Normal pediatric values of carotid artery intima-media thickness measured by B-mode ultrasound and radiofrequency echo tracking respecting the consensus: a systematic review.

BACKGROUND: Carotid artery intima-media thickness (IMT) is a sub-clinical radiologic marker of atherosclerosis in children. It is associated with adult-onset vascular disease. OBJECTIVE: To determine normal pediatric values of IMT from results observed in the literature. METHODS: Our systematic review was conducted according to PRISMA guidelines. We reviewed 2298 English articles from inception to February 2023. Inclusion criteria included studies evaluating B-mode and radiofrequency (RF)-based IMT measurements based on the American Heart Association, the Association for European Pediatric Cardiology, the Mannheim Consensus, and the American Society of Echocardiography recommendations. A meta-analysis of aggregate data was conducted to obtain the confidence interval (CI) for IMT, using a 95% confidence level. RESULTS: We obtained 88 B-mode-based IMT measurement studies with 6184 children and six radiofrequency echo-tracking-based studies with 766 children. Mean IMT in the pediatric population was 0.43 mm, 95% [CI] 0,42 to 0.44, using the B-mode technique, and 0.41 mm, 95% [CI] 0.36 to 0.45 using the radiofrequency technique. No significant relationship was detected between IMT and age (p value = 0.83). Finally, no significant effect of sex on IMT was found (p value = 0.82 for B-mode and p value = 0.62 for RF). CONCLUSION: Based on the studies selected in this literature review, we were unable to conclude that there was a significant difference between the average IMT of boys and girls. No relationship was demonstrated between age and IMT. IMT is technique-specific, and normal values should be interpreted according to recommendations of recognized consensus to counteract the current heterogeneity in literature. CLINICAL RELEVANCE STATEMENT: Technique and children-specific Intima media thickness measurements help clinicians and scientists to assess the risk of atherosclerosis in children. KEY POINTS: • Intima-media thickness (IMT) does not correlate with age in children without risk factors. • According to current literature, there is no difference in IMT between healthy boys and girls. • There is heterogeneity, even with studies abiding by the official consensus.

Understanding the diagnosis of superior mesenteric artery syndrome: analysis of the location of duodenal impression on upper gastrointestinal studies.

BACKGROUND: Upper gastrointestinal (GI) contrast studies are frequently requested to aid superior mesenteric artery syndrome diagnosis, a rare entity. Compression of the third duodenal part is expected to be mid-to-left of the midline where the superior mesenteric artery arises from the aorta; however, a duodenal impression to the right of the midline due to normal anatomic impression by the inferior vena cava (IVC) is often encountered and frequently misdiagnosed. OBJECTIVE: The purpose of this study was to determine the frequencies of (1) normal right-of-midline duodenal impressions and (2) mid-to-left of midline compressions in upper GI studies in a tertiary pediatric referral center. MATERIALS AND METHODS: All upper GI studies performed at our institution over 2 years were retrospectively evaluated to determine whether the duodenum had vertical duodenal impression to the right of the vertebral midline, mid-to-left of the vertebral midline, or no identifiable duodenal impression at all. RESULTS: In total, 538 upper GI studies were included in this analysis. A total of 275 male and 247 female patients between 0 and 17 years of age (median: 6 years, range: 1 month-17 years) were included. Of 538 total upper GI studies, there were 240 studies (44.6%) with a right-of-midline impression. There were only 10 studies (1.9%) with a mid-to-left of midline compression, and 9/10 also showed a concurrent right-sided impression sign. CONCLUSION: Right-of-midline duodenal impression is a normal anatomic finding caused by the IVC and should not be confused with superior mesenteric artery syndrome. In the presence of an appropriate clinical context, proximal duodenal dilation, "to-and-fro" motion of contrast, and duodenal impression at mid-to-left of midline, a diagnosis of superior mesenteric artery syndrome should be considered.

Non-Invasive Vascular Elastography as a One-Step Imaging Technique to Evaluate Early Vascular Changes in Children Compared to B-Mode-Based Intima-Media Thickness Technique : A Validation Study Using Inter- and Intra-Rater Reliability.

