Extraskeletal Calcifications in Hutchinson-Gilford Progeria Syndrome

PURPOSE

Children with Hutchinson-Gilford progeria syndrome (HGPS), a rare premature aging disease, exhibit extraskeletal calcifications detected by radiographic analysis and on physical examination. The aim of this study was to describe the natural history and pathophysiology of these abnormal calcifications in HGPS, and to determine whether medications and/or supplements tested in clinical trials alter their development.

METHODS

Children from two successive clinical trials administering 1) lonafarnib (n = 26) and 2) lonafarnib + pravastatin + zoledronic acid (n = 37) were studied at baseline (pre-therapy), one year on therapy, and at end-of-therapy (3.3-4.3 years after the baseline visit). Calcium supplementation (oral calcium carbonate) was administered during the first year of the second trial and was subsequently discontinued. Information on calcifications was obtained from physical examinations, radiographs, and serum and urinary biochemical measures. The mineral content of two skin-derived calcifications was determined by x-ray diffraction.

RESULTS

Extraskeletal calcifications were detected radiographically in 12/39 (31%) patients at baseline. The odds of exhibiting calcifications increased with age (p = 0.045). The odds were unaffected by receipt of lonafarnib, pravastatin, and zoledronate therapies. However, administration of calcium carbonate supplementation, in conjunction with all three therapeutic agents, significantly increased the odds of developing calcifications (p = 0.009), with the odds plateauing after the supplement's discontinuation. Composition analysis of calcinosis cutis showed hydroxyapatite similar to bone. Although serum calcium, phosphorus, and parathyroid hormone (PTH) were within normal limits at baseline and on-therapy, PTH increased significantly after lonafarnib initiation (p < 0.001). Both the urinary calcium/creatinine ratio and tubular reabsorption of phosphate (TRP) were elevated at baseline in 22/39 (56%) and 31/37 (84%) evaluable patients, respectively, with no significant changes while on-therapy. The mean calcium × phosphorus product (Ca × Pi) was within normal limits, but plasma magnesium decreased over both clinical trials. Fibroblast growth factor 23 (FGF23) was lower compared to age-matched controls (p = 0.03).

CONCLUSIONS

Extraskeletal calcifications increased with age in children with HGPS and were composed of hydroxyapatite. The urinary calcium/creatinine ratio and TRP were elevated for age while FGF23 was decreased. Magnesium decreased and PTH increased after lonafarnib therapy which may alter the ability to mobilize calcium. These findings demonstrate that children with HGPS with normal renal function and an unremarkable Ca × Pi develop extraskeletal calcifications by an unidentified mechanism that may involve decreased plasma magnesium and FGF23. Calcium carbonate accelerated their development and is, therefore, not recommended for routine supplementation in these children.

Thymic size on chest radiograph and rapid disease progression in human immunodeficiency virus 1-infected children

BACKGROUND

Early infection of the thymus, an organ central to the ontogeny of the immune system, has been proposed as a cause of rapid progression in pediatric HIV disease.

OBJECTIVE

To test the hypothesis that small thymic volume is associated with rapid disease progression in HIV-infected children.

DESIGN

Three pediatric radiologists established criteria for rating the size of the thymic profile on chest radiographs. All available baseline chest radiographs were reviewed in a random sequence, with radiologists blinded to study subjects' clinical status. A consensus was reached on whether the thymus was normal or small for age.

SETTING

A prospective multicenter study of the natural history of HIV-1 infection in children, the Pediatric Pulmonary and Cardiovascular Complications of Vertically Transmitted Human Immunodeficiency Virus Infection (P2C2) Study.

PATIENTS

Fifty-eight HIV-infected children and 38 control children (uninfected but born to HIV-infected women) for whom chest radiographs in the first year of life were available.

MAIN OUTCOME MEASURE

Rapid progression of HIV disease, defined as CDC Clinical Category C (severely symptomatic) or Immunologic Category 3 (severe immunosuppression) by 1 year of age.

RESULTS

The mean age at the time of chest radiography was 3.5 months. Ten (17%) HIV-infected children had reduced thymic profile size, whereas no controls did (P = 0.006). Of the 58 (59%) HIV-infected children 34 were classified as rapid progressors, and 9 (26%) of them had reduced thymus size, compared with 1 (4%) of the non-rapid progressor children [odds ratio, 8.28; 95% confidence interval (CI), 1.0, 70.5; P = 0.035]. Baseline mean CD4+ count was 1642 (95% CI 1322 to 2009) cells/microl for those with normal thymus and 740 (95% CI 380 to 1275) cells/microl for those with reduced thymus (P = 0.007).

