Contrast-enhanced voiding ultrasonography to detect intrarenal reflux in children: comparison with 99mTc-DMSA renal scans

Purpose@#This study evaluated the diagnostic performance of contrast-enhanced voiding ultrasonography (CeVUS) for detecting intrarenal reflux (IRR) and the correlation between CeVUS-detected IRR sites and photon defect sites in acute 99mTc-dimercaptosuccinic acid (DMSA) renal scans in pediatric patients. @*Methods@#Fifty-four kidneys from 27 patients (20 males and seven females; mean age, 5.6±4.1 months) who underwent CeVUS and acute DMSA renal scans for recurrent urinary tract infection (UTIs) or pyelonephritis were included. Pediatric experts compared the results of CeVUS with acute DMSA renal scans. @*Results@#Thirteen renal units (13/54, 24.1%) in 10 patients (nine males and one female; mean age, 6.3±3.7 months; age range, 0 to 13 months) showed vesicoureteral reflux and eight renal units (8/54, 14.8%) demonstrated IRR on CeVUS. Ten renal units in eight patients (six males and two females; mean age, 6.9±1.4 months; age range, 2 to 13 months) showed 19 photon defects on acute DMSA renal scans. Fifty-two renal units (96.3%) showed concordant results, and two renal units (3.7%) showed discordant results between CeVUS and acute DMSA renal scans. IRR accounted for 15/19 (78.9%) photon defects in eight renal units of seven patients using CeVUS. In a per-renal-unit analysis, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CeVUS were 80%, 100%, 100%, 95.7%, and 96.3%, respectively. @*Conclusion@#CeVUS showed good performance in detecting IRR, and the IRR sites detected by CeVUS closely correlated with photon defect sites in acute DMSA scans. CeVUS may play an important role in managing patients with recurrent UTIs or pyelonephritis with reduced radiation exposure.

Deep Learning-Assisted Diagnosis of Pediatric Skull Fractures on Plain Radiographs

Objective@#To develop and evaluate a deep learning-based artificial intelligence (AI) model for detecting skull fractures on plain radiographs in children. @*Materials and Methods@#This retrospective multi-center study consisted of a development dataset acquired from two hospitals (n = 149 and 264) and an external test set (n = 95) from a third hospital. Datasets included children with head trauma who underwent both skull radiography and cranial computed tomography (CT). The development dataset was split into training, tuning, and internal test sets in a ratio of 7:1:2. The reference standard for skull fracture was cranial CT. Two radiology residents, a pediatric radiologist, and two emergency physicians participated in a two-session observer study on an external test set with and without AI assistance. We obtained the area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity along with their 95% confidence intervals (CIs). @*Results@#The AI model showed an AUROC of 0.922 (95% CI, 0.842–0.969) in the internal test set and 0.870 (95% CI, 0.785–0.930) in the external test set. The model had a sensitivity of 81.1% (95% CI, 64.8%–92.0%) and specificity of 91.3% (95% CI, 79.2%–97.6%) for the internal test set and 78.9% (95% CI, 54.4%–93.9%) and 88.2% (95% CI, 78.7%– 94.4%), respectively, for the external test set. With the model’s assistance, significant AUROC improvement was observed in radiology residents (pooled results) and emergency physicians (pooled results) with the difference from reading without AI assistance of 0.094 (95% CI, 0.020–0.168; p = 0.012) and 0.069 (95% CI, 0.002–0.136; p = 0.043), respectively, but not in the pediatric radiologist with the difference of 0.008 (95% CI, -0.074–0.090; p = 0.850). @*Conclusion@#A deep learning-based AI model improved the performance of inexperienced radiologists and emergency physicians in diagnosing pediatric skull fractures on plain radiographs.

