Publications by authors named "Kassa Darge"

168 Publications

Contrast-enhanced ultrasound in children: a first-of-its-kind comprehensive compendium!

Pediatr Radiol 2021 Jul 23. Epub 2021 Jul 23.

Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.

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http://dx.doi.org/10.1007/s00247-021-05120-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8300977PMC
July 2021

Cerebrospinal Fluid Flow Detection in Post-hemorrhagic Hydrocephalus With Novel Microvascular Imaging Modality.

J Ultrasound Med 2021 Jul 21. Epub 2021 Jul 21.

Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

Cerebrospinal fluid flow dynamics serve as an important biomarker to guide medical and/or surgical intervention of hydrocephalus in infants. Imaging of cerebrospinal fluid flow can be assessed with magnetic resonance imaging, but routine evaluation is limited by practical challenges. We show for the first time that cerebrospinal fluid flow can be depicted using brain ultrasound by implementing highly sensitive ultrasound-based microvascular imaging technology (B-flow). This novel application could potentially expand the use of this technology beyond its current application in depiction of vascular flow pathologies in newborns.
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http://dx.doi.org/10.1002/jum.15781DOI Listing
July 2021

Robert A. Zimmerman, MD (1938-2021).

Pediatr Radiol 2021 Jul 18;51(8):1535-1536. Epub 2021 Jun 18.

Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.

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http://dx.doi.org/10.1007/s00247-021-05121-9DOI Listing
July 2021

Pediatric contrast-enhanced ultrasound: shedding light on the pursuit of approval in the United States.

Pediatr Radiol 2021 Jun 11. Epub 2021 Jun 11.

Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN, USA.

For two decades, pediatric contrast US has been well accepted throughout Europe and other parts of the world outside the United States because of its high diagnostic efficacy and extremely favorable safety profile. This includes intravenous (IV) administration, contrast-enhanced US (CEUS) and the intravesical application, contrast-enhanced voiding urosonography (ceVUS). However, the breakthrough for pediatric contrast US in the United States did not come until 2016, when the U.S. Food and Drug Administration (FDA) approved the first pediatric indication for a US contrast agent. This initial approval covered the use of Lumason (Bracco Diagnostics, Monroe Township, NJ) for the evaluation of focal liver lesions via IV administration in children. A second pediatric indication followed shortly thereafter, when the FDA extended the use of Lumason for assessing known or suspected vesicoureteral reflux via intravesical application in children. Both initial pediatric approvals were granted without prospective pediatric clinical trials, based instead on published literature describing favorable safety and efficacy in children. Three years later, in 2019, the FDA approved Lumason for pediatric echocardiography following a clinical trial involving a total of 12 subjects at 2 sites. The story of how we achieved these FDA approvals spans more than a decade and involves the extraordinary dedication of two professional societies, namely the International Contrast Ultrasound Society (ICUS) and the Society for Pediatric Radiology (SPR). Credit also must be given to the FDA staff for their commitment to the welfare of children and their openness to compelling evidence that contrast US is a safe, reliable, radiation-free imaging option for our pediatric patients. Understanding the history of this approval process will impact the practical application of US contrast agents, particularly when expanding off-label indications in the pediatric population. This article describes the background of the FDA's approval of pediatric contrast US applications to better illuminate the potential pathways to approvals of future indications.
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http://dx.doi.org/10.1007/s00247-021-05102-yDOI Listing
June 2021

Reproductive hormone concentrations and associated anatomical responses: does soy formula affect minipuberty in boys?

J Clin Endocrinol Metab 2021 May 20. Epub 2021 May 20.

Biostatistics and Computational Biology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC.

Context: Soy formula feeding is common in infancy and is a source of high exposure to phytoestrogens, documented to influence vaginal cytology in female infants. Its influence on minipuberty in males has not been established.

Objective: To assess the association between infant feeding practice and longitudinally measured reproductive hormones and hormone-responsive tissues in infant boys.

Design: The Infant Feeding and Early Development study was a prospective cohort of maternal-infant dyads requiring exclusive soy formula, cow-milk formula, or breastmilk feeding during study follow-up. Reproductive hormone concentrations and male anatomical measurements were longitudinally assessed from birth to 28 weeks.

Setting: Clinic-based cohort.

Participants: 147 mother-infant boy pairs.

Interventions: not applicable.

Main Outcome Measure: Serum testosterone and luteinizing hormone (LH) concentrations, stretched penile length, anogenital distance, and testis volume.

Results: Median serum testosterone was at pubertal levels at 2 weeks [176 ng/dL (quartiles:124, 232)] and remained in this range until 12 weeks, in all feeding groups. We did not observe differences in trajectories of hormone concentrations or anatomical measures between boys fed soy formula (n=55) and boys fed cow-milk formula (n=54). Compared with breastfed boys (n=38), soy-formula-fed boys had a more rapid increase in penile length (p=0.004) and slower initial lengthening of AGD (p=0.03), but no differences in hormone trajectories.

Conclusions: Reproductive hormone concentrations and anatomical responses followed similar trajectories in soy and cow-milk formula-fed infant boys. Our findings suggest that these measures of early male reproductive development do not respond to phytoestrogen exposure during infancy.
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http://dx.doi.org/10.1210/clinem/dgab354DOI Listing
May 2021

Starting a pediatric contrast ultrasound service: made simple!

