Topography of cerebral white-matter disease of prematurity studied prospectively in 1607 very-low-birthweight infants.

The objective of this study was to evaluate to what extent (1) the characteristics of localization, distribution, and size of echodense and echolucent abnormalities enable individuals to be designated as having either periventricular hemorrhagic infarction or periventricular leukomalacia and (2) the characteristics of periventricular hemorrhagic infarction and periventricular leukomalacia are independent occurrences. The population for this study consisted of 1607 infants with birthweights of 500 to 1500 g, born between January 1991 and December 1993, who had at least one cranial ultrasound scan read independently by at least two ultrasonographers. The ultrasound data collection form diagrammed six standard coronal views. The cerebrum was divided into 17 zones in each hemisphere. All abnormalities were described as being echodense or echolucent and were classified on the basis of their size, laterality, location, and evolution. Eight percent (134/1607) of infants had at least one white-matter abnormality. The prevalence of white-matter disease decreased with increasing gestational age. Most abnormalities were small or medium sized and unilateral; only large echodensities tended to be bilateral and asymmetric. Large abnormalities, whether echodense or echolucent, were more likely than smaller abnormalities to be widespread, and the extent of cerebral involvement was independent of whether abnormalities were unilateral or bilateral. Large abnormalities were relatively more likely than small abnormalities to involve anterior planes. Small abnormalities, whether echodense or echolucent, or whether unilateral or bilateral, preferentially occurred near the trigone. Using the characteristics of location, size, and laterality/symmetry, we were able to allocate only 53% of infants with white-matter abnormalities to periventricular hemorrhagic infarction or periventricular leukomalacia. Assuming that periventricular leukomalacia and periventricular hemorrhagic infarction are independent and do not share risk factors, and that each occurs in approximately 5% of infants, we would have expected 0.25%, or about 4 individuals, to have abnormalities with characteristics of both periventricular leukomalacia and periventricular hemorrhagic infarction, whereas we found 63 such infants. Most infants with white-matter disease could not be clearly designated as having periventricular hemorrhagic infarction or periventricular leukomalacia only. Periventricular hemorrhagic infarction contributes to the risk of periventricular leukomalacia occurrence, or the two sorts of abnormalities share common risk antecedent factors. The descriptive term echodense or echolucent and the generic term white-matter disease of prematurity should be used instead of periventricular leukomalacia or periventricular hemorrhagic infarction when referring to sonographically defined white-matter abnormalities.

Early failure of Pavlik harness treatment for developmental hip dysplasia: clinical and ultrasound predictors.

A cohort of 93 patients with developmental dysplasia of the hip (DDH) treated with a Pavlik harness were evaluated to determine predictors of treatment failure. Failure was defined as failure to achieve or maintain hip reduction in the Pavlik harness. Of 93 patients (137 hips), 17 (26 hips) failed Pavlik harness treatment. Univariate risk factors for failure included bilaterality, initial clinical exam, and initial ultrasound (US) percent coverage. Clinical exam and initial percent coverage were multivariate risk factors for failure. Among initially clinically dislocatable hips, a low initial US alpha angle correlated with an increased likelihood of failure. All (6/6) patients with an initially irreducible hip and an initial coverage of <20% by US eventually failed treatment. Gender, side of pathology, and age at diagnosis and initiation of treatment did not correlate with failure. Irreducibility by physical exam combined with US coverage of <20% identified a patient group that uniformly failed Pavlik harness treatment. These patients may be candidates for alternative bracing, traction, or closed or open reduction.

Variability of diuresis renography interpretation due to method of post-diuretic renal pelvic clearance half-time determination.

PURPOSE: We assessed variability in the interpretation of diuresis renography that may result from using different methods of clearance half-time determination. MATERIALS AND METHODS: We reviewed 152 diuresis renography studies performed at diagnosis or during followup of 53 children enrolled in a prospective study assessing the natural history of unilateral neonatal hydronephrosis. Studies were classified as nonobstructive, indeterminate or obstructive using 4 methods of half-time determination. Intermethod correlation and agreement were evaluated. We compared the proportion of nonobstructive, indeterminate and obstructive classifications by each method, and the interpretation of individual studies based on each method. RESULTS: Among methods we noted a high degree of correlation and fair to excellent agreement (Spearman rho = 0.86 to 0.92 and kappa = 0.57 to 0.86, respectively). However, in 27.8% of intermethod comparisons the proportion of studies classified as nonobstructive, indeterminate and obstructive differed significantly (p <0.05). The classification of pelvicaliceal drainage varied by method for all but the most severely dilated systems. In individual studies classification by 1 method was discordant with classification by another in 19% of comparisons. Of the discordant interpretations 97.7% involved nonobstructive versus indeterminate or indeterminate versus obstructive classifications. CONCLUSIONS: Variability in classifying drainage patterns based on half-time requires that practitioners be circumspect when applying this parameter for managing asymptomatic hydronephrosis. It also necessitates the description of quantitative methodology in published series of this important clinical problem.

