Clinical outcomes of patients with corticosteroid refractory immune checkpoint inhibitor-induced enterocolitis treated with infliximab

INTRODUCTION

Immune checkpoint inhibitors (CPIs) have changed the treatment landscape for many cancers, but also cause severe inflammatory side effects including enterocolitis. CPI-induced enterocolitis is treated empirically with corticosteroids, and infliximab (IFX) is used in corticosteroid-refractory cases. However, robust outcome data for these patients are scarce.

METHODS

We conducted a multicenter (six cancer centers), cohort study of outcomes in patients treated with IFX for corticosteroid-refractory CPI-induced enterocolitis between 2007 and 2020. The primary outcome was corticosteroid-free clinical remission (CFCR) with Common Terminology Criteria for Adverse Events (CTCAE) grade 0 for diarrhea at 12 weeks after IFX initiation. We also assessed cancer outcomes at 1 year using RECIST V1.1 criteria.

RESULTS

127 patients (73 male; median age 59 years) were treated with IFX for corticosteroid-refractory CPI-induced enterocolitis. Ninety-six (75.6%) patients had diarrhea CTCAE grade >2 and 115 (90.6%) required hospitalization for colitis. CFCR was 41.2% at 12 weeks and 50.9% at 26 weeks. In multivariable logistic regression, IFX-resistant enterocolitis was associated with rectal bleeding (OR 0.19; 95% CI 0.04 to 0.80; p=0.03) and absence of colonic crypt abscesses (OR 2.16; 95% CI 1.13 to 8.05; p=0.03). Cancer non-progression was significantly more common in patients with IFX-resistant enterocolitis (64.4%) as compared with patients with IFX-responsive enterocolitis (37.5%; p=0.013).

CONCLUSION

This is the largest study to date reporting outcomes of IFX therapy in patients with corticosteroid-refractory CPI-induced enterocolitis. Using predefined robust endpoints, we have demonstrated that fewer than half of patients achieved CFCR. Our data also indicate that cancer outcomes may be better in patients developing prolonged and severe inflammatory side effects of CPI therapy.

Radiation dose to the lens from CT of the head in young people

AIM

To determine cumulative scan frequencies and estimate lens dose for paediatric computed tomography (CT) head examinations in the context of potential cataract risk.

MATERIALS AND METHODS

The cumulative number of head-region CT examinations among a cohort of 410,997 children and young adults who underwent CT in the UK between 1985 and 2014 was calculated. Images from a sample of these head examinations (n=668) were reviewed to determine the level of eye inclusion. Lens dose per scan was estimated using the computer program, NCICT V1.0, for different levels of eye inclusion and exposure settings typical of past and present clinical practice.

RESULTS

In total 284,878 patients underwent 448,108 head-region CT examinations. The majority of patients (72%) had a single recorded head-region examination. A small subset (∼1%, n=2,494) underwent ≥10 examinations, while 0.1% (n=387) underwent ≥20. The lens was included within the imaged region for 57% of reviewed routine head examinations. In many cases, this appeared to be intentional, i.e. protocol driven. In others, there appeared to have been an attempt to exclude the eyes through gantry angulation. Estimated lens doses were 20-75 mGy (mean: 47 mGy) where the eye was fully included within the examination range and 2-7 mGy (mean: 3.1 mGy) where the lens was fully excluded. Potential cumulative lens doses ranged from ∼3 mGy to ∼4,700 mGy, with 2,335 patients potentially receiving >500 mGy.

CONCLUSION

The majority of young people will receive cumulative lens doses well below 500 mGy, meaning the risk of cataract induction is likely to be very small.

