CT outperforms radiographs at a comparable radiation dose in the assessment for spondylolysis

BACKGROUND

Lumbar spondylolysis, a unilateral or bilateral fracture at pars interarticularis, is a common cause of low back pain in children. The initial imaging study in the diagnosis of lumbar spondylolysis has historically been lumbar spine radiographs; however, radiographs can be equivocal or false-negative. Definitive diagnosis can be achieved with computed tomography (CT), but its use has been limited due to the dose of ionizing radiation to the patient.

OBJECTIVE

By limiting the z-axis coverage to the relevant anatomy and optimizing the CT protocol, we are able to provide a definitive diagnosis of fractures of the pars interarticularis at comparable or lower radiation dose than commonly performed lumbar spine radiographs. As there is no gold standard for the diagnosis of spondylolysis besides surgery, we compared interobserver agreement and degree of confidence to determine which modality is preferable.

MATERIALS AND METHODS

Sixty-two patients with low back pain ages 5-18 years were assessed for the presence of spondylolyis. Forty-seven patients were evaluated by radiography and 15 patients were evaluated by limited field-of-view CT. Both radiographic and CT examinations were assessed anonymously in random order for the presence or absence of spondylolyisis by six raters. Agreement was assessed among raters using a Fleiss Kappa statistic for multiple raters.

RESULTS

CT provided a significantly higher level of agreement among raters than radiographs (P < 0.001). The overall Kappa for rater agreement with radiographs was 0.24, 0.34 and 0.40 for 2, 3 or 4 views, respectively, and 0.88 with CT.

CONCLUSION

Interobserver agreement is significantly greater using limited z-axis coverage CT when compared with radiographs. Radiologist confidence improved significantly with CT compared to radiographs regardless of the number of views.

Effect of pravastatin on total kidney volume, left ventricular mass index, and microalbuminuria in pediatric autosomal dominant polycystic kidney disease

BACKGROUND AND OBJECTIVES

In autosomal dominant polycystic kidney disease (ADPKD), progressive kidney cyst formation commonly leads to ESRD. Because important manifestations of ADPKD may be evident in childhood, early intervention may have the largest effect on long-term outcome. Statins are known to slow progressive nephropathy in animal models of ADPKD. This randomized double-blind placebo-controlled phase III clinical trial was conducted from 2007 to 2012 to assess the effect of pravastatin on height-corrected total kidney volume (HtTKV) and left ventricular mass index (LVMI) by magnetic resonance imaging (MRI) and urine microalbumin excretion (UAE) in children and young adults with ADPKD.

DESIGNS, SETTING, PARTICIPANTS, & MEASUREMENTS

There were 110 pediatric participants with ADPKD and normal kidney function receiving lisinopril who were randomized to treatment with pravastatin or placebo for a 3-year period with evaluation at 0, 18, and 36 months. The primary outcome variable was a ≥ 20% change in HtTKV, LVMI, or UAE over the study period.

RESULTS

Ninety-one participants completed the 3-year study (83%). Fewer participants receiving pravastatin achieved the primary endpoint compared with participants receiving placebo (69% versus 88%; P=0.03). This was due primarily to a lower proportion reaching the increase in HtTKV (46% versus 68%; P=0.03), with similar findings observed between study groups for LVMI (25% versus 38%; P=0.18) and UAE (47% versus 39%; P=0.50). The percent change in HtTKV adjusted for age, sex, and hypertension status over the 3-year period was significantly decreased with pravastatin (23% ± 3% versus 31% ± 3%; P=0.02).

CONCLUSIONS

Pravastatin is an effective agent to slow progression of structural kidney disease in children and young adults with ADPKD. These findings support a role for early intervention with pravastatin in this condition.

Clinical presentation of cervical ribs in the pediatric population

Cervical ribs may cause thoracic outlet syndrome in adults, but symptoms are poorly described in children. In our series, 88.8% of the 322 children were asymptomatic. The most common symptoms were neck mass and pain. Useful diagnostic tools were cervical spine and chest radiographs. Differential diagnosis of a supraclavicular mass includes cervical ribs.

Effect of statin therapy on disease progression in pediatric ADPKD: design and baseline characteristics of participants

Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic kidney condition and is associated with important renal and cardiovascular manifestations in childhood. Renal cystic disease can be documented in some cases as early as in utero. Early intervention is critical if the long-term complications of this condition, including end-stage renal disease, are to be ameliorated. Here we describe our ongoing randomized double-blind placebo-controlled phase III clinical trial to assess the effect of pravastatin treatment on renal and cardiovascular disease progression in 107 children and young adults age 8-22 years with ADPKD who are receiving the angiotensin converting enzyme inhibitor lisinopril. Baseline demographic and laboratory data are provided. Results of this study could markedly impact the standard of care for evaluation and treatment of ADPKD in this population.