Feasibility Study of Synthetic Diffusion-Weighted MRIin Patients with Breast Cancer in Comparison withConventional Diffusion-Weighted MRI

Objective@#To investigate the clinical feasibility of synthetic diffusion-weighted imaging (sDWI) at different b-values in patientswith breast cancer by assessing the diagnostic image quality and the quantitative measurements compared with conventionaldiffusion-weighted imaging (cDWI). @*Materials and Methods@#Fifty patients with breast cancer were assessed using cDWI at b-values of 800 and 1500 s/mm2 (cDWI800and cDWI1500) and sDWI at b-values of 1000 and 1500 s/mm2 (sDWI1000 and sDWI1500). Qualitative analysis (normal glandulartissue suppression, overall image quality, and lesion conspicuity) was performed using a 4-point Likert-scale for all DWI setsand the cancer detection rate (CDR) was calculated. We also evaluated cancer-to-parenchyma contrast ratios for each DWI setin 45 patients with the lesion identified on any of the DWI sets. Statistical comparisons were performed using Friedman test,one-way analysis of variance, and Cochran’s Q test. @*Results@#All parameters of qualitative analysis, cancer-to-parenchyma contrast ratios, and CDR increased with increasingb-values, regardless of the type of imaging (synthetic or conventional) (p< 0.001). Additionally, sDWI1500 provided better lesionconspicuity than cDWI1500 (3.52 ± 0.92 vs. 3.39 ± 0.90, p< 0.05). Although cDWI1500 showed better normal glandular tissuesuppression and overall image quality than sDWI1500 (3.66 ± 0.78 and 3.73 ± 0.62 vs. 3.32 ± 0.90 and 3.35 ± 0.81, respectively;p< 0.05), there was no significant difference in their CDR (90.0%). Cancer-to-parenchyma contrast ratios were greater insDWI1500 than in cDWI1500 (0.63 ± 0.17 vs. 0.55 ± 0.18, p< 0.001). @*Conclusion@#sDWI1500 can be feasible for evaluating breast cancers in clinical practice. It provides higher tumor conspicuity,better cancer-to-parenchyma contrast ratio, and comparable CDR when compared with cDWI1500.

Incidence and Risk Factors of Nausea and Vomiting after Exposure to Low-Osmolality Iodinated Contrast Media in Children: A Focus on Preparative Fasting

Objective@#To evaluate the incidence and risk factors of emetic complications associated with the intravenous administration of low-osmolality iodinated contrast media (ICM) in children undergoing computed tomography (CT). @*Materials and Methods@#All children who underwent contrast-enhanced CT between April 2017 and July 2019 were included.Pediatric patients were instructed on the preparative dietary protocol at our institution. Experienced nurses in the radiology department monitored the children during the CT scans and recorded any emetic complications in their electronic medical records. These data were used to calculate the incidence of emetic complications. Various patient factors and technical factors, including fasting duration, the type and volume of ICM, and ongoing chemotherapy, were evaluated to identify risk factors for emetic complications using univariate and multivariate logistic regression analyses. @*Results@#Among the 864 children (mean age, 8.4 ± 5.7 years) evaluated, 18 (2.1%) experienced emetic complications (6 experienced nausea only and 12 experienced nausea and vomiting). None of the children developed aspiration pneumonia.The mean fasting duration of patients with emesis was 7.9 ± 5.7 hours (range, 3–21 hours), whereas that of patients without nausea was 8.7 ± 5.7 hours (range, 0–24 hours). Fasting duration was not associated with the development of nausea and vomiting (p = 0.634). Multivariate logistic regression analysis revealed that ongoing chemotherapy (odds ratio [OR] = 4.323;95% confidence interval [CI] = 1.430–13.064; p = 0.009), iomeprol use (OR = 7.219; 95% CI = 1.442–36.146; p = 0.016), and iohexol use (OR = 5.241; 95% CI = 1.350–20.346;p = 0.017) were independent risk factors for emetic complications. @*Conclusion@#Only a small proportion (2.1%) of children experienced nausea or vomiting after exposure to low-osmolality ICM.Many children underwent excessive fasting; however, fasting duration was not associated with nausea and vomiting. Moreover, ongoing chemotherapy and the use of iomeprol or iohexol were identified as potential risk factors for emetic complications in children.

