Implementation of ultrasound and fast magnetic resonance imaging pathway reduces computed tomography utilization in children with suspected appendicitis.

PURPOSE: Computed tomography (CT) is still used in the imaging diagnosis of acute appendicitis in children at many hospitals. We implemented an ultrasound (US) and fast magnetic resonance imaging (MRI) pathway for suspected appendicitis at our institution with the goal of reducing radiation exposure in children. METHODS: All children (< 18 years old) who underwent appendectomy between January 2011 and July 2021 were reviewed. Data were collected on all imaging studies performed. In December 2015, we initiated an imaging pathway for suspected acute appendicitis. US was the initial imaging study, and a rapid protocol MRI was performed if US was equivocal. Those could not tolerate MRI underwent CT. We evaluated the difference in percentage of patients who underwent CT before and after pathway initiation. RESULTS: 554 patients who underwent appendectomy did not have prior imaging studies on presentation to our hospital and were included in analysis. After initiating the pathway, the use of abdominal US increased from 87% (220 of 254) to 97% (291 of 300, p < 0.0001) and the use of MRI increased by 100% (0 MRIs pre-protocol, 90 of 300 patients post-protocol, p < 0.0001). CT utilization decreased significantly from 32% (82 of 254) to 2% (6 of 300, p < 0.0001). CONCLUSION: Embracing a new US and rapid MRI pathway to evaluate pediatric patients with suspected acute appendicitis resulted in significant reduction in CT utilization and therefore radiation exposure.

Normal 24-hour urine calcium concentrations after long-term daily oral intake of vitamin D in doses ranging from 5000 to 50,000 international units in 14 adult hospitalized psychiatric patients.

Many controversies exist regarding vitamin D3 supplementation. These include not only diseases that are responsive to vitamin D supplementation, but also the long-term safety of prolonged daily oral vitamin D3 intake above 4000-10,000 International Units (IU). In particular, supplementation levels that do not result in adverse events, and the upper limits of safe serum 25-hydroxyvitamin D (25OHD) concentrations. Adverse reactions reported to occur with excessive vitamin D intake include hypercalcemia, renal failure, calcium crystal formation, undetectable parathyroid hormone concentrations, and hypercalciuria, all of which are reported to be reversible. To address the long-term safety of vitamin D supplementation, we previously reported data from patients in our hospital who have been voluntarily supplemented with vitamin D3 ranging from 5,000 to 10,000 IU/day since July 2011 as a standard of care for the prevention and treatment of vitamin D deficiency. Historically 90% of patients have agreed to daily supplementation, with most taking 10,000 IU/day. These data indicate no evidence for hypercalcemia, renal failure, calcium crystal formation, nephrolithiasis. or undetectable parathyroid hormone concentrations in patients taking 5000 or 10,000 IU/day for extended periods of time. As another measure for potential vitamin D toxicity, we retrospectively assessed 24-hour urine calcium excretion in 14 individuals on long-term daily oral vitamin D intake ranging from 5000 to 50,000 IU/day to further assess the safety of supplementation using these doses. This included patients taking either 5000 (4), 10,000 (9), or 50,000 (1) IU/day. Time on supplementation ranged from 10 to 102 months. A patient taking 400 IU/day and getting frequent sun exposure was also included. All fifteen 24-hour urine calcium measurements were normal. The current findings complement our experience with over 7000 patients in the past 13 years, indicating that prolonged daily oral intake of vitamin D3 ranging from 5000 to 10,000 IU/day is safe.

Oral and Topical Vitamin D, Sunshine, and UVB Phototherapy Safely Control Psoriasis in Patients with Normal Pretreatment Serum 25-Hydroxyvitamin D Concentrations: A Literature Review and Discussion of Health Implications.

Vitamin D, sunshine and UVB phototherapy were first reported in the early 1900s to control psoriasis, cure rickets and cure tuberculosis (TB). Vitamin D also controlled asthma and rheumatoid arthritis with intakes ranging from 60,000 to 600,000 International Units (IU)/day. In the 1980s, interest in treating psoriasis with vitamin D rekindled. Since 1985 four different oral forms of vitamin D (D2, D3, 1-hydroxyvitaminD3 (1(OH)D3) and 1,25-dihydroxyvitaminD3 (calcitriol)) and several topical formulations have been reported safe and effective treatments for psoriasis-as has UVB phototherapy and sunshine. In this review we show that many pre-treatment serum 25(OH)D concentrations fall within the current range of normal, while many post-treatment concentrations fall outside the upper limit of this normal (100 ng/mL). Yet, psoriasis patients showed significant clinical improvement without complications using these treatments. Current estimates of vitamin D sufficiency appear to underestimate serum 25(OH)D concentrations required for optimal health in psoriasis patients, while concentrations associated with adverse events appear to be much higher than current estimates of safe serum 25(OH)D concentrations. Based on these observations, the therapeutic index for vitamin D needs to be reexamined in the treatment of psoriasis and other diseases strongly linked to vitamin D deficiency, including COVID-19 infections, which may also improve safely with sufficient vitamin D intake or UVB exposure.

