key: cord- -cxr ul q authors: cianchi, giovanni; bonizzoli, manuela; pasquini, andrea; bonacchi, massimo; zagli, giovanni; ciapetti, marco; sani, guido; batacchi, stefano; biondi, simona; bernardo, pasquale; lazzeri, chiara; giovannini, valtere; azzi, alberta; abbate, rosanna; gensini, gianfranco; peris, adriano title: ventilatory and ecmo treatment of h n -induced severe respiratory failure: results of an italian referral ecmo center date: - - journal: bmc pulm med doi: . / - - - sha: doc_id: cord_uid: cxr ul q background: since the first outbreak of a respiratory illness caused by h n virus in mexico, several reports have described the need of intensive care or extracorporeal membrane oxygenation (ecmo) assistance in young and often healthy patients. here we describe our experience in h n -induced ards using both ventilation strategy and ecmo assistance. methods: following italian ministry of health instructions, an emergency service was established at the careggi teaching hospital (florence, italy) for the novel pandemic influenza. from sept to jan , all patients admitted to our intensive care unit (icu) of the emergency department with ards due to h n infection were studied. all ecmo treatments were veno-venous. h n infection was confirmed by pcr assayed on pharyngeal swab, subglottic aspiration and bronchoalveolar lavage. lung pathology was evaluated daily by lung ultrasound (lus) examination. results: a total of patients were studied: underwent ecmo treatment, and responded to protective mechanical ventilation. two patients had co-infection by legionella pneumophila. one woman was pregnant. in our series, pcr from bronchoalveolar lavage had a % sensitivity compared to % from pharyngeal swab samples. the routine use of lus limited the number of chest x-ray examinations and decreased transportation to radiology for ct-scan, increasing patient safety and avoiding the transitory disconnection from ventilator. no major complications occurred during ecmo treatments. in three cases, bleeding from vascular access sites due to heparin infusion required blood transfusions. overall mortality rate was . %. conclusions: in our experience, early ecmo assistance resulted safe and feasible, considering the life threatening condition, in h n -induced ards. lung ultrasound is an effective mean for daily assessment of ards patients. since the first outbreak of a respiratory illness caused by influenza a (h n ) virus in mexico [ ] , several reports have described the need of intensive care [ ] [ ] [ ] or extracorporeal membrane oxygenation (ecmo) assistance [ ] in young and often healthy patients. beginning august , the italian ministry of health and the tuscany ministry of health issued instructions to identify and establish referral centers able to care for the more severely ill influenza patients. therefore, several referral centers were identified throughout the national territory among the hospitals already experienced in extracorporeal respiratory support techniques. the referral ecmo centres, in addition to being capable of guaranteeing the most advanced treatment in influenza related respiratory failure, were also entrusted with providing support to the nearby hospitals and assuring safe transportation. in the present investigation we report our experience, as an ecmo referral center, in h n -induced acute respiratory distress syndrome (ards) and we present the critical care service planning in response to the h n pandemic. following the instructions of the italian ministry of health and tuscany regional ministry of health, an emergency medical service was established in the careggi hospital in florence italy for the novel pandemic influenza. the careggi hospital ecmo team is composed of: an intensivist, a cardiac surgeon, a cardiologist, a nurse, and a perfusionist. all of the members of the team are properly trained in ecmo treatment. an ambulance and a car are equipped with an ecmo circuit, a transport ventilator and all of the materials needed to initiate extracorporeal support in the peripheral hospitals, and permit safe transportation while on extracorporeal circulation to our referral hospital. the requirement of ecmo was decided based on the italian ministry of health criteria (table ) . from september to january , all patients admitted to our icu with severe respiratory failure due to h n infection were included in this study. patient demographics and clinical characteristics were collected from institutional icu database (filemaker pro, file-maker, inc, usa), from italian group for the evaluation of interventions in intensive care medicine database (giviti margherita project, istituto mario negri, bergamo, italy) and from ecmo national network database. discrete variables are expressed as counts and percentages, whereas continuous variables are reported as medians with th to th interquartile range (iqr). the internal review board approved this retrospective study and informed consent for data publication was obtained from the patients or relatives. pressure volume curves were calculated with ventilator's built in application (draeger evita xl, draeger medical ag, lubeck germany) starting from a peep level of cm h o, with a pressure limit of . ventilation parameters were set on the basis of this calculation, with a peep of cmh o above the lower inflection point of the pressure-volume curve, and a peek pressure below the upper inflection point. in all cases, pressure plateau was limited to cmh o and the tidal volume was kept below ml/kg [ ] . recruitment manoeuvres ( sec at cmh o) were performed twice a day, if needed, to improve pulmonary gas exchange. cannulation was conducted percutaneously with seldinger technique in all cases, and cannulas position was confirmed by transesophageal echocardiography. heparin infusion during extracorporeal lung assistance was monitored every two hours by bedside aptt measurement (hemochron jr. signature plus, itc europe, milan, it), which was maintained between and seconds. in case of renal replacement therapy requirement in ecmo patients, a continuous veno-venous hemodiafiltration circuit was assembled on the ecmo circuit (aspiration on pre-pump line, restitution on preoxygenation line). ecmo patients were ventilated with protective parameters, and respiratory rate and ecmo flow were adjusted to achieve normocarbia and oxygen saturation above %. assayed on pharyngeal swab, subglottic aspiration and bronchoalveolar lavage in accordance with published guidelines [ ] . bronchoalveolar specimens were obtained with a mini-invasive system (kimberly-clark bal cath, kimberly-klark n.v. zaventem -belgium), or by bronchoscopy. patients were isolated in negative pressure atmosphere rooms, and staff wore full protective garments (including ffp respirators, m italia spa, segrate, italy), until consecutive tests were confirmed negative. during the study period only one case of suspected transmission of influenza to a nurse occurred. antiviral therapy consisted in oral oseltamivir ( mg twice daily) and inhaled zanamivir ( mg twice daily). blood and urinary cultures, tracheal aspirate, and pharyngeal swab were obtained upon patient admission. empiric antimicrobial regimen at icu admission was initiated with levofloxacin and amoxicillin/clavulanate; eventually specific antimicrobial therapy was varied or ended on the basis of microbiological results. steroids were administered at low dosage ( mg metilprednisolon twice per day) to prevent lung fibrosis. diuretics were administered at different dosages, depending on clinical judgment and the patient's renal function. lung ultra sound (lus) examinations were daily performed by the attending physician, with a multifrequency convex probe ( . - mhz, mylab tm cv, esaote, genova, it). with the patient in semirecumbent position, lateral and anterior views were obtained from base to apex of the chest. posterior axillary line was followed during lateral transversal examinations. chest quadrants defined by the intercostal spaces and the parasternal, mid-clavicular, and anterior axillary lines were scanned on the anterior chest wall [ ] . the occurrence and extension of parenchymal consolidations, alveolar interstitial syndrome (measured by the number of b-lines), and morphology of pleural line were evaluated [ ] [ ] [ ] . pleural effusions were estimated by using balik's formula [ , ] . in order to ensure a uniform record, and allow to follow the evolution of the findings over time, all exams were recorded in an electronic form, in which the description of the main lus features was predetermined [ ] . during the study period, patients requiring invasive ventilation treatment and/or ecmo were admitted or transferred to our icu. baseline and clinical characteristics of patients admitted for h n -induced severe respiratory failure are summarized in table . the median time between initial, non specific, symptoms and respiratory failure was days (iqr - . ), and severe hypoxia, unresponsiveness to non-invasive ventilation, was the main clinical feature. our patients were young, median age . years, none of them older than years, and eight ( %) younger than . two patients were severely obese (bmi > ), one woman was pregnant ( weeks), two patients had a history of chronic obstructive respiratory disease (copd), and one had diabetes. two patients had legionella pneumophila coinfection at admission, and one young patient ( years old) with suspect viral myocarditis and heart failure. at admission the patients, with the exception of the two coinfected, presented low leukocyte and platelet count and low plasma procalcitonin levels, significant levels of lactate dehydrogenase (ldh), creatine kinase (ck), and c-reactive protein ( table ). median duration of mechanical ventilation (days) was . (iqr . - . ) and median icu length of stay (days) was (iqr - . ). the pregnant woman continued the pregnancy without significant complications. in icu infection rate was low with two ventilator associated pneumonia and two asymptomatic positive blood cultures in two ecmo patients. one ecmo patient died due to a systemic secondary infection by aspergillus: this patient was the only non-surviving patient (overall mortality rate . %). rt-pcrs from bronchoalveolar lavage samples were positive in all patients included in this study. on the contrary, rt-pcr dosed on pharyngeal swab resulted positive in less than % of patients at icu admission, and in % of patients in the second day ( figure ). also efficacy of antiviral therapy was reliably followed through rt-pcr from bronchoalveolar samples, since analysis on pharyngeal swabs became negative quite early. finally, no rt-pcr significant for h n infection from subglottic aspirate sample was found. in one patient, intravenous administration of zanamivir was needed, since the patient remained positive to viral infection after two weeks of therapy. intravenous formulation of zanamivir is still subjected to pre-phase clinical trial investigation, even if some reports on its safety profile are already available in literature. therefore, local ethical committee approval was requested and the manufacturer provided the drug for use. zanamivir was administered intravenously for five days ( mg twice daily), as indicated by the producer. the patient's respiratory function improved and rt-pcr became negative after the third day. no adverse reaction was noted. a total of lus have been performed. during every lus, the following parameters were considered: pleural line aspect and motility, presence of consolidations, occurrence and severity of alveolar interstitial syndrome (based on the number of b-lines), presence of pleural effusion and occurrence of pneumothorax. pleural thickness was described in % of cases and mostly bilaterally. lung base was always involved. lung gliding was present in % of lus, even if decreased ( %). pathological lung pulse was found in % of lus, often in proximity to large parenchyma consolidations. pleural effusion occurred in patients. two spontaneous pneumothorax have been detected with lus during icu treatment. alveolar interstitial syndrome was present in all ultrasound examinations, with the presence of normal lung pattern (spared areas). in % of cases, b-lines were described as moderate/many. at lung recovery, residual b-lines patterns were found mostly at both bases. white lung feature occurred in about % of lus performed, mostly in the anterior and lateral scans. white lung was never uniformly distributed, but it was alternated to spared areas, or areas with a limited number of b-lines. consolidations were found in % of cases. most of them were multiple ( %), and lung bases were always involved. contiguous subpleural consolidations were also present, increasing the pleural thickness laterally, mostly at the base and the apical part. aerial bronchograms were always found within the consolidation pattern. the routine use of lus limited the number of conventional radiology examinations (table ). in ecmo patients group, the higher number of chest x-ray examinations was needed to verify the correct cannulae positioning. in both groups, bedside lus limited the transportation to the ct-scan room, increasing patient safety and avoiding the transitory disconnection of the patient from the ventilator. ecmo was needed in patients (table ). in cases, the ecmo team was alerted and extracorporeal oxygenation was implanted directly at peripheral icus. no major transportation related problems were faced, even in the case of a long distance journey ( km). median duration of ecmo support was days (iqr - . ), with a median duration of mechanical ventilation (days) of (iqr - ). main clinical features and ventilatory and ecmo parameters of patients treated with ecmo are presented in table . bleeding was the most important complication. in three cases, bleeding from vascular access sites due to heparin infusion required blood transfusions. three patients presented prolonged oropharyngeal bleeding and transfusions were required. among them, one needed electrical coagulation of a palatine injury, probably related to nursing manoeuvres. two patients presented severe intra-bronchial bleeding, and several flexible bronchoscopy examinations and clot suctions were required. in one of these patients, bleeding from the lower airways during the weaning phase from ecmo, and ecmo removal has been hastened. table summarizes the main differences between patients who underwent to ecmo treatment and patients only ventilated. despite the small sample, ecmo patients clearly showed a higher critical illness score (saps ii), and worst pulmonary gas exchange compared to patients who did not required extracorporeal lung assistance. coinfection and comorbidities at admission were present only in ecmo patients. our study population is young, comprising mainly healthy subjects, as previously reported [ , , ] . risk factors are similar to other studies, such as obesity, diabetes and pregnancy. in the present case series, bacterial infection rate at presentation was low. previous reports showed incidence of secondary superinfection by streptococcus pneumoniae, staphylococcus aureus, pseudomonas aeruginosa, acinetobacter baumannii, escherichia coli [ , , ] . in our experience, we found two cases ( . %) of co-infection with legionella pneumophila, which is, to the best of our knowledge, a new epidemiological data, since no other case has been reported in literature. it is questionable whether legionella pneumophila infection occurred before or after h n pneumonia. however, it could be that h n pneumonia was associated with a lower reactivity of the immune system, as suggested by the low leucocytes count reported in our sample and by other authors [ , , ] . one young patient presented heart failure, and viral myocarditis was suspected. the association of influenza with myocarditis is debated [ ] , and h n related myocarditis, has rarely been reported [ ] . furthermore, in our patient prolonged pre-hospital hypoxia was present and myocardial hypoxemia damage might have been involved. the patient required inotrope/vasoactive support for several days and eventually recovered fully with normal heart function. our observations confirm the responsiveness of this infection to antiviral therapy. we adopted a two-modality administration, both oral and inhaled. our choice was made in consideration of the decrease in gut motility and adsorption usually observed in critically ill patients. the world health organization (who) has questioned the sensibility of rt-pcr analysis for h n in pharyngeal swab sample, encouraging analysis on samples from the lower respiratory tract. we routinely monitor h n infection on three compartments: pharyngeal swab, subglottic aspiration, and bronchoalveolar lavage. in our experience, bronchoalveolar lavage at admission was positive in all patients while pharyngeal swab resulted positive in only % of cases. as shown in figure , rt-pcr from pharyngeal swab at icu admission failed to demonstrate the viral infection in patients. similarly, the time course showed that rt-pcr from pharyngeal swab resulted negative in an average time of days after therapy start. conversely rt-pcrs from bronchoalveolar lavage remained positive for a longer period and resulted more reliable for infection monitoring and assessment of the efficacy of administered therapy. based on our experience, rt-pcr from bronchoalveolar lavage resulted to be the most reliable method to diagnose and monitor h n infection, since pharyngeal swab does not offer enough sensibility, neither for antiviral therapy initiation nor for antiviral therapy management. as subglottic aspiration resulted persistently negative, we do not recommend this sampling for diagnosis and monitoring of h n infection. despite the severe clinical pictures, we experienced a very low mortality rate: only one patient out of died ( , %). one of the surviving patients presented a lung cavern for a past pulmonary infection, and deceased for a secondary superinfection by aspergillus, probably already colonizing lung parenchyma before the onset of viral infection. our mortality rate is surprisingly low in comparison to a larger series of h n patients, even when extracorporeal support technique were employed [ , ] . our finding can be related to the small number of patients included the study and definitive comparison with larger studies could be misleading. however, despite the severity of symptoms and the rapid progression to ards, h n respiratory failure presents a relatively benign course when adequately treated, if compared to non-h n induced ards, reported to have a mortality rate from % to % [ ] [ ] [ ] [ ] . several factors may account for the favourable outcome in our series. all patients received protective ventilation. in particular, ecmo support permitted the maintenance of patients under a protective tidal volume with a respiratory rate below per min, and a fio below %, compared with non-ecmo patients who needed a higher respiratory rate and fio to maintain an acceptable pulmonary gas exchange. the availability of easily accessible tools for pulmonary mechanics evaluations on modern ventilators allowed an individualized and appropriate setting of ventilation pressure within the thresholds of so called "protective ventilation" [ ] . furthermore, early access to ecmo resource allowed the maintenance of protective ventilation even in more severe patients (table ). in this regard, lactate dehydrogenase is commonly considered a marker of lung damage, and in h n pneumonia is reported as high [ ] . in our ecmo patients, lactate dehydrogenase values presented lower levels than in non-ecmo patients ( u/l vs iu/l, respectively), suggesting that in ecmo patients the reduced need of pulmonary ventilation could reduce lung ventilatory stress and enhance healing, regardless of the more impaired lung condition. however, it is possible that, since the technique has gained popularity and experience gathered to demonstrate its feasibility, we used ecmo also in patients who might previously have been successfully treated conventionally, and this may have influenced mortality. moreover, more than half of our ecmo patients needed to be land-transported from other hospitals in an advanced stage of respiratory failure. this may have further encouraged an early treatment with ecmo to ensure the safest transport. bleeding is commonly reported during ecmo treatment [ ] , and either anticoagulation or platelet and coagulation cascade activation through oxygenator and pump is involved [ ] . in our population bleeding also occurred more frequently in ecmo patients, and they required more transfusions compared to non ecmo patients. nevertheless, in our experience, bleeding from cannulas insertion site or from upper airways, despite requiring transfusion, were not life threatening, and could be managed. in only two cases did severe bleeding occur in the lower respiratory tract. fortunately in one case it occurred during weaning from ecmo, and it ceased after extracorporeal support removal. the other patient died from pulmonary aspergillosis and the haemorrhage could be also related to parenchyma disruption caused by the fungus. monitoring heparin regimen is extremely important during extracorporeal circulation, and activated clotted time is commonly measured bedside. some debate exists regarding the optimal range and the accuracy of pointof-care measuring devices [ ] [ ] [ ] . in our protocol, we usually measured aptt every two hours with hemochron jr. in order to closely monitor heparin administration in the low range of dosage. in our clinical practice, lung recovery and response to treatment are daily assessed by lus examination, following several recent reports which underline the reliability of lus in the evaluation and management of chest disorders [ , ] . despite ct-scan is the reference technique for evaluating lung lesions, it requires a transitory disconnection of the patient from the ventilator to permit the transportation radiology suite with potential risk of alveolar de-recruitment and worsening of oxygenation. moreover, severe complications have been reported in intra-hospital transportation of critically ill patients [ , ] . as we recently reported [ ] , the routine use of bedside lus has significantly reduce of the number of ct-scan and chest x-ray examinations in critical patients. the potential clinical benefit of reducing in-hospital transport for diagnostic radiology, it can be particularly relevant in patients with ecmo. in these patients, in fact, transportation requires time and a significant commitment of resources, although it was proved feasible both for inhospital [ , ] and for inter-hospital long distance transportations [ , ] . another advantage of lus is the ability to evaluate the effectiveness of alveolar recruitment manoeuvres with the possibility to visualize real-time imagines of lung parenchyma re-aeration [ , , ] . finally, pleural effusions can be accurately diagnosed and monitored with lus and in case of need for treatment an ultra-sound guided technique is recommended [ , ] . this option seems to be particularly appropriate ecmo patients, where bleeding for conventional chest tube placement can occur in consideration of the need of heparin infusion. the present case series comprises a small number of patients, and naturally, it cannot be considered a high grade of evidence trial. however, our experience might be helpful for intensivists challenging h n -induced ards. for h n infection monitoring (or diagnosis, if patient was intubated before) bronchoalveolar lavage can be more reliable than pharyngeal swab in order of the higher sensitivity. in our clinical practice, ecmo therapy resulted safe and feasible in the context of a life threatening condition, and it might be taken into consideration as a therapeutic choice rather than a rescue solution in experienced centers. • ecmo might be taken into consideration as a safe therapeutic choice rather than a rescue solution in ards. • rt-pcr from bronchial lavage is more accurate than from pharyngeal swab, in h n diagnosis. • lung ultrasonography is a safe and reliable method to follow the pathology evolution/recovery of lung. • lung ultrasonography can limit the need of ct-scan and chest x-ray examinations. list of abbreviations ards: acute respiratory distress syndrome; bmi: body mass index; cvvh: continuous veno-venous hemofiltration; ecmo: extracorporeal membrane oxygenation; icu: intensive care unit; los: length of stay; lus: lung ultrasound; rt-pcr: real-time reverse transcriptase-polymerase-chain-reaction; saps: simplified acute physiology score. pneumonia and respiratory failure from swine-origin influenza a (h n ) in mexico intensive care adult patients with severe respiratory failure caused by influenza a (h n )v in spain hospitalized patients with h n influenza in the united states severe respiratory disease concurrent with the circulation of h n influenza acute respiratory distress syndrome higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome cdc protocol of realtime rt-pcr for influenza a (h n ). geneva: world health organization the value of lung ultrasound monitoring in h n acute respiratory distress syndrome ultrasound diagnosis of alveolar consolidation in the critically ill lung ultrasound in acute respiratory distress syndrome and acute lung injury the coming boom ultrasound estimation of volume of pleural fluid in mechanically ventilated patients the use of point-of-care bedside lung ultrasound significantly reduces the number of radiographs and computed tomography scans in critically ill patients time needed to achieve completeness and accuracy in bedside lung ultrasound reporting in intensive care unit h n influenza in australia and new zealand influenza as a trigger for acute myocardial infarction or death from cardiovascular disease: a systematic review myocarditis in a juvenile patient with influenza a virus infection extracorporeal lung support for patients who had severe respiratory failure secondary to influenza a (h n ) infection in canada efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (cesar): a multicentre randomised controlled trial mortality rates for patients with acute lung injury/ ards have decreased over time has mortality from acute respiratory distress syndrome decreased over time?: a systematic review extracorporeal life support for management of refractory cardiac or respiratory failure: initial experience in a tertiary centre ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. the acute respiratory distress syndrome network extracorporeal membrane oxygenation in adults with severe respiratory failure: a multicenter database coagulation and anticoagulation in extracorporeal membrane oxygenation long-term extracorporeal circulation management: the role of low-and high-range heparin act tests maintaining adequate anticoagulation on extracorporeal membrane oxygenation therapy: hemochron junior low range versus hemochron activated clotting time systems vary in precision and bias and are not interchangeable when following heparin management protocols during cardiopulmonary bypass ultrasound assessment of antibiotic-induced pulmonary reaeration in ventilator-associated pneumonia* intrahospital transport of critically ill patients review of a large clinical series: intrahospital transport of critically ill patients: outcomes, timing, and patterns chest and abdominal ct during extracorporeal membrane oxygenation: clinical benefits in diagnosis and treatment management benefits and safety of computed tomography in patients undergoing extracorporeal membrane oxygenation therapy: experience of a single centre inter-hospital transportation of patients with severe acute respiratory failure on extracorporeal membrane oxygenation-national and international experience transportation of critically ill patients on extracorporeal membrane oxygenation safety of ultrasound-guided thoracentesis in patients receiving mechanical ventilation the study was supported by institutional funds only. authors' contributions ap, mb, gc, ap, sb, mc, gs, mb, vg, gg organized the ecmo center. ap, mb, gc, gs, vg, gg designed the study. ap, mb, gc, ap, mc, sb, mb, sb reviewed the literature. sb collected data. pb and cl performed cardiologic and transesophageal assistance. mb performed ecmo invasive procedures. aa and ra performed laboratory and microbiological analysis; gc, gz, sb, cl wrote the draft. all authors have read, revised and approved the manuscript. the authors declare that they have no competing interests. key: cord- - lmqp jd authors: rodriguez-fanjul, javier; jordan, i.; balaguer, m.; batista-muñoz, a.; ramon, m.; bobillo-perez, s. title: early surfactant replacement guided by lung ultrasound in preterm newborns with rds: the ultrasurf randomised controlled trial date: - - journal: eur j pediatr doi: . /s - - -y sha: doc_id: cord_uid: lmqp jd this study aimed to investigate whether using lung ultrasound (lus) scores in premature newborns with respiratory distress syndrome (rds) allows for earlier surfactant therapy (within the first h of life) than using fio( ) criteria. this was a randomised, non-blinded clinical trial conducted in a neonatal intensive care unit. the inclusion criteria were newborns with a gestational age of ≤ weeks and rds. patients meeting the inclusion criteria were randomly assigned to two groups: the ultrasound group, administered surfactant based on lus score and/or fio( ) threshold, and the control group, guided by fio( ) only. fifty-six patients were included. the ultrasound group received surfactant earlier ( h of life vs. h, p < . ), with lower fio( ) ( % vs. %, p = . ) and lower co( ) ( vs. , p = . ). after surfactant treatment, newborns in the ultrasound group presented a greater spo( ) (p = . ) and spo( )/fio( ) ratio (p = . ). conclusions: lus score allowed an earlier surfactant therapy, reduced oxygen exposure early in life and a better oxygenation after the treatment. this early surfactant replacement may lead to reduced oxygen exposure. the management of respiratory distress syndrome (rds) in premature newborns is centred on the use of nasal continuous positive airway pressure (ncpap) [ ] . determining the need for surfactant treatment is currently guided only by the newborn's requirement for oxygen therapy. in recent guidelines, early therapy with surfactant is suggested in patients requiring ncpap of at least cmh and an fio over . [ ] . certainly, this cut-off can be considered arbitrary, given that the current evidence is based on observational studies that considered fio requirements greater than . as a predictor of respiratory failure [ ] and may not accurately reflect the patient's oxygenation [ ] . therefore, it is challenging for neonatologists to identify the newborns who will benefit from early surfactant treatment (within the first h of life), which is known to decrease pneumothorax and bronchopulmonary dysplasia and to improve survival rates [ ] . however, patients receiving surfactant may present side effects including bradycardia, oxygen desaturation and pulmonary haemorrhage, among others [ ] . for decades, clinicians have used chest x-rays (cxr) to identify rds, as they show the pathology's characteristic diffuse reticulogranular pattern or ground glass appearance. however, this technique has low sensitivity and specificity [ ] . moreover, thanks to improvements in standard prenatal and postnatal care, the rds-like cxr image has also become more uncommon [ ] . lung ultrasound (lus) has emerged as a bedside technique that helps clinicians to identify rds patients in neonatal intensive care units (nicus) [ ] [ ] [ ] [ ] [ ] . some studies have shown a high correlation between lus findings and oxygenation status/need for surfactant therapy [ , ] . furthermore, some studies have shown lus score to be a more accurate diagnostic criterion than fio [ , [ ] [ ] [ ] , and the latest european respiratory distress guidelines highlight its potential use in identifying patients with rds [ ] . a recent high-quality prospective study showed that lus improved timeliness in surfactant administration in a tertiary nicu during two time periods [ ] , but no clinical trial has evaluated the use of surfactant therapy guided by lus only versus conventional fio guidance. moreover, there is an increased understanding about the potential lifelong impact of excessive oxygen exposure during the first hours of life in preterm infants, and lus may help to avoid this oxygen toxicity [ ] by reducing exposure to it. this study aims to investigate if using lus score ensures timely surfactant administration in premature patients better than fio does. this was a randomised, non-blinded clinical trial conducted in the nicu of hospital joan xxiii, tarragona, in spain, between january and march . the study was carried out in accordance with the declaration of helsinki and was approved by the local ethics committee and institutional review board (eim / ). the study was registered at clinicaltrials.gov, with identifier nct . written informed consent was obtained prenatally from the patients' parents or guardians. inclusion criteria were premature newborns under the gestational age (ga) of weeks with rds [ ] , defined as respiratory distress appearing within the first h of life which required ncpap to keep peripheral oxygen saturation (spo ) above %, with clinical signs of respiratory difficulty (polypnoea, chest retractions, nasal flutter, etc.) and a complete, sustained and prompt response to surfactant and/or lung recruitment. an additional, non-mandatory criterion was lung images that support the diagnosis. exclusion criteria were as follows: non-acceptance of the informed consent, chromosomal abnormalities, complex congenital malformations, signs of early-onset septic shock, mechanical ventilation and patients who received surfactant in the delivery room as part of advanced resuscitation following the pertinent european guidelines [ ] . the main objective of the study was to determine if a diagnosis of rds guided by a lus algorithm allowed for earlier surfactant therapy (within the first h of life) in comparison with using an fio threshold alone. the secondary objective was to assess the different levels of oxygen exposure in early life for each group. other secondary outcomes were spo /fio ratio (s/f ratio) after surfactant therapy (see below), the need for mechanical ventilation (mv) (defined as mv during the first days of life [ ] ), duration of invasive and non-invasive mechanical ventilation, ventilator-free days [ ] , duration of supplemental oxygen requirements, length of stay in the nicu and bronchopulmonary dysplasia [ ] . patients who met the inclusion criteria were randomly assigned to two groups, using the "random" function in the ms-excel® programme. a binary sequence of random numbers was generated following a balanced block sampling (friedman procedure) and held by the principal investigator. a total of physicians enrolled participants, all them fully trained in the use of lus. the principal investigator assigned participants to interventions based on the randomised list. patients with a gestational age of under weeks were included as they were born during the study period: -ultrasound group: the neonatologist-researcher (nr) who was not the attending clinician performed the lus at admission during the first hour of life. the neonatologistassistant (na) for the baby was not blinded to the result of the lus. patients received surfactant therapy as soon as the lus score was higher than or fio requirements exceeded % in patients with a ga of < / weeks or % in patients whose ga was > / weeks ( fig. ) [ ] . this lus threshold has been found to be the one with the best diagnostic accuracy [ , , ] . -control group: the nr performed the lus at admission during the first hour of life. the na was not blinded to the result of the lus. the patient received surfactant therapy only when fio requirements exceeded % in patients with a ga of < / weeks or % in patients whose ga was > / weeks (fig. ). our unit follows the european guidelines for respiratory support in premature newborns [ ] . in the delivery room, patients received face mask ventilation with continuous positive airway pressure and a target peak inspiratory pressure. unresponsive patients were intubated in the delivery room and received early surfactant administration, so they were excluded from the study. those who were responsive at birth were transferred to the nicu on ncpap if they were born before weeks of ga. once admitted to the unit, patients were placed under variable flow ncpap using the appropriate nasal prongs or facial mask with a pressure between and cmh , with oxygen being increased as needed to keep spo between and %. patients were intubated if fio > % despite surfactant therapy, if they had multiple episodes of apnoea (> episodes per hour or > episode requiring rescue with positive-pressure ventilation) or if respiratory acidosis was detected (pco > mmhg and ph < . in capillary samples). the lus study protocol included longitudinal scans of the anterior, lateral and posterior chest walls performed with a lineal mhz probe (sonosite edge ii) during the first hour of life once patients were in the nicu. focus was placed on the pleural line, and no harmonics were used. three scans were performed per hemithorax (anterior, lateral and posterior) and a -to -point score was given for each scanned area (with a total score ranging from to ), in accordance with previous studies published in the literature [ , , ] ; was the cut-off score for initiating surfactant treatment [ ] . clinical patient data were recorded, including spo and s/f ratio [ ] at the time of the lus scan and when the patient received surfactant therapy, min after the procedure. co and ph were analysed before surfactant administration, using arterialised capillary blood samples. we acknowledge that s/f is an imperfect oxygenation metric, as it may be influenced by foetal haemoglobin, peripheral perfusion, patent ductus arteriosus, temperature and other factors. surfactant therapy was exclusively administered through less invasive surfactant administration (lisa). the first dose given was mg/kg of poractant alfa (curosurf ®, chiesi farmaceutici, parma, italy) [ ] . bradycardia was defined as a heart rate of less than bpm and desaturation was defined as a drop in oxygen saturation to < %. these complications were considered to be related to the procedure if they were recorded during the next min after the surfactant therapy. ventilator-free days were calculated as the number of days in the nicu without invasive mechanical ventilation, within the first days of life; this number is zero for patients who died in the nicu [ ] . the sample size was calculated using the ene . ® programme. a sample size of patients for each group was required if assuming % power to reject the null hypothesis (no differences between the lung ultrasound and control groups) and accepting an alternative hypothesis with a twotailed type i error (alpha) value as determined by the bibliography. we performed a pre-analysis to detect differences between data from previous studies [ ] and our data, observing a relatively delayed surfactant administration in our control group (timely administration in % vs. % of cases reported by the esther study [ ] ). this exploratory analysis included the patients in our study, and patients in each respective group, giving us a statistically significant sample size. the statistical analyses were performed using the spss® . . categorical variables were expressed as frequency (percentage) and compared using the chi-squared test or fisher's exact test, as needed. continuous variables were expressed as median (interquartile range) and compared using the mann-whitney u test. a value of p < . was considered statistically significant. a total of newborns were included, in the ultrasound group and in the control group. figure shows the flow chart for patients. no patient was lost due to death or dropout during the study. descriptive population data are included in table . there were no differences between both groups as far as the main clinical characteristics, including gender, weight, ga and apgar score. figure shows the lus images of a patient who received surfactant and another who did not. surfactant therapy was required in . % of patients in the ultrasound group and in . % of patients in the control group (p = . ). surfactant administration occurred earlier in the ultrasound group than in the control group, with statistically significant differences: h of life (iqr - ) vs. h (iqr - . ), with p < . . figure represents the proportion of patients who received early surfactant therapy (in the first h of life) in each group. all patients in the ultrasound group received surfactant therapy based on the lus score threshold. table summarises the results of the secondary outcomes. patients in the ultrasound group had better oxygenation after surfactant therapy, with lower fio requirements and a better s/f. however, no differences were detected regarding respiratory support (days of non-invasive and invasive mechanical ventilation, ventilator-free