Shortage of paediatric radiologists acting as an expert witness: position statement from the British Society of Paediatric Radiology (BSPR) National Working Group on Imaging in Suspected Physical Abuse (SPA)

One of the most challenging areas of radiological imaging in children is the diagnosis of physical abuse. There is a dearth of paediatric radiologists willing to act as expert witnesses, particularly in the family courts. There are a number of reasons why radiologists may not be interested or willing to put themselves forward to work as expert witnesses in this field. A group of imaging experts recently formed the "British Society of Paediatric Radiology (BSPR) Working Group on Imaging in Suspected Physical Abuse (SPA)". The group comprises radiologists and neuroradiologists with current or previous experience of providing expert witness reports to the court in cases of SPA. The group met in January 2019 to explore pragmatic solutions to the chronic inefficiencies in both medical and legal practices and the challenges that arise from working in a legal arena with different structures, goals, and assessment criteria. Key issues concerned organisational inefficiencies, variable support from National Health Service Trusts and the Royal College of Radiologists to conduct this work, and the risk/benefit of involvement. This work is important for the patient, parents, and society in general, and highly rewarding for clinical practitioners who are involved, but there are several issues with current practices that discourage active participation. With several members of the group either retired or close to retirement, the shortage of experts is becoming a pressing issue within the UK, which requires an engaged multidisciplinary group to come up with creative solutions. Here, the group provide a consensus opinion highlighting the current barriers and potential facilitators to increasing the number of radiologists willing to provide opinions to the court.

Field energetics and lung function in wild bottlenose dolphins, Tursiops truncatus, in Sarasota Bay Florida

We measured respiratory flow rates, and expired O2 in 32 (2-34 years, body mass [Mb] range: 73-291 kg) common bottlenose dolphins (Tursiops truncatus) during voluntary breaths on land or in water (between 2014 and 2017). The data were used to measure the resting O2 consumption rate ([Formula: see text], range: 0.76-9.45 ml O2 min-1 kg-1) and tidal volume (VT, range: 2.2-10.4 l) during rest. For adult dolphins, the resting VT, but not [Formula: see text], correlated with body mass (Mb, range: 141-291 kg) with an allometric mass-exponent of 0.41. These data suggest that the mass-specific VT of larger dolphins decreases considerably more than that of terrestrial mammals (mass-exponent: 1.03). The average resting [Formula: see text] was similar to previously published metabolic measurements from the same species. Our data indicate that the resting metabolic rate for a 150 kg dolphin would be 3.9 ml O2 min-1 kg-1, and the metabolic rate for active animals, assuming a multiplier of 3-6, would range from 11.7 to 23.4 ml O2 min-1 kg-1.\absbreak Our measurements provide novel data for resting energy use and respiratory physiology in wild cetaceans, which may have significant value for conservation efforts and for understanding the bioenergetic requirements of this species.

CT scanning in children and risk of cancer: what three large-scale studies have demonstrated

That irradiation from diagnostic CT examinations has caused cancers in a small minority of young patients in the past is no longer controversial. Three recent studies from the UK, Australia and the USA have published data supporting a small but real risk of a CT scan in early life being associated with a later risk of malignancy, due solely to the CT scan. The American study showed a temporary increase in the frequency of CT scanning of children with regrettably large variation in radiation dose per scan. Most of the patients in the published studies had their CT examinations over a decade ago, and it is likely in more recent years that widespread reductions in tube current-time product (mAs) have substantially lessened the radiation burden to children from CT. It must be remembered that CT is a very useful clinical test. Whenever CT is justified, the clinical benefit virtually always outweighs the longer term very small risk of malignancy.

Increased uptake on99mTc bone scintigraphy in a case of tumoral calcinosis in a child

Tumoral calcinosis is an idiopathic condition resulting in the periarticular deposition of calcium crystals and salts in soft tissues. It is rare in children, and even rarer in idiopathic form. We present a case of a 2-year-old female with tumoral calcinosis in the supraclavicular region, and, in particular, focus on the pertinent radiological findings with radiography, MRI and bone scintigraphy.

Radiation doses from fluoroscopically guided cardiac catheterization procedures in children and young adults in the United Kingdom: a multicentre study

OBJECTIVE

To gather data on radiation doses from fluoroscopically guided cardiac catheterization procedures in patients aged under 22 years at multiple centres and over a prolonged period in the UK. To evaluate and explain variation in doses. To estimate patient-specific organ doses and allow for possible future epidemiological analysis of associated cancer risks.

