To investigate the right ventricular (RV) strain in pectus excavatum (PE) patients using cardiac magnetic resonance tissue tracking (CMR TT).
Fifty consecutive pectus excavatum patients, 10 to 32 ...years of age (mean age 15 ± 4 years), underwent routine cardiac magnetic resonance imaging (CMR) including standard measures of chest geometry and cardiac size and function. The control group consisted of 20 healthy patients with a mean age of 17 ± 5 years. RV longitudinal and circumferential strain magnitude was assessed by a dedicated RV tissue tracking software.
Fifty patients with images of sufficient quality were included in the analysis. The mean right and left ventricular ejection fractions were 55 ± 5% and 59 ± 4%. The RV global longitudinal strain was -21.88 ± 4.63%. The RV circumferential strain at base, mid-cavity and apex were -13.66 ± 3.09%, -11.31 ± 2.79%, -20.73 ± 3.45%, respectively. There was no statistically significant decrease in right ventricular or left ventricular ejection fraction between patients and controls (p > 0.05 for each). There was no significant difference in RV global longitudinal strain between two groups (-21.88 ± 4.63 versus -21.99 ± 3.58; p = 0.93). However, there was significant decrease in mid-cavity circumferential strain magnitude in pectus patients compared with controls (-11.31 ± 2.79 versus -16.19 ± 2.86; p < 0.001). PE patients had a significantly higher basal circumferential strain (-13.66 ± 3.09% versus -9.76 ± 1.79; p < 0.001) as well as apical circumferential strain (-20.73 ± 3.45% versus -12.07 ± 3.38) than control group.
Mid-cavity circumferential strain but not longitudinal strain is reduced in pectus excavatum patients. Basal circumferential strain as well as apical circumferential strain were increased as compensatory mechanism for reduced mid-cavity circumferential strain. Further studies are needed to establish clinical significance of this finding.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Cardiovascular magnetic resonance (CMR) angiography (CMRA) is an important non-invasive imaging tool for congenital heart disease (CHD) and aortopathy patients. The conventional 3D balanced ...steady-state free precession (bSSFP) sequence is often confounded by imaging artifacts. We sought to compare the respiratory navigated and electrocardiogram (ECG) gated modified Dixon (mDixon) CMRA sequence to conventional non-gated dynamic multi-phase contrast enhanced CMRA (CE-CMRA) and bSSFP across a variety of diagnoses.
We included 24 patients with CHD or aortopathy with CMR performed between September 2017 to December 2017. Each patient had undergone CE-CMRA, followed by a bSSFP and mDixon angiogram. Patients with CMR-incompatible implants or contraindications to contrast were excluded. The studies were rated according to image quality at a scale from 1 (poor) to 4 (excellent) based on diagnostic adequacy, artifact burden, vascular border delineation, myocardium-blood pool contrast, and visualization of pulmonary and systemic veins and coronaries. Contrast-to-noise ratio (CNR), signal-to-noise ratio (SNR) and quantitative vascular measurements were compared between the two gated sequences. Bland-Altman plots were generated to compare paired measures.
All scans were diagnostically adequate. Mean (SD) quality scores were 3.4 (0.7) for the mDixon, 3.2 (0.5) for the bSSFP and 3.4 (0.5) for the CE-CMRA. Qualitatively, the intracardiac anatomy and myocardium-blood pool definition were better in the bSSFP; however, mDixon images showed enhanced vessel wall sharpness with less blurring surrounding the anatomical borders distally. Coronary origins were identified in all cases. Pulmonary veins were visualized in 92% of mDixon sequences, 75% of bSSFP and 96% of CE-CMRA. Similarly, neck veins were identified in 92, 83 and 96% respectively. Artifacts prevented vascular measurement in 6/192 (3%) and 4/192 (2%) of total vascular measurements for the mDixon and bSSFP, respectively. However, the size of signal void and field distortion were significantly worse in the latter, particularly for flow and metal induced artifacts.
In patients with congenital heart disease, ECG gated mDixon angiography yields high fidelity vascular images including better delineation of head and neck vasculature and pulmonary veins and fewer artifacts than the comparable bSSFP sequence. It should be considered as the preferred strategy for successful CHD imaging in patients with valve stenosis, vascular stents, or metallic implants.
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DOBA, GEOZS, IJS, IMTLJ, IZUM, KILJ, KISLJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBJE, UILJ, UKNU, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The authors of national guidelines emphasize the use of history and examination findings to diagnose community-acquired pneumonia (CAP) in outpatient children. Little is known about the interrater ...reliability of the physical examination in children with suspected CAP.