days and duration of oxygen therapy) or frequency of bronchopulmonary dysplasia. the frequency of complications after surfactant administration was no different between groups: desaturation occurred in ( . %) patients in the ultrasound group and in ( . %) in the control group, bradycardia in ( . %) patient in the ultrasound group and in ( . %) in the control group and apnoea in ( . %) newborn in the control group (all p = . ). the median duration of the lus scan was min (iqr - ). this study demonstrates that the use of lus improves the timeliness of surfactant administration without increasing the number of patients requiring surfactant treatment. to our knowledge, this is the first study to assess lus score thresholds vs. fio requirement thresholds only to guide surfactant replacement therapy in a clinical trial. moreover, patients receiving surfactant in the ultrasound group had lower fio requirements, better oxygenation (s/f ratio) and better blood gases when surfactant was administered. no patient in the ultrasound group received surfactant as determined by the fio requirement thresholds. lus is a simple bedside tool that is easy to perform and is quick (our results show that the procedure lasts min), has a high interobserver agreement among clinicians [ ] irrespective of observer expertise and can be repeated several times. on an lus, patients with rds show an irregular, thickened pleural line, an absence of a lines and coalescent b lines showing [ ] white lung. this pattern's severity is scored according to the areas involved [ ] [ ] [ ] . moreover, different studies in premature newborns have shown its correlation with oxygenation [ , ] and with the quality of the endogenous surfactant available [ ] . in addition, lus score has been validated as being on par with other imaging techniques such as ct scans in adults [ ] . our findings are consistent with previous studies published on this matter. in their study, raschetti et al. [ ] found an improvement in early surfactant administration without encountering problems when patients were treated according to lus instead of fio . this data is confirmed by our results: patients in the ultrasound group were in better oxygenation conditions after surfactant treatment, receiving lower oxygen data are expressed as mean (standard deviation) or median ( th - th percentile) and number (%) as appropriate. ga gestational age, paw mean airway pressure, s/f spo /fio ratio. co and ph were analysed using arterialised capillary blood samples fig. flow chart of patients therapy ( % vs. %) and having a better s/f ratio. co was higher in the control group, indicating a more severe rds and that surfactant replacement should have been administered earlier in this group. the diffusion of co is times higher than o diffusion in restrictive disorders, so this is consistent with the higher fio requirements observed in the control group. the lower s/f ratio observed after surfactant therapy in both groups could be related to the number of patients who presented desaturation after the procedure, since oxygenation was measured very close to the surfactant administration and no serial evaluation was performed. despite the better oxygenation parameters, we did not find any improvement in respiratory support, such as later events (sepsis, extrapulmonary disorders). this may be explained by the small sample size of our study and by several other variables that may affect the need for respiratory support. moreover, it was found that patients in the ultrasound group received surfactant earlier and the maximal fio requirement reached was lower ( % vs. %), without encountering any differences in the overall need for surfactant. the use of lus score in the ultrasound group resulted in earlier surfactant administration. the timeliest surfactant administration may be achieved by using lus, not just using fio by itself as has been done up to now. the low rate of timely surfactant administration in the control group in comparison with other studies [ ] may be due to our cxr procedure: in most cases, the surfactant treatment was not initiated until the cxr was taken and evaluated. therefore, we believe that lus can be extremely useful for all nicus that tend to have a delayed cxr time. it is well known that oxygen treatment in premature newborns leads to oxidative stress, damaging proteins, lipids and dna and placing these fragile preterm patients at high risk for epigenetic changes to the dna [ , ] . as there is not yet a well-established oxygen saturation target and the cut-off value for surfactant treatment may be arbitrary, these patients may receive higher oxygen content. this can trigger the activation of pro-inflammatory and pro-apoptotic pathways, which may contribute to bronchopulmonary dysplasia and other pathologies [ ] before surfactant treatment is given during the first hours of life. by contrast, basing the surfactant treatment on lus score seems to decrease the maximal fio and the duration of oxygen treatment and may help to decrease oxygen toxicity. multiple studies have evaluated the use of lus to predict the need for surfactant or non-invasive ventilation failure in patients with rds [ ] [ ] [ ] . moreover, lus seems to predict the need for surfactant administration better than fio . also, lus may help to identify those patients who do not require surfactant lung ultrasound of a newborn with an lus score > treatment and may help clinicians to identify other causes, apart from rds, of hypoxia and non-invasive ventilation failure, so they can treat the patient accordingly [ , , ] . due to our study protocol, patients intubated in the delivery room or transferred from other centres were excluded; this may explain the early surfactant administration in both groups (median h vs. h) when compared with other studies [ , ] . our study has several limitations. firstly, it was carried out at a single centre and our sample size is small. in addition, not all the patients received surfactant treatment. however, differences in the need for surfactant administration between both groups were not statistically significant, and earlier treatment was demonstrated in the ultrasound group. another limitation is that although we included premature newborns younger than weeks, including extremely premature ones (ga < weeks), it would have been better to classify the patients according to their ga, but this would have required a larger, randomised multicentre study. another limitation was that the attending clinicians were not blinded to the ultrasound findings. however, we enrolled a homogeneous population of preterm newborns with a ga between and weeks with rds who were all treated according to the same nicu protocol, with lus performed at a specific time in the first hour, thus decreasing the possible variances in the lus score. in addition, we did not find any differences in the overall need for surfactant in both groups, which rules out the possibility of surfactant being given to patients who did not require it. since lus is routinely used in our unit as the first-line chest imaging technique and the medical team has considerable knowledge regarding ultrasounds, our results may be different from those obtained in other units where lus is less frequently used (or may be more difficult to apply) and where cxr remains the imaging technique of choice. therefore, it has been shown that lus improves timeliness in surfactant replacement. larger, randomised multicentre studies are likely necessary to evaluate its use more in depth, especially in very premature patients under weeks. our results may help to continue the investigation into the use of lus to guide surfactant therapy in conjunction with fio parameters. less invasive surfactant administration versus intubation for surfactant delivery in preterm infants with respiratory distress syndrome: a systematic review and meta-analysis european 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pharmacokinetics and clinical predictors of surfactant redosing in respiratory distress syndrome effect of different probes and expertise on the interpretation reliability of point-of-care lung ultrasound lung ultrasound in children: what does it give us? lung ultrasound accuracy in respiratory distress syndrome and transient tachypnea of the newborn visual assessment versus computer-assisted gray scale analysis in the ultrasound evaluation of neonatal respiratory status a noninvasive surfactant adsorption test predicting the need for surfactant therapy in preterm infants treated with continuous positive airway pressure assessment of lung aeration and recruitment by ct scan ultrasound in acute respiratory distress syndrome patients oxygen and oxidative stress in the perinatal period biomarkers of oxidative stress in the fetus and in the newborn using quality improvement methods to reduce variation in surfactant administration ventilator-associated pneumonia in neonates: the role of point of care lung ultrasound publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements we would like to thank the premature newborns and families who accepted joining this study. authors' contributions jrf, sbp, abm and mr conceived and designed the study. mb, ij and sbp analysed the data. jrf, sbp, mb and ij wrote the first draft of the manuscript. abm and mr contributed to the writing of the manuscript. all authors agree with the manuscript's results and conclusions, jointly developed the structure and arguments for the paper, made critical revisions and reviewed and approved the final version of the manuscript.funding information there is no external funding source. conflict of interest the authors declare that they have no conflicts of interest or financial relationship with any organization.ethical approval this study was approved by the local healthcare ethics committee and the institutional review board.informed consent written informed consent was obtained from all the parents of the participants. key: cord- -qyqs j authors: sachin, sasidharan; chakrabarti, dhritiman; gopalakrishna, kadarapura nanjundaiah; bharadwaj, suparna title: ultrasonographic evaluation of lung and heart in predicting successful weaning in mechanically ventilated neurosurgical patients date: - - journal: j clin monit comput doi: . /s - - - sha: doc_id: cord_uid: qyqs j in critically ill neurosurgical patients, delayed and premature extubation increases the risk of morbidity and mortality. assessment of critically ill patients before and during spontaneous breathing trial (sbt) is crucial in predicting weaning failure. we explored the trend of changes with integrated lung and cardiac ultrasonography in predicting success of weaning in neurosurgical patients. lung ultrasound and cardiac ultrasound was performed before and after min and min of sbt. lung ultrasound score (lus, range – ) was calculated using a predefined method of assessment of six chest regions on either side. the left ventricular function was evaluated by measuring fractional area change. the maximum velocities of mitral inflow e and a waves (e/a), deceleration time of e wave (dte) and tissue doppler based e′ wave at lateral annulus to calculate e/e′, were measured to assess left ventricular filling pressure. twenty seven patients underwent sbt, among these had success and five had failure of sbt. the sbt failure group had higher baseline lus and progressively higher lus during sbt compared to the success group, suggesting significant lung de-recruitment. there was significant increase in the lv filling pressure (increase e/a and e/e′, decrease in dte) after and min of sbt in failure group compared to the success group. point of care lung and cardiac ultrasonography may be useful in detecting cardiopulmonary changes induced by sbt. higher lung aeration loss and lv filling pressure were observed with sbt failure group. prediction of weaning failure, particularly in neurosurgical patients is challenging. delayed weaning and extubation in acute brain injured patients increases the rate of mortality and prolongs length of stay in intensive care unit (icu) [ ] . similarly, early attempts of weaning are complicated by post-extubation respiratory dysfunction and reintubation, associated with increased mortality, higher rate of tracheostomy, increased duration of ventilatory support and prolonged length of icu stay [ , ] . the common reasons for endotracheal intubation and mechanical ventilation in neurosurgical patients include impaired neurological function, airway protection or raised intracranial pressure, in addition to cardiorespiratory abnormalities. the primary aim of care for these patients is to detect and prevent any secondary neurological insult while supporting systemic and neurological homeostasis. hypoxia and hypercarbia are factors which need to be absolutely avoided while caring for such patients. mechanical ventilation is continued until the patient is clinically stabilized and primary neurological damage has been taken care. subsequently the transition from control ventilation to spontaneous ventilation begins [ , ] . literature suggests that glasgow coma scale (gcs) of or above and presence of adequate cough reflex are more likely to predict successful extubation in neurosurgical patients. these data also suggest that complete neurological recovery is not necessary to execute successful extubation [ , ] . the aetiology for weaning failure from ventilatory support is usually multifactorial, involving composite interaction between cardiac and lung function. in icu, utility of numerous respiratory indices to guide weaning process have been replaced by spontaneous breathing trial (sbt) [ , ] . apart from loss of lung aeration due to transition from prolonged mechanical ventilation to spontaneous breathing, there is increase lv preload and after load, and decrease in lv compliance. these factors may increase lv filling pressure leading to failure of weaning [ , ] . to enhance the success of weaning, apart from the clinical assessment, ultrasonic evaluation of cardiorespiratory system before and during sbt is very important in anticipating weaning failure [ ] . assessment of lung aeration by ultrasonography is rapidly gaining significance in weaning protocol [ ] . apart from lung ultrasonography, the role of transthoracic echocardiography in successfully predicting weaning capability has been investigated in the recent times [ ] . cardiac related weaning failure may be due to systolic lv dysfunction or isolated diastolic dysfunction representing nearly % of all failed weaning [ , ] the aim of this prospective observational study was to evaluate the cardiorespiratory ultrasonographic parameters in patients being weaned and contrasting the trend of changes in those successfully completing sbt in comparison to sbt failure. this prospective observational study was conducted over a month period (from december to may ) after obtaining approval from the institute ethics committee (iec). informed consent was obtained from patients next of kin. this trial was registered in clinical trial registry with clinicaltrials.gov identifier: nct . consecutive adult neurosurgical patients (age > years) who were mechanically ventilated for longer than h and planned for weaning were recruited. inclusion in the study was allowed when patients' underlying disease that required mechanical ventilation was considered reversed or stabilised by the attending physician, rendering them eligible for sbt. exclusion criteria included age less than years, pregnancy, gcs score less than , pre-weaning pao /fio ratio of less than , severe icu acquired neuromyopathy, lower cranial nerve involvement, tracheostomized patients, patients with high spinal cord lesions (above t ), presence of thoracostomy, pneumothorax or pneumomediastinum or pleural effusion, presence of rib fractures, patients having severe left ventricular dysfunction (lvef < %), valvular heart disease and patients with planned prophylactic noninvasive ventilation. secondary exclusion criteria consisted of uncooperative patient behavior or absence of a proper ultrasonographic window allowing adequate visualization of the lung or the heart. for every patient, standard medical care was provided by the icu physician in charge. discontinuation from mechanical ventilation/weaning was attempted according to clinical judgment of the intensivist. the treating physician was blind to the ultrasound results. when the patient was deemed ready for sbt, they were allowed to breathe spontaneously through a t-tube circuit with oxygen flow at l/min for h during the first sbt. subsequent time of weaning was determined by the treating physician. sbt failure was defined as inability to tolerate a t-piece trial for to min [ ] . criteria for failure to tolerate sbt consisted of the following: a. change in level of consciousness b. clinical features of respiratory distress (respiratory rate > breaths/min, arterial oxygen saturation < %, paradoxical thoracoabdominal breathing or use of accessory respiratory muscles) c. haemodynamic instability (heart rate > , systolic blood pressure < mmhg or % change from baseline) patients with sbt failure were put back on controlled ventilatory mode. patients who underwent successful sbt were continued with the weaning protocol. the successful sbt patients were monitored for extubation failure. criteria for failed extubation included patient requiring either reintubation or non-invasive ventilation or high-flow nasal oxygen therapy within h following extubation [ ] . the lung ultrasound and echocardiographic parameters including haemodynamics were measured and documented during the following time points: ( ) before sbt ( ) min after initiating sbt ( ) min after sbt lung ultrasonography was performed by a trained investigator using - mhz probe (esaote ultrasound system, mylab tm gamma, genova, italy). each intercostal space of upper and lower parts of the anterior, lateral, and posterior regions of the left and right chest wall was examined [ ] . all of the patients underwent transthoracic echocardiographic examination by . - . data was collated offline in a microsoft excel spreadsheet (ver. ). analysis was conducted using r software (ver. . . ) [ ] . interval scale variables are represented as medians and inter-quartile ranges, and categorical data as frequencies and proportions. demographic data and single time point variables were compared between the groups using mann-whitney u-test (in view of small sample size) for interval scale data and using chi-square test or fisher test (as appropriate) for categorical data. it was found that age and chronic obstructive pulmonary disease (copd) was significantly different for the outcome groups of successful/ failure sbt. however, due to small sample size, and complete separation of outcome with inclusion of confounding covariates, regression analysis could not be conducted. non parametric longitudinal design analysis using rank method was conducted using "nparld" package of r for between group hypothesis testing of repeated measures data (pre sbt, min sbt and min sbt time points) [ ] . p < . was taken as level for statistical significance. thirty patients were assessed for inclusion into the study. three patients had neurological deterioration and were excluded. twenty-seven patients were included and underwent sbt (success = , failure = ). among sbt success patients, ( . %) had extubation failure. age and proportion of copd were found to be significantly different for sbt success and failure groups (table ). baseline lus were found to be significantly higher in sbt failure group compared to success group (p = . , table ). lus was found to increase during the course of sbt in both the groups ( table , fig. ) and the increase was found to be statistically significant (p < . for both groups). overall between group comparison was found to be statistically significant (p < . ), which probably builds up on the baseline difference. group*time interaction (difference of trend of change of lus over time, compared between the two groups) was not found to be significantly different (p = . ). there was no difference of baseline heart rate (hr), systolic and diastolic blood pressures (sbp, dbp) between two groups (table ) . within group effect showed a statistically significant increase of hr in both the groups ( table , fig. ), blood pressures did not change significantly in the sbt success group, while they increased in the sbt failure group. interaction effect was found to be statistically significant for all the hemodynamic variables, showing a higher rate of change in the failure group compared to the success group. since interaction effect was found significant, between group effect will not be discussed. baseline values of e/eʹ ratio, e/a ratio and dte did not show any difference between the two groups ( table ) . sbt failure group registered statistically significant increases in e/eʹ ratio and e/a ratio, and reduction in dte (table , fig. ). in the sbt success group, e/eʹ ratio was found to increase slightly (p = . ), while e/a ratio and dte stayed relatively constant over the time points. interaction effect was found to be statistically significant for e/a ratio and dte (p < . and p = . respectively), and trending towards significance for e/eʹ ratio (p = . ). between group effect for e/eʹ ratio was not found to be statistically significant. baseline fac was not found to be significantly different between the two groups (p = . ). fac decreased significantly in the sbt failure group (p < . , table , fig. ) , while sbt success group registered no change (p = . ). between group effect was not found to be statistically significant, while interaction effect was found to be trending towards significance (p = . ). the same is probably due to small sample size and explained by the within group changes discussed above. the reasons for weaning failure from ventilatory support are usually multifactorial and include complex interaction between cardiac and respiratory dysfunction [ ] . we present trend of changes in lung ultrasound findings and echocardiographic cardiac status during sbt. brisk dynamic changes in the pulmonary and cardiac load taking place throughout the sbt can be picked up by cardiopulmonary sonography in real time. in our study sbt failure group had higher basal lus (p = . , table ) and progressively increasing lus at min and at end of sbt denoting significant lung de-recruitment (fig. ) . there was no difference in the lv filling pressure before sbt between success and failure groups ( table ) , but there was significant increase in the lv filling pressure (increase e/a and e/e′, decrease in dte) after and min of sbt in failure group compared to the success group (table , fig. ). in our trial none of the patients had lv systolic dysfunction before or at the fig. ). increase in lus leading to significant de-recruitment and increase in lv filling pressure may have cumulatively contributed to failure of sbt. it is difficult to differentiate incidence of cardiac or pulmonary related weaning failure, because the increase in cardiac and pulmonary load are strongly interconnected [ ] . in a study by soummer [ ] , fig. depicting trend of change of lus and hemodynamic variables over sbt time points. sbt spontaneous breathing trial, lus lung ultrasound score, sbp systolic blood pressure, dbp diastolic blood pressure, hr heart rate patients with lower lus had better aeration and patients with progressive higher lus during sbt had progressive lung de-recruitment. initiation of weaning in our study was based on a clinical decision of treating intensivist, assuming that the respiratory condition has been optimally stabilised. however, without objective evidence, the process of weaning may be initiated far before normalization of pulmonary function. sbt failure or extubation failure is likely due to fac fractional area change, sbt spontaneous breathing trial, e doppler mitral early diastolic wave, a doppler mitral late diastolic wave, dte deceleration time of e wave, e′ tissue doppler based early diastolic wave at lateral annulus inadequate lung reaeration at the time of sbt. lung ultrasonography provides a reliable method to estimate regional aeration of lung [ , ] . literature suggests transition from mechanical ventilation to spontaneous breathing is linked with increased cardiac preload and after load [ , ] . similar to our study results, literature suggests there are significant changes in doppler mitral flow indexes (increase in e/a, e/e′ and decrease in dte) following initiation of sbt, suggesting increase in left ventricular filling pressure [ , ] . integrative use of cardiothoracic chest ultrasound data may help in predicting sbt failure or post extubation distress in critically ill patients [ , ] . during sbt, success group had more stable blood pressure, while the failure group had progressive increase in heart rate and blood pressure. this may be due to a reflex mechanism to compensate for imbalance in cardiopulmonary load during sbt [ ] . patients with higher age and presence of copd were more likely to have sbt failure in our series. in a study by asehnoune et al. [ ] , age more than years in severe brain injured patients was one of the predictors for weaning failure. also, weaning failure has been shown to be common in patients with copd [ , ] . extubation failure may occur despite successful sbt due to other causes such as upper airway obstruction due to airway oedema, inability to handle excessive secretion, neurological impairment and inadequate muscle strength. in this series . % of sbt success patients had extubation failure. reasons for reintubation included neurological deterioration (n = ) and inability of the patient to manage excessive secretions after extubation (n = ). currently, indices intended to predict sbt failure are indirect evidence of loss of lung aeration such as oxygen saturation defect, tachypnoea to compensate minute ventilation, altered mental status, tachycardia and hemodynamic instability [ ] . direct assessment of regional lung aeration provides a major advantage in predicting sbt success. lung ultrasound has replaced conventional radiological means of assessing lung aeration, because it is point of care, easily repeatable, non-invasive and highly predictable [ , ] . several trials have shown utility of lung ultrasound for lung re-aeration following antimicrobial therapy in ventilator associated pneumonia (vap) [ ] , assessing positive end-expiratory pressure (peep) and prone position induced lung recruitment [ ] and resolution of pulmonary oedema [ ] . lung ultrasound based detection of sbt induced de-recruitment may not elicit the cause for aeration loss. the other probable factors involved in sbt induced lung aeration loss like fluid overload, massive pleural effusion, pulmonary infection, cardiac dysfunction, copious bronchial secretions and diaphragmatic dysfunction should be screened simultaneously and managed accordingly. this is a single institution, observational study with small sample size, which limits generalizability of the findings. before generalising the results of this study, a randomized, multicentre interventional study is required to assess the impact of combined cardiothoracic chest ultrasound monitoring during sbt. in this study a single investigator performed ultrasound examination who had months experience in lung cardiac ultrasound. trials have shown the learning curve for gaining skills in chest ultrasonography ranges from weeks to months based on the expertise level [ ] [ ] [ ] . in sbt failure group, we were unable to differentiate the major contributor-lung aeration loss or increased lv filling pressure or a combined effect. the criteria for failure to tolerate sbt was based on clinical judgement (parameters include change of level of consciousness, clinical features of respiratory distress, and haemodynamic instability). another objective assessment determining failure of sbt, like arterial blood gas analysis was not used in this study during sbt. we did not evaluate biological markers of cardiovascular system during sbt like circulating b-type and atrial natriuretic peptides (bnp, anp) to predict weaning success [ ] . bedside lung and cardiac sonographic examination before and during sbt may help in predicting success of sbt. higher lus, e/a, e/e' ratios and lower dte were observed in patients who failed sbt. larger studies using this modality as a guiding tool for sbt are required to confirm these findings. implications of extubation delay in brain-injured patients meeting standard weaning criteria re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation effect of failed extubation on the outcome of mechanical ventilation liberation of neurosurgical patients from mechanical ventilation and tracheostomy in neurocritical care removing the critically ill patient from mechanical ventilation predictors of successful extubation in neurosurgical patients rate of reintubation in mechanically ventilated neurosurgical and neurologic patients: evaluation of a systematic approach to weaning and extubation evidence-based assessments in the ventilator discontinuation process a randomized, controlled trial of the role of weaning predictors in clinical decision making acute left ventricular dysfunction during unsuccessful weaning from mechanical ventilation variation in natriuretic peptides and mitral flow indexes during successful ventilatory weaning: a preliminary study ultrasonography evaluation during the weaning process: the heart, the diaphragm, the pleura and the lung ultrasound assessment of lung aeration loss during a successful weaning trial predicts postextubation distress* echocardiographic diagnosis of pulmonary artery occlusion pressure elevation during weaning from mechanical ventilation weaning failure of cardiac origin: recent advances weaning-induced cardiac dysfunction: where are we today? behavior of lung ultrasound findings during spontaneous breathing trial. rev bras ter intensiva a clinical description of extubation failure in patients with primary brain injury clinical review: bedside lung ultrasound in critical care practice bedside ultrasound assessment of positive end-expiratory pressure-induced lung recruitment evaluation of left ventricular filling pressure by transthoracic doppler echocardiography in the intensive care unit r: a language and environment for statistical computing. r foundation for statistical computing nparld: an r software package for the nonparametric analysis of longitudinal data in factorial experiments weaning from mechanical ventilation weaning failure from cardiovascular origin echocardiography: a help in the weaning process integrated use of bedside lung ultrasound and echocardiography in acute respiratory failure: a prospective observational study in icu usefulness of cardiothoracic chest ultrasound in the management of acute respiratory failure in critical care practice breathing as exercise: the cardiovascular response to weaning from mechanical ventilation extubation success prediction in a multicentric cohort of patients with severe brain injury. anesthesiology clinical characteristics, respiratory functional parameters, and outcome of a -h t-piece trial in patients weaning from mechanical ventilation the use of point-of-care bedside lung ultrasound significantly reduces the number of radiographs and computed tomography scans in critically ill patients ultrasound assessment of antibiotic-induced pulmonary reaeration in ventilator-associated pneumonia ultrasound comet-tail images": a marker of pulmonary edema: a comparative study with wedge pressure and extravascular lung water evaluation of ultrasound lung comets by hand-held echocardiography implementation of real-time ultrasound in a thoracic surgery practice toward an ultrasound curriculum for critical care medicine key: cord- -oj wsstz authors: rodríguez-fanjul, javier; guitart, carmina; bobillo-perez, sara; balaguer, mònica; jordan, iolanda title: procalcitonin and lung ultrasound algorithm to diagnose severe pneumonia in critical paediatric patients (prolusp study). a randomised clinical trial date: - - journal: respir res doi: . /s - - -z sha: doc_id: cord_uid: oj wsstz background: lung ultrasound (lus) in combination with a biomarker has not yet been studied. we propose a clinical trial where the primary aims are: . to assess whether an algorithm with lus and procalcitonin (pct) may be useful for diagnosing bacterial pneumonia; . to analyse the sensitivity and specificity of lus vs chest x-ray (cxr). methods/design: a -year clinical trial. inclusion criteria: children younger than years old with suspected pneumonia in a paediatric intensive care unit. patients will be randomised into two groups: experimental group: lus will be performed as first lung image. control group: cxr will be performed as first pulmonary image. patients will be classified according to the image and the pct: a) pct < ng/ml and lus/cxr are not suggestive of bacterial pneumonia (bn), no antibiotic will be prescribed; b) lus/cxr are suggestive of bn, regardless of the pct, antibiotic therapy is recommended; c) lus/cxr is not suggestive of bn and pct > ng/ml, antibiotic therapy is recommended. conclusion: this algorithm will help us to diagnose bacterial pneumonia and to prescribe the correct antibiotic treatment. a reduction of antibiotics per patient, of the treatment length, and of the exposure to ionizing radiation and in costs is expected. trial registration: nct . therefore, there is a need to have an examination tool that can be used at the patient's bedside and which is easily reproducible to help detect lung consolidations. lus has recently emerged as a radiation-free technique; it is non-invasive, with a high interobserver [ ] agreement for lung pathologies such as consolidation [ ] , pleural effusion [ ] , interstitial syndrome [ ] , and pneumothorax [ ] . to determine the etiology, conventional microbiology tests such as blood culture, pleural aspiration, and bronchoalveolar lavage are usual practices, but some of these are invasive, may not detect all etiologies [ ] , and the results may not be immediate. besides this, the use of biomarkers such as procalcitonin (pct) has become more widespread during the past years, helping clinicians diagnose bacterial etiology, especially in patients who have only had a fever for a few hours or those admitted to intensive care units [ ] [ ] [ ] [ ] [ ] . the use of pct has allowed for a decrease in antibiotic prescription [ , ] , even in nosocomial and community pneumonia [ , ] . despite its role in the diagnosis of pneumonia, pct values without any other tests may not be a complete diagnostic biomarker for pneumonia. quality of care is defined by the world health organization as medical care in which the patient is diagnosed and treated correctly, according to current medical knowledge (scientific and technical quality), and to their biological factors (optimal state of health to attain), with a minimum cost (efficiency), minimum possible exposure to risk for more harm, and maximum patient satisfaction [ ] . at the hospital level, a quality assurance plan should include different levels of action. the first step is level of quality promotion, which requires institutional support and the availability of clinical and quality protocols. the second step is the research level: descriptive studies for detecting and quantifying a specific situation or health issue, and the use of databases or specific studies to evaluate health services, among others. therefore, we propose this clinical trial, based on combining lus and pct in an algorithm with the aim to improve quality of care in children with pneumonia in a picu. we hypothesize that the diagnostic performance of lus and pct will be better than conventional cxr. the study is designed as a randomized, blinded clinical trial of children with severe community or nosocomial pneumonia. it will be conducted at a single picu at sant joan de déu hospital, a tertiary children's hospital in barcelona. period of recruitment and follow-up was from september to december . our primary goal is to improve the quality of care in children with suspected community or nosocomial pneumonia in a picu. the main objectives are: . to assess whether a diagnostic algorithm for pneumonia that combines lus and pct may be useful in indicating and determining the duration of antibiotic treatment. . to analyse the sensitivity and specificity of lus, compared to cxr, for severe community or nosocomial pneumonia. the secondary aims are: . to quantify the irradiation dose avoided using lus to replace cxr, and to determine if there is an associated decrease in costs. inclusion: children under years old with suspected community pneumonia who require admission to the picu or patients with suspected nosocomial pneumonia during their picu stay. exclusion: patients with underlying pathologies such as cystic fibrosis or who are immunocompromised. patients who develop nosocomial pneumonia after being included in the study due to community pneumonia. patients who have a cxr taken before being admitted to the picu. withdrawal and abandonment criteria: violation of study protocol, withdrawal of parental consent, death. patients withdrawing or with loss of protocol adherence will be excluded from the study. -community pneumonia: patients with compatible clinical suspicion (fever, cough, tachypnoea, shortness of breath, abnormal respiratory auscultation sounds, hypoventilation, tubular breath sounds, thoracic or abdominal pain), compatible cxr (lobar consolidation, airspace opacity, pleural effusion, bullae, etc.) or lus, changes in blood with a c-reactive protein higher than mg/l and/or pct higher than ng/ml. -nosocomial pneumonia: based on the clinical pulmonary infection score (cpis) ( table ). -ventilator-associated pneumonia: defined according to the center for disease control criteria (cdc). lus procedure lus will be performed by any of the intensive care physicians who have received standard training in lus (winfocus pncus bl p) and who have at least years of experience using it. team sessions focusing on the diagnosis of pneumonia with lus will be repeated every months to ensure quality and consistency in the lus exam. the supplemental data included in the shah et al. article will be used [ ] . subjects will be examined while they are in supine position. imaging will be performed using a portable ultrasound device (toshiba® xario ). a -mhz linear or a -mhz convex probe will be used, depending on the weight or size of the patient. a scan will be taken systematically in areas for each hemithorax (anterior, lateral, and posterior), according to international recommendations [ ] . each area will be examined longitudinally and transversally. in each area the following will be evaluated [ ] : alines, b-lines (number and distance between them), lung sliding (m-mode), pleural space, lung consolidations, small subpleural consolidations, dynamic air bronchogram, vascular pattern, presence of lung point, and lung pulse. the determination of a bacterial pneumonia ultrasound pattern will be based on the presence of lung consolidation with air bronchograms, which in initial stages are detected as small subpleural hypoechoic zones of less than cm with bronchogram (not seen using conventional cxr) [ ] [ ] [ ] [ ] . the determination of a viral pneumonia ultrasound pattern will be based on the presence of b-lines or coalescent b-lines with small subpleural consolidations of less than cm, without bronchogram [ , ] . the first thing to do will be to obtain consent from the parent(s) or legal guardian(s). patients who meet the inclusion criteria and sign the inform consent were randomly assigned to two groups using the "random" function in ms-excel xp® program. a binary series of random numbers were generated according to the procedure described by friedman. to procure a similar number of patients in both groups, the procedure created the sequence through a balanced block sampling. the series of numbers were held by the principal investigator and depending on the number of the patient tit was be assigned to on or another group. a total of physicians enrolled participants, and the principal investigator assigned participants to interventions, depending on the randomized list. (fig. ) -experimental group : the paediatrician-researcher (pr) performs the lus at admission/suspicion as the first lung image test. if the paediatrician assistant (pa) requires a cxr, it can be performed, but the pr will not see the cxr. patients will be subdivided into groups: a. if pct is < ng/ml and lus is not suggestive of bacterial pneumonia (normal or viral), the patient will not receive an antibiotic. b. if lus is suggestive of bacterial pneumonia, regardless of pct value, an antibiotic will be recommended. c. if lus is not suggestive of bacterial pneumonia, but pct values are > ng/ml, an antibiotic will be recommended to cover other infectious etiologies. -control group : cxr will be performed as a first lung image test. criteria to start an antibiotic will depend on the current unit protocol. a. if pct is < ng/ml and cxr is not suggestive