Biomedical subjects
Publications and source records attributed to S K Fernbach.
Preoperative CT and ultrasound of a 16-month-old girl with abdominal mass demonstrated the calcified mass and a copious amount of ascites. Pathological examination of the tumor revealed neuroblastoma, a tumor not usually associated with peritoneal seeding or ascites.
The Society for Fetal Urology (SFU) was founded in 1988 to study the postnatal evolution of prenatally detected anomalies of the urinary tract by following those neonates whose prenatal studies have brought them to medical attention while asymptomatic. The SFU has attempted to standardize methods of performing and grading the ultrasound and radionuclide examinations in this population. A system to grade upper tract dilatation or hydronephrosis (HN) imaged by ultrasound has been developed and is being used by SFU members in 36 institutions. The appearance of the calices, renal pelvis and renal parenchyma are key in determining the grade of HN and are illustrated in this article.
OBJECTIVE: The objectives of the study were to determine the prevalence of periosteal reaction of the ribs in infants treated with extracorporeal membrane oxygenation and to evaluate its association with soft-tissue swelling. MATERIALS AND METHODS: The chest radiographs of 100 consecutive neonates treated with extracorporeal membrane oxygenation were evaluated to determine the maximal soft-tissue swelling during therapy and whether periosteal reaction of the ribs developed. The length of extracorporeal membrane oxygenation and the time elapsed before periosteal reaction developed were recorded. The medical records of those with periosteal reaction were reviewed to determine known causes of this condition. The records of a control group of 11 neonates were evaluated in the same manner. RESULTS: Periosteal reaction of the ribs developed in 13 (21%) of the 61 neonates who had less than 11 mm of soft-tissue swelling. In 69% of those with periosteal reaction, the finding first was seen 21-32 days after birth. In the control group, periosteal reaction developed in only one, a neonate who had vibrator chest physiotherapy. CONCLUSION: Periosteal reaction of the ribs in patients treated with extracorporeal membrane oxygenation is associated with soft-tissue swelling greater than 11 mm. The periosteal reaction appears to be a self-limiting and benign process.
Extramedullary hematopoiesis (EMH) is known to occur in clinical settings associated with severe anemia. Because very young children with anemia can usually recruit the still large compartment of red marrow, EMH is more frequently seen in adults. We have observed two young girls, who were unable to produce sufficient blood products in their marrow and instead developed EMH, one with documented and rarely reported renal involvement. They are described below.
Dilatation of the urinary tract is detected in a number of settings throughout childhood. Children may be asymptomatic or present with urinary tract infection, hematuria, or voiding symptoms. Evaluation of the affected urinary tract may require standard radiographic techniques (VCUG, EU) complemented by ultrasound and nuclear medicine studies. The goal of imaging is to differentiate hydronephrosis (HN) from hydroureteronephrosis (HUN) and to provide the correct diagnosis so that appropriate treatment can be given. This article reviews and demonstrates the findings in some common and uncommon causes of HN and HUN.
Sixty-five consecutive patients seen in a pediatric emergency department, in whom the diagnosis of intussusception was considered, had an ultrasound examination of the abdomen before a barium enema. The mean age of the patients was 1.7 years (range 2 weeks to 5 years). Intussusception was detected by ultrasonography in all 20 cases proved by barium enema. There were three false-positive ultrasound results (sensitivity = 100%, confidence interval (Cl) = 86% to 100%; specificity = 93%, Cl = 86% to 96%). Normal findings on ultrasonography correlated with a negative barium enema results in 42 of 42 cases (negative predictive value = 100%, Cl = 94% to 100%). No intussusception was missed by ultrasonography. To determine which patients would most benefit from ultrasonography, we divided patients into either a high-risk group (81% with intussusception) or a low-risk group (14% with intussusception) on the basis of clinical symptoms (p less than 0.01). If each high-risk child had a barium enema and each low-risk child had an ultrasound study as their initial diagnostic test, 89% of the patients in this study would have undergone only one examination. We conclude that ultrasonography can be used as a rapid, sensitive screening procedure in the diagnosis or exclusion of childhood intussusception. Children considered at low risk of having intussusception on the basis of clinical symptoms should initially have an ultrasound examination; patients at high risk should have an immediate barium enema.
In children, ultrasonography has been valuable in demonstrating a wide range of congenital lesions that were previously seen indirectly or only after more invasive procedures. It has replaced many studies that necessitated oral or vascular contrast and ionizing radiation. Real-time ultrasonography has found a role in the evaluation of the diaphragm, gastroesophageal reflux, bowel peristalsis, and hip stability.
