Publications by authors named "Bairbre Connolly"

131 Publications

Image-guided chest tube drainage in the management of chylothorax post cardiac surgery in children: a single-center case series.

Pediatr Radiol 2021 Jan 30. Epub 2021 Jan 30.

Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada.

Background: In children, chylothorax post cardiac surgery can be difficult to treat, may run a protracted course, and remains a source of morbidity and mortality.

Objective: To analyze the experience with percutaneous image-guided chest-tube drainage in the management of post-cardiac-surgery chylothoraces in children.

Materials And Methods: We conducted a single-center retrospective case series of 37 post-cardiac-surgery chylothoraces in 34 children (20 boys; 59%), requiring 48 drainage procedures with placement of 53 image-guided chest tubes over the time period 2004 to 2015. We analyzed clinical and procedural details, adverse events and outcomes. Median age was 0.6 years, median weight 7.2 kg.

Results: Attempted treatments of chylothoraces prior to image-guided chest tubes included dietary restrictions (32/37, 86%), octreotide (12/37, 32%), steroids (7/37, 19%) and thoracic duct ligation (5/37, 14%). Image-guided chest tubes (n=43/53, 81%) were single unilateral in 29 children, bilateral in 4 (n=8/53, 15%), and there were two ipsilateral tubes in one (2/53, 4%). Effusions were isolated, walled-off, in 33/53 (62%). In 20/48 procedures (42%) effusions were septated/complex. The mean drainage through image-guided chest tubes was 17.3 mL/kg in the first 24 h, and 13.4 mL/kg/day from diagnosis to chest tube removal; total mean drainage from all chest tubes was 19.6 mL/kg/day. Nine major and 27 minor maintenance procedures were required during 1,207 tube-days (rate: 30 maintenance/1,000 tube-days). Median tube dwell time was 21 days (range 4-57 days). There were eight mild adverse events, three moderate adverse events and no severe adverse events related to image-guided chest tubes. Radiologic resolution was achieved in 26/37 (70%). Twenty-three children (68%) survived to discharge; 11 children (32%) died from underlying cardiac disease.

Conclusion: Management of chylothorax post-cardiac-surgery in children is multidisciplinary, requiring concomitant multipronged approaches, often through a protracted course. Multiple image-guided chest tube drainages can help achieve resolution with few complications. Interventional radiology involvement in tube care and maintenance is required. Overall, mortality remains high.
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http://dx.doi.org/10.1007/s00247-020-04928-2DOI Listing
January 2021

Society of Interventional Radiology Quality Improvement Standards on Percutaneous Needle Biopsy in Adult and Pediatric Patients.

J Vasc Interv Radiol 2020 11 1;31(11):1840-1848. Epub 2020 Oct 1.

Department of Interventional Radiology, MD Anderson Cancer Center, Houston, Texas.

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http://dx.doi.org/10.1016/j.jvir.2020.07.012DOI Listing
November 2020

The utility of post-biopsy ultrasonography in detecting complications after percutaneous liver biopsy in children.

Pediatr Radiol 2020 11 13;50(12):1717-1723. Epub 2020 Aug 13.

Department of Medical Imaging, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada.

Background: Surveillance post image-guided percutaneous liver biopsy in children is variable.

Objective: The aim of this study was to assess the value of 4-6-h post-procedure ultrasonography (US) in detecting post-liver-biopsy hemorrhage.

Materials And Methods: This prospective study included pediatric patients who underwent US-guided percutaneous liver biopsies. All children had a US study obtained pre-procedure and one obtained 4-6 h post-procedure; US examinations were deemed positive if abnormalities were present. We also reviewed any subsequent imaging that was performed within 7 days (late imaging) at the discretion of the referring team. Changes in US findings (ΔUS) were graded by two radiologists using a descriptive non-validated scale (none, minimal, marked). Hemoglobin (Hb) levels were assessed pre-procedure and 4 h post-procedure. The diagnostic accuracy of US changes for detecting post-procedural hemorrhage was calculated based on a drop in Hb >1.5 g/dL or Hb >15% from baseline (ΔHb). We used a Kruskal-Wallis test to correlate the ΔHb with ΔUS. Association between late-imaging and post-procedure US findings was tested using a chi-square test. We included 224 biopsies.

Results: The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of post-procedure US in detecting post-procedure hemorrhage ranged 26.3-42.1%, 72.4-93.3%, 0.22-0.42, and 0.87-0.88, respectively. No significant association was seen between the ΔHb and sonographic findings (P=0.068). No significant difference was seen in the need for late imaging between children who did and those who did not have positive US findings (P=0.814).

Conclusion: The sensitivity and PPV of post-procedure US in detecting post-procedural hemorrhage are low. Our findings do not support routine post-procedure surveillance US.
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http://dx.doi.org/10.1007/s00247-020-04783-1DOI Listing
November 2020

Image guided sacroiliac joint corticosteroid injections in children: an 18-year single-center retrospective study.

Pediatr Rheumatol Online J 2020 Jun 17;18(1):52. Epub 2020 Jun 17.

Division of Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.

Background: Sacroiliitis is commonly seen in enthesitis-related arthritis (ERA), a subtype of juvenile idiopathic arthritis (JIA). Sacroiliitis is characterized by the inflammation of the sacroiliac (SI) joints (+/- adjacent tissues). The treatment options include systemic therapy with or without corticosteroid SI joint injections. Image guided SI joint injections are frequently requested in pediatric patients with sacroiliitis. The purpose of this study was to evaluate the feasibility and efficacy of SI joint injections in children with sacroiliitis.

Methods: A retrospective study of patients referred to Interventional Radiology (IR) for SI joint corticosteroid injections (2000-2018). Clinical information was collected from Electronic Patient Charts and procedural details from PACS. Efficacy was determined clinically, by MRI, or both when available.

Results: 50 patients (13.8 years; M:F = 35:15) underwent image-guided SI joint corticosteroid injections. Most common indications were JIA (84%) and inflammatory bowel disease (14%). 80% had bilateral injections. 80% were performed under general anesthesia and 20% under sedation. The corticosteroid of choice was triamcinolone hexacetonide in 98% of patients. Needle guidance and confirmation was performed using CT and fluoroscopy (54%), Cone Beam CT (CBCT, 46%), with initial ultrasound assistance in 34%. All procedures were technically successful without any complications. 32/50 patients had long-term follow-up (2 years); 21/32 (66%) had clinical improvement within 3-months. Of 15 patients who had both pre- and post-procedure MRIs, 93% showed short-term improvement. At 2 years, 6% of patients were in remission, 44% continued the same treatment and 47% escalated treatment.

