Jane M. Matsumoto

MR enterography in pediatric inflammatory bowel disease: retrospective assessment of patient tolerance, image quality, and initial performance estimates.

OBJECTIVE The purpose of this article was to evaluate image quality, oral contrast administration and bowel distention, side effects, and performance estimates of MR enterography in a large cohort of pediatric patients with inflammatory bowel disease (IBD). MATERIALS AND METHODS A retrospective analysis of the pediatric IBD clinic database (2007-2010) was performed. Eighty-five MR enterography studies in 70 patients were performed without sedation. All pediatric patients with the potential diagnosis of IBD were included, with the exception of studies performed on patients with ileoanal pouch anatomy. The quantity of ingested oral contrast material and number of adverse events were recorded. Retrospectively, image quality (including motion artifact and bowel distention) and enteric inflammation were assessed. Correlation between radiographic findings and endoscopic findings was tested by the Fisher exact test. RESULTS Eighty-five MR enterography studies were performed without sedation in 70 patients (mean age, 15.6 years; age range, 9-18 years) over 30 months. The mean image quality for unenhanced images was significantly higher than for contrast-enhanced images (4.7 vs 4.1, p < 0.0001), with unacceptable image quality occurring on both unenhanced and contrast-enhanced sequences in one patient. The amount of oral contrast material ingested correlated with patient age (p = 0.009), with acceptable bowel distention occurring in 93% (78/85). Two patients had nausea or emesis and one experienced a syncopal episode after MR enterography. Sensitivity and specificity of MR enterography for active disease of the terminal ileum, right colon, and left colon were 80% and 85.2%, 79.1% and 77.8%, and 90.3% and 63.6%, respectively. CONCLUSION MR enterography is feasible in patients 9 years old and older without sedation. Acceptable image quality can be achieved in nearly all patients, but a small minority will have suboptimal bowel distention or minor adverse events. Oral contrast ingestion regimes can be based on patient age. Performance estimates in children parallel reports in adults.

Individualizing Management of Complex Esophageal Pathology Using Three-Dimensional Printed Models

PURPOSE In complex esophageal cases, conventional two-dimensional imaging is limited in demonstrating anatomic relationships. We describe the utility of three-dimensional (3D) printed models for complex patients to individualize care. DESCRIPTION Oral effervescent agents, with positive enteric contrast, distended the esophagus during computed tomography (CT) scanning to facilitate segmentation during post-processing. The CT data were segmented, converted into a stereolithography file, and printed using photopolymer materials. EVALUATION In 1 patient with a left pneumonectomy, aortic bypass, and esophageal diversion, 3D printing enabled visualization of the native esophagus and facilitated endoscopic mucosal resection, followed by hiatal dissection and division of the gastroesophageal junction as treatment. In a second patient, 3D printing allowed enhanced visualization of multiple esophageal diverticula, allowing for optimization of the surgical approach. CONCLUSIONS Printing of 3D anatomic models in patients with complex esophageal pathology facilitates planning the optimal surgical approach and anticipating potential difficulties for the multidisciplinary team. These models are invaluable for patient education.

Health‐related quality of life in children and young adults with post‐thrombotic syndrome: Results from a cross‐sectional study

While post‐thrombotic syndrome (PTS) is increasingly recognized in children with a history of deep vein thrombosis (DVT), its impact on the health‐related quality of life (HRQoL) is unknown. Our objective was to evaluate the association between the PTS and HRQoL by surveying a cohort of patients treated at our institution for DVT.

Retrograde Filling of the Renal Vein on Computerized Tomography for Blunt Renal Trauma: an Indicator of Renal Artery Injury

Assessment of the traumatically injured pediatric patient with computerized tomography has become standard medical practice. We report the unique finding of retrograde flow of intravenous contrast material into the renal vein as a diagnostic indicator of traumatic renal artery injury. With the increasing use of high-speed computerized tomography as the initial study to evaluate and stage blunt abdominal trauma, this finding may assist the physician in the early diagnosis of severe renovascular injury.

The role of imaging, deliberate practice, structure, and improvisation in approaching surgical perfection

From the Departments of Cardiovascular Surgery, Urology, and Radiology, Mayo Clinic, Rochester, Minn; Jazz Impact Appreciative Inquiry Consulting, New York, NY; Department of Psychology, Florida State University, Tallahassee, Fla; and Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. Received for publication Dec 5, 2016; revisions received March 14, 2017; accepted for publication April 3, 2017; available ahead of print May 26, 2017. Address for reprints: Joseph A. Dearani, MD, Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (E-mail: jdearani@mayo.edu). J Thorac Cardiovasc Surg 2017;154:1329-36 0022-5223/

Metastatic chondroblastoma with elevated creatine kinase and paraneoplastic neurologic autoimmunity.