Pediatr Radiol 2021 May 12. Epub 2021 May 12.

Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.

The addition of contrast US to an existing pediatric US service requires several preparatory steps. This overview provides a guide to simplify the process. Initially, it is important to communicate to all stakeholders the justifications for pediatric contrast US, including (1) its comparable or better diagnostic results relative to other modalities; (2) its reduction in procedural sedation or anesthesia by avoiding MRI or CT; (3) its reduction or elimination of radiation exposure by not having to perform fluoroscopy or CT; (4) the higher safety profile of US contrast agents (UCA) compared to other contrast agents; (5) the improved exam comfort and ease inherent to US, leading to better patient and family experience, including bedside US exams for children who cannot be transported; (6) the need for another diagnostic option in light of increasing demand by parents and providers; and (7) its status as an approved and reimbursable exam. It is necessary to have an UCA incorporated into the pharmacy formulary noting that only SonoVue/Lumason is currently approved for pediatric use. In the United States this UCA is approved for intravenous administration for cardiac and liver imaging and for vesicoureteric reflux detection with intravesical application. In Europe and China it is only approved for the intravesical use in children. All other applications are off-label. The US scanner needs to be equipped with contrast-specific software. The UCA has to be prepared just before the exam and it is important to strictly follow the steps as outlined in the packaging inserts in order to prevent premature destruction of the microbubbles. The initial training in contrast US is best focused on the frontline staff actually performing the US studies; these might be sonographers, pediatric or interventional radiologists, or trainees. It is important from the outset to educate the referring physicians about contrast US. It is helpful to participate in existing contrast US courses, particularly those with hands-on components.
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http://dx.doi.org/10.1007/s00247-021-04998-wDOI Listing
May 2021

Contrast-enhanced ultrasound of the kidneys and adrenals in children.

Pediatr Radiol 2021 May 12. Epub 2021 May 12.

Department of Radiology, Medical University of Gdansk, Gdansk, Poland.

Pediatric applications of contrast-enhanced ultrasound (CEUS) are growing. Evaluation of the kidneys and adrenal glands in children using intravenous administration of US contrast agents, however, is still an off-label indication. Pediatric CEUS applications for kidneys are similar to those in adults, including ischemic disorders, pseudo- versus real tumors, indeterminate lesions, complex cystic lesions, complicated pyelonephritis, and abscesses. CEUS applications for evaluation of adrenal glands in children are limited, mainly focusing on the assessment and follow-up of adrenal trauma and the differentiation between an adrenal hemorrhage and a mass. This review addresses the current experience in pediatric CEUS of the kidneys and adrenal glands. By extrapolating the established knowledge for US contrast evaluations in the adult kidney to the pediatric context we can note opportunities for CEUS clinical use in children.
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http://dx.doi.org/10.1007/s00247-020-04849-0DOI Listing
May 2021

Contrast-enhanced genitosonography and colosonography: emerging alternatives to fluoroscopy.

Pediatr Radiol 2021 May 12. Epub 2021 May 12.

Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Imaging plays a crucial role in evaluating newborns and infants with cloacal and urogenital malformations. Contrast-enhanced genitosonography (ceGS) and contrast-enhanced colosonography (ceCS) are sensitive and radiation-free alternatives to fluoroscopic genitography and colography for diagnosis and surgical planning. These imaging techniques are performed by instilling a US contrast agent into specific body cavities to define the genitourinary and colorectal anatomy. This review article presents the experience with ceGS and ceCS applications in children, focusing on the background, examination technique, and interpretation of imaging findings, as well as strengths and weaknesses compared to conventional techniques.
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http://dx.doi.org/10.1007/s00247-020-04770-6DOI Listing
May 2021

Practical approach for the diagnosis of biliary atresia on imaging, part 2: magnetic resonance cholecystopancreatography, hepatobiliary scintigraphy, percutaneous cholecysto-cholangiography, endoscopic retrograde cholangiopancreatography, percutaneous liver biopsy, risk scores and decisional flowchart.

Pediatr Radiol 2021 Jul 11;51(8):1545-1554. Epub 2021 May 11.

APHM, Equipe d'Accueil 3279 - IFR 125, Service d'Imagerie Pédiatrique et Prénatale, Hôpital Timone Enfants, Aix Marseille Univ, Marseille, France.

We aim to present a practical approach to imaging in suspected biliary atresia, an inflammatory cholangiopathy of infancy resulting in progressive fibrosis and obliteration of extrahepatic and intrahepatic bile ducts. Left untreated or with failure of the Kasai procedure, biliary atresia progresses to biliary cirrhosis, end-stage liver failure and death within the first years of life. Differentiating biliary atresia from other nonsurgical causes of neonatal cholestasis is difficult as there is no single method for diagnosing biliary atresia and clinical, laboratory and imaging features of this disease overlap with those of other causes of neonatal cholestasis. In this second part, we discuss the roles of magnetic resonance (MR) cholecystopancreatography, hepatobiliary scintigraphy, percutaneous biopsy and percutaneous cholecysto-cholangiography. Among imaging techniques, ultrasound (US) signs have a high specificity, although a normal US examination does not rule out biliary atresia. Other imaging techniques with direct opacification of the biliary tree combined with percutaneous liver biopsy have roles in equivocal cases. MR cholecystopancreatography and hepatobiliary scintigraphy are not useful for the diagnosis of biliary atresia. We propose a decisional flowchart for biliary atresia diagnosis based on US signs, including elastography, percutaneous cholecysto-cholangiography or endoscopic retrograde cholangiopancreatography and liver biopsy.
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http://dx.doi.org/10.1007/s00247-021-05034-7DOI Listing
July 2021

Contrast-enhanced ultrasound of the small organs in children.