This was a prospective cohort study of children with suspected CAP presenting to a pediatric emergency department from July 2013 to May 2016. Children aged 3 months to 18 years with lower respiratory signs or symptoms who received a chest radiograph were included. We excluded children hospitalized ≤14 days before the study visit and those with a chronic medical condition or aspiration. Two clinicians performed independent examinations and completed identical forms reporting examination findings. Interrater reliability for each finding was reported by using Fleiss' kappa (κ) for categorical variables and intraclass correlation coefficient (ICC) for continuous variables.
No examination finding had substantial agreement (κ/ICC > 0.8). Two findings (retractions, wheezing) had moderate to substantial agreement (κ/ICC = 0.6-0.8). Nine findings (abdominal pain, pleuritic pain, nasal flaring, skin color, overall impression, cool extremities, tachypnea, respiratory rate, and crackles/rales) had fair to moderate agreement (κ/ICC = 0.4-0.6). Eight findings (capillary refill time, cough, rhonchi, head bobbing, behavior, grunting, general appearance, and decreased breath sounds) had poor to fair reliability (κ/ICC = 0-0.4). Only 3 examination findings had acceptable agreement, with the lower 95% confidence limit >0.4: wheezing, retractions, and respiratory rate.
In this study, we found fair to moderate reliability of many findings used to diagnose CAP. Only 3 findings had acceptable levels of reliability. These findings must be considered in the clinical management and research of pediatric CAP.
Programs administered by the U.S. Department of Energy under the American Recovery and Reinvestment Act (ARRA) of 2009 were designed to spur investment in clean energy and jump-start the economy. ...There was considerable variation, however, in the proportion of obligated funds that states spent during each year. A primary goal of the ARRA was to infuse as much money as possible into the struggling economy; however, there was significant variation in the success with which states implemented these programs. This article draws on and extends the literature on intergovernmental implementation to explain such variation. The authors argue that jurisdictional capacity and federal guidance were important determinants of the rate at which states spent ARRA funds and, more important, that these factors interacted with one another in the implementation process. This assertion is tested using a mixed-methods approach that includes a regression analysis of state ARRA spending between 2009 and 2012, as well as an evaluation of interviews conducted with 46 state agency representatives responsible for spending ARRA energy funds.
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BFBNIB, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NMLJ, NUK, ODKLJ, OILJ, PILJ, PNG, PRFLJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Antibiotic therapy is often prescribed for suspected community-acquired pneumonia (CAP) in children despite a lack of knowledge of causative pathogen. Our objective in this study was to investigate ...the association between antibiotic prescription and treatment failure in children with suspected CAP who are discharged from the hospital emergency department (ED).
We performed a prospective cohort study of children (ages 3 months-18 years) who were discharged from the ED with suspected CAP. The primary exposure was antibiotic receipt or prescription. The primary outcome was treatment failure (ie, hospitalization after being discharged from the ED, return visit with antibiotic initiation or change, or antibiotic change within 7-15 days from the ED visit). The secondary outcomes included parent-reported quality-of-life measures. Propensity score matching was used to limit potential bias attributable to treatment selection between children who did and did not receive an antibiotic prescription.
Of 337 eligible children, 294 were matched on the basis of propensity score. There was no statistical difference in treatment failure between children who received antibiotics and those who did not (odds ratio 1.0; 95% confidence interval 0.45-2.2). There was no difference in the proportion of children with return visits with hospitalization (3.4% with antibiotics versus 3.4% without), initiation and/or change of antibiotics (4.8% vs 6.1%), or parent-reported quality-of-life measures.
Among children with suspected CAP, the outcomes were not statistically different between those who did and did not receive an antibiotic prescription.
Contrast-enhanced MRI is commonly used to evaluate thoracic central venous patency in children and young adults. A flow-independent noncontrast non-ECG-gated 3D MRA-MR venography (MRV) technique ...described in 2019 as "relaxation-enhanced angiography without contrast and triggering (REACT)" may facilitate such evaluation.
The purpose of our study was to compare image quality, diagnostic confidence, and interreader agreement between respiratory-triggered REACT and 3D Dixon-based contrast-enhanced MRV (CE-MRV) for evaluating thoracic central venous patency in children and young adults.
This retrospective study included 42 consecutive children and young adults who underwent MRI of the neck and chest to evaluate central venous patency between August 2019 and January 2021 (median age, 5.2 years; IQR, 1.4-15.1 years; 22 female patients and 20 male patients). Examinations included respiratory-triggered REACT and navigator-gated CE-MRV sequences based on the institution's standard-of-care protocol. Six pediatric radiologists from four different institutions independently reviewed REACT and CE-MRV sequences; they assessed overall image quality (scale, 1-5; 5 = excellent), diagnostic confidence (scale, 1-5; 5 = extremely confident), and presence of clinically relevant artifact(s). Readers classified seven major central vessels as normal or abnormal (e.g., narrowing, thrombosis, or occlusion). Analysis used Wilcoxon signed rank and McNemar tests and Fleiss kappa coefficients.