METHODS

Patient-specific data including kerma area product and screening times from 10,257 procedures carried out on 7726 patients at 3 UK hospitals from 1994 until 2013 were collected. Organ doses were estimated from these data using a dedicated dosimetry system based on Monte Carlo computer simulations.

RESULTS

Radiation doses from these procedures have fallen significantly over the past two decades. The organs receiving the highest doses per procedure were the lungs (median across whole cohort, 20.5 mSv), heart (19.7 mSv) and breasts (13.1 mSv). Median cumulative doses, taking into account multiple procedures, were 23.2, 22.2 and 16.7 mSv for these organs, respectively. Bone marrow doses were relatively low (median per procedure, 3.2 mSv; cumulative, 3.6 mSv).

CONCLUSION

Most modern cardiac catheterizations in children are moderately low-dose procedures. Technological advances appear to be the single most important factor in the fall in doses. Patients undergoing heart transplants undergo the most procedures. An epidemiological assessment of cancer risks following these procedures may be possible, especially using older data when doses were higher.

ADVANCES IN KNOWLEDGE

This is the first large-scale, patient-specific assessment of organ doses from these procedures in a young population.

Reversible acute anuric kidney injury after surgical evacuation of perinephric hematomas as a complication of renal transplant biopsies

Percutaneous renal transplant biopsy is the gold standard investigation to diagnose the cause of renal allograft dysfunction. There are inherent risks to this investigation, despite the procedure becoming safer due to the increased utilization of ultrasound-guided techniques. These biopsy risks can be increased when there is acute rejection present with a swollen transplanted kidney. Subcapsular hematomas are not uncommon after percutaneous renal transplant biopsies, but we describe two cases of post-biopsy subcapsular hematoma which were associated with acute renal allograft dysfunction in pediatric renal transplant recipients who did not have acute rejection.

Social support and religion: mental health service use and treatment of schizophrenia

The perceptions and religious beliefs held by family members, mental health and health care professionals, and the community may affect the treatment of individuals with schizophrenia. To better identify and understand the influence of families, professionals and community members on individual's treatment for schizophrenia, this review paper examines: (1) the religious perceptions of families, professionals, and the public towards schizophrenia; (2) religious perceptions of the etiology of schizophrenia; (3) how others perceive religion as a coping mechanism; and (4) how religion influences treatment engagement and help-seeking behaviors. MEDLINE and PsycInfo databases were systematically searched from 1980 to 2010 using the terms schizophrenia, schizoaffective, schizophreniform, psychotic disorder not otherwise specified and religion, religiosity, spirituality, and faith. Forty-three (n = 43) original research studies met the inclusion criteria. This study found that religious beliefs influence the treatment of schizophrenia in the following ways: Religious themes were positively associated with coping, treatment engagement and help-seeking behavior. Evidence of religious underpinnings was found in perceptions of etiology. The findings also indicate that there is often both a preference among family members and caregivers to utilize religious-based professionals and caution toward mental health professionals. Researchers and professionals may find avenues for improving treatment through examining the interaction of religious and schizophrenia at the social support level.

Robotic-assisted transabdominal cerclage (RoboTAC) in the non-pregnant patient

The use of cerclage, either through vaginal or abdominal routes, to assist in delaying pre-term delivery among select women with cervical insufficiency may be beneficial, but can also carry significant morbidity. Robotic-assisted transabdominal cervical cerclage (RoboTAC) in the non-pregnant patient has the ability to not only reduce associated morbidity, but also offer the same benefits as the more traditional laparotomy and laparoscopic approaches, while removing the risk to an in situ fetus. We report the use of robotic-assisted transabdominal cervical cerclage in 24 non-pregnant women. Feasibility of the procedure is discussed along with a description of the technical surgical details. In addition, limited pregnancy outcomes are presented. Our results suggest that RoboTAC is a safe alternative to the traditional laparotomy procedure with quicker recovery time.

