CMR Imaging 6 Months After Myocarditis Associated with the BNT162b2 mRNA COVID-19 Vaccine.

Temporal association between BNT162b2 mRNA COVID-19 vaccine and myocarditis (PCVM) has been reported. We herein present early and 6-month clinical follow-up and cardiac magnetic resonance imaging (CMR) of patients with PVCM. A retrospective collection of data from 15 patients with PCVM and abnormal CMR was performed. Clinical manifestation, laboratory data, hospitalizations, treatment protocols, and imaging studies were collected early (up to 2 months) and later. In nine patients, an additional CMR evaluation was performed 6 months after diagnosis. PCVM was diagnosed in 15 patients, mean age 17 ± 1 (median 17.2, range 14.9-19 years) years, predominantly in males. Mean time from vaccination to onset of symptoms was 4.4 ± 6.7 (median 3, range 0-28) days. All patients had CMR post diagnosis at 4 ± 3 (median 3, range 1-9) weeks, 4/5 patients had hyper enhancement on the T2 sequences representing edemaQuery, and 12 pathological Late glandolinium enhancement. A repeat scan performed after 5-6 months was positive for scar formation in 7/9 patients. PCVM is a rare complication, affecting predominantly males and appearing usually within the first week after administration of the second dose of the vaccine. It usually is a mild disease, with clinical resolution with anti-inflammatory treatment. Late CMR follow up demonstrated resolution of the edema in all patients, while some had evidence of residual myocardial scarring.

Ultrasound Cardiac Output Monitor (USCOM™) Measurements Prove Unreliable Compared to Cardiac Magnetic Resonance Imaging in Adolescents with Cardiac Disease.

The purpose of this stuy is to prospectively assess the reliability of the ultrasound cardiac output monitor (USCOM™) for measuring stroke volume index and predicting left ventricular outflow tract diameter in adolescents with heart disease. Sixty consecutive adolescents with heart disease attending a tertiary medical center underwent USCOM™ assessment immediately after cardiac magnetic resonance imaging. USCOM™ measured stroke volume index and predicted left ventricular outflow tract diameter were compared to cardiac magnetic resonance imaging-derived values using Bland-Altman analysis. Ten patients with an abnormal left ventricular outflow tract were excluded from the analysis. An adequate USCOM™ signal was obtained in 49/50 patients. Mean stroke volume index was 46.1 ml/m2 by the USCOM™ (range 22-66.9 ml/m2) and 42.9 ml/m2 by cardiac magnetic resonance imaging (range 24.7-59.9 ml/m2). The bias (mean difference) was 3.2 ml/m2; precision (± 2SD of differences), 17 ml/m2; and mean percentage error, 38%. The mean (± 2SD) left ventricular outflow tract diameter was 0.445 ± 0.536 cm smaller by the USCOM™ algorithm prediction than by cardiac magnetic resonance imaging. Attempted adjustment of USCOM™ stroke volume index using cardiac magnetic resonance imaging left ventricular outflow tract diameter failed to improve agreement between the two modalities (bias 28.4 ml/m2, precision 44.1 ml/m2, percentage error 77.3%). Our study raises concerns regarding the reliability of USCOM™ for stroke volume index measurement in adolescents with cardiac disease, which did not improve even after adjusting for its inaccurate left ventricular outflow tract diameter prediction.

Blunt High-Grade Pancreatic Injury in Children: A 20-Year Experience in Two Pediatric Surgical Centers.

BACKGROUND: Pancreatic trauma is uncommon in pediatric patients and presents diagnostic and therapeutic challenges. While non-operative management (NOM) of minor pancreatic injuries is well accepted, the management of major pancreatic injuries remains controversial. OBJECTIVES: To evaluate management strategies for major blunt pancreatic injury in children. METHODS: Data were retrospectively collected for all children treated for grade III or higher pancreatic injury due to blunt abdominal trauma from 1992 to 2015 at two medical centers. Data included demographics, mechanism of injury, laboratory and imaging studies, management strategy, clinical course, operative findings, and outcome. RESULTS: The cohort included seven boys and four girls aged 4-15 years old (median 9). Six patients had associated abdominal (mainly liver, n=3) injuries. The main mechanism of injury was bicycle (handlebar) trauma (n=6). Five patients had grade III injury and six had grade IV. The highest mean amylase level was recorded at 48 hours after injury (1418 U/L). Management strategies included conservative (n=5) and operative treatment (n=6): distal (n=3) and central (n=1) pancreatectomy, drainage only (n=2) based on the computed tomography findings and patient hemodynamic stability. Pseudocyst developed in all NOM patients (n=5) and two OM cases, and one patient developed a pancreatic fistula. There were no differences in average length of hospital stay. CONCLUSIONS: NOM of high-grade blunt pancreatic injury in children may pose a higher risk of pseudocyst formation than OM, with a similar hospitalization time. However, pseudocyst is a relatively benign complication with a high rate of spontaneous resolution with no need for surgical intervention.

Routine chest X-ray following ultrasound-guided internal jugular vein catheterization in critically ill children: A prospective observational Study.