of bacterial pneumonia (normal or viral), the patient will not receive an antibiotic. b. if cxr is suggestive of bacterial pneumonia, regardless of pct value, an antibiotic will be recommended. c. if cxr is not suggestive of bacterial pneumonia, but pct value is > ng/ml, an antibiotic will be recommended to cover other infectious etiologies. radiological and ultrasound patterns will be classified as: pneumonia (viral or bacterial), atelectasis, or parapneumonic pleural effusion (table ). lus will be performed every day following admission and recorded and stored. lus images will be later analysed by a paediatric radiologist who is an expert in lus and who has not seen the initial assessment and cxr, in order to evaluate interobserver agreement. cxr will be also be reported on by a paediatric radiologist consultant who has not seen the other results. the antibiotics protocol guided by lus and pct will be considered an improvement in the quality of care if a reduction in the prescription of antibiotics is observed, and also if there is a reduction in the number of days on antibiotics. another primary outcome will be the increase in the sensitivity and specificity when diagnosing bacterial pneumonia using lus. secondary outcomes will be the reduction of the irradiation dose using the new protocol (with a reduction in economic costs as well), and a high lus interobserver agreement. the study coordinator will register patients, verifying compliance with all the inclusion criteria. an external company will be appointed to monitor the study and ensure compliance with correct clinical practice principles (iche ). once the notebooks are audited, they will be entered into a validated database, one with restricted access by user level, which is equipped with inconsistency detection filters, and which affords data traceability until the database is no longer needed. data access: all the physicians and clinical researchers involved in the study, the ethics committee, and the relevant health authorities will have access to the data. sample size calculations will be performed using the statistical program ene . ®. the main variable will be the existence of differences between cxr and lus in patients with community pneumonia and nosocomial pneumonia. h will be considered as the existence of differences between lus and cxr. an % power will be required to detect differences in the contrast of the null hypothesis h : p = p , using a bilateral x test for two independent samples. if we consider a significance level of %, it will be necessary to include units in the control group and units in the experimental group. a total of patients will be included for community pneumonia. twenty-eight patients per group will be included for nosocomial pneumonia; therefore, there will be patients in total for this kind of pneumonia. after months of recruitment, a preliminary analysis will be carried out to guarantee the safety of the patients. respiratory infection represents around - % of the picu admissions, depending on the season. there will be an estimated - recruitable patients per year, so it is expected that the calculated sample size will be attainable. using the "random" function of the ms-excel xp® program, a binary series of random numbers will be generated, according to the procedure described by friedman [ ] . this procedure creates the sequence by means of balanced block sampling to ensure a similar number of patients in each group. the series of numbers will be in the possession of the picu's head researcher. depending on that number, each patient will be assigned to one group or the other. if a patient is randomized but does not complete the treatment, their data will not be analysed, and their random number will not be reused. the categorical variables will be compared using the chi-square test. the quantitative analysis will be compared using student's t-test or the mann-whitney u test, depending on whether the sample follows a normal distribution or not. a multivariate logistic regression analysis will be performed on those variables with statistical significance or a clear tendency in the univariate analysis to detect which factors represent a protective factor or not, in terms of quality. the analysis of the interobserver agreement will be performed using cronbach's alpha. a p < . will be considered significant. the statistical program spps® . will be used. nowadays, care standards are focused on the quality of care. as the world health organization stipulates, the patient must be diagnosed and treated correctly. this clinical trial is focused on improving the quality of care for paediatric patients with suspected bacterial pneumonia. lus has good diagnostic accuracy for pneumonia in children, even if the exam is performed by a nonexpert physician [ ] . our algorithm will help us to diagnose bacterial pneumonia accurately, and to prescribe the correct antibiotic treatment. a reduction in patients on antibiotics and in the number of days on antibiotics is expected. secondarily, a reduction in exposure to ionizing radiation and in costs is expected. for many years, lus has been integrated into the management of critically ill paediatric and neonatal patients at our hospital. some articles have been published by our group regarding the use of lus in different pathologies, such as prematurity, pulmonary arterial hypertension, during the postoperative period after cardiopulmonary bypass, etc. [ ] [ ] [ ] . for the application of this clinical trial, all the researchers will be intensivists who are experts in lus, and regular internal training will be essential to guarantee objective results. in addition, our group has extensive experience in the use of pct for the diagnosis of bacterial infection in other medical situations, such as after cardiopulmonary bypass in children and new-borns [ , ] . furthermore, we have experience in pct-guided antibiotic policy, with a reduction in the number of days on antibiotics without adverse events in children with nosocomial infections [ ] and in children after cardiopulmonary bypass [ ] . the use procalcitonin and lung ultrasound algorithm will help us diagnose bacterial pneumonia accurately and prescribe the correct antibiotic treatment. a reduction in patients on antibiotics and in a reduction in exposure to ionizing radiation and in costs is expected. this clinical trial is focused on improving the quality of care for paediatric patients with suspected bacterial pneumonia. supplementary information accompanies this paper at https://doi.org/ . /s - - -z. additional file supplemental table . clinical pulmonary infection score. table . summary of the main findings using chest x-rays and lung ultrasound for diagnosing pneumonia. additional file supplemental figure . study protocol diagram. we expect that with the estimated number of patients, relatively high for a paediatric study, and the homogeneity of the patients suffering from this pathology, we will have sufficient statistical power to obtain reliable data. another limitation could be that since ultrasound-based assessments are user-dependent, there could be interobserver variability. thanks to the internal training program, we believe that this limitation will be minimized. this protocol is for a study that it is ongoing, authors are still analysing data. no publications containing the results of this study have been already published neither submitted to any journal. authors disclose any potential financial or ethical conflicts of interest regarding the contents. clinical trial, trial registration: nct . what is the key message of your article? we propose an algorithm to use in the diagnosis of pneumonia to improve the quality of care in paediatric critical care. what does it add to the existing literature? there are few papers about the use of lung ultrasound with pneumonia but, to our knowledge, this is the first clinical trial to assess the use of lung ultrasound and laboratory biomarkers to improve the diagnosis of bacterial pneumonia in critically ill children admitted to a paediatric intensive care unit. what is the impact? the algorithm should improve bacterial pneumonia diagnosis and therefore the treatment of either community-acquired or nosocomial pneumonia in patients with respiratory infection suspicion. the impact should be seen in reduction of antibiotic indication in patients with non-bacterial pneumonia, reduction of radiation given to paediatric patients and reduction costs of its technique. all the authors contributed to the conception and design of the protocol, acquisition of data, analysis and interpretation of data; drafting the article and revising it critically for important intellectual content; and they approval the final version to be published. this study has been financially supported by official grant from spain sanitary ministerium. no other institutions have financed this research. this study has been funded by instituto de salud carlos iii through the project " pi / " (co-funded by european regional development fund/european social fund "a way to make europe"/"investing in your future"). project " pi / ", funded by instituto de salud carlos iii and co-funded by european union (erdf/esf, "a way to make europe"/"investing in your future"). funding: isciii ("pi / "), co-funded by erdf/esf, "a way to make europe"/"investing in your future"). availability of data and materials not applicable. the study will be conducted in accordance with the ich cp (ich e and ich e ) and the declaration of helsinki. the protocol study was approved by the local health care ethics committee and the institutional review board of the sant joan de déu hospital. the identities of the patients will be kept confidential throughout the entire study. complete filiation data and written consent will be kept in the researcher's file. the data obtained will be treated according to the organic law / on protection of personal data. according to this law, the personal data collected from the subjects will be only those necessary to fulfil the study's objectives. study participants will have the right to access their personal data and to request its rectification or cancellation. given that the patients included in the study will be minors or will be in critical condition, in all cases informed consent will be requested from the legal representatives of these patients. not applicable. the authors declare that they have no competing interests. commiting to child survival: a promise renewed surviving sepsis campaign the spectrum of viral pathogens in children with severe acute lower respiratory tract infection: a -year prospective study in the pediatric intensive care unit prospective multicenter study of viral etiology and hospital length of stay in children with severe bronchiolitis surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock viral-bacterial coinfection affects the presentation and alters the prognosis of severe communityacquired pneumonia challenges in severe 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study lung ultrasound as a predictor of mechanical ventilation in neonates older than weeks a multicenter lung ultrasound study on transient tachypnea of the neonate procalcitonin: a useful biomarker to discriminate infection after cardiopulmonary bypass in children procalcitonin-guidance reduces antibiotic exposure in children with nosocomial infection (prorani) publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations received: april accepted: july key: cord- -wfsq u o authors: favot, mark; malik, adrienne; rowland, jonathan; haber, brian; ehrman, robert; harrison, nicholas title: point-of-care lung ultrasound for detecting severe presentations of coronavirus disease in the emergency department: a retrospective analysis date: - - journal: crit care explor doi: . /cce. sha: doc_id: cord_uid: wfsq u o objectives: analyze the diagnostic test characteristics of point-of-care lung ultrasound for patients suspected to have novel coronavirus disease . design: retrospective cohort. setting: two emergency departments in detroit, michigan, united states, during a local coronavirus disease outbreak (march to april ). patients: emergency department patients receiving lung ultrasound for clinical suspicion of coronavirus disease during the study period. interventions: none, observational analysis only. measurements and main results: by a reference standard of serial reverse transcriptase-polymerase chain reactions, patients were coronavirus disease positive, negative, and eight untested (test results lost, died prior to testing, and/or did not meet hospital guidelines for rationing of reverse transcriptase-polymerase chain reaction tests). thirty-three percent, %, %, and % had mortality, icu admission, intubation, and venous or arterial thromboembolism, respectively. receiver operating characteristics, area under the curve, sensitivity, and specificity with % cis were calculated for five lung ultrasound patterns coded by a blinded reviewer and chest radiograph. chest radiograph had area under the curve = . ( % ci, . – . ), % sensitivity ( % ci, – %), and % specificity ( % ci, – %). two lung ultrasound patterns had a statistically significant area under the curve: symmetric bilateral pulmonary edema (area under the curve, . ; % ci, . – . ), and a nondependent bilateral pulmonary edema pattern (edema in superior lung ≥ inferior lung and no pleural effusion; area under the curve, . ; % ci, . – . ). chest radiograph plus the nondependent bilateral pulmonary edema pattern showed a statistically improved area under the curve ( . ; % ci, . – . ) compared to either alone, but at the ideal cutoff had sensitivity and specificity equivalent to nondependent bilateral pulmonary edema only ( % and %, respectively). the strongest combination of clinical, chest radiograph, and lung ultrasound factors for diagnosis was nondependent bilateral pulmonary edema pattern with temperature and oxygen saturation (area under the curve, . ; % ci, . – . ; sensitivity = % [ – %]; specificity = % [ – %] at the ideal cutoff), which was superior to chest radiograph alone. conclusions: lung ultrasound diagnosed severe presentations of coronavirus disease with similar sensitivity to chest radiograph, ct, and reverse transcriptase-polymerase chain reaction (on first testing) and improved specificity compared to chest radiograph. diagnostically useful lung ultrasound patterns differed from those hypothesized by previous, nonanalytical, reports (case series and expert opinion), and should be evaluated in a rigorous prospective study. objectives: analyze the diagnostic test characteristics of point-ofcare lung ultrasound for patients suspected to have novel coronavirus disease . design: retrospective cohort. setting: two emergency departments in detroit, michigan, united states, during a local coronavirus disease outbreak (march to april ). patients: emergency department patients receiving lung ultrasound for clinical suspicion of coronavirus disease during the study period. interventions: none, observational analysis only. measurements and main results: by a reference standard of serial reverse transcriptase-polymerase chain reactions, patients were coronavirus disease positive, negative, and eight untested (test results lost, died prior to testing, and/or did not meet hospital guidelines for rationing of reverse transcriptase-polymerase chain reaction tests). thirty-three percent, %, %, and % had mortality, icu admission, intubation, and venous or arterial thromboembolism, respectively. receiver operating characteristics, area under the curve, sensitivity, and specificity with % cis were calculated for five lung ultrasound patterns coded by a blinded reviewer and chest radiograph. chest radiograph had area under the curve = . ( % ci, . - . ), % sensitivity ( % ci, - %), and % specificity ( % ci, - %). two lung ultrasound patterns had a statistically significant area under the curve: symmetric bilateral pulmonary edema (area under the curve, . ; % ci, . - . ), and a nondependent bilateral pulmonary edema pattern (edema in superior lung ≥ inferior lung and no pleural effusion; area under the curve, . ; % ci, . - . ). chest radiograph plus the nondependent bilateral pulmonary edema pattern showed a statistically improved area under the curve ( . ; % ci, . - . ) compared to either alone, but at the ideal cutoff had sensitivity and specificity equivalent to nondependent bilateral pulmonary edema only ( % and %, respectively). the strongest combination of clinical, chest radiograph, and lung ultrasound factors for diagnosis was nondependent bilateral pulmonary edema pattern with temperature and oxygen saturation (area under the curve, . ; % ci, . - . ; sensitivity = % [ - %]; specificity = % [ - %] at the ideal cutoff), which was superior to chest radiograph alone. conclusions: lung ultrasound diagnosed severe presentations of coronavirus disease with similar sensitivity to chest radiograph, ct, and reverse transcriptase-polymerase chain reaction (on first testing) and improved specificity compared to chest radiograph. diagnostically useful lung ultrasound patterns differed from those hypothesized by previous, nonanalytical, reports (case series and expert opinion), and should be evaluated in a rigorous prospective study. key words: covid- ; diagnosis; emergency department; point of care; sensitivity and specificity; ultrasound t he coronavirus disease (covid- ) pandemic is impacting the lives of nearly everyone around the world in ways that are difficult to comprehend. clinicians caring for patients with suspicion for covid- are forced to consider the manner in which we use various imaging tests to aid in providing the most appropriate, individualized care possible ( ). unfortunately, diagnostic modalities, including chest radiograph (cxr) ( ), ct ( ), and reverse-transcription polymerase chain reaction (rt-pcr) on first test ( ), have been reported to suffer from poor sensitivity. as a result, serial testing has been recommended ( ) when any one of these modalities is negative, which increases the exposures staff and patients to covid- in the hospital while also potentially delaying diagnosis in critically ill patients. point-of-care lung ultrasound (lus) has been suggested as a useful diagnostic modality in these patients ( ) as it limits www.ccejournal.org • volume • e covid- exposure of ancillary staff, minimizes travel within the hospital for patients, can be performed at the bedside within minutes, and has been shown to be diagnostically superior to cxr in critically ill patients with other respiratory complaints ( ) . lus patterns for detecting covid- have been suggested ( , ) based on ultrasound (us) theory, case reports, and extrapolation from ct findings; however, diagnostic performance data in an observational analytical study are lacking ( ) . the objective of this study was to describe lus findings in patients being evaluated for covid- and retrospectively assess the diagnostic test characteristics of different lus patterns. we performed a retrospective study of a convenience sample of patients in two large urban emergency departments (eds) in detroit, michigan from march , , to april , . irb approval was obtained as part of a larger covid- registry at our institution. patients with suspected covid- who underwent a diagnostic lus examination with images archived in the ed us database were eligible for inclusion; only patients with complete examinations ( images, described below) were included. with the exception of lus performed solely to assess for pneumothorax, our standard ed lus protocol is based on a prior lus in heart failure trial which uses a horizontal probe orientation to maximize the amount of visualized pleural line ( ) . all images were obtained using a curvilinear probe on a zonare z pro ultrasound system (mindray north america, mahwah, nj) with a lus preset: cm depth, clip length of seconds, and multibeam former and tissue harmonics deactivated. four zones are interrogated in each hemithorax: superior and inferior in both the anterior and lateral chest (supplemental fig. , supplemental digital content , http:// links.lww.com/ccx/a ; legend, supplemental digital content , http://links.lww.com/ccx/a ). our standard lus protocol is to scan patients in the supine position with head-of-bed elevated - °; however, actual position was not recorded in this convenience sample of patients. assessment for pleural effusion was done by placing the probe in a vertical position (indicator to head) at the costal margin in the mid-axillary line such that both the lung and liver or spleen were visible. based on prior reports of lus findings suggestive of covid- lung disease ( - ), lus images were coded by a blinded us fellowship-trained observer for the presence of nonconfluent and confluent b-lines (based on the same methodology used in the b-lines lung ultrasound-guided emergency department management of acute heart failure (blushed-ahf) study above [ ] ), subpleural consolidations, and pleural effusions. two lung zone patterns were also examined: symmetric bilateral b-lines (vs asymmetric, unilateral, or no b-lines) and nondependent bilateral pulmonary edema (ndbpe; bilateral b-lines with superior count ≥ inferior count and no pleural effusions). the ndbpe pattern was chosen based on the hypothesis that covid- lus findings may be similar to those seen in acute respiratory distress syndrome (ards). while multiple lus findings were evaluated, no findings or patterns were a priori considered diagnostic for covid- (i.e., this is a retrospective analysis of extant findings, not a prospective assessment of any specific pattern). demographics, vital signs, test results, hospital course, and other clinical characteristics were recorded. sonographers were not specifically blinded to results of other diagnostic test results. concurrent point-of-care echocardiography was performed on an insufficient number of patients to meaningfully inform the analysis, and thus, results of these examinations were not included. test characteristics and receiver operating characteristic (roc) area under the curve (auc) for individual lus patterns and cxr (pulmonary edema and/or infiltrate, as bilateral vs unilateral vs none) were compared to a reference standard of serial rt-pcr ( ) in rstudio v . . (rstudio, boston, ma), using the proc package ( ) . logistic regression was used to model the joint utility of cxr and the lus pattern with highest auc. aucs were compared by delong test and ideal cutoffs calculated by youden j statistic. in a post hoc exploratory analysis, we sought to derive the highest performing combination of potential diagnostic predictors (vital signs, laboratory tests, cxr, lus) in a logistic model selected by examination of akaike information criteria, clinical plausibility, model parsimony, auc, and the hosmer-lemeshow (hl) statistic. physical examination findings were not considered in this step as they were not defined a priori, thereby precluding unbiased interpretation. complete case analysis (cca) can overoptimistically bias prediction models when data are suspected missing at random because missingness is not only a research reality but also a clinical one ( ) . thus, multiple imputation (mi) by fully conditional specification (m = ) was performed in sas v . (sas institute, cary nc) for eight patients without rt-pcr and three without cxr. mi modeling for the response variable was isolated from predictors in downstream analyses, performed in two bootstrapped stages ( ) . to help protect against model overfitting and bias from mi, logistic models were fit to stage , and model performance measures (hl, roc, diagnostic characteristics) were calculated on the bootstrapped stage using a "pool-last" approach ( ). all analyses were compared to cca in sensitivity analysis. sixty-four patients underwent lus as part of an evaluation for covid- . see tables and , respectively, for characteristics and outcomes. fifty-six patients had rt-pcr testing for covid- , with positivity of % ( % ci, - %). median count of rt-pcr tests per patient was one in positives and two in negative cases. nineteen of patients with in-hospital mortality tested positive for covid- , while one died before testing completion. diagnostic test performance for covid- diagnosis is described for cxr, lus patterns, and the two multipredictor models by roc plots (fig. ) . bilateral infiltrate/edema on cxr was % sensitive ( % ci, - %), % specific ( % ci, - %), with auc . ( % ci, . - . ). the strongest performing lus finding was the ndbpe pattern (auc, . ; % ci, . - . ; sensitivity = % [ % ci, - %], specificity = % [ % ci, - %]). symmetric bilateral b-lines showed modest univariate diagnostic discrimination for covid- (fig. a) , while subpleural consolidation, confluent, and nonconfluent b-line patterns ( fig. b-d) failed to reach statistical significance ( % ci of auc crossed . ). combined cxr and ndbpe lus pattern (fig. g) showed significantly stronger diagnostic prediction (auc, . ; % ci, . - . ) than either cxr or ndbpe alone (p = . and . , respectively). in the exploratory analysis, the optimal diagnostic combination of clinical factors, cxr, and lus patterns was ndbpe, fever (temperature ≥ °c), and hypoxia (room air pulse oximetry ≤ %). no other tested combination of cxr, lus, or clinical factors added performance or parsimony beyond this model (auc, . ; % ci, . - . ; sensitivity = % [ - %]; specificity = % [ - %] at the ideal cutoff). the ndbpe/fever/hypoxia model performance was nonsignificantly different compared to the cxr/ ndbpe model (p = . ) and was superior to cxr alone (p = . ) and ndbpe alone (p < . ). by contrast, a model of cxr/ fever/hypoxia (auc, . ; % ci, . - . ; sensitivity = % [ - %]; specificity = % [ - %]) had superior overall discrimination compared to cxr alone (p = . ) but not to ndbpe alone (p = . ), or to the combination of ndbpe and cxr (p = . ). at the ideal cutoffs, the cxr/fever/hypoxia model had similar specificity but inferior sensitivity (p = . ) to the ndbpe/fever/hypoxia model and even to ndbpe alone (p = . ). our results suggest that a ndbpe pattern on lus offers additive diagnostic value to portable cxr in ed patients with suspected covid- . the ndbpe pattern was similarly sensitive to cxr, ct, and first-test rt-pcr ( ), had improved specificity compared to cxr, can be rapidly performed at point of care, and minimizes ancillary staff exposure and patient transport. rt-pcr requires serial testing at this time (e.g., up to five tests to detect one positive patient in our sample), so a lus-based strategy with the test characteristics we observed could be highly valuable for risk-stratification, cohorting of infected patients within the hospital, early guidance in management decisions, and resource-flexibility under pandemic conditions of resourcescarcity. the earlier diagnostic certainty that can be achieved using a lus-based imaging protocol could also offer front-line physicians some relief from the cognitive and psychological stresses associated with providing medical care during a pandemic. multiple prior studies, as well as a meta-analysis, have reported that lus is superior to cxr for diagnosing many lung pathologies in critical illness, including alveolar interstitial syndrome (ais) in ards ( ) . for example, lichtenstein et al ( ) reported a sensitivity and specificity of % and % for lus versus % and % for cxr in ais. in our study, neither modality performed as well as this. there are several possible explanations for this. first, there is varied severity of pulmonary involvement with covid- , and some patients may have minimal (or no) lung findings early in the disease process, thereby reducing sensitivity. additionally, rt-pcr is an imperfect gold standard, and as such, a patient's result on this test may not accurately reflect disease status, thereby negatively impacting lus test characteristics. this study took place during the local peak of the pandemic, and thus, any patient who presented during this time with respiratory symptoms was likely to have been considered a potential covid- patient, which could negatively impact specificity. in contrast to recent publications on lus in covid- comprised of case reports, letters to the editor, and expert opinion in mostly noncritically ill patients ( ), our study offers analytical (albeit retrospective) observational evidence of lus diagnostic performance in a cohort of patients with a range of severities and relatively high mortality rate. subpleural consolidations, confluent versus nonconfluent b-lines, and basilar-predominant changes had been suggested to be useful for covid- diagnosis in such reports ( , ) but failed to reach statistically significant diagnostic discrimination here. discrimination for the ndbpe pattern was strong, and when part of a simple clinical score including hypoxia and fever (fig. ) , outperformed cxr. while we present data on a larger cohort, our results should nonetheless be considered hypothesis-generating. prospective, external validation of our approach is needed before it is incorporated into routine practice. future studies should also consider the effect of diverse clinical populations (i.e., mixed covid- /non-covid- groups and broad clinical severity) on the accuracy of our approach, as well as the potential additive value of point-of-care echocardiography. our study has several limitations. first, retrospective design and convenience sampling mean that these results should be interpreted as hypothesis-generating. our use of mi in eight cases without reference standard could have biased our findings, although inconsistent access to rapid covid- rt-pcr is the current reality in many countries, including the united states. difficulties in obtaining accurate and timely covid- testing is a prime reason why a lus-based strategy would be useful in the first place. cca results were equal or more favorable for lus compared to results from mi. this is consistent with our overall mi modeling strategy, treating the uncertainties of mi modeling as additive to the uncertainty of missingness as a clinical reality ( ), with an assumption that cca was over-optimistic. as a gold standard, rt-pcr is imperfect, even when performed serially, and diagnostic accuracy calculated may have been affected. we could not mandate or control for the effect of patient positioning due to the retrospective nature of this study and chose to evaluate whether or not distribution of extravascular lung fluid in a nondependent pattern (superior lung zones having equal to or more fluid than inferior, gravity-dependent lung zones) would be predictive of covid- lung disease because the majority of the patients seen in our ed early in the pandemic were ambulatory at arrival (even the critically ill). however, based on what is known about distribution of pulmonary edema in acute heart failure (ahf), lung water is able to change locations fairly rapidly as patient positioning changes ( ) . a follow-up study examining this phenomenon in covid- patients would be prudent. another potential limitation is that the extent to which lus findings were purely acute versus acute-on-chronic is unknown. lack of concurrently obtained echocardiography data likewise precludes understanding if left heart dysfunction contributed to findings on lus. additionally, the high in-hospital mortality rate of patients in our cohort may represent spectrum bias, with providers having been more likely to perform lus in sicker patients. the decision to perform a lus may also have been the result of knowledge of the results of other diagnostic tests by the sonographer, such as cxr. finally, the lus patterns observed in our study may not be representative of those with milder disease. the findings described in the present study demonstrate that lus has the potential to add value to the care of patients with suspected covid- , but useful patterns were different from what has been suggested in nonanalytical publications. since this is a hypothesis-generating study, no firm conclusions can be made as to why one imaging pattern may have outperformed another; however, analysis of the case-mix of patients may provide some clues. as an example, subpleural consolidation on lus had been hypothesized ( ) as a potentially useful finding in covid- due to utility of this pattern to identify viral and bacterial pneumonia other than covid- ; however, we did not find this to be the case. it is therefore perhaps notable that eight of the patients who were confirmed covid- negative had a discharge diagnosis of pneumonia due to pathogens other than covid- . while we cannot rule out that these were false negatives for covid- pneumonia (i.e., after serial testing), four of those eight had concomitant bacteremia with a pulmonary pathogen, one had pneumocystis pneumonia, one had confirmed invasive pulmonary aspergillosis, and one had confirmed influenza a. these seven of eight with a highly plausible alternative pulmonary infection could also demonstrate pleural lus findings, and therefore evaluation for subpleural consolidation may simply have failed to distinguish these alternative infectious lung diseases from covid- . furthermore, covid- presentations were particularly severe in our report, with marked mortality rates and high rates of comorbidities. consequently, an ards-like pulmonary edema picture of covid- may have predominated the case-mix more so than the uncomplicated pneumonia expected in mild presentations of covid- , with the latter expected to be more consistent with lus findings of consolidation compared to the former. while we consider the severity of covid- presentations a strength of our report given a paucity of lus data for critically ill covid- patients ( ) , it thus also must be considered a limitation. just as the predominance of a "less-sick" covid- population in previous lus reports ( ) causes a spectrum bias toward results more specific to mild covid- , our comparatively ill cohort (and any selection bias that may have led to it) likely introduces a spectrum bias toward lus findings more characteristic of severe presentations (e.g., icu-admitted patients, with high mortality) ( ) . by contrast, the ndbpe pattern that we describe performed well. there is precedent for the lack of a base-apex gradient on lus as one factor differentiating pneumogenic pulmonary edema (specifically ards) from cardiogenic pulmonary edema ( ) . this is consistent with the ndbpe pattern we observed here, possibly by highlighting again that more severe presentations of covid- involve the manifestation of bilateral increased extravascular lung fluid that is not hydrostatic in nature (i.e., an ards-type picture). notably, four of the five covid- negative patients who were diagnosed with ahf or volume overload from decompensated renal disease were absent the ndbpe pattern. it is possible then that the ndbpe pattern helped to differentiate critically ill covid- patients from those with cardiogenic pulmonary edema or volume overload from renal failure ( ) , although this too is simply a hypothesis and needs testing in prospective study. the differentiation of pneumogenic pulmonary edema (e.g., ards, viral pneumonitis) from cardiogenic edema has long been a challenge on lus ( ) , and echocardiographic evaluation of filling pressures has proved useful to this end in the past. thus, concurrent ventricular filling pressures will also be needed to confirm the supposition that ndbpe on lus can help rule-in covid- lung disease in part by screening out cardiogenic and renal pulmonary edema ( ) . future research should test the hypotheses generated here with an explicit prospective design, inclusion of a broad spectrum of covid- severity, multiple observations across the ed to icu, and rigorous methods for diagnostic adjudication beyond the rt-pcr reference standard alone which would likely include ct of the thorax if feasible. covid- ): a perspective from china imaging profile of the covid- infection: radiologic findings and literature review diagnostic performance between ct and initial real-time rt-pcr for clinically suspected coronavirus disease (covid- ) patients outside wuhan, china is there a role for lung ultrasound during the covid- pandemic? diagnostic accuracy of chest radiograph, and when concomitantly studied lung ultrasound, in critically ill patients with respiratory symptoms: a systematic review and meta-analysis point-of-care lung ultrasound in patients with covid- -a narrative review design and rational of the b-lines lung ultrasound-guided emergency department management of acute heart failure (blushed-ahf) pilot trial the estimation and use of predictions for the assessment of model performance using large samples with multiply imputed data comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome proc: an open-source package for r and s+ to analyze and compare roc curves impact of patient positioning on lung ultrasound findings in acute heart failure spectrum bias-why clinicians need to be cautious when applying diagnostic test studies thoracic ultrasound and sars-covid- : a pictorial essay diagnosing acute heart failure in the emergency department: a systematic review and meta-analysis critical care ultrasonography in acute respiratory failure drs. favot and harrison contributed equally as co-first authors.dr. harrison was responsible for analysis and interpretation of data. drs. favot, malik, and harrison were responsible for drafting of article. drs. favot, ehrman, and harrison were responsible for critical revision of article. drs. favot, malik, ehrman, and harrison were responsible for study conception and design. all authors were involved in acquisition of data.supplemental digital content is available for this article. direct url citations appear in the html and pdf versions of this article on the journal's website (http://journals.lww.com/ccejournal).the authors have disclosed that they do not have any potential conflicts of interest. key: cord- -mryrl s authors: raimondi, francesco; yousef, nadya; migliaro, fiorella; capasso, letizia; de luca, daniele title: point-of-care lung ultrasound in neonatology: classification into descriptive and functional applications date: - - journal: pediatr res doi: . /s - - - sha: doc_id: cord_uid: mryrl s lung ultrasound (lus) is the latest amongst imaging techniques: it is a radiation-free, inexpensive, point-of-care tool that the clinician can use at the bedside. this review summarises the rapidly growing scientific evidence on lus in neonatology, dividing it into descriptive and functional applications. we report the description of the main ultrasound features of neonatal respiratory disorders and functional applications of lus aiming to help a clinical decision (such as surfactant administration, chest drainage etc). amongst the functional applications, we propose safe (sonographic algorithm for life threatening emergencies) as a standardised protocol for emergency functional lus in critical neonates. safe has been funded by a specific grant issued by the european society for paediatric research. future potential development of lus in neonatology might be linked to its quantitative evaluation: we also discuss available data and research directions using computer-aided diagnostic techniques. finally, tools and opportunities to teach lus and expand the research network are briefly presented. the first report on the use of lung ultrasonography (lus) in adult medicine appeared in and lus has been rapidly gaining popularity, also in paediatrics and in neonatology. lus is a point-ofcare, easy-to-learn, radiation-free, bedside, quick and repeatable technique. lus signs vary little by age, which makes it especially suitable for use in the smallest patients and in the critical care setting. in the past years, there has been a notable increment in publications on the use of lus in neonatology (fig. ) , and even more in adult medicine. we demonstrated that launching a lus program in their neonatal intensive care unit (nicu) roughly halved the number of chest radiograms and significantly decreased the mean radiation dose/patient. we present a comprehensive review on lus in neonatology with an emphasis on pathophysiology and on a classification into descriptive (qualitative) and functional (semiquantitative) applications. lus is a powerful diagnostic technique and a noninvasive research tool to describe several neonatal respiratory disorders in a qualitative manner. international lus guidelines for adult critical care include a short chapter about applications in infants, based on the little data available in , and conclude that the use of descriptive lus may be of interest. many studies have been published since then, and we aim to review the knowledge available today. the main lus semiology patterns are illustrated in fig. and in the supplementary material s -s . the description of lus findings for each neonatal lung disorder is summarised in table . transient tachypnoea of the neonate the main pathophysiological feature of transient tachypnoea of the neonate (ttn) is delayed lung fluid re-absorption during the foetal life transition and this creates a mainly interstitial, ab