Mariana L. Meyers

Reliability of Renal Length Measurements Made With Ultrasound Compared With Measurements From Helical CT Multiplanar Reformat Images

OBJECTIVE The purpose of this article is to determine the reliability of sonographic renal length measurements compared with measurements obtained from helical CT multiplanar reformat images and compared with standard renal growth curves. MATERIALS AND METHODS A retrospective review was performed of 76 subjects who underwent both renal ultrasound and abdominal CT within 2 weeks of one another. Renal lengths were measured using oblique coronal reformat images of helically acquired CT data by two observers on two occasions. Intraobserver and interobserver error for these measurements were calculated. Ultrasound renal length measurements were compared with CT measurements. Measurement variation was compared with standard renal growth curves. RESULTS The mean (± SD) of the absolute value of interobserver error of CT measurements was 0.9 ± 0.8 mm. Compared with CT, individual ultrasound measurements underestimated renal length by 1.5 ± 5.6 mm on average, with a 95% CI of -12.5 to 9.5 mm. When the maximum of three ultrasound renal length measurements was used, the SD was 4.7 mm, with a 95% CI of -8.2 to 10.1 mm of the reported renal length. This corresponds to greater or less than 3.3 years of normal renal growth. CONCLUSION Lack of renal growth can be asserted only when renal length falls below the growth curve, taking into account the corresponding measurement error limits, which we found to be greater or less than 9.3 mm. If the follow-up measurement falls within these limits, one should not infer lack of appropriate renal growth, even if the renal length measurement decreases or remains unchanged for up to 3 years.

Higher Pavlik Harness Treatment Failure Is Seen in Graf Type IV Ortolani-positive Hips in Males.

BackgroundPatients with developmental dysplasia of the hip (DDH) whose hips are dislocated but reducible (Ortolani positive) are more likely to experience Pavlik harness treatment failure than are patients with dysplastic and reduced but dislocatable (Barlow positive) hips. However, data regarding factors associated with failure are limited and conflicting.Questions/PurposesWe asked: (1) What is the frequency of Pavlik harness treatment failure among Ortolani-positive hips, Barlow-positive hips, and dysplastic hips? (2) What are the factors predictive of failure of Pavlik harness treatment for Ortolani-positive hips?MethodsIn this retrospective study we identified 150 patients who underwent the Pavlik harness method for treatment of DDH between August 2011 and July 2015. Six patients initially treated at an outside facility, four patients with associated conditions, and three who pursued treatment elsewhere were excluded. A total of 137 patients (215 hips) with a median age at the time of Pavlik placement of 30 days (range, 4–155 days) were included. Of the 215 hips, 78 (36.3%) were Ortolani positive, 60 (27.9%) were Barlow positive, and 77 (35.8%) were stable, with the diagnosis of dysplasia made on ultrasound. All patients were treated with the Pavlik harness method. The primary outcome was failure of the Pavlik harness to achieve and maintain concentric hip reduction assessed by examination and ultrasound. All patients were followed after completion of Pavlik treatment for a minimum of 2 months (mean, 3 months; range, 2–4 months). In addition, 90% (122 of 137) of the patients were followed for a minimum of 6 months. Patient-specific data including family history, breech versus cephalic presentation at birth, age, sex, laterality, and hip abduction were recorded. Ultrasound data at the time of diagnosis included Graf classification, alpha angle, and percentage of femoral head coverage.ResultsThe Pavlik harness method failed in 27% (21 of 78) of hips that were Ortolani positive, 8% (six of 77) with dysplasia, and 5% (three of 60) that were Barlow positive. After controlling for potential confounding variables, such as range of hip abduction, male sex (adjusted odds ratio [OR], 6.9; 95% CI, 2.0–24.2; p = 0.002) and Graf Type IV ultrasound classification (dislocated hip with alpha angle less than 43° and labrum displaced downward) (OR, 4.4; 95% CI, 1.3–15.4; p = 0.019) were identified as independent predictors of failure of Pavlik treatment among Ortolani-positive hips.ConclusionsUltrasound imaging of the hip should be part of the initial assessment for Ortolani-positive hips, as the ultrasound classification was found to have prognostic implications. Parents of male infants with Graf Type IV hips should be counseled regarding the higher risk of Pavlik failure. Future well-designed prospective controlled studies are necessary to establish whether alternative strategies to the Pavlik harness might improve the early outcomes of DDH in males with Graf Type IV hips.Level of EvidenceLevel III, therapeutic study.

