The Modified Bosniak Classification for Intermediate-Risk Renal Cysts in Children

OBJECTIVES

To examine correlations of the modified Bosniak categories assigned by radiologists to histological results and inter-rater reliability, focusing on intermediate-risk lesions.

MATERIALS AND METHODS

The data of pediatric patients who underwent surgery for intermediate-risk complex renal cyst at a tertiary medical center in 2006-2019 were collected retrospectively. Four pediatric radiologists from 2 different medical centers reviewed the available imaging scans, and assigned each to one of the four modified Bosniak classification categories. Binary cohorts of the Bosniak categories (I-II vs III-IV) were compared to the histological results. Diagnostic accuracy (benign- vs intermediate-risk lesion) was calculated for each radiologist and for each imaging modality. Krippendorff's α test was used to measure inter-rater reliability.

RESULTS

The cohort included seven children, each with 1 complex cyst that was rated as intermediate-risk on pathological study. The median age was 1.5 years (IQR 1, 11.9). A correct classification was made in 41/56 imaging readings (sensitivity 73.2%). Applying Krippendorff's test to the binary Bosniak cohorts yielded poor inter-rater agreement (α = 0.08).

CONCLUSION

Implementation of the modified Bosniak classification in children caused a disconcerting underestimation of intermediate risk. There was a low inter-rater consistency for the categories intended to guide decisions regarding surgery or conservative management. The findings suggest that clinicians should be cautious using the modified Bosniak system for children.

Increased Renal Echogenicity in Children With Appendicitis

OBJECTIVES

Ultrasound (US) is an important modality for the detection of acute appendicitis in children but has limited sensitivity and specificity. Therefore, additional US findings may contribute to the diagnosis. In our experience, children with acute appendicitis often have increased renal cortical echogenicity on US imaging. The purpose of this study was to examine the association of increased renal cortical echogenicity with appendicitis.

METHODS

This study included 240 consecutive pediatric patients with no renal or liver disease who underwent US examinations for suspected appendicitis between February 2014 and January 2016. Ultrasound images of the liver and right kidney were retrospectively reviewed, and the echogenicity of the renal cortex was classified as less than the liver, equal to the liver, or greater than the liver.

RESULTS

The renal cortex was abnormally hyperechoic in 38 (50%) of all of the patients who had appendicitis according to US (P < .001) and in 47% of patients who underwent appendectomy (P = .002). Overall, 36% of patients with increased renal cortical echogenicity had a diagnosis of appendicitis. After correction for variables, patients with renal hyperechogenicity had a 2.5 times chance of appendicitis (odds ratio, 2.5).

CONCLUSIONS

There is a statistically significant association between increased renal cortical echogenicity and appendicitis. In the absence of hepatic or renal disease, this finding may increase the accuracy of the US diagnosis of appendicitis. Increased renal cortical echogenicity may be added to the list of US findings accompanying acute appendicitis in children.

Growth of the colon and rectum throughout gestation: evaluation with fetal MRI

Background

Congenital abnormalities of the gastrointestinal tract are increasingly being evaluated by prenatal magnetic resonance imaging (MRI). However, there is a paucity of reports describing the normal quantitative development of the fetal colon and rectum on MRI.

Purpose

To provide growth curves of the MRI estimated diameter of the fetal colon and rectum as a function of gestational age.

Material and Methods

This is a retrospective review of 191 singleton fetal MRI studies at 25–39 weeks of gestation. Measurements included maximal diameter of the ascending, transverse, and descending colon on coronal and sagittal views, maximal diameter of the rectum on coronal and sagittal views, and maximal diameter of the rectum at the level of the bladder base on sagittal views. Median growth curves were built using a generalized additive model. Confidence regions were built for 10th, 25th, 75th, and 90th percentiles.

Results

Smoothed growth curves for the median, and one and three quartiles for each of the five sections as a function of gestational age were calculated. All graphs had a slightly exponential curve.

