Efficacy and safety of deep sedation by non-anesthesiologists for cardiac MRI in children

Background

Cardiac MRI has become widespread to characterize cardiac lesions in children. No study has examined the role of deep sedation performed by non-anesthesiologists for this investigation.

Objective

We hypothesized that deep sedation provided by non-anesthesiologists can be provided with a similar safety and efficacy profile to general anesthesia provided by anesthesiologists.

Materials and methods

This is a retrospective chart review of children who underwent cardiac MRI over a 5-year period. The following data were collected from the medical records: demographic data, cardiac lesion, American Society of Anesthesiologists (ASA) physical status, sedation type, provider, medications, sedation duration and adverse events or interventions. Image and sedation adequacy were recorded.

Results

Of 1,465 studies identified, 1,197 met inclusion criteria; 43 studies (3.6%) used general anesthesia, 506 (42.3%) had deep sedation and eight (0.7%) required anxiolysis only. The remaining 640 studies (53.5%) were performed without sedation. There were two complications in the general anesthesia group (4.7%) versus 17 in the deep sedation group (3.4%). Sedation was considered inadequate in 22 of the 506 deep sedation patients (4.3%). Adequate images were obtained in 95.3% of general anesthesia patients versus 86.6% of deep sedation patients.

Conclusion

There was no difference in the incidence of adverse events or cardiac MRI image adequacy for children receiving general anesthesia by anesthesiologists versus deep sedation by non-anesthesiologists. In summary, this study demonstrates that an appropriately trained sedation provider can provide deep sedation for cardiac MRI without the need for general anesthesia in selected cases.     

Tick-borne encephalitis in children and adolescents in the Czech Republic between 1960 and 2007

Background

The Czech Republic ranks among the countries with the highest prevalence of tick-borne encephalitis worldwide. The region of West Bohemia has the second highest morbidity within the Czech Republic.

Methods

Between 1960 and 2007, laboratories confirmed 410 cases of tick-borne encephalitis in children and adolescents of West Bohemia. Available epidemiological data were analyzed.

Results

The highest incidence (per 100 000 population) was found in the group of 15?C19 years for both genders (males: 6.2; females: 4.3). Data on the consumption of non-pasteurized milk were found in 5.4% of patients. The preschool age group showed its highest incidence in June and September, and the risk of infection for older children was in July and August.

Conclusions

The current low coverage of vaccination leads to an insignificant improvement to the overall frequency of this disease.     

Bare spot of the glenoid fossa in children: incidence and MRI features

Background

The bare spot of the glenoid fossa is a normal cartilage defect seen frequently in adults. It has been used on arthroscopy as a landmark for the center of the glenoid fossa. There are no reports of this variant in children, but we have noted it on some pediatric clinical shoulder MRI studies.

Objective

Our main purpose is to evaluate the incidence of the bare spot in children and define location and MRI features.

Materials and methods

Shoulder MRI studies (total 570) from 2004 to 2008 were reviewed. Children were divided into two age groups: group 1, 0–10 years (n?=?200), group 2, 11–20 years (n?=?370).

Results

A total of 12 bare spots (2.1%) were identified; all were seen in group 2. Eight (67%) were central and four were eccentric in the glenoid fossa. All showed a well-marginated focal cartilage defect containing hyperintense joint fluid or contrast agent. Three also had air.

Conclusion

The bare spot is seen in children. The absence in children younger than 10 years and the low incidence in the second decade support the proposed acquired nature. Familiarity with this finding is important so as not to misinterpret it as a pathologic condition.     

Recurrence of acute appendicitis after non-operative treatment of appendiceal abscess in children: a single-centre experience

Background/purpose

The aim of this study was to evaluate the incidence of recurrence of acute appendicitis after initial successful non-operative treatment of appendiceal abscess in children.

Methods

This study was an observational cohort study of children treated non-operatively for appendiceal abscess at a large tertiary referral centre from 2006 to 2010. The primary outcome was recurrence of acute appendicitis. Secondary outcome variables were re-admission and interval appendectomy.

