Application of the postnatal urinary tract dilation classification system to predict the need for surgical intervention among neonates and young infants

Purpose@#The aim of this study was to validate the postnatal urinary tract dilation (UTD) classification system by correlating it with the need for surgical intervention. @*Methods@#Young infants who underwent ultrasound (US) examinations for prenatal hydronephrosis were retrospectively identified. The kidney units (KUs; right, left, or bilateral) were graded from UTD P0 (very low risk) to P3 (high risk) based on seven US criteria from the UTD system. Surgery-free survival curves were constructed using the Kaplan-Meier method. Univariable and multivariable Cox proportional-hazards regression analysis clustered by patients was performed. Interobserver agreement was analyzed using the weighted kappa coefficient. @*Results@#In total, 504 KUs from 336 patients (mean age, 18.3±15.9 days; range, 1 to 94 days; males, n=276) were included, with a median follow-up of 24.2 months. Fifty-eight KUs underwent surgical intervention. Significant differences were observed among the Kaplan-Meier curves stratified into UTD groups (P<0.001). The presence of anterior-posterior renal pelvic diameter ≥15 mm (hazard ratio [HR], 8.602; 95% confidence interval [CI], 1.558 to 43.065), peripheral calyceal dilation (HR, 8.190; 95% CI, 1.558 to 43.065), ureteral dilation (HR, 2.619; 95% CI, 1.274 to 5.380), parenchymal thickness abnormality (HR, 3.371; 95% CI, 1.574 to 7.223), bladder abnormality (HR, 12.209; 95% CI, 3.616 to 41.225) were significantly associated with the occurrence of surgery. The interobserver agreement was moderate to almost perfect agreement for US features (κ=0.564-0.898) and substantial for final UTD grades (κ=0.716). @*Conclusion@#The UTD classification system is reliable and appropriately stratifies the risk of surgical intervention.

Bone Age Assessment Using Artificial Intelligence in Korean Pediatric Population: A Comparison of Deep-Learning Models Trained With Healthy Chronological and Greulich-Pyle Ages as Labels

Objective@#To develop a deep-learning-based bone age prediction model optimized for Korean children and adolescents and evaluate its feasibility by comparing it with a Greulich-Pyle-based deep-learning model. @*Materials and Methods@#A convolutional neural network was trained to predict age according to the bone development shown on a hand radiograph (bone age) using 21036 hand radiographs of Korean children and adolescents without known bone development-affecting diseases/conditions obtained between 1998 and 2019 (median age [interquartile range {IQR}], 9 [7–12] years; male:female, 11794:9242) and their chronological ages as labels (Korean model). We constructed 2 separate external datasets consisting of Korean children and adolescents with healthy bone development (Institution 1: n = 343;median age [IQR], 10 [4–15] years; male: female, 183:160; Institution 2: n = 321; median age [IQR], 9 [5–14] years; male:female, 164:157) to test the model performance. The mean absolute error (MAE), root mean square error (RMSE), and proportions of bone age predictions within 6, 12, 18, and 24 months of the reference age (chronological age) were compared between the Korean model and a commercial model (VUNO Med-BoneAge version 1.1; VUNO) trained with Greulich-Pyle-based age as the label (GP-based model). @*Results@#Compared with the GP-based model, the Korean model showed a lower RMSE (11.2 vs. 13.8 months; P = 0.004) and MAE (8.2 vs. 10.5 months; P = 0.002), a higher proportion of bone age predictions within 18 months of chronological age (88.3% vs. 82.2%; P = 0.031) for Institution 1, and a lower MAE (9.5 vs. 11.0 months; P = 0.022) and higher proportion of bone age predictions within 6 months (44.5% vs. 36.4%; P = 0.044) for Institution 2. @*Conclusion@#The Korean model trained using the chronological ages of Korean children and adolescents without known bone development-affecting diseases/conditions as labels performed better in bone age assessment than the GP-based model in the Korean pediatric population. Further validation is required to confirm its accuracy.

Accuracy of attenuation imaging in the assessment of pediatric hepatic steatosis: correlation with the controlled attenuation parameter

