Is Oral Contrast Beneficial for Visualization of the Appendix in Low-Weight Children?Les produits de contraste par voie orale sont-ils utiles pour visualiser l’appendice chez les enfants de petit poids?

Purpose: It has been shown that oral contrast does not improve the diagnostic accuracy of Computed Tomography (CT) for appendicitis in pediatric patients; however, the cohorts in these studies were not stratified by weight or body mass index. The purpose of this study is to assess the benefit of oral contrast administration for identifying the appendix in younger children in the lower weight quartile. Materials and Methods: This retrospective study comprised 100 patients (2–10 years) in lower weight quartile who had intravenous contrast-enhanced CT of the abdomen and pelvis, 37 of which with oral contrast, and 63 without. A pediatric radiologist and a pediatric radiology fellow independently assessed whether the appendix was visualized or not. In case of discrepancy, an additional pediatric radiologist was the “tie-breaker.” Chi-squared test was used to compare the proportion of visualized appendix between the groups (with and without oral contrast). Inter-rater reliability was determined using Cohen’s Kappa coefficient. Results: There was no significant difference in the visualization of the appendix between the group with oral contrast and without ( P = 1). The Cohen Kappa coefficients were .33 (.05, .62) and .91 (.73, 1.00) for the “no oral” and “oral” groups, respectively, yielding evidence of a difference ( P = .007). Conclusions: There was no significant difference in the visualization of the appendix using CT with or without oral contrast in low-weight pediatric patients. The inter-rater reliability, however, was significantly higher in the group given oral contrast. Additional studies assessing the value of oral contrast for the sole indication of appendicitis may provide clearer results.

Laparoscopic Resection of Pediatric Solid Pseudopapillary Tumors of the Pancreas

Background Solid pseudopapillary tumors (SPTs) of the pancreas arise rarely in children, are often large, and can associate intimately with splenic vessels. Splenic preservation is a fundamental consideration when resecting distal SPT. Occasionally, the main splenic vessels must be divided to resect the SPT with negative margins, but the spleen can be preserved if the short gastric vessels remain intact (ie, Warshaw procedure). The purpose of this study was to evaluate outcomes of distal pancreatectomy (DP) for SPT in children and to highlight 2 cases of splenic preservation using the Warshaw procedure. Methods Patients 19 years and younger who were treated at a single children’s hospital between July 2004 and January 2021 were examined. Patient characteristics were collected from the electronic medical record. A pediatric radiologist calculated SPT and pre- and post-operative (ie, non-infarcted) splenic volumes. Results Eleven patients received DP for SPT. Six DPs were performed open and 5 laparoscopically. The spleen was preserved in 3 open and 4 laparoscopic DPs. A laparoscopic Warshaw procedure was performed in 2 patients. Laparoscopic resection associated with less frequent epidural use ( P = .015), shorter time to full diet ( P = .030), and post-operative length of stay ( P = .009), compared to open resection. Average residual splenic volume after the laparoscopic Warshaw procedure was 70% of preoperative volume. Discussion Laparoscopic DP for pediatric SPT achieved similar oncologic goals to open resection. Splenic preservation was feasible with laparoscopy in most cases and was successfully supplemented with the Warshaw procedure, which has not been previously reported for SPT resection in children.

Communicating incidental and reportable findings from research MRIs: considering factors beyond the findings in an underrepresented pediatric population