Extension of academic pediatric radiology to the community setting: experience in two sites.

BACKGROUND: Children are better served by radiologists and technical personnel trained in the care of pediatric patients. However, a variety of obstacles may limit the access of children to dedicated pediatric imaging facilities. OBJECTIVE: We designed and implemented two models for providing community-based imaging by academic pediatric radiologists. MATERIALS: and methods. The first site was an outpatient clinic staffed by physicians from the university-affiliated children's hospital. Imaging services included radiography, fluoroscopy, and ultrasound. The second site was a full-service community hospital radiology department staffed by a group practice, with pediatric imaging covered by the children's hospital radiologists. Facility, equipment, and protocol modifications were required to maintain quality standards. Success of these models was determined by volume statistics, referring physician/patient satisfaction surveys, and quality-assurance (QA) programs. RESULTS: The outpatient satellite had a 48 % increase in total examinations from the first year to the second year and 87 % the third year. Pediatric examinations in the community hospital increased over 1000 % the first 7 months. Referring physicians reported increased diagnostic information and patient satisfaction compared to previous service. QA efforts revealed improved image quality when pediatric radiologists were present, but some continuing difficulties off-hours. CONCLUSION: We successfully implemented pediatric imaging programs in previously underserved communities. This resulted in increased pediatric radiologist supervision and interpretation of examinations performed on children and improved referring physician and patient satisfaction.

Small intestinal obstruction by remnants of the omphalomesenteric duct: findings on contrast enema.

OBJECTIVE: We reviewed the contrast enema examinations and medical records of six patients with small intestinal obstruction due to omphalomesenteric duct remnant to evaluate for characteristic imaging findings. RESULTS: In five out of the six patients the point of obstruction was demonstrated on the enema; in three patients, the characteristic "beak" of a volvulus was seen, either in the terminal ileum or cecum. In three patients, there was medial deviation of the cecum. CONCLUSION: The characteristic radiographic features of volvulus at the cecum or terminal ileum and medial deviation of the cecum should suggest persistence of an omphalomesenteric duct remnant as the etiology of obstruction in a child less than 2 years of age. The appearance of omphalomesenteric duct remnant obstruction on enema examination, though not specific, is characteristic and should be familiar to pediatric radiologists.

Maternal infection, fetal inflammatory response, and brain damage in very low birth weight infants. Developmental Epidemiology Network Investigators.

Echolucent images (EL) of cerebral white matter, seen on cranial ultrasonographic scans of very low birth weight newborns, predict motor and cognitive limitations. We tested the hypothesis that markers of maternal and feto-placental infection were associated with risks of both early (diagnosed at a median age of 7 d) and late (median age = 21 d) EL in a multi-center cohort of 1078 infants <1500 x g. Maternal infection was indicated by fever, leukocytosis, and receipt of antibiotic; fetoplacental inflammation was indicated by the presence of fetal vasculitis (i.e. of the placental chorionic plate or the umbilical cord). The effect of membrane inflammation was also assessed. All analyses were performed separately in infants born within 1 h of membrane rupture (n = 537), or after a longer interval (n = 541), to determine whether infection markers have different effects in infants who are unlikely to have experienced ascending amniotic sac infection as a consequence of membrane rupture. Placental membrane inflammation by itself was not associated with risk of EL at any time. The risks of both early and late EL were substantially increased in infants with fetal vasculitis, but the association with early EL was found only in infants born > or =1 after membrane rupture and who had membrane inflammation (adjusted OR not calculable), whereas the association of fetal vasculitis with late EL was seen only in infants born <1 h after membrane rupture (OR = 10.8; p = 0.05). Maternal receipt of antibiotic in the 24 h just before delivery was associated with late EL only if delivery occurred <1 h after membrane rupture (OR = 6.9; p = 0.01). Indicators of maternal infection and of a fetal inflammatory response are strongly and independently associated with EL, particularly late EL.

White matter disorders of prematurity: association with intraventricular hemorrhage and ventriculomegaly. The Developmental Epidemiology Network.