Purpose@#This study evaluated the accuracy of attenuation imaging (ATI) for the assessment of hepatic steatosis in pediatric patients, in comparison with the FibroScan vibration-controlled transient elastography controlled attenuation parameter (CAP). @*Methods@#Consecutive pediatric patients referred for evaluation of obesity who underwent both ATI and FibroScan between February 2020 and September 2021 were included. The correlation between attenuation coefficient (AC) and CAP values was assessed using the Spearman test. The AC cutoff value for discriminating hepatic steatosis corresponding to a CAP value of 241 dB/m was calculated. Multivariable linear regression analysis was performed to estimate the strength of the association between AC and CAP. The diagnostic accuracy of AC cutoffs was estimated using the imperfect gold-standard methodology based on a two-level Bayesian latent class model. @*Results@#Seventy patients (median age, 12.5 years; interquartile range, 11.0 to 14.0 years; male:female, 58:12) were included. AC and CAP showed a moderate-to-good correlation (ρ =0.646, P<0.001). Multivariable regression analysis affirmed the significant association between AC and CAP (P<0.001). The correlation was not evident in patients with a body mass index ≥30 kg/m2 (ρ=-0.202, P=0.551). Linear regression revealed that an AC cutoff of 0.66 dB/cm/MHz corresponded to a CAP of 241 dB/m (sensitivity, 0.93; 95% confidence interval [CI], 0.85 to 0.98 and specificity, 0.87; 95% CI, 0.56 to 1.00). @*Conclusion@#ATI showed an acceptable correlation with CAP values in a pediatric population, especially in patients with a body mass index <30 kg/m2. An AC cutoff of 0.66 dB/cm/MHz, corresponding to a CAP of 241 dB/m, can accurately diagnose hepatic steatosis.

Re-Assessment of Applicability of Greulich and Pyle-Based Bone Age to Korean Children Using Manual and Deep Learning-Based Automated Method

Purpose@#To evaluate the applicability of Greulich-Pyle (GP) standards to bone age (BA) assessment in healthy Korean children using manual and deep learning-based methods. @*Materials and Methods@#We collected 485 hand radiographs of healthy children aged 2–17 years (262 boys) between 2008 and 2017. Based on GP method, BA was assessed manually by two radiologists and automatically by two deep learning-based BA assessment (DLBAA), which estimated GP-assigned (original model) and optimal (modified model) BAs. Estimated BA was compared to chronological age (CA) using intraclass correlation (ICC), Bland-Altman analysis, linear regression, mean absolute error, and root mean square error. The proportion of children showing a difference >12 months between the estimated BA and CA was calculated. @*Results@#CA and all estimated BA showed excellent agreement (ICC ≥0.978, p12 months in 44.3%, 44.5%, 39.2%, and 36.1% for radiologist 1, radiologist 2, original, and modified DLBAA models, respectively. @*Conclusion@#Contemporary healthy Korean children showed different rates of skeletal development than GP standard-BA, and systemic bias should be considered when determining children’s skeletal maturation.

A Novel COL4A1 Mutation in a Neonate with Intrauterine Intraventricular Hemorrhage and Porencephaly

Collagen type IV alpha 1 (COL4A1) plays an important role in construction of the basement membranes of all human tissues, especially vessels. Mutations in COL4A1 lead to various multisystemic dysfunctions, including hereditary porencephaly, hemorrhagic stroke, hemiplegia, cerebral small vessel disease, and nephropathy. In this study, we describe a neonatal case featuring a novel de novo COL4A1 mutation, manifesting as fetal intraventricular hemorrhage and porencephaly. This patient is one of the youngest to have been diagnosed with the most severe phenotype. Our experience may assist clinicians in the diagnosis and management of this extremely rare genetic condition.

Factors That Affect the Rehabilitation Duration in Patients With Congenital Muscular Torticollis

OBJECTIVE: To determine which factors affect the rehabilitation duration in patients with congenital muscular torticollis (CMT) and to predict the duration of rehabilitation and prognosis. METHODS: One hundred and eighteen patients (79 males and 39 females) who were diagnosed with CMT and received physical therapy were enrolled in this study. We retrospectively reviewed the information in terms of sex, gestational age, birth weight, methods of delivery, fetal presentation, age at diagnosis, the affected sternocleidomastoid (SCM) muscle site, SCM muscle thickness, ratio of muscle thickness on the affected side to that on the unaffected side (called the 'abnormal/normal [A/N] ratio'), and range of motion for cervical rotation and side bending. RESULTS: The SCM muscle thickness and A/N ratio had a positive linear relationship with the rehabilitation duration. Patients who were in the breech position needed longer rehabilitation. The birth weight and age at diagnosis were negatively correlated with the rehabilitation duration. However, the cervical range of motion, mass site, sex, gestational age, and methods of delivery were not correlated with the rehabilitation duration. CONCLUSION: Patients with a thicker SCM, lower birth weight, and history of breech delivery had a longer rehabilitation duration.