extrinseco lung oedema. lus shows a high sensitivity and specificity to detect alveolar-interstitial oedema and to estimate extravascular lung water (evlw) in adults through the evaluation of b-lines, which are vertical dynamic artefacts arising at the fluid/ air interface. , b-lines may be sparse or confluent, creating a continuum that is generally referred to as an 'alveolar-interstitial pattern'. using lus, substantial liquid retention has been demonstrated at years of life in % of healthy neonates, while %, % and % of neonates had completed airway liquid clearance at , and h, respectively. moreover, it seems that neonates born by an elective caesarean section have higher fluid retention early after birth than those vaginally delivered. [ ] [ ] [ ] consistently, copetti and cattarossi showed that neonates with ttn have both interstitial oedema (represented by b-lines), and normal areas (represented by a-lines). a sharp increase in echogenicity was described in the lower lung fields of ttn neonates and the authors named this finding 'double lung' point. subsequent publications showed that the double lung point is not a perfect diagnostic tool for ttn, whose ultrasound appearance may include pleural line thickness, a more diffused alveolar-interstitial pattern and the presence of normally aerated areas. , this seems to be confirmed by the preliminary data of an ongoing multicentre, international study. despite the rich semiology and the absence of a unique diagnostic sign, the distinction between ttn and respiratory distress syndrome (rds) is relatively easy (see below), but it should be kept in mind that clinical and laboratory data must always be integrated with lus to refine the diagnosis. respiratory distress syndrome the typical lus appearance of respiratory distress syndrome (rds) consists of bilateral white lungs (i.e., the diffuse alveolar-interstitial pattern) with no spared areas reflecting decreased air/fluid ratio. other findings include 'sub-pleural' small consolidations and/or an irregular pleural line. these results have been confirmed by multiple studies. [ ] [ ] [ ] [ ] [ ] [ ] since rds is a more severe and diffuse condition than ttn, the absence of spared areas (with a-lines) seems the most noticeable sign and, contrary to ttn, in the absence of any treatment, lus appearance will not improve quickly. there is a high inter-observer agreement among physicians with different levels of lus expertise, which makes the differential diagnosis between rds and ttn reliable, irrespective of the operator. lus is also useful in diagnosing the complications of rds, such as pulmonary haemorrhage, pneumothorax (pnx) or atelectasis. , two pathophysiological aspects must be considered: ( ) clinical and laboratory data must always be integrated with lus to refine the diagnosis of rds, especially when it may coexist with other conditions, like pneumonia, early-onset sepsis or air leaks; ( ) mixed-type situations may exist where fluid retention is associated with partial surfactant deficiency, as this has been recently demonstrated by lamellar body count. interestingly, a semiquantitative lus score describing lung aeration (see below) correlated with lamellar body count. these mixed ttn/rds cases may last longer than classical ttn and may sometimes require noninvasive respiratory support or even a surfactant. unlike chest x-rays, lus appearance does not change shortly after surfactant administration, and this is intrinsically due to their different properties: lus detects lung fluid content, while xrays directly detect lung aeration. surfactant replacement unavoidably implies some fluid administration even with the more concentrated surfactant preparations. animal data demonstrate an almost total evlw clearance h after surfactant administration. however, the same process seems more variable and heterogeneous in human neonates, as lus appearance may be influenced by respiratory support, gestational age, fluid intake, pre-existing condition (pure rds or a more complex situation with superimposed lung inflammation and surfactant catabolism, such as acute respiratory distress syndrome (ards)) and the eventual simultaneous development of broncho-pulmonary dysplasia (bpd). neonatal ards ards is an acute, life-threatening respiratory failure, characterised by extensive lung tissue inflammation, endothelial injury and both quantitative and qualitative secondary surfactant dysfunction, leading to loss of lung aeration. neonatal ards shares the same biological and pathophysiological aspects of the syndrome in lung ultrasound semiology. the basic semiology patterns are illustrated: these patterns may be variably found in different respiratory disorders described in table . arrows indicate the sub-pleural consolidation, the border of a consolidation, the double lung point or the lung point. the size threshold to distinguish micro-consolidations (sub-pleural) from consolidations ( . cm) is arbitrary. some semiology patterns are also dynamically shown in the videos in supplementary material older patients: thus, signs on lung imaging are similar. lus findings in neonatal ards consist of bilateral diffuse loss of aeration, which may vary from a diffuse alveolar-interstitial to an irregular alveolar pattern with consolidations with bronchograms and/or atelectases. lung imaging is one of the diagnostic criteria included in the montreux definition of neonatal ards, but this officially requires x-ray findings (diffuse, bilateral and irregular opacities or infiltrates, or complete opacification of the lungs, which are not fully explained by local effusion, atelectasis, rds, ttn or congenital lung anomalies). nonetheless, lus has been used for the diagnosis of ards in adults and is considered suitable in neonates if sufficient clinical expertise exists for its interpretation. despite similarities with the syndrome in older patients, neonatal ards may also have different triggers, such as meconium aspiration syndrome (mas), lung haemorrhage, perinatal asphyxia or necrotising enterocolitis that are peculiar to newborn age. meconium aspiration syndrome meconium aspiration syndrome (mas) is the only ards-triggering condition for which lus findings have been formally described so far and they consist of a mix of normal lung areas, coalescent or sparse alveolar-interstitial pattern and consolidations with bronchograms. these signs are irregularly present all over the lungs and may change over time as the meconium-driven inflammation progresses; meconium plugs may also occur and create atelectases. these findings were confirmed in a larger study of neonates with mas and a dissociation between clinical severity and imaging findings may sometimes occur. in summary, lus signs in mas include all the possible findings ranging from normally aerated zones to a complete loss of aeration, and, when the injury is sufficiently severe and diffuse, the lesions may cause an important oxygenation impairment and qualify as neonatal ards. air leak syndromes lus signs of pnx (see supplementary material s and s ) are the absence of lung sliding and of any other sign other than a-lines; these findings are described in detail elsewhere. lus has a higher diagnostic accuracy than conventional radiology for the diagnosis of pnx in adults, as it has been demonstrated by a metaanalysis of studies. therefore, lus can potentially detect subclinical pnx that may go radiologically underdiagnosed and that does not require treatment. recently, a case report and two diagnostic accuracy studies suggest that lus may also be very useful in the diagnosis of neonatal pnx. [ ] [ ] [ ] in critically ill babies, lus can be used for rapid detection of life-threatening tension pnx: an international multicentre study confirmed that lus has an optimal diagnostic accuracy and is quicker than conventional radiology. lus also resulted more accurately than chest transillumination (which is also less accurate than conventional radiology). a case report described the use of lus to detect and follow up neonatal interstitial emphysema. no formal lus description of neonatal pneumomediastinum exists. however, pneumomediastinum has been detected in children as ( ) the absence of lung sliding on parasternal scan (with normal sliding in other chest areas); ( ) a parasternal 'still' lung point, since the air collection displaces the lungs laterally and reveals the border between the air-filled mediastinum and the displaced lung; this still lung point does not move with spontaneous breathing and it remains under the parasternal area; ( ) impossibility to obtain a normal parasternal heart view due to air artefact, regardless of the breathing cycle. , pneumonia lus typically shows pneumonia as the presence of consolidations with irregular borders and air bronchograms, associated with pleural line abnormalities, and alveolar-interstitial pattern in the adjacent areas if the inflammatory process is extended. the presence of these signs carries an optimal diagnostic accuracy according to a study performed on neonates with symptomatic pneumonia and controls. similar results were obtained in a larger cohort of chinese neonates, of whom were diagnosed with pneumonia by routine lus: among cases without any sign of lung disease by chest radiograms, there were cases with clinical and ultrasound evidence of pneumonia. these data are fully consistent with those obtained in older patients. in fact, a meta-analysis of eight diagnostic studies ( paediatric patients, including both neonates and children) yielded a sensitivity and a specificity of and %, respectively, which is superior to the accuracy of chest radiograms and comparable to that obtained combining radiology and laboratory exams. similarly, a meta-analysis of studies ( adults) showed that lus has a high accuracy (sensitivity %, specificity %) to diagnose pneumonia defined by the combination of radiological and clinical data. finally, a smaller metaanalysis of studies ( adults) showed lus to be more accurate than conventional radiology or computerised tomography (ct) alone. some points still deserve to be investigated. there are no specific data regarding pneumonia of different types (i.e. congenital, community-acquired or ventilator-associated), although lobar or haemilobar consolidations are useful to diagnose ventilatorassociated pneumonia in adults, when coupled with clinical diagnostic criteria. thresholds for the size of consolidations and exact measurement methods also need to be defined. bronchiolitis and other viral low tract respiratory infections bronchiolitis, often caused by respiratory syncytial virus (rsv), is essentially an airway inflammatory disease causing obstructive respiratory failure with possible secondary involvement of the alveolar tissue. therefore, from an ultrasound point of view, bronchiolitis presents as a nonhomogeneous pleural line abnormalities (pleural line thickening and/or irregularities), small 'subpleural' and/or larger consolidations or an alveolar-interstitial pattern, in the case of parenchymal involvement. for the sickest patients, consolidations may span across several intercostal spaces, due to associated atelectasis, viral alveolar injury or superimposed bacterial infection. if the lung injury is severe enough, patients may qualify for rsv-induced ards and this is characterised by a shift towards a mainly restrictive and severe respiratory failure with a greater loss of aeration, as described above. lus findings correlate with disease severity, with a higher proportion of hospitalised patients having positive findings compared to outpatients. moreover, findings gradually resolve with clinical improvement and the lung aeration correlates with the duration of oxygen therapy both in spontaneously breathing infants and in those needing noninvasive respiratory support. a good concordance among operators of different expertise has been reported for the ultrasound evaluation of bronchiolitis, similar to that reported for restrictive disorders. bronchiolitis findings are non-specific and shared with other viral low tract respiratory infections; thus, laboratory tests are warranted to clarify the aetiology and also rule out bacterial coinfection. only one study has evaluated lus during a h n outbreak suggesting moderate accuracy in distinguishing viral and bacterial pneumonias, as these were showing an interstitial pattern and consolidations, respectively. however, this study was performed during an outbreak and may be biased by the high disease prevalence. consistently, other case series in adults have shown nonspecific lus findings in influenza and measles. [ ] [ ] [ ] no specific neonatal studies are available in this field. broncho-pulmonary dysplasia early prediction of worsening respiratory conditions and bronchopulmonary dysplasia (bpd) is a potentially interesting application for lus, as other techniques have failed in this regard. , two studies published in the nineties addressed lus features of bpd using the trans-abdominal approach. the authors found that in bpd-developing babies, lus showed the persistence or the appearance of nonhomogeneous retro-diaphragmatic hyperechogenicity, which was not visible in controls. , . since then, ultrasound technology and our understanding of bpd have greatly improved. data on transthoracic lus and bpd are currently lacking. moreover, there are no lus data describing 'developing bpd' or the new concept of chronic pulmonary insufficiency of prematurity, that may provide new interesting areas of application for lus. malformations lus has been used to describe congenital pulmonary airway malformations (cpam), which have a variable appearance (a large or micro-cystic lesion or irregular consolidations) in line with the four histological types described in the most recent cpam classification. , the gold standard to diagnose lung malformations remains the ct-scan, though lus may allow to suspect cpam in the absence of an antenatal diagnosis. functional lung ultrasound lus may also be used in a more 'functional' way, to guide therapeutic interventions or to assist during invasive procedures. some examples of these applications already exist in the form of lus scores or decision-making protocols in adult critical care. , we shall review a few neonatal data and provide specific proposals for these applications in neonatology. scores for semi-quantitative lus a basic, three-stage classification can be set as coalescent b lines (i.e. the 'white lung image'), sparse b lines and the normal, diffuse a-line pattern. using this simple system, our group monitored the postnatal lung fluid clearance and predicted nicu admission in a cohort of late preterm and term infants. this information may be particularly valuable to healthcare providers in level i/ii perinatal centres. we also investigated the usefulness of lus linking a specific lus profile to a therapeutic decision: the presence of a bilateral severe alveolar-interstitial pattern reliably predicted the need for intubation in nicu-admitted preterm neonates (sensitivity . %, specificity %). similar results were found by other authors in a cohort of neonates older than weeks, arbitrarily classifying the lus findings as low (normal or ttn) or high risk (rds, mas, pneumothorax or pneumonia). these papers used descriptive lus to predict or guide clinical decision but did not quantify the lus findings. since lus detects the artefacts generated by the accumulation of fluid, and given that artefacts may be ranked according to the air/fluid ratio, it is possible to create scores inversely reflecting lung aeration. several semi-quantitative scores are available in adult critical care and their description is beyond our scope. nonetheless, all lus scores are based on the same semiology and, interestingly, they seem only useful in restrictive lung disorders. in fact, an obstructive condition will create air-trapping and this might not be distinguishable from a normally aerated lung at lus, as both present with a-lines. consistently, lus scores may well evaluate lung aeration, but they cannot detect over-distension, as it has been proven in ventilated adults. despite these limitations, lus scores offer the advantage of allowing serial semi-quantitative evaluations of the disease severity. we described the first lus score to be used in neonates with respiratory failure modifying a score already used in adult critical care. the main modifications were ( ) fewer lung areas to scan given the smaller chest size; ( ) use of a small linear or a microlinear 'hockey-stick' probe instead of a convex one. we were able to demonstrate that the lus score is suitable and inversely correlated to oxygenation. the score is based on three chest areas for each side (upper anterior, lower anterior and lateral) and a -to- score is given for each area: more details are shown in supplementary material s . the lus score is able to predict the need for surfactant treatment in preterm infants below weeks' gestation (area under the curve: . ( % ci: . - . ; p < . )), and in extremely preterm neonates affected by rds (area under the curve: . ( % ci: . - . ; p < . )). the diagnostic accuracy was lower in late preterm and term neonates since they may be affected by various lung disorders with different appearance and severity, such as rds and ttn, but also aspiration syndromes and sepsis or ards. lus score calculation has a high inter-observer agreement regardless of the ultrasonographers' experience. computer-aided image analyses provide an appealing approach for interpreting lus and different technologies are being developed. for instance, ultrasound lung texture analysis has already been used to examine the foetal lung and predict the need of respiratory support. we found a significant correlation between the lus score calculated by the ultrasonographer or by a supervised machine-learning approach and oxygenation indexes, while a lus score obtained with greyscale analysis, another computerised image analysis technique, did not correlate with oxygenation. computer technology is progressing fast and we speculate a future when ultrasound images will be processed free of subjective interpretation. in the meantime, available data demonstrate that a visually calculated lus score is a useful and easy tool to predict surfactant need in preterm neonates with rds, to evaluate lung aeration while titrating the respiratory support or to be used as a research outcome measure. lus score has its drawbacks (i.e. a semi-quantitative measure, impossibility to detect air-trapping) but is more easy and quickly available at the bedside than more complex techniques, such as electrical impedance tomography or respiratory inductance plethysmography. , semi-quantitative lus has not only been used for respiratory failure due to a primary pulmonary disorder, but also for neonates with heart defects causing cardiogenic lung oedema. the latter is much more common in adults and, in these cases, the lus score has been calculated simply by counting b-lines, provided that there was no consolidation due to a parenchymal process. neonates with congenital heart defects predisposing to pulmonary overflow have a higher b-line count than babies without overflow and the b-line score also correlates with the duration of ventilation. similar applications could be proposed to evaluate pulmonary overflow in the case of haemodynamically significant patent ductus arteriosus or to guide fluid management albeit specific studies are currently lacking. standardised protocol for functional lus: the safe algorithm there is a need for specific protocols integrating lus findings into diagnostic and/or operative flow-charts. formal lus protocols for the evaluation of trauma, ( ) pleural effusion. the algorithm only takes a few minutes and aims to help diagnosing the most urgent treatable complications whilst awaiting expert help. a paediatric cardiologist evaluation of congenital heart defects is included in the algorithm but only when the most urgent causes have been already ruled out. safe is designed for the average neonatologist and may be applied using any probe without losing time to change it commonly used in adult critical care. thus, lus needs to be integrated into appropriate decision-making algorithms in neonatology. point-of-care ultrasound is rapidly growing and guidelines about neonatologist-performed echocardiography have been already published, , but there are no formal algorithms for the use of lus in neonatology. a project in this direction has been specifically funded by a european society for paediatric research grant and aimed to create the 'safe protocol' (sonographic algorithm for life threatening emergencies) to standardise the use of lus in critically ill neonates. the safe protocol is designed for use in the case of unexpected and severe decompensation (bradycardia or severe desaturation requiring resuscitative manoeuvres or significantly increasing oxygen/ ventilator parameters to maintain stable oxygen saturation levels) in formerly stable infants in the nicu. it aims to help the diagnosis of the most urgent treatable complications: current knowledge on the ultrasound detection of the most critical neonatal complications was integrated into the algorithm and rapid diagnosis of unexpected and potentially fatal complications was prioritised. the safe protocol starts with an easy, subjective 'eyeball' assessment of myocardial contractility, which is comparable to other techniques which are more accurate but unsuitable during emergencies. , then, safe uses standardised items together with a simplified and rapid rule-in/rule-out approach to detect only three main life-threatening complications. as shown in fig. , the ultrasound algorithm is designed by order of urgency. hence, ruling out cardiac tamponade, which is a rare condition, is the first step in the decision tree since it may be rapidly fatal in the absence of prompt intervention followed by pneumothorax, and lastly, pleural effusion. the latter is also quite unusual, but it is associated to central venous lines often used in nicu care: current guidelines for adult critical care recommend the use of lus for the diagnosis of pleural effusion, as it outperforms chest x-rays. safe is designed for the average neonatologist, it requires only minimal training and can be performed with a single ultrasound probe, as it targets basic ultrasound signs. a preliminary evaluation of safe after basic training in an academic nicu has shown that the algorithm is quick and easy to perform, even for lesserexperienced clinicians. the safe protocol will need to be evaluated prospectively, as it has been done for similar algorithms (bedside lung ultrasound in emergency (blue) and fluid administration limited by lung sonography (falls)) presently used in adult critical care. [ ] [ ] [ ] moreover, although any probe can be used, the optimal probe needs to be determined with a specific study. further work to expand the safe protocol to include other organs is ongoing. lus-guided procedures lus has been used to guide invasive procedures in order to reduce associated complications. lus guidance is recommended for chest tube placement in adults, as this effectively reduces complications. there are no neonatal studies about these procedures, but it is highly probable that lus may provide similar advantages, also because of the smaller patients' size. we demonstrated that the lus detection of tension pnx is extremely accurate and quicker than using conventional radiology. other authors successfully performed a lus-guided drainage of a lifethreatening tension pneumomediastinum. even in the absence of specific studies, the use of lus is advisable in these situations, where enough expertise exists, as lus will likely assist the operator and make the procedure easier. lus has been shown to be effective for verifying endotracheal tube (ett) position in patients of different ages. this can be achieved by assessing the normal sliding on both hemithoraces that confirms ventilation; in turn, other studies have aimed to directly visualise the ett tip position. jaeel et al. recently performed a systematic review of neonatal studies on this topic. the studies report a successful visualisation of the tube tip in more than % of cases and this correlated with the position observed on chest radiograms in - % of cases. we must acknowledge that there were variations in techniques, calculations, probes and operators' expertise across the studies: lus visualisation of ett does not seem to be straightforward and is potentially subjected to erroneous interpretation. simpler techniques (such as digital palpation of the ett tip in the suprasternal notch) have also been proposed. unless convincing evidence is published, lus cannot be recommended as a routine technique to verify ett placement, while end-tidal co measurement is recognised as the gold standard. lus is relatively easy to learn in vivo and we have organised successful practical courses since . however, some interesting bench models have been created to mimic lus semiology and teach lus-guided procedures, although they may also be useful as an educational tool for descriptive lus. models have been created with plastic phantoms or a wet sponge with or without pork ribs, but also simply using a hand with a wet foam. [ ] [ ] [ ] [ ] conclusion there is a rapid growth in the use of lus in neonatology and an increasingly large body of evidence supporting its use in neonatal respiratory care. however, the knowledge available is still far from that acquired in adult critical care. methodological stringency and multicentre studies are needed. therefore, we have founded the neolus group (neonatal lung ultrasound for the neonate and the small infant): a dedicated research network currently counting more than members around the world and disposing of a dedicated page on social networks. this and other initiatives will contribute to the further development of lus in neonatology. a bedside ultrasound sign ruling out pneumothorax in the critically ill. lung sliding neonatal lung ultrasound exam guidelines lung ultrasound decreased radiation exposure in preterm infants in a neonatal intensive care unit international evidence-based recommendations for point-of-care lung ultrasound the comet-tail artifact. an ultrasound sign of alveolarinterstitial syndrome lung ultrasound predicts well extravascular lung water but is of limited usefulness in the prediction of wedge pressure lung ultrasound immediately after birth to describe normal neonatal transition: an observational study lung ultrasound during the initiation of breathing in healthy term and late preterm infants immediately after birth, a prospective, observational study delayed lung liquid absorption after cesarean section at term the 'double lung point': an ultrasound sign diagnostic of transient tachypnea of the newborn lung ultrasound accuracy in respiratory distress syndrome and transient tachypnea of the newborn lung ultrasonography to diagnose transient tachypnea of the newborn is the double lung point an accurate diagnostic marker fir transient tachypnoea of the neonate? a prospective international study clinical data are essential to validate lung ultrasound diagnosis of neonatal transient tachypnea and its differentiation from 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echocardiography in europe: consensus statement endorsed by european society for paediatric research (espr) and european society for neonatology (esn) techniques for comprehensive two dimensional echocardiographic assessment of left ventricular systolic function the search for intelligent quantitation in echocardiography: "eyeball," "trackball" and beyond the safe protocol: a sonographic algorithm for life-threatening emergencies in the neonatal intensive care unit recommendations on the use of ultrasound guidance for adult thoracentesis: a position statement of the society of hospital medicine ultrasound-guided thoracentesis: is it a safer method ultrasound guided percutaneous relief of tension pneumomediastinum in a -day-old newborn ultrasonography for endotracheal tube position in infants and children a role of end-tidal co( ) monitoring for assessment of tracheal intubations in very low birth weight infants during neonatal resuscitation at birth creating thoracic phantoms for diagnostic and procedural ultrasound training phantom model and scoring system to assess ability in ultrasound-guided chest drain positioning randomized, noninferiority study between video versus hand ultrasound with wet foam dressing materials to simulate b-lines in lung ultrasound: a consort-compliant article economical sponge phantom for teaching, understanding, and researching a-and bline reverberation artifacts in lung ultrasound the authors are grateful to the espr pulmonology section for their support. the authors are also indebted with philippe durand (md) for the cpam image. the authors also wish to thank samsung (seoul, south korea) for the technical assistance provided. videos in the supplementary material have been taken with samsung hm a or with general electrics ge logiq e , using a high-frequency linear probe. the development of the safe algorithm has been supported by the espr cure & care research grant (received by ny). the online version of this article (https://doi.org/ . /s - - - ) contains supplementary material, which is available to authorized users. publisher's note: springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- - qixiew authors: bennett, david; de vita, elda; mezzasalma, fabrizio; lanzarone, nicola; cameli, paolo; bianchi, francesco; perillo, felice; bargagli, elena; mazzei, maria antonietta; volterrani, luca; scolletta, sabino; valente, serafina; franchi, federico; frediani, bruno; sestini, piersante title: portable pocket-sized ultrasound scanner for the evaluation of lung involvement in covid- patients date: - - journal: ultrasound med biol doi: . /j.ultrasmedbio. . . sha: doc_id: cord_uid: qixiew ultrasound imaging of the lung (lus) and associated tissues has demonstrated clinical utility in covid- patients. the aim of the present study was to evaluate the possibilities of a portable pocket-sized ultrasound scanner in the evaluation of lung involvement in patients with covid- pneumonia. we conducted paired readings in lus evaluations on hospitalized patients with covid- . the lung ultrasound scans were performed on the same day with a standard high-end ultrasound scanner (venue go™, ge healthcare, chicago, il, usa) and a pocket-sized ultrasound scanner (butterfly iq, butterfly network inc., guilford, ct, usa). / scans were performed on severe, on moderate and on mild patients. no difference in days since onset of symptoms was observed between groups ( . ± . , . ± . , . ± . days, respectively, p= . ). no significant differences were found between lus scores obtained with the high-end and the portable pocket-sized ultrasound scanner. lus scores in patients with mild respiratory impairment were significantly lower than in moderate and severe patients. our study confirms the possibilities of portable pocket-sized ultrasound imaging of the lung in covid- patients. portable pocket-sized ultrasound scanners are cheap, easy to handle and equivalent to standard scanners for non-invasive assessment of severity and dynamic observation of lung lesions in covid- patients. coronavirus disease , caused by infection with severe acute respiratory syndrome coronavirus (sars-cov- ), emerged in china in december and quickly spread all over the globe. the clinical features are fever, dyspnoea, dry cough, fatigue and diarrhoea (wan et. ) . pharyngodynia, nasal congestion, rhinorrhoea and anosmia have also been reported (chen et al. , hopkins et al. , mason , gattinoni et al. . interstitial pneumonia is very common and a high percentage of patients ( - %) develop severe acute respiratory distress syndrome (ards) and require intensive care (lovato and de filippis , remuzzi and remuzzi , yuan et al. . current therapeutic strategy involves agents counteracting viral invasion and replication, and inhibitors of cytokine-sustained inflammatory reactions. no specific antiviral therapy has yet been identified (capecchi et al. , conticini et al. . ultrasound imaging of the lung (lus) is a promising technique in many acute and chronic parenchymal conditions that determine interstitial syndrome. these include cardiogenic and noncardiogenic pulmonary oedema, ards, interstitial pulmonary fibrosis and a variety of conditions determining lung consolidations, such as pneumonia and lung cancer (mojoli et al. ). in covid- patients, it demonstrated clinical utility due to the typical sonographic characteristics of affected lungs by providing indications for clinical decisions and the management of associated respiratory failure and lung injury (smith et al. ) . the aim of the present study was to evaluate the possibilities of a portable pocket-sized ultrasound scanner in the evaluation of lung involvement in patients with covid- pneumonia. we conducted lus evaluations on patients admitted to the covid unit of siena university hospital with symptoms compatible with covid- , a positive sars-cov- nasalpharyngeal swab and radiological evidence of interstitial pneumonia. the patients were divided into three severity categories based on respiratory impairment: mild pao /fio > in room air or oxygen flow; moderate pao /fio between and in room air or oxygen-therapy, cpap, niv or hfnc; severe pao /fio < on oxygen-therapy, cpap, niv, hfnc or mechanical ventilation. up to six regions of the chest were identified: anterosuperior (a); anteroinferior (b); lateralsuperior (c); lateralinferior (d); posterosuperior (e); posteroinferior (f). one of four different aeration patterns was recorded according to a specific scoring system: a = points (normal aeration, presence of lung sliding with a lines or less than two isolated b lines), b = point (moderate loss of lung aeration, multiple well-defined b lines), b = points (severe loss of lung aeration, multiple coalescent b lines), c = points (lung consolidation and tissue-like pattern). pleural effusion and pneumothorax were also recorded. a score of was normal and was the worst. due to clinical conditions, the upper posterior region (e) could not explored in some patients, so the mean of the regions explored was calculated for the purposes of statistical analysis (total sum ( to ) divided by number of regions explored ( or on each side). our step-by-step approach to lus in covid- patients was comparable to the clue protocol (manivel v) . imaging were obtained by two different operators, both experts in lung ultrasound. the research was approved by the local ethics committee (oss_reos n° ) and informed consent was obtained from each participant. student's t-test was used to compare pairs of groups and anova to compare three or more groups, followed by holm-sidak's multiple comparisons test, when the former were significant. normal distribution of data was checked using d'agostino-pearson test (command sktest of stata). the presence and possible sources of systematic bias between the two instruments was investigated in the complete dataset of the individual readings at thoracic location in each patient. we used multilevel mixed-effects linear regression models with the difference in score on the same thoracic location (butterfly-ge) as the outcome variable, changes in vertical level of the thoracic location (high vs. low), side (right vs. left), horizontal level (anterior, lateral, posterior) and severity as fixed effect variables, and the patient as a random effect variable. the primary outcome of the study was the assessment of the bias and of limits of agreement (loa) between the total patient score obtained with the two instruments, computed with the bland altman method (balnd and altman ). a secondary outcome was the assessment of the concordance between the two instruments. as no single measure of concordance is generally the paired lus scans on covid- patients ( male and female; age at presentation . ± . years) produced the following results. no difference in age was found between severity groups; / scans were performed on severe, on moderate and on mild patients. no difference in days since onset of symptoms was observed between groups ( . ± . , . ± . , . ± . days, respectively, p= . ). when assessed on the full dataset of paired readings in lus, no significant differences were found between lus scores obtained with the high-end and the portable pocket-sized ultrasound, with a mean difference in score of - . ± . points (ns). the score difference did not change significantly according to lung side ( . ± . points), vertical level (- . ± . points), clinical severity ( . .± . points per each level). a significant difference, however, was found between the two instruments according the horizontal location of the site, with the difference between the two instruments resulting slightly but significantly greater on the posterior compared to the anterior side of the thorax ( . ± . points, p < . ). total average scores obtained with the two instruments were normally distributed, as was their difference. average patient scores correlated with clinical severity (p< . , figure ) all the computed parameters showed an excellent degree of concordance between the two instruments ( table ) lung ultrasound imaging is a non-invasive technique that provides useful indications for clinical decisions concerning covid- patients (smith et al. , wang et al. . it is safe, repeatable, radiation-free and economical and can be used at the point of care. here we evaluated the possibilities of a portable pocket-sized ultrasound scanner in covid- patients with pneumonia. we included a cohort of covid- patients who were hospitalized with respiratory failure of different severity. all were scanned with a standard high-end ultrasound scanner and a portable pocket-sized ultrasound scanner. the results of the portable scanner were practically identical to those of the high-end scanner in the assessment of lung interstitial syndrome according the blue protocol (lichtenstein ): bland-altman bias was found to be close to zero, with very narrow limits of agreement and all the other parameters of concordance were in the range of substantial or excellent agreement. furthermore, no systematic bias was observed according to disease severity or anatomical site of analysis, except for a statistically significant but practically negligible difference in the posterior side of the thorax, possibly a spurious finding. due to its easy handling and dynamic nature, lus is increasingly used in clinical settings, especially in critical care (mojoli et al. ) . in sars-cov- infection, it is invaluable in clinical management, showing higher accuracy than chest radiography (smith et al. ) and good correlation with ct imaging and pneumonia severity (nouvenne et al. , zieleskiewicz et al. ). in experimental models of ards, it was found to detect lung lesions before the onset of hypoxemia (soldati et al. ) . point-of-care ultrasound has great possibilities in many branches of medicine, especially emergency and critical care where it can be invaluable in the safe management of covid- , since it allows concomitant clinical examination and lung imaging at the bedside by the same doctor (smith et al. , buonsenso et al. ). an observational study, named identifier: nct ), is currently ongoing. the study is designed to assess whether focused lung ultrasound examination can improve the diagnosis of covid- lung disease and/or make an alternative diagnosis at a patient's initial hospital presentation. in our study we also found a statistically significant correlation between portable scanner findings and disease severity, confirming previous reports of . %, . %, . % sensitivity, . %, . %, . % specificity and . %, . %, . % diagnostic accuracy in detecting mild, moderate and severe lung lesions, respectively (lu et al. ) . the main limit of our study were its retrospective nature, preventing the analysis of the effect of the order of measurements with the two instruments and the effect of different observers (both can be considered to have been random, but there was no systematic protocol), and the limited number of patients undergoing imaging, however a considerable number of lung scans were analysed and clearly demonstrated, for the first time, that the performances of the portable and highend scanners were interchangeable. the use of portable ultrasound devices has increased in recent years, creating a flourishing market. a big advantage of portable devices is time saving at the bedside and in prehospital situations; limits are battery runtime, narrow field of vision, and low penetration (stock et al. , esr . in covid- patients, these devices could be of help for triage purpose as well by providing instant and objective information of the severity of the disease and may avoid further imaging in mild patients, however findings are not specific and may not correlate to clinical outcome and qualified operators are necessary; combination with clinical and physiological data is strongly recommended. their utility has been argued by several authors (gibson et al. , qian et al. , but this is the first study providing a demonstration of their use in daily clinical practice in covid- patients. in conclusion, our study confirms the possibilities of portable ultrasound imaging of the lung in covid- patients. portable pocket-sized ultrasound scanners are cheap, easy to handle and equivalent to standard scanners for non-invasive assessment of severity and dynamic observation of lung lesions in covid- patients with pneumonia. these ultrasound scanners can play a decisive role when healthcare resources are scarce, during pandemics and in emergency situations, such as the present covid- outbreak. statistical methods for assessing agreement between two methods of clinical measurement a practical guide to assess the reproducibility of echocardiographic measurements covid- outbreak: less stethoscope, more ultrasound antirheumatic agents in covid- : is il- the right target? 