Möbius Syndrome Demonstrated by the High-Resolution MR Imaging: a Case Report and Review of Literature

Möbius syndrome is a rare congenital condition, characterized by abducens and facial nerve palsy, resulting in limitation of lateral gaze movement and facial diplegia. However, to our knowledge, there have been few studies on evaluation of cranial nerves, on MR imaging in Möbius syndrome. Herein, we describe a rare case of Möbius syndrome representing limitation of lateral gaze, and weakness of facial expression, since the neonatal period. In this case, high-resolution MR imaging played a key role in diagnosing Möbius syndrome, by direct visualization of corresponding cranial nerves abnormalities.

Arterial Spin Labeling MRI for Quantitative Assessment of Cerebral Perfusion Before and After Cerebral Revascularization in Children with Moyamoya Disease

OBJECTIVE: To determine the correlation between cerebral blood flow (CBF) on arterial spin labeling (ASL) MRI and the degree of postoperative revascularization assessed on digital subtraction angiography in children with moyamoya disease (MMD). MATERIALS AND METHODS: Twenty-one children (9 boys and 12 girls; mean age, 8.4 ± 3.6 years; age range, 3–16 years) with MMD who underwent both pseudocontinuous ASL MRI at 1.5T and catheter angiography before and after superficial temporal artery encephaloduroarteriosynangiosis were included in this retrospective study. The degree of revascularization in the middle cerebral artery (MCA) territory was evaluated on external carotid angiography and was graded on a 3-point scale. On ASL CBF maps, regions of interest were manually drawn over the MCA territory of the operated side at the level of the centrum semi-ovale and over the cerebellum. The normalized CBF (nCBF) was calculated by dividing the CBF of the MCA territory by the CBF of the cerebellum. Changes in nCBFs were calculated by subtracting the preoperative nCBF values from the postoperative nCBF values. The correlation between nCBF changes measured with ASL and the revascularization grade from direct angiography was evaluated. RESULTS: The nCBF value on the operated side increased after the operation (p = 0.001). The higher the degree of revascularization, the greater the nCBF change was: poor revascularization (grade 1), −0.043 ± 0.212; fair revascularization (grade 2), 0.345 ± 0.176; good revascularization (grade 3), 0.453 ± 0.182 (p = 0.005, Jockheere-Terpstra test). The interobserver agreement was excellent for the measured CBF values of the three readers (0.91–0.97). CONCLUSION: The nCBF values of the MCA territory obtained from ASL MRI increased after the revascularization procedure in children with MMD, and the degree of nCBF change showed a significant correlation with the degree of collateral formation evaluated via catheter angiography.

Clinical Availability of Waters' Projection in Sinus Elevation Procedures

Differential Diagnosis of Oral Lesions for the Initial Diagnosis of Acute Lymphoblastic Leukemia

Mitochondrial Dysfunction of Immortalized Human Adipose Tissue-Derived Mesenchymal Stromal Cells from Patients with Parkinson's Disease

Mitochondrial dysfunction in dopaminergic neurons of patients with idiopathic and familial Parkinson's disease (PD) is well known although the underlying mechanism is not clear. We established a homogeneous population of human adipose tissue-derived mesenchymal stromal cells (hAD-MSCs) from human adult patients with early-onset hereditary familial Parkin-defect PD as well as late-onset idiopathic PD by immortalizing cells with the hTERT gene to better understand the underlying mechanism of PD. The hAD-MSCs from patients with idiopathic PD were designated as "PD", from patients with Parkin-defect PD as "Parkin" and from patients with pituitary adenomas as "non-PD" in short. The pGRN145 plasmid containing hTERT was introduced to establish telomerase immortalized cells. The established hTERT-immortalized cell lines showed chromosomal aneuploidy sustained stably over two-years. The morphological study of mitochondria in the primary and immortalized hAD-MSCs showed that the mitochondria of the non-PD were normal; however, those of the PD and Parkin were gradually damaged. A striking decrease in mitochondrial complex I, II, and IV activities was observed in the hTERT-immortalized cells from the patients with idiopathic and Parkin-defect PD. Comparative Western blot analyses were performed to investigate the expressions of PD specific marker proteins in the hTERT-immortalized cell lines. This study suggests that the hTERT-immortalized hAD-MSC cell lines established from patients with idiopathic and familial Parkin-defect PD could be good cellular models to evaluate mitochondrial dysfunction to better understand the pathogenesis of PD and to develop early diagnostic markers and effective therapy targets for the treatment of PD.