Added value of abdominal cross-sectional imaging (CT or MRI) in staging of Wilms' tumours

AIM

To assess the added information gained from computed tomography (CT) or magnetic resonance imaging (MRI) of the abdomen over abdominal ultrasound in children undergoing staging of Wilms' tumours.

MATERIALS AND METHOD

Fifty-two consecutive patients with histologically proven Wilms' tumours were identified. Each had an initial staging abdominal ultrasound followed by either a CT or MRI examination of the abdomen. Details including tumour size, site, and characteristics, presence of lymph nodes, local invasion, evidence of nephroblastomatosis, and any other relevant finding were gathered from the report of each ultrasound and CT or MRI. Each CT/MRI was then re-reviewed by a consultant paediatric radiologist and a paediatric radiology fellow. The difference in findings between the ultrasound and cross-sectional imaging were noted.

RESULTS

Twelve patients were excluded from the study because the CT/MRI was performed before the ultrasound, or imaging was incomplete. Twenty-six patients were female, 14 male. The ages ranged from 9 months to 10.8 years (mean 3.75 years). Twenty-one patients out of the remaining 40 had additional findings detected on the CT or MRI examination that had not been reported on the ultrasound. The most important additional findings included three patients with nephroblastomatosis and two with contralateral tumours. Other findings included two patients with tumour haemorrhage, four with abdominal lymph node enlargement, three with inferior vena cava (IVC)/renal vein thrombus, four with adjacent organ invasion, one patient where the origin of the abdominal tumour was confirmed as renal, and one patient where possible liver invasion was excluded.

CONCLUSION

In over half the patients, CT or MRI added additional information in the local staging of Wilms' tumours. Sole reliance on ultrasound for Wilms' staging risks missing significant abnormalities.

Development of a database of organ doses for paediatric and young adult CT scans in the United Kingdom

Despite great potential benefits, there are concerns about the possible harm from medical imaging including the risk of radiation-related cancer. There are particular concerns about computed tomography (CT) scans in children because both radiation dose and sensitivity to radiation for children are typically higher than for adults undergoing equivalent procedures. As direct empirical data on the cancer risks from CT scans are lacking, the authors are conducting a retrospective cohort study of over 240,000 children in the UK who underwent CT scans. The main objective of the study is to quantify the magnitude of the cancer risk in relation to the radiation dose from CT scans. In this paper, the methods used to estimate typical organ-specific doses delivered by CT scans to children are described. An organ dose database from Monte Carlo radiation transport-based computer simulations using a series of computational human phantoms from newborn to adults for both male and female was established. Organ doses vary with patient size and sex, examination types and CT technical settings. Therefore, information on patient age, sex and examination type from electronic radiology information systems and technical settings obtained from two national surveys in the UK were used to estimate radiation dose. Absorbed doses to the brain, thyroid, breast and red bone marrow were calculated for reference male and female individuals with the ages of newborns, 1, 5, 10, 15 and 20 y for a total of 17 different scan types in the pre- and post-2001 time periods. In general, estimated organ doses were slightly higher for females than males which might be attributed to the smaller body size of the females. The younger children received higher doses in pre-2001 period when adult CT settings were typically used for children. Paediatric-specific adjustments were assumed to be used more frequently after 2001, since then radiation doses to children have often been smaller than those to adults. The database here is the first detailed organ-specific paediatric CT scan database for the UK. As well as forming the basis for the UK study, the results and description of the methods will also serve as a key resource for paediatric CT scan studies currently underway in other countries.

Urogenital tumours in childhood

The commonest urogenital tumours in childhood are Wilms tumour of the kidney and rhabdomyosarcoma in the pelvis. We review these tumours along with other primary renal tumours and less common ovarian and testicular tumours in childhood. Current clinical concepts, relevant staging investigations and imaging features are described.