Conclusion: Image-guided SI joint injections are safe and technically feasible in children. Imaging modalities for guidance have evolved, with CBCT being the current first choice. Most patients showed short-term clinical and imaging improvement, requiring long-term maintenance or escalation of medical treatment.
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http://dx.doi.org/10.1186/s12969-020-00435-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301971PMC
June 2020

Hemodialysis Catheters in Infants: A Retrospective Single-Center Cohort Study.

J Vasc Interv Radiol 2020 05 15;31(5):778-786. Epub 2020 Apr 15.

Image Guided Therapy, Department of Medical Imaging, The Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, ON M5G 1X8, Canada.

Purpose: Evaluate technical aspects and outcomes of insertion/maintenance of hemodialysis (HD) central venous catheter (CVC) during infancy.

Materials And Methods: Single-center retrospective study of 29 infants who underwent 49 HD-CVC insertions between 2002 and 2016. Demographics, procedural, and post-procedural details, interventional radiology (IR) maintenance procedures, technical modifications, complications, and outcomes were evaluated. Technical adjustments during HD-CVC placement to adapt catheter length to patient size were labeled "modifications." CVCs requiring return visit to IR were called IR-maintenance procedures. Mean age and weight at HD-CVC insertion were 117 days and 4.9 kg.

Results: Of the 29 patients, 13 (45%) required renal-replacement-therapy (RRT) as neonates, 10 (34%) commenced RRT with peritoneal dialysis (PD), and 19 (66%) with HD. Fifteen nontunneled and 34 tunneled HD-CVCs were inserted while patients were ≤1 year. Technical modifications were required placing 25/49 (51%) HD-CVCs: 5/15 (33%) nontunneled and 20/34 (59%) tunneled catheters (P = .08). Patients underwent ≤6 dialysis-cycles/patient during infancy (mean 2.3), and a mean of 4.1 and 49 HD-sessions/catheter for nontunneled and tunneled HD-CVCs, respectively. Mean primary and secondary device service, and total access site intervals for tunneled HD-CVCs were 75, 115, and 201 days, respectively. A total of 26 of 49 (53%) patients required IR-maintenance procedures. Nontunneled lines had greater catheter-related bloodstream infections per 1,000 catheter-days than tunneled HD-CVCs (9.25 vs. 0.85/1,000 catheter days; P = .02). Nineteen patients (65%) survived over 1 year. At final evaluation (December 2017): 8/19 survived transplantation, 5/19 remained on RRT, 2/19 completely recovered, 1/19 lost to follow-up, and 3 died at 1.3, 2, and 10 years.

Conclusions: Placement/maintenance of HD-CVCs in infants pose specific challenges, requiring insertion modifications, and IR-maintenance procedures to maintain function.
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http://dx.doi.org/10.1016/j.jvir.2020.01.020DOI Listing
May 2020

Use of Tissue Plasminogen Activator in Abdominal Abscesses in Children-A Single-Center Randomized Control Trial.

Can Assoc Radiol J 2020 Apr 13:846537120914263. Epub 2020 Apr 13.

Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada.

Purpose: To establish the efficacy of once-per-day intracavitary tissue plasminogen activator (tPA) in the treatment of pediatric intra-abdominal abscesses.

Methods: A single-center prospective, double-blinded, randomized controlled trial of the use of intracavitary tPA in abdominal abscesses in children. Patients were randomized to either tPA-treatment or saline-treatment groups. Primary outcome was drainage catheter dwell (hours). Secondary outcomes were length of hospital stay, times to discharge, clinical and sonographic resolution, and adverse events (AEs).

Results: Twenty-eight children were randomized to either group (n = 14 each). Demographics between groups were not significantly different (age = .28; weight = .40; gender = .44). There were significantly more abscesses in the tPA-treated group ( = .03). Abscesses were secondary to perforated appendicitis (n = 25) or postappendectomy (n = 3). Thirty-four abscesses were drained, 4 aspirated, 3 neither drained/aspirated. There was no significant difference in number of drains ( = .14), drain size ( = .19), primary outcome ( = .077), or secondary outcomes found. No procedural or intervention drug-related AEs occurred. No patient in the saline-treated group required to be switched/treated with tPA.

Conclusion: No significant difference in the length of catheter dwell time, procedure time to discharge, or time to resolution was found. Intracavitary tPA was not associated with morbidity or mortality. The results neither support nor negate routine use of tPA in the drainage of intra-abdominal abscess in children. It is possible that a multicentre study with a larger number of patients may answer this question more definitively.
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http://dx.doi.org/10.1177/0846537120914263DOI Listing
April 2020

Dosimetric Feasibility of Cone-Beam CT in Pediatric Image-Guided Retrograde Gastrostomy Tube Insertions.

Can Assoc Radiol J 2020 Feb 22;71(1):68-74. Epub 2020 Jan 22.

Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada.

Purpose: Cone-beam computed tomography (CBCT) in interventional radiology allows volumetric imaging with open patient access. This work aimed to assess radiation dose metrics of CBCT in simulated image-guided retrograde gastrostomy (IGRG) tube insertions in pediatric anthropomorphic phantoms and to compare them to measured radiation dose metrics obtained using fluoroscopy during clinical IGRG tube insertions in children.

Methods: Radiation dose indices obtained from radiation dose structured reports of fluoroscopic IGRG tube insertions were retrospectively evaluated in a consecutive cohort of 30 children. Dose indices were fractionated into 3 clinical stages for each procedure (, , and ). These 3 stages in 30 patients (3 × 30 = 90 patient stages) were compared to dose indices measured from 4 CBCT acquisition protocols acquired in pediatric phantoms.