Background: Childhood obesity is linked to higher adult mortality and morbidity from atherosclerosis. It is primordial to detect at-risk children earlier-on to prevent disease progression. Carotid intima-media thickness (IMT) is a subclinical radiological marker for early atherosclerosis. B-mode ultrasound is a known technique to assess IMT, but no gold standard technique exists in children. Non-invasive vascular elastography (NIVE) using speckle statistics is an innovative alternative to evaluate IMT and adds by providing translation, strain and shear strain measurements. Validation studies for both techniques lack in children. Purpose: Validate the reproducibility of the 2 techniques in Canadian children. Methods: We conducted a prospective study where anthropometry, blood pressure, IMT and elastography were measured. Six operators obtained 2 measurements for both carotid arteries using both techniques, for a total of 720 measurements. Inter- and intra-class correlation coefficients (ICC) were calculated for each measurement technique and elastography parameters. Results: 30 participants (13.0 ± 1.26 years, 17 girls) were recruited. Twelve were overweight. No significant difference was found in mean IMT between weight groups for either technique (P = .15 and P = .60). We found excellent inter- (ICC = .98 [95% Confidence Interval (CI): .97; .99]) and intra- (ICC = .90-.93) operator reliability for the B-mode technique, and good inter (ICC = .70 [95% CI: .47; .85]) and intra- (ICC = .71-.91) operator reliability for the NIVE-based technique. Poor reliability was found between techniques (ICC = .30 [95% CI: -.31; .65). For elastography parameters, translation was the most reliable (ICC = .94-.95). Conclusion: IMT measurement is reproducible in children but not between techniques. NIVE gives the advantage of evaluating elastography.

Stakeholders' perspectives on the future of artificial intelligence in radiology: a scoping review.

OBJECTIVES: Artificial intelligence (AI) has the potential to impact clinical practice and healthcare delivery. AI is of particular significance in radiology due to its use in automatic analysis of image characteristics. This scoping review examines stakeholder perspectives on AI use in radiology, the benefits, risks, and challenges to its integration. METHODS: A search was conducted from 1960 to November 2019 in EMBASE, PubMed/MEDLINE, Web of Science, Cochrane Library, CINAHL, and grey literature. Publications reflecting stakeholder attitudes toward AI were included with no restrictions. RESULTS: Commentaries (n = 32), surveys (n = 13), presentation abstracts (n = 8), narrative reviews (n = 8), and a social media study (n = 1) were included from 62 eligible publications. These represent the views of radiologists, surgeons, medical students, patients, computer scientists, and the general public. Seven themes were identified (predicted impact, potential replacement, trust in AI, knowledge of AI, education, economic considerations, and medicolegal implications). Stakeholders anticipate a significant impact on radiology, though replacement of radiologists is unlikely in the near future. Knowledge of AI is limited for non-computer scientists and further education is desired. Many expressed the need for collaboration between radiologists and AI specialists to successfully improve patient care. CONCLUSIONS: Stakeholder views generally suggest that AI can improve the practice of radiology and consider the replacement of radiologists unlikely. Most stakeholders identified the need for education and training on AI, as well as collaborative efforts to improve AI implementation. Further research is needed to gain perspectives from non-Western countries, non-radiologist stakeholders, on economic considerations, and medicolegal implications. KEY POINTS: Stakeholders generally expressed that AI alone cannot be used to replace radiologists. The scope of practice is expected to shift with AI use affecting areas from image interpretation to patient care. Patients and the general public do not know how to address potential errors made by AI systems while radiologists believe that they should be "in-the-loop" in terms of responsibility. Ethical accountability strategies must be developed across governance levels. Students, residents, and radiologists believe that there is a lack in AI education during medical school and residency. The radiology community should work with IT specialists to ensure that AI technology benefits their work and centres patients.

Quality Assurance and Performance Improvement Project for Suspected Appendicitis.

INTRODUCTION: Considerable variability exists in the diagnosis and management of acute appendicitis, affecting both quality and costs of care. This prospective cohort study aimed to decrease unnecessary radiological investigations, standardize radiological imaging, avoid unnecessary hospital admissions, and decrease our institution rate of negative appendectomy. METHODS: A multidisciplinary appendicitis care pathway was implemented. This pathway involved the use of the Pediatric Appendicitis Score, standardization of ultrasound reporting, and risk stratification to determine patient disposition. Patients were prospectively enrolled in the pathway and compared a preimplementation retrospective cohort. RESULTS: We included 235 patients in this study that took place between February 2017 and January 2018. An 88.5% pathway adherence rate for appropriate referral for ultrasounds, an 84% compliance rate for correct risk stratification, and the need for a surgical consult were achieved. After implementation, standardization of ultrasound (U/S) reporting increased from 0% to 78%. The rate of computed tomography utilization decreased from 7.3% to 4.7%. An appendectomy was completed in 68 (29%) of patients. There was only 1 (1.5%) negative appendectomy, compared to the prepathway institutional negative appendectomy rate of 4%. CONCLUSION: The implementation of a standardized, evidence-based, appendicitis care pathway has the potential to improve quality of care by reducing negative appendectomies, unnecessary computed tomography scans, and unnecessary hospital admissions. The participation of the emergency and diagnostic imaging departments is critical to the successful implementation of this quality improvement measure. This simple, effective model can be easily implemented at other centers to improve the care of children.