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perspective lung ultrasound for critically ill patients lung ultrasound in covid- pneumonia: correlations with chest ct on hospital admission a valuable and affordable handheld ultrasound in combating covid- covid- and italy: what next? lancet point-of-care lung ultrasound in patients with covid- -a narrative review is there a role for lung ultrasound during the covid- pandemic? comparison of a pocket-size ultrasound device with a premium ultrasound machine: diagnostic value and time required in bedside ultrasound examination clinical features and treatment of covid- patients in northeast chongqing usefulness of lung ultrasound blines in connective tissue disease-associated interstitial lung disease: a literature review monitoring transmissibility and mortality of covid- in comparative study of lung ultrasound and chest computed tomography scan in the assessment of severity of confirmed covid- pneumonia key: cord- - h jmn authors: zamboni, paolo title: covid- as a vascular disease: lesson learned from imaging and blood biomarkers date: - - journal: diagnostics (basel) doi: . /diagnostics sha: doc_id: cord_uid: h jmn covid- , a disease initially thought to be prominently an interstitial pneumonia with varying degrees of severity, can be considered a vascular disease with regards to serious complications and causes of mortality. quite recently, blood clots have emerged as the common factor unifying many of the symptoms initially attributed without an explanation to covid- . cardiovascular biomarkers and particularly, d-dimer and troponin appear to be very powerful prognostic markers, signaling the need for earlier and more aggressive interventions and treatments in order to avoid and/or minimize arterial/venous thromboembolism and myocardial infarct. the ultrasound imaging patterns at both the lung and peripheral vascular level can also be very useful weapons that have the advantage of being able to monitor longitudinally the clinical picture, something that real-time pcr/nasopharyngeal swab is not able to do and that ct can only pursue with significant radiation exposure. a lesson learned in the early phase of the covid- pandemic suggests quitting and starting again with targeted imaging and blood vascular biomarkers. italy was the first western country to be stricken by the coronavirus pandemic. from the outset, it became mandatory to identify and isolate covid- patients, many of whom were then admitted to hospital. the most common symptoms of the disease at onset were fever, fatigue, dry cough, dyspnea, runny nose or other upper respiratory tract symptoms. ageusia and anosmia were also found to be characteristic symptoms, albeit with more rare presentation, while gastrointestinal symptoms account for a minority of cases. laboratory tests also found covid- to be associated with changes in blood chemistry, with d-dimer, lactate dehydrogenase (ldh) and the aspartate transaminase to alanine transaminase ratio (ast-alt) all showing interesting changes in the negative predictive value to positive predicted value (npv-ppv) relationship [ , ] . as the covid- outbreak progressed, chest x-rays were found to display relatively low sensitivity, whereas chest ct exhibited higher sensitivity scores, with the latter achieving: sensitivity of %, specificity of %, ppv of %, and npv of %, with real-time pcr/nasopharyngeal swab (swab-pcr) as the reference method [ ] . given such a low specificity score, the use of dedicated software up to the introduction of artificial intelligence can allow chest ct to significantly improve the reporting speed and the diagnostic accuracy, as well [ , ] . an alternative approach that has great potential is lung ultrasound (lus), which has been shown to be capable of diagnosing interstitial pneumonia with great accuracy compared with chest ct [ ] . indeed, the receiver operating characteristic curves for lus have shown a strong relationship between sensitivity and specificity, with area under the curve scores of . and . , respectively, achieved in two distinct meta-analyses [ , ] . unfortunately, the use of swab-pcr as the primary diagnostic tool for covid- leaves much to be desired. indeed, of the , covid- patients at the wuhan university hospital, only % had a positive swab-pcr [ ] , with diagnosis in the remaining % of cases achieved through contact history, symptoms, blood chemistry tests and pulmonary ct. furthermore, in another large study, in % of patients with negative swab-pcr, chest ct demonstrated interstitial pneumonia often consistent with covid- etiology. moreover, by means of analysis of serial swab-pcr assays and ct scans, the mean interval time between the initial negative to positive swab-pcr result was . ± . days [ ] . as such, there is general agreement that a negative swab-pcr test should be interpreted with caution and a repeat test may be needed [ , , ] . finally, we must not to forget serology testing for viral antibodies, which is an important indicator of previous exposure to the virus. in a longitudinal study, sensitivity and specificity for detecting seropositivity at ≥ days following a positive sars-cov- swab-pcr result, was . % and . % when assaying for the panels of igm and igg. the median time to seropositivity observed for a reactive igm and igg result from the date of a positive pcr was days (iqr: . - days) and days (iqr: . - . days), respectively [ ] . the sars-cov- spike protein is known to bind to the angiotensin-converting enzyme (ace ) receptor on the surface of human cells. the spike protein is processed by membrane proteases, including tmprss , and is internalized into the cell, leading to infection [ ] . ace receptors are abundantly expressed by endothelial cells. in a paper published in april , it has been demonstrated that the sars-cov- virus can infect the endothelial cells in the lungs, heart, kidneys, liver, and intestines of patients with covid- infection [ ] . the demonstration of endothelial cell injury across vascular beds of different organs gives light to unexplained symptoms and clinical courses described in early reports of the covid- pandemic. in particular, histological analysis revealed the presence of the virus within endothelial cells was associated with clusters of inflammatory cells. this finding suggests that sars-cov- infection initiates endothelial inflammation throughout the entire human organism, as well as apoptosis, something that explains the systemic macro and microcirculatory involvement in different vascular beds and their clinical sequelae in patients with covid- [ ] . moreover, evidence of viral endothelial injury helps to explain why patients with pre-existing cardiovascular disease are particularly associated with adverse outcomes in covid- . notwithstanding this, awareness that covid- targets the endothelial cells provides a rationale for exploring several established cardiovascular therapies known to protect the endothelium in the hope of reducing viral replication [ ] [ ] [ ] [ ] [ ] . in the past few months, blood clots have emerged as the common factor unifying many of the mysterious symptoms attributed to covid- , a disease that had initially been thought to largely affect the lungs in the form of pneumonia. early findings in covid- autopsies showed deep vein thrombosis (dvt) in % of cases, complicated by fatal venous thromboembolism (vte) in % of patients. in addition, sudden cardiac death and kidney infarct complications were found in the other % of patients of this initial cohort [ ] . recently, the hypothesis that covid- pneumonia might be complicated by vte has been supported by an increased number of reports in the covid- literature [ ] [ ] [ ] [ ] [ ] [ ] (figure ). since the initial reports, an increase in circulating d-dimer levels has been reported, without being clarified if the cause was the cytokine storm of covid- interstitial pneumonia or if there were overlapping thrombotic phenomena. furthermore, increased levels of such a biomarker are associated with poor prognosis and/or death [ ] . indeed, it has been determined that a cutoff value . µg/ml of d-dimer can predict in-hospital mortality, with a sensitivity of . % and a specificity of . %. covid- patients with d-dimer levels ≥ . µg/ml have been shown to have a significantly higher diagnostics , , of incidence of mortality when comparing to those who with d-dimer levels < . µg/ml (p < . ). fatal vte in course of covid- is preceded by changes in blood coagulation biomarkers such as increased values of d-dimer, decreased antithrombin values, prothrombin time, and thrombin time [ ] . the addition of systemic proinflammatory cytokines release as a consequence of endothelial inflammation, as well as the expression of the ace receptors for sars-cov- on the membrane of the vascular muscle and endothelial cells, may help to explain why covid- patients are also susceptible to arterial thrombosis, even in young non-arteriosclerotic individuals [ ] . furthermore, cerebral circulation may also be involved, as retrospective analysis in wuhan revealed, where % of the deaths among covid- patients were stroke-related [ ] . since the initial reports, an increase in circulating d-dimer levels has been reported, without being clarified if the cause was the cytokine storm of covid- interstitial pneumonia or if there were overlapping thrombotic phenomena. furthermore, increased levels of such a biomarker are associated with poor prognosis and/or death [ ] . indeed, it has been determined that a cutoff value . µg/ml of d-dimer can predict in-hospital mortality, with a sensitivity of . % and a specificity of . %. covid- patients with d-dimer levels ≥ . µg/ml have been shown to have a significantly higher incidence of mortality when comparing to those who with d-dimer levels < . µg/ml (p< . ). fatal vte in course of covid- is preceded by changes in blood coagulation biomarkers such as increased values of d-dimer, decreased antithrombin values, prothrombin time, and thrombin time [ ] . the addition of systemic proinflammatory cytokines release as a consequence of endothelial inflammation, as well as the expression of the ace receptors for sars-cov- on the membrane of the vascular muscle and endothelial cells, may help to explain why covid- patients are also susceptible to arterial thrombosis, even in young non-arteriosclerotic individuals [ ] . furthermore, cerebral circulation may also be involved, as retrospective analysis in wuhan revealed, where % of the deaths among covid- patients were stroke-related [ ] . finally, elevated cardiac troponin levels are associated with myocardial injury, and in turn, with a fatal outcome in the clinical course of covid- [ ] [ ] [ ] . this is evident by the paradox that patients with underlying cardiovascular disease but without increased troponin achieve better outcomes than younger patients without comorbidities but higher troponin levels. in a single center study, the stratification of the mortality rate in the subgroups of patients during hospitalization for covid- was respectively: . % for patients without underlying chronic cardiovascular disease and normal troponin t levels; . % for those with comorbidities and normal troponin levels; . % for those without associated cardiovascular diseases but elevated troponin levels; . % for those with both underlying cardiovascular diseases and elevated troponin. however, patients with underlying comorbidities were more likely to exhibit elevation of troponin t as compared with the patients without previous cardiovascular diseases, respectively . % versus . % [ ] . given this, it is important to triage patients with suspected covid- according to their history of cardiovascular disease, assessing, at least, their d-dimer and troponin levels. finally, elevated cardiac troponin levels are associated with myocardial injury, and in turn, with a fatal outcome in the clinical course of covid- [ ] [ ] [ ] . this is evident by the paradox that patients with underlying cardiovascular disease but without increased troponin achieve better outcomes than younger patients without comorbidities but higher troponin levels. in a single center study, the stratification of the mortality rate in the subgroups of patients during hospitalization for covid- was respectively: . % for patients without underlying chronic cardiovascular disease and normal troponin t levels; . % for those with comorbidities and normal troponin levels; . % for those without associated cardiovascular diseases but elevated troponin levels; . % for those with both underlying cardiovascular diseases and elevated troponin. however, patients with underlying comorbidities were more likely to exhibit elevation of troponin t as compared with the patients without previous cardiovascular diseases, respectively . % versus . % [ ] . given this, it is important to triage patients with suspected covid- according to their history of cardiovascular disease, assessing, at least, their d-dimer and troponin levels. there is a growing body of evidence suggesting that sars-cov- can bind the glycosaminoglycans (gags), including heparin. the latter acts as a decoy, preferentially binding to the sars-cov- s spike protein and inhibiting sars-cov- entry into cells. initial binding with heparin appears also to change the conformation of the spike protein inhibiting downstream binding and processing of the ace receptor and tmprss , respectively. it has been recently demonstrated that intact recombinant s s spike protein from sars-cov- can bind to a human cell line that expresses ace and tmprss , and shown that unfractionated heparin and some low molecular weight heparins (lmwh), particularly enoxaparin in routine clinical use, determines a robust inhibition of s s binding [ ] [ ] [ ] [ ] . in light of what has been previously reported on the pathophysiological, diagnostic, and prognostic value of d-dimer, the dual role of heparin as a therapeutic weapon becomes clear-on the one hand, as a powerful inhibitor of the entry of the virus into cells, and on the other, as a preventer of the thromboembolic process. this is something which appears to be confirmed in clinical practice, since early analysis of in-hospital patients has revealed that anticoagulant treatment is associated with decreased mortality in covid- patients. the -day mortality in covid- patients with alteration of coagulation parameters including d-dimer in the lmwh group was significantly lower than in the non-user group. again, the rate of mortality was significantly higher in patients with d-dimer > -fold with respect to the upper limit of normality than in those below, respectively . % versus . % p = . [ ] . i do not want to comment here on the consequences of the high percentage of false negatives of swab-pcr in a pandemic, nor discuss the reasons for swab-pcr vulnerability. rather, we simply point out that there is an urgent need for a faster and more sensitive test to regulate access to hospitals, including the surgical unit, especially in emergency circumstances. as such, this issue continues to be an open diagnostic problem that affects both patients and health care professionals. looking at the current diagnosis of covid- , it would appear that both chest ct and lus have a valuable role to play in the triaging of patients into hospitals, especially in cases of emergency surgery or in situations where surgery cannot be procrastinated. however, the use of ct scans to identify covid- carriers has the disadvantage that it increases their exposure to radiation, as well as being a relatively costly health care procedure [ ] . recently, a group of lus experts developed a standardized protocol for investigation of covid- pneumonia [ ] . to this end, they suggested to use a tablet e-connected to a wireless probe, with both wrapped in single use plastic film covers [ ] [ ] [ ] [ ] [ ] . as such, this strategy minimizes the risk of contamination and facilitates easy disinfection and sterilization of equipment ( figure ). diagnostics , , of that intact recombinant s s spike protein from sars-cov- can bind to a human cell line that expresses ace and tmprss , and shown that unfractionated heparin and some low molecular weight heparins (lmwh), particularly enoxaparin in routine clinical use, determines a robust inhibition of s s binding [ ] [ ] [ ] [ ] . in light of what has been previously reported on the pathophysiological, diagnostic, and prognostic value of d-dimer, the dual role of heparin as a therapeutic weapon becomes clear-on the one hand, as a powerful inhibitor of the entry of the virus into cells, and on the other, as a preventer of the thromboembolic process. this is something which appears to be confirmed in clinical practice, since early analysis of in-hospital patients has revealed that anticoagulant treatment is associated with decreased mortality in covid- patients. the -day mortality in covid- patients with alteration of coagulation parameters including d-dimer in the lmwh group was significantly lower than in the non-user group. again, the rate of mortality was significantly higher in patients with ddimer > -fold with respect to the upper limit of normality than in those below, respectively . % versus . % p = . [ ] . i do not want to comment here on the consequences of the high percentage of false negatives of swab-pcr in a pandemic, nor discuss the reasons for swab-pcr vulnerability. rather, we simply point out that there is an urgent need for a faster and more sensitive test to regulate access to hospitals, including the surgical unit, especially in emergency circumstances. as such, this issue continues to be an open diagnostic problem that affects both patients and health care professionals. looking at the current diagnosis of covid- , it would appear that both chest ct and lus have a valuable role to play in the triaging of patients into hospitals, especially in cases of emergency surgery or in situations where surgery cannot be procrastinated. however, the use of ct scans to identify covid- carriers has the disadvantage that it increases their exposure to radiation, as well as being a relatively costly health care procedure [ ] . recently, a group of lus experts developed a standardized protocol for investigation of covid- pneumonia [ ] . to this end, they suggested to use a tablet e-connected to a wireless probe, with both wrapped in single use plastic film covers [ ] [ ] [ ] [ ] [ ] . as such, this strategy minimizes the risk of contamination and facilitates easy disinfection and sterilization of equipment ( figure ). a wireless ultrasound probe with respectively a . mhz convex probe on the right side, and a . mhz linear probe on the left one. the transducer, wrapped with a single use plastic cover to avoid contamination, is wi-fi connected with the tablet which in turn, is encircled by a plastic film. wireless ultrasound equipment to avoid contamination. a wireless ultrasound probe with respectively a . mhz convex probe on the right side, and a . mhz linear probe on the left one. the transducer, wrapped with a single use plastic cover to avoid contamination, is wi-fi connected with the tablet which in turn, is encircled by a plastic film. it has been also suggested that lus should involve two operators in the acquisition protocol in order to reduce their exposure time to covid- patients, with the first scanning and the second one storing the images. both convex and linear probes can be used. moreover, the standard lus diagnostics , , of investigation is composed by intercostal windows, seven for each side: three posteriorly along the paravertebral line; two laterally along the mid-axillary line; two anteriorly along the mid-clavicular line, these latter ones below and above the inter-nipple line, respectively. the lus in patients not able to maintain a sitting position can be performed in lateral decubitus. covid- pneumonia can be also scored for severity by lus (figure ). it has been also suggested that lus should involve two operators in the acquisition protocol in order to reduce their exposure time to covid- patients, with the first scanning and the second one storing the images. both convex and linear probes can be used. moreover, the standard lus investigation is composed by intercostal windows, seven for each side: three posteriorly along the paravertebral line; two laterally along the mid-axillary line; two anteriorly along the mid-clavicular line, these latter ones below and above the inter-nipple line, respectively. the lus in patients not able to maintain a sitting position can be performed in lateral decubitus. covid- pneumonia can be also scored for severity by lus (figure ) . the introduction of the severity score leads us to prefer lus to both swab-pcr and ct scan for the following clinical needs:  when following-up the evolution of covid- pneumonia, in situations where the use of a ct scan would expose the patient to an excess of radiation.  when monitoring longitudinally health care professionals. since it is expected that the pandemic will continue for some time, it will also be necessary to monitor medical staff. for this purpose, lus would be ideal. based on the incubation time, it would seem reasonable to repeat the survey every two weeks. ideally, preliminary lus screening would be undertaken before admission, in general, to hospital, and particularly to surgical departments. in the case of a positive lus test, ideally corroborated by hepatic and coagulation blood markers (as discussed above), the patient would be isolated and surgically treated according to covid- hospital protocol. by contrast, in the case of negative lus outcome and blood laboratory test, the patient would follow the standard route. in a department of surgery, this approach could represent a fast, sensitive, cost effective assessment, which would protect other patients and health care staff during the pandemic. finally, lus would permit the avoidance of x-rays and can be rapidly performed by the surgeons, reducing the overwhelming of the radiology services. from this point of view, the development of an e-learning lus educational program represents a matter of urgency. the introduction of the severity score leads us to prefer lus to both swab-pcr and ct scan for the following clinical needs: • when following-up the evolution of covid- pneumonia, in situations where the use of a ct scan would expose the patient to an excess of radiation. • when monitoring longitudinally health care professionals. since it is expected that the pandemic will continue for some time, it will also be necessary to monitor medical staff. for this purpose, lus would be ideal. based on the incubation time, it would seem reasonable to repeat the survey every two weeks. ideally, preliminary lus screening would be undertaken before admission, in general, to hospital, and particularly to surgical departments. in the case of a positive lus test, ideally corroborated by hepatic and coagulation blood markers (as discussed above), the patient would be isolated and surgically treated according to covid- hospital protocol. by contrast, in the case of negative lus outcome and blood laboratory test, the patient would follow the standard route. in a department of surgery, this approach could represent a fast, sensitive, cost effective assessment, which would protect other patients and health care staff during the pandemic. finally, lus would permit the avoidance of x-rays and can be rapidly performed by the surgeons, reducing the overwhelming of the radiology services. from this point of view, the development of an e-learning lus educational program represents a matter of urgency. as described above, an elevation in d-dimer levels is a common finding in patients with covid- . throughout the pandemic, several reported cases have associated this biomarker with acute dvt and/or vte. clinical suspicion of vte is thought to be higher in cases with dvt symptoms, with rapid and disproportionate hypoxemia, or acute unexplained right ventricular dysfunction [ ] . at the beginning of the pandemic, the presence of elevated d-dimer did not warrant routine ultrasound investigation. ultrasound investigation, currently used to diagnose dvt, was therefore not adopted, given the risk of transmitting infection to other patients or health care workers. however, with the subsequent introduction of wireless ultrasound probes, which can be rapidly covered in single use transparent films, has completely changed this scenario ( figure ). as such, lus is rapidly becoming a useful, cost effective, and safe diagnostic tool for identifying and clinically assessing covid- pneumonia. the first-line imaging test in the diagnostic management of patients presenting with clinically suspected dvt is compression ultrasonography (cus), a powerful ultrasound biomarker [ ] [ ] [ ] (figure ). diagnostics , , of as described above, an elevation in d-dimer levels is a common finding in patients with covid- . throughout the pandemic, several reported cases have associated this biomarker with acute dvt and/or vte. clinical suspicion of vte is thought to be higher in cases with dvt symptoms, with rapid and disproportionate hypoxemia, or acute unexplained right ventricular dysfunction [ ] . at the beginning of the pandemic, the presence of elevated d-dimer did not warrant routine ultrasound investigation. ultrasound investigation, currently used to diagnose dvt, was therefore not adopted, given the risk of transmitting infection to other patients or health care workers. however, with the subsequent introduction of wireless ultrasound probes, which can be rapidly covered in single use transparent films, has completely changed this scenario ( figure ). as such, lus is rapidly becoming a useful, cost effective, and safe diagnostic tool for identifying and clinically assessing covid- pneumonia. the first-line imaging test in the diagnostic management of patients presenting with clinically suspected dvt is compression ultrasonography (cus), a powerful ultrasound biomarker [ ] [ ] [ ] ( figure ). the ultrasound scan might include a second cus examination after to days following an initial negative cus to evaluate if a possible distal dvt has propagated to the proximal veins. single limited, serial limited, and whole-leg cus are the current imaging strategies for the diagnosis of dvt. preference for one strategy over the other differs between centers and sonographers [ ] [ ] [ ] [ ] . due to frequent association with vte, it could be reasonable to complete the lus screening protocol with cus investigation at the level of the jugular, subclavian, femoral, popliteal, and calf muscular venous segment, according to the above protocols. the addition of ultrasound venous images to the lus protocol takes just a few minutes and is able to provide fundamental prognostic and therapeutic information (figure ) . finally, taking into account all the above data for the diagnosis of covid- and the frequent vte complications, the usual dvt diagnostic algorithm could be usefully modified by means of blood and ultrasound vascular biomarkers, according to a novel flowchart illustrated in figure . the ultrasound scan might include a second cus examination after to days following an initial negative cus to evaluate if a possible distal dvt has propagated to the proximal veins. single limited, serial limited, and whole-leg cus are the current imaging strategies for the diagnosis of dvt. preference for one strategy over the other differs between centers and sonographers [ ] [ ] [ ] [ ] . due to frequent association with vte, it could be reasonable to complete the lus screening protocol with cus investigation at the level of the jugular, subclavian, femoral, popliteal, and calf muscular venous segment, according to the above protocols. the addition of ultrasound venous images to the lus protocol takes just a few minutes and is able to provide fundamental prognostic and therapeutic information (figure ) . finally, taking into account all the above data for the diagnosis of covid- and the frequent vte complications, the usual dvt diagnostic algorithm could be usefully modified by means of blood and ultrasound vascular biomarkers, according to a novel flowchart illustrated in figure . as mentioned above, both ct and lus detect subpleural consolidation areas in the course of covid- pneumonia. some authors, in the light of frequent vte complications, have raised the question as to whether these areas of consolidation might actually be indicative of segmental pulmonary embolus [ ] . to answer their question, it has recently been proposed that contrastenhanced ultrasound (ceus) be used when performing lus scans [ ] . tee et al., were able to demonstrate by means of ceus that irregular areas of subpleural consolidation at lus are avascular and therefore, most likely represent microinfarcts. conversely, consolidation of non-thrombotic origin would be seen to have some enhancement at ceus investigation. the same cannot be seen by using ct due to the superior spatial resolution of ultrasound. vascular biomarkers confirm that covid- , a disease initially thought to be exclusively an interstitial pneumonia with varying degrees of severity, can also be considered a vascular disease, especially with regards to more serious complications and causes of mortality. particularly, both ddimer and troponin appear to be very powerful prognostic markers, signaling the need for earlier and more aggressive interventions and treatments. the ultrasound imaging pattern at both lung and peripheral vascular level can also be very useful weapons that have the advantage of being able to monitor longitudinally the clinical picture, something that swab-pcr is not able to do and that ct can only pursue with significant radiation exposure. as mentioned above, both ct and lus detect subpleural consolidation areas in the course of covid- pneumonia. some authors, in the light of frequent vte complications, have raised the question as to whether these areas of consolidation might actually be indicative of segmental pulmonary embolus [ ] . to answer their question, it has recently been proposed that contrast-enhanced ultrasound (ceus) be used when performing lus scans [ ] . tee et al., were able to demonstrate by means of ceus that irregular areas of subpleural consolidation at lus are avascular and therefore, most likely represent microinfarcts. conversely, consolidation of non-thrombotic origin would be seen to have some enhancement at ceus investigation. the same cannot be seen by using ct due to the superior spatial resolution of ultrasound. vascular biomarkers confirm that covid- , a disease initially thought to be exclusively an interstitial pneumonia with varying degrees of severity, can also be considered a vascular disease, especially with regards to more serious complications and causes of mortality. particularly, both d-dimer and troponin appear to be very powerful prognostic markers, signaling the need for earlier and more aggressive interventions and treatments. the ultrasound imaging pattern at both lung and peripheral vascular level can also be very useful weapons that have the advantage of being able to monitor longitudinally the clinical picture, something that swab-pcr is not able to do and that ct can only pursue with significant radiation exposure. funding: this research received no external funding. characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention correlation of chest ct and rt-pcr testing in coronavirus disease (covid- ) in china: a report of cases artificial intelligence-enabled rapid diagnosis of patients with covid- clinically applicable ai system for accurate diagnosis, quantitative measurements, and prognosis of covid- pneumonia using computed tomography lung ultrasound for the 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identification, grading and serial follow-up of severity of lung involvement for management of patients with covid- point of care and intensive care lung ultrasound: a reference guide for practitioners during covid- point-of-care lung ultrasound findings in novel coronavirus disease- pnemoniae: a case report and potential applications during covid- outbreak chinese critical care ultrasound study group (ccusg). findings of lung ultrasonography of novel corona virus pneumonia during the - epidemic prévalence de la thrombose veineuse diagnostiquée par échographie-doppler des membres inférieurs dans la suspicion d'embolie pulmonaire et dans l'embolie pulmonaire confirmée risk of deep vein thrombosis following a single negative whole-leg compression ultrasound: a systematic review and meta-analysis diagnostic accuracy of three ultrasonography strategies for deep vein thrombosis of the lower extremity: a systematic review and meta-analysis advances in the diagnosis of venous thromboembolism: a literature review are subpleural consolidations indicators for segmental pulmonary embolism in covid- ? contrast-enhanced ultrasound (ceus) of the lung reveals multiple areas of microthrombi in a covid- patient this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the author thanks basel plus srl milan, italy, for the free loan of wireless ultrasound equipment during the covid- pandemic. the author declares no conflicts of interest. the author thanks basel plus srl milan, italy, for the free loan of wireless ultrasound equipment during the covid- pandemic. the author declares no conflict of interest.diagnostics , , key: cord- - vk vcgk authors: antúnez‐montes, omar yassef title: proposal to unify the colorimetric triage system with the standardized lung ultrasound score for covid‐ date: - - journal: j ultrasound med doi: . /jum. sha: doc_id: cord_uid: vk vcgk nan to the editor: i read with great interest the findings published by soldati et al, who proposed a magnificent and simple standardization of the lesions captured by pulmonary ultrasound (us) for patients with coronavirus disease . this approach opens the possibilities of treatment in out-of-hospital settings such as care by highly trained personnel who work in ground or air ambulances or remote locations and those with limited resources such as countries with emerging economies. the scoring levels proposed according to the characteristics of the lung lesions are correlated with our colorimetric triage proposal and can be linked together in a joint classification system, as proposed below. we recently published a proposal for us triage based on the characteristic lesion patterns caused by covid- (severe respiratory syndrome coronavirus ) that are identifiable by lung ultrasound (lus) and the possible type of clinical presentation of a patient with or without respiratory symptoms, without the need for a confirmatory test when interviewing the patient at a geographic location with an accelerated contagion mechanism. the triage is divided into colors (green, yellow, and red), making for an intuitive and rapid classification of the severity of the patients as follows: this system allows professionals to determine the severity even in the prehospital phase because of the acknowledgment of any suggestive imaging that is highly suspicious of severity. with portable or pocket devices at the patient's bedside, the exploration allows a real-time reassessment of the condition of patients in their home, the ed, the icu, or field hospitals, reducing time, money, and the risk of nosocomial exposure to the virus, helping prevent saturation of the medical service sector, as is happening already in the rest of the world, especially in developing economies and those lacking resources. the point-of-care ultrasound (pocus) lung scan has the versatility of being reproduced as many times as necessary with immediate results, having the opportunity to change the triage color at the moment, reclassifying the severity or improvement of the disease. this pocus lung triage can help professionals identify low-risk (green) cases at first contact, which can lead to considering them "negative by lus" and testing them, and the patients can be put in isolation; those "suggestive or positive by lus" (yellow and red) with abnormal patterns ought to be evaluated in the ed. we suggest that health care workers, particularly those operating in low-to middle-resource settings, unify the lus covid proposed score with the colorimetric triage, as exemplified in figures and . . green: those confirmed or suspected covid- cases with good clinical conditions and an lus score of in most lung areas or in some areas. these patients are at low risk and can be monitored at home. . yellow: those confirmed or suspected patients with medium risk according to clinical symptoms and an lus score of in most areas (those with and irregular and indented pleural line with vertical artifacts will have a score of ) or in some areas (broken pleural line, subpleural consolidation, and patchy areas of white lung). these patients have a moderate risk and should be evaluated in the hospital, unless accurate and frequent home medical services can be guaranteed . red: those moderately to seriously ill patients evaluated by health care workers with an lus score of or in most areas (mainly in the middle and basal areas of the posterior thorax). these patients are at high risk and should be quickly evaluated in the hospital and admitted. the proposed unification of the criteria maintains the simplicity of both systems and strengthens them by providing diagnostic tools and allowing classification and rapid dispatch of patients to other areas. it can provide opportunities for participation of a wide variety of professionals in the er and icu and allow physicians from different settings to speak the same language in observation areas, field hospitals, remote rural areas with a lack of resources, and ground and air ambulances. in summary, a green triage will indicate a patient with mild illness and a pocus lung score of in almost all areas: observe at home. a yellow triage will indicate a patient with moderate disease with a possible transition to severe disease and a pocus lung score of in most areas or in some: close observation at home if it can be guaranteed; otherwise, assess in the hospital. a red triage will indicate a patient with serious or critical illness and yield a pocus lung score of or in most areas: provide hospital care. the versatility of this system allows the identification of confirmed or suspected patients due to the type of lung injury captured during the lung pocus exploration and clinically suspicious presentations at geographic locations with an accelerated contagion curve for covid- . omar yassef antúnez-montes, md proposal for international standardization of the use of lung ultrasound for patients with covid- : a simple, quantitative, reproducible method routine use of point-of-care lung ultrasound during the covid- pandemic key: cord- - zhe ejy authors: zhu, shu-ting; tao, fang-yi; xu, jing-hong; liao, shu-sheng; shen, chuan-li; shi, bin-bin; liang, zeng-hui; li, qiao title: utility of point-of-care lung ultrasound for clinical classification of covid- date: - - journal: ultrasound med biol doi: . /j.ultrasmedbio. . . sha: doc_id: cord_uid: zhe ejy in this study, the utility of point-of-care lung ultrasound for the clinical classification of coronavirus disease (covid- ) was prospectively assessed. twenty-seven adult patients with covid- underwent bedside lung ultrasonography (lus) examinations three times within the first two weeks of admission to the isolation ward. we divided the exams into three groups (i.e., moderate group, severe group, and critically ill group). lung scores were calculated as the sum of points. a rank sum test and bivariate correlation analysis were carried out to determine the correlation between lus on admission and the clinical classification of covid- . there were dramatic differences in lus (p< . ) among the three groups, and lus scores (r= . ) correlated positively with clinical severity (p< . ). in addition, moderate, severe, and critically ill patients were more likely to have low (≤ ), medium ( - ), and high scores (≥ ), respectively. this study provides stratification criteria of lus scores to assist in quantitatively evaluating covid- patients. covid- , which is caused by severe acute respiratory syndrome corona virus (sars-cov- ), is