OBJECTIVES: Because intraventricular hemorrhage (IVH) often precedes the development of sonographically defined white matter damage (WMD) in very preterm infants, we sought to identify the IVH characteristics that predict WMD. HYPOTHESES: We evaluated variations on the null hypothesis that infants with IVH are no more likely than infants without IVH to have WMD. These variations dealt with characteristics of the IVH (presence or absence of ventriculomegaly) or characteristics of the WMD (size, localization, and laterality). METHODS: A total of 1605 infants weighing 500 to 1500 g at birth between January 1991 and December 1993 underwent standardized cranial ultrasound studies with 6 standard coronal and 5 sagittal views at postnatal days 1 to 3, 7 to 10, and at 3 to 8 weeks. RESULTS: A total of 129 (8%) infants had WMD, either an echodensity alone (n = 59), an echolucency alone (n = 18), or both (n = 52). In analyses that controlled for gestational age, IVH was associated with a fivefold to ninefold increased risk of WMD regardless of size, laterality, or extent of lesions (P

Comparison of sonicated albumin enhanced sonography to fluoroscopic and radionuclide voiding cystography for detecting vesicoureteral reflux.

PURPOSE: We compared sonicated albumin enhanced sonography to fluoroscopic and radionuclide voiding cystography for detecting vesicoureteral reflux. MATERIALS AND METHODS: After obtaining informed consent we enrolled in our study 20 patients with known or suspected vesicoureteral reflux and no contraindications to intravesical sonicated albumin. All patients underwent albumin enhanced sonography, following which 10 patients each underwent radionuclide and fluoroscopic voiding cystography. Reflux was graded by the observing radiologist and urologist. RESULTS: In 10 patients albumin enhanced sonography demonstrated reflux in 6 of the 7 (83%) ureters in which radionuclide cystography identified reflux. In 2 patients ultrasound studies were inadequate due to excessive movement during the procedure, and the patients were classified as unevaluable. In the remaining 10 patients 12 of 20 ureters (60%) were equal in the absence or presence of and degree of reflux on enhanced sonography and voiding cystourethrography. In 6 ureters voiding cystourethrography detected reflux more readily or revealed a higher grade of reflux. Two ureters had a higher reflux grade on enhanced sonography. No adverse effects were associated with intravesical sonicated albumin. CONCLUSIONS: In experienced hands sonicated albumin enhanced sonography is safe for evaluating vesicoureteral reflux. It provides the simultaneous evaluation of renal contours, parenchyma and size in addition to bladder visualization. This new technique may prove to be useful as a followup study in patients with previously documented reflux or as a primary study for sibling screening.

Jarcho-Levin syndrome: prenatal diagnosis, perinatal care, and follow-up of siblings.

Jarcho-Levin syndrome (JLS), spondylothoracic or spondylocostal dysostosis, is a rare entity with variable clinical severity. This syndrome is usually diagnosed in individuals with short neck, short trunk, and short stature with multiple vertebral anomalies at all levels of the vertebral column, including "butterfly vertebrae," hemivertebrae, and fused, hypoplastic vertebrae. The small size of the thorax in newborns frequently leads to respiratory compromise and death in infancy. We report a family in which the diagnosis of JLS in a 1-year-old led to prenatal ultrasound diagnosis of JLS in a sibling. Aggressive neonatal care of the sibling, who developed respiratory failure soon after birth, led to an excellent outcome. This case confirms the utility of the prenatal ultrasound diagnosis of JLS and suggests that when the diagnosis of JLS is known prenatally, appropriate preparations can be made for specialized prenatal and postnatal care that may improve survival.

Vesicoureteral reflux in children: incidence and severity in siblings.

PURPOSE: We attempted to determine the incidence of vesicoureteral reflux in asymptomatic siblings of children with reflux at different ages and assess the incidence of renal damage in asymptomatic siblings with reflux. MATERIALS AND METHODS: We reviewed radionuclide cystograms of 482 consecutively referred siblings of children with vesicoureteral reflux, including 295 girls and 187 boys 2 weeks to 12.8 years old (mean age 2.8 years). Ultrasonograms and renal cortical scintigrams of children with reflux were evaluated. All siblings were considered asymptomatic by the referring physicians. RESULTS: The overall incidence of vesicoureteral reflux was 36.5%, and the incidence in girls and boys was 39.3 and 32.1%, respectively. Children 24 months old or younger had the highest incidence (45.7%) and the highest risk of bilateral reflux. From ages 25 to 72 months the incidence of reflux was 33.1% and in siblings older than 72 months it was 7%. Reflux of urine to the level of the renal pelvis was detected in 28.6% of all referred siblings. Renal damage was observed on sonography or scintigraphy in 4.7% of the siblings with reflux. CONCLUSIONS: The high incidence of vesicoureteral reflux through age 72 months indicates that it is important to screen siblings of children with reflux at an early age to prevent renal damage, which can occur in the absence of symptomatic urinary tract infection.