CONCLUSION

Early thymic involution is associated with rapidly progressive disease in HIV-infected children.

Digit effects produced by prenatal exposure to antiepileptic drugs

The hypothesis tested was that digit anomalies among individuals exposed in utero to antiepileptic drugs (AED) are best identified by a systematic search, including radiographs and dermatoglyphics, rather than relying only on visual inspection. A systematic search was made for five types of digit abnormalities in 46 AED-exposed individuals ages 5-29 years in comparison with controls: visible anomalies, size of fingernails, dermal ridge patterns, length of metacarpals and phalanges, and qualitative changes in the distal phalanges. Among the AED-exposed, nail size was not decreased. However, there was a 10.8% frequency of digit anomalies, a 12% frequency of three or more arch patterns, and significant shortening and qualitative changes in the distal phalanges, all of which are consistent with the fetal effects of AED. Among the 42 individuals who underwent all evaluations, 14.3% had two or more of these abnormalities, most of which would not be identified by clinical inspection. This frequency is much higher in these AED-exposed individuals than in the general population. Radiographs in 13 individuals over a period of several years showed that the changes in the phalanges and metacarpals persisted.

Cystic fibrosis: predictors of accelerated decline and distribution of disease in 230 patients

OBJECTIVE

The purpose of this study was to determine predictors of accelerated deterioration in radiographic manifestations of cystic fibrosis. The incidence and distribution of focally accentuated disease were also studied.

MATERIALS AND METHODS

From 230 patients, 3038 chest radiographs were scored using the Brasfield system. Scores were plotted against age, and a single age-based severity curve was created. Specific observations (at least one episode in the first 5 years of life of air trapping, linear markings, nodular cystic lesions, or large lesions) were assessed to determine predictors of accelerated decline in scores compared with the aggregate scores plotted in the age-based severity curve. Specific observations were noted as present or absent and graded as to severity. A specific observation was counted as present if seen on at least one occasion. (The number of occasions on which the observation was made did not affect statistical analysis.) We also evaluated the distribution of lung disease by assessing the severity and nature of disease through specific lobar distribution.

RESULTS

Males showed a slightly greater rate of radiologic decline. Early development of air trapping or bronchiectasis was associated with an accelerated rate of decline over time. Lobe-dominant disease occurred in one third of all images and in two thirds of the patients. It varied with age in its incidence, location, and etiology.

CONCLUSION

Hyperinflation or bronchiectasis that occurs before age 5 is associated with accelerated radiographic deterioration. The incidence and location of lobe-dominant disease varied with age in these patients.

Cystic fibrosis: a system for assessing and predicting progression

OBJECTIVE

This study presents a radiography-based database scoring changes over time in a large population of patients with cystic fibrosis. The purpose of this database is to provide comparison for groups of patients undergoing experimental treatment to assess effect of the treatment. The data may also be used to compare individuals with their age-matched cohorts with cystic fibrosis.

MATERIALS AND METHODS

From 230 patients, 3038 chest radiographs were scored using the Brasfield system. The scores from radiographs from all the patients were individually plotted for age, and a single age-based severity curve was created. The age-based severity curve was compared with similar curves derived from pulmonary function studies of a subset of the same patient population.

RESULTS

We found high inter- and intraobserver reliability. The difference between the observers averaged 1.3 Brasfield points, the scale of which ranges up to 25 points. The age-based severity curve was presented as mean Brasfield scores versus age (birth to > 30 years) plotted with 95% confidence limits; the curve was also plotted in percentiles. The rate of decline of this curve was similar to the decline of pulmonary function studies in this patient population.

CONCLUSION

The age-based curve, a structural anatomic parameter, differs from pulmonary function studies, which are functional. Thus the age-based severity curve provides an additional, independent basis for comparison between groups and individuals. It may be used for the initial assessment of lung disease and for gauging and predicting the rate of decline. The curve may be used as a long-range outcome criterion to evaluate new treatments in groups of patients with cystic fibrosis.

Chest radiographic data acquisition and quality assurance in multicenter studies

BACKGROUND

Multicenter studies rely on data derived from different institutions. Forms can be designed to standardize the reporting process allowing reliable comparison of data.