Results: The mean proportion of radiation dose during planning, insertion, and confirmation was 35%, 38% and 27%, with mean reference-point air kerma (range) measured to be 1.0 (0.02-6.0) mGy, 0.9 (0.03-4.1) mGy, and 0.7 (0.04-3.7) mGy, respectively. Cone-beam computed tomography dose varied greatly depending on technical parameters and protocol selection, ranging from 0.7 to 39.3 mGy. In 19% of patient stages, the most dose-sparing CBCT protocol evaluated on phantoms delivered less radiation than the radiation dose indices recorded from patient's fluoroscopy.

Conclusions: From a dosimetric perspective, radiation delivered in CBCT can vary widely, yet can be appreciably low. With appropriate CBCT protocol selection, the radiation dose delivered may be sufficiently low to warrant consideration for use, if clinically needed during difficult IGRG tube insertions, and satisfy the interventionalist's benefit-risk assessment.
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http://dx.doi.org/10.1177/0846537119885680DOI Listing
February 2020

Effectiveness of Intrapleural Tissue Plasminogen Activator and Dornase Alfa vs Tissue Plasminogen Activator Alone in Children with Pleural Empyema: A Randomized Clinical Trial.

JAMA Pediatr 2020 04;174(4):332-340

Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Importance: Clinical guidelines recommend that children with pleural empyema be treated with chest tube insertion and intrapleural fibrinolytics. The addition of dornase alfa (DNase) has been reported to improve outcomes in adults but remains unproven in children.

Objective: To determine if intrapleural tissue plasminogen activator (tPA) and DNase is more effective than tPA and placebo at reducing hospital length of stay in children with pleural empyema.

Design, Setting, And Participants: This multicenter, parallel-group, placebo-controlled, superiority randomized clinical trial included children diagnosed as having pleural empyema requiring drainage aged 6 months to 18 years treated at 6 tertiary Canadian children's hospitals. A total of 379 children were assessed for eligibility; 281 were excluded and 98 were randomized. One child was excluded after randomization for not meeting the inclusion criteria. Data were collected from March 4, 2013, to December 13, 2017.

Interventions: Participants underwent chest tube insertion and 3 daily administrations of intrapleural tPA, 4 mg, followed by DNase, 5 mg (intervention group), or 5 mL of normal saline (placebo; control group). Participants, families, clinical staff, and members of the study team were blinded to allocation.

Main Outcomes And Measures: The primary outcome was hospital length of stay from chest tube insertion to discharge. Secondary outcomes included time to meeting discharge criteria, time to chest tube removal, mean fever duration, additional pleural drainage procedures, hospital readmissions, and total health care cost.

Results: Of the 97 analyzed children with pleural empyema, 52 (54%) were male, and the mean (SD) age was 5.1 (3.6) years. A total of 49 children were randomized to tPA and DNase and 48 were randomized to tPA and placebo. Treatment with tPA and DNase was not associated with decreased hospital length of stay compared with tPA and placebo (mean [SD] length of stay, 9.0 [4.9] vs 9.1 [5.3] days; mean difference, -0.1 days; 95% CI, -2.0 to 2.1; P = .96). Similarly, no significant differences were observed for any of the secondary outcomes. Of the 14 adverse events in the tPA and DNase group, 6 (43%) were serious; of the 21 adverse events in the tPA and placebo group, 8 (38%) were serious. There were no deaths.

Conclusions And Relevance: The addition of DNase to intrapleural tPA for children with pleural empyema had no effect on hospital length of stay or other outcomes compared with tPA with placebo. Clinical practice guidelines should continue to support the use of chest tube insertion and intrapleural fibrinolytics alone as first-line treatment for pediatric empyema.

Trial Registration: ClinicalTrials.gov identifier: NCT01717742.
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http://dx.doi.org/10.1001/jamapediatrics.2019.5863DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042898PMC
April 2020

Arrhythmias in Children with Peripherally Inserted Central Catheters (PICCs).

Pediatr Cardiol 2020 Feb 18;41(2):407-413. Epub 2019 Dec 18.

Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada.

To analyze the prevalence, types, and risk factors for cardiac arrhythmias associated with peripherally inserted central catheters (PICCs) in children. This is a case-control single center retrospective study. From 3180 PICCs inserted in children (< 18 years old) between 2009 and 2013, cases with new onset arrhythmias were identified. Demographics, type and timing of arrhythmias, and possible risk factors were analyzed. ECGs, rhythm strips, physicians' records, and anti-arrhythmic management were confirmatory. The level of the PICC's tip in the superior vena cava (SVC) or right atrium (RA) was ascertained from chest X-rays and counted in rib units (RU) and vertebra units (VU). Cases were matched (1:1 ratio) to controls by weight and date of insertion. Descriptive statistics were performed. A two-sided p value < 0.05 was considered significant. Thirty-one children (1%) developed arrhythmias, 16/31 (56%) were males, and 24/31 (77%) were < 1-year age. Arrhythmias were atrial 22 (71%), ventricular 4 (13%), and undetermined 5 (16%). Median PICC dwell time was 16 days. 14/31 (45%) cases and 9/31 (29%) controls had underlying structural heart disease. PICCs central tip position was lower among cases than controls (RU 6 vs 5). Odds Ratio for developing arrhythmia was 4.5 (95% CI 0.98-20.83) if the tip lays below 6.25RU. Arrhythmias were resolved with anti-arrhythmic agents in 52% (16/31) and with PICC exchange/manipulation in 32% (10/31) cases. Two children died unrelated to arrhythmia. Prevalence of arrhythmias associated with PICCs in children is low (1%). Arrhythmias are 4.5 times more likely when PICC's central tip position is deeper than 6.25RU.
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http://dx.doi.org/10.1007/s00246-019-02274-1DOI Listing
February 2020

Evaluation of implanted venous port-a-caths in children with medical complexity and neurologic impairment.

Pediatr Radiol 2019 09 13;49(10):1354-1361. Epub 2019 Jul 13.

Image Guided Therapy Centre, Diagnostic Imaging Department, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada.

Background: Children with medical complexity and associated neurologic impairment frequently face difficulties with venous access. Intermittently they require urgent intravenous administration of fluids and medication.

Objective: To analyze the use of implanted port-a-caths in children with medical complexity who have neurologic impairment and difficult venous access.