The distribution of overall image quality scores was higher (
= .02) for REACT than for CE-MRV for one reader (both sequences: median score, 5). Image quality scores were not significantly different between the sequences for the remaining five readers (all
> .05). Diagnostic confidence scores and frequency of clinically relevant artifact(s) were not significantly different between sequences for any reader (all
> .05). Interreader agreement for vessel classification as normal or abnormal was similar between sequences for all seven vessels (REACT: κ = 0.37-0.81; CE-MRV: κ = 0.34-0.81). Pooling readers and vessels, 65.4% of vessels were normal by both sequences; 18.7%, abnormal by both sequences; 9.8%, abnormal by REACT only; and 6.1%, abnormal by CE-MRV only.
Respiratory-triggered REACT, in comparison with CE-MRV, showed no significant difference in image quality (aside from for one of six readers), diagnostic confidence, or frequency of artifact(s), with similar interreader agreement for vessel classification as normal or abnormal.
High-resolution 3D MRV performed without IV contrast material can be used to assess central venous patency in children and young adults.
Childhood interstitial lung disease (chILD) is a heterogeneous group of uncommon, mostly chronic pediatric pulmonary disorders characterized by impaired gas exchange and diffuse abnormalities on ...imaging. A subset of these diseases occurs more frequently in infants and young children than in older children and teenagers. Some of these disorders occur in certain clinical scenarios and/or have typical imaging features that can help the radiologist recognize when to suggest a possible diagnosis and potentially spare a child a lung biopsy. We review the clinical, histopathological and computed tomography features of chILD more prevalent in infancy, including diffuse developmental disorders, growth abnormalities, specific conditions of undefined etiology, and surfactant dysfunction mutations and related disorders, to familiarize the pediatric radiologist with this group of disorders.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, VSZLJ, ZAGLJ
MRCP provides noninvasive imaging of the biliary tree and pancreatic duct. In our experience, MRCP image quality is commonly suboptimal in children.
The purpose of this study was to characterize the ...frequency of nondi-agnostic 3D fast spin-echo (FSE) MRCP acquisitions and determine predictors of nondi-agnostic MRCP image quality in children.
This retrospective study included 200 randomly selected pediatric patients (101 female and 99 male patients; mean age, 11.7 years) who underwent MRCP between January 1, 2019, and December 31, 2020. Patient- and examination-related variables were recorded. Three fellowship-trained pediatric radiologists independently reviewed 3D FSE MRCP acquisitions for diagnostic quality (diagnostic vs nondiagnostic) and overall image quality score on a scale from 1 to 5 (1 = worst image quality imaginable, 5 = best image quality imaginable). After computing interreader agreement, analyses used readers' most common diagnostic quality assessment and mean image quality score. Multivariable logistic regression and linear regression analyses were used to identify predictor variables of a diagnostic examination and higher image quality score.
Interreader agreement for an MRCP acquisition being diagnostic quality, expressed as a kappa coefficient, was 0.53-0.71; interreader agreement for image quality score, expressed as an intraclass correlation coefficient, was 0.68-0.74. A total of 36 of 200 (18%) MRCP acquisitions were nondiagnostic; the mean image quality score was 3.5 ± 1.1 (SD). Multivariable predictors of a diagnostic MRCP acquisition included greater body mass index (OR = 1.11 95% CI, 1.02-1.21;
= .02), scanner field strength of 1.5 T (odds ratio OR = 2.87 95% CI, 1.23-6.68;
= .01), and presence of acute pancreatitis (OR = 4.91 95% CI, 1.53-15.77;
= .008). Multivariable predictors of a higher image quality score (β = 0.05-0.94) included older age (
= .01), imaging performed with patient under sedation or general anesthesia (
< .001), presence of biliary dilatation (
= .004), and inpatient status (
= .02). A lower image quality score was predicted by a scanner field strength of 3 T (β = -0.61;
< .001). A greater amount of time between the start of the MRI examination and the MRCP acquisition exhibited a nonsignificant association with a decrease in the image quality score (
= .06).
Pediatric MRCP acquisitions are commonly nondiagnostic. Patient-specific and technical factors systematically impact MRCP image quality in children.
Recognition of image quality predictors that are potentially modifiable and amendable to proactive intervention can guide efforts to optimize MRCP image quality in children.
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