Future directions in interventional pediatric radiology

In conclusion, the explosion of interventional radiology and its impact on the pediatric patient have resulted in a completely new approach to the subspecialty of interventional pediatric radiology. The interventional radiologist has become an integral part of the management of patients and has become directly involved in the day-to-day care of patients. The use of interventional MR imaging recently has been described in clinical trial. Open-configuration magnets that allow full access to the patient and are equipped with instrument tracking systems provide an interactive environment in which biopsies, endoscopic procedures, and minimally invasive interventions or surgeries are performed. In addition, thermal ablation and image-based control of energy deposition also can be performed. Among these procedures, noninvasive MR-guided focused ultrasound ablation has the most promising future and may replace some conventional surgery. The merging of new and exciting technologies including MR, ultrasound, CT, and fluoroscopy into an environment in which both surgical and interventional radiologic procedures can be performed with image guidance is the basis of the operating room of the future. The role of the interventional radiologist as both the imager and interventionalist is central to this procedural environment; however, the interventional radiologist must accept all the responsibilities of imaging, therapy, patient care, and associated complications.     

Interventional radiology in the acute pediatric abdomen

This article addresses the most common types of interventional procedures performed in the pediatric abdomen. Nonvascular interventions are stressed because they are more common than vascular interventions.     

Practical approaches to pediatric gastrointestinal radiology

Radiologic evaluation of the pediatric gastrointestinal tract requires knowledge of the specific problems acutely afflicting the gastrointestinal tract in children and the specialized approaches required for accurate radiologic diagnosis. Efficacious radiologic evaluation and accurate diagnosis are possible only when the radiologist is aware of the presence and significance of clinical findings. The radiologist must take an active role in formulating a presumptive diagnosis and determining the best course of radiologic examination. Careful correlation of clinical and radiologic findings is necessary to assure accurate diagnosis and appropriate treatment.     

New intensifier screens in pediatric radiology (authors transl)

On the basis of the physical and clinical findings of this investigation, the characteristics of new screens made of rare earths were described. The possibilities of application for pediatric radiology and those advantages which can be achieved with the new screens were discussed. Possible technical difficulties were mentioned.     

Ovarian masses in the pediatric patient

Ovarian masses in the pediatric patient are uncommon. Children with ovarian tumors, however, pose diagnostic and therapeutic challenges because their presentation can mimic other more common intraabdominal disorders and their tumor histology varies widely. The refinement of surgical techniques and the advent of more effective chemotherapy in the past 25 years has increased overall survival rates from approximately 20% to 70%, thus improving the outcome for girls with malignant tumors. This article summarizes the current evaluation and management of ovarian masses in childhood and reviews pertinent pathology.     

Genitourinary trauma in the pediatric patient

Trauma is the major source of mortality in the pediatric population. A retrospective review was performed on patients admitted to the Children's Hospital and Health Center Trauma Program, San Diego, California, from August 1984 to May 1990. The purpose of this review was to evaluate pediatric trauma and to determine the best treatment and evaluation for genitourinary injuries. Blunt trauma was responsible for 98 percent of the injuries, with renal injuries being the most common. Bladder (7) and male urethral (2) injuries, and vaginal lacerations (8) also occurred. The most severe renal injuries (70%) and all significant bladder and urethral injuries were associated with gross hematuria. Hypotension was present in 31 percent of patients but rarely required surgical exploration for correction. Eighty-six patients underwent radiographic imaging. Computerized tomography (CT) scans demonstrated the most information about intra-abdominal solid organ injuries but was inaccurate in detecting bladder or urethral injuries. Genitourinary injury is common in children but rarely requires surgical management. CT scan is the best study to determine extent of solid-organ injury but is inferior to cystourethrography to diagnose bladder or urethral injuries.     

Pain control in the pediatric patient

PURPOSE: To investigate the ultrasonographic (US) characteristics of subdural empyema (SDE) and its differentiation from reactive subdural effusion (RSE) in infants with meningitis. MATERIALS AND METHODS: Images in 10 infants with SDE with or without RSE complicating meningitis were retrospectively reviewed and correlated with clinical findings and compared with US and magnetic resonance (MR) images in four infants with meningitis and RSE. RESULTS: At US, 15 of 16 SDEs in the 10 infants were seen as heterogeneous to hyperechoic convexity collections. Hyperechoic strands were seen in 12 SDEs. Other findings included a thick, echogenic inner membrane (n = 9), increased echogenicity of pia-arachnoid and exudates in the subarachnoid space (n = 16), mass effect (n = 16), and loculated extraaxial collections (n = 2). MR imaging findings correlated well with US and surgical results. At computed tomography, SDE was misinterpreted as RSE in one patient, due to the absence of inner membrane contrast material enhancement. Clinical outcome was related to the degree of brain damage consequent to meningitis and the chronicity of SDE. RSEs in seven infants (three with concurrent SDE) were anechoic; an inner membrane was seen in six, and increased pia-arachnoid echogenicity was seen in four. CONCLUSION: SDE has complex US features that are helpful for differentiation from anechoic RSE in infants with meningitis.     

