Biomedical subjects
K A Feinstein
Publications and source records attributed to K A Feinstein.
Sonographic demonstration of a normal thyroid gland excludes ectopic thyroid in patients with thyroglossal duct cyst.
OBJECTIVE: Preoperative thyroid scintigraphy has been performed in patients with presumed thyroglossal duct cyst to document a normal thyroid and to exclude the possibility of an ectopic thyroid mimicking a thyroglossal duct cyst. Often, an ectopic thyroid is the patient's only functioning thyroid tissue, and its removal will result in hypothyroidism. The purpose of this study was to determine whether demonstration of a normal thyroid gland by sonography in children with thyroglossal duct cyst can exclude ectopic thyroid and thereby obviate routine preoperative thyroid scintigraphy. MATERIALS AND METHODS: We studied 30 patients with pathologically proved thyroglossal duct cysts who had neck sonograms. The sonograms were evaluated for the presence or absence of a normal thyroid gland. The medical records of these children were also reviewed. Three children had normal preoperative radionuclide thyroid scans. All the children were clinically euthyroid preoperatively. Follow-up was available in 15 of the 30 patients, and all of these patients were clinically euthyroid postoperatively. RESULTS: A sonographically normal thyroid gland was detected in all patients. CONCLUSION: Preoperative sonographic identification of a normal thyroid gland in patients with thyroglossal duct cyst confirms a source of thyroid hormone separate from the thyroglossal duct cyst and thus excludes ectopic thyroid. Routine thyroid scintigraphy is not necessary.
Abnormalities of the bladder in children: imaging findings.
Radiologic evaluation of the genitourinary tract in infants and children frequently focuses on the kidneys. The bladder may be imaged in a cursory or perfunctory manner or not at all. Unfortunately, this practice contributes to errors in diagnosis of renal abnormalities both prenatally and throughout childhood. For example, a "renal cyst" diagnosed prenatally really might be the obstructed upper pole of a duplex kidney; scanning the bladder is necessary to detect the dilated distal ureter or ureterocele below. Similarly, the bladder might have a congenital anomaly when the kidneys are normal. The appearance of many common and a few uncommon bladder anomalies in children are described in this article. Some normal variants and acquired problems, such as tumors and neurogenic bladder, are discussed and illustrated because these can cause problems in diagnosis. Changes in the appearance of the bladder produced by surgery to correct vesicoureteral reflux are also presented.
Periosteal reaction of the ribs in neonates treated with extracorporeal membrane oxygenation: prevalence and association with soft-tissue swelling.
OBJECTIVE: The objectives of the study were to determine the prevalence of periosteal reaction of the ribs in infants treated with extracorporeal membrane oxygenation and to evaluate its association with soft-tissue swelling. MATERIALS AND METHODS: The chest radiographs of 100 consecutive neonates treated with extracorporeal membrane oxygenation were evaluated to determine the maximal soft-tissue swelling during therapy and whether periosteal reaction of the ribs developed. The length of extracorporeal membrane oxygenation and the time elapsed before periosteal reaction developed were recorded. The medical records of those with periosteal reaction were reviewed to determine known causes of this condition. The records of a control group of 11 neonates were evaluated in the same manner. RESULTS: Periosteal reaction of the ribs developed in 13 (21%) of the 61 neonates who had less than 11 mm of soft-tissue swelling. In 69% of those with periosteal reaction, the finding first was seen 21-32 days after birth. In the control group, periosteal reaction developed in only one, a neonate who had vibrator chest physiotherapy. CONCLUSION: Periosteal reaction of the ribs in patients treated with extracorporeal membrane oxygenation is associated with soft-tissue swelling greater than 11 mm. The periosteal reaction appears to be a self-limiting and benign process.
Osteomyelitis in hospitalized children with chickenpox: imaging findings in four cases.