Pediatr Radiol 2021 Apr 8. Epub 2021 Apr 8.

Department of Radiology, King's College Hospital, Denmark Hill, London, UK.

In pediatric and adult populations, intravenous contrast-enhanced ultrasound (CEUS) remains off-label for imaging of organs other than the liver and heart. This limited scope inhibits potential benefits of the new modality from a more widespread utilization. Yet, CEUS is potentially useful for imaging small organs such as the thyroid gland, lymph nodes, testes, ovaries and uterus, with all having locations and vasculature favorable for this type of examination. In the adult population, the utility of CEUS has been demonstrated in a growing number of studies for the evaluation of these small organs. The aim of this article is to present a review of pediatric CEUS of the thyroid gland, lymph nodes, testes, ovaries and uterus as well as to draw from the adult literature indications for possible applications in children.
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http://dx.doi.org/10.1007/s00247-021-05006-xDOI Listing
April 2021

The Wash-Out of Contrast-Enhanced Ultrasound for Evaluation of Hypoxic Ischemic Injury in Neonates and Infants: Preliminary Findings.

Ultrasound Q 2021 Mar 24. Epub 2021 Mar 24.

Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA Department of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD Perleman School of Medicine, University of Pennsylvania, Philadelphia, PA Department of Radiology, Texas Children's Hospital, Houston, TX.

Abstract: We evaluated the use of quantitative contrast-enhanced ultrasound (CEUS) to study wash-out behavior of ultrasound contrast agents in the pediatric brain in cases of hypoxic ischemic injury (HII). Six neonates and young infants were imaged using CEUS for suspected HII in the Neonatal Intensive Care Unit/Pediatric Intensive Care Unit. After receiving a bolus of ultrasound contrast agent Lumason (Bracco Diagnostics Inc.), analysis was performed in the whole brain, cortex, cortical/subcortical gray and white matter and central gray nuclei to quantify wash-out metrics and ratios. On magnetic resonance imaging clinical imaging findings, 3 children were classified as unaffected and 3 with classical imaging findings consistent with HII. A lower wash-out rate was found in the case of HII compared with the unaffected cases. Here, we present initial work exploring the wash-out behavior for differentiation between unaffected and HII in the brain. These preliminary findings are indicative of altered hemodynamics in HII and are promising for the potential use of CEUS to quantitatively differentiate between the unaffected and HII brain. Little is known about the CEUS wash-out dynamics, especially in the setting of the pediatric brain injury. Our preliminary findings are encouraging and warrant further investigation into the mechanisms behind delayed clearance of the ultrasound contrast agent in the setting of HII.
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http://dx.doi.org/10.1097/RUQ.0000000000000560DOI Listing
March 2021

Contrast-enhanced voiding urosonography, part 1: vesicoureteral reflux evaluation.

Pediatr Radiol 2021 Mar 31. Epub 2021 Mar 31.

Pediatric Ultrasound Center, Thessaloniki, Greece.

Contrast-enhanced voiding urosonography (ceVUS) is a well-established, sensitive and safe ultrasound (US) modality for detecting and grading vesicoureteral reflux (VUR) and urethral imaging in children. Nearly three decades of remarkable advances in US technology and US contrast agents have refined ceVUS's diagnostic potential. The recent approval of Lumason/SonoVue in the United States, Europe and China for pediatric intravesical applications marked the beginning of a new era for this type of contrast US imaging. Consequently, the use of ceVUS in children has expanded to multiple places around the globe. In the first part of this review article, we describe the current experience in the use of ceVUS for VUR evaluation, with an emphasis on historical background, examination technique, image interpretation and diagnostic accuracy. In the second part, we will present the role of ceVUS for urethral imaging in children.
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http://dx.doi.org/10.1007/s00247-020-04906-8DOI Listing
March 2021

The impact of per diem senior pediatric radiologists in an academic setting.

Pediatr Radiol 2021 May 17;51(5):686-690. Epub 2020 Nov 17.

Department of Radiology, Children's Hospital of Philadelphia, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA.

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http://dx.doi.org/10.1007/s00247-020-04886-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670107PMC
May 2021

Practical approach to imaging diagnosis of biliary atresia, Part 1: prenatal ultrasound and magnetic resonance imaging, and postnatal ultrasound.

Pediatr Radiol 2021 02 17;51(2):314-331. Epub 2020 Nov 17.

Aix Marseille Université, AP-HM, Equipe d'Accueil 3279 - IFR 125, Hôpital Timone Enfants, Service d'Imagerie Pédiatrique et Prénatale, Marseille, France.