OBJECTIVE

The purpose of the report is to provide a standardized method, developed as a part of a multicenter study of vertically transmitted HIV, for assessing chest radiographic results.

MATERIALS AND METHODS

Eight hundred and five infants and children were studied at five centers; 3057 chest radiographs were scored. Data were entered using a forced-choice, graded response for 12 findings. Quality assurance measures and inter-rater agreement statistics are reported.

RESULTS

The form used for reporting chest radiographic results is presented. Inter-rater agreement was moderate to high for most findings, with the best correlation reported for the presence of bronchovascular markings and/or reticular densities addressed as a composite question (kappa = 0.71). The presence of nodular densities (kappa = 0.56) and parenchymal consolidation (kappa = 0.57) had moderate agreement. Agreement for lung volume was low.

CONCLUSION

The current tool, developed for use in the pediatric population, is applicable to any study involving the assessment of pediatric chest radiographs for a large population, whether at one or many centers.

A study of level of lesion, associated malformations and sib occurrence risks in spina bifida

Neural tube defects remain the most serious common birth defect and, despite considerable progress in understanding these malformations, the etiology of most cases remains unknown. It has been proposed that the cause may vary with the type and location of the malformation but, if these variables are to be studied, a rigorous classification of cases is required. This has become more important as birth prevalence has fallen, mainly due to prenatal diagnosis and elective termination of pregnancy, and future studies will increasingly require collaboration between centres. In this study we have combined data from Ottawa, Ontario, and Boston, Massachusetts, in an attempt to examine the effect of level of spina bifida on sib occurrence rates and the rates of associated malformations, and to compare the level of lesion when determined radiographically with that recorded on the clinical chart. Malformations appeared to be more frequent with thoracic spina bifida and were more often associated with additional vertebral anomalies. Significant differences were found between the upper level of lesion recorded in the clinical file and that visible radiographically. Sib recurrences were too few for statistical comparison, but the data suggest a higher rate among sibs and more distant relatives of propositi with upper level lesions. There was not evidence to support a greater than expected concordance for level of lesion between sibs.

Pseudomembranous colitis: CT findings in children

A spectrum of nodular haustral thickening and an accordion pattern have been reported as specific features of pseudomembranous colitis (PMC) in adults. A retrospective review of nine patients with PMC was performed to assess whether this spectrum of CT findings also occurred in children. In four girls and five boys, CT scans were performed within 3 days of a positive stool toxin assay for Clostridium difficile. Documented CT abnormalities included nodular haustral thickening, the accordion pattern, colonic wall thickening, ascites, and pericolonic edema. These results were then correlated as to their impact on the clinical outcome. Circumferential colon wall thickening was identified in 7/9 (78 %) patients (mean thickening 14.5 mm). Nodular haustral thickening was identified in 4/9 (44 %) and the accordion pattern in 2/9 (22 %). Other findings included pericolonic edema in 3/9 (33 %) and ascites in 1/9 (11 %). Wall thickening was confined to the left colon and rectum in 2/9 (22 %), to the right colon in 2/9 (22 %), and involved the whole colon in 3/9 (33 %). Although CT findings associated with PMC in children may be suggestive for this diagnosis, CT is less specific than laboratory and clinical findings.

A radiologic update on medical diseases of the newborn chest

This paper reviews the common spectrum of medical diseases of the neonatal chest. Emphasis is on radiographic changes that have been produced by the introduction of new therapeutic maneuvers, particularly the use of artificial surfactant in treating hyaline membrane disease and the survival of profoundly premature newborns (less than 650 g). A discussion of meconium aspiration syndrome, neonatal pneumonia, transient tachypnea of the newborn, congenital lymphangiectasia, and congenital heart disease is also included. The effects on the neonatal chest radiograph of extracorporeal membrane oxygenation and high-frequency ventilation are also mentioned.