Results

Eighty-nine patients were discharged after successful non-operative treatment of appendiceal abscess. The median age was 10.1 (1.3–16.3) years. Nine patients underwent surgery during the follow-up period. Five patients were re-admitted with ongoing symptoms leading to an appendectomy. They all returned shortly after discharge and are considered failures of initial treatment. Two of 82 patients returned with a new episode of acute appendicitis during the trial period. Hence, the recurrence rate was 2.4 % during 5.1 years of follow-up.

Conclusion

Our data support the strategy of not performing an interval appendectomy after successful non-operative treatment with antibiotics of an appendiceal abscess in children.     

Small-bowel MRI in children and young adults with Crohn disease: retrospective head-to-head comparison of contrast-enhanced and diffusion-weighted MRI

Background

Small-bowel MRI based on contrast-enhanced T1-weighted sequences has been challenged by diffusion-weighted imaging (DWI) for detection of inflammatory bowel lesions and complications in patients with Crohn disease.

Objective

To evaluate free-breathing DWI, as compared to contrast-enhanced MRI, in children, adolescents and young adults with Crohn disease.

Materials and methods

This retrospective study included 33 children and young adults with Crohn disease ages 17?±?3 years (mean ± standard deviation) and 27 matched controls who underwent small-bowel MRI with contrast-enhanced T1-weighted sequences and DWI at 1.5 T. The detectability of Crohn manifestations was determined. Concurrent colonoscopy as reference was available in two-thirds of the children with Crohn disease.

Results

DWI and contrast-enhanced MRI correctly identified 32 and 31 patients, respectively. All 22 small-bowel lesions and all Crohn complications were detected. False-positive findings (two on DWI, one on contrast-enhanced MRI), compared to colonoscopy, were a result of large-bowel lumen collapse. Inflammatory wall thickening was comparable on DWI and contrast-enhanced MRI. DWI was superior to contrast-enhanced MRI for detection of lesions in 27% of the assessed bowel segments and equal to contrast-enhanced MRI in 71% of segments.

Conclusion

DWI facilitates fast, accurate and comprehensive workup in Crohn disease without the need for intravenous administration of contrast medium. Contrast-enhanced MRI is superior in terms of spatial resolution and multiplanar acquisition.     

Clinical and MRI features of neurological complications after influenza A (H1N1) infection in critically ill children

Background

Influenza A (H1N1) can cause severe neurological complications.

Objective

The purpose of this study was to analyze clinical and MRI features of neurological complications after H1N1 infection in critically ill children.

Materials and methods

We retrospectively analyzed clinical and neuroimaging findings in 17 children who were hospitalized in an intensive care unit with severe neurological complications after H1N1 infection in South China between September 2009 and December 2011. All children underwent pre- and post-contrast-enhanced brain MRI. Postmortem studies were performed in two children.

Results

Six children died, five because of acute necrotizing encephalopathy (ANE) and one because of intracranial fungal infection. Eleven recovered; their manifestations of H1N1 were meningitis (3), encephalitis (1) and influenza encephalopathy (7). MRI features of ANE included multiple symmetrical brain lesions demonstrating prolonged T1 and T2 signal in the thalami, internal capsule, lenticular nucleus and pontine tegmentum. Postmortem MRI in two children with acute necrotizing encephalopathy showed diffuse prolonged T1 and T2 signal in the bilateral thalami, brainstem deformation and tonsillar herniation.

Conclusion

Fatal neurological complications in children after H1N1 infection include ANE and opportunistic fungal infection. MRI is essential for identification of neurological complications and for clinical evaluation.     

Clinical impact of gadolinium in the MRI diagnosis of musculoskeletal infection in children

Background

The incremental value of gadolinium in the diagnosis of musculoskeletal infection by MRI is controversial.

Objective

To compare diagnostic utility of noncontrast with contrast MRI in the evaluation of pediatric musculoskeletal infections.

Materials and methods

We reviewed 90 gadolinium-enhanced MRIs in children with suspected musculoskeletal infection. Noncontrast and contrast MRI scans were evaluated to determine sensitivity and specificity in the diagnosis of musculoskeletal infection and identification of abscesses.