Anterior Ischemic Optic Neuropathy in a Child Receiving Chronic Hemodialysis.

Anterior ischemic optic neuropathy (AION) occurs due to hypoperfusion of the optic nerve and is a rare complication in patients receiving maintenance dialysis. To date, AION has only been reported in 22 children, all of whom were receiving peritoneal dialysis. We report the first case of AION in a 2-year 11-month-old child receiving chronic hemodialysis secondary to polycystic kidney disease from a phosphomannomutase 2 gene mutation. This case highlights the consideration for frequent blood pressure monitoring and ophthalmic screening in a certain cohort of children receiving chronic dialysis.

Conservative management of neonatal cerebral sinovenous thrombosis with coexisting thrombophilia.

: Neonatal cerebral sinovenous thrombosis (CSVT) comprises approximately 50% of all pediatric-related CSVT. Although guidelines support anticoagulation in pediatric CSVT, the role of anticoagulation in neonatal CSVT remains controversial. This case report details the course of a neonate diagnosed with extensive CSVT and concurrent bilateral thalamic and intraventricular hemorrhage. Due to existing hemorrhage at the time of diagnosis, anticoagulation therapy was not administered. Despite coexisting protein C and antithrombin deficiency, CSVT resolved spontaneously, and neurodevelopmental follow-up after 13 years suggests a good prognosis. Although our case had a positive outcome, the association between the use of anticoagulation with concurrent hemorrhage and long-term outcome in neonatal CSVT has not been investigated in prospective studies to firmly guide optimum treatment. Current literature and guidelines for the treatment of neonatal CSVT are reviewed in this article. Until robust studies are available, expert opinion recommends anticoagulation in a stable neonate with CSVT.

Synthesis, characterisation and in vitro cytotoxicity of mixed ligand Pt(ii) oxadiazoline complexes with hexamethylenetetramine and 7-nitro-1,3,5-triazaadamantane.

trans-Platinum(ii) oxadiazoline complexes with 7-nitro-1,3,5-triazaadamantane (NO2-TAA) or hexamethylenetetramine (hmta) ligands have been synthesised from trans-[PtCl2(PhCN)2] via cycloaddition of nitrones to one of the coordinated nitriles, followed by exchange of the other nitrile by NO2-TAA or hmta. Stoichiometric control allows for the selective synthesis of mono- and dinuclear complexes where 7-NO2TAA and hmta act as mono- and bidentate ligands, respectively. Precursors and the target complexes trans-[PtCl2(hmta)(oxadiazoline)], trans-[PtCl2(NO2-TAA)(oxadiazoline)] and trans-[{PtCl2(oxadiazoline)}2(hmta)] were characterised by elemental analysis, IR and multinuclear (1H, 13C, 195Pt) NMR spectroscopy. DFT (B3LYP/6-31G*/LANL08) and AIM calculations suggest a stronger bonding of hmta with the [PtCl2(oxadiazoline)] fragment, in agreement with the experimentally observed reactivity in the ligand exchange (hmta > 7-NO2TAA). Replacement of the nitrile by hmta is predicted to be more exothermic than that with 7-NO2-TAA, although the activation barriers are similar. Protonation of the non-coordinated N atoms is anticipated to weaken the Pt-N bond and lower the activation barrier for ligand exchange. This effect might help activate these compounds in a slightly acidic environment such as some tumour tissues. Ten of the new compounds were tested for their in vitro cytotoxicity in the human cancer cell lines HeLa and A549. Some of the mononuclear complexes are more potent than cisplatin, and their activity is still high in A549 where cisplatin shows little effect. The dinuclear complexes are inactive, presumably due to their lipophilicity and reduced solubility in water.

Analysis of surgical and MRI factors associated with cerebellar mutism.