Conclusion

This study provides normal ranges of the prenatal colon and rectum as a function of gestational age. They may serve as reference values when interpreting fetal MRI.

The Added Value of the Lateral Chest Radiograph for Diagnosing Community Acquired Pneumonia in the Pediatric Emergency Department

BACKGROUND

Opinions differ as to the need of a lateral radiograph for diagnosing community acquired pneumonia in children referred to the emergency department. A lateral radiograph increases the ionizing radiation burden but at the same time may improve specificity and sensitivity in this population.

OBJECTIVES

To determine the value of the frontal and lateral chest radiographs compared to frontal view stand-alone images for the management of children with suspected community acquired pneumonia seen in a pediatric emergency department.

METHODS

Chest radiographs from 451 children with clinically suspected pneumonia were retrospectively reviewed. Interpretation of frontal views was compared to interpretation of combined frontal and lateral view, the latter being the gold standard.

RESULTS

Findings consistent with bacterial pneumonia were diagnosed in 94 (20.8%) of the frontal stand-alone radiographs and in 109 (24.2%) of the combined frontal and lateral radiographs. The sensitivity, specificity, positive predictive value, and negative predictive value of the frontal radiograph alone were 86.2%, 93.9%, 81.7%, and 95.5%, respectively. False positive and false negative rates were 15% and 21%, respectively, for the frontal view alone. The number of lateral radiographs needed to diagnose one community acquired pneumonia was 29.

CONCLUSIONS

The lateral chest radiograph improves the diagnosis of pediatric community acquired pneumonia to a certain degree and may prevent overtreatment with antibiotics.

Sonographic Detection of Accessory Adrenal Tissue in Neonates

OBJECTIVES

The purpose of this study was to describe the incidence and appearance of accessory adrenal tissue in neonates, as diagnosed by high-resolution sonography, and increase the awareness of this entity.

METHODS

We examined the adrenal glands in 153 neonates referred for renal and urinary tract sonography at our institution between January 2014 and January 2015. All kidneys and adrenal glands, except for ectopic kidneys, were scanned with the neonate prone and a linear array transducer with frequency of 11 or 14 MHz.

RESULTS

In 9 neonates (5.9%), sonography showed a round, well-defined structure adjacent to the adrenal gland with a hyperechoic center and hypoechoic periphery, similar to the echogenicity of the normal adrenal medulla and cortex, respectively. The largest diameter of the structure measured 2.9 to 4.5 mm. On follow-up studies, which were available for 7 neonates, the structure was not evident, and the suprarenal area was normal.

CONCLUSIONS

Accessory adrenal tissue can be identified in the suprarenal area in neonates with high-resolution sonography. Radiologists and sonographers caring for neonates should be aware of this finding and not confuse it with disease.

BCGitis and BCGosis in children with primary immunodeficiency - imaging characteristics

BACKGROUND

When administered to an immune-compromised patient, BCG (Bacille Calmette-Guérin) can cause disseminated and life-threatening infections.

OBJECTIVE

To describe the imaging findings in children with primary immunodeficiency and BCG-related infections.

MATERIALS AND METHODS

We reviewed the imaging findings of children with primary immunodeficiency treated at a children's hospital during 2012-2014 with localized or disseminated BCG infection. Imaging modalities included US, CT and radiography.

RESULTS

Nine children with primary immunodeficiency had clinical signs of post-vaccination BCGitis; seven of these children showed disseminated disease and two showed only regional lesions with characteristic ipsilateral lymphadenopathy. Overall, lymphadenopathy was the most prevalent feature (n = 8) and characteristically appeared as a ring-enhancing hypodense (CT) or hypoechoic (US) lesion. Visceral involvement with multiple abscesses appeared in the spleen (n = 2), liver (n = 1) and bones (n = 1). All lesions regressed following appropriate anti-tuberculosis treatment.

CONCLUSION

BCG infection needs to be considered in children with typical findings and with suspected primary immunodeficiency.