Retained fetal lung liquid in congenital lobar emphysema: a possible predictor of polyalveolar lobe

The purpose of this study was to determine whether retention of fetal lung liquid is more prevalent in polyalveolar congenital lobar emphysema than in conventional congenital lobar emphysema. Two patients with congenital lobar emphysema were prospectively identified in a 3-year period. Twenty-five such patients were identified in a retrospective study covering 39 years. Medical records were available for 22 patients who had 23 emphysematous lobes. Both babies from the prospective study and six subjects from the retrospective group had respiratory symptoms and underwent chest X-ray in the first day of life. Six of the eight babies with respiratory symptoms and chest imaging in the first day of life had retention of fetal lung liquid in an emphysematous lobe. All six of these lobes were polyalveolar. The lobe in one child was a polyalveolar lobe but without retained fetal lung liquid, and one child exhibited conventional lobar emphysema also without retained fetal lung liquid. One polyalveolar lobe caused no neonatal symptoms and was not imaged until the child was 3 months old. No baby with conventional lobar emphysema was shown to have retained fetal lung liquid. There seems to be a correlation between polyalveolar lobe and onset of respiratory symptoms in the first day of life. Retention of fetal lung liquid within the affected lobe was documented only in cases of polyalveolar lobe.

Voiding cystourethrography in children: value of digital fluoroscopy in reducing radiation dose

Voiding cystourethrography is a commonly used fluoroscopic procedure in children that can directly irradiate the gonads. As a consequence, much attention has been given to reducing the dose of radiation received during the procedure. A digital fluoroscope, especially adapted for use in children, was evaluated for potential reduction of the dose of radiation during the procedure. Entrance and midplane doses were calculated on child-sized phantoms by using the digital fluoroscope, digital spot films, and 105-mm spot films. Subsequently, data were collected on 47 children, grouped by ages (neonate to 1 year, 1-5 years, and 5-7 years), in whom voiding cystourethrography was performed by using the same exposure factors as those for the phantoms. On the basis of the exposure doses for the phantoms and recorded clinical peak kilovoltages, milliamperes, milliseconds, and fluoroscopic time, average skin and ovarian doses were calculated for each group of children. These doses were compared with previously reported doses for fluoroscopic and radionuclide voiding cystourethrography. Results of line-pair resolution studies for the digital spot films and 105-mm spot films were similar. Images from the digital device and 105-mm images obtained on a conventional fluoroscope were considered equally adequate for clinical decision making. The average midplane and skin doses with digital spot films for children less than 5 years old were equal to or less than 0.66 and 2.37 mGy, respectively, as opposed to 1.37 and 5.32 mGy with the 105-mm spot films. Previously reported ovarian doses range from 2.52 to 10.0 mGy for fluoroscopic voiding cystourethrography and from 0.04 to 0.05 mGy for radionuclide voiding cystourethrography. The use of digital spot films reduced dose approximately 50% compared with 105-mm spot films; the ovarian dose was 0.62 mGy greater than that for radionuclide voiding cystourethrography.

Videofluoroscopic analysis of the infant swallow

A better understanding of the abnormal infant swallowing mechanism requires better knowledge of the normal infant swallow. Twenty-one full-term infants under six months of age were examined using videofluoroscopy of the swallowing portion of upper gastrointestinal examinations. Components of the oral and pharyngeal stages of swallowing were evaluated. Results showed high reliability between two raters in obtaining measurement data. There was variability in suck and oral transit time, which was correlated to the number of sucks per swallow. All infants appeared to move their tongue in a "stripping" motion, and collected the material in various sites in the oral cavity or oropharynx before initiation of the swallow. The incidence of nasopharyngeal reflux was low (9.5%). The majority of infants demonstrated a slight residue in their valleculae and hesitation in the cervical esophagus. These findings indicate that videofluoroscopy provides an objective and systematic method for analyzing the infant swallowing mechanism.

Epiphyseal marrow in infancy: MR imaging

Hypointense epiphyseal marrow on T1-weighted magnetic resonance images often suggests disease. To determine whether hypointense marrow sometimes represents normal red marrow in a recently ossified epiphyseal center, the authors studied 38 infants without known marrow disease. Patients with hypointense epiphyseal marrow on T1-weighted images were younger (3.9 months +/- 3.2) than those with hyperintense marrow (9.6 months +/- 3.9) (P less than .001). T1-weighted imaging and histologic correlation were also performed in animals. The signal was hypointense and the marrow was red in the epiphyseal centers of all newborn animals, while all 6-week-old animals had hyperintense signal and yellow marrow. The authors conclude that hypointense marrow on T1-weighted images represents normal red marrow in a recently formed ossification center in newborn rabbits and lambs, and the same is probably true in humans. Epiphyseal marrow becomes hyperintense within a few months of development of the secondary center of ossification.