Background The application of advanced imaging in pediatric research trials introduces the challenge of how to effectively handle and communicate incidental and reportable findings. This challenge is amplified in underserved populations that experience disparities in access to healthcare as recommendations for follow-up care may be difficult to coordinate. Therefore, the purpose of the present report is to describe the process for identifying and communicating findings from a research MRI to low-income Latino children and families. Methods Latino adolescents (n = 86) aged 12–16 years old with obesity and prediabetes underwent a research MRI (3 Tesla Philips Ingenia®) as part of a randomized controlled diabetes prevention trial. The research MRIs were performed at baseline and 6 months to assess changes in whole-abdominal fat distribution and organ fat in response to the intervention. An institutional pathway was developed for identifying and reporting findings to participants and families. The pathway was developed through a collaborative process with hospital administration, research compliance, radiology, and the research team. All research images were reviewed by a board-certified pediatric radiologist who conveyed findings to the study pediatrician for determination of clinical actionability and reportability to children and families. Pediatric sub-specialists were consulted as necessary and a primary care practitioner (PCP) from a free community health clinic agreed to receive referrals for uninsured participants. Results A total of 139 images (86 pre- and 53 post-intervention) were reviewed with 31 findings identified and 23 deemed clinically actionable and reportable. The only reportable finding was severely elevated liver fat (> 10%, n = 14) with the most common and concerning incidental findings being horseshoe kidney (n = 1) and lung lesion (n = 1). The remainder (n = 7) were less serious. Of youth with a reportable or incidental finding, 18 had a PCP but only 7 scheduled a follow-up appointment. Seven participants without a PCP were referred to a safety-net clinic for follow-up. Conclusions With the increased utilization of high-resolution imaging in pediatric research, additional standardization is needed on what, when, and how to return incidental and reportable findings to participants, particularly among historically underrepresented populations that may be underserved in the community. Trial registration Preventing Diabetes in Latino Youth, NCT02615353

Fetal Brain Biometric Measurements on 3D Super-Resolution Reconstructed T2-Weighted MRI: An Intra- and Inter-observer Agreement Study

We present the comparison of two-dimensional (2D) fetal brain biometry on magnetic resonance (MR) images using orthogonal 2D T2-weighted sequences (T2WSs) vs. one 3D super-resolution (SR) reconstructed volume and evaluation of the level of confidence and concordance between an experienced pediatric radiologist (obs1) and a junior radiologist (obs2). Twenty-five normal fetal brain MRI scans (18–34 weeks of gestation) including orthogonal 3-mm-thick T2WSs were analyzed retrospectively. One 3D SR volume was reconstructed per subject based on multiple series of T2WSs. The two observers performed 11 2D biometric measurements (specifying their level of confidence) on T2WS and SR volumes. Measurements were compared using the paired Wilcoxon rank sum test between observers for each dataset (T2WS and SR) and between T2WS and SR for each observer. Bland–Altman plots were used to assess the agreement between each pair of measurements. Measurements were made with low confidence in three subjects by obs1 and in 11 subjects by obs2 (mostly concerning the length of the corpus callosum on T2WS). Inter-rater intra-dataset comparisons showed no significant difference (p > 0.05), except for brain axial biparietal diameter (BIP) on T2WS and for brain and skull coronal BIP and coronal transverse cerebellar diameter (DTC) on SR. None of them remained significant after correction for multiple comparisons. Inter-dataset intra-rater comparisons showed statistical differences in brain axial and coronal BIP for both observers, skull coronal BIP for obs1, and axial and coronal DTC for obs2. After correction for multiple comparisons, only axial brain BIP remained significantly different, but differences were small (2.95 ± 1.73 mm). SR allows similar fetal brain biometry as compared to using the conventional T2WS while improving the level of confidence in the measurements and using a single reconstructed volume.

Artificial intelligence in the endocrine clinic: automated bone age analysis in arabic children from UAE