a new public health crisis threatening the world. the disease is transmitted primarily via direct contact or through droplets generated by an infected individual when coughing or sneezing (rothe et al. ). sars-cov- binds to angiotensin receptor (ace ) expressed by cells of the lung, making the lung the primary site of damage (singhal ) . the most frequent symptoms of covid- pneumonia are fever, cough, and fatigue; other symptoms include sore throat, myalgia, hemoptysis, and dyspnea. these symptoms are similar to those of other respiratory infections. interestingly, the severity of covid- varies, ranging from an asymptomatic state to acute respiratory distress syndrome and multiorgan dysfunction (huang et al. ； ren et al. . therefore, effective therapies warrant the specific identification of disease severity. lus has been rapidly developed in the last few years. although it was originally proposed for a range of clinical applications in the s, the technique has spread mainly in the last decade. currently, acute respiratory failure, circulatory failure and cardiac arrest can be assessed by lus. lus can also be utilized for quantitative assessment of lung aeration and may be a useful tool to guide mechanical ventilation (mojoli et al. ) . moreover, prior research has shown that lus affected clinical decisions for up to % of intensive care unit patients (xirouchaki et al. ) . the unique benefits of lus in the current context include bedside feasibility, no radiation, low cost and easy application (see et al. ). indeed, due to its ready availability at the bedside, lus may play a pivotal role in monitoring serial changes in covid- pneumonia. the current clinical evidence strongly suggests the potential diagnostic accuracy of lus for covid- (volpicelli and gargani ) . previous studies have reported that bedside lus correlates with ct findings in adults with covid- pneumonia (poggiali et al. ) . although the latter technique is considered one of the primary imagological criteria for the diagnosis of covid- , the disadvantages of radiographic examinations make lus a complementary method for covid- patients. some investigators suggest that lung abnormalities in the pediatric population and pregnant women with covid- can be effectively detected by radiation-free lus (buonsenso et al. c ；denina et al. ). in addition, ultrasound, especially the use of pocket devices, is considered relatively safer because it reduces the exposure of health care workers to infected patients . early studies suggested that the irregular pleural line with small subpleural consolidations, white lung, confluents and irregular vertical artifacts (b-lines) are ultrasonic manifestations of covid- pneumonia , and lus scores have been used for the identification of patients with lung involvement and disease severity (vetrugno et al. ) . however, such studies are mostly subject case reports, and further research is lacking. thus, the present study was undertaken to investigate correlations between lus and the severity of covid- , aiming to clarify the diagnostic and monitoring role of lus in covid- pneumonia. the prospective observational study included patients with imaging signs of covid- pneumonia (moderate and above) in the isolation ward of the first affiliated hospital of wen zhou medical university from february st , , to march st , . all patients underwent three bedside lus scans within the first two weeks of admission. we ensured that all patients were admitted in the early stages of covid- because patients with confirmed covid- are immediately admitted to the isolation ward in china. the interval between each ultrasound examination was three to five days. the study protocol was reviewed and approved by the ethics committee of the first affiliated hospital of wen zhou medical university. the next of kin of all subjects provided informed consent for participation in this study. exclusion criteria: ( ) patients with mild disease who lacked imaging signs of pneumonia; ( ) patients with any conditions that interfered with lus assessment, such as obstruction on the scan area and chest deformity; ( ) patients receiving examinations fewer than three times due to a short duration of hospitalization; ( ) patients lacking clinical data. a bedside lus was performed by a trained sonographer using a c - -rs transducer ( . - mhz), ge vivid iq. set (ge healthcare, wuxi, jiangsu, china). the study depth was set to approximately - cm (depending on the body habitus). the sonographer wore the standard personal protections as per who indications and disinfected the probe with % hydrogen peroxide after the examination. ten ( anterior, lateral, and posterior) lung zones were scanned in sequence ( figure ). the anterior, lateral and posterior zones were divided by the anterior and posterior axillary lines. the anterior and lateral regions were divided into upper and lower parts, respectively, by the th rib. scanning started in the anterior zone, descending from the clavicle to the th rib (zone a ) and then downwards to the upper surface of the abdominal organs (zone a ). after that, the scan proceeded down from the axilla to the th rib (zone l ) and then to the upper margin of the abdominal organs (zone l ). we examined the posterior (zone p) and scanned the abdominal contents from the upper lung boundary. the contralateral thoracic cavity was then examined. the anterolateral parts of the chest wall were examined in the supine position and the posterior parts either in the lateral or seated position. this study had no impact on the treatment of the patients. the sonographic signs of lung aeration were classified into the following four scoring patterns (soldati et al. a) (figure ): ( ) score : the presence of lung sliding, with a lines or isolated b lines (less than or equal to two) and the pleural line continuous and regular; ( ) score : the pleural line was indented, with multiple spaced b lines of an interval of approximately mm; ( ) score : the pleural line was broken, with coalescent b lines at an interval of ≤ mm; ( ) score : dense and largely extended white lung with or without larger consolidations. for a given region of interest, points were allocated according to the worst ultrasound score pattern observed. the lung scores were calculated as the sum of points (the highest score was ). statistical analysis was performed with spss . software (spss, chicago, il, usa). we divided the exams into three groups (i.e., moderate group, severe group, and critically ill group) according to guidelines on diagnosis and treatment of novel coronavirus pneumonia (trial, seventh edition) at each examination (table ) . clinical data, including the lus score, blood biochemistry (alanine aminotransferase, aspartate aminotransferase, r-glutamyl transferase, creatinine, and blood urea nitrogen), routine blood examinations (leukocyte count and lymphocyte count), and blood coagulation function (d-dimer), were monitored synchronously. the distribution of lus scores among the three groups is provided. in addition, categorical variables with p< . according to the spearman test were analyzed. such categorical variables are expressed as percentages, and results were compared with those of the kruskal-wallis test or wilcoxon test, as appropriate. a p-value less than . was considered statistically significant. of the patients with covid- enrolled in our study, ( %) were male and ( %) female, with an average age of . ± . years (range, - years). the distribution of lus scores for the three covid- groups is summarized in figure . thirty-five exams ( %) were classified into the moderate group, ( %) into the severe group, and ( %) into the critically ill group. the mean lus scores of the critically ill, severe and moderate groups were . ± . (range, - ), . ± . (range, - ), and . ± . (range, - ) , respectively. according to spearman correlation test results (table ) then, we divided the lus scores into three scales (low ≤ ; <medium< ; high ≥ ) and compared them with the severity of covid- disease ( table ). the wilcoxon test results (p<. ) showed that the distribution of severity among the low-lus, medium-lus and high-lus groups differed. in addition, critically ill patients have a high proportion in the high-lus group ( %), with a lower proportion in the medium-lu and low-lus group ( . %, . %). moderate, severity and critically ill patients are more likely to be present in the low-lus, medium-lus and high-lus groups, respectively. according to kruskal-wallis test results, lymphocytopenia (p< . ), leukocytosis (p= . ), increased ast (p= . ), increased rgt (p= . ), and increased bun (p= . ) were more commonly observed in the critically ill group (table ) . however, no significant difference in d-dimer levels was observed among the three groups. the spread of the covid- around the world is posing a tremendous danger to human health in and puts unprecedented pressure on health care workers. the number of cases continues to rise, and more than million people have been infected thus far. therefore, effective therapies warrant the specific identification of disease severity, as the severity of the disease varies according to patients' symptoms and imaging characteristics. however, limitations of radiological imaging are obvious: ( ) it is dangerous and time-consuming because of the transport of critically ill patients followed by the necessary decontamination procedures (peng et al. ); ( ) it is not suitable for pregnant women and children to receive repeated examinations due to the radioactivity involved (yoon et al. ) ; and ( ) the depiction based on a portable device does not always correlate with the clinical picture. conversely, lus examinations do not have the above limitations, and changes in pulmonary and cardiac signs can be observed by bedside ultrasound in real time. in a previous observational study, lus was considered a useful tool to assess and monitor lung involvement in pregnant women with covid- and even played a significant role in treatment decisions (buonsenso et al. c) . as a result, lus is probably regarded as the best complement to radiography of the chest (pierce ；see et al. . ultrasound is an appropriate tool for the management of respiratory failure and lung injury caused by covid- because histopathological progression of covid- pneumonia occurs in the distal region of the lung, as characterized by alveolar injury and edema, interstitial thickening, and gravitational enhancement (soldati et al. b) . several lus patterns of covid- pneumonia described in the literature include separate and coalescent b-lines, irregular and fragmented pleural lines, and small peripheral consolidations. these lus patterns were confirmed in this study as well. accordingly, some previous articles strongly emphasize the importance of bedside lus for the diagnosis and clinical management of covid- in the novel covid- era. however, there is little further research on whether lus can quantitatively assess the severity of this disease. in this study, we used lus scores of points to explore the applicability of the technique for covid- rather than the points suggested by soldati et al. (soldati et al. a ). the two evaluation methods are essentially the same, with the -point lus score dividing the posterior (zone p) into three sections. however, as a -point scan could be completed in a shorter time, it would be extremely serviceable for intensive care unit patients. the results showed that the lus score correlated highly positively with clinical severity, demonstrating the potential of lus for quantitative management of covid- . we first found that moderate, severe, and critically ill patients were more likely to have low lus, medium lus and high lus scores, respectively. this kind of classification of lus scores can effectively stratify covid- pneumonia severity and helpfully guide clinical monitoring. in addition, lymphocytopenia (p< . ) and leukocytosis have been reported to occur as the disease progressed (cheng kb et al. ) , as verified in the present research. ast, rgt, and bun levels correlated weakly with covid- severity, and their distributions were different in the three covid- groups. our study has certain limitations. first, our sample size was small. to better evaluate the utility of lus in the management of patients with covid- , future studies with a larger number of patients are needed. second, multiple lus exams were performed for the same patients, resulting in the inclusion of independent exams; this is because the total number of cases in this study was very small in the early stages of the epidemic. this situation may have caused statistical error but did not change the final conclusion. third, the lack of clinical outcome (death, intensive care admission, ventilation) was also a limitation. as a result, using lus to predict the risk for intensive care unit admission and death, as the research of nicola et al.， was not involved (bonadia et al. ). finally, our study was a cross-sectional study, which can only indicate whether lus scores are highly related to the severity of covid- but cannot provide prognostic information. in this study, a significant correlation was found between lus scores, leukocytes, lymphocytes and clinical classification of covid- . we also obtained stratification criteria of lus scores for covid- . although further research is needed, the findings expand the applications of ultrasound in covid- from the complementary point of care to severity stratification, which will be helpful for guiding clinicians in accurate diagnosis and treatment outcome follow-up on patients with covid . lung ultrasound findings are associated with mortality and need for intensive care admission in covid- patients evaluated in the emergency department covid- outbreak: less stethoscope, more ultrasound point-of-care lung ultrasound findings in novel coronavirus disease- pnemoniae: a case report and potential applications during covid- outbreak clinical role of lung ultrasound for diagnosis and monitoring of covid- pneumonia in pregnant women clinical characteristics of patients with common and severe type coronavirus disease lung ultrasound in children with covid- clinical features of patients infected with novel coronavirus in lung ultrasound for critically ill patients critical care ultrasound study g. findings of lung ultrasonography of novel corona virus pneumonia during the - epidemic clarifying the role of lung ultrasonography in covid- respiratory disease can lung us help critical care clinicians in the early diagnosis of novel coronavirus (covid- ) pneumonia? radiology identification of a novel coronavirus causing severe pneumonia in human: a descriptive study transmission of -ncov infection from an asymptomatic contact in germany chest radiography versus lung ultrasound for identification of acute respiratory distress syndrome: a retrospective observational study a review of coronavirus disease- (covid- ) proposal for international standardization of the use of lung ultrasound for patients with covid- : a simple, quantitative, reproducible method is there a role for lung ultrasound during the covid- pandemic? our italian experience using lung ultrasound for identification, grading and serial follow-up of severity of lung involvement for management of patients with covid- sonographic signs and patterns of covid- pneumonia updated understanding of the outbreak of novel coronavirus ( -ncov) in wuhan impact of lung ultrasound on clinical decision making in critically ill patients chest radiographic and ct findings of the novel coronavirus disease (covid- ): analysis of nine patients treated in korea the authors would like to thank all the emergency doctors and nurses of their hospital for the help and energy in coping with this difficult public health crisis. the authors declare that they have no conflicts of interest. key: cord- -ugmv om authors: pare, joseph r.; camelo, ingrid; mayo, kelly c.; leo, megan m.; dugas, julianne n.; nelson, kerrie p.; baker, william e.; shareef, faizah; mitchell, patricia m.; schechter-perkins, elissa m. title: point-of-care lung ultrasound is more sensitive than chest radiograph for evaluation of covid- date: - - journal: west j emerg med doi: . /westjem. . . sha: doc_id: cord_uid: ugmv om introduction: current recommendations for diagnostic imaging for moderately to severely ill patients with suspected coronavirus disease (covid- ) include chest radiograph (cxr). our primary objective was to determine whether lung ultrasound (lus) b-lines, when excluding patients with alternative etiologies for b-lines, are more sensitive for the associated diagnosis of covid- than cxr. methods: this was a retrospective cohort study of all patients who presented to a single, academic emergency department in the united states between march and april , , and received lus, cxr, and viral testing for covid- as part of their diagnostic evaluation. the primary objective was to estimate the test characteristics of both lus b-lines and cxr for the associated diagnosis of covid- . our secondary objective was to evaluate the proportion of patients with covid- that have secondary lus findings of pleural abnormalities and subpleural consolidations. results: we identified patients who underwent both lus and cxr and were tested for covid- . of these, / ( %) tested positive. lus was more sensitive ( . %, % confidence interval (ci), . – . ) for the associated diagnosis of covid- than cxr ( . %, % ci, . – . ; p = . ). lus and cxr specificity were . % ( % ci, . – . ) and . % ( % ci, . – . ), respectively (p = . ). secondary lus findings of patients with covid- demonstrated / ( . %) had pleural abnormalities and / ( %) had subpleural consolidations. conclusion: among patients who underwent lus and cxr, lus was found to have a higher sensitivity than cxr for the evaluation of covid- . this data could have important implications as an aid in the diagnostic evaluation of covid- , particularly where viral testing is not available or restricted. if generalizable, future directions would include defining how to incorporate lus into clinical management and its role in screening lower-risk populations. novel coronavirus, sars-cov- , is responsible for causing the coronavirus disease . with an estimated case fatality rate of %, covid- has resulted in over , deaths worldwide to date. covid- 's mortality pocus is more sensitive than cxr for evaluation of pare et al. what do we already know about this issue? lung ultrasound (lus) has been shown to outperform chest radiograph (cxr) in its ability to detect abnormalities with non-coronavirus disease (covid- ) pulmonary infections. what was the research question? to determine if b-lines detected by lus are more sensitive for the associated diagnosis of covid- than an abnormal cxr. what was the major finding of the study? b-lines detected by lus were more sensitive for the associated diagnosis of covid- than an abnormal cxr. in locations where viral testing is not available or has significant delays, lus may provide important information for the evaluation of suspected covid- . is primarily due to lung injury resulting in acute respiratory distress syndrome (ards). the definition of ards has changed over time; however, using the berlin definition it would include acute bilateral lung injury in the absence of fluid overload, causing hypoxemia and respiratory failure. physicians evaluating patients may wish to order radiographic imaging to screen for findings of covid- , evaluate severity of pulmonary involvement, or assess for alternative etiologies of illness. radiographic results may alter the treating physician's concern for covid- thereby guiding patient counseling, or supporting clinical choices such as hospitalization, the need for closer follow-up, or anticipating complications of the disease. the american college of radiology (acr) recommended the use of portable chest radiograph (cxr) when medically necessary for patients with suspected or known covid- , which does not include screening purposes. however, it is estimated that portable cxr is only % sensitive for findings of covid- . when compared to cxr, lung ultrasound (lus) may offer improved diagnostic accuracy in the evaluation of patients with suspected covid- pneumonia. lus has a high sensitivity and often out-performs cxr in the diagnosis of other pulmonary infections. lus findings for covid- have been reported in the literature and include b-lines, pleural abnormalities, and subpleural consolidations. [ ] [ ] [ ] evaluation of b-lines is already within the scope of practice for emergency physicians (ep), and instruction in interpreting lus is part of current residency education standards. lus is a safe, readily available tool that can be employed by eps to provide real-time clinical assessment for covid- . lab testing utility is hampered by delays in results, accuracy, and availability. cxr may miss pulmonary disease, and the acr has cautioned against routine screening with chest computed tomography (ct), citing concerns of poor specificity of ground-glass opacities for covid- as well as infection control procedures necessary to decontaminate the ct scanner. regarding infection control procedures, we expect that portable (or hand-held) ultrasounds would be easier to decontaminate than portable cxr machines or ct suites. our primary aim was to determine whether detection of b-lines on lus, among patients without alternative etiologies for their presence, is more sensitive for the diagnosis of covid- than cxr. our secondary aim was to evaluate the proportion of patients with covid- that have secondary lus findings of pleural abnormalities and subpleural consolidations. this was a retrospective, observational, cohort study of patients undergoing covid- testing (based on real-time reverse transcriptase-polymerase chain reaction [rt-pcr] of nasopharyngeal sampling performed on an assay developed by the center for regenerative medicine at boston university, operating under an emergency use authorization], who also had both diagnostic lus and cxr for the evaluation of covid- in the emergency department (ed). this study had institutional review board approval and was conducted based on standards for reporting of diagnostic accuracy studies (stard) guidelines and best practices for retrospective reviews. this investigation was performed at a large urban academic ed in the united states with > , visits per year. the ed is associated with an emergency medicine residency and clinical ultrasound fellowship, and has six dedicated portable ultrasound machines (philips sparq, wayne, pa; and mindray te , arnold, md). all ultrasound studies are transferred wirelessly and stored in qpath (telexy, blaine, wa). there was no formal education for lus specific to covid- ; however, all physicians have had structured training in lus. all physicians were provided literature from a small study of patients with covid- that had lung zones evaluated with ultrasound, which found % of patients had abnormal lus findings at the posterior lung bases. when performing point-of-care ultrasound in the clinical setting, all eps at our institution are required to archive at least one image that is representative of their findings. pocus is more sensitive than cxr for evaluation of covid- all ultrasound studies completed in the ed between march , -april , , were reviewed for lus imaging. we reviewed the electronic health record (ehr), epic (verona, wi) to determine whether covid- testing was performed. subjects were included for evaluation if they had a covid- test performed during the index hospitalization or within two weeks of the lus examination. at the hospital during this time period, covid- testing was performed only on people with symptoms concerning for disease, and no routine screening practices were in place. however, performance of viral testing was at physician discretion, and those without viral testing were excluded from analysis. we also excluded subjects if they did not have a cxr. lastly, based on ehr review from patient history or physician documentation, patients were excluded if they had reasons for alternative causes of b-lines (congestive heart failure, renal disease leading to volume overload, or underlying lung disease), as it would not be possible to determine the etiology of the abnormal ultrasound results. all lung ultrasounds were reviewed by two expert eps, both with clinical ultrasound fellowship training (jrp and kcm), who were blinded to covid- results. when disagreements occurred, a third ultrasound fellowship-trained, blinded independent expert reviewer adjudicated (mml). lus were scored as positive or negative after review of all images. subjects were considered to have a positive lus if any b-lines were detected. the reviewers further graded positive ultrasounds as having - b-lines or ≥ b-lines. if b-lines coalesced, the score was graded as ≥ b-lines if the area of b-lines took up ≥ % of the intercostal space. although ground-glass opacities can manifest as thinner b-lines < mm apart, we allowed for percentage grading to account for coalescing in addition to "light beam" artifact, which is a broader, band-shaped artifact described in covid- . because covid- is reported to cause focal and diffuse lung disease, we chose the image with the most b-lines detected at one intercostal space to score each patient. the images were subsequently evaluated for subpleural consolidations and pleural abnormalities ( figure and online supplemental videos a-e). we defined subpleural consolidations as an area of hypoechoic focus at the pleural line. these areas may be associated with increased b-lines originating from this area of hypoechoic focus. for pleural abnormalities we defined this as a) loss of pleural line echogenicity; b) irregular contour of the pleural line; or c) areas that appeared > millimeters in thickness by visual estimation. secondary lus findings were determined by a consensus of all reviewers. finalized cxr reports were recorded. we classified cxrs as positive if the report included infection in the differential, as defined by words such as opacity, consolidation, or airspace disease. cxrs were classified as negative if no abnormality was noted, an abnormality was noted but attributed to a non-infectious etiology, or was inconclusive for infectious process. after lus scoring and data collection, clinical data including demographics, co-morbidities, vital signs, and laboratory values, was collected from the ehr by two investigators (jrp and fs) using a standardized abstraction technique and entered into redcap. the primary outcome measure was the sensitivity of lus compared to cxr for the detection of covid- , using the rt-pcr laboratory test as the reference standard. secondary outcome measures were the proportion of additional secondary lus findings (pleural abnormalities or subpleural consolidation) detected. a sample size of patients with an estimated sensitivity of % for cxr and % for lus yields % power with an alpha of . assuming % disease prevalence. we used an estimated sensitivity of % based on results of cxr findings in influenza, as the referenced paper of % was not available at the time this study was designed. , we compared sensitivities of lus and cxr using a two-sided mcnemar's test. patient demographics were evaluated with descriptive statistics, fisher's exact tests, wilcoxon sum-ranked test, chi-squared tests, and welch's t-test. inter-rater reliability for pocus is more sensitive than cxr for evaluation of covid- pare et al. the primary outcome between the two primary reviewers was assessed by cohen's kappa. a total of ultrasound studies were completed over the -day study period (figure ). of these, had lus performed. among these, met inclusion criteria, and / tested positive for covid- by rt-pcr ( %). four patients admitted with initial negative results were retested, and two were found to be positive. these two subjects were classified in the total patients with covid- . table describes the demographic and clinical information of the included patients. the sensitivity and specificity of b-lines on lus associated with covid- were . % ( % ci, . - . ) and . % ( % ci, . - . ), respectively. the association between cxr and covid- results had a sensitivity and specificity (appendix) of . % ( % ci, . - . ) and . % ( % ci, . - . ). lus was more sensitive than cxr for the association of pulmonary findings of covid- (p = . ). while there was a trend for cxr to be more specific for the associated diagnosis of covid- , this was not found to be statistically significant (p = . ). additional lus test characteristics are provided in table . cohen's kappa for interrater agreement between the two expert lus reviewers for the primary outcome was strong (κ = . , % ci, . - . ). there were only three cases out of where there was disagreement on the primary outcome between the two reviewers. these involved cases where b-lines were more subtle. b-lines were more frequently detected in patients with covid- ( / patients with covid- and / patients without, p < . ). of the patients with confirmed covid- infection, had pleural abnormalities ( . %) and had subpleural consolidations ( %). of the subjects without covid- , three had pleural irregularities ( . %) and two had subpleural consolidations ( . %). there was a mean of . lus images recorded per patient, which was not significantly different between covid- results, and a median of lus images taken per patient. images were more frequently obtained with a curvilinear probe / , ( %), than the phased array probe, / ( . %). of the lus studies, / ( . %) were completed by residents or physician assistants, / ( . %) by an ultrasound fellow, / ( . %) by ultrasound faculty, and / ( . %) by non-fellowship trained eps. of the cxrs performed, / ( . %) were performed as portable examinations. the one -view cxr was a false negative. to our knowledge this is the first study to evaluate the test characteristics of lus for covid- . we also are the first to compare the diagnostic performance of lus to the more conventional use of cxr. although preliminary, this work provides important results for the application of lus for detection of covid- . this investigation offers compelling evidence that b-lines detected by lus are more frequently associated with covid- than an abnormal cxr. this finding is in line with the performance of lus in other pulmonary disease entities. , we used rt-pcr as the reference standard for diagnosis of covid- . however, it is known that the test characteristics of rt-pcr are dependent on collection technique, timing in disease process, and processing technique. in our population there were two negative rt-pcr tests that were positive on repeat testing. both patients with initially negative rt-pcr tests had positive lus findings; thus, it is possible lus is more sensitive than rt-pcr for covid- . further research would be necessary to substantiate this theory. our study reports a sensitivity of % for cxr, which is lower than the reported % for portable cxr. it is unknown whether the radiologists in that previous study were blinded, and it is also unclear how body mass index or other variables may have resulted in our reported lower sensitivity for cxr. it is unknown how two-view cxrs would perform for the detection of lung involvement from covid- , as it might evidence that lus is more sensitive for the associated diagnosis of covid- than cxr has potential global implications. these results may be of particular importance to settings with significant delays in viral rt-pcr testing, settings in which rt-pcr testing is restricted or not available, or where cxr or ct are not accessible. further scientific investigation could determine how lus at the time of initial evaluation may aid the physician in counseling patients with regard to findings suggestive of covid- . our investigation provides important new data for the role of lus relative to cxr for patients being evaluated for covid- . conversely, lus did have a lower specificity than cxr. as noted, - b-lines may be non-pathologic; however, only one patient in this study was found to have - b-lines that did in fact have covid- . it is possible that using lus with only one or two b-lines to direct care for patients suspected of having covid- could lead to unnecessary isolation or further medical testing. additionally, there are other etiologies for lus b-lines, and our results will likely be most valuable when interpreted in the clinical context of the medical evaluation. physicians should have an estimation of pretest probability when performing and interpreting diagnostic testing, and lus for covid- is no exception to this rule. in this population with a high prevalence of disease (as judged by rt-pcr results), a positive lus was a good predictor of disease. further work is necessary to better delineate how to incorporate these findings into screening for asymptomatic patients, diagnostic algorithms, and clinical management strategies. since this was a retrospective study, it is unclear why physicians chose to perform both cxr and lus. it is also unknown whether the result of either diagnostic test affected the physician's choice to perform the other test. additionally, the treating physician was not blinded to the patient's history, exam, or cxr. it is possible that knowledge of these data points would change the extent to which the physician performed their lus. despite this, there were a similar number of images recorded for patients with and without covid- . over half of the studies performed were performed by non-fellowship trained eps. further work is needed to validate these findings in a population of eps without fellowship training. identification of b-lines is a core skill of eps; therefore, we anticipate the findings would be similar. another limitation was the use of rt-pcr for the diagnosis of covid- , as it likely misses some cases. some of the tests classified as false positive may have actually been true positives. rt-pcr was chosen as the reference standard since that is what is currently used at our, and most, institutions nationally, and viral culture is not feasible at this time. inconclusive cxrs were scored as negative, which might favor the analysis toward lus. this was done, in accordance with stard guidelines, because inconclusive cxrs do not provide diagnostic guidance in real time. we used b-lines in this study as a reliable marker for covid- . it is possible a comprehensive evaluation including pleural abnormalities and subpleural consolidations would improve the test characteristics of lus. we chose to only include b-lines for our assessment as b-lines are already familiar to eps and would be easier to implement. we included any number of b-lines (one or more) as abnormal; however, it has been reported - b-lines may not be pathologic. we selected this approach to maximize the sensitivity of lus at the cost of specificity. this investigation provides evidence that lus is more sensitive for the associated diagnosis of covid- than cxr when excluding patients with other expected causes of b-lines. this work could have important implications where viral testing is restricted or alternative diagnostic imaging is not available. further work may find lus for the evaluation and care of covid- patients to be of clinical benefit and may also have a role to guide testing as screening and contact tracing are expanded. the many estimates of the covid- case fatality rate clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china acute respiratory distress syndrome: the berlin definition american college of radiology. acr recommendations for the use of chest radiography and computed tomography (ct) for available at: https://www. acr.org/advocacy-and-economics/acr-position-statements/ recommendations-for-chest-radiography-and-ct-for-suspected-covid -infection frequency and distribution of chest radiographic findings in covid- positive patients accuracy of lung ultrasonography versus chest radiography for the diagnosis of adult community-acquired pneumonia: review of the literature and meta-analysis can lung us help critical care clinicians in the early diagnosis of novel coronavirus (covid- ) pneumonia? findings of lung ultrasonography of novel corona virus pneumonia during the - epidemic a preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (covid- ) diagnosing acute heart failure in the emergency department: a systematic review and metaanalysis guidelines for reporting diagnostic accuracy studies: explanation and elaboration relevance of lung ultrasound in the diagnosis of acute respiratory failure: the blue protocol what's new in lung ultrasound during the covid- pandemic transforming growth factor beta- as a predictor of fibrosis in tuberculous pleurisy pulmonary imaging of pandemic influenza h n infection: relationship between clinical presentation and disease burden on chest radiography and ct a coefficient of agreement for nominal scales key: cord- -prczsz m authors: yassa, murat; mutlu, memiş ali; kalafat, erkan; birol, pınar; yirmibeş, cihangir; tekin, arzu bilge; sandal, kemal; ayanoğlu, esra; yassa, mahmut; kılınç, ceyhun; tug, niyazi title: how to perform and interpret the lung ultrasound by the obstetricians in pregnant women during the sars-cov- pandemic date: - - journal: turk j obstet gynecol doi: . /tjod.galenos. . sha: doc_id: cord_uid: prczsz m objective: evidence for the use of lung ultrasound scan (lus) examinations in coronavirus pneumonia is rapidly growing. the safe and non-ionizing nature of lus drew attention, particularly for pregnant women. this study aimed to contribute to the interpretation of lus findings in pregnant women for the obstetricians. materials and methods: lus was performed to pregnant women suspected of or diagnosed as having severe acute respiratory syndrome coronavirus- (sars-cov- ) in the first hours of admission. fourteen areas ( posterior, lateral, and anterior) were scanned per patient for at least seconds along the indicated anatomical landmarks. the scan was performed in supine, right-sided and left-sided positions, respectively. each area was given a score between and according to the specific pattern. results: in this study, still images and videoclips that enabled dynamic and real-time evaluation were provided. pleural line assessment, physiologic a-lines, pathologic b-lines, light beam pattern, white lung pattern, and specific patterns for quick recognition and evaluation are described. conclusion: the potential advantages and limitations of lus and its areas of use for obstetricians are discussed. lus is a promising supplementary imaging tool during the sars-cov- pandemic. it is easy to perform and may be feasible in the hands of obstetricians after a brief didactic course. it may be a firstline imaging modality for pregnant women. chest computed tomography (ct) is the gold standard in the diagnosis of coronavirus diseases- (covid- ) pneumonia. the prominent features of covid- are subpleural, ground-glass consolidative pulmonary opacities ( , ) . however, ct is relatively expensive, not feasible for monitoring and patients admitted to the intensive care unit, has an ionizing radiation nature and carries the risk of transmission during transportation ( ) . by contrast, lung ultrasound scanning (lus) is easy to perform, has a non-ionizing nature, and has the advantages of bed-side application and thus is well suited for monitoring patients ( ) ( ) ( ) ( ) . its interpretation is accepted as relatively easy because it is mainly based on pattern recognition and provides real-time dynamic images ( , ) . lus has been traditionally used by nonradiologists as an adjunctive imaging tool ( ) . pulmonologists, emergency medicine physicians, thoracic and cardiac surgeons often benefit from lus in the management of traumatic conditions and intraoperative situations ( ) . obstetricians also use ultrasound liberally in their routine clinical practice. practically, the examination of the maternal lungs immediately after obstetric sonographic evaluation could be feasible for obstetricians, basically to ascertain the presence or absence of normality and specific patterns, and thus to determine the need for further multidisciplinary management ( ) . the attenuation of sound waves by the lung and bone tissues limits the use of lus in the diagnosis of central lung diseases; therefore, lus mainly targets artifacts that originate from peripulmonary lesions to reach a diagnosis ( ) . changes in the lung parenchyma following covid- pneumonia begin in the distal regions and progress proximally ( ) . lesions are mostly located in the posterior and inferior fields of both lungs ( ) . this feature makes lus non-inferior to ct in the pandemic setting compared with other respiratory disorders. the pathologic progression of pneumonia of covid- provides credibility to a surface imaging modality such as lus ( ) . herein, it was aimed to provide a didactical, pictorial review to assist obstetricians in the multidisciplinary management of pregnant women suspected or diagnosed as haing covid- infection. in this educational, non-systematic pictorial review, all lung images and videoclips were