Neonatal cranial ultrasonography

We trace the evolution of pediatric cranial sonography from its inception to the present. Technical considerations and Doppler imaging are discussed. Scanning techniques and a review of the sonographic landmarks of normal anatomy are presented. Knowledge of these landmarks will facilitate screening examinations. We then present clinical and screening indications for cranial sonography in the neonate, emphasizing the pathogenesis and classification of intracranial hemorrhage and porencephaly. Finally a description of inflammatory lesions and their sonographic appearances and a review of cystic and solid lesions completes the discussion of cranial sonography in the neonate.

Coexisting nephrolithiasis and cholelithiasis in premature infants

Though the coexistence of nephrolithiasis and cholelithiasis in premature infants is extremely rare, we report four patients seen in a two year period. All patients weighed less than 1100 grams at birth, developed severe bronchopulmonary dysplasia, and all had Grade III or IV bilateral intraventricular hemorrhages. All four infants received prolonged furosemide therapy lasting at least 28 consecutive days. The renal stones disappeared in all four upon cessation of therapy, while in none have the gallstones disappeared after a mean follow-up period of 13 months. Ultrasound was superior in identifying and monitoring these stones. Their presence resulted in manipulating diuretic therapy which then was shown to limit renal and possibly biliary complications.

Hand-foot-genital syndrome: the importance of hallux varus

The hand-foot-genital syndrome is an autosomal dominant disorder previously reported in six families. This report of the seventh family identified with this syndrome is presented to emphasize the frequent occurrence of medial deviation of the first toes (hallux varus).

Familial superior mesenteric artery syndrome

Five members of a family of eight, including the father and four daughters, presented with symptoms previously attributed to the superior mesenteric artery syndrome. The four daughters also had radiographic studies supporting that diagnosis. This familial clustering raises the possibility of a genetic predisposition to this symptom and radiographic complex.

Retrograde colostomy and ileostomy enemas in neonates and infants: a simple combination of techniques

A combination of previously known techniques for retrograde opacification of ileostomies and colostomies has been used successfully in neonates and infants. This combination of techniques used on very small stomas allows easy retrograde opacification of bowel. The technique uses a small feeding tube, a larger Foley catheter with an inflatable balloon, and a Lucite compression device, the construction and use of which are discussed here.

Determination of leg length discrepancy. A comparison of weight-bearing and supine imaging

Leg length discrepancy (LLD) may be determined by comparison of leg (lower extremity) lengths measured during physical examination or by radiographic means. Leg lengths may be measured with the patient in standing, weight-bearing position or in supine position. We used a low dose digital radiographic unit to test the hypothesis that there is a difference in LLD determined from radiographs obtained with the patient standing and those obtained with the patient supine. Conventional physical examination measurements also were compared with the radiographic measurements. The amount of LLD that is clinically meaningful has not been established, although 10 to 12 mm has been used as a threshold difference of clinical meaningfulness in the past. Analysis of our data, using 10 mm as the threshold of difference, reveals high level correlation by linear regression analysis and no significant difference by t-test between measurements obtained from standing and supine radiographs. A weak correlation and statistical difference existed between each set of radiographic measurements and physical examination measurements.

CT in the evaluation of pleural versus pulmonary disease in children

Post pneumonic empyema in children is the result of infection by Staphylococcus aureus in approximately 80% of cases. Approximately 93% of children with empyema respond well to treatment with appropriate antibiotics and drainage of the pleural space. We present seven children in whom such therapy failed to produce an adequate response. Computed tomography alone clearly excluded persistent pneumonia as a cause of symptoms while in all seven patients revealing an unexpectedly extensive empyema rind. This information, coupled with the lack of clinical improvement and the specific organism isolated, led to a change in clinical management. These children were infected by organisms other than Staphylococcus aureus and required surgical decortication of the fibrinous pleural rind to alleviate persistent symptoms.

The evolution of neonatal herpes encephalitis as demonstrated by cranial ultrasound with CT correlation

Three neonates with herpes encephalitis had serial cranial ultrasound and CT studies performed during their hospitalization. Initially, subtle changes of diffuse brain edema were present but with no ventricular compression. A second phase revealed progressive brain edema with ventricular compression. A third phase with enlarging ventricles indicates developing encephalomalacia. Occasionally cyst formation may be noted within the cerebral white matter, a phenomenon initially more readily evident by ultrasound.