OBJECTIVE: The most common complications of chickenpox are skin and soft-tissue infections. Pneumonia and CNS involvement occur less often, and skeletal complications are considered rare. The purpose of this study was to evaluate the imaging findings of osteomyelitis in children after chickenpox. MATERIALS AND METHODS: We retrospectively reviewed the records of children admitted to our institution because of chickenpox and analyzed the imaging findings in those who had skeletal involvement. Ninety-seven patients were admitted between January 1991 and January 1993 because of chickenpox or a complication thereof. Four previously healthy patients, three boys and one girl, between 1 and 6 years old had osteomyelitis. Staphylococcus aureus was isolated from bone in one patient, and group A beta-hemolytic streptococcus was isolated from blood cultures in another. No organism was grown in the other two; necrotic bone was recovered from one lesion and the other healed with periosteal formation of new bone typical of osteomyelitis. All patients were treated with IV antibiotics, and their recoveries were uncomplicated. RESULTS: Conventional radiographs showed loss of fat planes in three patients and destruction of bone in two. Bone scintigraphy showed increased uptake of radionuclide in early and late phases in three patients. Uptake in one case was extensive, with a central area of relatively little uptake corresponding to a subperiosteal fluid collection. CT in two and MR imaging in one showed subperiosteal fluid collections surrounding the involved bones in association with bone and marrow changes. CONCLUSION: Osteomyelitis was the fourth most common complication of chickenpox in our series. The appearances on conventional radiographs and scintigrams are indistinguishable from those of typical bacterial osteomyelitis. However, CT and MR imaging showed subperiosteal fluid collections in three of four patients, an appearance only occasionally seen with typical osteomyelitis.
Extramedullary hematopoiesis in the kidneys in infant siblings with myelofibrosis.
Extramedullary hematopoiesis (EMH) is known to occur in clinical settings associated with severe anemia. Because very young children with anemia can usually recruit the still large compartment of red marrow, EMH is more frequently seen in adults. We have observed two young girls, who were unable to produce sufficient blood products in their marrow and instead developed EMH, one with documented and rarely reported renal involvement. They are described below.
Clinical application of ultrasonography in the diagnosis of intussusception.
Sixty-five consecutive patients seen in a pediatric emergency department, in whom the diagnosis of intussusception was considered, had an ultrasound examination of the abdomen before a barium enema. The mean age of the patients was 1.7 years (range 2 weeks to 5 years). Intussusception was detected by ultrasonography in all 20 cases proved by barium enema. There were three false-positive ultrasound results (sensitivity = 100%, confidence interval (Cl) = 86% to 100%; specificity = 93%, Cl = 86% to 96%). Normal findings on ultrasonography correlated with a negative barium enema results in 42 of 42 cases (negative predictive value = 100%, Cl = 94% to 100%). No intussusception was missed by ultrasonography. To determine which patients would most benefit from ultrasonography, we divided patients into either a high-risk group (81% with intussusception) or a low-risk group (14% with intussusception) on the basis of clinical symptoms (p less than 0.01). If each high-risk child had a barium enema and each low-risk child had an ultrasound study as their initial diagnostic test, 89% of the patients in this study would have undergone only one examination. We conclude that ultrasonography can be used as a rapid, sensitive screening procedure in the diagnosis or exclusion of childhood intussusception. Children considered at low risk of having intussusception on the basis of clinical symptoms should initially have an ultrasound examination; patients at high risk should have an immediate barium enema.
Prenatal events and the risk of subependymal/intraventricular haemorrhage in very low birthweight neonates.
The effects of prenatal factors on the risk of subependymal and/or intraventricular brain haemorrhage in very low birthweight (VLBW) neonates were studied. Data were collected on 201 consecutively born VLBW neonates without major congenital anomalies, who were born at a regional obstetric referral centre. Brain haemorrhage was identified by cranial ultrasound examinations. The reliability of these examinations (concordance among readers' interpretations) was assessed and found to be moderate (kappa = 0.47 for the finding of subependymal haemorrhage (SEH); kappa = 0.50 for the finding of intraventricular haemorrhage (IVH)). Prenatal factors were more strongly associated with IVH than with SEH. In univariable analyses, maternal pre-eclampsia, multiple gestation and maternal treatment with betamethasone were associated most strongly with a decreased risk of haemorrhage whereas labour and vaginal delivery were associated most strongly with an increased risk. These associations remained in a multivariable analysis which included prenatal events (maternal illnesses, fetal presentation and obstetrical interventions), as well as gestational age, birthweight, gender, treatment with assisted ventilation, and the occurrence of pneumothorax. Further aetiological study of the effects of prenatal factors could provide information useful in preventing SEH/IVH.
Selected topics in pediatric ultrasonography--1992.
In children, ultrasonography has been valuable in demonstrating a wide range of congenital lesions that were previously seen indirectly or only after more invasive procedures. It has replaced many studies that necessitated oral or vascular contrast and ionizing radiation. Real-time ultrasonography has found a role in the evaluation of the diaphragm, gastroesophageal reflux, bowel peristalsis, and hip stability.
The deformed petrous bone: a new plain film sign of premature lambdoid synostosis.