Lens injuries induced by occupational exposure in non-optimized interventional radiology laboratories

Several cases of ophthalmologically confirmed lens injuries, caused by occupational radiation exposure, have occurred in two X-ray rooms devoted to vascular and visceral interventional radiology procedures. Both laboratories were equipped with overcouch X-ray systems not designed for interventional radiology and without specific tools for radiation protection of the eyes. Typical workloads ranged from between two and five procedures per day. For the two radiologists affected, estimates for the dose to eye lens ranged from 450 to 900 mSv per year, over several years. Once the incidents had been detected, the X-ray systems in both rooms were removed and new equipment specifically designed for interventional radiology was installed, including suspended shielding screens. Since these lens injuries were only detected accidentally, measures to avoid similar occurrences in the future are discussed.     

Tracheostomy in the young pediatric burn patient

OBJECTIVE: To evaluate the incidence of complications in comparison with the benefits of tracheostomy in young pediatric burn patients (newborn to 3 years old). DESIGN: Retrospective survey. SETTING: Tertiary care burn center. PATIENTS: A total of 1549 consecutive pediatric burn patients, of whom 180 were intubated. INTERVENTIONS: Tracheostomy was performed in 76 children. MAIN OUTCOME MEASURES: Duration of mechanical ventilation, mortality, respiratory complications, airway complications, and condition of the airway at discharge from the hospital. RESULTS: Seventy-six patients required tracheostomy. Their mean burn size was 34% total body surface area and mean length of stay in the hospital was 56 days. There were no perioperative complications. Eight patients (10%) could not be decannulated because of airway obstruction. Five of these outgrew their obstruction, 2 required surgery, and 1 continues to be evaluated for laryngeal reconstruction. CONCLUSION: Pediatric tracheostomy can be performed safely with no perioperative complications and acceptable chronic morbidity.     

Management of the pediatric burn patient

The care of children with burns represents a therapeutic dilemma for many practitioners who periodically work with thermally injured patients. In this article, the authors emphasize the pathophysiology of thermal injury with special attention to the burned child. Within this framework, pain control, resuscitation, wound care, and the importance of a "burn care team" are discussed as important factors in the care of these children.     

Perioperative management of the pediatric patient

Children are not just small adults. Perioperative nurses working with pediatric patients plan nursing interventions based on established principles of perioperative practice as well as incorporating concepts of growth and development relating to the child. A thorough assessment of the pediatric patient prior to surgery enables the perioperative nurse to plan for the surgical procedure, modifying as need be for the individual patient's specific needs. With adequate preparation, communication, and emotional support, the pediatric surgical experience can be positive for the child, parents, and perioperative team.     

Cytomegalovirus retinitis in a pediatric AIDS patient

INTRODUCTION: Cytomegalovirus retinitis (CMV) is the most frequently found opportunistic eye infection in adults with AIDS, with mean incidence of 20%-50%. However, only 5% of children with AIDS have this infection. CLINICAL CASE: We present the case of a six year old girl with stage C3 AIDS diagnosed at the age of 20 months, who developed unilateral diffuse retinitis due to CMV. The infection involved the posterior pole of the right eye, with retinal atrophy along the temporal vascular arcodes, and an active advance front in the temporal macula. The optic nerve was not found to be involved although the peripheral areas of the retina were involved leading to rhegmatogenous detachment of the superotemporal retina. In view of the systemic deterioration of the patient, no specific anti-CMV treatment was given. The patient died of respiratory insufficiency a few weeks later. CONCLUSIONS: CMV retinitis in paediatric AIDS patients is usually associated with more severe illness and a poorer general health than the adult population. In view of the absence of symptoms in these patients, periodic ophthalmoscopic examinations should be done in those who have severe immunological deterioration.     