Neuronal autophagy and neurodegenerative diseases

Autophagy is a dynamic cellular pathway involved in the turnover of proteins, protein complexes, and organelles through lysosomal degradation. The integrity of postmitotic neurons is heavily dependent on high basal autophagy compared to non-neuronal cells as misfolded proteins and damaged organelles cannot be diluted through cell division. Moreover, neurons contain the specialized structures for intercellular communication, such as axons, dendrites and synapses, which require the reciprocal transport of proteins, organelles and autophagosomes over significant distances from the soma. Defects in autophagy affect the intercellular communication and subsequently, contributing to neurodegeneration. The presence of abnormal autophagic activity is frequently observed in selective neuronal populations afflicted in common neurodegenerative diseases, such as Alzheimer's disease, Parkinson's disease, Huntington's disease and amyotrophic lateral sclerosis. These observations have provoked controversy regarding whether the increase in autophagosomes observed in the degenerating neurons play a protective role or instead contribute to pathogenic neuronal cell death. It is still unknown what factors may determine whether active autophagy is beneficial or pathogenic during neurodegeneration. In this review, we consider both the normal and pathophysiological roles of neuronal autophagy and its potential therapeutic implications for common neurodegenerative diseases.

Submental Intubation with Reinforced Tube for Intubating Laryngeal Mask Airway

Submental endotracheal intubation is a simple and secure alternative to either nasoendotracheal intubation or a tracheostomy in the airway management of maxillofacial trauma. However, a submental endotracheal intubation is quite difficult to manage if adverse events such as a tube obstruction, accidental extubation, or a leaking cuff with the endotracheal tube in the submental route occur, which could endanger the patient. This paper describes the use of a LMA-Fastrach (TM) ETT in the submental endotracheal intubation of patients suffering from maxillofacial trauma. One of the patients was a 16-year-old male, and the other was a 19-year-old male. They were scheduled for an open reduction and internal fixation of the maxillofacial fracture including naso-orbital-ethmoidal (NOE) complex, and a zygomaticomaxillary complex fracture. A submental intubation with a LMA-Fastrach (TM) ETT was performed in both cases, and the operation proceeded without any difficulties. These cases show that the use of the LMA- Fastrach (TM) ETT can improve the safety and efficacy of submental endotracheal intubation. This is because the LMA- Fastrach (TM) ETT has a freely detachable connector, and is flexible enough to keep the patency despite the acute angle of airway.

A clinical study on the care of oral complications in the admission patients with major malignant tumors

Submental Intubation with a Reinforced Tube for an Intubating Laryngeal Mask Airway (ILMA) / 대한마취과학회지

Nasotracheal intubation, when performed after craniomaxillofacial trauma, may result in the passage of the tube into the cranium, causing significant brain damage. Orotracheal intubation may be preferred, but interferes with the placement of intermaxillary fixation. To avoid these problems, a tracheostomy may be an alternative but it carries significant morbidity. The submental route for endotracheal intubation has been proposed as an alternative to a tracheostomy in the surgical management of craniomaxillofacial trauma. Ideally, this maneuver is performed by using a reinforced tube. Unfortunately, however, some reinforced tracheal tubes are manufactured with nondetachable connectors. Removing them forcefully may be possible, but they will then stay dangerously loose after reconnection. We report a case in which a standard oral Ring-Adair-Elwyn (RAE) tube and reinforced tube for ILMA was used so not to be loose after the reconnection.