Materials And Methods: We performed a single-center observational study of port-a-caths placed by interventional radiologists in children with medical complexity with neurologic impairment. We analyzed peripheral intravenous access attempts, peripheral intravenous starts, peripheral intravenous complications, alternative temporary central venous access devices, port-a-cath insertions, catheter days, access days, port-a-cath-related complications, hospital admissions and emergency department visits. We compared the year pre port-a-cath to the year post port-a-cath.

Results: Twenty-one children with medical complexity with neurologic impairment (10 boys, 11 girls; median age 4.1 years; median weight 13.7 kg) underwent 26 port-a-cath insertions (median catheter days 787). In the year post port-a-cath compared to pre port-a-cath there was a highly significant reduction (P<0.001) in numbers of peripheral intravenous attempts, peripheral intravenous starts and skin punctures; and a significant reduction (P<0.05) in need for other devices, number of emergency department visits, emergency department visits resulting in hospital admissions, and total admissions. Adverse events were graded as mild (n=18), moderate (n=6) and severe (n=0).

Conclusion: Port-a-cath placement in children with medical complexity with neurologic impairment significantly reduced all peripheral intravenous attempts, peripheral intravenous starts, skin punctures, total number of emergency department visits, visits culminating in admission, and total number of inpatient admissions. Advantages must be considered against potential port-a-cath-related adverse events.
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http://dx.doi.org/10.1007/s00247-019-04470-wDOI Listing
September 2019

Experience with Compressed Gelfoam Plugs in Children during Liver Biopsies and Other IR Procedures: A Retrospective Single-Center Case Series.

J Vasc Interv Radiol 2019 Nov 13;30(11):1855-1862. Epub 2019 Jun 13.

Department of Diagnostic Imaging, Division of Image Guided Therapy, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.

Purpose: To analyze the experience using compressed gelfoam plugs (CGPs) in children during liver biopsies and other interventional procedures.

Materials And Methods: This was a single-center, retrospective, consecutive case series of 477 various pediatric interventional radiology procedures using CGPs (January 2012 to December 2016) performed on 397 children (209 males, 188 females; median age, 7 years [range, 9 days-17.8 years]; median weight, 18 kg [range, 2.7-141 kg]). Of 477 procedures, most (n = 371) were liver biopsies, 98 were biopsies of other organs, and 8 were non-biopsy procedures. Analysis focused on liver biopsies.

Results: Of liver biopsies, a median of 2 CGPs were used per procedure, and the mean drop in hemoglobin was -0.36 g/dl (-3.0% change). Thirty-seven mild, 8 moderate, 2 severe, and 1 life-threatening (an anaphylaxis to CGP) adverse events (AEs) occurred. Analysis of liver biopsies with AEs showed significant association between number of passes, cores, and focal-type lesions (unadjusted logistic regression: P = .007, P = .022, P = .028, respectively) and age, weight, and number of passes (adjusted multiple logistic regression: P = .006, P = .032, P = .046, respectively). Technical problems relating to CGP deployment were noted in 5 (1%), without any AEs.

Conclusions: CGPs were used in a wide variety of procedures and organs in children. There was 1 life-threatening AE resulting from the rare risk of anaphylaxis caused by the gelfoam-containing plug. After liver biopsies, transfusion was required in 2/371 (0.5%) procedures, 1 related to pre-biopsy anemia (0.25%).
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http://dx.doi.org/10.1016/j.jvir.2019.04.004DOI Listing
November 2019

Use of the Transrectal Ultrasound Probe in Aspiration and Drainage in Pediatric Patients: A Retrospective Observational Study.

J Vasc Interv Radiol 2019 Jun 5;30(6):908-914. Epub 2019 Apr 5.

Division of Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, Department of Medical Imaging, University of Toronto, 555 University Avenue, 2810B, Toronto, Canada M5G 1X8.

Purpose: To retrospectively evaluate the safety and efficacy of transrectal ultrasound (TRUS) probe use for aspiration and drainage of pelvic abscesses in children.

Materials And Methods: Patient demographics, procedural details, technical success, safety, and clinical course of TRUS procedures were retrospectively analyzed. Between 2007 and 2016, 118 TRUS-guided procedures were performed in 115 children (60 males, 55 females); median age was 12.4 years (range, 2.4-17.9 years) and median weight was 45 kg (range, 12.6-112 kg). Ten children were 5 years of age or younger.

Results: In total, 113/118 procedures were performed under general anesthesia. The rectum accommodated the probe and needle guide without resistance in all children (technical feasibility, 100%). Abscesses were anterior to the rectum in 116/118 and posterior in 2/118. One hundred twelve collections were drained, 4 were aspirated, and 2 procedures were aborted, both subsequently successfully drained (2 and 3 days later). One patient underwent repeat drainage after 28 months. No major complications were reported. Median times to temperature normalization was 0 days (mean, 1.2; range, 0-13 days), catheter dwell time 5 days (mean, 6; range, 2-21 days), drain removal to discharge 1 day (mean, 2; range, 0-41 days), and follow-up 117 days (mean, 195; range, 5-2,690 days).

Conclusions: TRUS-guided drainage using the TRUS probe and needle guide is a safe and effective method for aspiration and drainage of pelvic abscesses in children as young as 2 years.
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http://dx.doi.org/10.1016/j.jvir.2018.09.023DOI Listing
June 2019

Clinical Impact of Chronic Venous Changes Induced by Central Lines in Children: A Cohort with Abnormal Venograms.

J Vasc Interv Radiol 2019 May 27;30(5):715-723. Epub 2019 Mar 27.

Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, ON, M5G 1X8, Canada.

Purpose: To explore the hypothesis that central venous stenosis/obstructions (CVS/O) in children are influenced by prior central venous access devices (CVADs) and are associated with future risk for thromboses.

Material And Methods: A convenience sample of 100 patients with abnormal venography (stenosis, collaterals, occlusions) documented during peripherally inserted central catheter (PICC) placements were identified from consecutive PICC placements (January 2008 to November 2012). The patients (41 males, 59 females, median age 2.7 years, median weight 11 kg) were categorized based on venographic presence (Group A, n = 53) or absence (Group B, n = 47) of visible connection to the superior vena cava. Each patient's CVAD history, before and after venography, was analyzed (until October 2016).