Magnetic resonance imaging of kidney and cyst volume in children with ADPKD

BACKGROUND AND OBJECTIVES

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease and has important clinical manifestations in childhood. Numerous studies have documented the superiority of magnetic resonance imaging (MRI) for serial monitoring of kidney and cyst volume in this condition in adults. However, no studies have examined the utility of MRI for serial assessment of kidney and cyst volume in children with ADPKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Subjects 4 to 21 years of age with ADPKD underwent abdominal MRI on an annual basis for 5 years. Subjects were grouped according to BP as hypertensive (HBP; BP≥95th percentile for age, height, and gender) or as normotensive (NBP; BP<95th percentile). Total kidney volume (TKV), cyst volume, and cyst number were assessed by stereology.

RESULTS

MRI studies (n=302) were obtained in 77 children with ADPKD. TKV and cyst volume were significantly increased in HBP versus NBP subjects. HBP subjects demonstrated a greater increase in fractional cyst volume over time versus NBP subjects. Cyst number increased more rapidly in HBP ADPKD children.

CONCLUSIONS

This is the first large-scale clinical study examining the utility of MRI for serial assessment of TKV, cyst volume, and cyst number in children with ADPKD. These results demonstrate that MRI is an acceptable means to follow these parameters in children with ADPKD. Because of the embryonic occurrence of cysts, interventional trials are needed in ADPKD children and MRI may be the preferred renal imaging approach.

Prospective change in renal volume and function in children with ADPKD

BACKGROUND AND OBJECTIVES

Autosomal dominant polycystic kidney disease (ADPKD) is a progressive hereditary disorder affecting children and young adults. Early intervention may be necessary to significantly affect the long-term consequences of this disease.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The authors conducted a 5-yr randomized clinical trial to assess the effect of BP control with angiotensin-converting enzyme inhibition (ACEI) on disease progression in 85 children and young adults with ADPKD. Study groups were determined by subject BP, including hypertension (BP >or= 95th percentile), borderline hypertension (BP 75 to 95th percentile), and severe ADPKD (BP <or=75th percentile with > 10 renal cysts). The primary outcome variable was renal volume by ultrasound, with secondary outcome variables including left ventricular mass index (LVMI) and microalbuminuria. In secondary analysis, the authors compared results between hypertensive and normotensive groups.

RESULTS

The authors were not able to demonstrate a significant effect of ACEI on renal growth in young subjects with ADPKD. Hypertensive children were at particular risk for increases in renal volume and LVMI and decreased renal function as compared with the other study groups, and borderline hypertensive children were at high risk to develop hypertension over time. However, ACEI treatment was associated with stable renal function and LVMI in this group of children.

CONCLUSIONS

Close monitoring of cardiovascular and renal status is indicated in ADPKD children with hypertension or borderline hypertension. In contrast to effects in hypertensive ADPKD children, ACEI treatment in normotensive or borderline hypertensive ADPKD children may prevent the development of increased LVMI and deterioration in renal function.

Increased left ventricular mass in children with autosomal dominant polycystic kidney disease and borderline hypertension

Autosomal dominant polycystic kidney disease (ADPKD) is a common hereditary condition that may be diagnosed in utero. Our goal was to evaluate symptoms of ADPKD in children, including left ventricular mass index (LVMI), renal volume, renal function and microalbuminuria in relation to systolic and diastolic blood pressure. Eighty-five children were stratified by blood pressure into three cohorts: hypertensive (95th percentile and over), borderline hypertensive (75-95th percentile) and normotensive (75th percentile and below). There were no differences in gender, age, height, renal function, or microalbuminuria between the groups. Both the hypertensive and borderline hypertensive children had a significantly higher LVMI than normotensive children, with no significant difference between hypertensive and borderline hypertensive groups. There was a significant correlation between renal volume and both systolic and diastolic blood pressures in all subjects. Renal volume in hypertensive children was significantly larger than in the borderline hypertensive group, with no significant difference between normotensive and borderline hypertensive groups. These findings show that an increase in LVMI may be detected earlier than an increase in renal volume in children with ADPKD and borderline hypertension, suggesting that close monitoring of cardiac status is indicated in these children.

ACR Appropriateness Criteria on headache-child

In a pediatric patient with an isolated headache or a classic migraine unaccompanied by neurologic signs, presence of a seizure, or supporting historical data, an imaging workup is usually not indicated. For a sudden severe headache or a headache with positive neurologic signs or symptoms or supporting historical data, MRI or CT should be considered. For the acute severe (thunderclap) headache, CTA, MRA, or catheter angiography may be appropriate.

Early inhaled nitric oxide therapy in premature newborns with respiratory failure

BACKGROUND

The safety and efficacy of early, low-dose, prolonged therapy with inhaled nitric oxide in premature newborns with respiratory failure are uncertain.

METHODS

We performed a multicenter, randomized trial involving 793 newborns who were 34 weeks of gestational age or less and had respiratory failure requiring mechanical ventilation. Newborns were randomly assigned to receive either inhaled nitric oxide (5 ppm) or placebo gas for 21 days or until extubation, with stratification according to birth weight (500 to 749 g, 750 to 999 g, or 1000 to 1250 g). The primary efficacy outcome was a composite of death or bronchopulmonary dysplasia at 36 weeks of postmenstrual age. Secondary safety outcomes included severe intracranial hemorrhage, periventricular leukomalacia, and ventriculomegaly.