36.00 Copyright 2017 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2017.04.045

Prevalence and risk factors for post thrombotic syndrome after deep vein thrombosis in children: A cohort study

A 17-year-old girl presented with chondroblastoma of the fibula and pulmonary metastases. Serum creatine kinase (CK) was elevated for a decade preoperatively and fell to near normal after tumor excision. An episode of aseptic meningitis 3 months later led to serologic detection of three antibody markers of paraneoplastic neurologic autoimmunity that in adult patients are characteristic of thymoma and lung carcinoma: muscle-type acetylcholine receptor (AChR) autoantibody (Ab), type 2 Purkinje cell cytoplasmic Ab (PCA-2), and collapsin response-mediator protein-5-IgG (CRMP-5-IgG). Locally recurrent chondroblastoma was excised 1 year later. Serum CK was elevated, CRMP-5-IgG was positive, PCA-2 was lower, and AChR Ab was undetectable. Three years after diagnosis she has stable pulmonary metastases, with elevated CK, higher PCA-2, positive CRMP-5-IgG, and undetectable AChR Ab. The association of metastatic chondroblastoma, elevated CK, and an evolving profile of paraneoplastic autoantibodies reveals a previously unrecognized immunobiologic dimension of chondroblastoma.

Radiation Dose Reduction in Pediatric Body CT Using Iterative Reconstruction and a Novel Image-Based Denoising Method

BACKGROUND While post thrombotic syndrome (PTS) is increasingly recognized as a frequent and potentially serious complication of deep vein thrombosis (DVT) in children, limited information is available regarding predictors of PTS. METHODS Using the Mayo Clinic Master Diagnostic Index, all pediatric patients (age 0 to 18 years) with a potential DVT based on ICD-8 codes over the 15-year period, 1995 to 2009 were identified. A validated PTS survey instrument was mailed to eligible patients followed by a second mailing and three reminder phone calls for non-responders. Baseline clinical and radiographic characteristics were abstracted from patient medical records and tested as potential predictors of PTS using logistic regression. Associations were summarized by calculating odds ratios (OR) and corresponding 95% confidence intervals. RESULTS Ninety patients agreed to participate. The mean age (±SD) at DVT diagnosis and survey completion were 12.8 (±6.1) and 19.3 (±7.7) years, respectively. Fifty three respondents (59%) reported mild PTS whereas 12 (13%) reported moderate-to-severe PTS. Pain (34%) and dilated blood vessels (40%) were the most frequent PTS symptom and sign, respectively. On multivariate analysis, predictors of PTS included duration between incident DVT and survey completion (OR 1.75; 95% CI: 1.08-2.84) and number of thrombosed vein segments (OR 1.40; 95% CI: 1.05-1.86). CONCLUSION Over 70% of children with DVT report subsequent symptoms or signs of PTS, though only 13% report clinically significant, moderate-to-severe PTS. Number of thrombosed vein segments at diagnosis and time duration between incident DVT and survey completion were independent predictors of PTS.

Three-dimensional prototyping for procedural simulation of transcatheter mitral valve replacement in patients with mitral annular calcification

OBJECTIVE The objective of this study was to evaluate the radiation dose reduction potential of a novel image-based denoising technique in pediatric abdominopelvic and chest CT examinations and compare it with a commercial iterative reconstruction method. MATERIALS AND METHODS Data were retrospectively collected from 50 (25 abdominopelvic and 25 chest) clinically indicated pediatric CT examinations. For each examination, a validated noise-insertion tool was used to simulate half-dose data, which were reconstructed using filtered back-projection (FBP) and sinogram-affirmed iterative reconstruction (SAFIRE) methods. A newly developed denoising technique, adaptive nonlocal means (aNLM), was also applied. For each of the 50 patients, three pediatric radiologists evaluated four datasets: full dose plus FBP, half dose plus FBP, half dose plus SAFIRE, and half dose plus aNLM. For each examination, the order of preference for the four datasets was ranked. The organ-specific diagnosis and diagnostic confidence for five primary organs were recorded. RESULTS The mean (± SD) volume CT dose index for the full-dose scan was 5.3 ± 2.1 mGy for abdominopelvic examinations and 2.4 ± 1.1 mGy for chest examinations. For abdominopelvic examinations, there was no statistically significant difference between the half dose plus aNLM dataset and the full dose plus FBP dataset (3.6 ± 1.0 vs 3.6 ± 0.9, respectively; p = 0.52), and aNLM performed better than SAFIRE. For chest examinations, there was no statistically significant difference between the half dose plus SAFIRE and the full dose plus FBP (4.1 ± 0.6 vs 4.2 ± 0.6, respectively; p = 0.67), and SAFIRE performed better than aNLM. For all organs, there was more than 85% agreement in organ-specific diagnosis among the three half-dose configurations and the full dose plus FBP configuration. CONCLUSION Although a novel image-based denoising technique performed better than a commercial iterative reconstruction method in pediatric abdominopelvic CT examinations, it performed worse in pediatric chest CT examinations. A 50% dose reduction can be achieved while maintaining diagnostic quality.

MRI guided wire localization muscle biopsy in a child with juvenile dermatomyositis.

Three‐dimensional (3D) prototyping is a novel technology which can be used to plan and guide complex procedures such as transcatheter mitral valve replacement (TMVR).