Pitfalls in paediatric oncology imaging

Imaging a new mass lesion in a child requires careful consideration of a variety of issues. The age of the child is an important factor in determining the appropriate test to start with and the age also helps provide an appropriate differential diagnosis, which can then be used to guide further imaging. The long-term outcome for most children with cancer is very good, with over 70% achieving 5-year survival and presumed cure. Consequently their imaging requirements should be regarded as equal to all other children. Minimizing exposure to ionizing radiation, particularly where follow-up imaging is required is an important consideration. This article focuses specifically on general paediatric radiology and neuro-oncology imaging is not addressed. The pitfalls to be aware of in plain radiography, ultrasonography, computed tomography, magnetic resonance imaging and nuclear medicine (positron emission tomography-computed tomography and single photon emission computed tomography) in children with a proven or suspected malignancy are discussed.

Self-reported quality of life in children and young people with chronic kidney disease

Chronic kidney disease (CKD) would be expected to impact upon the quality of life (QoL) of children and young people; therefore, it is important that they are given the means to express their opinions about how they perceive their own QoL. We used the Generic Children's Quality of Life Measure (GCQ) in 225 paediatric renal patients (118 male, mean age 13.6 years, range 6.2-18.9 years) from seven UK centres. Of these, 47 were on dialysis (23 on haemodialysis), 128 were post-transplant (47 pre-emptive) and 49 had advanced CKD. A comparison between the 124 renal patients (65 male, mean age 11.2 years) in the same age range as the general population (6-14 years) showed a higher GCQ QoL score for the renal patients (p = 0.02). Analysis of the whole group of renal patients (n = 225) revealed no significant difference between the mean GCQ scores of participants in various treatment modalities (p = 0.26) and no significant differences between gender (p = 0.90) and age group (p = 0.44). The results indicate that young people can perceive their QoL as good despite living with what others may perceive as severe limitations. This may seem counter-intuitive, but QoL is a subjective measure and thus may be difficult to predict from observable limitations (health status). The GCQ is an ideal measure for use in annual departmental audits of generic paediatric QoL and may help to individualise the work of psychosocial teams with each patient.

Bronchomegaly as a complication of fetal endoscopic tracheal occlusion. A caution and a possible solution

Fetal medicine is developing rapidly and aims to improve the outcome for fetuses with congenital anomalies. Fetal endoscopic tracheal occlusion (FETO) has been developed for fetuses with congenital diaphragmatic hernia to counterbalance the compression of the lung by the abdominal viscera, preserving the pulmonary maturation. Because the perinatal morbidity and mortality of patients treated with FETO have decreased, new complications are emerging in the older survivors. Tracheomegaly has been reported to be a late complication of FETO, sometimes requiring tracheostomy. We report a case of bronchial dilatation after FETO and suggest an alternative surgical treatment.

Ankylosing spondylitis monocytes show upregulation of proteins involved in inflammation and the ubiquitin proteasome pathway

OBJECTIVES

To determine if peripheral blood monocytes from patients with ankylosing spondylitis (AS) differed in protein expression compared to rheumatoid arthritis (RA) and healthy controls (HC).

METHODS

Monocyte protein expression was characterised by 2D gel electrophoresis and by label-free quantitative expression profiling, using nano-ultra performance liquid chromatography coupled to electrospray ionisation mass spectrometry (ESI-MS(E), where (E) refers to low/high collision energy switching). Data sets were analysed using the Waters expression profiling system and Ingenuity pathway analysis (IPA).

RESULTS

Two-dimensional gel electrophoresis showed upregulation of proteasomal constituents in AS monocytes, including the beta subunit of proteasome activator (PA)28. Monocyte expression profiling and IPA showed that significant changes in protein expression within the ubiquitin proteasome pathway (UPP) were restricted to AS monocytes. Statistically significant differences in protein expression involving the leucocyte extravasation, vascular endothelial growth factor, integrin and Toll-like receptor signalling pathways were seen in AS and RA monocytes compared to healthy controls. No evidence of upregulation of proteins involved in the endoplasmic reticulum stress response pathway was found in either AS or RA monocytes. Finally, the PA28 complex was shown to increase the generation of human leucocyte antigen (HLA)-B27 antigenic epitopes by the proteasome in vitro.