Body Mass Index, relative weight and Waist-hip ratio of school children and adolescents in Seoul

BACKGROUND: The purpose of this study is to obtain the accurate information on the obesity indices, such as body mass index(BMI), relative weight and waist-hip ratio(WHR) and to investigate their relationship in order to assess the childhood and adolescent obesity more appropriately. METHODS: In May, 1995, a total of 6943(male; 3469, female; 3474) students from primary, middle and high schools in Seoul were selected and each students height, weight, waist and hip circumference data were collected. RESULTS: The BMI increased with age in both sexes. From age 12 to 16, values of BMI 50th percentiles for females exceeded those for males. And the BMI 95th percentiles at the age of 13 to 14 years were higher for females than for males. The prevalence of obesity by relative weight was higher in males than in females(male ; 17.9%, female ; 13.1%). The WHR was higher in males than females in all age group and decreased with age in both sexes, showing more sharp reduction in females. Strong correlations were observed between the BMI and the relative weight, and the BMI and the relative weight correlated closely with WHR. The WHR was significanly higher in obese group' than in non-obese group. In the female obese group aged 6 to 11 years, no significant correlation was found between the relative weight and the WHR. CONCLUSIONS: There were significant relationships between the indices of obesity and body fat distribution. This study suggests that WHR as well as BMI and relative weight might be useful in assessing the childhood and adolescent obesity.

The Usefulness of Clock Drawing Test as Screening for Dementia On the basis of the correlation between clock drawing and MMSE-K

BACKGROUND: The prevalence of dementia is estimated to be as high as 11.3% among coummunity-dwelling persons over 65 years of age in Korea. The fear of dementia for both patients and families is growing because of the chronicity and progressiveness of the disease. Though the recognition, evaluation, and management of patients with dementia are important for the care of older pateint, unfortunately, MMSE takes 5 to 10 minutes to administer and is cumbersome to carry for all elderly patients in busy office. The Clock Drawing Test has been known as valid, easily administered and low cost screening procedure for the congnitive impaiment associated with dementia in general geriatric clinic population. In this study, we assessed the usefulness of this measure as a screening test for dementia, on the basis of the correlation between clock drawing and MMSE-K. METHODS: The subjects for this study consisted of 47 elderly who visited to two elderly clubs in Seoul from April 1996 through June 1996 or the outpatient department of Family medicine of the Ehwa Mok-dong hospital. They received the Mini-Mental Status Exam and the Clock Drawing test. Three observers evaluated them by ratings from 10(best) to 1(worst). Inter-rater reliability of scores from the Clock Drawing Test was assessed and Pearson correlation coefficients were used to examine the relationships between scores from the Clock Drawing Test and MMSE-K. RESULTS: Their mean age was 75.4 years with range of 65 to 91 years. There were 34 women and 13 men. Correlations between individual raters was highly significant(y=0.8939, 0.8552, and 0.8698, respectively ; P<0.01). Compared to scores on MMSE-K, rating from clock drawings by each of 3 raters revealed statistically significant correlations(y=0.7164, 0.7398, and 0.6884, respectively ; P<0.01). CONCLUSIONS: The clock drawings can be rated reliably by even untrained observers and performance on this task relates significantly to performance on MMSE-K of severity. We confirmed the usefulness of clock drawings as a simple, easily administered, low cost, and reliable general screening tool for dementia in a general geriatric clinic population.

A case of Diphyllobothrium latum infection

Human diphyllobolthriasis is chiefly caused by infection with Diphyllobothrium latum(D. latum) through eating raw or unproperly cooked fish such as salmon, trout or perch. D. latum is worldwidely distributed, but not a common parasite of humans, and its prevalence in Korea is not high. The first worm-proven case of D. latum infection was first reported in 1971 and about 30 cases have been reported in Korea until now. However, with the increasing popularity of eating raw salmon, trout and perch, this tapeworm infection tends to increase in Korea. Most of the patients infected by D. latum have not showed the specific symptoms and only non-specific gastrointestinal symptoms(anorexia, nausea, vomiting, diarrhea, abdominal pain). We report a case which includes a chain whitish, threadlike tapeworm segments spontaneously discharged in the patients stool. On reviewing the literature, the present case is the first report of D. latum infection by eating cultured salmon. The patient was treated with 600mg single dose of Praziquantel.