Hydrocele of the spermatic cord: embryology and ultrasonographic appearance.

Five cases of hydrocele of the spermatic cord are presented. All five patients had a firm inguinal mass, and ultrasonography, performed to exclude adenopathy, incarcerated hernia, and paratesticular tumor, showed an avascular cystic mass superior to and separate from the testicle. A testicular hydrocele did not coexist. This typical appearance should lead to a confident diagnosis of this benign but rare anomaly. Elective surgery may prevent the development of an acquired indirect hernia.

Fate of the reconstructed carotid artery after extracorporeal membrane oxygenation.

Reconstruction of the right common carotid artery has been shown to be feasible in neonates after extracorporeal membrane oxygenation (ECMO). However, the long-term outcome after carotid artery reconstruction (CAR) remains unknown. The purpose of this study was to evaluate the natural progression of the anastomotic site after CAR. Between February 1990 and June 1993, 201 patients received ECMO. All veno-arterial (VA) ECMO patients (n = 172) were considered candidates for reconstruction unless a significant neurological event (ie, intracranial hemorrhage, stroke) had occurred; the duration of ECMO exceeded 10 days, making carotid mobilization difficult; or the patient's prognosis was deemed poor. Reconstruction was performed by excising the arteriotomy site, followed by primary end-to-end anastomosis. Reconstruction was abandoned and the artery ligated if an intimal flap, arterial thrombosis, or excessive tension was encountered. After reconstruction all patients had early carotid ultrasonography and either head computed tomography (CT) or magnetic resonance imaging (MRI). Subsequent ultrasound examinations were performed at approximately 6-month intervals. Diameter index (DI) (a measure of anastomotic narrowing) was calculated using ultrasound by dividing the anastomotic diameter by the diameter of the carotid artery 5 mm proximal to the anastomosis. Forty-three of 172 VA ECMO patients (25%) had successful reconstruction. Long-term follow-up data were available on 27 patients. These 27 patients had 39 ultrasound examinations, with an average follow-up time of 7.3 months (range, 4 days to 29 months). All carotid arteries were patent. Linear regression analysis showed significant improvement in the DI with time (P = .0001, r2 = .382).(ABSTRACT TRUNCATED AT 250 WORDS)

Second trimester prenatal findings in duodenal and esophageal atresia without tracheoesophageal fistula.

The combination of duodenal atresia and esophageal atresia without tracheoesophageal fistula leads to a closed loop of bowel involving the distal esophagus, stomach, and duodenum. Prenatally, this association of anomalies is visualized as a characteristic dilated C-shaped fluid collection in the fetal abdomen. We report three cases of the association of duodenal and esophageal atresia without tracheoesophageal fistula, identified sonographically in the second trimester of pregnancy.

A comparison of the perioperative neurologic effects of hypothermic circulatory arrest versus low-flow cardiopulmonary bypass in infant heart surgery.

BACKGROUND: Hypothermic circulatory arrest is a widely used support technique during heart surgery in infants, but its effects on neurologic outcome have been controversial. An alternative method, low-flow cardiopulmonary bypass, maintains continuous cerebral circulation but may increase exposure to known pump-related sources of brain injury, such as embolism or inadequate cerebral perfusion. METHODS: We compared the incidence of perioperative brain injury after deep hypothermia and support consisting predominantly of total circulatory arrest with the incidence after deep hypothermia and support consisting predominantly of low-flow cardiopulmonary bypass in a randomized, single-center trial. The criteria for eligibility included a diagnosis of transposition of the great arteries with an intact ventricular septum or a ventricular septal defect and a planned arterial-switch operation before the age of three months. RESULTS: Of 171 patients with D-transposition of the great arteries, 129 (66 of whom were assigned to circulatory arrest and 63 to low-flow bypass) had an intact ventricular septum, and 42 (21 assigned to circulatory arrest and 21 to low-flow bypass) had a ventricular septal defect. After adjustment for diagnosis, assignment to circulatory arrest as compared with low-flow bypass was associated with a higher risk of clinical seizures (odds ratio, 11.4; 95 percent confidence interval, 1.4 to 93.0), a tendency to a higher risk of ictal activity on continuous electroencephalographic (EEG) monitoring during the first 48 hours after surgery (odds ratio, 2.5; 95 percent confidence interval, 1.0 to 6.4), a longer recovery time to the first reappearance of EEG activity (only in the group with an intact ventricular septum, P < 0.001), and greater release of the brain isoenzyme of creatine kinase in the first 6 hours after surgery (P = 0.046). Analyses comparing durations of circulatory arrest produced results similar to those of analyses comparing treatments. CONCLUSIONS: In heart surgery in infants, a strategy consisting predominantly of circulatory arrest is associated with greater central nervous system perturbation in the early postoperative period than a strategy consisting predominantly of low-flow cardiopulmonary bypass. Assessment of the effect of these findings on later outcomes awaits follow-up of this cohort.