CONCLUSIONS

Our proteomic analyses support the hypothesis that monocytes play an important role in the pathogenesis of AS and RA, and further suggest a specific role in AS for the UPP. Quantitative proteomic expression profiling constitutes a powerful new tool for rheumatology research.

The role of radiology in paediatric soft tissue sarcomas

Paediatric soft tissue sarcomas (STS) are a group of malignant tumours that originate from primitive mesenchymal tissue and account for 7% of all childhood tumours. Rhabdomyosarcomas (RMS) and undifferentiated sarcomas account for approximately 50% of soft tissue sarcomas in children and non-rhabdomyomatous soft tissue sarcomas (NRSTS) the remainder. The prognosis and biology of STS tumours vary greatly depending on the age of the patient, the primary site, tumour size, tumour invasiveness, histologic grade, depth of invasion, and extent of disease at diagnosis. Over recent years, there has been a marked improvement in survival rates in children and adolescents with soft tissue sarcoma and ongoing international studies continue to aim to improve these survival rates whilst attempting to reduce the morbidity associated with treatment. Radiology plays a crucial role in the initial diagnosis and staging of STS, in the long term follow-up and in the assessment of many treatment related complications. We review the epidemiology, histology, clinical presentation, staging and prognosis of soft tissue sarcomas and discuss the role of radiology in their management.

The radiation burden of radiological investigations

The harmful effects of ionising radiation are widely acknowledged. It has been reported that young children, particularly girls, have a higher sensitivity to radiation than adults. However, the exact detrimental effects of radiation, particularly at the low doses used in routine diagnostic radiography, are unknown and the subject of much controversy. Computed tomography (CT) accounts for about 9% of all radiological examinations but is responsible for 47% of medical radiation dose. Approximately 11% of CT examinations performed are in the paediatric population, but the long-term hazards of CT are unknown.

Renal primitive neuroectodermal tumor in childhood with intracardiac extension

Primary primitive neuroectodermal tumors of the kidney are exceptionally rare and usually affect children and young adults. We report the first pediatric case of renal primitive neuroectodermal tumor presenting with tumor extension along the inferior vena cava to the right ventricle. This case highlights that when considering a renal tumor with significant intravascular extension in the pediatric age group, although the most likely diagnosis remains Wilms tumor, other rare entities may also demonstrate similar clinical and imaging features.

Computed tomography versus bronchography in the diagnosis and management of tracheobronchomalacia in ventilator dependent infants

AIM

To assess the relative accuracy of dynamic spiral computed tomography (CT) compared with tracheobronchography, in a population of ventilator dependent infants with suspected tracheobroncho-malacia (TBM).

SETTING

Paediatric intensive care unit in a tertiary teaching hospital.

PATIENTS AND METHODS

Infants referred for investigation and management of ventilator dependence and suspected of having TBM were recruited into the study. Tracheobronchography and CT were performed during the same admission by different investigators who were blinded to the results of the other investigation. The study was approved by the hospital research ethics committee, and signed parental consent was obtained.

RESULTS

Sixteen infants were recruited into the study. Fifteen had been born prematurely, and five had cardiovascular malformations. In 10 patients there was good or partial correlation between the two investigations, but in six patients there was poor or no correlation. Bronchography consistently showed more dynamic abnormalities, although CT picked up an unsuspected double aortic arch. Radiation doses were 0.27-2.47 mSv with bronchography and 0.86-10.67 mSv with CT.

CONCLUSIONS

Bronchography was a better investigation for diagnosing TBM and in determining opening pressures. Spiral CT is unreliable in the assessment of TBM in ventilator dependent infants. In addition, radiation doses were considerably higher with CT.