We present a practical approach to imaging in suspected biliary atresia, an inflammatory cholangiopathy of infancy resulting in progressive fibrosis and obliteration of extrahepatic and intrahepatic bile ducts. Left untreated or with failure of the Kasai procedure, biliary atresia progresses towards biliary cirrhosis, end-stage liver failure and death by age 3. Differentiation of biliary atresia from other nonsurgical causes of neonatal cholestasis is challenging because there is no single method for diagnosing biliary atresia, and clinical, laboratory and imaging features of this disease overlap with those of other causes of neonatal cholestasis. Concerning imaging, our systematic literature review shows that ultrasonography is the main tool for pre- and neonatal diagnosis. Key prenatal features, when present, are non-visualisation of the gallbladder, cyst in the liver hilum, heterotaxy syndrome and irregular gallbladder walls. Postnatal imaging features have a very high specificity when present, but a variable sensitivity. Triangular cord sign and abnormal gallbladder have the highest sensitivity and specificity. The presence of macro- or microcyst or polysplenia syndrome is highly specific but less sensitive. The diameter of the hepatic artery and hepatic subcapsular flow are less reliable. When present in the context of acholic stools, dilated intrahepatic bile ducts rule out biliary atresia. Importantly, a normal US exam does not rule out biliary atresia. Signs of chronic hepatopathy and portal hypertension (portosystemic derivations such as patent ductus venosus, recanalised umbilical vein, splenomegaly and ascites) should be actively identified for - but are not specific for - biliary atresia.
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http://dx.doi.org/10.1007/s00247-020-04840-9DOI Listing
February 2021

Hand Bone Age Radiography: Comparison Between Slot-scanning and Conventional Techniques.

J Pediatr Orthop 2021 Feb;41(2):e167-e173

Division of Orthopedic Surgery, Children's Hospital of Philadelphia.

Background: Determination and longitudinal monitoring of progressive skeletal maturity are essential in the management of children with scoliosis. Although different methods for determining skeletal maturity exists, the most widely practiced method relies on the ossification pattern of the bones of the hand and wrist, which is traditionally acquired using conventional techniques and after the acquisition of the spine using the low-dose slot-scanning technique. Whereas the existing published literature has published promising results on the use of the slot-scanning technique to acquire these hand and wrist radiographs, image quality and radiation dose have not been systematically compared between these techniques. Thus, the objective of our study is to compare image quality, interpretation reliability, and radiation dose of hand bone age radiographs between slot-scanning and conventional techniques using age- and sex-matched children.

Methods: This retrospective study included children who underwent hand radiographs using slot-scanning between October 1, 2019 and December 31, 2019; and matched children who underwent conventional radiography. Blinded to technique, 5 readers reviewed all radiographs after randomization to rate image quality and to determine bone age using the Greulich and Pyle classification. Dose area product was recorded. Mann-Whitney and t tests were used to compare variables between techniques and intraclass correlation (ICC) to determine observer agreement.

Results: Our study cohort of 194 children (128 girls, 66 boys; mean age: 13.7±2.3 y) included 97 slot-scanning and 97 conventional radiographs. One (1%) slot-scanning and no conventional radiograph was rated poor in image quality. There was almost perfect interpretation reliability with slot-scanning with high interobserver (ICC=0.948) and intraobserver (ICC=0.996) agreements, comparable with conventional radiographs (ICCs=0.919 and 0.996, respectively). Dose area product (n=158) was lower (P<0.002) with slot-scanning than with conventional techniques.

Conclusion: Almost perfect interobserver reliability and intraobserver reproducibility with slot-scanning radiographs (performed using significantly lower radiation doses) suggest that this technique for hand bone age determination can be a reliable adjunct to scoliosis monitoring.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BPO.0000000000001710DOI Listing
February 2021

Contrast-enhanced Ultrasound-State of the Art in North America: Society of Radiologists in Ultrasound White Paper.

Ultrasound Q 2020 Sep;36(4S Suppl 1):S1-S39

Department of Radiology, Boston Children's Hospital, Boston, MA.

On October 24, 2017, in Chicago, the Society of Radiologists in Ultrasound convened a panel of specialists in contrast-enhanced ultrasound (CEUS) to arrive at a white paper regarding the use of CEUS in noncardiac applications in North America. Recommendations are based on analysis of the current literature and common practice strategies. They represent a reasonable approach to introduce the advantages of this safe and noninvasive technique for the benefit of our patients. Characterization of liver nodules with CEUS, as the approval indication worldwide, is the major focus of this endeavor. In addition, many off label uses are reviewed and literature supporting these indications provided.Key Points(1) Contrast-enhanced ultrasound (CEUS) allows cross-sectional imaging of the liver, kidneys and multiple other solid and hollow viscera, providing excellent characterization of identified focal mass lesions.(2) Performed with the injection of a microbubble contrast agent, CEUS provides a safe and readily available imaging technique which requires no ionizing radiation, making it appropriate for use in all ages, in those with renal insufficiency and when a portable examination is needed.(3) The CEUS can be considered in abdominal imaging whenever blood flow information is of value to diagnosis.(4) Dynamic real-time acquisition and the use of a purely intravascular contrast agent are the 2 most essential technical aspects of CEUS imaging which distinguish it from both computed tomography and magnetic resonance scan.
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http://dx.doi.org/10.1097/RUQ.0000000000000515DOI Listing
September 2020

Contrast -Enhanced Ultrasound: State of the Art in North America.

