the strongest relation with greater ECD decline. CONCLUSIONS: DMEK eyes with a completely attached graft and operated in an early stage of FECD may show the lowest endothelial cell loss postoperatively.
Assuntos
Perda de Células Endoteliais da Córnea/patologia , Ceratoplastia Endotelial com Remoção da Lâmina Limitante Posterior , Endotélio Corneano/patologia , Distrofia Endotelial de Fuchs/cirurgia , Complicações Pós-Operatórias , Idoso , Idoso de 80 Anos ou mais , Contagem de Células , Paquimetria Corneana , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Doadores de Tecidos , Acuidade VisualRESUMO
Brainstem disconnection is a very rare neonatal abnormality, with only seven cases reported. We report a unique case of a neonate who presented at delivery with hypertonia, dysmorphic facial features, and respiratory distress, as well as numerous musculoskeletal and genitourinary abnormalities. MRI of the brain showed disconnection between the pons and medulla with cerebellar hypoplasia and absent cerebellar peduncles. It aided in the description of the neurological and vascular anomalies associated with this diagnosis.