Results

Pre- and post-contrast diagnosis of osteomyelitis sensitivity was 89% and 91% (P?=?1.00) and specificity was 96% and 96% (P?=?1.00), respectively; septic arthritis sensitivity was 50% and 67% (P?=?1.00) and specificity was 98% and 98% (P?=?1.00), respectively; cellulitis/myositis sensitivity was 100% and 100% (P?=?1.00) and specificity was 84% and 88% (P?=?0.59), respectively; abscess for the total group was 22 (24.4%) and 42 (46.6%), respectively (P?<?0.0001). Abscesses identified only on contrast sequences led to intervention in eight additional children. No child with a final diagnosis of infection had a normal pre-contrast study.

Conclusion

Intravenous gadolinium should not be routinely administered in the imaging work-up of nonspinal musculoskeletal infections, particularly when pre-contrast images are normal. However, gadolinium contrast significantly increases the detection of abscesses, particularly small ones that might not require surgical intervention.     

Diagnostic performance of contrast-enhanced MR for acute appendicitis and alternative causes of abdominal pain in children

Objective

Unenhanced MRI has emerged as a useful tool for diagnosing pediatric acute appendicitis. The use of contrast-enhanced MRI for diagnosing pediatric appendicitis has not been documented. The purpose of this study is to examine the diagnostic performance of contrast-enhanced MRI for acute appendicitis and alternative entities in the pediatric population presenting with acute abdominal pain.

Materials and methods

A retrospective review was conducted of 364 consecutive pediatric patients undergoing contrast-enhanced MRI for the evaluation of possible appendicitis at a single institution between November 2012 and September 2013.

Results

There were 132 cases of pathologically confirmed appendicitis out of 364 pediatric patients (36.3%) included in the study. Overall sensitivity and specificity were 96.2% (95% CI [91.4–98.4%]) and 95.7% (95% CI [92.3–97.6%]), respectively. Positive predictive value and negative predictive value were 92.7% (95% CI [86.6–96.3%]) and 97.8% (95% CI [94.7–99.1%]), respectively. The appendix was visualized in 243 cases (66.8%). Imaging confirmed alternative diagnoses in 75 patients, including most commonly colitis, enteritis or terminal ileitis (n?=?25, 6.9%), adnexal cysts (n?=?25, 6.9%) and mesenteric adenitis (n?=?7, 1.9%).

Conclusion

Contrast-enhanced MRI is capable of accurately diagnosing acute appendicitis while detecting many alternative entities of abdominal pain, and it allows good visualization of the appendix. Further evaluation is needed to determine whether contrast-enhanced MRI provides an advantage over non-enhanced MRI for imaging evaluation of acute abdominal pain in the pediatric population.     

Lactobacillus rhamnosus GG supplementation for preventing respiratory infections in children: A Meta-analysis of Randomized, Placebo-controlled Trials

Objective

To systematically review the effectiveness of administering Lactobacillus rhamnosus GG (LGG) for preventing respiratory infections in children.

Design

Systematic Review and Meta-analysis.

Data sources

Electronic databases and trial registries.

Results

Four RCTs involving 1805 participants met the inclusion criteria. Compared with placebo, LGG administration was associated with a reduced incidence of acute otitis media (four RCTs, n=1805, RR 0.76, 95% CI 0.64–0.91, fixed effects model, NNT 17, 95% CI 11–46), a reduced risk of upper respiratory infections (one RCT, n=281, RR 0.62, 95% CI 0.50–0.78, NNT 4, 95% CI 3–8) and antibiotic treatments (four RCTs, n=1805, RR 0.80, 95% CI 0.71–0.91, fixed effects model). There was no significant difference between the LGG and the control groups in the risk of overall respiratory infections and the incidence of lower respiratory infections. However, subgroup analysis of two studies on children older than 1 year showed significant reduction in the risk of overall respiratory infections (two RCTs, n=794, RR 0.73, 95% CI 0.57–0.92, random effects model, NNT 8, 95% CI 5–14). Adverse effects were similar in both groups. No serious adverse events were reported.

