Pallavi Sagar

Gangrenous cholecystitis: prediction with CT imaging

The aim of this study is to determine the usefulness of different patterns of gallbladder mucosal enhancement on contrast-enhanced computed tomography (CT) for differentiating between gangrenous and uncomplicated acute cholecystitis. This retrospective evaluation involved 56 patients with histopathologically proved acute cholecystitis (32 with gangrenous and 24 with uncomplicated acute cholecystitis) who had preoperative contrast-enhanced CT imaging. CT in 38 patients showed a gallbladder mucosal enhancement pattern that could be categorized into continuous, discontinuous, and/or irregular categories. In the other 18 patients, the mucosal enhancement pattern could not be classified due to lack of mucosal enhancement or inadequate mucosal enhancement. On contrast-enhanced CT evaluation, continuous and discontinuous and/or irregular mucosal enhancement patterns were seen in 20 and 18 patients, respectively. Among the 20 patients with continuous mucosal enhancement, 17 had uncomplicated acute cholecystitis. Seventeen of the 18 patients with discontinuous and/or irregular mucosal enhancement had gangrenous cholecystitis. The sensitivity and positive predictive value (PPV) of discontinuous and/or irregular mucosal enhancement in the diagnosis of gangrenous cholecystitis were 30.3% and 94.4% (17 of 18), respectively. The sensitivity and PPV of continuous mucosal enhancement in the diagnosis of uncomplicated acute cholecystitis were 30.3% and 85.5% (17 of 20), respectively. There was a statistically significant difference (p = 0.0005) between the PPV of discontinuous and/or irregular (94.4%) and that of continuous (15%) mucosal enhancement for predicting gangrenous cholecystitis. The pattern of gallbladder mucosal enhancement on CT can be used as a reliable criterion for distinguishing acute, uncomplicated cholecystitis from gangrenous cholecystitis.

Relationship Between Radiologist Training Level and Fluoroscopy Time for Voiding Cystourethrography

OBJECTIVE The objective of our study was to determine whether voiding cystourethrography (VCUG) fluoroscopy time is related to the training level of the performing radiologist. MATERIALS AND METHODS VCUG reports with normal findings from 2008 to 2011 at one institution were retrospectively reviewed. The average fluoroscopy time was calculated for first-year radiology residents, senior radiology residents, pediatric radiology fellows, and attending pediatric radiologists. The average fluoroscopy time was also calculated for radiologist sex, patient sex, and patient age group. The analysis of variance was used to evaluate differences in average fluoroscopy times between training levels of radiologists, patient age groups, and patient sexes. RESULTS We reviewed 784 VCUG reports with normal findings: 340 (43.4%) were performed by first-year residents; 181 (23%), by senior residents; 161 (20.5%), by fellows; and 102 (13%), by attending pediatric radiologists. The overall average fluoroscopy time was 1.86 minutes (SD ± 0.98). The attending pediatric radiologists had the shortest average fluoroscopy time (1.63 ± 0.92 minutes), significantly shorter than senior residents (1.96 ± 1.09 minutes; p = 0.0070) and fellows (1.91 ± 0.85 minutes; p = 0.0255). There was no significant difference between attending radiologists and first-year residents (1.85 ± 1.00 minutes; p = 0.0550). The male-to-female ratio of radiologists was 54% versus 46%, with identical average fluoroscopy times: male radiologists, 1.86 ± 1.05 minutes; female radiologists, 1.86 ± 0.90 minutes. There was no significant difference in average fluoroscopy times among patient age groups: 1.93, 1.76, and 1.78 minutes, respectively, for groups A (0-1 years), B (> 1 to ≤ 5 years), and C (> 5 years) (p = 0.1750, 0.4605, 0.6303). The average fluoroscopy time for male patients (2.02 ± 1.00 minutes) was significantly longer than that for female patients (1.71 ± 0.95 minutes; p < 0.0001). CONCLUSION Attending pediatric radiologists have the shortest fluoroscopy time; the differences between their average time compared with the average times of pediatric radiology fellows and of senior radiology residents were statistically significant. The average fluoroscopy time is longer for male patients than for female patients.