Sonography with sonicated albumin in the detection of vesicoureteral reflux.

The primary radiological procedures for diagnosing vesicoureteral reflux are fluoroscopic and radionuclide cystography. Ultrasonography, with no ionizing radiation, would be useful as a screening tool for the diagnosis of reflux due to its absence of radiation exposure. We evaluated the usefulness of ultrasonography with sonicated albumin in the diagnosis of vesicoureteral reflux. Sonicated albumin contains approximately 3 to 5 x 10(8) microspheres per ml., which are echogenic. Sonicated albumin was tested in vitro, alone, and in human and porcine urine to assess microsphere stability. Urine dilutions, specific gravity, temperature and pH were used as variables. The mode of delivery was also tested in vitro and in vivo. These studies showed that sonicated albumin microspheres were stable over a wide range of chemical variables and urine composition. Sonicated albumin produced an image of uniform echogenicity when it was pre-loaded into a Foley catheter and followed by saline infusion in vitro. Fluoroscopic cystograms, using standard radiopaque contrast media, in 5 Hanford mini-swine in which unilateral reflux had been created previously confirmed the presence of reflux unilaterally. Sonographic cystograms with various dilutions of sonicated albumin in 0.9% sodium chloride (1:100, 1:250, 1:500, 1:750 and 1:1,000) were performed. At a dilution of 1:100 sonicated albumin produced dramatic echogenicity in the bladder and refluxing ureters during sonographic imaging. The microspheres appeared to be stable for prolonged periods (more than 40 minutes), thus allowing for a careful sonographic assessment of the entire genitourinary tract. Sonicated albumin may be valuable for the sonographic detection of vesicoureteral reflux.

Ultrasonography of the female pelvis in childhood and adolescence.

The age of the patient is crucial in the consideration of differential diagnoses for pelvic disease. This is especially true in the pediatric population. Ultrasonography is the first, and often only, imaging required for female babies, children, and young adults who present with signs and symptoms referable to the pelvis. Usually, children come to attention because of pelvic mass, pelvic pain, ambiguous genitalia, or abnormal sexual development. It should be remembered that congenital anomalies may not become apparent until the onset of puberty. In all cases, good practice requires that adnexal and uterine anatomy and screening views of each kidney are documented on hard copy. Further evaluation, which consists of MR or CT scanning, depends on the results of the ultrasonograms, the clinical examination, and acuity of the problem.

Urolithiasis in a children's hospital: 1985-1990.

We performed a retrospective study of patients who had urinary tract stones and were seen at our hospital from 1985-1990. The study was intended to determine the prevalence of urolithiasis and optimal approaches to imaging. Clinical data and imaging studies of 87 patients were reviewed. The mean age was 15.7 years with a range of 3 months to 44 years. Fifty-four percent of patients were male. Most patients had a known predisposing cause for urolithiasis; patients with myelodysplasia and structural urologic problems predominated. Plain films were performed in 77 patients; 57% showed stones. Ultrasonograms were performed in 71 patients; 77% showed stones. Excretory urograms (EU) were performed in 49 patients; 84% showed either stones or their effect on the urinary tract. Computed tomographic (CT) scan was performed in 25 patients; all showed stones.

Use of ultrasonography in dysplasia of the immature hip.

Real-time ultrasonography reconstruction is an imaging technique of relatively recent origin that has dramatically affected the diagnosis and treatment of patients with hip dysplasia. Ultrasonography is replacing conventional radiography as the primary method of diagnosing hip dysplasia and evaluating its treatment during the first six to nine months of life. While conventional radiography reveals a familiar two-dimensional image of ossified structures and to a much lesser extent, soft-tissue structures, it has disadvantages that include ionizing radiation, a relative inability to evaluate unossified tissues, and an inability to gain three-dimensional information without supplemental techniques.