The surgical risk factors and neuro-imaging characteristics associated with cerebellar mutism (CM) remain unclear and require further investigation. Therefore, we aimed to examine surgical and MRI findings associated with CM in children following posterior fossa tumor resection. Using our data registry, we retrospectively collected data from pediatric patients who acquired CM and were matched based on age and pathology type with individuals who did not acquire CM after posterior fossa surgery. The strength of association between surgical and MRI variables and CM were examined using odds ratios (ORs) and corresponding 95% confidence intervals (CIs). A total of 22 patients (11 with and 11 without CM) were included. Medulloblastoma was the most common pathology among CM patients (91%); the remaining 9% were diagnosed with a pilocytic astrocytoma. Tumor attachment to the floor of the fourth ventricle (OR 6; 95% CI 0.7-276), calcification/hemosiderin deposition (OR 7; 95% CI 0.9-315.5), and post-operative peri-ventricular ischemia on MRI (OR 5; 95% CI 0.5-236.5) were found to have the highest measures of association with CM. Our results may suggest that tumor attachment to the floor of the fourth ventricle, pathological calcification, and post-operative ischemia have a relatively higher prevalence in patients with CM. Collectively, our work calls for a larger multi-institutional cohort study of CM patients to encourage further investigation of the determinants and management of CM in order to potentially minimize its development and predict onset.

Six of one, half a dozen of the other: A measure of multidisciplinary inter/intra-rater reliability of the society for fetal urology and urinary tract dilation grading systems for hydronephrosis.

INTRODUCTION: The urinary tract dilation (UTD) classification system was introduced to standardize terminology in the reporting of hydronephrosis (HN), and bridge a gap between pre- and postnatal classification such as the Society for Fetal Urology (SFU) grading system. Herein we compare the intra/inter-rater reliability of both grading systems. MATERIALS AND METHODS: SFU (I-IV) and UTD (I-III) grades were independently assigned by 13 raters (9 pediatric urology staff, 2 nephrologists, 2 radiologists), twice, 3 weeks apart, to 50 sagittal postnatal ultrasonographic views of hydronephrotic kidneys. Data regarding ureteral measurements and bladder abnormalities were included to allow proper UTD categorization. Ten images were repeated to assess intra-rater reliability. Krippendorff's alpha coefficient was used to measure overall and by grade intra/inter-rater reliability. Reliability between specialties and training levels were also analyzed. RESULTS: Overall inter-rater reliability was slightly higher for SFU (α = 0.842, 95% CI 0.812-0.879, in session 1; and α = 0.808, 95% CI 0.775-0.839, in session 2) than for UTD (α = 0.774, 95% CI 0.715-0.827, in session 1; and α = 0.679, 95% CI 0.605-0.750, in session 2). Reliability for intermediate grades (SFU II/III and UTD 2) of HN was poor regardless of the system. Reliabilities for SFU and UTD classifications among Urology, Nephrology, and Radiology, as well as between training levels were not significantly different. DISCUSSION: Despite the introduction of HN grading systems to standardize the interpretation and reporting of renal ultrasound in infants with HN, none have been proven superior in allowing clinicians to distinguish between "moderate" grades. While this study demonstrated high reliability in distinguishing between "mild" (SFU I/II and UTD 1) and "severe" (SFU IV and UTD 3) grades of HN, the overall reliability between specialties was poor. This is in keeping with a previous report of modest inter-rater reliability of the SFU system. This drawback is likely explained by the subjective interpretation required to assign grades, which can be impacted by experience, image quality, and scanning technique. As shown in the figure, which demonstrates SFU II (a) and SFU III (b), as assigned by a radiologist, it is possible to make an argument that either of these images can be classified into both categories that were observed during the grading sessions of this study. CONCLUSION: Although both systems have acceptable reliability, the SFU grading system showed higher overall intra/inter-rater reliability regardless of rater specialty than the UTD classification. Inter-rater reliability for SFU grades II/III and UTD 2 was low, highlighting the limitations of both classifications in regards to properly segregating moderate HN grades.

Vaginal Yolk Sac Tumor in an Infant: A Case Report and Literature Review of the Last 30 Years.

Vaginal yolk sac tumor is a rare malignant germ-cell tumor occurring most commonly in young girls. The treatment has evolved over the last 3 decades from radical surgery to conservative surgery with chemotherapy to chemotherapy alone. Here we present a case of a 6-month-old girl successfully treated with upfront surgery followed by chemotherapy. We include a literature review of studies on vaginal yolk sac tumor published in the last 30 years. We discuss the role of upfront surgery where possible followed by chemotherapy as a safe alternative to chemotherapy alone for the treatment of this rare malignancy.