Complications of vaginal atresia in association with a duplicated mullerian duct

A mullerian duct duplication with a vaginal atresia can present as a painful abdominal mass in a female caused by a hematometrocolpos and a hemosalpinx. This set of signs and symptoms, if caused by an associated unilateral vaginal atresia, may be found in a female with normal menstrual periods, and (1) can be misdiagnosed with often tragic consequences caused by unnecessary salpingectomy, or even hysterectomy; (2) can be successfully treated by creating an adequate channel for drainage through the area of vaginal atresia; and (3) has a high association with unilateral renal agenesis. Because of this last point, recognition of either a mullerian duct duplication or unilateral renal agenesis should prompt an investigation for the other abnormality.

Low-dose flying spot digital radiography of the chest: sensitivity studies

Standard film examinations of the chest were compared with low-dose flying spot digital radiographic examinations obtained with a prototype unit in 174 patients. Analysis of pooled data from a double-blind study of 120 patients showed that film was more sensitive than digital images in the detection of pulmonary parenchymal abnormalities, that is, abnormal opacities, atelectasis, scar, and interstitial lung disease (P less than .05). Analysis of pooled data from a side-by-side study of 54 patients showed that the digital images were more sensitive than film in the detection of normal mediastinal and pleural soft-tissue contours, including the azygoesophageal recess, paraspinal line, and vertebral disk spaces (P less than .05). However, film was more sensitive than digital images in the detection of abnormalities of the lung, including scar, interstitial lung disease, septal lines, and the presence of vascular catheters (P less than .05). These findings suggest that low-dose flying spot digital radiography of the chest, as performed with this specific prototype unit, is not adequate to replace film in the detection of abnormalities of the lung parenchyma.

Hand radiographs in Russell-Silver syndrome

Left-hand radiographs were analyzed for bone age of 15 patients with Russell-Silver syndrome. No single finding was pathognomonic. However, in children between 2 and 10 years of age, the concordance of significantly delayed maturation, clinodactyly, fifth middle or distal phalangeal hypoplasia, ivory epiphyses, and a second metacarpal pseudoepiphyses is suggestive and should prompt a search for the well-recognized clinical features of this condition.

Radiation dose reduction in the evaluation of scoliosis: an application of digital radiography

This report documents the clinical testing of scanning beam digital radiography as an imaging method in patients with scoliosis. This type of digital imaging requires a skin exposure of only 2.4 mR (0.619 microC/kg) per image, compared with the lowest possible posteroanterior screen-film exposure of 10 mR (2.58 microC/kg) at the chest and 60 mR (15.48 microC/kg) at the lumbar spine. Digital radiographic and screen-film images were obtained on multiple test objects and 273 patients. Scoliosis measurements using screen-film radiographs and digital radiographs were comparable to within a mean difference of 1 degrees at many different degrees of severity. The low-dose digital images were found to be useful and accurate for the detection and measurement of scoliosis after the first screen-film radiographs have excluded tumors and structural abnormalities.

Radiation dose reduction during hysterosalpingography: an application of scanning-beam digital radiography

Hysterosalpingography was performed in 31 patients by means of a low-dose scanning-beam digital radiographic system. The technique permits adequate evaluation of gynecologic abnormalities while allowing significant reduction in radiation: 2.4-mR (6.1 X 10(-7) C/kg) exposure to the skin and 0.7-mrad (7 X 10(-6) Gy) mean dose to the ovaries per image obtained. Sixteen patients demonstrated readily recognizable and documented abnormalities, corroborated by laparoscopy, laparotomy, or other supportive evidence.

Correlation of pulmonary signs and symptoms with chest radiographs in the pediatric age group

One hundred twenty-five pediatric emergency department patients were studied prospectively to determine whether any findings on the physical examination were predictive of abnormalities seen on chest radiograph. We attempted to find possible correlations between such clinical examination findings, recorded prior to radiographic examination, and three subgroups of radiographic findings: pneumonia, any major radiographic abnormality, and any radiographic abnormality whatsoever. The best screen for pneumonia was presence of fever (temperature greater than two standard deviations above age-related norms), with a sensitivity of 94% and a negative predictive value of 97%. The sign with highest positive and negative predictive value for the presence of any radiographic abnormalities was tachypnea. A subgroup with either normal breath sounds, or findings limited to wheezing, prolonged expiration, cough and/or rhonchi on chest examination proved to be at low risk for any major chest radiographic abnormality. Patients with other chest examination findings comprised a high-risk group with a 34% risk of a major radiographic abnormality, as compared to a 7% incidence in the low-risk group. Thus, absence of fever suggests absence of pneumonia, while chest examination findings other than wheezing, cough, prolonged expiration, or rhonchi significantly increase the likelihood of pneumonia in this population. Physical examination findings can help the clinician determine the need for chest radiography in the pediatric emergency patient.