Case 12-2008: A Newborn Infant with Intermittent Apnea and Seizures

From the Department of Pathology, University Hospitals Case Medical Center, Cleveland (R.W.R.); the Departments of Radiology (P.S.), Pediatric Cardiology (M.E.K.), Pediatric Neurology (K.S.K.), Pediatric Hematology/Oncology (E.F.G.), and Pathology (D.J.R.), Massachusetts General Hospital, Boston; the Department of Pathology , Case Western Reserve University School of Medicine, Cleveland (R.W.R.); and the Departments of Radiology (P.S.), Pediatrics (M.E.K., K.S.K., E.F.G.), and Pathology (D.J.R.), Harvard Medical School, Boston.

MRI with synchronized audio to evaluate velopharyngeal insufficiency.

Objective To demonstrate the feasibility of simultaneous-acquired magnetic resonance imaging (MRI) and high-quality synchronized audio recording for evaluating velopharyngeal closure. Design Institutional Review Board–approved case series. Setting Tertiary care hospital. Patients Three healthy adult volunteers with a normal speech pattern. Interventions MRI with simultaneous recorded audio files evaluating velopharyngeal closure. Main outcome measure Precise imaging and audio coordination of specific phonatory tasks. Results Synchronization of MRI and audio in all three adults. Conclusion Our novel imaging and audio protocol provides simultaneous acquired MRI with synchronized high quality audio for evaluating velopharyngeal closure. This technique may provide the opportunity to improve diagnosis and surgical planning in patients with velopharyngeal insufficiency.

Avascular necrosis of the metacarpal head: a report of two cases and review of literature

BackgroundAvascular necrosis (AVN) of the metacarpal head is a rare condition that can go unrecognized on radiography and progress to degenerative arthritis. Few reports describe the association with trauma, steroid use and systemic lupus erythematosus (SLE). Optimal treatment for this condition has not been established and long-term prognosis is unknown.ObjectiveWe present two cases of children with AVN of the fourth metacarpal head with a relatively recent history of indirect hand trauma.Materials and methodsBoth of our cases had radiographs and MRI of the hand.ResultsMRI was diagnostic in both cases; however, radiographs were reported as normal in the early stage in one case.ConclusionAVN of the metacarpal head is rare but can occur in children. Pediatric radiologists should be aware of this uncommon clinical entity, especially in light of increased involvement of children in sporting activities. Active children with hand trauma and children treated with steroids for a variety of conditions are particularly at risk.

Case records of the Massachusetts General Hospital. Case 12-2008. A newborn infant with intermittent apnea and seizures.

From the Department of Pathology, University Hospitals Case Medical Center, Cleveland (R.W.R.); the Departments of Radiology (P.S.), Pediatric Cardiology (M.E.K.), Pediatric Neurology (K.S.K.), Pediatric Hematology/Oncology (E.F.G.), and Pathology (D.J.R.), Massachusetts General Hospital, Boston; the Department of Pathology , Case Western Reserve University School of Medicine, Cleveland (R.W.R.); and the Departments of Radiology (P.S.), Pediatrics (M.E.K., K.S.K., E.F.G.), and Pathology (D.J.R.), Harvard Medical School, Boston.

Case records of the Massachusetts General Hospital. Case 29-2008. A 19-year-old man with weight loss and abdominal pain.