The presence of vesicoureteric reflux does not identify a population at risk for renal scarring following a first urinary tract infection

BACKGROUND

Childhood urinary tract infection (UTI) with or without vesicoureteric reflux (VUR) may predispose to renal scarring. There is no clear consensus in the literature regarding imaging following UTI in infancy.

AIMS

To define the role of cystography following a first UTI in children aged under 1 year, when urinary tract ultrasonography (US) is normal.

METHODS

Retrospective data collection of 108 children (216 renal units) aged under 1 year at the time of a bacteriologically proven UTI. All had a normal US and underwent both catheter cystogram and DMSA test. Sensitivity, specificity, likelihood ratios positive and negative, and diagnostic odds ratio were calculated for VUR on cystography versus scarring on DMSA.

RESULTS

VUR was shown in 25 (11.6%) renal units. Scarring on DMSA was seen in 8 (3.7 %) kidneys. Only 16% of kidneys with VUR had associated scarring; 50% of scarred kidneys were not associated with VUR. The likelihood ratio positive was 4.95 (95% CI 2.22 to 11.05) and the likelihood ratio negative was 0.56 (95% CI 0.28 to 1.11). The diagnostic odds ratio was 8.9, suggesting that cystography provided little additional information.

CONCLUSION

Since only 16% of children with VUR had an abnormal kidney, the presence of VUR does not identify a susceptible population with an abnormal kidney on DMSA. In the context of a normal ultrasound examination, cystography contributes little to the management of children under the age of 1 year with a UTI. In this context, a normal DMSA study reinforces the redundancy of cystography.

Advances in paediatric tumour imaging

There have been a number of major advances in imaging technology in recent years. Here we discuss in detail multislice CT and PET, since these are the two modalities generating the most interest in cancer imaging, but which also have the potential for significantly increasing the radiation burden in the paediatric population. In addition, we focus on the implications of the new Response Evaluation Criteria In Solid Tumours (RECIST) guidelines, which describe a significant new method of tumour size measurement.

Primary spontaneous pneumothorax in children: the role of CT in guiding management

AIM

Primary spontaneous pneumothorax (PSP) is rare in older children and most likely to be associated with apical subpleural blebs; there is a significant risk of recurrence. Our aim was to assess the radiological findings and final treatment of PSP in children presenting at our institution.

METHODS

The study included 3 children presenting over a 15-month period at our institution with PSP; the clinical features at presentation and examination findings were recorded. The chest radiographic and CT appearances and findings at surgery were reviewed.

RESULTS

In all cases, chest pain and breathlessness were presenting features and initial treatment included intercostal chest drainage. Chest radiographs on admission raised the suspicion of unilateral apical blebs in 2 children and bilateral apical blebs in the 3rd. Chest CT demonstrated apical blebs/cysts in all 3 children. The cysts ranged in size from 0.5 to 3.0 cm and were bilateral in 2 children. Surgery confirmed the radiological findings in all cases.

CONCLUSION

CT is of value in the detection of apical pleural blebs in children with PSP. On CT, particular attention should be paid to the lung apices, where majority of blebs in otherwise healthy young patients are located. Prompt diagnosis of a morphological abnormality in these children is likely to expedite definitive surgical treatment.

Spontaneous postnatal involution of intraabdominal pulmonary sequestration

Prenatal ultrasonography in 2 pregnant women identified a suprarenal echogenic mass. The lesions were treated conservatively and involuted with time. These masses were consistent with a suprarenal pulmonary sequestration.

Pseudarthrosis presenting as a late complication of meningococcal septicaemia and disseminated intravascular coagulation

Late skeletal complications of meningococcal septicaemia and disseminated intravascular coagulation are well recognised in children and are largely centred on the growing epimetaphyseal region of long bones. In this article we describe a case of pseudarthrosis of the mid-ulna presenting 18 months following a devastating episode of meningococcal septicaemia in a 3-year-old boy. Radiographs and MRI demonstrated the ulna abnormality. We briefly review the late skeletal complications of the disease and other causes of pseudarthrosis.