Objective: Artificial intelligence (AI) is playing an increasing role in patient assessment. AI bone age analysis is such a tool, but its value in Arabic children presenting to an endocrine clinic has not been explored. We compared results from an experienced pediatric radiologist and the AI bone age system, BoneXpert (BX), (Visiana, Denmark) to assess its utility in a cohort of children presenting to the Al Jalila Children’s Specialty Hospital endocrine service. Materials and Methods: We conducted a retrospective chart review of 47 children with growth disorders, initially assessed by a single experienced radiologist and subsequently by BX, to confirm the usefulness of the BX system in our population. The results of the analyses were analysed using a Bland-Altman plot constructed to compare differences between the radiologist’s interpretation and BX across the available range of bone age. Results: Forty-four of the patient x-ray images were analysed by BX. Three X-ray images were rejected by BX due to post-processing artifacts, which prevented computer interpretation. For the remaining 44 X-rays, there was a close correlation between radiologist and BX results (r=0.93; p <0.00001). Two radiographs were identified with a large discrepancy in the reported bone ages. Blinded, independent re-evaluation of the radiographs showed the original manually interpreted bone age to have been erroneous, with the BX results corresponding closely to the amended bone age. A small positive bias was noted in bone age (+0.39 years) in the BX analyses, relative to manual interpretation. Conclusions: AI bone age analysis was of high utility in Arabic children from UAE presenting to an endocrine clinic, with results highly comparable to an experienced radiologist. In the two cases where a large discrepancy was found, independent re-evaluation showed AI analysis was correct.

Whole-body [18F]-FDG-PET/MRI for staging of pediatric non-Hodgkin lymphoma: first results from a single-center evaluation

Aim In 2015, the revised International Pediatric Non-Hodgkin Lymphoma Staging System was published. It mentions [18F]-FDG-PET/MRI as the latest method to perform whole-body imaging. However, supporting data are pending. Our aim was to investigate the performance of whole-body [18F]-FDG-PET/MRI in pediatric non-Hodgkin lymphoma patients by using a limited number of MRI sequences. Materials and methods Ten pediatric patients with histologically proven non-Hodgkin lymphoma underwent whole-body [18F]-FDG-PET/MRI at staging. The retrospective analysis included three steps: First, [18F]-FDG-PET and MR scans were evaluated separately by a nuclear medicine physician and a pediatric radiologist. Nineteen nodal and two extranodal regions as well as six organs were checked for involvement. Second, discrepant findings were reviewed together in order to reach consensus. Third, [18F]-FDG-PET/MRI findings were correlated with the results of other clinical investigations. Results Of the 190 lymph node regions evaluated, four were rated controversial. Consensus was reached by considering metabolic, functional and morphologic information combined. Concordantly, [18F]-FDG-PET and MRI detected Waldeyer’s ring involvement in two patients whose Waldeyer’s ring was negative on clinical assessment. In four patients MRI showed pleural effusion. However, in only two of them an increased glucose metabolism as a reliable sign of pleural involvement was detectable. In six patients [18F]-FDG-PET and MRI detected skeletal lesions although bone marrow biopsy was positive in only one of them. Conclusion Despite the small number of cases evaluated, whole-body [18F]-FDG-PET turned out to be a valuable tool for staging of pediatric non-Hodgkin lymphoma.

The Utility of Gallbladder Absence on Ultrasound for Children With Biliary Atresia

Background: Biliary Atresia (BA) is congenital condition, where infant intra- and extrahepatic bile ducts become obliterated, leading to cholestasis, and cirrhosis if untreated. This study aims to assess the predictive measure of absent gallbladder on ultrasounds (US) performed in infants with cholestasis for diagnosing BA.Method: After Institutional Review Board approval, retrospective chart reviews of 61 infants with cholestasis found 43 (70.5%) were diagnosed with BA. A pediatric radiologist provided interpretations of all ultrasounds in a blinded fashion. Statistical analysis was used to assess the utility of absence of gallbladder on US in predicting BA, confirmed intraoperatively.Results: Absent gallbladder on US predicts absent gallbladder with 77% accuracy, 92% sensitivity, 73% specificity, PPV 43%, and NPV 97% (P &lt; 0.001, Fisher exact test). To diagnose BA, absent gallbladder on US has 66% accuracy, 53% sensitivity, 94% specificity, 96% PPV, and 46% NPV (P &lt; 0.001, Fisher exact test).Conclusion: Sonographic gallbladder absence has high specificity and PPV, indicating utility for BA diagnosis; however, it is not useful for ruling out BA given its low sensitivity.