Results: Before venogram, Group B patients were associated with a higher number of previous CVADs, larger diameter devices, greater incidence of malposition, and more use of polyurethane catheters than Group A patients (P < .001). An ipsilateral PICC was successfully placed in 98% of Group A, compared to 32% of Group B (P < .001). After venogram, significantly more Doppler ultrasounds (DUS) were performed and thromboses diagnosed in Group B (57% and 36%) compared to Group A (21% and 8%) (P < .003; P = .001), respectively.

Conclusions: Previous catheter characteristics influenced the severity of venographic changes of CVS/O (Group B). Group B was associated with more subsequent symptomatic thromboses. This information may assist parents and referring physicians to anticipate potential adverse sequelae from CVS/O on the child's venous health.
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http://dx.doi.org/10.1016/j.jvir.2018.08.034DOI Listing
May 2019

Increased risk of symptomatic upper-extremity venous thrombosis with multiple peripherally inserted central catheter insertions in pediatric patients.

Pediatr Radiol 2018 07 27;48(7):1013-1020. Epub 2018 Feb 27.

Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.

Background: Peripherally inserted central catheters (PICCs) are associated with superficial and deep venous thrombosis of the arm.

Objective: The purpose of this study was to analyze the sequelae of repeated upper limb PICC insertions in children, in terms of the frequency of upper limb thrombosis in this patient group.

Materials And Methods: The study population included all children who underwent their first successful arm PICC insertion between January 2010 and December 2015. We included subsequent ipsilateral arm PICCs in the analysis. Patients were followed until March 2016 or until any alternative central venous line insertion. For each PICC insertion, we collected demographic variables and line characteristics. We correlated all symptomatic deep and superficial thromboses of the arm with the PICC database.

Results: Applying inclusion and exclusion criteria, 2,180 PICCs remained for analysis. We identified first, second, third and fourth PICC insertions in the same arm in 1,955, 181, 38 and 6 patients, respectively. In total there were 57 upper body deep symptomatic thrombotic events. An increasing odds ratio was seen with higher numbers of PICC insertions, which was significant when comparing the first with the third and fourth PICC insertions in the same arm (odds ratio [OR] 6.00, 95% confidence interval [CI] 2.25-16.04, P=0.0004). Double-lumen PICCs were associated with a significantly higher risk of thrombosis than single lumen (OR 2.77, 95% CI 1.72-4.47, P=0.0003).

Conclusion: Repetitive PICC insertions in the same arm are associated with an increased risk of symptomatic thrombosis. Double-lumen PICCs are associated with a higher risk of thrombosis compared to single-lumen lines.
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http://dx.doi.org/10.1007/s00247-018-4096-xDOI Listing
July 2018

Serial Balloon Dilation to Relieve Gastric Outlet Obstruction Induced by the Ingestion of Toilet Cleaner.

J Pediatr Gastroenterol Nutr 2018 02;66(2):e56

Department of Pediatric Gastroenterology, Hepatology and Nutrition.

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http://dx.doi.org/10.1097/MPG.0000000000001126DOI Listing
February 2018

COST ANALYSIS OF PERIPHERALLY INSERTED CENTRAL CATHETER IN PEDIATRIC PATIENTS.

Int J Technol Assess Health Care 2018 Jan 20;34(1):38-45. Epub 2017 Dec 20.

Institute of Health Policy,Management and

Purpose: A peripherally inserted central catheter (PICC) is a useful option in providing secure venous access, which enables patients to be discharged earlier with the provision of home care. The objective was to identify the costs associated with having a PICC from a societal perspective, and to identify factors that are associated with total PICC costs.

Methods: Data were obtained from a retrospective cohort of 469 hospitalized pediatric patients with PICCs inserted. Both direct and indirect costs were estimated from a societal perspective. Insertion costs, complication costs, nurse and physician assessment costs, inpatient ward costs, catheter removal costs, home care costs, travel costs, and the cost associated with productivity losses incurred by parents were included in this study.

Results: Based on catheter dwell time, the median total cost associated with a PICC per patient per day (including inpatient hospital costs) was $3,133.5 ($2,210.7-$9,627.0) in 2017 Canadian dollars ($1.00USD = $1.25CAD in 2017). The adjusted mean cost per patient per day was $2,648.2 ($2,402.4-$2,920.4). Excluding inpatient ward costs, the median total and adjusted costs per patient per day were $198.8 ($91.8-$2,475.8) and $362.7($341.0-$386.0), respectively. Younger age, occurrence of complications, more catheter dwell days, wards with more intensive care, and the absence of home care were significant factors associated with higher total PICC costs.

Conclusions: This study has demonstrated the costs associated with PICCs. This information may be helpful for healthcare providers to understand PICC related cost in children and resource implications.
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http://dx.doi.org/10.1017/S026646231700109XDOI Listing
January 2018

Pediatric Percutaneous Nephrostomy: A Multicenter Experience.

J Vasc Interv Radiol 2018 03 6;29(3):328-334. Epub 2017 Dec 6.

The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104.

Purpose: To analyze technique, outcomes, and complications of a large series of pediatric percutaneous nephrostomy (PCN) procedures performed at 4 tertiary pediatric centers.

Materials And Methods: Retrospective multicenter study of PCNs performed during an 11-year period. Six hundred seventy-five PCNs were performed on 441 patients (median age: 4 y, range: 1 d-18 y, median weight: 17 kg, range: 0.7-112 kg); 31% were younger than 1 year. The most frequent indications for PCN procedures included hydronephrosis (57%), calculus (14%), and infection (12%). Forty-five percent of patients had severe and 32% had moderate hydronephrosis.

Results: Technical success was 99% (n = 668); 7 failures occurred from lost access, during tract dilatation (n = 5) and during staghorn calculi without dilatation (n = 2). General anesthesia was used in 73% of procedures. Combined ultrasound and fluoroscopy was used in 98% of procedures. Of the 668 procedures, 561 (84%) were primary nephrostomy insertions, and 107 (16%) were a variety of exchanges (secondary catheter insertions). Twenty-four of 675 (4%) were transplanted kidneys. Access sites included lower (47%), mid (28%), and upper (12%) poles and pelvis (11%). Catheters were predominantly 7-8 French (n = 352). The mean catheter dwell time was 25 days (0-220 d). Total primary catheter days were 14,482, with an additional 2,241 days after secondary procedures. Follow-up in 653/668 (98%) procedures documented elective removal (79%) and salvage procedures (21%), which included wire exchange (8.7%), nephroureteral stent/catheter conversion (8.8%), and tube upsizing (3.5%). Periprocedural complications occurred in 30/668 (4.5%) procedures: 1 major (0.1%) self-limiting hematuria requiring transfusion and 29 (4.4%) minor complications.