Multidetector CT Findings of Bowel Transection in Blunt Abdominal Trauma

OBJECTIVE: Though a number of CT findings of bowel and mesenteric injuries in blunt abdominal trauma are described in literature, no studies on the specific CT signs of a transected bowel have been published. In the present study we describe the incidence and new CT signs of bowel transection in blunt abdominal trauma. MATERIALS AND METHODS: We investigated the incidence of bowel transection in 513 patients admitted for blunt abdominal trauma who underwent multidetector CT (MDCT). The MDCT findings of 8 patients with a surgically proven complete bowel transection were assessed retrospectively. We report novel CT signs that are unique for transection, such as complete cutoff sign (transection of bowel loop), Janus sign (abnormal dual bowel wall enhancement, both increased and decreased), and fecal spillage. RESULTS: The incidence of bowel transection in blunt abdominal trauma was 1.56%. In eight cases of bowel transection, percentage of CT signs unique for bowel transection were as follows: complete cutoff in 8 (100%), Janus sign in 6 (100%, excluding duodenal injury), and fecal spillage in 2 (25%). The combination of complete cutoff and Janus sign were highly specific findings in patients with bowel transection. CONCLUSION: Complete cut off and Janus sign are the unique CT findings to help detect bowel transection in blunt abdominal trauma and recognition of these findings enables an accurate and prompt diagnosis for emergency laparotomy leading to reduced mortality and morbidity.

Bronchopulmonary Dysplasia: New High Resolution Computed Tomography Scoring System and Correlation between the High Resolution Computed Tomography Score and Clinical Severity

OBJECTIVE: To develop an high resolution computed tomography (HRCT) scoring system for the assessment of bronchopulmonary dysplasia (BPD) and determine its usefulness as compared with the chest radiographic score. MATERIALS AND METHODS: Forty-two very low-birth-weight preterm infants with BPD (25 male, 17 female) were prospectively evaluated with HRCT performed at the mean age of 39.1-week postmenstrual age. Clinical severity of BPD was categorized as mild, moderate or severe. The HRCT score (0-36) of each patient was the sum of the number of bronchopulmonary segments with 1) hyperaeration and 2) parenchymal lesions (linear lesions, segmental atelectasis, consolidation and architectural distortion), respectively. We compared the HRCT scores with the chest radiographic scores (the Toce system) in terms of correlation with clinical severity. RESULTS: The HRCT score had good interobserver (r = 0.969, p < 0.001) and intraobserver (r = 0.986, p < 0.001) reproducibility. The HRCT score showed better correlation (r = 0.646, p < 0.001) with the clinical severity of BPD than the chest radiographic score (r = 0.410, p = 0.007). The hyperaeration score showed better correlation (r = 0.738, p < 0.001) with the clinical severity of BPD than the parenchymal score (r = 0.523, p < 0.001). CONCLUSION: We have developed a new HRCT scoring system for BPD based on the quantitative evaluation of pulmonary abnormalities of BPD consisting of the hyperaeration score and the parenchymal score. The HRCT score shows better correlation with the clinical severity of BPD than the radiographic score.

Imaging Findings of Angiomyxolipoma of the Spermatic Cord Mimicking Inguinal Hernia

We report the case in a 72-year-old man who presented with a right inguinal mass and with a one month history that was initially interpreted as an inguinal hernia. Ultrasonography (US) and computed tomography (CT) demonstrated a right inguinal mass, including myxoid and fat component, extending from the right spermatic cord to the right inguinal subcutaneous layer. Mass excision was performed, and the diagnosis turned out to be angiomyxolipoma. Angiomyxolipoma is a rare tumor and the preoperative diagnosis of this disease is very difficult. However, angiomyxolipoma of the spermatic cord should be considered in the differential diagnosis in patients with an irreducible inguinal mass. Imaging diagnosis, such as US and CT may help to make a preoperative diagnosis.

A Case of Infantile Urinary Tract Infection that Progressed to Renal Abscess Despite Early Antibi otic Treatment

Urinary tract infection (UTI) is most commonly diagnosed bacterial infection in febrile infants. Renal abscess is a very rare complication of UTI in children. Early diagnosis and treatment with appropriate antibiotics are important because renal scar correlates positively with the time of treatment. Renal ultrasonography and abdominal computerized tomography facilitates an earlier diagnosis and is also useful in establishing percutaneous drainage. Extended broad spectrum antibiotics therapy alone can be effective in most types of renal abscesses in infant, but some antibiotics-resistant cases need surgical drainage or nephrectomy. We report a case of a infant UTI, that progressed to renal abscess despite early antibiotic treatment and was treated with US guided percutaneous needle aspiration.

Sonographic Findings of Morel-Lavallee Lesions

PURPOSE: We reviewed the sonographic features of Morel-Lavallee lesions by correlating the US image findings with a lesion's age. MATERIALS AND METHODS: We obtained the sonography reports of 20 Morel-Lavallee lesions of the hip and extremities from 18 patients with a history of trauma. The US images were reviewed to characterize the echogenicity, shape, homogeneity, margins, location and size of the lesions. The results were correlated with the age of the lesions and the clinical histories. RESULTS: All the Morel-Lavallee lesions were hypoechoic or anechoic fluid collections located between the subcutaneous fat and the underlying fascia. Regarding the shape of the fluid collections, the lobular shaped lesions were all less than 21 days for the lesion's age, and the flat fluid collections were all greater than 1 month of age. Regarding the homogeneity, the heterogeneous fluid collections were all less than 25 days of age, and the homogeneous fluid collections were all greater than 1 month of age. CONCLUSION: A Morel-Lavallee lesion is seen as a posttraumatic fluid collection in the potential space between the subcutaneous fat and the underlying fascia on an ultrasound examination. Acute Morel-Lavallee lesions tended to be heterogeneous and lobular, and they became more homogeneous and flat in shape as the lesions evolved. Awareness of these imaging findings will help us to properly diagnose Morel-Lavallee lesions.