Towne-view skull radiographs of 38 infants with unilateral lambdoid synostosis were reviewed. The diagnosis of lambdoid synostosis was based on other plain film findings, CT findings, or clinical examination. All patients had deformity of the ipsilateral petrous bone, presumably because of pressure caused by redirected brain growth. Specific changes included flattening of the petrous ridge and depression of the roof of the mastoid portion of the petrous bone and adjacent structures such as the semicircular canals. Flattening of the petrous ridge and depression of the roof of the mastoid portion of the petrous bone are useful signs of lambdoid synostosis when sutural closure has produced sutural indistinctness rather than sclerosis.
Radiologic evaluation of the child with craniosynostosis.
The radiologic diagnosis of craniosynostosis is made in most instances based on routine skull films, because each suture closure produces characteristic changes. Computed tomography (CT) was originally used only to evaluate the intracranial contents. In the last 5 years changes in morphology at the skull base and in the calvarium have been better demonstrated with three-dimensional CT. This article describes and illustrates the appearance of craniosynostosis on skull radiographs and CT.
Evaluation of joint disease in the pediatric hand.
Juvenile rheumatoid arthritis, leukemia, hypertrophic osteoarthropathy, sickle cell disease, and child abuse can all be causes of joint disease in the child's hand. The role of radiology is to diagnose disease and follow disease progression so that therapy can be modified. Because much of the child's hand is unossified cartilage, measurements, bone mineralization, and maturation are important components of the radiologic evaluation.
Variability of renal length in type I glycogen storage disease.
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Urinoma formation in posterior urethral valves: relationship to later renal function.
A retrospective analysis of radiologically determined individual renal function was performed in five boys who presented in the neonatal period with posterior urethral valves, vesicoureteral reflux and documented urinoma formation. Renal function was evaluated with scintigraphy. There was reflux in eight of ten ureters. Six of these ureters had an associated urinoma and compromised renal function in the neonatal period. In two of the boys the kidney with urinoma functioned better than the contralateral kidney with reflux alone. In two other boys with unilateral urinoma the contralateral ureter did not reflux and the affected kidney functioned less well. In follow up (20 to 36 months) seven of the ten kidneys have a near normal appearance or function. Those kidneys which are now abnormal were noted to be abnormal in the neonatal period.
Sonographic characteristics of small cerebral blood vessels. An in vivo and postmortem study.
The ultrasound appearance of small cerebral blood vessels was investigated with in vivo and postmortem sonography. Linear echoes corresponding in distribution to small branches of major cerebral blood vessels, particularly deep medullary veins, were seen during cranial sonography of living neonates, neonatal postmortem brains, and adult postmortem brains following intravascular injection of a barium sulfate-gelatin suspension. Ease of visualization of the echoes was angle dependent, a phenomenon termed anisotropy. When imaged in cross-section, these reflectors appeared as tiny, closely spaced dots, demonstrating their tubular nature. Additionally, the barium-injected adult postmortem specimens were studied by computed tomography and plain-film radiography, enabling correlation between radiography and sonography. This study demonstrates that small branches of the major intracranial blood vessels can be imaged as linear echoes and closely spaced dots by high-resolution sonography. It is important to recognize the vascular origin of these echoes to avoid the pitfall of misinterpreting them as originating from pathologic processes such as periventricular leukomalacia.
Nephroblastomatosis: comparison of CT with US and urography.
A review of the imaging studies of five children with Wilms tumor and nephroblastomatosis demonstrated that contrast-enhanced computed tomography (CT) can show the multifocal involvement of nephroblastomatosis more accurately than either excretory urography or real-time ultrasound (US). In all five children, CT demonstrated multiple areas of nephroblastomatosis along the renal cortex. US showed a single intrarenal mass in each child (one bilaterally) but did not show the cortical nephroblastomatosis. Excretory urography also demonstrated only the dominant mass of the Wilms tumor. The superiority of CT is attributed to better spatial resolution and soft-tissue contrast differentiation and clear demarcation between nonenhanced nephroblastomatosis and enhanced normal renal parenchyma. Contrast-enhanced CT is therefore recommended for the evaluation of clinically abnormal and contralateral kidneys in all children with suspected Wilms tumor.
Septated urinomas in the neonate.
Perirenal urinomas may develop when obstruction to urinary flow creates sufficient back pressure to produce extravasation of urine. Such fluid collections have been described as mainly sonolucent. However, in the last 2 years, we have imaged five neonates with multiple, marked septations of the urinoma, four with posterior urethral valves and one with a ureteropelvic junction obstruction. Diagnostic confusion may arise when the kidney is not identified, when the septated nature of the urinoma is not recognized, and when urinary tract obstruction is not seen.
The viewbox. Primary tuberculosis.
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