Neonatal aortoiliac compression caused by a distended bladder

Neonatal aortoiliac insufficiency caused by a distended urinary bladder is an unusual occurrence that can be difficult to distinguish from aortoiliac thrombosis. Real-time sonography can permit recognition of the abnormality, demonstration of the related pathophysiology, and exclusion of other causes of aortoiliac occlusion.

Neonatal intracranial hemorrhage and phenobarbital

We enrolled 280 intubated babies with birth weights of less than 1,751 g in a double-blind randomized prospective clinical trial to evaluate whether phenobarbital influences the likelihood of developing subependymal-intraventricular-intraparenchymal hemorrhage. Phenobarbital was associated with an increased risk of developing any subependymal-intraventricular-intraparenchymal hemorrhage and was not associated with a diminished risk of either severe hemorrhage or germinal matrix hemorrhage. This increased risk was apparent even after we considered the influence of phenobarbital levels, timing of phenobarbital administrations, institutional differences, quality of ultrasound scans, gestational age- and birth weight-specific effects, ascertainment bias, and other possible confounders of phenobarbital administration.

Acquired ureteropelvic junction obstruction in childhood

Ureteropelvic junction (UPJ) obstruction is generally considered to be a congenital lesion or occasionally an intermittent phenomena relating to periods of increased urine flow. Acquired ureteropelvic junction obstruction without a recognizable secondary cause is quite unusual. We present a 5.5-year-old boy who, 4 years after repair of a right sided UPJ obstruction, developed a significant left-sided UPJ obstruction in a system which previously had been normal.

Pelvic kidney in cloacal exstrophy

Four of five patients with cloacal exstrophy seen at the Massachusetts General Hospital since 1978 have had pelvic kidneys. This association is discussed and a possible embryological explanation considered.

Computed tomography in stage III neuroblastoma

This multicenter study was designed to determine if CT can assess operability in stage III neuroblastoma. Nineteen children (11 boys, eight girls), aged 2-51 months, considered to have, by conventional clinical and radiographic examinations, localized neuroblastoma that crossed the midline were examined by CT. After intravenous and oral contrast media enhancements, CT was able to show the relation of the tumor to the adjacent vital vessels: aorta, celiac axis, and superior mesenteric artery. In all 15 patients, tumors that encased the aorta or its major branches were unresectable. However, three of four tumors crossing the midline but not coming into contact with the aorta or adherent only to one side of the vessel could be resected. Because surgery currently plays the major role in the treatment of neuroblastoma, the relation of the tumor to the aorta and great vessels is a more reliable and important factor in predicting the outcome of these children than the extension and location of the tumor with reference to the midline. CT after intravenous contrast enhancement can establish this relation and assess resectability.

Low-dose transaxial tomography. An alternative to computed tomography for the evaluation of anteversion of the femur during childhood

Low-dose transaxial tomography is a technique that can produce cross-sectional images of the hips and femurs in children to permit calculation of the angle of femoral anteversion. Transaxial tomography was compared with computed tomography in terms of measured radiation dose and image quality. Transaxial tomography was found to require at least 90% less radiation dose, and the images were judged to be acceptable for the determination of anteversion.

[False mass of the thoracic wall in obese adolescent girls]

Each of four obese adolescent females were thought to have pre-sternal anterior chest wall "masses" when evaluated by lateral chest radiograph. All had normal physical examinations. The apparent chest wall masses were found to be an artifact created by partial midline contact of both, large breasts, surrounded by a partial midline air space adding contrast to the adjacent soft tissue. Manual abduction of the breasts was followed by disappearance of the apparent radiographic abnormality.

CT of neonatal herpes encephalitis

Seven neonates with proven herpes (HSV type 2) encephalitis exhibited a characteristic sequence of findings on cranial computed tomography (CT). The initial CT abnormalities in all infants were fingerlike areas of cortical increased attenuation noted on unenhanced scans obtained 2-30 days after presentation. These usually were accentuated by increased white-matter lucency. Subsequently (more than 30 days after presentation), extensive cerebral destruction, multicystic encephalomalacia, and calcification were seen on follow-up CT scans obtained in five infants.