Cerebellar hemorrhage in very low birth weight premature infants: the advantage of the posterolateral fontanelle view

OBJECTIVE

The purpose of this study was to determine the prevalence of cerebellar hemorrhage in very low birth weight infants using the posterolateral fontanelle for ultrasound (US) examination.

METHODS

The study included 125 very low birth weight premature infants (defined as equal or less than 1500 grams at birth) hospitalized in the premature or neonatal intensive care departments that had at least one head US examination including both anterior and posterolateral fontanelle scans.

RESULTS

On US performed through the posterolateral fontanelle, four (3.2%) infants had echogenic posterior fossa lesions interpreted as hemorrhages. None of these lesions were initially or retrospectively observed through the standard anterior fontanelle scan. Two infants died at age 4 and 39 days, respectively. All survivors are being followed up in the hospital's neurodevelopment outpatient clinic.

CONCLUSIONS

Cerebellar hemorrhage may be overlooked on standard anterior fontanelle views. The posterolateral approach may assist in diagnosing these lesions.

Bone age in the 21st century: is Greulich and Pyle's atlas accurate for Israeli children?

BACKGROUND

The applicability today of Greulich and Pyle's Radiographic Atlas of Skeletal Development of the Hand and Wrist (G&P) is uncertain.

OBJECTIVE

The purpose of this study was to determine whether G&P is accurate in Israeli children today.

MATERIALS AND METHODS

Left-hand radiographs of 679 children (375 boys) ranging in age from 1 day to 18 years old were obtained for trauma in the period 2001-2009 and were evaluated for bone age according to G&P. Individual bone age was plotted against calendar age and smoothed to obtain the association between calendar age and bone age. Any difference was assessed with Wilcoxon signed-rank test.

RESULTS

In girls, there was no significant difference between bone age and calendar age (P = 0.188). G&P underestimated bone age in boys <15 years old (median difference, 2.3 months; P < 0.0001) and overestimated bone age in boys ≥15 years old (median difference, 2.9 months; P = 0.0043). The largest median difference (5.4 months; P = 0.0003) was seen in boys 6-10 years old.

CONCLUSION

The differences between calendar age and bone age according to G&P were relatively small compared with normal variance and are unlikely to be of clinical importance.

Chest radiograph findings in children with laboratory confirmed pandemic H1N1 virus infection

INTRODUCTION

Since its onset in the spring of 2009, the H1N1 pandemic has kept health-care professionals busy worldwide. Even though it often causes respiratory tract illness, reports describing the radiological manifestations in infected children are few. The purpose of this study was twofold: to review the chest radiograph findings in children with laboratory-confirmed pandemic (H1N1) 2009 influenza virus and compare them with the chest radiographic findings in children with the same symptoms but laboratory negative.

METHODS

Informed consent was not required by the institutional review board for this retrospective study. We identified 151 children who were tested for pandemic H1N1 virus and had chest radiographs. Chest radiographs were evaluated for the presence of airway disease including hyperinflation, subsegmental atelectasis and peribronchial cuffing, airspace disease, pleural effusion or any combination of these, and compared for H1N1-positive and H1N1-negative children, for healthy and non-healthy children separately.

RESULTS

No statistically significant difference between H1N1-tested positive children and H1N1-tested negative children was found for the proportion of abnormal chest rays (P=1 for healthy children, P=0.08 for children with chronic disease). For individual findings, there was no difference between H1N1-tested positive healthy children and H1N1-tested negative healthy children (P>0.083 for each finding) In children with chronic disease, there was significantly more subsegmental atelectasis (P=0.037) in the radiographs of H1N1-tested negative children.

CONCLUSION

Chest radiographs have non-specific findings in cases of suspected swine flu in children and have limited value in distinguishing H1N1 from non-H1N1 viral infections for both healthy children and children with chronic disease.

