Evaluation of Diaphragmatic Thickness and Dysfunction by Ultrasonography in Mechanically Ventilated Children for Assessment of Extubation Success

Objectives: This study aimed to evaluate diaphragm thickness (DT) and diaphragmatic thickening fraction (DTF) in mechanically ventilated children, and study the association of these measurements with extubation success. Methods: Consecutive children aged one month to 18 years, who required mechanical ventilation (MV) for more than 24 hours at our institution, were enrolled between April, 2019 to October, 2020. Ultrasonographic measurements of DT were documented, and DTF was calculated from baseline (within 24 hours of MV) until 14 days of MV, and up to three days post-extubation. Results: Of the 54 childrenenrolled, 40 underwent planned extubation trial, of which 9 (22.5%) had extubation failure. Pre-extubation and post-extubation DTF between children in extubation-success and extubation-failure groups were comparable (P=0.074). There was no significant difference in the diaphragm atrophy rate between the two groups (P=0.819). Binary logistic regression showed significantly decreased probability of successful extubation with total ventilation duration (P=0.012) and mean DTF% before extubation (P=0.033). Conclusion: Despite evidence of diaphragmatic atrophy in critically ill children receiving mechanical ventilation, there was no significant difference in DTF between extubation success and failure groups.

Point-of-Care Thoracic Ultrasound in Children with Bronchiolitis

Objective To characterize thoracic (lung and diaphragm) ultrasound fndings in children<2 y with bronchiolitis, evaluate correlation between lung ultrasound severity score (USS) and bronchiolitis severity score (BSS), and study the interobserver agreement of USS between study pediatrician and radiologist. Methods In this prospective observational study, thoracic ultrasound was performed on children with bronchiolitis by the study pediatrician and USS score was assigned. A radiologist blinded to all clinical information, performed an independent thoracic ultrasound. Demographics, clinical course, and other relevant details were recorded. Results Fifty-three children were enrolled; 29/53 patients (54.7%) were classifed as mild bronchiolitis and 24/53 (45.2%) had moderate bronchiolitis as per clinical score; 13.2% (7/53) patients had both anterior and posterior subpleural consolidation and went on to require higher respiratory support either in the form of continuous positive airway pressure in 71.4% (5/7), oxygen for>24 h in 14.2% (1/7), or heated humidifed high-fow nasal cannula in 14.2% (1/7). These results were statistically signifcant (p<0.001). A statistically signifcant correlation was found between the USS and type and duration of respiratory support (p value 0.002) and with the mean duration of hospital stay (p value<0.001). There was signifcant correlation between the BSS and USS (p<0.001). There was a very good agreement between the ultrasound fndings of study pediatrician and radiologist (kappa 0.83). Conclusion The fndings of lung ultrasound (LUS) are not specifc for bronchiolitis. However, LUS can be used as a good prognostic tool in patients with bronchiolitis.

Neuroendocrine tumors of the urinary bladder - Report of two cases

Primary paraganglioma and small cell neuroendocrine carcinoma of the urinary bladder are rare tumors, comprising 0.05% of all bladder tumors and <1% of all malignant bladder tumors, respectively. These tumors can be the cause of a diagnostic dilemma or misdiagnosis on morphology. Paraganglioma is often mistaken for urothelial carcinoma and small cell carcinoma for poorly differentiated carcinoma or lymphoma. Herein, we report a case of primary paraganglioma and another of a small cell carcinoma of the urinary bladder and discuss their closest differential diagnoses. The diagnostic pitfalls should be kept in mind so that correct, timely diagnosis of these entities can be made due to implications in the management and prognosis.

Epithelioid angiomyolipoma with tumor thrombus in IVC and right atrium

Epithelioid angiomyolipoma is an uncommon subtype of renal angiomyolipoma associated with potentially malignant behavior and is considered a distinct entity by the World Health Organization classification of renal tumors. We present a case of an epithelioid variant of angiomyolipoma with extension into the renal vein, inferior vena cava reaching up to the right atrium. Pre-operatively, a diagnosis of renal cell carcinoma was considered based on imaging findings. Intra-operatively due to extensive adhesions, surgical resection was not performed and only tissue sampling was performed for histopathology. Microscopic examination revealed short fascicles of spindle cells and perivascular epithelioid cells. A differential diagnosis of renal cell carcinoma with sarcomatoid differentiation was considered. The immunohistochemical profile showed tumor cells that express Melan-A and smooth muscle actin, while they were negative for pan-cytokeratin, PAX8, CK7, CD117 and CD34. Therefore a diagnosis of epithelioid angiomyolipoma was rendered. The presence of intravascular thrombi on radiological investigation and carcinoma-like growth pattern on light microscopy may compound an erroneous diagnosis of renal cell carcinoma. Hence, it is prudent for the urologist to consider differential diagnosis other than renal cell carcinoma when confronted with a renal neoplasm presenting with intravascular thrombi. In these cases, a core biopsy should be planned pre-operatively and diagnosis should be made with aid of appropriate immunohistochemical markers.

Pancreatic Incidentalomas:Review and Current Management Recommendations

There has been significant increase in the detection of incidental pancreatic lesions due to widespread use of cross-sectional imaging like computed tomography and magnetic resonance imaging supplemented with improvements in imaging resolution. Hence, accurate diagnosis (benign, borderline, or malignant lesion) and adequate follow-up is advised for these incidentally detected pancreatic lesions. In this article, we would review the various pancreatic parenchymal (cystic or solid) and ductal lesions (congenital or pathological), discuss the algorithmic approach in management of incidental pancreatic lesions, and highlight the key imaging features for accurate diagnosis