The traditional areas of interest in pediatric gastrointestinal radiology (gastroesophageal reflux, malrotation, necrotizing enterocolitis) were the source of many new and important studies in the past year. Information gleaned from correlative nonradiologic studies or from newer modalities provided the new focus of interest. The imaging and treatment of intussusception remains a topic in which literature is evolving. Pneumatic reduction is repeatedly being shown to be safe and effective. There have been a large number of studies addressing polysplenia, biliary atresia, and liver transplantation. Images of the anomalies associated with polysplenia were published in several sources. One paper reported better than previously described results of liver transplantation in the subset of patients with polysplenia and biliary atresia.
The radiologic evaluation of the neonate with a suspected or clinically palpable renal mass has evolved. There is increasing use of ultrasound and a parallel decrease of excretory urography. Postnatal imaging studies should be performed in a sequence to complement data provided by prenatal sonography, clinical examination, and family history.
The sonographic and computed tomographic findings in 12 children aged 1-6 years with clear cell sarcoma of the kidney were reviewed retrospectively. Tumor size, calcification, and internal architecture were characterized and correlated with the gross pathologic findings. All tumors were unilateral and large (8.5-16 cm in diameter). Except for one, all masses were predominantly solid, and all contained some well-defined portions of low attenuation or hypoechogenicity that represented tumor necrosis. In addition, seven tumors contained uncomplicated fluid-filled cysts with diameters ranging from a few millimeters to 5 cm. Extension into the inferior vena cava was not noted. The radiologic features of clear cell sarcoma of the kidney are common to all malignant renal neoplasms. Some cases, however, may have features that simulate those of benign conditions, such as multilocular cystic nephroma or segmental cystic dysplasia. No pattern was discerned that would permit discrimination between clear cell sarcoma of the kidney and the most common renal neoplasm of childhood, Wilms tumor.
In the past 3 years, eight of 20 male neonates with stigmata of the VATER association were found to have significant urethral abnormalities. Three had megalourethra, two had duplication of the urethra, and one each had an anterior urethral valve, congenital stricture, and hypospadias. In only five of eight was the extent of the abnormality clinically apparent. All three infants with megalourethra and imperforate anus died because of the coexistence of other severe congenital anomalies. Prior literature has described but not stressed the increased prevalence of urethral abnormalities in children with the VATER association. Because of the high prevalence (eight of 20) of significant urethral anomalies, we perform voiding cystourethrography on all males with the stigmata of the VATER association, even in the absence of clinical symptoms.
Towne-view skull radiographs of 38 infants with unilateral lambdoid synostosis were reviewed. The diagnosis of lambdoid synostosis was based on other plain film findings, CT findings, or clinical examination. All patients had deformity of the ipsilateral petrous bone, presumably because of pressure caused by redirected brain growth. Specific changes included flattening of the petrous ridge and depression of the roof of the mastoid portion of the petrous bone and adjacent structures such as the semicircular canals. Flattening of the petrous ridge and depression of the roof of the mastoid portion of the petrous bone are useful signs of lambdoid synostosis when sutural closure has produced sutural indistinctness rather than sclerosis.
The radiologic diagnosis of craniosynostosis is made in most instances based on routine skull films, because each suture closure produces characteristic changes. Computed tomography (CT) was originally used only to evaluate the intracranial contents. In the last 5 years changes in morphology at the skull base and in the calvarium have been better demonstrated with three-dimensional CT. This article describes and illustrates the appearance of craniosynostosis on skull radiographs and CT.
A retrospective analysis of 100 renal sonograms (200 kidneys) was performed to determine how the appearance of the renal pelvis varies in the supine und prone projections. The renal pelvis had no distention in either projection in 100 kidneys. The prone position produced dilatation of a previously normal pelvis with 60 kidneys or increasing dilatation in 6 kidneys. Other changes in the renal pelvis were also identified. We believe this positional change is due to shifting of urine from the normal sized calyces (when supine) to the distensible renal pelvis (when prone). It is possible that elevation of bladder pressure in the prone position may also impede urine flow and produce the observed changes. However, it is important to recognize that the slight dilatation of the renal pelvis does not indicate pathology.
A retrospective analysis of radiologically determined individual renal function was performed in five boys who presented in the neonatal period with posterior urethral valves, vesicoureteral reflux and documented urinoma formation. Renal function was evaluated with scintigraphy. There was reflux in eight of ten ureters. Six of these ureters had an associated urinoma and compromised renal function in the neonatal period. In two of the boys the kidney with urinoma functioned better than the contralateral kidney with reflux alone. In two other boys with unilateral urinoma the contralateral ureter did not reflux and the affected kidney functioned less well. In follow up (20 to 36 months) seven of the ten kidneys have a near normal appearance or function. Those kidneys which are now abnormal were noted to be abnormal in the neonatal period.
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