Small carpal bone surface area, a characteristic of Turner's syndrome

An abnormality which has received little attention but may be easily recognized on radiographs of the hand of patients with Turner's syndrome is described. Eleven of thirty-one patients (35.5%) with Turner's syndrome were shown on radiographs of the hand to have a visually detectable smallness on the bone surface area of the carpus when compared to the area of the second through fifth metacarpals. Values for the "C/M" ratio (the area of the carpals divided by the area of the second through fifth metacarpals) were calculated for films of 31 individuals with gonadal dysgenesis and compared with those from bone age-matched films of seventy-six individuals with normal development of the hand and wrist. A consistent difference with minimal overlap was documented. For all of the films of patients with Turner's syndrome the C/M ratio averaged 89% of the value in the films of the controls. In the 11 patients in whose films smallness was visually apparent, the C/M ratio averaged 82% of controls while in those where the diminution was detected only by planimetry the C/M ratio averaged 91% of controls. The incidence of a diminished C/M ratio was compared with the incidence of four other previously described signs of Turner's syndrome; although not seen as often as the coarse reticular pattern or delayed bone age, the C/M sign was recognizable without planimetry at least as commonly as the "metacarpal sign," and a decreased carpal angle and/or Madelung's deformity. Taken together, these several criteria suggest the radiographic diagnosis of Turner's syndrome in more than 93% of cases.

Premature sternal fusion in gonadal dysgenesis with coarctation

Gonadal dysgenesis and coarctation of the aorta were found in four patients to be associated with premature sternal fusion but possible etiologic relationship to shield chest deformity in suggested.

Esophageal stricture secondary to drug-induced toxic epidermal necrolysis

Toxic epidermal necrolysis is a cutaneous disorder with high morbidity and mortality. Esophageal stricture has rarely been reported following recovery from this abnormality. A case is presented demonstrating the occurrence of an esophageal stricture following successful therapy. New methods of treatment are changing the mortality and morbidity such that esophageal stricture will be observed more frequently.

Gastroesophageal reflux in children: results of a standardized fluoroscopic approach

This retrospective study of 470 children undergoing barium upper gastrointestinal examinations was performed with three goals in mind: (1) to document the incidence of gastroesophageal reflux discovered during standardized upper gastrointestinal examination; (2) to compare the amount of gastroesophageal reflux detected in patients with symptoms suggestive of reflux as opposed to those who had no such symptoms; and (3) to ascertain the effect on reflux of the presence of a lower esophageal "beak." About 65% of the children studied had gastroesophageal reflux. Reflux was seen more commonly when symptoms of reflux were present (75.9%) than when not (36.8%). The amount of reflux seen over 5 min was greater if symptoms were present (mean incidence 2.72 bouts) than when not (mean incidence 0.76 bouts). Most importantly, there was a significant decrease in the amount of reflux seen with increase in patient age; age-related criteria for "acceptable" gastroesophageal reflux are presented. The presence of an esophageal "beak" is associated with an increased amount of reflux (94.4%) as opposed to no such "beak" (67.8%). The data suggest that gastroesophageal reflux is present in a large percentage of pediatric patients, whether there are symptoms to suggest reflux or not. Since reflux diminishes with increasing age, age-related criteria for an "acceptable" amount of reflux should be used rather than a universal judgment based on three episodes. Reflux to the cervical esophagus occurs frequently, both with and without symptoms of reflux, and may not be a reliable solitary indication for therapy. An esophageal "beak" is associated with an increase in reflux and may have important prognostic implications.

Duplication of the müllerian ducts and genitourinary malformations. Part II: analysis of malformations

Forty-seven females with duplication of the uterus and cervix were retrospectively studied to obtain a better understanding of the reasons for failure of fusion of the müllerian ducts by analyzing the associated genitourinary malformations. Thirty-one of the 47 patients had major genitourinary malformations that corresponded to three main complexes of anomalies. Cloacal anomalies were present in 16 patients, exstrophy in two, and combined cloacal and exstrophic deformities in another two. Renal malformations ipsilateral to a unilateral occluded müllerian duct were seen in 11 patients, and in four of these an ectopic ureter opened into the occluded duct. From the analysis of these anomalies it is proposed that duplication of the female genital system, when not an isolated event, may be secondary to interference of the normal process of müllerian fusion by a persistent cloacal duct, an abnormal pelvic girdle, or an ectopic ureter.