RESULTS

Overall, there was no significant difference in the incidence of death or bronchopulmonary dysplasia between patients receiving inhaled nitric oxide and those receiving placebo (71.6 percent vs. 75.3 percent, P=0.24). However, for infants with a birth weight between 1000 and 1250 g, as compared with placebo, inhaled nitric oxide therapy reduced the incidence of bronchopulmonary dysplasia (29.8 percent vs. 59.6 percent); for the cohort overall, such treatment reduced the combined end point of intracranial hemorrhage, periventricular leukomalacia, or ventriculomegaly (17.5 percent vs. 23.9 percent, P=0.03) and of periventricular leukomalacia alone (5.2 percent vs. 9.0 percent, P=0.048). Inhaled nitric oxide therapy did not increase the incidence of pulmonary hemorrhage or other adverse events.

CONCLUSIONS

Among premature newborns with respiratory failure, low-dose inhaled nitric oxide did not reduce the overall incidence of bronchopulmonary dysplasia, except among infants with a birth weight of at least 1000 g, but it did reduce the overall risk of brain injury. (ClinicalTrials.gov number, NCT00006401 [ClinicalTrials.gov].).

Giant cystic abdominal masses in children

In this pictorial essay the common and uncommon causes of large cystic and cyst-like abdominal masses in children are reviewed. We discuss and illustrate the following: mesenchymal hamartoma, choledochal cyst, hydrops of the gallbladder, congenital splenic cyst, pancreatic pseudocyst, pancreatic cystadenoma, hydronephrosis, multicystic dysplastic kidney, multilocular cystic nephroma, adrenal hemorrhage, mesenteric and omental cysts, gastrointestinal duplication cyst, meconium pseudocyst, ovarian cysts and cystic neoplasms, hematocolpos, urachal cysts, appendiceal abscess, abdominal and sacrococcygeal teratoma, and CSF pseudocyst. We also describe imaging features and clues to the diagnosis.

Design and baseline characteristics of participants in the study of antihypertensive therapy in children and adolescents with autosomal dominant polycystic kidney disease (ADPKD)

In this manuscript, we describe our ongoing randomized clinical trial to assess the efficacy of blood pressure control with angiotensin converting enzyme (ACE) inhibition on renal cyst growth over a 5-year study period in children and young adults aged 4-21 years with autosomal dominant polycystic kidney disease (ADPKD). Baseline demographic and laboratory data for the study groups are reported. Results of this study could significantly impact the standard of care for management of ADPKD in this population.

Physiologic response to moderate altitude exposure among infants and young children

Substantial numbers of children are exposed to moderate altitude while traveling to mountain resorts with their families. Although there has been extensive study of the adult physiologic response to altitude exposure, few studies of infants and young children exist. This investigation examines the acute physiologic responses to moderate altitude exposure among young children and the relationship of these responses to the development of acute mountain sickness (AMS). Children 3 to 36 months old participated in the prospective observational study, which included baseline measurements at 1610 m and measurements after a 24-h exposure to 3109 m. Measurements included pulse and respiratory rate, end-tidal CO(2), arterial oxygen saturation (pulse oximetry), cerebral tissue oxygenation (St(O2)) by near-infrared spectroscopy, middle cerebral artery resistive index by transcranial Doppler, lateral ventricle volumes (ultrasound), and clinical evaluation for the presence of acute mountain sickness (Children's Lake Louise Score). Twenty-four children (13 girls and 11 boys, age 14.5 +/- 10.2 months) participated. After acute exposure to 3109 m, these children showed an increase in respiratory rate from 45 +/- 13 to 51.9 +/- 15 breaths/min (p < 0.008), accompanied by a decrease of end-tidal CO(2) from 31 +/- 3 to 28 +/- 2 mm Hg (p < 0.001) and a reduction of arterial oxygen saturation from 95 +/- 2 to 91 +/- 2% (p < 0.001). St(O2) also decreased from 78 +/- 8 to 67 +/- 13% (p < 0.001), and this reduction appeared to be related to age (r = 0.58, p < 0.05), with lower saturations found in younger children. No evidence of increased intracranial pressure, as assessed by middle cerebral artery resistive index, was seen during ascent. Seven subjects developed symptoms of AMS; however, no relationship was found between the physiologic changes observed and the presence of symptoms. Ascent from 1610 to 3109 m resulted in tachypnea, relative hypoxia, hypocapnia, and a reduction in cerebral tissue oxygenation (St(O2)). The reduction in St(O2) appeared to be related to age, with infants appearing to be the most susceptible to cerebral tissue oxygen desaturation at high altitude. No relationship appears to exist between the presence of AMS and the physiologic measurements.

The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children

BACKGROUND

Rib fractures have a strong association with nonaccidental trauma (NAT) and severe trauma. The purposes of this study were to evaluate rib fractures in children to determine (1) the positive predictive value of a rib fracture in defining NAT and (2) the frequency of rib fractures as the only skeletal manifestation of NAT.

METHODS

We reviewed the medical records and imaging of all children with rib fractures over a 6-year period. NAT was determined by the Child Advocacy and Protection team.