Conclusions: PCN is safe and successful in children of all ages, with few major complications. PCN in children is associated with specific technical challenges and requires ongoing management tailored to the very young to achieve good outcomes.
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http://dx.doi.org/10.1016/j.jvir.2017.09.017DOI Listing
March 2018

Perforations associated with peripherally inserted central catheters in a neonatal population.

Pediatr Radiol 2018 01 6;48(1):109-119. Epub 2017 Oct 6.

Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada.

Background: Peripherally inserted central catheters (PICCs) are increasingly used in neonates but perforations can result in devastating complications such as pericardial and pleural effusions. Identifying risk factors may guide surveillance and reduce morbidity and mortality.

Objective: To determine the risk factors for PICC perforation in neonates.

Materials And Methods: Retrospective case:control (1:2) study of neonates admitted between 2004-2014. Charts and imaging were reviewed for clinical and therapeutic risk factors.

Results: Among 3,454 PICCs, 15 cases of perforation (incidence 0.4%, 5 pericardial effusions, 10 pleural effusions) were matched to 30 controls, based on gestation and insertion date. Timing of perforations post-insertion was median 4 days for pericardial effusions and 21.5 days for pleural effusions. A risk factor for pericardial effusion was lower weight at PICC insertion compared with controls. There were no statistically significant differences between cases and controls in catheter material, insertion site, PICC size and lumen number. Among upper limb PICCs, pericardial effusions were associated with tip positions more proximal to the heart at insertion (P=0.005) and at perforation (P=0.008), compared with controls. Pleural effusions were associated with tip positions more distal from the heart at perforation (P=0.008). Within 48 h before perforation, high/medium risk infusions included total parenteral nutrition (100% cases vs. 56.7% controls, P=0.002) and vancomycin (60% cases vs. 23.3% controls, P=0.02).

Conclusion: PICC-associated pericardial effusions and pleural effusions are rare but inherent risks and can occur at any time after insertion. Risk factors and etiologies are multifactorial, but PICC tip position may be a modifiable risk factor. To mitigate this risk, we have developed and disseminated guidelines for target PICC positions and routinely do radiographs to monitor PICCs for migration and malposition in our NICU. The increased knowledge of risk profiles from this study has helped focus surveillance efforts and facilitate early recognition and treatment.
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http://dx.doi.org/10.1007/s00247-017-3983-xDOI Listing
January 2018

Technique, Safety, and Yield of Bone Biopsies for Histomorphometry in Children.

J Vasc Interv Radiol 2017 Nov 18;28(11):1577-1583. Epub 2017 Aug 18.

Division of Image Guided Therapy, Diagnostic Imaging, Department of Medical Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada.

Purpose: To evaluate image-guided bone biopsy for bone histomorphometry to assess osteoporosis in children with respect to safety and yield.

Materials And Methods: A single-center retrospective review was performed of 79 bone biopsies in 73 patients performed between 2007 and 2015. Biopsies of the iliac bone were performed under general anesthesia, after tetracycline labeling, using a Rochester needle (Medical Innovations International, Inc, Rochester, Minnesota). Ultrasound and fluoroscopic guidance were used in all procedures. Biopsy technique, technical success, safety, and histomorphometry results (complete, incomplete, none) were analyzed.

Results: There were 41 male patients (51.8%). Technical success was achieved in 76/79 (96%) procedures. Of 79 biopsies, 75 (95%) were uneventful. Unplanned overnight observation was required in 3 (minor SIR grade B), and prolonged hospital stay owing to hematoma causing nerve compression pain was required in 1 (major SIR grade D). Complete histomorphometric reports were obtained in 69 (87%) procedures, incomplete reports were obtained in 7 (9%), and no reports were obtained in 3(4%). Incomplete reports were insufficient to provide a definitive diagnosis or guide treatment. Histomorphometry impacted subsequent therapy in 69 (87%) biopsies.

Conclusions: Image-guided bone biopsy for osteoporosis using the Rochester needle is a valuable and safe technique for establishing the diagnosis of osteoporosis and directing treatment based on histomorphometry results.
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http://dx.doi.org/10.1016/j.jvir.2017.07.003DOI Listing
November 2017

Proposal of a New Adverse Event Classification by the Society of Interventional Radiology Standards of Practice Committee.

J Vasc Interv Radiol 2017 Oct 27;28(10):1432-1437.e3. Epub 2017 Jul 27.

Department of Radiology, Stratton Medical Center, 113 Holland Ave., Albany, NY 12208. Electronic address:

Purpose: To develop a new adverse event (AE) classification for the interventional radiology (IR) procedures and evaluate its clinical, research, and educational value compared with the existing Society of Interventional Radiology (SIR) classification via an SIR member survey.

Materials And Methods: A new AE classification was developed by members of the Standards of Practice Committee of the SIR. Subsequently, a survey was created by a group of 18 members from the SIR Standards of Practice Committee and Service Lines. Twelve clinical AE case scenarios were generated that encompassed a broad spectrum of IR procedures and potential AEs. Survey questions were designed to evaluate the following domains: educational and research values, accountability for intraprocedural challenges, consistency of AE reporting, unambiguity, and potential for incorporation into existing quality-assurance framework. For each AE scenario, the survey participants were instructed to answer questions about the proposed and existing SIR classifications. SIR members were invited via online survey links, and 68 members participated among 140 surveyed. Answers on new and existing classifications were evaluated and compared statistically. Overall comparison between the two surveys was performed by generalized linear modeling.

Results: The proposed AE classification received superior evaluations in terms of consistency of reporting (P < .05) and potential for incorporation into existing quality-assurance framework (P < .05). Respondents gave a higher overall rating to the educational and research value of the new compared with the existing classification (P < .05).

Conclusions: This study proposed an AE classification system that outperformed the existing SIR classification in the studied domains.
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http://dx.doi.org/10.1016/j.jvir.2017.06.019DOI Listing
October 2017

Intrapleural Dornase and Tissue Plasminogen Activator in pediatric empyema (DTPA): a study protocol for a randomized controlled trial.