obtained with a dedicated machine [esaote s.p.a., italy; manufactured by: eizo nanao corp., model: ea ] for use in pregnant women with suspicion or diagnosis of covid- . a - -mhz convex transducer was used on the regular obstetric preset. fourteen areas ( posterior, lateral, and anterior) were scanned per patient for at least seconds along the indicated anatomical landmarks ( ) . the scan was performed in supine, right-sided and left-sided positions, respectively ( figure ). where applicable, scanning from the intercostal space was preferred. each area was given a score between and according to the specific pattern ( ) . the pattern with a continuous and regular pleural line and horizontal artifacts, referred to as a-lines, was classified as score . the pattern with an indented pleural line and sporadic vertical white areas below the point of discontinuity in the pleural line, referred to as sporadic b-lines, was classified as score . the pattern with a broken pleura, small consolidated areas below the discontinuity, and multiple vertical white areas that reached the bottom of the field of view, referred to as multiple b-lines, was classified as score . the pattern with a severely broken pleura and a dense and largely extended white lung pattern with or without larger consolidations was classified as score . at the end of the procedure, the highest score obtained for each area was noted (e.g. landmark , score ; landmark , score ; and so on) ( ) . local instutional ethical board and national scientific research board approved the study. written consent was obtained from all patients underwent lung ultrasound. figure - , video - ) were provided and explained in detail. in addition, four featured videos were added showing pleural effusion, the co-existence of scores and , and perihepatic and pericardial effusions (video - ). the clinical characteristics and outcomes of the patients were not in the scope of this study and were therefore not presented. the ribs and their posterior shadowing can be seen when the probe is positioned longitudinally. transverse positioning of the probe on the intercostal spaces should be preferred, where applicable. pleural line assessment: attention should be paid to the sliding, thickness, and irregularities (e.g. unsmooth, discontinuous or interrupted, indentation, broken pleura) of pleural line and subpleural effusion, if they exist. the visceral and parietal parts of pleura slide over each other in backward and forward directions with respiratory movements called the normal sliding sign ( ) . the sliding sign is absent in some clinical conditions such as pneumothorax. the subpleural consolidations appear as an irregular hypoechoic area. small patchy, strip or nodule consolidations can often be observed as a subpleural lesion. in the covid- infection, pleural thickening and subpleural effusion were found to be about - mm and - mm, respectively, which can change as the disease progresses ( ) . a-lines: these represent repetitive reverberation artifacts and commonly appear as horizontal, parallel lines at regular intervals ( ) . these lines represent a normal inflated peripheral lung when combined with a normal pleural sliding sign ( ) . b-lines: these lines are well-defined vertical hyperechoic artifacts arising from the pleural line and reach the bottom of the screen ( ) . these lines move with the pleural line during respiration and may erase a-lines ( ) . sporadic/coalescent or multiple b-lines can be seen and the density and combination of the pathologic signs may be correlated with the probability of disease ( ) . sometimes, fewer than three b-lines between two adjacent ribs may be seen in % of normal lungs ( , ) . however, possible false-positive cases should also be approached with great caution in the pandemic settings and should be considered as a possible pathologic condition until proven otherwise. there are also false vertical lines including c-, e-and z-lines, which can commonly be mistaken for b-lines. however, for obstetricians working in the covid- pandemic setting, discriminating those from pathologic b-lines may not be clinically relevant because they refer to specialist's (such as radiologist and pulmonologist) considerations to differentiate from underlying diseases. in addition, they are mainly differentiated with b-lines concerning their synchronous movements with inspiration and expiration. basically, an obstetrician should pay attention to the synchronized vertical lines that move with respiration. light beam pattern: a specific pattern that consists of a shining band-form artifact spreading down from a large portion of a regular pleural line and often has an on-off effect with respiration that may also have normal a-lines visible in the background ( ) . this pattern was proposed to reflect the acute phase of ground-glass opacities during the early spread of the active covid- pneumonia ( ) . white lung pattern: this pattern corresponds to the increased density of the lung parenchyma in which physiologic a-lines and other vertical artifacts including b-lines are erased ( ) . pleural effusions and air bronchograms, which are the reflection of air-filled bronchus in the context of opacity are rarely seen in covid- infections and should lead physicians to superinfections or other differential diagnoses ( ) . obstetricians should be responsive during the severe acute respiratory syndrome coronavirus- pandemic because they are the frontline physicians for the pregnant population ( ) and should be ready for the second wave or the next epidemics or pandemics caused by other viruses. the use of lus for pregnant women in the hands of obstetricians can make a difference during such exceptional and critical situations ( ) . this pictorial study can be used for the training of obstetricians in the pandemic setting and encourage the liberal use of lus. lus cannot be a substitute for chest ct; however, it has certain advantages over ct as an adjunctive method in the diagnosis and management of respiratory involvement of covid- infection, particularly for pregnant women ( , , ) . the sensitivity and specificity of lus in several clinical conditions range between % and %, and between % and %, respectively ( , ) . authors postulate that lus should be the first choice of imaging method in pregnant women suspected of having covid- infection. however, lus findings should be evaluated with the patient's background because they are not always specifically attributable. more importantly, mild lus findings (score ) in an asymptomatic woman should be approached cautiously. for example, a-lines that are known as physiologic artifacts can represent abnormal signs in atelectasis, asthma, chronic obstructive pulmonary disease, and pneumothorax ( ) . similarly, b-lines can represent normal signs in healthy patients when they are fewer than three and do not reach the bottom of the screen ( ) . we have previously shared our clinical experience in eight cases showing that the use of lus immediately after the fetal assessment can positively affect the clinical management of pregnant women infected with covid- ( ) . as physicians without formal radiology residency training, we organized a brief course that consisted of a didactic lecture and handson ultrasound examinations supervised by experts ( ) . this approach has been previously tested and found that lus is feasible following theoretical training combined with still images taken from pregnant women infected with covid- ( , ) . the interobserver agreement between obstetricians with different levels of experience on still-images and videoclips of lus was found as good ( ) . lus is a promising non-invasive, safe, and easily learned and performed imaging tool that can be used in pregnant women suspected of having covid- pneumonia following an initial fetal assessment. this technical pictorial study can encourage the reasonable learning of lus for obstetricians in the pandemic setting. chest ct findings in coronavirus disease- (covid- ): relationship to duration of infection the diagnosis of pneumonia in a pregnant woman with coronavirus disease using maternal lung ultrasound point-of-care lung ultrasound in patients with covid- -a narrative review how to perform lung ultrasound in pregnant women with suspected covid- lung ultrasound can influence the clinical treatment of pregnant women with covid- effectiveness of a'fast lung ultrasound teaching program'for gynecologists/obstetricians dealing with pregnant women with suspicion of covid- infection advances in lung ultrasound a preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (covid- ) proposal for international standardization of the use of lung ultrasound for patients with covid- : a simple, quantitative, reproducible method practical approach to lung ultrasound sonographic signs and patterns of covid- pneumonia chest computed tomography and lung ultrasound findings in covid- pneumonia: a pocket review for non-radiologists near-term pregnant women's attitude towards, concern about and knowledge of the covid- pandemic lung ultrasound and computed tomographic findings in pregnant woman with covid- emergency thoracic us: the essentials the lung ultrasound: facts or artifacts? in the era of covid- outbreak lung ultrasound in pregnant women during the covid- pandemic: an interobserver agreement study among obstetricians outcomes of universal sars-cov- testing program in pregnant women admitted to hospital and the adjuvant role of lung ultrasound in screening: a prospective cohort study the authors thank taha yusuf kuzan md (radiologist) for his valuable contributions in the interpretation of the images. key: cord- -ktg b jb authors: mohamed, mouhand f. h.; al-shokri, shaikha; yousaf, zohaib; danjuma, mohammed; parambil, jessiya; mohamed, samreen; mubasher, mahmood; dauleh, mujahed m.; hasanain, bara; alkahlout, mohamed awni; abubeker, ibrahim y. title: frequency of abnormalities detected by point-of-care lung ultrasound in symptomatic covid- patients: systematic review and meta-analysis date: - - journal: am j trop med hyg doi: . /ajtmh. - sha: doc_id: cord_uid: ktg b jb the covid- pandemic has resulted in significant morbidity, mortality, and strained healthcare systems worldwide. thus, a search for modalities that can expedite and improve the diagnosis and management of this entity is underway. recent data suggested the utility of lung ultrasound (lus) in the diagnosis of covid- by detecting an interstitial pattern (b-pattern). hence, we aimed to pool the proportion of various reported lung abnormalities detected by lus in symptomatic covid- patients. we conducted a systematic review (pubmed, medline, and embase until april , ) and a proportion meta-analysis. we included seven studies examining the role of lus in covid- patients. the pooled proportion (pp) of b-pattern detected by lung ultrasound (us) was . ( % ci: . – . i( ) %, q . ). the pp of finding pleural line abnormalities was . ( % ci: . – . i( ) %, q . ), of pleural thickening was . ( % . – . i( ) %, q . ), of subpleural or pulmonary consolidation was . ( % ci: . – . i( ) %, q . ), and of pleural effusion was . ( % ci: . – . i( ) %, q . ). our meta-analysis revealed that almost all sars-cov- –infected patients have abnormal lung us. the most common abnormality is interstitial involvement depicted as b-pattern. the finding from our review highlights the potential role of this modality in the triage, diagnosis, and follow-up of covid- patients. a sizable diagnostic accuracy study comparing lus, computed tomography scan, and covid- –specific tests is warranted to further test this finding and to delineate the diagnostic and prognostic yield of each of these modalities. the covid- pandemic has put enormous pressure on healthcare systems all around the globe. since its advent, there has been a quest for aiding symptoms, signs, laboratory, and imaging modalities that assist in triaging and prioritizing patients for testing and isolation. this is of exceptional value when dealing with atypical presentations of covid- or when working in resource-depleted settings. computed tomography (ct) scan of the chest has emerged as the imaging modality of choice in the diagnosis of this disease. the main findings are that of interstitial involvement. however, the difficulties associated with the transfer of infectious and potentially sick patients, disinfecting the machine, ionizing radiation exposure, immediate availability concerns, and the need for lesions follow-up made it less appealing as a triaging tool for clinicians, especially those working in the front line. , lung ultrasound (lus) or point-of-care ultrasound (pocus) has gained popularity in the triage, diagnosis, and follow-up of various lung lesions and is considered an alternative to chest x-ray (cxr) and ct scan. , it is used routinely by critical care specialists, emergency physicians, and, recently, internists. it demonstrated a better diagnostic yield than a cxr in the early diagnosis of h n pandemic viral pneumonia. recent data suggested the potential utility of lung us in the diagnosis of covid- , depicting interstitial phenomenon as evident by b-lines. , , lung us is a tempting modality, given the ease of use, availability in many emergency departments, relative ease of disinfection, and potential role in the follow-up. , thus, we aimed to explore the potential utility of this modality by systematically reviewing the literature and describing the frequency of b-pattern detected by lung us. in addition, we describe the frequency of other lung abnormalities detected by this modality. this is a systematic review and a meta-analysis keeping with prisma guidance. study eligibility criteria. we included case series and observational studies guided by the following inclusion criteria: search strategy. we performed a comprehensive literature search of pubmed, medline, and embase since their inception, with no limitations. the search was updated on april , . example of a database search strategy is as follows: ("lus" or "point of care ultrasound" or pocus or ultrasound or "ultrasound"/exp/mj or "point of care ultrasound"/ exp/mj) and ("covid- " or (sars and cov and ) or "covid " or "covid "/exp/mj or "covid- "/exp/mj). besides, we performed a manual reference search and freetext search on google and google scholar to further add to the search comprehensiveness. screening and data extraction. initial title and abstract screening were conducted by two reviewers (m. f. h. m. and s. a.). potentially eligible articles were imported for full-text review and assessed for inclusion. a third reviewer (i. y. a.) adjudicated discrepancies guided by the protocol whenever disagreement arose that was not settled by discussion. we extracted data using an excel sheet. examples of data collected are author, year of publication, study type, type of probe, frequency of various lung abnormalities, and the severity of the illness. outcome. we performed a scoping search and reviewed some of the constituent studies to identify the commonly reported outcomes. this was done at the design phase before proceeding with the actual search. we opted to summarize the pooled proportion (pp) of various lung abnormalities detected by lus. these abnormalities are as follows: . b-pattern (positive if three or more b-lines were present in a lung region, confluent b-lines, or white lung appearance). . pleural line abnormalities: some of the constituent studies did not use a uniform description when referring to pleural changes. hence, we pooled the higher frequency of either pleural thickening or pleural line irregularities. . pleural thickening was solely pooled. . consolidations: the reporting of consolidation was incomplete. so, we chose to combine subpleural and pulmonary consolidations and considered the higher frequency of the two. study quality and risk of bias assessment. we used the qudas quality assessment score to judge the quality of the included studies in our review. statistical analysis. we used a proportion meta-analysis to summarize or pool the frequency of various findings on lung us (based on our scoping review, we concluded that the sensitivity, specificity, and diagnostic accuracy could not be computed from the constituent studies). we used the random-effects model (double arcsine transformation and back transformation). i was used to adjudicate heterogeneity (> % was considered marked). the analysis was conducted via metaxl version . (epigear international, sunrise beach, queensland, australia). our initial database search has retrieved potentially relevant articles. finally, after duplicate removal and full-text screening (all articles excluded were duplicates, reviews, opinions, or case reports), seven articles were included in our quantitative synthesis ( figure flow diagram). , , , - a total of six observational studies and a case series describing a total of patients constituted our review population ( table presents a summary of the included studies). lung zones examined. five studies reported on the number of lung zones examined. twelve zones were examined in four studies, whereas in one study, zones were examined ( table ) . the proportion of b-pattern. all seven studies reported on the frequency of b-pattern. the pp of b-pattern in the review population is . ( % ci: . - . i %, q . ). the results were homogenous and consistent among studies (figure ) . the proportion of pleural line abnormalities. five studies reported the frequency of pleural line abnormalities. the frequency of these abnormalities ranged between % and % ( table ). the pp is . ( % ci: . - . i %, q . ) (figure ). one study did not report the exact frequency but stated that most patients had pleural thickening; hence, pooling this additional study may have led to a slight increase in the pp. the proportion of pleural thickening. five studies reported the frequency of pleural thickening. the pp of pleural thickening is . ( % . - . i %, q . ). this was less than the pp of pleural line abnormalities because of one study that reported a % frequency of pleural thickening while reporting a % frequency of pleural line irregularities. there was marked heterogeneity evident by the high i ( figure ). as explained earlier, the study by peng et al. reported that pleural thickening has occurred in most patients without specifying the frequency, hence excluded from the computation of this pp. the proportion of consolidations. six studies reported on the frequency of subpleural or pulmonary consolidations detected by lung us. the frequency ranged from % to %. the pp is . ( % ci: . - . i %, q . ) (figure ) . i indicated a marked heterogeneity. the proportion of pleural effusion. five studies reported the frequency of pleural effusion detected by lung us. it ranged from % to . % in four studies, whereas in one study, % of the patients had pleural effusion. the pp of this finding was the lowest at . ( % ci: . - . i %, q . ). the results of these studies were significantly heterogeneous ( figure ) . risk of bias assessment. the funnel plot depicted moderate to marked asymmetry, suggesting potential publication bias (supplemental figure ) . for comparison, we populated doi plots with lfk indices to ascertain the publication bias. using these additional measures, only pleural line abnormalities, finding remained at high risk of publication bias. we used the quadas tool to assess the study quality and risk of bias; the included studies mostly revealed an unclear or moderate risk of bias (supplemental material table ). there was marked heterogeneity with regard to pooling the proportion of pleural thickening, consolidation, or pleural effusion. covid- has struck the world with surprise, resulting in elated morbidity and mortality, strained the healthcare system, and depleted the resources even in resource-rich settings. up to the date of submitting this manuscript, covid- has affected million individuals (confirmed cases) and resulted in more than , deaths worldwide. tools to aid in the early identification and follow-up are needed in an attempt to provide appropriate care and to allocate resources better. , computed tomography scan has surfaced as a useful imaging modality in the diagnosis and follow-up of covid- . , although useful, its use is limited, as explained earlier. the recent interest in point-of-care ultrasound (pocus) of the figure . forest plot presenting (a) the pooled proportion of b-pattern and (b) consolidation (the higher frequency of subpleural or pulmonary consolidations reported by the primary study) detected by lung ultrasound in symptomatic covid- patients. *i is % for b-pattern proportion, suggesting homogeneity of data. there is marked heterogeneity depicted by extremely high i for the finding of consolidation. lungs is due to its portability, steep learning curve, a relatively easier sterilization process, absence of ionizing radiation exposure, and its role in the follow-up. moreover, it has an excellent correlation with ct scan in various pulmonary diseases (b-lines, subpleural consolidations, and irregular pleural line). , the use of pocus is of greater value in resourcelimited settings, for example, in some tropical areas where other diagnostic modalities may not be readily available, and testing resources may be limited. in these settings, basic ultrasound image acquisition and interpretation skills can be taught to healthcare providers of varying experiences, following a brief training course. in our review, b-pattern predominated, occurring with a pooled frequency (pf) of % ( - %). the results were consistent and homogenous across all the constituent studies. pleural line abnormalities were present in two-thirds of the cases (pf %, % ci: - %), the frequency of other findings was less in our review, and the results were extremely heterogeneous. this heterogeneity is likely owing to differences in the settings, patient populations, number of lung zones examined, the level of operator expertise, ultrasound machine or probe used, stage and severity of the illness. hence, the presence of these findings (consolidations, pleural thickening, or pleural effusion) may be useful in the triage, prognosis, and follow-up. however, their absence cannot be used to rule out covid- . two of the constituent studies (guorong et al. and poggiali et al. ) demonstrated a good correlation between the lus and ct scan findings. furthermore, guorong et al. demonstrated that the lus findings improve synchronously with clinical improvement, suggesting a potential role of lus in the clinical follow-up. however, this role needs to be supported by future studies. , it is worthy to note two studies that were excluded from our review. the first study examined the role of lung us in asymptomatic patients with covid- , hence excluded. in their retrospective analysis of nine asymptomatic patients, lus revealed abnormalities in % (n = / ). one patient had b-pattern, and the other patient had pulmonary consolidations. whereas the frequency of b-pattern was low in this study, ct scan did similarly depict abnormalities in only % (n = / ), indicating a possible low yield of various imaging modalities in asymptomatic covid- patients. the second study was excluded as it was limited to a pediatric cohort. they retrospectively analyzed the data of eight covid- -infected children; % (n = / ) had abnormalities on lung us (b-pattern n = / , consolidations n = / ). on clinical improvement, all the lesions radiologically improved either partially or entirely, hinting toward a potential role of us in the clinical follow-up. in the h n pandemic, lus findings were used to differentiate between viral and bacterial pneumonia with an excellent interobserver agreement. bacterial pneumonia findings were lung consolidations with sonographic air bronchograms. however, the findings noted in cases of viral pneumonia were similar to our findings (b-pattern, pleural line abnormalities, or subpleural consolidations). , it may be argued that lus findings may not enable clinicians to differentiate covid- from other viral lung infections; however, having such a prevalent finding amid a pandemic will lead to faster diagnostic and therapeutic decisions and better resource allocation. our review aimed to pool the reported proportions of various findings detected by pocus lungs and is the first metaanalysis aimed at assessing the role of lung us or pocus in the diagnosis of covid- . the authors are of the view that this will be of value to frontline clinicians. we believe that the findings from our review will assist in the integration of this useful modality in the triage, diagnosis, management, and follow-up of covid- patients. our review is limited by a small number of constituent studies, a small number of patients, unclear bias risk, and inability to rule out publication bias. also, there is a lack of unifying definitions and inconsistencies in the reporting of various lung abnormalities. inadequate reporting of the extensiveness of lus findings (lung areas involved or a representative lus score) may limit its role in the temporal follow-up and its prognostic value. finally, we were not able to calculate the sensitivity and specificity owing to the absence of data necessary for their computation. a well-conducted diagnostic accuracy study comparing lus, ct scan, and various specific tests for covid- (pcr, igm, and igg on serial measurements) to ascertain the sensitivity, specificity, and diagnostic accuracy of each modality in the diagnosis of covid- is needed. in addition, we suggest studying lus on various severity spectrum of the disease to identify findings that correlate with disease severity. the results of the recently planned and ongoing trials, such as pocusco, echovid- , pocusars-cov- , virus, and covilus, will address some of the aforementioned limitations. [ ] [ ] [ ] [ ] [ ] conclusion evidence of interstitial lung involvement, as depicted by b-pattern, is the most common and consistent finding on lung us in covid- patients. although nonspecific, the presence of this finding amid the covid- pandemic, in addition to other characteristic symptoms, will increase the disease likelihood. thus, pocus will likely play a vital role in the future triage, diagnosis, management, and follow-up of covid- patients. all together to fight novel coronavirus disease (covid- ) the characteristics and clinical value of chest ct images of novel coronavirus pneumonia lung ultrasound for daily monitoring of ards patients on extracorporeal membrane oxygenation: preliminary experience ultrasound in covid- : a timeline of ultrasound findings in relation to ct point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial lung us surface wave elastography in interstitial lung disease staging point-of-care 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after a pointof-care ultrasound course: does clinical rank matter? application value of lung ultrasound in asymptomatic patients with confirmed covid- lung ultrasound in children with covid- coronavirus (covid- ) diagnostic lung ul-trasound study -full text view -clinicaltrials lung ultrasound to diagnose covid- -full text view -clinicaltrials accuracy of lung ultrasound in the diagnosis of covid pneumonia -full text view -clinicaltrials the role of ultrasound in covid- -full text view -clinicaltrials point of care ultrasonography for riskstratification of covid- patients -full text view -clinical-trials acknowledgments: we thank the reviewers for their constructive feedback that led to improving the manuscript. publication charges for this article were waived due to the ongoing pandemic of covid- .disclosure: no ethical approval was sought, given that this is a secondary synthesis of the already available literature. the data used in this review are available on reasonable request. this is an open-access article distributed under the terms of the creative commons attribution (cc-by) license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. key: cord- -uo ghf authors: cocconcelli, elisabetta; biondini, davide; giraudo, chiara; lococo, sara; bernardinello, nicol; fichera, giulia; barbiero, giulio; castelli, gioele; cavinato, silvia; ferrari, anna; saetta, marina; cattelan, annamaria; spagnolo, paolo; balestro, elisabetta title: clinical features and chest imaging as predictors of intensity of care in patients with covid- date: - - journal: j clin med doi: . /jcm sha: doc_id: cord_uid: uo ghf coronavirus disease (covid- ) has rapidly become a global pandemic with lung disease representing the main cause of morbidity and mortality. conventional chest-x ray (cxr) and ultrasound (us) are valuable instruments to assess the extent of lung involvement. we investigated the relationship between cxr scores on admission and the level of medical care required in patients with covid- . further, we assessed the cxr-us correlation to explore the role of ultrasound in monitoring the course of covid- pneumonia. clinical features and cxr scores were obtained at admission and correlated with the level of intensity of care required [high- (himc) versus low-intensity medical care (limc)]. in a subgroup of patients, us findings were correlated with clinical and radiographic parameters. on hospital admission, cxr global score was higher in himcs compared to limc. smoking history, po( ) on admission, cardiovascular and oncologic diseases were independent predictors of himc. the us score was positively correlated with fio( ) while the correlation with cxr global score only trended towards significance. our study identifies clinical and radiographic features that strongly correlate with higher levels of medical care. the role of lung ultrasound in this setting remains undetermined and needs to be explored in larger prospective studies. since december , when the first cases of coronavirus disease (covid- ) were reported, the diffusion of the severe acute respiratory syndrome coronavirus type (sars-cov- ) has rapidly spread from the hubei province in china to involve up to states and territories to date, reaching pandemic proportions [ ] . despite epidemiological reports showing that approximately half of the infected people are asymptomatic [ ] , the spectrum of respiratory manifestations may range from mild symptoms, such as dry cough, fever, and fatigue, to acute respiratory distress syndrome (ards), requiring admission to intensive care unit (icu) and mechanical ventilation (mv). in this scenario, thoracic radiology plays a key role in early detection of lung involvement from covid- . chest computed tomography (ct) is the technique with the highest sensitivity, but the risk of contamination and the need for a dedicated hospital organization makes ct hardly available in an emergency setting. portable chest x-ray (cxr) and ultrasonography (us) are quicker, safer and less expensive alternatives [ ] . cxr is recommended as first level assessment by several scientific societies (american college of radiology, society of thoracic radiology) in the context of the sars-cov- pandemic [ ] . predominant cxr features in patients with covid- include lower lobe, peripheral, bilateral ground glass opacities (ggo) or consolidations [ ] , similar to other forms of viral pneumonias, such as the h n strain [ ] . yet, cxr could be normal in as many as % cases, peaking its sensibility in patients with advanced disease [ ] [ ] [ ] . in the last three decades, lung us (lus) has become increasingly important in clinical practice, particularly in the assessment of patients with pneumonia, with sensitivity and specificity of % and %, respectively, especially when performed by experienced operators [ ] . in the covid- pandemic, lus has been used in multiple centers as first radiological approach in patients with suspected pneumonia. the main ultrasound findings include multiple b-lines (separated or coalescent), peripheral consolidations and thickened pleural lines [ ] , which however are nonspecific and found in a number of infectious and non-infectious diseases [ ] . the use of lus and cxr in combination has the potential to facilitate the identifications of ards [ ] . with this background, we investigated the relationship between cxr severity score on admission and the level of medical care required in patients with covid- . further, we assessed the radiographic-ultrasound correlation with the aim to explore the value of ultrasound in monitoring the course of covid- pneumonia. in this longitudinal retrospective study, we identified a cohort of clinically well-characterized patients with sars-cov- infection referred to the university hospital of padova (division of infectious and tropical diseases, respiratory disease unit and intensive care unit) between march and may . one hundred and two patients were included in the study (table ) since the diagnosis of sars-cov- infection was made based on nasopharyngeal swab positivity. clinical and demographics data, and cxrs were obtained on admission. a subset of patients ( / , . %), who were hospitalized in a low-intensity care setting, underwent a bedside lus and a cxr in the late phase of covid- pneumonia. the aim of performing lus and cxr in parallel was to explore the relation between these two procedures. the need for invasive/non-invasive ventilation or high-flow nasal cannula (hfnc), which required admission to icu or to the respiratory icu, was considered as high-intensity medical care (himc), while the need for low flow oxygen supplementation through nasal cannula or face mask, which required the setting of a general ward, was considered as low-intensity medical care (limc). the level of care could change over time based on patient's clinical conditions. for all patients, clinical data (demographics and comorbidities), gas exchange values (fio , po and po /fio ) were collected on admission (table ) . we have categorized the five most frequent type of comorbidities: cardiovascular diseases (cvd), respiratory diseases, metabolic diseases, autoimmune diseases and oncologic diseases. among the metabolic comorbidities, we have considered diabetes mellitus, obesity and dyslipidemia ( %). oncologic history mentioned the different organs affected (i.e., lung, prostate, pancreas. breast, colon). this was a retrospective study on anonymized patient's data collected from electronic medical records. the study protocol complies to the ethical guidelines of the declaration of helsinki and, in agreement with national regulation on retrospective observational studies, it was notified and approved by the local ethics committee (n • / . . ) and the need for patient's informed consent was waived. we retrieved data on patients hospitalized for covid- between march and may at the university hospital of padova, one of the most affected areas in north-east of italy. we screened records of all patients admitted to our hospital with a diagnosis of sars-cov infection. for each patient, a single image plane cxr was available on hospital admission. two radiologists (c.g., g.b.) with more than ten years of experience in the thoracic field, who were blind to clinical data, scored the images independently using a semi-quantitative scale. this represented a modification of previously reported scoring systems that allowed to evaluate the extension of ground glass opacities (ggo) and consolidation (co) [ , , ] . for each lung lobe, the two radiologists assessed the extent of ggo and co using the following scale: (normal), (up to % of the lobe involved), ( % to % of the lobe involved), and (more than % of the lobe involved). the sum of the scores for each lung lobe and a final value of ggo and co score for each patient was then calculated ( table ). the cxr "global" score was calculated as the sum of the ggo and co scores of each patient, with a maximum score of . finally, each patient was classified as "normal", "ggo prevalent", "co prevalent", or "mixed" based on the prevalent cxr pattern [ ] . table . baseline radiological scores of the overall population hospitalized for sars-cov- related infection, and of the two subgroups categorized in low (limc) and high (himc) intensity medical care. a subset of patients underwent bed-side lus. the examination was conducted with a portable mylab tm gold ultrasound unit (esaote, genova, italy) and a dedicated ca convex transducer (range of frequency - mhz). we used low frequency and a single-focal modality at the pleural line. the depth was arranged on - cm and the harmonic-imaging system was deactivated. the lus score was calculated across chest zones (six on each hemithorax) using a scale from (normal pattern, a-lines or non-significant b-lines), (significant b-lines ≥ per rib space), and (coalescent b-lines with or without small consolidations) to (consolidation), as previously reported [ ] . a final "us global score" was calculated for each patient with a maximum score of . categorical variables were described as absolute (n) and relative values (%), whereas continuous variables were described as median and range. to compare demographic data and baseline clinical characteristics between limc and himc groups, chi square test and fisher's exact test for categorical variables and mann-whitney u test for continuous variables were used, as appropriate. the correlation between cxr global score and po , fio , p/f ratio on admission was assessed for the entire study population and in the limc and himc groups using the nonparametric spearman's rank method. univariate logistic regression analysis, followed by a multivariate logistic regression, was performed to detect the strongest predictors of level of care. the covariates included in the final model were those that were significant in the univariate regression analyses. the correlation between lus global score and the corresponding cxr global score and fio was calculated using the nonparametric spearman's rank method. all data were analyzed using spss software version . (us: ibm corp., new york, ny, usa). p-values < . were considered statistically significant. the graphs were obtained using the statistical package graphpad prism . (graphpad software, inc., la jolla, san diego, ca, usa). demographic and clinical characteristics at baseline (i.e., on hospital admission) are summarized in table . most patients were male ( %) with a median age on admission of years. seventy-one patients required limc during hospitalization and thirty-one himc. patients requiring himc (himcs) were mainly male ( vs. %; p = . ) and older [ vs. ( - ) years; p = . ], with a higher body mass index (bmi) [ ( - ) vs. ( - ) kg/m ; p = . ]. moreover, they had a heavier smoking history ( ( - ) vs. ( - ) pack/year (py); p = . ) and were mainly former smokers ( %). the most common presenting symptoms were fever ( %), cough ( %) and shortness of breath ( %), and with % of patients complaining of impaired sensory. the frequency of these symptoms did not differ between himcs and limcs. interestingly, although the time interval between onset of respiratory symptoms and admission to the emergency unit was similar, himcs showed a greater impairment of respiratory gas exchange with a lower po on room air on admission ( ( - ) vs. ( - ) mmhg; p < . ), greater fio requirement at the time of admission ( ( - ) vs. ( - ) %; p < . ) and worse p/f ( ( - ) vs. ( - ); p < . ) compared to limcs. in the overall population, cvds were the most frequent comorbidities ( %) that we observed. among the metabolic comorbidities, diabetes mellitus was the most prevalent ( %), followed by obesity ( %) and dyslipidemia ( %). hypothyroidism was the most frequent condition among the autoimmune diseases ( %). oncologic diseases ( %) were equally distributed among organs affected (i.e., lung, prostate, pancreas. breast, colon). himcs reported more comorbidities, in particular cardiovascular diseases (cvds) ( vs. % of cases; p = . ), metabolic diseases ( vs. %; p = . ) and oncologic diseases ( vs. %; p = . ). furthermore, this patient group showed a higher frequency of bacterial co-infections ( vs. %; p = . ) during hospitalization. finally, the hospitalization time was significantly longer for himcs compared to limcs [ ( - ) vs. ( - ) days; p < . ], with patients dying among himcs and only one among limcs (p = . ). on admission, himcs showed a more severe radiological impairment compared to limcs, with higher x-ray global score [ ( - ) vs. ( - ); p < . ], ggo score ( ( - ) vs. ( - ); p < . ) and co score ( ( - ) vs. ( - ); p = . ), respectively. when considering the prevalent cxr pattern, only one patient among himcs had a normal cxr on admission compared to limcs ( ; p = . ), with similar proportion of patients with "ggo prevalent" and "co prevalent" patterns in the himc and limc groups. in the overall study population, a positive correlation was observed between cxr global score and fio on admission (r = . , p < . ). when stratified by level of care, the correlation between cxr global score and fio on admission was confirmed in limcs (r = . , p < . ) but not in himc (figure a ). in the overall study population, we observed a negative correlation between cxr global score and po on admission (r = − . , p < . ). when stratified by level of care, the correlation between cxr global score and po on admission was