RESULTS

In children younger than 3 years of age, the positive predictive value (PPV) of a rib fracture as an indicator of NAT was 95%. The positive predictive value increased to 100% once historical and clinical circumstance excluded all other causes for rib fractures.

CONCLUSION

In this study, rib fracture(s) were the only skeletal manifestation of NAT in 29% of the children.

Progression of autosomal-dominant polycystic kidney disease in children

BACKGROUND

Although many case reports describe manifestations of autosomal-dominant polycystic kidney disease (ADPKD) in children, no longitudinal studies have examined the natural progression or risk factors for more rapid progression in a large number of children from ADPKD families.

METHODS

Since 1985, we have studied 312 children from 131 families with a history, a physical examination, blood and urine chemistries, an abdominal ultrasonography, and gene linkage analysis. One hundred fifteen of 185 affected children were studied multiple times for up to 15 years. Renal volumes were determined by ultrasound imaging. Graphs of mean renal volumes according to age were compared between affected and unaffected children, ADPKD children with and without early severe disease, and children with and without high blood pressure.

RESULTS

Affected children had faster renal growth than unaffected children. ADPKD children with severe renal enlargement at a young age continued to experience faster renal growth than those with mild enlargement or normal kidney size for their age, and affected children with high blood pressure had faster renal growth than those with lower blood pressure. Glomerular filtration rate did not decrease in any children except for two with unusually severe early onset disease.

CONCLUSIONS

The progression of ADPKD clearly occurs in childhood and manifests as an increase in cyst number and renal size. This study identifies children at risk for rapid renal enlargement who may benefit the most from future therapeutic interventions.

Progression of autosomal-dominant polycystic kidney disease in children

BACKGROUND

Although many case reports describe manifestations of autosomal-dominant polycystic kidney disease (ADPKD) in children, no longitudinal studies have examined the natural progression or risk factors for more rapid progression in a large number of children from ADPKD families.

METHODS

Since 1985, we have studied 312 children from 131 families with a history, a physical examination, blood and urine chemistries, an abdominal ultrasonography, and gene linkage analysis. One hundred fifteen of 185 affected children were studied multiple times for up to 15 years. Renal volumes were determined by ultrasound imaging. Graphs of mean renal volumes according to age were compared between affected and unaffected children, ADPKD children with and without early severe disease, and children with and without high blood pressure.

RESULTS

Affected children had faster renal growth than unaffected children. ADPKD children with severe renal enlargement at a young age continued to experience faster renal growth than those with mild enlargement or normal kidney size for their age, and affected children with high blood pressure had faster renal growth than those with lower blood pressure. Glomerular filtration rate did not decrease in any children except for two with unusually severe early onset disease.

CONCLUSIONS

The progression of ADPKD clearly occurs in childhood and manifests as an increase in cyst number and renal size. This study identifies children at risk for rapid renal enlargement who may benefit the most from future therapeutic interventions.

MRI-compatible audio/visual system: impact on pediatric sedation

BACKGROUND

While sedation is necessary for much pediatric imaging, there are new alternatives that may help patients hold still without medication.

OBJECTIVE

We examined the effect of an audio/visual system consisting of video goggles and earphones on the need for sedation during magnetic resonance imaging (MRI).

MATERIALS AND METHODS

All MRI examinations from May 1999 to October 1999 performed after installation of the MRVision 2000 (Resonance Technology, Inc.) were compared to the same 6-month period in 1998. Imaging and sedation protocols remained constant. Data collected included: patient age, type of examination, use of intravenous contrast enhancement, and need for sedation. The average supply charge and nursing cost per sedated patient were calculated.

RESULTS

The 955 patients from 1998 and 1,112 patients from 1999 were similar in demographics and examination distribution. There was an overall reduction in the percent of patients requiring sedation in the group using the video goggle system from 49 to 40% (P < 0.001). There was no significant change for 0-2 years (P = 0.805), but there was a reduction from 53 to 40% for age 3-10 years (P < 0.001) and 16 to 8% for those older than 10 years (P < 0.001). There was a 17% decrease in MRI room time for those patients whose examinations could be performed without sedation. Sedation costs per patient were $80 for nursing and $29 for supplies.

CONCLUSION

The use of this video system reduced the number of children requiring sedation for MRI examination by 18%. In addition to reducing patient risk, this can potentially reduce cost.

Intussusception: clinical and radiographic factors influencing reducibility

Hydrostatic reduction of intussusception by barium or air enema has been widely accepted. The five-year experience with this procedure at two children's hospitals is reviewed and the results compared to previous studies. Various clinical and radiographic factors are evaluated in relation to the reduction rate. The findings show that the more distal the intussusception is encountered, the lower the rate of reduction. However, 25% are reduced within the rectum with no evidence of increased complications. Small bowel obstruction and prolonged duration of signs and symptoms decreased the rate of reduction statistically but there is no significant increase in complication rate in those attempted, contrary to a previous report. The cresent sign (dissection sign) and age of the patient are not significant factors in reduction as reported by other studies.