Trials 2017 06 24;18(1):293. Epub 2017 Jun 24.

The Hospital for Sick Children, Department of Pediatrics, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.

Background: A randomized controlled trial of adults with empyema recently demonstrated decreased length of stay in hospital in patients treated with intrapleurally administered dornase alfa and fibrinolytics compared to fibrinolytics alone. Whether this treatment strategy is safe and effective in children remains unknown.

Methods/design: This study protocol is for a superiority, placebo-controlled, parallel-design, multicenter randomized controlled trial. The participants are previously well children admitted to a children's hospital with a diagnosis of empyema requiring chest tube insertion and fibrinolytics administered intrapleurally. Children will be randomized after the treating physician has decided that pleural drainage is required but prior to chest tube insertion. After chest tube insertion, participants in the treatment group will receive intrapleurally administered tissue plasminogen activator (tPA) 4 mg followed by dornase alfa 5 mg. Participants in the placebo group will receive tPA 4 mg followed by normal saline. Study treatments will be administered once daily for 3 days. All participants, parents or caregivers, clinicians, and research personnel will remain blinded. The primary outcome is length of stay from chest tube insertion to discharge from hospital. Secondary outcomes include time to meeting discharge criteria, chest tube duration, fever duration, need for additional procedures, adverse events, hospital readmission, cost of hospitalization, and mortality.

Discussion: This multicenter randomized controlled trial will assess the safety, effectiveness, and cost-effectiveness of combined treatment with dornase alfa and fibrinolytics compared to fibrinolytics alone for the treatment of empyema in children.

Trial Registration: ClinicalTrials.gov: NCT01717742 . Registered on 8 October 2012.
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http://dx.doi.org/10.1186/s13063-017-2026-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5482972PMC
June 2017

Measuring hemoglobin prior to early discharge without routine surveillance ultrasound after percutaneous native renal biopsy in children.

Pediatr Nephrol 2017 10 5;32(10):1927-1934. Epub 2017 May 5.

Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1H4, Canada.

Background: We aimed to evaluate the role of post-procedural hemoglobin (hb), without pre-discharge ultrasound (US), after US-guided renal biopsy in children.

Methods: A retrospective review was conducted of consecutive outpatient native kidney biopsies over an 8-year period. Procedures were performed under real-time US guidance. Data collected included number of passes, presence and size of perinephric hematoma, age, body mass index (BMI), blood pressure (BP), fasting status, hb and platelets. Continuous variables were expressed as mean ± standard deviation, group differences were tested with Student's unpaired t test and analysis of variance and correlations were assessed using Pearson's r. Significance was defined as p < 0.05. Hb changes (g/L), percentage hb (%hb) change, hematoma size and positive and negative predictive values (PPV, NPV, respectively) were analyzed.

Results: A total of 330 procedures in 300 children (141 females, mean age 11.2 ± 4.30 years) were analyzed. Post-procedural hematoma occurred in 63%. There was a significant (p = 0.0001) post-procedural hb decrease of 6.3 ± 5.5 g/L and %hb decrease of 4.56 ± 4.01%. Fasting during pre-procedural hb estimation and procedural hematoma was associated with a greater hb drop. A ≥10% hb drop had 73% PPV for repeat blood work and US and a 17% PPV for admission, whereas a <10% hb drop had a NPV of 84% and 98%, respectively. Hb change showed a weak correlation with age, and hematoma size showed a weak inverse correlation with platelet count, but no correlation with BMI, number of passes or BP.

Conclusions: Bleeding complications from US-guided native kidney biopsies in pediatric outpatients can be safely followed by a complete blood count at 6 h post procedure. A 10% hb decrease is strongly associated with requirement for further testing and/or admission.
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http://dx.doi.org/10.1007/s00467-017-3680-xDOI Listing
October 2017

Ultrasound-guided steroid tendon sheath injections in juvenile idiopathic arthritis: a 10-year single-center retrospective study.

Pediatr Rheumatol Online J 2017 Apr 11;15(1):22. Epub 2017 Apr 11.

Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.

Background: The aims of this study were to: (a) Identify tendon sheaths most commonly treated with steroid injections in a pediatric patient population with Juvenile Idiopathic Arthritis (JIA); (b) Describe technical aspects of the procedure; (c) Characterize sonographic appearance of tenosynovitis in JIA; (d) Assess agreement between clinical request and sites injected.

Methods: This was a 10 year single-center retrospective study (May 2006-April 2016) of patients with JIA referred by Rheumatology for ultrasound-guided tendon sheath injections. Patient demographics, clinical referral information, sonographic appearance of the tendon sheaths and technical aspects of the procedure were analyzed.

Results: There were 308 procedures of 244 patients (75% female, mean age 9.6 years) who underwent a total of 926 tendon sheath injections. Ankle tendons were most commonly injected (84.9%), specifically the tendon sheaths of tibialis posterior (22.3%), peroneus longus (20%) and brevis (19.7%). The majority of treated sites (91.9%) showed peritendinous fluid and sheath thickening on ultrasound. There were 2 minor intra-procedure complications without sequelae. A good agreement between clinical request and sites injected was observed.

Conclusions: Ultrasound-guided tendon sheath injections with steroids are used frequently to treat patients with JIA. It is a safe intervention with a high technical success rate. The ankle region, specifically the medial compartment, is the site most commonly injected in this group of patients. The most common sonographic finding is peritendinous fluid and sheath thickening. These findings might assist clinicians and radiologists to characterize and more effectively manage tenosynovitis in patients with JIA.
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http://dx.doi.org/10.1186/s12969-017-0155-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5387283PMC
April 2017

Pediatric interventional radiology workforce survey: 10-year follow-up.

Pediatr Radiol 2017 May 6;47(6):651-656. Epub 2017 Mar 6.

Seattle Radiologists and Foundry10, Seattle, WA, USA.

Background: Pediatric interventional radiology is a distinct subspecialty differing from both pediatric diagnostic radiology and adult interventional radiology. We conducted a workforce survey in 2005 to evaluate the state of pediatric interventional radiology at that time. Since then there have been many advancements to the subspecialty, including the founding of the Society for Pediatric Interventional Radiology (SPIR).