The yield of early postnatal ultrasound scan in neonates with documented antenatal hydronephrosis

We retrospectively assessed the yield of early postnatal ultrasound scans in neonates with documented antenatal hydronephrosis. We reviewed recording data of prenatal renal ultrasound for 178 newborn infants and the results of renal ultrasound performed during the first days of life. Of 119 infants with prenatal diagnosis of mild hydronephrosis (renal pelvic diameter <10 mm), 116 (97.5%) had postnatal ultrasound results showing normal or mild hydronephrosis. Prenatal diagnosis of severe hydronephrosis (renal pelvic diameter >20 mm; 10 infants) was correlated with high incidence (90%) of moderate and severe postnatal hydronephrosis. Prenatal diagnosis of moderate hydronephrosis (renal pelvic diameter 10 to 20 mm) resulted in moderate postnatal hydronephrosis in 20% and improvement in 80% of the newborn infants. Our evidence supports the option of delaying postnatal renal ultrasound in infants with prenatal diagnosis of mild hydronephrosis (renal pelvic diameter <10 mm). This strategy can safely reduce the number of early postnatal studies and consequently significantly decrease hospitals' inpatient workload.

SEDATION DURING VOIDING CYSTOURETHROGRAPHY: COMPARISON OF THE EFFICACY AND SAFETY OF USING ORAL MIDAZOLAM AND CONTINUOUS FLOW NITROUS OXIDE

PURPOSE

We compare the efficacy and safety profile of oral midazolam and continuous flow 50% nitrous oxide (N(2)O) for alleviating anxiety and pain during voiding cystourethrography (VCU) in children.

MATERIALS AND METHODS

This prospective, randomized clinical trial study was conducted in the radiology unit of a tertiary care center. Children older than 3 years scheduled for VCU were given either 0.5 mg/kg midazolam orally or continuous flow 50% N(2)O. Main outcomes were degree of anxiety and pain as assessed by the attending nurse and radiologist performing the test using a behavioral anxiety score, a distress score and an overall satisfaction score, side effects and recovery profile.

RESULTS

The study included 47 children (89% girls) with a mean age of 6 years (range 3 to 15). There were 24 subjects in the midazolam group and 23 in the N(2)O group. Midazolam and N(2)O provided adequate anxiety and pain relief to perform the examination, yet children given N(2)O required less restraining and experienced a significantly shorter recovery time (29 +/- 10 vs 63 +/- 25 minutes, p <0.001).

CONCLUSIONS

Continuous flow 50% nitrous oxide and oral midazolam are comparably safe and effective in reducing anxiety and distress during VCU in children older than 3 years. However, N(2)O provides a more rapid onset of sedating effect and has a shorter recovery time.

Intraoperative magnetic resonance imaging-guided drainage of nonpalpable abscesses

SUMMARY

Intraoperative magnetic resonance imaging provides the surgeon with powerful, high-resolution, real-time imaging. Procedures may be performed with minimal invasion, with the benefit of reduced tissue damage, improved wound healing, and a better cosmetic result. The authors present a case of a leukemic pediatric patient with a few large, deeply situated, nonpalpable abscesses that were drained successfully with intraoperative magnetic resonance imaging guidance. In this case, this new intraoperative imaging method enabled minimal invasiveness, with fast recovery.

Upper gastrointestinal bleeding due to gastric ulcers in children with gastrostomy tubes

The authors describe four children with gastrostomy tubes (G-tubes) presenting with upper gastrointestinal bleeding due to gastric ulcers years after G-tube insertion. They review the literature and discuss the possible mechanisms of gastric ulcer formation in these patients.

Virtual bronchoscopy in children: early clinical experience

OBJECTIVE

Virtual bronchoscopy is a new noninvasive technique that provides an internal view of the tracheobronchial tree. The purpose of our study was to assess the role of this technique as compared with fiberoptic bronchoscopy in the evaluation of suspected compression or narrowing of the trachea and main bronchi in children.

CONCLUSION

Preliminary results suggest that virtual bronchoscopy may have a useful complementary role to fiberoptic bronchoscopy in evaluation of the tracheobronchial tree of children.