Chest radiography versus chest CT in the evaluation for pulmonary metastases in patients with Wilms' tumor: a retrospective review

BACKGROUND

Determination of the presence of pulmonary metastases in children with Wilms' tumor is an important part of staging and treatment. We sought to compare the efficacy of chest radiography (CXR) and chest CT in the evaluation for pulmonary metastases in patients with Wilms' tumor.

MATERIALS AND METHODS

This retrospective study included 83 children with Wilms' tumor diagnosed between 1980 and 1993. All patients with pulmonary nodules (n = 12) as well as 14 Wilms' tumor patients without pulmonary metastases (control group) had blinded review of the CXR and chest CTs by three pediatric radiologists. Presence, size, and certainty of metastatic diagnosis were recorded. Medical records were reviewed. The remaining 57 patients had review of their medical and imaging records to confirm the absence of pulmonary metastases.

RESULTS

Ten of the 12 with pulmonary masses had imaging available for review. Eight had both positive CXR and chest CT examinations. Two patients had pulmonary nodules seen by CT only: one had a right cardiophrenic angle mass and died as a result of liver metastases. The other had a solitary nodule, which proved to be a plasma-cell granuloma. Overall, the CXR and chest CT data concur in 79/81 (98%).

CONCLUSION

CXR alone appears adequate for the diagnosis or exclusion of pulmonary metastases in patients with Wilms' tumor.

Pattern of recurrence in children with midline posterior fossa malignant neoplasms

BACKGROUND

Surveillance imaging of the brain and spinal neuraxis in patients with posterior fossa malignant tumors is commonly performed, with the assumption that early detection of tumor recurrence will improve outcome. However, the benefit of this imaging has not been proven.

PURPOSE

To evaluate the usefulness of spinal surveillance imaging in children with nonmetastatic (at diagnosis, M0) posterior fossa ependymoma and medulloblastoma.

MATERIALS AND METHODS

This retrospective study included 65 children (3 months to 16 years, mean 5.7 years) treated between 1985 and 1997 for ependymoma (22) and medulloblastoma (43). Medical records were reviewed for pathology and treatment data. Serial imaging of the head and spine was reviewed for evidence of tumor recurrence.

RESULTS

Twenty-four patients (37 %) had tumor recurrence, including 13 with ependymoma and 11 with medulloblastoma. Of the 17/24 recurrent patients initially diagnosed as M0 (6 medulloblastoma and 11 ependymoma), 13 (76 %) had a cranial recurrence only, and 4 (24 %) presented with concomitant cranial and spinal recurrence. No M0 patient presented solely with spinal metastases at recurrence.

CONCLUSION

This study suggests that spinal surveillance imaging in patients with posterior fossa ependymoma or medulloblastoma initially staged as M0 may not be useful, as these patients initially recur intracranially. Thus, until an intracranial recurrence is detected, these patients may be spared the time, expense and sedation risk necessary for spinal imaging.

Successful use of intracavitary bleomycin for low-grade astrocytoma tumor cyst

We report successful use of bleomycin in a low-grade astrocytoma tumor cyst of the tectal plate. A 6-year-old male underwent subtotal resection of a low-grade astrocytoma of the tectal plate followed by chemotherapy and proton beam radiation at age 2 and a half. Despite resolution of the solid portion of the tumor, serial MRI showed enlargement of a bilobar tumor cyst 3 years after the original diagnosis. The patient developed progressive ataxia, short-term memory loss and dysconjugate gaze. Following stereotactic placement of an Ommaya reservoir into the cyst, Isovue contrast and CT scan were used to confirm the integrity of the cyst. Five consecutive daily doses of 3.0 mg of bleomycin were instilled into the cyst after removal of cyst fluid. The therapy was well tolerated in the outpatient setting, and the clinical findings resolved. Subsequent CT and MRI at 4 months and 2 years after bleomycin confirmed no recurrence of the tumor or cyst.

Renal asymmetry in children with autosomal dominant polycystic kidney disease

Although for decades autosomal dominant polycystic kidney disease (ADPKD) was considered a disease of adults, our recent longitudinal studies on children from ADPKD families have shown that the disease is evident by ultrasound imaging in approximately 75% of children who are carriers of the ADPKD1 gene, the most common form of ADPKD. Here we report that, in contrast to adults, the disease appears to be unilateral initially in approximately 17% of children. Asymmetric enlargement of the kidneys is also frequently observed. This renal asymmetry can be extreme and lead to diagnostic confusion. We present 2 unusual cases of asymmetric renal involvement that we have observed during the last 10 years. The first is a 14-year-old boy who was scheduled for a nephrectomy to relieve pain and whose family requested a second opinion. The second is a 10-year-old girl who was diagnosed with ADPKD in utero by prenatal ultrasound. After birth, 1 kidney progressively developed cysts and enlarged, whereas the other had only a few tiny cysts and remained normal in size. A review of the literature shows that presentations like these often lead to a nephrectomy or surgical biopsy. A carefully obtained family history and examination of both parents with ultrasound can help to avoid unnecessary invasive procedures. If pain is a prominent symptom, it can be treated by cyst aspiration if there are only a few cysts or a single dominant cyst. The molecular mechanism for extremely asymmetric renal disease remains to be elucidated.

