Imaging Gently

The role of chest X-ray in the diagnosis of neonatal respiratory distress syndrome: a systematic review concerning low-resource birth scenarios

BACKGROUND

Access to diagnostic tools like chest radiography (CXR) is challenging in resource-limited areas. Despite reduced reliance on CXR due to the need for quick clinical decisions, its usage remains prevalent in the approach to neonatal respiratory distress syndrome (NRDS).

OBJECTIVES

To assess CXR's role in diagnosing and grading NRDS severity compared to current clinical features and laboratory standards.

METHODS

A review of studies with NRDS diagnostic criteria was conducted across six databases (MEDLINE, EMBASE, BVS, Scopus-Elsevier, Web of Science, Cochrane) up to 3 March 2023. Independent reviewers selected studies, with discrepancies resolved by a senior reviewer. Data were organised into descriptive tables to highlight the use of CXR and clinical indicators of NRDS.

RESULTS

Out of 1,686 studies screened, 23 were selected, involving a total of 2,245 newborns. All selected studies used CXR to diagnose NRDS, and 21 (91%) applied it to assess disease severity. While seven reports (30%) indicated that CXR is irreplaceable by other diagnostic tools for NRDS diagnosis, 10 studies (43%) found that alternative methods surpassed CXR in several respects, such as severity assessment, monitoring progress, predicting the need for surfactant therapy, foreseeing Continuous Positive Airway Pressure failure, anticipating intubation requirements, and aiding in differential diagnosis.

CONCLUSION

CXR remains an important diagnostic tool for NRDS. Despite its continued use in scientific reports, the findings suggest that the study's outcomes may not fully reflect the current global clinical practices, especially in low-resource settings where the early NRDS approach remains a challenge for neonatal survival.Trial registration: PROSPERO number CRD42022336480.

Development and clinical feasibility of a reduced-dose radiograph in children for feeding tube placement

BACKGROUND

Temporary feeding tubes are commonly used but may lead to complications if malpositioned. Radiographs are the gold standard for assessing tube position, but clinician concern over radiation risks may curtail their use.

OBJECTIVE

We describe development and use of a reduced dose feeding tube radiograph (RDFTR) targeted for evaluation of feeding tube position.

MATERIALS AND METHODS

Age-based abdominal radiograph was adapted to use the lowest mAs setting of 0.32 mAs with field of view between carina and iliac crests. The protocol was tested in DIGI-13 line-pair plates and anthropomorphic phantoms. Retrospective review of initial clinical use compared dose area product (DAP) for RDFTR and routine abdomen, chest, or infant chest and abdomen. Review of RDFTR reports assessed tube visibility, malpositioning, and incidental critical findings.

RESULTS

Testing through a line-pair phantom showed loss of spatial resolution from 2.2 line pairs to 0.6 line pairs but preserved visibility of feeding tube tip in RDFTR protocol. DAP comparisons across 23,789 exams showed RDFTR reduced median DAP 72-93% compared to abdomen, 55-78% compared to chest, and 76-79% compared to infant chest and abdomen (p<0.001). Review of 3286 reports showed tube was visible in 3256 (99.1%), malpositioned in airway 8 times (0.2%) and in the esophagus 74 times (2.3%). The tip was not visualized in 30 (0.9%). Pneumothorax or pneumoperitoneum was noted seven times (0.2%) but was expected or spurious in five of these cases.

CONCLUSION

RDFTR significantly reduces radiation dose in children with temporary feeding tubes while maintaining visibility of tube tip.

Splenic rupture or infarction associated with Epstein-Barr virus infectious mononucleosis: a systematic literature review

BACKGROUND

Epstein-Barr virus (EBV), also known as human herpesvirus 4, is one of the most common pathogenic viruses in humans. EBV mononucleosis always involves the spleen and as such it predisposes to splenic rupture, often without a trauma, and splenic infarction. Nowadays the goal of management is to preserve the spleen, thereby eliminating the risk of post-splenectomy infections.

METHODS

To characterise these complications and their management, we performed a systematic review (PROSPERO CRD42022370268) following PRISMA guidelines in three databases: Excerpta Medica, the United States National Library of Medicine, and Web of Science. Articles listed in Google Scholar were also considered. Eligible articles were those describing splenic rupture or infarction in subjects with Epstein-Barr virus mononucleosis.

RESULTS

In the literature, we found 171 articles published since 1970, documenting 186 cases with splenic rupture and 29 with infarction. Both conditions predominantly occurred in males, 60% and 70% respectively. Splenic rupture was preceded by a trauma in 17 (9.1%) cases. Approximately 80% (n = 139) of cases occurred within three weeks of the onset of mononucleosis symptoms. A correlation was found between the World Society of Emergency Surgery splenic rupture score, which was retrospectively calculated, and surgical management: splenectomy in 84% (n = 44) of cases with a severe score and in 58% (n = 70) of cases with a moderate or minor score (p = 0.001). The mortality rate of splenic rupture was 4.8% (n = 9). In splenic infarction, an underlying haematological condition was observed in 21% (n = 6) of cases. The treatment of splenic infarction was always conservative without any fatal outcomes.

CONCLUSIONS

Similarly to traumatic splenic rupture, splenic preservation is increasingly common in the management of mononucleosis-associated cases as well. This complication is still occasionally fatal. Splenic infarction often occurs in subjects with a pre-existing haematological condition.

Test characteristics of focused assessment with sonography for trauma (FAST), repeated FAST, and clinical exam in prediction of intra-abdominal injury in children with blunt trauma

PURPOSE

In children with blunt abdominal trauma (BAT), focused assessment of sonography in trauma (FAST) has been reported with low sensitivity, on the whole, in the detection of intra-abdominal injuries (IAI). The aim of the present study was to assess test characteristics of FAST using different strategies including repeated FAST (reFAST), and physical exam findings.

METHODS

This retrospective study evaluated BAT pediatric patients with stable hemodynamics who underwent computed tomography (CT). Demographic data, initial physical examination, and results of FAST, reFAST (if done), and CT imaging were recorded. Different strategies of FAST were cross-tabulated with CT as the gold standard and test characteristics including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were interpreted.

RESULTS

129 patients with a mean age of 8.6 ± 4.7 were studied and 74% were male. Comparing CT-positive and -negative groups, from the demographic and clinical findings, only positive physical exam (tenderness or ecchymosis) was significantly higher in the CT-positive group (59% vs. 17%; p < 0.01). In a multivariate analysis, positive FAST modality and clinical exam remained independent predictors for a positive CT result (likelihood ratios of 34.6 and 6.4, respectively). Out of the different diagnostic strategies for the prediction of IAI, the best overall performance resulted from the FAST-reFAST-tenderness protocol with sensitivity, specificity, PPV, NPV, and accuracy of 87%, 77%, 70%, 91%, and 81%.

CONCLUSION

For children with blunt abdominal trauma, physical examination plus FAST and reFAST as needed, seems to have reasonable sensitivity, specificity, and accuracy in detecting intra-abdominal injuries and may reduce the need for CT scans.