Gaucher disease in children: radiology of non-central nervous system manifestations

The radiological findings in paediatric Gaucher disease (GD) are reviewed and future challenges for radiology are discussed. This overview is based on a literature review and our experience of children with GD in one of two national institutions for paediatric GD in the UK. GD is known to progress more rapidly in childhood. Current imaging is mainly suitable for ascertaining the complications of GD. The UK recommendations for routine radiological surveillance are discussed. With enzyme replacement therapy (ERT), which dramatically modifies the course of the disorder, the challenge for radiology in the future is likely to be assessing treatment efficacy rather than the detection of disease complications. Disease manifestations are likely to change in those on ERT and the most notable recent alteration in the disease profile in childhood is the virtual disappearance of the acute bone crisis in this population.

Causes and outcome of young infant admissions to a Kenyan district hospital

AIMS

To provide a comprehensive description of young infant admissions to a first referral level health facility in Kenya. These data, currently lacking, are important given present efforts to standardise their care through the integrated management of childhood illness (IMCI) and for prioritising both health care provision and disease prevention strategies.

METHODS

Prospective, 18 month observational study in a Kenyan district hospital of all admissions less than 3 months of age to the paediatric ward.

RESULTS

A total of 1080 infants were studied. Mortality was 18% overall, though in those aged 0-7 days it was 34%. Within two months of discharge a further 5% of infants aged <60 days on admission had died. Severe infection and prematurity together accounted for 57% of inpatient deaths in those aged <60 days, while jaundice and tetanus accounted for another 27%. S pneumoniae, group B streptococcus, E coli, and Klebsiella spp. were the most common causes of invasive bacterial disease. Hypoxaemia, hypoglycaemia, and an inability to feed were each present in more than 20% of infants aged 0-7 days. Both hypoxaemia and the inability to feed were associated with inpatient death (OR 3.8 (95% CI 2.5 to 5.8) and 7.4 (95% CI 4.8 to 11.2) respectively).

CONCLUSIONS

Young infants contribute substantially to paediatric inpatient mortality at the first referral level, highlighting the need both for basic supportive care facilities and improved disease prevention strategies.

Reduction in visceral slide is a good sign of underlying postoperative viscero-parietal adhesions in children

BACKGROUND/PURPOSE

Viscera stuck to the anterior abdominal wall from previous surgery risk injury during laparoscopic surgery. A prospective study was conducted to determine if these adhesions are detectable on ultrasound scan by showing a reduction in the normal visceral slide.

METHODS

Patients undergoing laparoscopic procedure after a previous laparotomy underwent preoperative real-time ultrasound scan to observe if viscera slides freely under the abdominal wall. A reduction in slide was considered a positive sign of underlying adhesions. These findings were correlated with the operative findings.

RESULTS

Anterior abdominal wall scans were performed on 17 children. Reduced visceral slide was seen in 10. Viscero-parietal adhesions were found in 9 of 10 patients. Visceral slide was reduced in a very localized area in 6 patients, and, in these, a loop of bowel (n = 3), liver and bowel (n = 2), or liver (n = 1) was adherent. In 4, reduced visceral slide was seen over a wide area. Extensive adhesions were found in 3 of 4. One renal transplant patient with peritonitis had a false-positive ultrasound scan. At laparotomy there were no adhesions. The peritonitis is thought to have prevented an adequate examination. Seven patients had normal visceral slide. Of these, 4 had no adhesions, but 3 children had flimsy omental adhesions. The sensitivity and specificity of visceral slide in predicting adhesions were 75% and 80%, respectively.

CONCLUSIONS

Reduction in visceral slide is a good sign of underlying postoperative viscero-parietal adhesions. Ultrasonographic mapping of the abdominal wall may be useful in selecting an adhesion-free site for trocar insertion in children with previous operations requiring laparoscopic procedures.