Clinical practice guidelines for the management of chronic sinusitis in children

Chronic sinusitis in children is a common and vexing disease for clinicians and the public. There are insufficient data in the literature to develop an evidence-based clinical guideline. Experience in managing pediatric chronic sinusitis has been gained through a multidisciplinary clinic at our institution during the past 3 years. A panel of experts was formed, and with the guidance of a guideline methodologist, the development of a rigorous outcome-based guideline was undertaken. Symptom-improvement and recurrence estimates for a variety of medical and surgical treatments were assessed. Wide probability estimates were made by the panelists in most cases. Although we refrained from making specific recommendations, we developed a ranked series of practical treatment options taking into account side effects and costs.

Comparison of intracranial computed tomographic (CT) findings in pediatric abusive and accidental head trauma

BACKGROUND

Child abuse specialists rely heavily on diagnostic neuroimaging.

OBJECTIVES

Study objectives were: (1) to compare the frequencies of six specific intracranial CT abnormalities in accidental and non-accidental pediatric head trauma, and (2) to assess interobserver agreement regarding these CT findings.

MATERIALS AND METHODS

Three pediatric radiologists blindly and independently reviewed cranial CT scans of pediatric patients who sustained closed head trauma between 1991 and 1994. All patients were less than 4 years of age. Study cases included thirty-nine (50 %) with non-accidental head trauma and thirty-nine (50 %) with accidental head trauma. Each scan was evaluated for the presence or absence of the following six intracranial findings: (1) interhemispheric falx hemorrhage, (2) subdural hemorrhage, (3) large (non-acute) extra-axial fluid, (4) basal ganglia edema, (5) posterior fossa hemorrhage, and (6) frontal-parietal shearing tear(s). Interobserver agreement was calculated as the percentage of total cases in which all reviewers agreed a specific CT finding was present or absent. Diagnosis required independent agreement by all three pediatric radiologists. The frequencies of these six intracranial CT abnormalities were compared between the two study groups by Chi-square analysis and Fisher's exact test.

RESULTS

Interobserver agreement between radiologists was greater than 80 % for all lesions evaluated, with the exception of frontal-parietal shearing tear(s). Interhemispheric falx hemorrhage, subdural hemorrhage, large (non-acute) extra-axial fluid, and basal ganglia edema were discovered significantly more frequently in non-accidental trauma (P </= .05).

CONCLUSION

Although not specific for child abuse, discovery of these intracranial CT abnormalities in young patients should prompt careful evaluation of family and injury circumstances for indicators of non-accidental trauma.

Esophageal foreign bodies: safety and efficacy of Foley catheter extraction of coins

OBJECTIVE

Continued controversy over the role of fluoroscopically guided Foley catheter removal of esophageal foreign bodies has limited the use of this technique despite its significant economic advantages. We reviewed our experience for the safety, efficacy, and applicability of this technique with pediatric patients who had swallowed coins.

MATERIALS AND METHODS

We retrospectively reviewed 10 years of experience with pediatric patients who had undergone fluoroscopically guided Foley catheter removal of coins. All the pediatric patients with a suspected esophageal foreign body were first evaluated by plain film radiography. Foley catheter extraction was attempted when a radiopaque coin was seen and the patient lacked signs of significant esophageal edema resulting in tracheal compromise. During the 10 years covered by our review, 14 pediatric radiologists with specific training in the Foley catheter technique were involved in such removals. A separate review (of consecutive pediatric patients who had a history of or symptoms suggesting ingestion of a foreign body) focused on the percentage of these patients in which the Foley catheter technique was used.

RESULTS

Of the 337 coin extractions attempted using a Foley catheter, coin extraction was successful in 322 (96%) of 337 patients. No complications were encountered. Our focused review found 422 consecutive patients who had undergone radiography to rule out foreign bodies. A radiopaque object was found in 249 (59%) of 422 patients. Of these 249 objects, 208 (84%) were ingested coins. Of 208 coins, 123 (59%) were retained in the esophagus; of these 123 coins retained in the esophagus, 116 (94%) were amenable to fluoroscopically guided Foley catheter extraction.

CONCLUSION

Fluoroscopically guided Foley catheter extraction of retained coins in pediatric patients who lack evidence of significant esophageal edema causing tracheal compromise is a safe and efficacious technique. It should be considered the technique of choice for such extractions.

Utility of ultrasonography in the diagnosis of autosomal dominant polycystic kidney disease in children

To determine the utility of ultrasonography (US) in diagnosing autosomal dominant polycystic kidney disease (ADPKD) in children, this study examined 106 children who were at 50% risk for the disease. The children underwent a history, physical examination, abdominal US, and gene linkage analysis (GLA) with tightly linked markers for ADPKD1 and ADPKD2 genes. Only ADPKD1 children were studied. A child was considered affected by US if any cysts were detected and affected by GLA if he or she shared the same haplotype as the affected parent. Forty-two children (40%) were considered to be unaffected by both GLA and US. Forty-eight children (45%) were considered affected by both modalities. Only two of these children had a single cyst. Fourteen children (13%) were considered affected by GLA with normal initial US. These children tended to have larger kidneys than children who were unaffected by GLA. Eight of these 14 children had subsequent positive ultrasonograms. Two children had a positive ultrasonogram with GLA showing them to be unaffected; in one of these children, a subsequent ultrasonogram was interpreted to be normal with a medullary pyramid. Thus, overall the false negative rate was 25%, and the false positive rate was 2%. The false negative rate was highest in the children who were 3 months to 5 years of age (38%). Clinicians must understand the utility of US in diagnosing ADPKD in at-risk children and must not interpret a normal study as absence of disease in this population.