MRI in verrucous venous malformation: role in diagnosis and treatment.

Verrucous venous malformation (VVM), recently reclassified from verrucous hemangioma, is a rare congenital vascular anomaly that is traditionally diagnosed on histopathologic analysis of deep tissue biopsy. This case report documents the utility of magnetic resonance imaging in confirming VVM diagnosis, characterizing lesion extent and guiding therapy.

Vascular anomaly imaging mimics and differential diagnoses.

Vascular anomalies can be correctly diagnosed in the majority of instances using the combination of clinical history, physical examination and imaging. In certain cases, the clinical work-up may be inconclusive or unavailable to the radiologist, and the imaging findings can be nonspecific, yielding more than one possible diagnosis. In this pictorial essay, we discuss diagnoses that can mimic vascular anomalies and highlight key differentiating imaging features.

Embryonal rhabdomyosarcoma of the biliary tree: A rare cause of obstructive jaundice in children which can mimic choledochal cysts.

Jaundice in children is more often due to hepatic disease than obstruction. Differential considerations for obstructive jaundice in children include choledocholithiasis, choledochal cysts and rare neoplasms. Rhabdomyosarcoma, the most common soft tissue sarcoma in pediatric patients, typically involves the head and neck, genitourinary system and extremities. Embryonal rhabdomyosarcoma of the biliary tree is a rare entity. We present a 3-year-old boy with abrupt onset obstructive jaundice. Although initial imaging suggested a dilated biliary system with fusiform common bile duct, sludge, and possible cholelithiasis, endoscopic retrograde cholangiopancreatogram (ERCP) diagnosed a common bile duct embryonal rhabdomyosarcoma and further imaging showed involvement of the cystic duct. This case illustrates the importance of considering malignant etiologies in cases of obstructive jaundice, particularly when imaging is not classic for common causes.

Dual-energy compared to single-energy CT in pediatric imaging: a phantom study for DECT clinical guidance.

BACKGROUND: Dual-energy CT technology is available on scanners from several vendors and offers significant advantages over classic single-energy CT technology in multiple clinical applications. Many studies have detailed dual-energy CT applications in adults and several have evaluated the relative radiation dose performance of dual-energy CT in adult imaging. However, little has been published on dual-energy CT imaging in the pediatric population, and the relative dose performance of dual-energy CT imaging in the pediatric population is not well described. OBJECTIVE: When evaluating dual-energy CT technology for implementation into a routine clinical pediatric imaging practice, the radiation dose implications must be considered, and when comparing relative CT dose performance, image quality must also be evaluated. Therefore the purpose of this study is to develop dual-energy CT scan protocols based on our optimized single-energy scan protocols and compare the dose. MATERIALS AND METHODS: We scanned the head, chest and abdomen regions of pediatric-size anthropomorphic phantoms with contrast inserts, using our optimized single-energy clinical imaging protocols on a Siemens Flash® CT scanner. We then scanned the phantoms in dual-energy mode using matching image-quality reference settings. The effective CT dose index volume (CTDIvol) of the scans was used as a surrogate for relative dose in comparing the single- and dual-energy scans. Additionally, we evaluated image quality using visual assessment and contrast-to-noise ratio. RESULTS: Dual-energy CT scans of the head and abdomen were dose-neutral for all three phantoms. Dual-energy CT scans of the chest showed a relative dose increase over the single-energy scan for 1- and 5-year-old child-based age-equivalent phantoms, ranging 11-20%. Quantitative analysis of image quality showed no statistically significant difference in image quality between the single-energy and dual-energy scans. There was no clinically significant difference in image quality by visual assessment. CONCLUSION: Dual-energy CT is dose-neutral in imaging the head and abdomen in children. It is not dose-neutral in chest imaging of very small children. With a better understanding of the dose consequences of converting single-energy protocols to dual-energy protocols we can begin to implement clinical dual-energy CT and utilize its unique capabilities in pediatric imaging.