Objective: To evaluate the current state of the pediatric interventional radiology workforce and compare findings with those of the initial 2005 workforce survey.

Materials And Methods: We sent a two-part survey electronically to members of SPIR, the Society for Pediatric Radiology (SPR), the Society of Chairmen of Radiology in Children's Hospitals (SCORCH) and the Society of Interventional Radiology (SIR). Part 1 focused on individual practitioners (n=177), while part 2 focused on group practices and was answered by a leader from each group (n=88). We examined descriptive statistics and, when possible, compared the results to the study from 2005.

Results: A total of 177 individuals replied (a 331% increase over the first study) and 88 pediatric interventional radiology (IR) service sites responded (a 131.6% increase). Pediatric IR has become a more clinically oriented specialty, with a statistically significant increase in services with admitting privileges, clinics and performance of daily rounds. Pediatric IR remains diverse in training and practice. Many challenges still exist, including anesthesia/hospital support, and the unknown impact of the new IR residency on pediatric IR training, although the workforce shortage has been somewhat alleviated, as demonstrated by the decreased mean call from 165 days/year to 67.2 days/year.

Conclusion: Pediatric interventional radiology practitioners and services have grown significantly since 2005, although the profile of this small subspecialty has changed and some challenges remain.
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http://dx.doi.org/10.1007/s00247-017-3796-yDOI Listing
May 2017

Peripherally Inserted Central Catheters in Pediatric Patients: To Repair or Not Repair.

Cardiovasc Intervent Radiol 2017 Jun 30;40(6):845-851. Epub 2017 Jan 30.

Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue Toronto, Toronto, ON, M5G 1X8, Canada.

Introduction: Preservation of venous access in children is a major concern in pediatric interventional radiology. If a peripherally inserted central catheter (PICC) breaks, there are two options: repair the line with a repair kit or exchange the line over a wire in the interventional suite. The purpose of this study is to assess the outcome of PICC repairs in children and to compare these with the outcomes of PICC exchange.

Materials And Methods: This is a single-center, retrospective study of central line-associated bloodstream infection (CLABSI) following management of externally broken PICCs (2010-2014). The occurrence of CLABSI within 30 days after repair (Group A) or exchange (Group B) of a line was analyzed, as well as PICCs exchanged following an initial and failed repair.

Results: A total of 235 PICC breaks were included in the study, of which 161 were repaired, and 116 of whom were successful (68%, Group A). No repair was performed in 74 PICCs-55/74 of these were exchanged over a wire (74%, Group B), and 19/74 lines were removed. The 30 days post-repair CLABSI rate (Group A) was 2.0 infections per 1000 catheter days, and the calculated risk was 4.3%. In comparison the 30 days post-exchange CLABSI rate (Group B) was 4.0 per 1000 catheter days and the calculated risk 10.9%. This difference was significant when adjusted for antibiotic use (OR 3.87; 95% CI 1.07-14.0, p = 0.039).

Conclusion: The results of this study support repairing a broken PICC instead of removing or replacing the line.
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http://dx.doi.org/10.1007/s00270-017-1580-xDOI Listing
June 2017

Correlation of PET/CT and Image-Guided Biopsies of Pediatric Malignancies.

AJR Am J Roentgenol 2017 Mar 27;208(3):656-662. Epub 2016 Dec 27.

2 Division of Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada.

Objective: The purpose of this study was to evaluate an early experience with correlation of PET/CT findings and image-guided biopsy results in pediatric patients.

Materials And Methods: In a single-center retrospective case series, the inclusion criterion was performance of image-guided biopsy within 6 weeks of PET/CT, either before or after the biopsy.

Results: Forty-five patients (23 boys, 22 girls; age range, 4-17 years; median, 10.5 years; weight range, 14.6-86.2 kg; median, 48 kg) underwent 47 PET/CT examinations and biopsies. Nineteen patients (20 biopsies) had known malignancy, and 26 patients had suspected malignancy. The results were malignant in 24 cases, benign in 16, and inadequate or normal in 7 cases. Thirty-nine of 47 PET/CT examinations had positive results, and eight had negative results. Final analysis of 37 of the 47 cases (confounders excluded) showed concordant results between biopsy and PET in 36 cases and discordant results in one case.

Conclusion: PET/CT can be used for disease staging and follow-up. In the future PET/CT can play a valuable role in directing image-guided biopsies of children.
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http://dx.doi.org/10.2214/AJR.15.15914DOI Listing
March 2017

Evaluation of the need for chest X-rays in the management of asymptomatic, intraluminal vascular access device occlusion in childhood cancer.

Pediatr Blood Cancer 2017 Jul 13;64(7). Epub 2016 Dec 13.

Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.

Background: Venous access device (VAD) occlusion from intraluminal thrombus is a common complication during childhood cancer treatment. Current practice at many institutions is to assess VAD position with a chest X-ray (CXR) prior to intraluminal administration of tissue plasminogen activator (tPA). We aimed to determine the utility of this practice.

Procedure: A retrospective chart review of children with newly diagnosed cancer with a VAD, treated at The Hospital for Sick Children between 2010 and 2011, was performed. Episodes of line occlusion were identified both by reviewing patient CXRs for indication and identifying tPA doses dispensed. These episodes were reviewed to determine whether CXR findings resulted in management other than tPA. Cases in which the X-ray resulted in a change in management were further reviewed to determine whether administration of tPA could have resulted in potential patient harm.

Results: A total of 330 patients with newly diagnosed cancer with VADs were identified. Eighty-five (25.8%) patients experienced 123 episodes of VAD occlusion. VAD occlusions occurred more frequently in patients with tunneled external central venous lines (16/39, 41.5%) and peripherally inserted central catheters (PICC) (27/73, 37.0%) versus PORT (42/216, 19.4%; P = 0.001). There were nine (8.1%) episodes of VAD occlusion evaluated with a CXR in which the findings led to a change in management other than administering tPA. In each case, multiple specialists independently concluded that administration of tPA would have been unlikely to cause patient harm.

Conclusion: Routine CXRs prior to the administration of tPA for asymptomatic VAD occlusion can safely be omitted.
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http://dx.doi.org/10.1002/pbc.26378DOI Listing
July 2017