Ultrasound Q 2020 Sep;36(3):206-217

Department of Radiology, Boston Children's Hospital, Boston, MA.

The Society of Radiologists in Ultrasound convened a panel of specialists in contrast-enhanced ultrasound (CEUS) to produce a white paper on noncardiac CEUS in North America. The panel met in Chicago, Illinois, on October 24 and 25, 2017. The recommendations are based on analysis of current literature and common practice strategies and are thought to represent a reasonable approach to introduce the advantages of this safe and noninvasive technique for the benefit of our patients. Characterization of liver nodules, and pediatric vascular and intravesicular applications comprise the approved indications for CEUS in the United States. They, along with the very successful off-label use of CEUS for the kidney, are included in this publication.Other off-label uses are presented with emphasis on their value and literature support in the online version.
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http://dx.doi.org/10.1097/RUQ.0000000000000514DOI Listing
September 2020

Magnetic resonance elastography to quantify liver disease severity in autosomal recessive polycystic kidney disease.

Abdom Radiol (NY) 2021 02 5;46(2):570-580. Epub 2020 Aug 5.

Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Objectives: To evaluate whether liver and spleen magnetic resonance elastography (MRE) can measure the severity of congenital hepatic fibrosis (CHF) and portal hypertension (pHTN) in individuals with autosomal recessive polycystic kidney disease (ARPKD), and to examine correlations between liver MRE and ultrasound (US) elastography.

Methods: Cross-sectional study of nine individuals with ARPKD and 14 healthy controls. MRE was performed to measure mean liver and spleen stiffness (kPa); US elastography was performed to measure point shear wave speed (SWS) in both liver lobes. We compared: (1) MRE liver and spleen stiffness between controls vs. ARPKD; and (2) MRE liver stiffness between participants with ARPKD without vs. with pHTN, and examined correlations between MRE liver stiffness, spleen length, platelet counts, and US elastography SWS. Receiver operating characteristic (ROC) analysis was performed to examine diagnostic accuracy of liver MRE.

Results: Participants with ARPKD (median age 16.8 [IQR 13.3, 18.9] years) had higher median MRE liver stiffness than controls (median age 14.7 [IQR 9.7, 16.7 years) (2.55 vs. 1.92 kPa, p = 0.008), but MRE spleen stiffness did not differ. ARPKD participants with pHTN had higher median MRE liver stiffness than those without (3.60 kPa vs 2.49 kPa, p = 0.05). Liver MRE and US elastography measurements were strongly correlated. To distinguish ARPKD vs. control groups, liver MRE had 78% sensitivity and 93% specificity at a proposed cut-off of 2.48 kPa [ROC area 0.83 (95% CI 0.63-1.00)].

Conclusion: Liver MRE may be a useful quantitative method to measure the severity of CHF and pHTN in individuals with ARPKD.
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http://dx.doi.org/10.1007/s00261-020-02694-1DOI Listing
February 2021

Does contrast-enhanced ultrasound have a role in evaluation and management of pediatric renal trauma? A preliminary experience.

J Pediatr Surg 2020 Dec 17;55(12):2740-2745. Epub 2020 Jun 17.

Division of Pediatric Urology, Department of Pediatric Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA.

Background: To report our initial experience using intravenous contrast-enhanced ultrasound (CEUS) in pediatric renal trauma with the potential for substantial radiation reduction.

Methods: A retrospective review of all patients who underwent intravenous CEUS at our institution between May 2015 and January 2018 for the suspicion of blunt renal trauma. CEUS was obtained either as an immediate or short-term comparison to contrast-enhanced computed tomography (CECT), or in outpatient follow-up.

Results: CEUS was performed on 7 patients (9 kidneys) with age range 2 months to 16 years old. CEUS was utilized as a comparison to CECT in 4 of 7 patients for initial evaluation, clinical change, or short-term follow-up. CEUS alone was used in one patient with low suspicion for renal injury. In the remaining two patients, CEUS was obtained as a follow-up study weeks after the initial CECT, following conservative management. All patients with confirmed renal injury by CECT (n = 5) underwent a follow-up CEUS at 1-2 months.

Conclusions: In an era of conservative management for renal trauma in which operative intervention is dictated more often by the clinical course than radiographic findings, it is reasonable to consider alternative imaging methods such as CEUS in stable patients to decrease radiation exposure.

Level Of Evidence Rating: IV.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.06.010DOI Listing
December 2020

Identification and characterization of calyceal diverticula with MR urography (MRU) in children.

Abdom Radiol (NY) 2021 01;46(1):303-310

Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Blvd, Philadelphia, PA, 19104, USA.

Purpose: To determine the MRU imaging findings of calyceal diverticula in a large cohort of children and to compare the frequency of calyceal diverticula in our cohort with what has been previously reported.

Methods: This was a HIPAA-compliant, IRB-approved retrospective study of all patients with suspected CD based on their medical records. All patients in this study underwent MRU at our institution between 2010 and 2017. Two pediatric radiologists reviewed each MRU blinded to clinical information and other urologic imaging regarding the presence, size, location, and morphology of the cyst and presence/absence of contrast within it. The time when contrast first appeared within the cystic mass was recorded, and a χ test was used to determine significance on differences between the different characteristics of renal cysts and diverticula.