Dr. Jennifer Broder (Pediatrics): A 19-year-old man was admitted to this hospital because of acute abdominal pain. He had been in his usual state of health until the evening before admission, when diffuse abdominal pain developed that was exacerbated by motion and was associated with abdominal distention and nausea. He took famotidine, with no relief. At 2:30 a.m., he was taken to the emergency department of a local hospital. He rated the pain as 8 (on a scale of 0 to 10, with 10 indicating the most severe pain). He did not have vomiting, diarrhea, constipation, fever, chest pain, or dysuria, and he reported no recent travel or contact with ill persons. He had had a normal bowel movement one day earlier, without straining or bleeding. The temperature was 36.6°C, the blood pressure 100/78 mm Hg, the pulse 38 beats per minute, the respirations 18 breaths per minute, and the oxygen saturation 98% while the patient was breathing ambient air. The skin was dry, and the abdomen was tense and distended, with no guarding or rebound tenderness. Laboratory-test results are shown in Table 1. An electrocardiogram revealed sinus bradycardia and nonspecific T-wave changes. Radiographs of the abdomen showed fecal material throughout the colon, distention of the small bowel, gaseous distention of the stomach, and no air–fluid levels. Radiographs of the chest were normal. Urinalysis showed 23 red cells per high-power field and occasional amorphous crystals. Intravenous fluids, morphine, ondansetron, and ranitidine were administered, and the patient was transferred to this hospital. A diagnosis of anorexia nervosa (restrictive form) had been made 4 years earlier. Weight gain had ceased after the age of 11 years (Fig. 1). On evaluation at the age of 15 years 3 months by an adolescent medicine specialist, the patient was unaware he had lost weight and reported no vomiting, diarrhea, binge eating, aversion to food, use of diuretics or laxatives, or obsession with exercise. The blood pressure was 112/59 mm Hg, the pulse 57 beats per minute, and the temperature 36.1°C. Maturation was Tanner stage 2 to 3; the height and weight are shown in Figure 1. The remainder of the examination was normal. He was admitted to another hospital. Evaluation for malabsorption, levels of serum electrolytes, and tests of thyroid, renal, and liver function were normal; results of other laboratory tests are shown in Table 1. During the hospital stay, orthostatic hypotension and bradycardia (30 to 40 beats per minute) Case 29-2008: A 19-Year-Old Man with Weight Loss and Abdominal Pain

Oxygen Saturation Can Predict Pediatric Pneumonia in a Resource-Limited Setting

BACKGROUND The World Health Organization (WHO) recommends using age-specific respiratory rates for diagnosing pneumonia in children. Past studies have evaluated the WHO criteria with mixed results. OBJECTIVE We examined the accuracy of clinical and laboratory factors for diagnosing pediatric pneumonia in resource-limited settings. METHODS We conducted a retrospective chart review of children under 5 years of age presenting with respiratory complaints to three rural hospitals in Rwanda who had received a chest radiograph. Data were collected on the presence or absence of 31 historical, clinical, and laboratory signs. Chest radiographs were interpreted by pediatric radiologists as the gold standard for diagnosing pneumonia. Overall correlation and test characteristics were calculated for each categorical variable as compared to the gold standard. For continuous variables, we created receiver operating characteristic (ROC) curves to determine their accuracy for predicting pneumonia. RESULTS Between May 2011 and April 2012, data were collected from 147 charts of children with respiratory complaints. Approximately 58% of our sample had radiologist-diagnosed pneumonia. Of the categorical variables, a negative blood smear for malaria (χ(2) = 6.21, p = 0.013) and the absence of history of asthma (χ(2) = 4.48, p = 0.034) were statistically associated with pneumonia. Of the continuous variables, only oxygen saturation had a statistically significant area under the ROC curve (AUC) of 0.675 (95% confidence interval [CI] 0.581-0.769 and p = 0.001). Respiratory rate had an AUC of 0.528 (95% CI 0.428-0.627 and p = 0.588). CONCLUSION Oxygen saturation was the best clinical predictor for pediatric pneumonia and should be further studied in a prospective sample of children with respiratory symptoms in a resource-limited setting.

Cardiac arrest: abdominal CT imaging features.

We report computed tomographic findings of two unusual cases of sudden cardiac arrest. The imaging features documented include reflux of contrast into the abdomen as indicated by opacification of renal veins, hepatic veins, inferior vena cava, and hepatic and renal parenchyma. The reflux of contrast into the portal vein in one patient has not been described in the literature. The thoracic findings were reflux of contrast into the coronary sinus, nonopacificaton of the left ventricle with intravenous contrast, and lack of cardiac motion artifact.

Adductor Insertion Avulsion Syndrome

A 51-year-old woman with a history of chronic thigh muscular exertion was examined for pain on the medial aspect of the thighs. A bone scan showed symmetric focal radiotracer uptake at the medial cortex of both proximal femoral shafts. SPECT localized the focal activity to the cortical surface of the femoral shafts. Findings of magnetic resonance imaging (MRI) were unremarkable and hot spots on the bone scan were localized to the anterior end of both adductor brevis muscle insertions. Plain radiographs of the femurs, which showed bilateral periosteal reactions along the medial proximal femoral shafts, further confirmed the diagnosis of thigh splints at the insertion of the adductor brevis.