Conclusion

The administration of Lactobacillus rhamnosus GG compared with placebo has the potential to reduce the incidence of acute otitis media, the upper respiratory infections and antibiotic use in children.     

MRI findings in patients with defecatory dysfunction after surgical correction of anorectal malformation

Background

Postoperative anorectal malformation patients frequently have defecatory dysfunction. MRI may be useful in the management of these patients.

Objective

To analyze static and dynamic MRI findings in patients with defecatory dysfunction after correction of anorectal malformation (ARM), and compare differences between patients with constipation and fecal incontinence.

Materials and methods

Pelvic MRI studies of 20 constipated and 32 incontinent postoperative ARM patients were analyzed retrospectively to determine the location and morphology of the neorectum, presence of peritoneal fat herniation, presence of scarring, development of the striated muscle complex (SMC) and any other abnormalities. The two groups were then compared using χ ²-test. Eighteen patients also underwent MRI defecography to evaluate pelvic floor function and abnormalities are reported.

Results

The children with incontinence were more likely to have abnormal location of the neorectum (P = 0.031), increased anorectal angle (ARA) (P = 0.031) and peritoneal fat herniation (P = 0.032), and less likely to have dilation of the neorectum (P = 0.027), than the children with constipation. There were no significant differences between the two groups in incidence of focal stenosis of the neorectum (P = 0.797), presence of extensive scarring (P = 0.591) and developmental agenesis of the SMC (P > 0.05). MRI defecography showed 6 anterior rectoceles, 6 cystoceles and 18 pelvic floor descents.

Conclusions

MRI is a helpful imaging modality in postoperative ARM patients with defecatory dysfunction, and it shows distinct differences between the children with constipation and incontinence and provides individualized information to guide further treatment.     

Congenital dacryocystocele: prenatal MRI findings

Background

Congenital dacryocystocele can be diagnosed prenatally by imaging. Prenatal MRI is increasingly utilized for fetal diagnosis.

Objective

To present the radiological and clinical features of seven fetuses with congenital dacryocystocele diagnosed with prenatal MRI.

Materials and methods

The institutional database of 1,028 consecutive prenatal MR examinations performed during a period of 4 years was reviewed retrospectively. The cases of congenital dacryocystocele were identified by reading the report of each MRI study.

Results

The incidence of dacryocystocele diagnosed with prenatal MRI was 0.7% (n?=?7/1,028). The dacryocystocele was bilateral in three fetuses. Mean gestational age at the time of diagnosis was 31 weeks. The indication for prenatal MRI was the presence or the suspicion of central nervous system abnormality in six fetuses and diaphragmatic hernia in one. Dacryocystocele was associated with an intranasal cyst in six of ten eyes. Prenatal sonography revealed dacryocystocele in only two of seven fetuses. Of eight eyes with postnatal follow-up, four did not have any lacrimal symptoms.

Conclusion

Prenatal MRI can delineate congenital dacryocystocele more clearly and in a more detailed fashion than ultrasonography. Presence of dacryocystocele was symptomatic in only 50% of our patients, supporting that prenatal diagnosis of dacryocystocele might follow a benign course.     

MR imaging findings suggestive of posterior reversible encephalopathy syndrome in adolescents with systemic lupus erythematosus

Background

Endothelial damage, hypertension and cytotoxic medications may serve as risk factors for the posterior reversible encephalopathy syndrome (PRES) in systemic lupus erythematosus. There have been few case reports of these findings in pediatric lupus patients.

Objective

We describe clinical and neuroimaging findings in children and adolescents with lupus and a PRES diagnosis.

Materials and methods

We identified all clinically acquired brain MRIs of lupus patients at a tertiary care pediatric hospital (2002–2008). We reviewed clinical features, conventional MRI and diffusion-weighted imaging (DWI) findings of patients with gray- and white-matter changes suggestive of vasogenic edema and PRES.