Results: Fifty children (29 girls and 21 boys; median age of 11.5 years, IQR 7-16) with a total of 66 individual cystic masses were included. 21 (21/66, 31.8%) Cystic masses demonstrated contrast filling and were characterized as diverticula, resulting in a frequency of 26.6 cases per 1000 patients (21/787). The remaining 45 cystic masses (45/66, 68.1%) were cysts. The median diameter of CD was 2.5 cm (IQR 1.5-3.7). Contrast was observed within the cystic mass on average at 4.6 min (SD ± 2.4; range 1.5-13 min). The agreement between both radiologists was 91% (k = 0.78). 6 Cysts and 18 CD were confirmed surgically, MRU demonstrated accurate diagnosis in 100% of those cases.

Conclusion: Magnetic resonance urography is reliable in differentiating calyceal diverticula from renal cysts. On MRU, all diverticula were identified within 15 min of contrast administration; hence longer delays in imaging are unnecessary.
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http://dx.doi.org/10.1007/s00261-020-02623-2DOI Listing
January 2021

Intraoperative contrast enhanced sonourethrography to characterize urethral stricture in a pediatric patient.

Urol Case Rep 2020 Sep 22;32:101223. Epub 2020 Apr 22.

Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA, 19104, USA.

Fluoroscopic retrograde urethrogram (RUG) is the current gold standard to define urethral strictures, however, sonourethrography (SU) has been shown to be effective in this setting as well. Some advantages of SU include more accurate measurement of stricture length, lack of radiation, and ability to assess soft tissue surrounding strictures to help guide operative management. Contrast enhanced ultrasound (CEUS) is an evolving imaging modality with increasing clinical utility in both pediatric and adult patient populations. We present a unique case in which contrast enhanced sonourethrography (CESU) was used to further characterize a urethral stricture intraoperatively to aid in surgical decision making.
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http://dx.doi.org/10.1016/j.eucr.2020.101223DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7191200PMC
September 2020

Characterization of ovarian development in girls from birth to 9 months.

Paediatr Perinat Epidemiol 2021 01 13;35(1):75-82. Epub 2020 Apr 13.

Biostatistics and Computational Biology Branch, National Institute of Environmental Health Sciences, NIH, Research Triangle Park, NC, USA.

Background: The minipuberty of infancy is a period of increased reproductive axis activity. Changes in reproductive hormone concentrations and organ size occur during this period, but longitudinal changes have not been well described.

Objectives: The objective of this study was to characterize ovarian growth trajectories and ovarian follicle development during the first 9 months of life in a large longitudinal cohort of healthy girls.

Methods: Data from the Infant Feeding and Early Development Study, a longitudinal cohort study of oestrogen-responsive outcomes in healthy infants, were used to estimate ovarian growth trajectories and describe the presence of ovarian antral follicles in girls 0-9 months old. Ovarian ultrasound evaluations were performed on the infants within 72 hours of birth (newborn visit) and at 4, 8, 16, 24, and 32 weeks of age. Mixed-effects regression splines were used to characterize changes in ovarian volume during infancy and assess the association between the presence of ovarian follicles at the newborn visit and ovarian growth.

Results: This analysis included 163 girls with two or more ovarian ultrasounds in the study. Results from the estimated overall ovarian growth trajectory show that ovarian volume increases more than sixfold during the first 16 weeks after birth and then remains relatively stable in the later weeks of infancy. Among girls with observable ovaries at the newborn visit (n = 133), girls with at least one visible ovarian follicle showed more rapid initial ovarian growth compared with girls without visible follicles.

Conclusions: Infant ovarian volume increased to a peak at 16 weeks, which was influenced by the number and size of developing follicles. This research contributes to future development of reference ranges for postnatal ovarian growth in healthy, term infants.
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http://dx.doi.org/10.1111/ppe.12673DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7554126PMC
January 2021

Pediatric Radiology Fellowship Creation as an International Education Outreach Effort in Ethiopia.

J Grad Med Educ 2020 Feb;12(1):98-103

Background: In 2008, there were no pediatric radiologists in Ethiopia, a country of 100 million people. The radiology residency programs lacked training in pediatric imaging acquisition and interpretation.

Objective: We established an accredited local pediatric radiology fellowship program in Ethiopia.

Methods: With assistance from US faculty from the Children's Hospital of Philadelphia, Ethiopian radiologists created a 2-year fellowship training program in a university-based Ethiopian radiology residency program that incorporated formal lectures and seminars, case tutorials, journal clubs, teleradiological conferences, paper presentations, and online courses from collaborating institutions. Formal accreditation of the program was achieved from the university, and core values were established to ensure sustainability and self-sufficiency. The Ethiopian institution provided funding for the fellows, and US faculty volunteered their time.

Results: In 2015, 2 radiologists were recruited to the new fellowship; after graduation in 2017, they formed the first pediatric radiology section at the Ethiopian institution. Three new fellows were recruited in 2019, and the program is now self-sustaining. Pediatric imaging training has also been added to the radiology residency.

Conclusions: Establishing a pediatric radiology fellowship in a country with high need but little existing faculty expertise is feasible through outreach efforts.
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http://dx.doi.org/10.4300/JGME-D-19-00291.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7012509PMC
February 2020

Intracavitary contrast-enhanced ultrasonography in children: review with procedural recommendations and clinical applications from the European Society of Paediatric Radiology abdominal imaging task force.