Indications for surgical intervention for gastrointestinal emergencies in children receiving chemotherapy

BACKGROUND

Abdominal pain in children receiving chemotherapy for cancer presents the clinician with unique problems due to the altered immunity of these patients or to the oncologic setting. The major clinical decisions regarding these patients are to determine if and when operative intervention is indicated.

METHODS

A retrospective study was done to examine the clinical, radiographic, and laboratory findings that indicate the need for surgical intervention. Sixty-eight of 1090 children who underwent treatment for cancer from October 1982 to December 1990 developed abdominal complaints requiring them to be hospitalized. Nineteen of these patients underwent exploratory laparotomy (operative), and the other 49 were observed (nonoperative).

RESULTS

No significant differences were observed in the phase of chemotherapy, treatment with vincristine or corticosteroids, or the hematologic indices between the operative and nonoperative groups. Eighteen of nineteen patients survived their surgeries. Seventeen (89%) of these laparotomies were positive based on the surgical pathology and the operative report. Peritoneal signs on physical examination (P < 0.001) or pneumatosis intestinalis on abdominal radiographs correlated with positive laparotomies (P = 0.001).

CONCLUSIONS

Peritoneal signs on physical examination or pneumatosis intestinalis on abdominal X-rays were associated with and specific for the presence of acute surgical disease of the abdomen in immunocompromised pediatric oncology patients.

The spectrum of autosomal dominant polycystic kidney disease in children

The natural history of autosomal dominant polycystic kidney disease (ADPKD) has not been well described in children, and it is not known whether a relationship exists between renal structural abnormalities and function in children as has been seen in adults. Therefore, 140 children from 67 ADPKD families were studied in a prospective study. Only 22 children came with a previous diagnosis of ADPKD. In 44% of all children, at least one cyst was found on ultrasound at a mean age of 8.7 yr. Of these, 60% were classified as having moderate disease on the basis of a total cyst number of 1 to 10 cysts, whereas 40% were considered to have severe disease with a total of more than 10 cysts. There was a significant relationship between the severity of the renal structural involvement and the frequency of flank and back pain, hypertension, and impaired renal concentrating capacity. However, GFR were not reduced in children with ADPKD and did not relate to structural severity. Thirty-nine children were seen for a follow-up visit 2 to 5 yr after the initial visit. No child had progressed from nonaffected to affected with ADPKD, but three of four children with only one cyst at the time of the initial study had progressed to bilateral cysts. Among the 22 ADPKD children who had a follow-up study, there was progression of the disease, reflected by an increase in cyst number and an increase in the frequency of pain and hypertension. However, GFR remained stable in all children.(ABSTRACT TRUNCATED AT 250 WORDS)

In utero development of pulmonary artery calcification in monochorionic twins: a report of three cases and discussion of the possible etiology

Pulmonary artery (PA) calcification is unusual in children, reportedly occurring only in conjunction with severe underlying valvular disease. Three newborns were found by chest X-ray study to have thin calcified rings of the PA. Two were pump twins in twin reversed arterial perfusion (TRAP) sequences, each with an acardiac cotwin, and the third was the recipient in a twin transfusion syndrome (TTS). Both twin pairs with TRAP sequence were premature, each pump twin presenting with cardiac decompensation. One remained well at 5 months of age, the other died at 5 1/2 months of age. The third, the premature recipient of twins with TTS, died at 24 h of age, and the donor cotwin died at 2 h of age. The two hearts were structurally normal at autopsy. Subtle intimal wrinkling was seen above the pulmonary valve leaflets, and the media was yellow and granular on cut section. Hyperplasia of the intima and media with disruption and calcification of the elastic fibers of the media was seen microscopically. These three cases of PA calcification occurring in utero were not related to structural valvular abnormalities but were presumably due to increased cardiac output in utero as each occurred in the volume-overloaded twin of the twin pair. Comparison of the weight differences between these three twin pairs with PA calcification suggests a relationship between the presence of PA calcification and the severity of the cardiac volume overload. In utero cardiac damage may contribute to the high morbidity and mortality rate seen in infants with TRAP sequence and TTS.

Peripheral neuroepithelioma of the soft tissues. A retrospective analysis of fifteen pediatric patients

PURPOSE

The purpose of this study was to determine the clinical outcome for pediatric patients with peripheral neuroepithelioma treated with combined modality therapy and followed long enough to account for late relapses.