Results

Six pediatric lupus patients presenting with seizures and altered mental status had MRI findings suggestive of PRES. In five children clinical and imaging changes were seen in conjunction with hypertension and active renal disease. MRI abnormalities were diffuse and involved frontal regions in five children. DWI changes reflected increased apparent diffusivity coefficient (unrestricted diffusion in all patients). Clinical and imaging changes significantly improved with antihypertensive and fluid management.

Conclusion

MRI changes suggestive of vasogenic edema and PRES may be seen in children with active lupus and hypertension. The differential diagnosis of seizures and altered mental status should include PRES in children, as it does in adults.     

Prevalence of radiographic semicircular canal dehiscence in very young children: an evaluation using high-resolution computed tomography of the temporal bones

Background

Previous studies suggest that semicircular canal dehiscences (SCDs) have a developmental origin.

Objective

We hypothesized that if SCDs originate during development, incidence of radiographic SCDs in young children will be higher than in adults.

Materials and methods

Thirty-four temporal bone HRCTs of children younger than 2?years and 40 temporal bone HRCTs of patients older than 18?years were reformatted and re-evaluated for presence of SCD or canal thinning. Results were compared with indications for HRCT and clinical information.

Results

SCDs were detected in 27.3% of children younger than 2?years of age (superior, 13.8%; posterior, 20%) and in 3% of adults (P? <?0.004). Of children with one radiographic dehiscence, 55.6% had multiple and 44% had bilateral SCDs on HRCT. No lateral canal SCDs were present. Thinning of bone overlying the semicircular canals was found in 44% of children younger than 2?years and 2.5% of adults (P?<?0.0001).

Conclusion

SCDs are more common on HRCTs of very young children. This supports the hypothesis that SCDs originate from discontinuation of bone deposition/maturation. However, SCDs on imaging do not necessarily correlate with canal dehiscence syndrome and should therefore be interpreted carefully.     

Prediction of compliance with MRI procedures among children of ages 3 years to 12 years

Background

A number of children are unable to comply with an MRI procedure and require general anesthetic. However, we lack information about which factors are associated with MRI compliance in young children.

Objective

To determine the strongest predictors of MRI compliance, focusing on variables that can be easily rated by patients’ parents.

Materials and methods

A sample of 205 children ages 3–11 years (mean age 6.6 years) who were at risk of non-compliance were recruited from a children’s hospital. Their parents completed a behavior assessment scale for children as well as a questionnaire that assessed their expectations of compliance and perception of their child’s typical medical compliance. The children subsequently completed a mock MRI with an educational play therapist and a clinical MRI, with the quality of the scan scored by the MRI technologist.

Results

Overall, 88.3% of children complied with the clinical scan and achieved diagnostic images, with age unrelated to compliance in this well-prepared patient group. The strongest predictors of MRI compliance were parental expectations and ratings of how well the child typically copes with medical procedures. Non-compliance was related to child attention problems and to poor adaptability among children. A total of 64 preschool-age children (91.4%) and 110 school-age children (95.7%) were correctly classified as compliant or non-compliant based on these predictor variables.

Conclusion

A child’s temperament, medical experiences and parental expectations provide important information in predicting which children successfully comply with an MRI procedure and which require general anesthesia. Further study is needed to explore the utility of these variables in predicting compliance at sites that do not have access to an MRI simulator.     

A retrospective review of pituitary MRI findings in children on growth hormone therapy

Background

Patients with congenital hypopituitarism might have the classic triad of pituitary stalk interruption syndrome, which consists of: (1) an interrupted or thin pituitary stalk, (2) an absent or ectopic posterior pituitary (EPP), and (3) anterior pituitary hypoplasia or aplasia.

Objective

To examine the relationship between pituitary anatomy and the degree of hormonal dysfunction.

Materials and methods

This study involved a retrospective review of MRI findings in all children diagnosed with congenital growth hormone deficiency from 1988 to 2010 at a tertiary-level pediatric hospital.