Comprehensive analysis of gene-environmental interactions with temporal gene expression profiles in Pseudomonas aeruginosa.

To explore gene-environment interactions, based on temporal gene expression information, we analyzed gene and treatment information intensively and inferred interaction networks accordingly. The main idea is that gene expression reflects the response of genes to environmental factors, assuming that variations of gene expression occur under different conditions. Then we classified experimental conditions into several subgroups based on the similarity of temporal gene expression profiles. This procedure is useful because it allows us to combine diverse gene expression data as they become available, and, especially, allowing us to lay the regulatory relationships on a concrete biological basis. By estimating the activation points, we can visualize the gene behavior, and obtain a consensus gene activation order, and hence describe conditional regulatory relationships. The estimation of activation points and building of synthetic genetic networks may result in important new insights in the ongoing endeavor to understand the complex network of gene regulation.

Maternal ethnicity influences on neonatal respiratory outcomes after antenatal corticosteroid use for anticipated preterm delivery.

OBJECTIVE: To explore the influence of maternal ethnicity on neonatal outcomes after antenatal corticosteroid administration. METHODS: A retrospective review of ethnicity, maternal factors, and neonatal birth outcomes was performed for preterm births at a single institution. Cases were limited to women who received antenatal corticosteroids. The impact of ethnicity on specific neonatal respiratory outcomes and mortality was analyzed by bivariate comparisons and by logistic regression analysis. RESULTS: Complete ethnicity data were obtained for 548 women. Controlling for gestational age at delivery, diabetes, whether the subject completed a course of steroids, and the dosing of the steroids, logistic regression demonstrated that ethnicity was independently associated with respiratory distress syndrome (compared to Caucasians: African-Americans OR 0.49 (95% CI 0.29-0.85); Filipinos OR 0.45 (95% CI 0.21-0.96). CONCLUSIONS: Ethnicity is independently associated with neonatal respiratory outcomes after antenatal corticosteroid use. Perhaps individualized dosing of antenatal corticosteroids is needed to further improve neonatal outcomes.

The first 48 hours: Comparing 12-hour and 24-hour betamethasone dosing when preterm deliveries occur rapidly.

OBJECTIVE: To compare neonatal outcomes when dosing betamethasone every 12 hours compared to the standard 24-hour dosing regimen when premature deliveries occur within 48 hours of presentation. METHODS: A retrospective chart review was performed on preterm deliveries from January 1, 1996 to July 1, 2000. Deliveries that occurred less than 48 hours after initiation of antenatal steroids were analyzed for neonatal outcomes. RESULTS: Betamethasone was given to 562 women, of whom 166 delivered less than 48 hours after beginning therapy. There were no statistically significant differences in the rates of respiratory distress syndrome, surfactant use, chronic lung disease, intraventricular hemorrhage, neonatal death, or other outcomes between the two groups. The only statistically significant difference between the two groups was for venous cord blood pH (7.27 vs. 7.32, p = 0.01). Separating the results into delivery from 0-24 and 24-48 hour groups, there were no significant differences between the 12-hour and 24-hour dosing groups, although small sample size limited conclusions. CONCLUSION: Dosing betamethasone in 12-hour intervals may result in similar neonatal outcomes compared to the standard 24-hour regimen when delivery occurs within 48 hours of therapy initiation.

Neonatal outcomes with different betamethasone dosing regimens: a comparison.

OBJECTIVE: To determine any differences in neonatal outcomes when dosing betamethasone every 12 hours vs. 24 hoursfor anticipated preterm delivery. STUDY DESIGN: A retrospective review of births at <36 weeks' gestation from January 1, 1996, to July 1, January 1, 1996, to July 1, 2000. Maternal and neonatal charts were reviewed. The deliveries were separated into 3 groups: those not receiving antenatal corticosteroids, those who received betamethasone 12 hours apart and those who received 24-hour dosing. Demographic, obstetric and neonatal variables were compared between the groups. RESULTS: There were 909 deliveries analyzed. With the 2 betamethasone groups, a significant difference was found for more maternal antibiotic use (90.4% vs. 83.6%, p=0.03), venous cord blood gas pH (7.31 vs. 7.32, p=0.04) and neonatal surfactant use (39.8% vs. 25.5%, p = 0.001) in the 12-hour group as compared to the 24-hour group. For all other outcomes there was no difference. CONCLUSION: Outcomes using a 12-hour dosing schedule of betamethasone were similar to those using a 24-hour regimen in this retrospective review. Twelvehour dosing could be considered an alternative way to deliver antenatal corticosteroids.