Pediatr Radiol 2020 04 13;50(4):596-606. Epub 2020 Feb 13.

Service d'Imagerie Pédiatrique et Prénatale, Hôpital Timone Enfants, Marseille, France.

Contrast-enhanced ultrasonography (US) has become an important supplementary tool in many clinical applications in children. Contrast-enhanced voiding urosonography and intravenous US contrast agents have proved useful in routine clinical practice. Other applications of intracavitary contrast-enhanced US, particularly in children, have not been widely investigated but could serve as a practical and radiation-free problem-solver in several clinical settings. Intracavitary contrast-enhanced US is a real-time imaging modality similar to fluoroscopy with iodinated contrast agent. The US contrast agent solution is administered into physiological or non-physiological body cavities. There is no definitive list of established indications for intracavitary US contrast agent application. However, intracavitary contrast-enhanced US can be used for many clinical applications. It offers excellent real-time spatial resolution and allows for a more accurate delineation of the cavity anatomy, including the internal architecture of complex collections and possible communications within the cavity or with the surrounding structures through fistulous tracts. It can provide valuable information related to the insertion of catheters and tubes, and identify related complications such as confirming the position and patency of a catheter and identifying causes for drainage dysfunction or leakage. Patency of the ureter and biliary ducts can be evaluated, too. US contrast agent solution can be administered orally or a via nasogastric tube, or as an enema to evaluate the gastrointestinal tract. In this review we present potential clinical applications and procedural and dose recommendations regarding intracavitary contrast-enhanced ultrasonography.
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http://dx.doi.org/10.1007/s00247-019-04611-1DOI Listing
April 2020

Small Bowel Crohn Disease at CT and MR Enterography: Imaging Atlas and Glossary of Terms.

Radiographics 2020 Mar-Apr;40(2):354-375. Epub 2020 Jan 17.

From the Department of Radiology, Thomas Jefferson University Hospital, 132 S 10th St, Philadelphia, PA 19107 (F.F.G.); Department of Radiology, Thomas Jefferson University Hospital, 132 S 10th St, Philadelphia, PA 19107 (F.F.G.); Department of Radiology, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pa (S.A.A., K.D.); Department of Radiology (J.G.F., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn.; Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (M.M.A.); Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio (J.R.D.); Department of Radiology, Rhode Island Hospital, Providence, R.I. (D.J.G.); Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (M.C.); Imaging Institute, Cleveland Clinic, Cleveland, Ohio (N.S.G.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.S.G.); Department of Radiology, University of Florida College of Medicine, Gainesville, Fla (J.R.G.); Department of Radiology, New York University Langone Health, New York, N.Y. (C.H.); Department of Radiology, Duke University Medical Center, Durham, N.C. (T.A.J.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Hospital Clínic of Barcelona, Barcelona, Spain (J.R.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S.); Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (B.T.); Centre for Medical Imaging, University College London, London, United Kingdom (S.A.T.); and Imaging Institute, Cleveland Clinic, Cleveland, Ohio (M.E.B.).

Representatives from the Society of Abdominal Radiology Crohn's Disease-Focused Panel, the Society for Pediatric Radiology, the American Gastroenterological Association, and other international experts recently reported consensus recommendations for standardized nomenclature for the interpretation and reporting of CT enterography and MR enterography findings of small bowel Crohn disease. The consensus recommendations included CT enterography and MR enterography bowel wall findings that are associated with Crohn disease, findings that occur with penetrating Crohn disease, and changes that occur in the mesentery related to Crohn disease. Also included were recommended radiology report impression statements that summarize the findings of small bowel Crohn disease at CT enterography and MR enterography. This article, authored by the Society of Abdominal Radiology Crohn's Disease-Focused Panel, illustrates the imaging findings and recommended radiology report impression statements described in the consensus recommendations with examples of CT enterography and MR enterography images. Additional interpretation guidelines for reporting CT enterography and MR enterography examinations are also presented. The recommended standardized nomenclature can be used to generate radiology report dictations that will help guide medical and surgical management for patients with small bowel Crohn disease. RSNA, 2020See discussion on this article by Heverhagen.
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http://dx.doi.org/10.1148/rg.2020190091DOI Listing
April 2021

State-of-the-Art Renal Imaging in Children.

Pediatrics 2020 02 8;145(2). Epub 2020 Jan 8.

Division of Body Imaging, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and.

Imaging modalities for diagnosing kidney and urinary tract disorders in children have developed rapidly over the last decade largely because of advancement of modern technology. General pediatricians and neonatologists are often the front line in detecting renal anomalies. There is a lack of knowledge of the applicability, indications, and nephrotoxic risks of novel renal imaging modalities. Here we describe the clinical impact of congenital anomalies of the kidneys and urinary tract and describe pediatric-specific renal imaging techniques by providing a practical guideline for the diagnosis of kidney and urinary tract disorders.
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http://dx.doi.org/10.1542/peds.2019-0829DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6993529PMC
February 2020

DTI of the kidney in children: comparison between normal kidneys and those with ureteropelvic junction (UPJ) obstruction.

MAGMA 2020 Feb 16;33(1):63-71. Epub 2019 Dec 16.

Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.