Comparison of congenital pulmonary airway malformation volume ratios calculated by ultrasound and magnetic resonance imaging

Abstract Objective: To compare congenital pulmonary airway malformation (CPAM) volume to head circumference ratios (CVRs) determined by different imaging modalities and calculation techniques. Methods: Fetal thoracic lesion images by ultrasound (US) and magnetic resonance imaging (MRI) were retrospectively reviewed and the CVRs were calculated. The CVRUS was determined by the standard method. The CVRMRI was calculated from T2-weighted sequences (HASTE/SSH-TSE) in two ways, dimensional measurements analogous to US technique (MRI-D) and by using a MRI-software calculated volume (MRI-V). CVR values between methods were compared using Wilcoxon matched-pairs signed-rank testing, Bland–Altman analyses, and Spearman correlations. Results: Appropriate images were available to compare CVRUS to CVRMRI-D for 20 patients and CVRUS to CVRMRI-V for 18 patients. There were no significant differences in CVR values between modalities. By Bland–Altman analyses, the CVR measurements were largely within the limits of agreement: 18 of 20 for CVRMRI-D and 17 of 18 for CVRMRI-V, with a slight bias towards larger measurements by MRI. Conclusions: Though values varied between modalities for individual patients, there was no systematic difference in CVRs determined by US or MRI. Fetal prognostic category for CPAMs did not change based on MRI in any patient in this series.

Initial Imaging for Pediatric Renal Tumors: An Opportunity for Improvement

Purpose: Current Childrens Oncology Group studies on renal malignancy focus on minimizing treatment side effects with a goal of decreasing long‐term complications. In this series we evaluate the patterns of initial imaging in children with renal tumors. Materials and Methods: We retrospectively reviewed records of 122 patients treated for renal tumors at our institution between 2005 and 2016. Ideal imaging was defined as cross‐sectional imaging of the chest, abdomen and pelvis in a single setting without any additional ionizing radiation exposing scans. Results: Median patient age was 33.5 months (range 1 to 195). A total of 101 patients (83%) were initially evaluated elsewhere and subsequently referred to oncology (67.2%) for further evaluation. Before treatment 58 patients (47.5%) underwent imaging that was obtained in an ideal manner. Compared to those undergoing ideal imaging, median additional radiation exposure was 2.31 mSv (range 0.9 to 11.5), 3.08 mSv (0.6 to 11.7) and 5.1 mSv (1.2 to 16) in patients younger than 5 years, 5 to 9 years old and 10 years or older, respectively. Factors associated with undergoing ideal imaging included undergoing abdominal ultrasound as an initial scan (OR 3.637, p = 0.001), while presentation to an emergency department resulted in a reduced likelihood of undergoing ideal imaging (OR 0.351, p = 0.012). Factors associated with a decreased likelihood of undergoing initial screening ultrasound included presenting with vague symptoms (OR 0.072, p = 0.045) and presenting to a tertiary care emergency department (OR 0.228, p = 0.027). Conclusions: Current patterns of initial imaging for pediatric renal tumors are often associated with unnecessary and avoidable imaging studies, resulting in increased radiation exposure. Presenting to the emergency room as the initial point of contact with vague symptoms is associated with a decreased likelihood of undergoing appropriate or ideal pretherapy imaging, while initial evaluation with ultrasound is associated with a greater likelihood of undergoing ideal imaging, reducing overall radiation exposure. We advocate initial abdominal ultrasound in all pediatric patients suspected of having an abdominal mass. Our data highlight an opportunity for quality improvement across specialties caring for children with renal tumors.

Ultrasound versus MRI: is there a difference in measurements of the fetal lateral ventricles?