BACKGROUND: Recent studies in adults have shown that routine chest X-ray following ultrasound-guided central venous catheter insertion through the internal jugular vein is unnecessary due to a low rate of complications. AIMS: To assess the usefulness of routine chest X-ray following ultrasound-guided central venous catheter insertion through the internal jugular veins in critically ill children. METHODS: A prospective observational study was conducted at a pediatric intensive care unit of a tertiary, university-affiliated pediatric medical center. All children under the age of 18 who underwent ultrasound-guided central venous catheter insertion through the right or left internal jugular vein between May 2018 and November 2019 were evaluated for eligibility. Procedures were prospectively documented, and chest X-ray was screened for pneumothorax, hemothorax, central venous catheter tip position, and resultant corrective interventions. RESULTS: Of 105 central venous catheter insertion attempts, 99 central venous catheters (94.3%) were inserted. All were located within the venous system. None were diagnosed with pneumo/hemothorax on chest X-ray. Twenty (20.2%; 95% CI 12.8%-29.5%) were defined as malpositioned by strict criteria; however, only one (1%) was judged significantly misplaced by the clinical team leading to its repositioning. CONCLUSIONS: In this critically ill pediatric cohort, all central venous catheters inserted under ultrasound guidance could have been used with safety prior to acquiring chest X-ray. Overall chest X-ray impacted patient management in only 1% of cases. Our results do not support delaying urgent central venous catheter use pending chest X-ray completion in critically ill children.

Magnetic resonance findings may aid in diagnosis of protracted febrile myalgia syndrome: a retrospective, multicenter study.

BACKGROUND: Protracted febrile myalgia syndrome (PFMS) is a rare complication of Familial Mediterranean fever (FMF). The diagnosis is based on clinical symptoms and is often challenging, especially when PFMS is the initial manifestation of FMF. The aim of this report was to describe the magnetic resonance imaging (MRI) findings in pediatric patients with PFMS. RESULTS: There were three girls and two boys ranging in age from 6 months to 16 years, all of Mediterranean ancestry. Three had high-grade fever, and all had elevated inflammatory markers. MRI of the extremities yielded findings suggestive of myositis, which together with the clinical picture, normal CPK levels, and supporting family history of FMF, suggested the diagnosis of PFMS. Out of most common MEFV mutations tested, one patient was homozygous for M694V mutation, three were heterozygous for M694V mutation, and one was compound heterozygous for the M694V and V726A mutations. CONCLUSIONS: MRI may serve as an auxiliary diagnostic tool in PFMS.

Do geography and ethnicity play a role in juvenile Spondyloarthritis? A multi-center binational retrospective study.

BACKGROUND: Observations among Israeli pediatric rheumatologists reveal that pediatric Juvenile Spondyloarthritis (JSpA) may present differently compared to patients from the United States (US). This study is aimed to compare the demographic and clinical variables of Israeli and US JSpA patients upon presentation. METHODS: We performed a retrospective, cross-sectional, multicenter comparison of JSpA patients among 3 large Israeli pediatric rheumatology centers and a large US pediatric rheumatology center. Patients with diagnosis of Juvenile Ankylosing Spondylitis (JAS) and/or Enthesitis-related Arthritis (ERA) were included. The demographic, clinical and radiologic features were compared. RESULTS: Overall 87 patients were included (39 Israeli, 48 US patients). Upon presentation, inflammatory back pain, sacroiliac joint tenderness and abnormal modified Schober test, were significantly more prevalent among Israeli patients (59% vs. 35.4, 48.7% vs. 16.7, and 41.2% vs. 21.5%, respectively, all p < 0.05), whereas peripheral arthritis and enthesitis were significantly more prevalent among US patients (43.6% vs. 91.7 and 7.7% vs. 39.6% in Israeli patients vs. US patients, p < 0.05). In addition, 96.7% of the Israeli patients versus 29.7% of the US patients demonstrated sacroiliitis on MRI (p < 0.001, N = 67). Less than one-third of the Israeli patients (32%) were HLA-B27 positive vs. 66.7% of US patients (p = 0.007). CONCLUSION: Israeli children with JSpA presented almost exclusively with axial disease compared to US patients who were more likely to present with peripheral symptoms. HLA B27 prevalence was significantly lower in the Israeli cohort compared to the US cohort. Further studies are needed to unravel the genetic and possibly environmental factors associated with these findings.

A possible genotype-phenotype correlation in Ashkenazi-Jewish individuals with Aicardi-Goutières syndrome associated with SAMHD1 mutation.

Aicardi-Goutières syndrome is a genetic neurodegenerative disorder with clinical symptoms mimicking a congenital viral infection. Mutations in 6 genes are known to cause the disease: 3 prime repair exonuclease1, ribonucleases H2A, B, and C, SAM domain and HD domain 1, and most recently ADAR1. HD domain 1 mutations were previously reported in the Ashkenazi-Jewish community. We report an additional patient of Ashkenazi-Jewish descent and review the other 3 cases affected with Aicardi-Goutières syndrome due to SAM domain and HD domain 1 (SAMHD1) mutations described in Israel. We propose that there may be a phenotypic-genotypic correlation in accordance with the type of mutations inherited in the SAMHD1 genotype and suggest that Aicardi-Goutières syndrome may not be a rare disease in the Ashkenazi-Jewish population.