Objective: To compare renal diffusion tensor imaging (DTI) parameters in patients with or without ureteropelvic junction (UPJ) obstruction.

Methods: Patients that underwent functional MR urography (MRU) with renal DTI were retrospectively selected. Kidneys deemed normal on T2-weighted images and functional parameters were used as controls and compared to those kidneys with morphologic and functional findings of UPJ obstruction. DTI included a 20-direction DTI with b values of b = 0 s/mm and b = 400 s/mm. Diffusion Toolkit was used for analysis and segmentation. TrackVis was used to draw regions of interest (ROI) covering the entire volume of the renal parenchyma, excluding the collecting system. Fibers were reconstructed using a deterministic fiber tracking algorithm. Whole kidney ROI-based analysis was performed to obtain cortico-medullary measurements (FA, ADC and track length) for each kidney. T tests were performed to compare means and statistical significance was defined at p < 0.05.

Results: 118 normal kidneys from 102 patients (median age 7 years, IQR 6-15 years; 58 males and 44 females) were compared to 22 kidneys from 16 patients (median age 13 years, IQR 3-15 years; 9 males and 7 females) with UPJ obstruction. Mean FA values were significantly lower (0.31 ± 0.07; n = 22) in kidneys with UPJ obstruction than normal kidneys (0.40 ± 0.08; n = 118) (p < 0.001). ADC was marginally significantly increased (p = 0.01) and track length was not significantly different (p = 0.24).

Conclusion: Our results suggest that DTI-derived metrics including FA and ADC are potential biomarkers to differentiate kidneys with UPJ obstruction and assess renal parenchymal damage.
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http://dx.doi.org/10.1007/s10334-019-00812-9DOI Listing
February 2020

Supine versus prone positioning for ultrasound evaluation of postnatal urinary tract dilation in children.

Pediatr Radiol 2020 03 12;50(3):357-362. Epub 2019 Nov 12.

Department of Radiology,, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.

Background: Ultrasound (US) is used in the initial evaluation and surveillance of urinary tract dilation in children. Urinary tract dilation is diagnosed in 1-2% of all pregnancies during routine prenatal sonography with technological advances in US imaging. Urinary tract dilation classification systems, including the 2014 multidisciplinary consensus, assess anterior-posterior renal pelvic diameter and calyceal dilation. There is no consensus regarding optimal patient positioning - supine versus prone - during US assessment of urinary tract dilation.

Objective: We performed this study to determine whether there is a significant difference in the measurement of the anterior-posterior renal pelvic diameter, presence of calyceal dilation, or resulting urinary tract dilation consensus score obtained between supine and prone positions.

Materials And Methods: Two raters retrospectively reviewed renal bladder US exams of children with urinary tract dilation of one or both kidneys. We included technically adequate US examinations of orthotopic kidneys that were imaged in both supine and prone positions; we excluded children with renal anomalies or prior surgery. Anterior-posterior renal pelvic diameter measurements as well as central and peripheral calyceal dilation were documented in both supine and prone positions. A postnatal urinary tract dilation consensus score was assigned to each kidney based only on these features.

Results: Urinary tract dilation in either the supine or prone position was performed in 146 kidneys (69 right, 77 left) in 89 children. Median age was 0.26 years (interquartile ratio [IQR] 0.08-0.61 years). Female-to-male ratio was 1:3 (21/89). The interclass correlations of the anterior-posterior renal pelvic diameter were 0.88 and 0.87 in the supine and prone positions, respectively, without significant differences (P=0.1). When comparing all kidneys together, the mean anterior-posterior renal pelvic diameter was 7.1 mm (95% confidence interval [CI] 6.4-7.8) in supine and 7.9 (95% CI 7.1-8.7) in prone, with a mean difference between the measurements of 0.83 mm (95% CI 0.3-1.4; P=0.16). Central calyceal and peripheral calyceal dilation were more commonly found in the prone position versus the supine position in both kidneys. Central calyceal dilation was observed in 15 cases in the prone but not in the supine position. In one kidney, it was seen only in the supine but not in the prone position. Overall the urinary tract dilation score differed between positions in 10.3% (15/146) of cases, most of them (14/15) with a higher score in prone compared to the supine position.

Conclusion: Scanning in prone position tends to more frequently show calyceal dilation and a greater size of the anterior-posterior renal pelvic diameter, resulting in higher urinary tract dilation classification scores, with almost perfect interobserver agreement.
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http://dx.doi.org/10.1007/s00247-019-04546-7DOI Listing
March 2020

Improved Diagnostic Sensitivity of Bowel Disease of Prematurity on Contrast-Enhanced Ultrasound.

J Ultrasound Med 2020 May 9;39(5):1031-1036. Epub 2019 Nov 9.

Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.

Bowel diseases of prematurity, including necrotizing enterocolitis, are dreaded ailments of neonates. Early diagnosis is difficult, with clinical and radiographic findings often inconclusive. We present a novel use of contrast-enhanced ultrasound in detection of pediatric bowel disease. Early identification of compromised blood flow or an at-risk bowel can be quantitatively detected and monitored. This ability has implications for guidance of emerging therapies, allowing targeting of inflammation. These findings represent an advancement in detection of bowel disease in neonates.
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http://dx.doi.org/10.1002/jum.15168DOI Listing
May 2020
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