Abstract Objective: To evaluate whether fetal brain lateral ventricle measurements differ between ultrasound (US) and MRI. Methods: We evaluated 115 fetuses with US and MRI performed within 24 h of each other. Ventricular measurements were performed in the axial plane at the level of the atria for both modalities and the right and left ventricles were evaluated separately. We compared mean measurements; mean differences, association with gestational age (GA), association with the presence of a brain anomaly, and agreement between MRI and US. Results: The LV and RV were measured in 65 and 64 cases, respectively. LV and RV size estimates were significantly greater when measured by MRI compared with US (p < 0.001). Therefore, LV and RV were 0.87 mm and 0.89 mm larger in MRI versus US, respectively. Neither GA at measurement or presence/absence of a brain anomaly was significantly associated with differences in measurements. When comparing the agreement between the US and MRI measurements for ventriculomegaly; the kappa level of agreement for the LV and RV was 0.74 for each. Conclusion: MRI measurements of ventricles are significantly larger than the measurements by US by ∼1 mm. There is a good level of agreement when categorizing by normal, mild and severe ventriculomegaly.

Twin pregnancy complicated by esophageal atresia, duodenal atresia, gastric perforation, and hypoplastic left heart structures in one twin: a case report and review of the literature

BackgroundThe antenatal diagnosis of a combined esophageal atresia without tracheoesophageal fistula and duodenal atresia with or without gastric perforation is a rare occurrence. These diagnoses are difficult and can be suspected on ultrasound by nonspecific findings including a small stomach and polyhydramnios. Fetal magnetic resonance imaging adds significant anatomical detail and can aid in the diagnosis of these complicated cases. Upon an extensive literature review, there are no reports documenting these combined findings in a twin pregnancy. Therefore we believe this is the first case report of an antenatal diagnosis of combined pure esophageal and duodenal atresia in a twin gestation.Case presentationWe present a case of a 30-year-old G1P0 white woman at 22-week gestation with a monochorionic-diamniotic twin pregnancy discordant for esophageal atresia, duodenal atresia with gastric perforation, hypoplastic left heart structures, and significant early gestation maternal polyhydramnios. In this case, fetal magnetic resonance imaging was able to depict additional findings including area of gastric wall rupture, hiatal hernia, dilation of the distal esophagus, and area of duodenal obstruction and thus facilitated the proper diagnosis. After extensive counseling at our multidisciplinary team meeting, the parents elected to proceed with radiofrequency ablation of the anomalous twin to maximize the survival of the normal co-twin. The procedure was performed successfully with complete cessation of flow in the umbilical artery and complete cardiac standstill in the anomalous twin with no detrimental effects on the healthy co-twin.ConclusionsPrenatal diagnosis of complex anomalies in twin pregnancies constitutes a multitude of ethical, religious, and cultural factors that come into play in the management of these cases. Fetal magnetic resonance imaging provides detailed valuable information that can assist in management options including possible prenatal intervention. The combination of a cystic structure with peristalsis-like movement above the diaphragm (for example, “the upper thoracic pouch sign”), polyhydramnios, and progressive distention of the stomach and duodenum should increase suspicion for a combined pure esophageal and duodenal atresia.

Normal Percentile Reference Curves and Correlation of Acetabular Index and Acetabular Depth Ratio in Children.