Medical radiation exposure in children and dose reduction

Medical imaging is an indispensible diagnostic tool in modern medicine enabling fast and accurate diagnosis. However, recent technological advances in medical equipment and increased utilization of the imaging modality have resulted in a significant increase in the exposure to ionizing radiation. The risk from radiation must be carefully considered in all examinations using ionizing radiation, especially in children. The risk of cancer in children from radiation exposure is higher than adults because pediatric patients are more radiosensitive and have more years ahead in which cancerous changes might occur. Therefore, pediatric protocols specifically designed for children must be used. However, many exams are still conducted using inappropriate adult protocols, which can result in excessive radiation. The most efficient way to reduce radiation is to avoid the examination if not justified. It has been suggested that one third to one half of pediatric CT exams are unnecessary or replaceable by other imaging modalities. If the exam is justified, then the parameters must be optimized to the imaging indication, scan area, body size, age, or weight of the patient according to the "as low as reasonably achievable" (ALARA) principle. The physician should always assess the radiation risk-benefit for each patient before ordering an examination using radiation.

A Case of Ascending Colon Diverticulitis with Perforation in a Child / 대한소아소화기영양학회지

A diverticulum is a blind pouch communicating with the gut. The term "diverticulitis" indicates inflammation of a diverticulum or diverticula, which is commonly accompanied by gross or microscopic perforation. Acute diverticuitis is a rare disorder in early childhood. Itis difficult to diagnose acute right colon diverticulitis from common causes of RLQ pain. We report a case of acute diverticulitis in the right colon in a 6-year-old girl. She complained of typical RLQ pain mimicking acute appendicitis,but was diagnosed with acute diverticulitis by CT scanning. Conservative treatment failed because of peritonitis due to perforation of an inflamed diverticulum. After the diverticulcetomy, the symptoms resolved.

A Case of Ascending Colon Diverticulitis with Perforation in a Child / 대한소아소화기영양학회지

A diverticulum is a blind pouch communicating with the gut. The term "diverticulitis" indicates inflammation of a diverticulum or diverticula, which is commonly accompanied by gross or microscopic perforation. Acute diverticuitis is a rare disorder in early childhood. Itis difficult to diagnose acute right colon diverticulitis from common causes of RLQ pain. We report a case of acute diverticulitis in the right colon in a 6-year-old girl. She complained of typical RLQ pain mimicking acute appendicitis,but was diagnosed with acute diverticulitis by CT scanning. Conservative treatment failed because of peritonitis due to perforation of an inflamed diverticulum. After the diverticulcetomy, the symptoms resolved.

Transcatheter Arterial Embolization of Nonvariceal Upper Gastrointestinal Bleeding with N-Butyl Cyanoacrylate

OBJECTIVE: To evaluate the clinical efficacy and safety of transcatheter arterial embolization (TAE) with N-Butyl Cyanoacrylate (NBCA) for nonvariceal upper gastrointestinal bleeding. MATERIALS AND METHODS: Between March 1999 and December 2002, TAE for nonvariceal upper gastrointestinal bleeding was performed in 93 patients. The endoscopic approach had failed or was discarded as an approach for control of bleeding in all study patients. Among the 93 patients NBCA was used as the primary embolic material for TAE in 32 patients (28 men, four women; mean age, 59.1 years). The indications for choosing NBCA as the embolic material were: inability to advance the microcatheter to the bleeding site and effective wedging of the microcatheter into the bleeding artery. TAE was performed using 1:1-1:3 mixtures of NBCA and iodized oil. The angiographic and clinical success rate, recurrent bleeding rate, procedure related complications and clinical outcomes were evaluated. RESULTS: The angiographic and clinical success rates were 100% and 91% (29/32), respectively. There were no serious ischemic complications. Recurrent bleeding occurred in three patients (9%) and they were managed with emergency surgery (n = 1) and with a successful second TAE (n = 2). Eighteen patients (56%) had a coagulopathy at the time of TAE and the clinical success rate in this group of patients was 83% (15/18). CONCLUSION: TAE with NBCA is a highly effective and safe treatment modality for nonvariceal upper gastrointestinal bleeding, especially when it is not possible to advance the microcatheter to the bleeding site and when the patient has a coagulopathy.