Reduction of scatter in diagnostic radiology by means of a scanning multiple slit assembly

Evidence is presented that an array of long, narrow beam-defining slits scanning a patient coupled with scatter-eliminating slots beneath the patient will substantially reduce scatter in diagnostic radiology. Scatter/primary ratios and the distribution of scatter in the plane of the image detector have been measured as a function of slit width and slot depth for a long, narrow beam-defining geometry. Using these data, calculations for the scatter/primary ratio incident on the image detector are made for a multiple slit assembly and compared with conventional grids. An improvement in contrast is obtained with little or no increase in patient exposure. Design considerations for the construction of such an array and data trends are discussed.     

Reduction of stress-induced analgesia following ethanol exposure in mice

In the present study, we examined the effects of ethanol treatment on the subsequent expression of opioid and nonopioid forms of swim stress-induced analgesia (SSIA). In Experiment 1, mice were injected with ethanol (2.5 g/kg, i.p.) or an equal volume of saline once a day for two days. Animals received no treatment on day 3. On day 4, the animals were tested for opioid (3-min swim in water maintained at 32 degrees C) or nonopioid (3-min swim in water maintained at 20 degrees C) SSIA in the hotplate test (52 degrees C). Mice pretreated with ethanol injections showed a decrease in nonopioid SSIA, but not in opioid SSIA. In Experiment 2, mice were given an ethanol solution (10%) or tap water to drink for 15 days. On day 16, all animals were given tap water to drink. On day 17, the animals were tested for opioid or nonopioid SSIA. Neither form of SSIA was modified in mice that drank the ethanol solution. These results show that ethanol pretreatment can modify nonopioid endogenous analgesic responses in mice. Further, the route of administration influences the effects of ethanol pretreatment on SSIA.     

The use of retinoids in the pediatric patient

Oral retinoids are molecules derived from vitamin A that represent one of the most important steps forward in dermatologic therapeutics in the present century. The treatment of acne, severe psoriasis, and severe disorders of keratinization, prevalent diseases in children and adolescents, have radically changed since the advent of oral retinoids. Like most highly-effective medications, oral retinoids also have important untoward effects. Specialists, and in particular, dermatologists and pediatricians should be prepared to maneuver the delicate balance between therapeutic efficacy and side effects in order to give the pediatric patient the maximum benefit with the lowest possible risk.     

The use of psychostimulants in the pediatric patient

The psychostimulant drugs have a long history of safe and effective usage in the treatment of ADHD. They remain the drugs of first choice in this condition. Children with ADHD should be aggressively treated with at least two different classes of psychostimulants before moving to nonpsychostimulant agents. As long as side effects are not troublesome, higher dosages may be used to adequately control the ADHD symptoms, and such high dosages do not impair learning. No evidence shows long-term effects of psychostimulants on growth. Effective use of the psychostimulants is essential for any clinician involved in the treatment of children with ADHD.     

Pharmacological considerations for the pediatric patient

The use of pharmacological agents in children warrants special consideration because children have variable pharmacokinetic parameters. Not only are the pharmacokinetic properties of drugs different in children as compared with adults, but these properties can undergo rapid change as children grow and mature. Furthermore, many drugs that would be useful in the pediatric population lack the indication for use in children and, therefore, dosing guidelines are not available. This paper presents an overview of basic pharmacokinetics in children and pediatric dosing guidelines.     

Endoscopic sural nerve harvest in the pediatric patient

A technique of endoscopic sural nerve harvest was devised to minimize the donor-site scarring in pediatric patients requiring peripheral nerve-grafting procedures. The harvests were performed under tourniquet control using two 2-cm incisions for access at the lateral malleolus and the midcalf. Endoscopic visualization and blunt dissection of the nerve were achieved with a 4-mm Hopkins telescope with 30-degree angled lens (Karl Storz GmbH, Tuttlingen, Germany) stabilized in an Emory retractor and attached to a video camera. The medial sural nerve was divided in the popliteal fossa proximally under endoscopic visualization. The lateral sural nerve was identified and harvested when present. Between June of 1994 and March of 1995, 18 patients underwent 27 sural nerve harvests using the endoscopic technique. Mean patient age was 3.3 years (range 4 to 197 months). Indications for surgery included obstetrical brachial plexus palsy (12), facial palsy (5), and ulnar nerve neuroma (1). Nerve-graft length harvested ranged from 13 to 41 cm. Mean tourniquet time per limb was 92 minutes. No nerve graft injury was noted on examination under the operating microscope. Postoperative pain, swelling, and ecchymosis were minimal. Donorsite scarring has been aesthetically satisfactory to date.