Results

Of the 52 MRIs reviewed in 52 children, 26 children had normal pituitary anatomy and 26 had one or more elements of the classic triad. Fourteen of fifteen children with multiple pituitary hormone deficiencies had structural anomalies on MRI. Twelve of 37 children with isolated growth hormone deficiency had an abnormal MRI.

Conclusion

Children with multiple pituitary hormone deficiencies were more likely to have the classic triad than children with isolated growth hormone deficiency. A normal MRI was the most common finding in children with isolated growth hormone deficiency.     

Percutaneous drainage of subperiosteal abscess: a potential treatment for osteomyelitis

Objective

Intravenous antibiotics and surgical drainage are the accepted methods of treating osteomyelitis complicated by abscess formation. The objective of this study was to determine whether percutaneous drainage of subperiosteal abscess is a potential treatment for osteomyelitis.

Materials and methods

Three pediatric patients with subperiosteal abscesses from acute osteomyelitis had percutaneous drainage with sonographic and fluoroscopic guidance using a Seldinger technique and an 8-F catheter.

Results

Two patients required no further intervention and had thee drainage catheter removed after 72 h. After completing a course of antibiotics they healed completely. One patient, after a week of purulent drainage, required open drainage including a bone .debridement of an area of septic necrosis.

Conclusion

Percutaneous drainage of subperiosteal abscess may be an alternative to surgical drainage when medical therapy alone is inadequate. Development of intraosseous abscess, necrosis or persistent drainage suggests further intervention may be necessary.     

The impact of preparation and support procedures for children with sickle cell disease undergoing MRI

Background

Children with sickle cell disease (SCD) often undergo MRI studies to assess brain injury or to quantify hepatic iron. MRI requires the child to lie motionless for 30–60?min, thus sedation/anesthesia might be used to facilitate successful completion of exams, but this poses additional risks for SCD patients. To improve children’s ability to cope with MRI examinations and avoid sedation, our institution established preparation and support procedures (PSP).

Objective

To investigate the impact of PSP in reducing the need for sedation during MRI exams among children with SCD.

Materials and methods

Data on successful completion of MRI testing were compared among 5- to 12-year-olds who underwent brain MRI or liver R2*MRI with or without receiving PSP.

Results

Seventy-one children with SCD (median age 9.85?years, range 5.57–12.99?years) underwent a brain MRI (n?=?60) or liver R2*MRI (n?=?11). Children who received PSP were more likely to complete an interpretable MRI exam than those who did not (30 of 33; 91% vs. 27 of 38; 71%, unadjusted OR?=?4.1 (P?=?0.04) and OR?=?8.5 (P?<?0.01) when adjusting for age.

Conclusion

PSP can help young children with SCD complete clinically interpretable, nonsedated MRI exams, avoiding the risks of sedation/anesthesia.     

MRI of radiographically occult ischial apophyseal avulsions

Background

Acute avulsions of unossified ischial apophyses in children may go undetected on radiography. Therapy includes rest and rehabilitation; however, substantial displacement may require surgery.

Objective

Our purpose is to illustrate the utility of MRI in the detection of these radiographically occult injuries in skeletally immature children.

Materials and methods

This retrospective study of more than 5?years included children with ischial avulsions who were evaluated with both radiography and MRI within 3?weeks of acute injury. Initially, radiographs were reviewed to identify those children with unossified ischial apophyses. Subsequently, their MRI examinations were assessed for physeal disruption, bone/soft tissue edema, periosteal/perichondrial elevation and disruption. Initial and follow-up radiographs (if available) were reviewed. Patient age, symptoms and offending activity were determined from clinical records.

Results

Five children met inclusion criteria. All initial radiographs were normal. MRI showed: edema (n?=?5), periosteal elevation (n?=?4), periosteal/perichondrial disruption (n?=?4), >5.5?mm displacement (n?=?0). Follow-up radiographs in two children (2 and 2.5?months from MRI) showed osseous ischial irregularity. The apophyses remained unossified.

Conclusions

Acute unossified ischial apophyseal avulsions in children may be radiographically undetected. In the setting of correlative clinical symptoms, MRI can be used to identify these injuries and to help direct appropriate therapy.