PATIENTS AND METHODS

Fifteen patients, ages 3 3/12 to 19 10/12 years, with peripheral neuroepithelioma (median follow-up 91 months) were diagnosed at The Children's Hospital, Denver, Colorado over the period 1980-1989. All of these malignancies originated in the soft tissues. A critical review of these cases was performed with particular consideration given to the site and stage of the tumor and to the radiographic findings at presentation. Thirteen patients had bulk (> 5 cm in the greatest dimension) or metastatic disease. Four patients had primary tumors involving the chest wall. All patients received chemotherapy, which included at least doxorubicin, vincristine, and cyclophosphamide. Definitive surgical resections were performed on 13 of 15 patients.

RESULTS

Five patients relapsed. Three were late relapses 24-44 months after diagnosis. Three of the five patients who relapsed had chest wall primaries. There were three deaths in this series due to peripheral neuroepithelioma and one due to sepsis. The overall survival was 68.5%, and the recurrence-free, survival 55.2%. Two patients with pulmonary relapses were treated with surgery and intensive chemotherapy and remain free of disease > 51 months following recurrence.

CONCLUSIONS

Combined treatment modalities appear to be important for optimal outcome. This series represents the first report of favorable outcome of peripheral neuroepithelioma using a series with follow-up that is long enough to account for late relapses.

Characteristics of very early onset autosomal dominant polycystic kidney disease

Eleven children from eight families with autosomal dominant polycystic kidney disease who were diagnosed in utero (6 children) or in the first year of life (5 children) are reported here. Four children were evaluated for symptoms and three because of a sibling with very early onset disease. In three children, abnormal kidneys were found incidentally on a pregnancy screening ultrasound, and in only one child, the diagnosis was made by an ultrasound specifically directed at detecting polycystic kidney disease. Females were disproportionately represented among both the affected parents and offspring. Eight of the children were girls, and all affected parents were mothers. In three families, the parent's diagnosis was established only after the birth of the affected child. In two of these and in one other family, the mother's disease appeared to be the result of a new mutation. The most consistent renal ultrasonographic findings in the children were enlargement and increased echogenicity. On follow-up over 3 to 15 yr (mean, 6.8 yr) two children had ESRD and eight children had normal or nearly normal renal function as assessed by creatinine clearance. Renal concentrating ability was reduced in four children in whom it was measured. All children had bilateral renal cysts on follow-up, and nine children were hypertensive. Possible risk factors for early-onset disease identified in this study were an affected mother, an affected sibling, and an apparent parental new mutation. Symptoms and complications occurred frequently, but outcome was better than reported previously.

Evaluation of the vomiting infant

This 12-month prospective study was undertaken to evaluate the cost, risk, and benefit of ultrasound followed by upper gastrointestinal series for the evaluation of the infant who vomits. Results suggest minimal morbidity from the upper gastrointestinal series, only a 33% reduction in the number of upper gastrointestinal series performed, and a 95% increase in cost if this imaging sequence is used. We conclude that the use of ultrasound for the initial evaluation of vomiting in infants substantially increases the cost with no meaningful decrease in morbidity and mortality.

IV Nembutal: safe sedation for children undergoing CT

In a prospective study of 225 consecutive pediatric patients who required sedation for CT imaging, we monitored oral and nasal air flow, transcutaneous oxygen saturation, and cardiac rate and rhythm before and after the administration of IV Nembutal. In addition, the first 50 patients in this series had blood pressures mechanically monitored at 1-min intervals. There was no significant change in the cardiac rate, rhythm, or blood pressure in any patient. Seventeen episodes (7.5%) of transient oxygen desaturation to 80% of baseline or less occurred after sedation. The patterns of oxygen desaturation in this series can be explained by the following mechanisms: (1) hyperventilation leading to hypocapnia with resultant loss of the CO2 stimulus of respiration (12 patients); (2) upper airway obstruction from pharyngeal muscle relaxation (three patients); (3) a shift in sensitivity of CNS CO2 receptors (one patient); and (4) central apnea (one patient). Oxygen desaturation normalized spontaneously in 14 patients. In two patients, oxygen saturations returned to normal after modification of head position to optimize airway patency. In one patient, mild stimulation was required to interrupt transient apnea. All but one patient in whom desaturation occurred showed oxygen desaturation within the first 5 min after IV sedation. At The Children's Hospital of Denver, IV Nembutal has been used in over 870 pediatric patients. No patient required resuscitation, intubation, or assisted ventilation. Only one patient required prolonged observation, and one patient demonstrated an idiosyncratic hyperactive response. The sedation failure rate was less than 1%. The average dose of sedation was reduced when compared with IM Nembutal because the rapid onset of activity after IV administration allowed titration of dose to patient response.

Intravenously administered pentobarbital sodium for sedation in pediatric CT

A retrospective study of 5,134 consecutive pediatric patients undergoing computed tomographic (CT) evaluation from January 1983 through December 1985 was conducted to analyze the need for sedation in a pediatric population; the safety, efficacy, and efficiency of various sedation regimens; and the pediatric radiologists' changing preference for certain sedatives. A marked preference for intravenous administration of pentobarbital sodium (Nembutal) evolved over the 3-year period analyzed. Intravenous Nembutal facilitated the most efficient use of available CT scanning time. Recovery times were reduced, and patient convenience was augmented. There were only two sedation failures in the 419 patients sedated with intravenous Nembutal, and there were no sedation-related complications.