Background: Radiographic surveillance of the hip is vital in the diagnosis and treatment of developmental dysplasia of the hip (DDH) in children. The acetabular index (AI) and the acetabular depth ratio (ADR) are radiographic parameters for evaluation of acetabular morphology. Normal reference curves for these parameters that allow for serial evaluation of acetabular development in a manner that is independent of age are necessary and clinically useful. The purpose of this study was (1) to establish normal values of AI and ADR in the normally developing pediatric hip up to age 14, (2) to generate percentile reference curves of both parameters, (3) to determine the extent of correlation between AI and ADR, and (4) to assess intrarater and interrater reliability of AI measurement. Methods: We identified 1734 patients who underwent anterior-posterior pelvic radiography between 2004 and 2014. A total of 1152 patients (age range, 0.15 to 13.97 y; 2304 hips) were identified as radiographically normal in the radiology report, signed by the attending pediatric radiologist on the basis of the absence of structural deformity of the hip and previously established reference values for DDH assessment. A review of the medical records confirmed that patients had no diagnosis of DDH or any other orthopaedic hip pathology. The AI and ADR were measured in all radiographs. Normal values and fully parametric percentile curves were generated from birth to skeletal maturity. Correlation between AI and ADR was assessed using linear regression analysis. Results: Normal AI decreased, and ADR increased, with age. Percentile curves were generated for AI and ADR. Using the provided equations, measured values can be converted to age-appropriate percentile and Z-score. The 2 parameters exhibited strong correlation (Pearson correlation=−0.789, P<0.001). For every unit increase in ADR, AI decreased by 0.94 degrees. Conclusions: We present updated normative values of AI that expand up to age 14, and novel reference values for ADR. The reference curves allow for the easy conversion of measured values to percentile and Z-score. Using the presented method during surveillance of the pathologic hip, change in acetabular development can now be assessed in a manner that is independent of age and the natural development of the acetabulum. Level of Evidence: Level IV—case series.

Prenatal MRI Diagnosis of Hirschsprung's Disease at 29 Weeks' Gestational Age in a Fetus with Heterotaxy and Polysplenia Syndrome

Prenatal diagnosis of Hirschsprungs disease is extremely rare and has only been suggested by ultrasound. This report presents a 29-week fetus with heterotaxy and polysplenia syndrome and prenatal diagnosis of nonrotation of the bowel and Hirschsprungs disease by fetal MRI. None of the previously reported findings in the literature suggestive of distal bowel obstruction were noted in this case. Rather, there was a diminutive size of the rectosigmoid compared to the rest of the colon. Fetal MRI has become an important tool in the fetal diagnosis of multiple anomalies and can aid in perinatal and immediate postnatal care of patients, such as those with Hirschsprungs disease.

Prenatal Diagnosis of Cloacal Exstrophy: A Case Report and Review of the Literature

Cloacal exstrophy (CE) is a rare congenital disorder with a number of significant associated anomalies. Fetal ultrasound has been used to identify CE; however, accurate diagnosis is challenging. Recently, magnetic resonance imaging has been reported to improve prenatal diagnosis and better characterize the associated defects. We report a case of CE accurately diagnosed using magnetic resonance imaging after fetal ultrasound was nondiagnostic and review the literature comparing the use of each modality.

Can a Modified Bosniak Classification System Risk Stratify Pediatric Cystic Renal Masses

Purpose: We characterize and apply the modified Bosniak classification system to a cohort of children with cystic renal lesions and known surgical pathology. Materials and Methods: We identified all patients at our institution with cystic renal masses who also underwent surgery for these lesions. Patients without available preoperative imaging or pathology were excluded. All radiological imaging was independently reviewed by a pediatric radiologist blinded to pathological findings. Imaging characteristics (size, border, septations, calcifications, solid components, vascularity) were recorded from the most recent preoperative ultrasounds and computerized tomograms. The modified Bosniak classification system was applied to these scans and then correlated with final pathology. Results: A total of 22 patients met study criteria. Median age at surgery was 6.1 years (range 11 months to 16.8 years). Of the patients 12 (54.5%) underwent open nephrectomy, 6 (27.3%) open partial nephrectomy, 2 (9.1%) laparoscopic cyst decortication, 1 (4.5%) open renal biopsy and 1 (4.5%) laparoscopic partial nephrectomy. Final pathology was benign in 9 cases (41%), intermediate in 6 (27%) and malignant in 7 (32%). All malignant lesions were modified Bosniak class 4, all intermediate lesions were modified class 3 or 4 and 8 of 9 benign lesions (89%) were modified class 1 or 2. Conclusions: Cystic renal lesions in children with a modified Bosniak class of 1 or 2 were most often benign, while class 3 or 4 lesions warranted surgical excision since more than 90% of masses harbored intermediate or malignant pathology. The modified Bosniak classification system appears to allow for a reasonable clinical risk stratification of pediatric cystic renal masses.