Pleura nodosum: fetal squamous debris in an unusual location.

We present a pathologic-radiologic case of a fetus with a right extralobar bronchopulmonary sequestration that required intervention in the form of a thoraco-amniotic shunt for management of a right pleural effusion. The intervention was successful in reducing the pleural effusion and the infant was born at 39 weeks gestational age but required some respiratory support for the 1st day of life. The pulmonary sequestration was excised on day 7 of life and demonstrated several small nodules on its pleural surface. Histologic examination demonstrated that the nodules consisted of granulomatous plaques containing squamous epithelium and hairs. The nodules are similar to those described in amnion nodosum, when the amniotic membrane incorporates fetal skin within the superficial tissue layers of the placenta in cases of oligohydramnios. To our knowledge, this is the 1st reported case of nodules containing amniotic fetal squamous debris to occur on lung visceral pleura.

Screening for placental insufficiency by transvaginal uterine artery Doppler at 22-24 weeks of gestation.

OBJECTIVE: To determine the value of routine transvaginal color Doppler assessment of the uterine arteries at 22-24 weeks of gestation in the prediction of placental insufficiency. METHODS: Women with singleton pregnancies scheduled for routine ultrasound scans at 22-24 weeks were offered Doppler assessment of the uterine arteries by transvaginal ultrasound. The pulsatility index (PI) was obtained for each artery and the mean value was calculated. A mean PI >95th percentile was considered increased. Screening characteristics for predicting placental insufficiency, defined as preeclampsia, fetal growth restriction or intrauterine death, were calculated. RESULTS: Doppler examination of the uterine arteries was carried out in 1,057 singleton pregnancies. The mean uterine artery PI was 1.03 and the 95th percentile was 1.55. In 54 cases (5.1%) the mean PI was >1.55 (screen-positive). In the study population there were 48 cases of preeclampsia (5.1%), 72 fetal growth restrictions (7.5%) and 7 intrauterine deaths (0.7%). The screen-positive group showed an incidence of 47.1% of combined adverse results. The relative risks after a positive screening test were 7.3 (CI 4.2-12.6) for pre-eclampsia, 3.9 (CI 2.3 - 6.6) for fetal growth restriction and 4.5 (CI 3.2-6.4) for overall placental insufficiency. CONCLUSIONS: Uterine artery Doppler at 22-24 weeks identifies women at higher risk for the development of subsequent complications of placental insufficiency. This test could be used in combination with other markers to stratify the level of care offered in the third trimester of pregnancy.

Vascular endothelial growth factor and inhibin A in follicular fluid of infertile patients who underwent in vitro fertilization with a gonadotropin-releasing hormone antagonist.

OBJECTIVE: To investigate the role of a gonadotropin-releasing hormone (GnRH) antagonist, minimal stimulation protocol, in the follicular fluid by measuring vascular endothelial growth factor (VEGF) and inhibin A. DESIGN: A cross-sectional prospective study. SETTING: Academic hospital. PATIENT(S): Seventy infertile patients submitted to in vitro fertilization (IVF). INTERVENTION(S): Patients were divided into two groups: group 1 (study) included 30 infertile patients subjected to IVF with a GnRH antagonist (minimal stimulation protocol); group 2 (control) included 40 infertile women who underwent natural-cycle IVF. MAIN OUTCOME MEASURE(S): Follicular fluid VEGF and inhibin A measurements. RESULT(S): The groups were comparable in terms of age, body mass index (BMI), and infertility characteristics. Moreover, follicular fluid VEGF and inhibin A concentrations (medians) were, respectively, 776 pg/ml (95% confidence interval [CI]: 775-1483) and 3,115 pg/mL (95% CI: 1,349-2,502) for group 1; 1,187.50 pg/mL (95% CI: 1,020-1,560) and 3,123.00 pg/mL (95% CI: 1,888-2,735) for group 2 (P>.05). CONCLUSION(S): We demonstrated that GnRH antagonist administration in infertile patients undergoing IVF did not alter the follicular fluid content of VEGF and inhibin A, and, probably, maturation and quality of oocytes as well. These results demonstrated the usefulness and safety of this drug on controlled ovarian stimulation (COS) protocols.

Focal dermal hypoplasia associated with split sternum--Goltz syndrome.

Focal dermal hypoplasia (Goltz syndrome) is an unusual congenital mesoectodermal syndrome. We report on a baby girl with multiple malformations, including focal dermal hypoplasia, characteristic facial features, skeletal anomalies and split sternum.