confirmed in limcs (r = − . ; p = . ) but not in himcs (figure b) . finally, in the overall study population, we observed a negative correlation between cxr global score and p/f on admission (r = − . , p < . ). when stratified by level of care, the correlation between cxr global score and p/f at admission was confirmed in both limcs (r = − . ; p = . ) and himcs (r =− . ; p = . ) (figure c) . univariate logistic regression analysis of factors associated with level of care revealed that sex, age, smoking history, fio , po in room air at admission, bacterial co-infections developed during hospitalization, cvds, metabolic and oncologic diseases and chest x-ray global score had significant positive association with a higher level of care in the entire study population (table ) . multivariate analysis performed using variables with statistical significance in univariate analysis revealed that smoking history (odds ratio . ; % ci: . - . ; p = . ), po values are expressed as odds ratio ( % confidence interval). logistic regression analysis in relation to level of care was used to determine the relationship of clinical and radiological characteristics with higher level of care needed during hospitalization. a subset of patients underwent a bed-side lus after a median time of days from admission. in parallel, cxrs were performed in the same patients at the same time point. the median lus global score was , whereas the median cxr global score was ( - ). the lus global score positively correlated with the fio requirement at the time of the us examination (r = . ; p = . ) ( figure ) . conversely, the correlation between lus global score and cxr global score only trended towards statistical significance (r = . , p = . ) ( figure ) . finally, the lus global score positively correlated with the cxr co score (r = . ; p = . ) (figure ) but not with the ggo score. j. clin. med. , , x for peer review of univariate logistic regression analysis of factors associated with level of care revealed that sex, age, smoking history, fio , po in room air at admission, bacterial co-infections developed during hospitalization, cvds, metabolic and oncologic diseases and chest x-ray global score had significant positive association with a higher level of care in the entire study population (table ) . multivariate analysis performed using variables with statistical significance in univariate analysis revealed that smoking history (odds ratio . ; % ci: . - . ; p = . ), po ( . , . - . ; p = . ), cvds ( . , . - ; p = . ), and oncologic diseases ( . , . - . ; p = . ) were independent predictors of higher level of care in patients with sars-cov- infection. values are expressed as odds ratio ( % confidence interval). logistic regression analysis in relation to level of care was used to determine the relationship of clinical and radiological characteristics with higher level of care needed during hospitalization. a subset of patients underwent a bed-side lus after a median time of days from admission. in parallel, cxrs were performed in the same patients at the same time point. the median lus global score was , whereas the median cxr global score was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the lus global score positively correlated with the fio requirement at the time of the us examination (r = . ; p = . ) ( figure ) . conversely, the correlation between lus global score and cxr global score only trended towards statistical significance (r = . , p = . ) ( figure ) . finally, the lus global score positively correlated with the cxr co score (r = . ; p = . ) (figure ) but not with the ggo score. this is a retrospective analysis of clinical features and radiographic severity scores in patients with covid- and how these parameters on hospital admission correlate with different levels of medical care (i.e., himc vs. limc). a subgroup of patients also underwent lus, which was correlated with chest radiographs. our study revealed that patients with covid- who required a himc are mainly men, former smokers with a higher pack/year of smoking history, older and with a higher bmi compared to patients requiring limc. furthermore, the majority of them reported at least one comorbidity (i.e., cardiovascular, metabolic, or oncologic) and required on emergency room oxygen supplementation due to low alveolar oxygen partial pressure (pao ). moreover, using a multivariate analysis, we found that a heavier smoking history, po level on room air, and presence of cardiovascular or oncological disease on admission were independent predictors of the need of himc. our findings mirror those from previous studies indicating that older male patients with comorbidities are at higher risk of pulmonary infection and fatal consequences from covid- [ , ] . in our study, we show that the number of pack-years was significantly higher in former smokers who required intensive care compared to those requiring limc. moreover, the proportion of former smokers was markedly increased among severe patients, whereas nonsmokers with covid- experienced a milder illness, which required low-flow oxygen supplementation. this is in line with other reports that explored the association between smoking and progression of covid- pneumonia [ ] . notably, in our study, multivariate analysis revealed that smoking this is a retrospective analysis of clinical features and radiographic severity scores in patients with covid- and how these parameters on hospital admission correlate with different levels of medical care (i.e., himc vs. limc). a subgroup of patients also underwent lus, which was correlated with chest radiographs. our study revealed that patients with covid- who required a himc are mainly men, former smokers with a higher pack/year of smoking history, older and with a higher bmi compared to patients requiring limc. furthermore, the majority of them reported at least one comorbidity (i.e., cardiovascular, metabolic, or oncologic) and required on emergency room oxygen supplementation due to low alveolar oxygen partial pressure (pao ). moreover, using a multivariate analysis, we found that a heavier smoking history, po level on room air, and presence of cardiovascular or oncological disease on admission were independent predictors of the need of himc. our findings mirror those from previous studies indicating that older male patients with comorbidities are at higher risk of pulmonary infection and fatal consequences from covid- [ , ] . in our study, we show that the number of pack-years was significantly higher in former smokers who required intensive care compared to those requiring limc. moreover, the proportion of former smokers was markedly increased among severe patients, whereas nonsmokers with covid- experienced a milder illness, which required low-flow oxygen supplementation. this is in line with other reports that explored the association between smoking and progression of covid- pneumonia [ ] . notably, in our study, multivariate analysis revealed that smoking this is a retrospective analysis of clinical features and radiographic severity scores in patients with covid- and how these parameters on hospital admission correlate with different levels of medical care (i.e., himc vs. limc). a subgroup of patients also underwent lus, which was correlated with chest radiographs. our study revealed that patients with covid- who required a himc are mainly men, former smokers with a higher pack/year of smoking history, older and with a higher bmi compared to patients requiring limc. furthermore, the majority of them reported at least one comorbidity (i.e., cardiovascular, metabolic, or oncologic) and required on emergency room oxygen supplementation due to low alveolar oxygen partial pressure (pao ). moreover, using a multivariate analysis, we found that a heavier smoking history, po level on room air, and presence of cardiovascular or oncological disease on admission were independent predictors of the need of himc. our findings mirror those from previous studies indicating that older male patients with comorbidities are at higher risk of pulmonary infection and fatal consequences from covid- [ , ] . in our study, we show that the number of pack-years was significantly higher in former smokers who required intensive care compared to those requiring limc. moreover, the proportion of former smokers was markedly increased among severe patients, whereas nonsmokers with covid- experienced a milder illness, which required low-flow oxygen supplementation. this is in line with other reports that explored the association between smoking and progression of covid- pneumonia [ ] . notably, in our study, multivariate analysis revealed that smoking history was an independent risk factor for himc. we speculate that cigarette smoke upregulates the expression of angiotensin-converting enzyme receptors, which in turn facilitate sars-cov- entry in the respiratory epithelium; this implies that smoking habit may represent a risk factor for developing severe illness even among former smokers. in other words, having quit smoking does not seem to prevent the risk of severe covid- pneumonia [ ] . chronic respiratory disease, including, among others, chronic obstructive pulmonary disease (copd), carry a worse prognosis when associated with chronic conditions, such as cardiovascular diseases [ ] [ ] [ ] . interestingly, in our cohort, concomitant cvds and neoplasms were independent risk factors for hospitalization in himc, with up to % of patients who required himc reporting an history of cvd (mainly arterial hypertension). a recent meta-analysis of patients concluded that hypertension, chronic respiratory disease and cvd are risk factors for severe covid- disease [ ] . considering our study population, we observed that cvds are the most frequent comorbidities ( % of cases), % of patients suffered from diabetes mellitus, % showed blood tests positive for dyslipidemia, and % of our patients were obese. we, therefore, are in line with an italian nationwide observational study of covid- inpatients which reported a linear direct relationship between the number of comorbidities and the risk of death [ ] . all these findings emphasize the importance of past medical history and comorbidities in the disease course of covid- patients, as they may predispose to worse outcome and higher intensity of care. ppo level < mmhg on admission to emergency room was an additional independent predictor of himc requirement. this is interesting, as the duration of symptoms (i.e., median of days) did not differ between patients requiring himc and patients requiring limc. thirty-one subjects required subsequent admission to icu due to worsening of pneumonia and gas exchange. on admission, these patients displayed extensive radiological impairment in terms of both ggo score and consolidation. in the overall population gas exchange parameters correlate significantly with radiological scores but, interestingly enough, this correlation was mainly due to patients who remained in the limc group. indeed, in this group, radiological score correlated negatively with ppo levels and positively with fio reflecting exact correspondence between respiratory failure and radiologic impairment. conversely, among patients who subsequently required himc, cxr at baseline showed a variety of radiologic impairment, ranging from normal to highly abnormal however without a concurrent relation with gas abnormality. this result might arise attention to that patients who display discrepancies between gas exchange parameters and cxr. pevious reports on cxr findings in covid- patients focused on the distribution and type of lung abnormalities. wong and coauthors demonstrated that cxr at baseline has a sensitivity of % for a diagnosis of covid- pneumonia, corroborating the utility of cxr in the initial evaluation of subjects with suspected covid- pneumonia, thus obviating the need for ct [ ] . toussie and colleagues have recently reported that initial cxr severity score is also an independent predictor of outcome in covid- patients [ ] . we could not replicate this finding, but our study population was older than that studied by toussie et al. the prognostic role of cxr in covid- pneumonia therefore needs to be clarified in larger studies. lung ultrasound has been suggested as a potential diagnostic tool for covid- pneumonia given the predominant involvement of the lung periphery [ ] ; lung ultrasound is a relatively simple technique that can be easily applied at patient bedside [ ] . in our study, we investigated its role in the late phase of covid- pneumonia and its relation with cxr in a subgroup of patients hospitalized in a low-intensity care setting. we found a significant correlation between lus features and fio level, suggesting these two parameters can be integrated into the evaluation of patients with covid- pneumonia. lus global score positively correlated with cxr consolidation score while the correlation with cxr global score only trended towards statistical significance. although only exploratory, these findings may anticipate further studies mainly focused on the utility of lus as a monitoring tool, possibly limiting the use of serial cxr, at least in the advanced phase of covid- pneumonia. in this regard, lus has been suggested as a potential substitute for cxr in the follow-up of various lung diseases in icu [ ] , reducing the number of cxrs performed and relative medical costs without affecting patient outcome. of interest in a recent study by møller-sørensen and colleagues, the usefulness of bed-side lus in icu patients treated with extracorporeal membrane oxygenation (ecmo) was assessed during the covid- pandemic. authors used a three-zone score for each lung (anterior, posterior and lateral) with a maximum of points for patient. lus score demonstrated a strong correlation with compliance during mechanical ventilation. moreover, a lower lus score advanced weaning capacity from ecmo [ ] . soldati and colleagues have also suggested that lus can be useful in covid- pneumonia by identifying disease extension and specific patterns, as well as their evolution toward the consolidation phase [ ] , thus providing further support to the role of lus in the follow-up of patients with covid- pneumonia. at present, however, the majority of studies performed during the covid- pandemic focused on ultrasonographic signs and disease patterns at presentation rather than overtime [ ] [ ] [ ] [ ] [ ] . accordingly, the role of lus in monitoring the evolution of covid- pneumonia needs to be confirmed in larger studies. the results of our study should be interpreted in the light of important limitations. first, this is not a longitudinal study and we retrospectively collected all clinical and radiological data; therefore, the accuracy of the clinical information depends on medical records, which may introduce inaccuracies. however, every effort was made to limit this risk, even asking to the patients to fill all the missing data when possible. second, the study population was relatively small, particularly the subset of patients for whom lus data were available, although this was an exploratory analysis, and its findings should be viewed as such. clearly, these data need to be validated in larger, independent, prospectively collected populations of patients. in summary, our study identified clinical features that strongly predict the level of medical setting required by patients with covid- pneumonia (himc or limc). these findings allow the identification of patients at risk for severe disease and worse outcome already on hospital admission. the correlation of lus with clinical parameters and radiological score provides the basis for future studies on the utility of lus in the follow-up of patients with covid- pneumonia. conflicts of interest: p.s. has received personal fees and non-financial support from roche, boehringer-ingelheim, zambon, and ppm services. e.b. has received personal fees from roche and boehringer-ingelheim. m.s. has received research grants for the department (not personal) to her institution from takeda ltd., chiesi farmaceutici and laboratori guidotti spa. these funds were not used to support this project. coronavirus suppression of a sars-cov- outbreak in the italian municipality of vo' review of chest radiograph findings of covid- pneumonia and suggested reporting language clinical and chest radiography features determine patient outcomes in young and middle age adults with covid- presenting cxr phenotype of h n . flu compared with contemporaneous non-h n , community acquired pneumonia, during pandemic and post-pandemic outbreaks' covid- ) infection: findings and correlation with clinical outcome frequency and 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covid- assessment with bedside lung ultrasound in a population of intensive care patients treated with mechanical ventilation and ecmo is there a role for lung ultrasound during the covid - pandemic? sonographic signs and patterns of covid- pneumonia a preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (covid- ) diagnostic accuracy of lung ultrasonography combined with procalcitonin for the diagnosis of pneumonia: a pilot study can lung us help critical care clinicians in the early diagnosis of novel coronavirus (covid- ) pneumonia? findings of lung ultrasonography of novel corona virus pneumonia during the - epidemic this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord- -zb o yf authors: nasrollahi, vida; mirzaie-asl, asghar; piri, khosro; nazeri, sonbol; mehrabi, rahim title: the effect of drought stress on the expression of key genes involved in the biosynthesis of triterpenoid saponins in liquorice (glycyrrhiza glabra) date: - - journal: phytochemistry doi: . /j.phytochem. . . sha: doc_id: cord_uid: zb o yf abstract glycyrrhiza glabra is an important medicinal plant throughout the world. glycyrrhizin is a triterpenoid that is among the most important secondary metabolites produced by liquorice. drought stress is proposed to enhance the levels of secondary metabolites. in this study, the effect of drought stress on the expression of important genes involved in the glycyrrhizin biosynthetic pathway was examined. drought stress at the seedling stage was applied to -day-old plants using polyethylene glycol. subsequently, the samples were collected , , or h post-treatment. at the adult plant stage, -month-old plants were subjected to drought stress by discontinuing irrigation. subsequently, samples were collected at , and days after drought imposition (s d, s d and s d, respectively). we performed semi-quantitative rt-pcr assays to evaluate the gene expression levels of sequalene synthase (sqs), β-amyrin synthase (bas), lupeol synthase (lus) and cycloartenol synthase (cas) during stress. finally, the glycyrrhizin content of stolons was determined via hplc. the results revealed that due to osmotic stress, the gene expression levels of sqs and bas were increased, whereas those of cas were relatively unchanged at the seedling stage. at the adult plant stage, the expression levels of sqs and bas were increased under drought stress conditions, whereas the gene expression level of cas remained relatively constant. the glycyrrhizin content in stolons was increased only under severe drought stress conditions (s d). our results indicate that application of controlled drought stress up-regulates the expression of key genes involved in the biosynthesis of triterpenoid saponins and directly enhances the production of secondary metabolites, including glycyrrhizin, in liquorice plants. the roots and stolons of glycyrrhiza plants (g. glabra l.) are among the most important sources of crude herbal drugs worldwide (gibson, ) . triterpene saponins are high molecular weight glycosides that are composed of a sugar moiety linked to triterpene or a steroid aglycone. precursors of saponins typically undergo various modifications prior to the addition of sugar molecules. the types and extent of the sugar molecules that comprise triterpene saponins differ greatly among saponin-containing plants (hayashi et al., (hayashi et al., , vincken et al., ) . the root of liquorice contains a large amount (up to %) of glycyrrhizin and oleanane-type triterpene saponins, which are known to have various food, industrial, cosmetic and pharmaceutical applications (armanini et al., ) . saponins are commercially used in food and industrial settings as foaming, detergent, wetting, emulsifying and sweetening agents (hostettmann and marston, ; shibata, ) . they are also utilised as ingredients in the cosmetics, cleansing and personal care sectors, such as shower gels, shampoos, hair conditioners, lotions, liquid soaps, baby care products, mouthwashes, and toothpastes. the pharmacological properties of glycyrrhizin and structural elucidation of triterpenes and saponins have been widely studied, revealing that these compounds have important pharmaceutical activities aside from their involvement in plant defence responses (agrell et al., ; mahato et al., mahato et al., , osbourn, ) . these important properties include anti-inflammatory, anti-bacterial, molluscicidal, antiulcer, insecticidal, and anti-allergic activities, as well as involvement in immune system activation (de leo et al., ; gopalsamy et al., ; he et al., ; kuzina et al., ; matsui et al., ; park et al., ; takahara et al., ) . glycyrrhizin also displays antivirus activity against several viruses, such as hiv (ito et al., (ito et al., , and severe acute respiratory syndrome (sars) caused by coronavirus (cinatl et al., ) . a number of sequential enzymatic reactions are required for the biosynthesis of triterpene saponins in plants. squalene (sqs) catalyses the formation of squalene from farnesyl diphosphate (hayashi, ). in the triterpene biosynthesis pathway, a common intermediate of triterpenoids, saponins and phytosterols is , oxidosqualene, which is cyclised via oxidosqualene cyclases (oscs) (abe et al., ; haralampidis et al., ; xu et al., ) . in g. glabra, there are three oscs: b-amyrin synthase (bas), lupeol synthase (lus) and cycloartenol synthase (cas). these three enzymes are involved in the cyclisation of , -oxidosqualene to generate oleanane-type triterpene saponins (glycyrrhizin and soyasaponins), lupane-type triterpene (betulinic acid) and phytosterols, respectively (mangas et al., ) . in previous studies, cdna from the genes encoding the oxidosqualene cyclases was cloned and characterised in g. glabra (hayashi et al., (hayashi et al., , (hayashi et al., , (hayashi et al., , . the availability of the sequences of these genes essentially facilitates the identification of the conditions under which their expression levels are enhanced. one critical abiotic stress that affects plant physiology and development is water deficiency caused by drought (gueta-dahan et al., ) . the production of plant secondary metabolites is strongly associated with the growth conditions, and stress conditions in particular exert a strong impact on the corresponding metabolic pathways. plants that are exposed to drought stress generally produce higher levels of secondary metabolites, including triterpenoids (selmar and kleinwächter, ) . successful and efficient use of deliberate drought stress can directly enhance secondary metabolite production. this enhancement can be achieved by applying special irrigation regimes that are both simple and inexpensive, but this approach requires extensive examination to optimise metabolite production (selmar and kleinwächter, ) . drought stress generally results in oxidative stress (lei et al., ) , which causes the formation of reactive oxygen species (ros) in chloroplasts and mitochondria (liu et al., ) . ros, such as superoxide (o À ), hydrogen peroxide (h o ), hydroxyl radical (ho À ), and singlet oxygen ( o ), disturb natural metabolism by inducing oxidative damage to lipids, proteins, nucleic acids, and photosynthesis pigments and enzymes (ozkur et al., ; smirnoff, ) . to prevent oxidative stress, plants employ enzymatic and non-enzymatic antioxidant defence mechanisms to scavenge ros (smirnoff, ) . there is evidence from various plant systems indicating that environmental stress, particularly drought and salt stresses, alters the quantities, activities and steady-state mrna levels of enzymes involved in oxygen radical scavenging (gueta-dahan et al., ) . it has been found that triterpenoids display antioxidant activity (okubo and yoshiki, ) . it has been demonstrated that glycyrrhizin and its hydrolysed metabolite b-glycyrrhetinic acid from g. glabra play an important role in ros scavenging, resulting in a significant reduction in oxidative damage (kim and lee, ) . as mentioned above, not only are glycyrrhizin and its derivatives involved in plant defence responses, but they also display important pharmaceutical activities. thus, the identification of key genes involved in glycyrrhizin production, as well as the conditions under which gene expression reaches to a maximal level, is of interest to the biomedical industry. to determine the optimal conditions under which glycyrrhizin production is maximally increased, we applied various drought stresses and assessed the expression levels of key genes, including sqs, bas, lus and cas, that are involved in triterpenoid saponin production. in addition, we assessed the enhancement of glycyrrhizin production in liquorice stolons treated with different wa tering regimes at various stages. at the seedling stage, the rwc of the entire seedlings was significantly decreased (p < . ) throughout the experimental period ( , and h) under the water-stressed conditions achieved using % (w/v) peg , reaching a minimum value at h ( fig. ) . at the adult plant stage, -month-old plants were selected for drought stress treatment, in which irrigation was discontinued thereafter. the stolons of these plants were collected after , and days of water stress, designated as s d , s d , and s d, respectively. the control plants (c d , c d and c d ) were maintained under normal irrigation conditions. no significant difference was detected in the rwc between the s d and c d samples, indicating that s d was not significantly stressed. however, the rwc was significantly reduced (p < . ) in the s d and s d samples compared to their corresponding controls (c d and c d , respectively). s d was considered as moderate stress, whereas s d displayed more severe stress. there was no significant difference in the rwc between the control samples from c d , c d and c d (data not shown) (fig. ) . we assessed the gene expression levels of sqs, bas, cas and lus at the seedling stage under drought stress conditions for four durations ( , , and h) and compared these expression levels the rwc of liquorice stolons subjected to drought stress. the control plants (c d , c d and c d ) were maintained under normal irrigation conditions. for the water-stressed plants (s d , s d and s d ), irrigation was discontinued, and the samples were collected after , and days after withdrawing irrigation, respectively. the values are expressed as the means of replicates. the mean values of each sample were analysed using the t-test to compare the corresponding control and stress treatments. the differences were considered to be significant if p < . , as indicated by an asterisk ( ⁄ ). to those of the control plants via semi-quantitative pcr using genespecific primers. the data in fig. illustrate the levels of sqs expression in liquorice seedlings over time. the expression level of sqs under stress conditions was increased shortly after stress treatment ( h) compared to the control conditions and remained unchanged afterwards. similarly, the expression level of bas gene under stress conditions (at , and h after stress treatment) was higher than that of the control samples. in contrast, the gene expression level of cas was unchanged throughout the duration of osmotic stress compared to that of the control conditions. the level of lus gene expression was not detectable in this experiment (data not shown). the gene expression of bas, sqs, cas and lus in stolons was also analysed semi-quantitatively for two durations of stress treatment (c d , s d c d , and s d ). the results revealed that the gene expression levels of sqs in the s d and s d samples were higher than those of the control samples (c d and c d , respectively). the highest gene expression levels of sqs were detected in the s d sample (fig. ) . the expression levels of the bas gene at s d and s d were significantly higher than those of the respective c d and c d controls. the mrna expression level of bas was higher in the s d sample than the s d sample (fig. ) . on the other hand, the gene expression level of cas was relatively constant throughout the drought stress (fig. ) . the gene expression level of lus was not detectable in this experiment (data not shown). effects of drought stress on the production of glycyrrhizin in stolons of liquorice hplc analysis was performed to compare the glycyrrhizin content in the stolons of water-stressed samples (s d , s d and s d ) and their respective controls (c d , c d and c d ). the results revealed that the glycyrrhizin content in the s d sample was the highest of all of the samples, up to . -fold greater than that of the control plants (p < . ), indicating that under severe stress conditions, glycyrrhizin production can be enhanced in the stolons of liquorice plants. the glycyrrhizin content in other samples, including c d , s d , s d , c d , s d and c d , was not significantly different (fig. ). the enzymes sqs, bas cas and lus are known to be involved in triterpenoid synthesis (hayashi, ) . sqs converts squalene to , -oxidosqualene, which serves as the substrate for the synthesis of glycyrrhizin and other triterpenoids. cas, bas, and lus encode oscs, which catalyse the cyclisation of , -oxidosqualene, a precursor of glycyrrhizin, betulinic acid and sitosterol (abe et al., ; haralampidis et al., ) . glycyrrhizin, soyasaponins and betulinic acid are located in different regions of intact liquorice plants, and the biosynthetic regulation of these constituents is also specific. it was previously demonstrated that the expression level of oscs was the most influential regulator of glycyrrhizin biosynthesis (hayashi, ). in addition, gene expression analysis revealed that the transcriptional expression level of bas was higher in cell culture and thickened main roots and root nodules of liquorice plants (hayashi, ) . choi et al. ( ) demonstrated that the gene expression of sqs was up-regulated in hairy root cultures of panax ginseng by treatment with methyl jasmonate (meja). . the expression levels of sqs, bas and cas in stolons of g. glabra in waterstressed samples (s d and s d refer to the samples subjected to or days after withdrawal of irrigation, respectively) and control samples (c d and c d refer to control samples that remained under optimal irrigation conditions). fig. . the effects of drought stress on the glycyrrhizin content of stolons. c d and c d refer to the samples cultivated under optimal irrigation conditions as controls. s d , s d and s d refer to water-stressed samples cultivated for , and days after withdrawal of irrigation, respectively. ⁄, significant differences compared to control values, which were calculated using the independent sample t-test (p < . ). in another study, up-regulation of the sqs and bas genes via meja and salicylic acid (sa) was reported (chen et al., ; suzuki et al., ) . in contrast, application of gibberellin a resulted in downregulation of bas, but the gene expression levels of lus and cas were unchanged. likewise, the gene expression levels of sqs and bas were down-regulated in g. glabra cells after addition of yeast extract to the cell culture. the mrna level of lus was down-regulated in g. glabra cells treated with jasmonate acid (ja) or meja, whereas under the same conditions, the mrna level of the cas gene was not altered (hayashi et al., ) . in addition, the cas mrna levels in the thickened main roots of g. glabra remained relatively constant throughout the seasons, indicating that the cas gene displays housekeeping gene-like expression in g. glabra (hayashi et al., ) . in agreement with these findings, our results also revealed that the gene expression of cas remained constant in plants grown under drought stress or control conditions. hayashi et al. ( ) reported that the level of lus mrna was not detectable under various cultivation conditions, which is similar to our finding that the expression of the lus gene was not detectable (data not shown). chen et al. ( ) found that the transcriptional expression level of bas in the roots of bupleurum kaoi was doubled due to treatment with meja. additionally, it was reported that the transcriptional expression level of bas was significantly increased in liquorice and medicago truncatula plants due to treatment with salicylic acid (suzuki et al., ) . pan et al. ( ) found that when glycyrrhiza uralensis seedlings were exposed to drought stress, the antioxidant enzymes were hyper-activated. studies using various plant systems demonstrated that environmental stress, including drought or salt stress, enhances the transcriptional expression levels and the activities of enzymes involved in oxygen radical scavenging (gueta-dahan et al., ) . drought stress generally stimulates oxidative stress (lei et al., ) resulting in the formation of ros in organelles, including chloroplasts and mitochondria (fu and huang, ) . subsequently, as a feed-back regulation mechanism, triterpenoids are produced as an antioxidant to scavenge ros (okubo and yoshiki, ) . there are many pieces of evidence indicating that glycyrrhizin and its hydrolysed metabolite b-glycyrrhetinic acid exert antioxidant effects (kim and lee, ) . in bupleurum spp., an incremental effect of drought stress on the levels of triterpenoids was also reported (zhu et al., ). triterpenes and aand b-amyrin metabolites extracted from jatropha gaumeri leaves displayed antioxidant activity (can-aké et al., ) . in hypericum brasiliense, the content of various betulinic acids was greatly higher in plants grown under drought stress than control conditions (nacif de abreu and mazzafera, ). nacif de abreu and mazzafera ( ) also reported that the total level of secondary metabolites in h. brasiliense was increased under drought stress compared to normal conditions. it has been reported that the three osc genes are differentially regulated. for example, the mrna level of bas is up-regulated by meja, whereas that of lus is down-regulated by meja (hayashi et al., ) . furthermore, the mrna level of bas is down-regulated by ga , whereas that of lus transcript is unchanged by ga (hayashi et al., ) . in contrast, the level of cas mrna is not altered when either meja or ga is applied (hayashi, ) . similarly, our results demonstrated that the expression of the sqs and bas genes is differentially regulated under drought stress. based on our results, drought stress increased the expression level of sqs and bas, whereas that of cas was unchanged. under drought stress, the concentration of enzymatic and nonenzymatic antioxidants tended to increase (pan et al., ) . increasing evidence indicates that glycyrrhizin, a triterpenoid saponin found in g. glabra, exerts an anti-oxidant effect, reducing oxidative damage (kim and lee, ) . drought stress increased the levels of glycyrrhizin in the stolons of g. glabra. based on our results, the level of glycyrrhizin was increased under the severe stress condition (s d ). in contrast, there was no increase in the concentration of glycyrrhizin in samples that were subjected to moderate stress (s d ). our results indicated that the glycyrrhizin content was only influenced by intense drought stress. glycyrrhizin is extracted from the liquorice of wild or cultivated glycyrrhiza plants. the recent over-utilisation of wild glycyrrhiza plants has resulted in a reduction in its natural reserves. cultivated glycyrrhiza is grown in some countries, but the glycyrrhizin content extracted from these plants is often low (hayashi and sudo, ). thus, identifying the conditions under which glycyrrhizin production is maximised is of interest. in this study, we found that drought stress increased the expression of important genes involved in the glycyrrhizin biosynthetic pathway. this result indicates that intense drought stress, as well as periodic drought stress, may help to increase the glycyrrhizin content in liquorice plants. therefore, we propose applying special irrigation regimes to directly enhance secondary metabolite production. this is technique a simple and inexpensive, but further investigation is required to optimise metabolite production. seeds of liquorice plants (g. glabra) were provided by pakan-bazr seed production company (isfahan, iran). the seeds table list of specific primers used in this study. sqs, sequalene synthase; bas, b-amyrin synthase; cas, cycloartenol synthase; and lus, lupeol synthase. accession were disinfected using h so ( %) for min and washed three times with sterile distilled water. the seeds were then allowed to germinate on sterile filter paper moistened with sterile distilled water in petri dishes. three-day-old seedlings were transferred to petri dishes padded with sterilised filter paper soaked with  hoagland solution and incubated at ± °c for a photoperiod of h of light. the drought stress experiment at seedling stage was performed by selecting -day-old seedlings displaying uniform growth. the seedlings were moved to filter paper soaked with distilled water containing % (w/v) peg to induce drought stress conditions. the entire seedlings were harvested for further analysis after , , or h of treatment. the drought stress experiment at the adult plant stage was performed as follows. first, stolons of liquorice plants were obtained from rishmac company in shiraz, iran, and were grown in pots in a greenhouse. each experiment was performed as a randomised complete block design (rcbd) with four replications. water stress treatment was performed on -month-old plants by discontinuing irrigation. subsequently, sampling was performed at , and days after drought imposition, designated as s d , s d and s d , respectively, while control plants (designated as c d , c d and c d , respectively) were maintained under optimal irrigation conditions. the samples of stolons were collected, immediately frozen in liquid n and stored at À °c for further analysis. the relative water content (rwc) of leaves and seedlings was calculated using the formula [(fresh weight-dry weight)/(saturated weight-dry weight)] * , as described previously (slatyer, ) . fresh leaves from the treated and control plants were weighed immediately after harvesting. the saturated weight was measured after placing the leaves in vials containing distilled water at °c for h and then blotting the leaves on dry filter paper. the samples were dried in an oven for h at °c, and the dry weight of samples was measured. analysis of variance was performed on the data using spss software (version ), and significant differences compared to the control values were determined using duncan's multiple range test and the independent sample t-test. total rna extraction and cdna synthesis total rna was extracted from stolons of g. glabra using rnx plus solution (cinnagen, iran) according to the manufacturer's instructions. to remove genomic dna contamination, total rna was treated with rnase-free dnase. the concentration of rna was estimated via spectrophotometry. approximately lg of total rna from each sample was subsequently subjected to first strand cdna synthesis using random hexamer primers and a m-mulv reverse transcriptase kit (cinnagen, iran) according to the manufacturer's instructions. pcr was performed on aliquots of the cdna templates to determine the gene expression levels of sqs, bas, cas and lus using a thermal cycler (eppendorf) under the following parameters: °c for min, followed by cycles of denaturing at °c for s, annealing at °c (sqs), °c (bas( )), °c (bas( )) or °c (cas) for s and extension at °c for s, and a final extension step at °c for min. the pcr primers used in this study were synthesised by bioneer (seoul, korea). the primers were designed using primer software (developed by steve rozen, helen j. skaletsky, , ) available on-line at http://www-genome.wi.mit.edu. the sqs, bas, cas and lus genes were amplified using the specific primers listed in table . s ribosomal rna (accession no. x ) was used as an internal control (shabani et al., ) . the pcr products ( ll) were electrophoresced on % agarose gels in tbe buffer and visually quantified. stolons were air-dried at room temperature for days. to measure the glycyrrhizin content of each sample, mg of dried stolon was lyophilised and subjected to glycyrrhizin extraction using ml of % (v/v) methanol at °c for h. the samples then were centrifuged at rpm for min at room temperature. the supernatant was transferred to a new tube and then evaporated to dryness using nitrogen (hayashi et al., ) . the residue extracts were used for high-performance liquid chromatography (hplc). a glycyrrhizin standard (glycyrrhizic acid ammonium salt) was purchased from fluka (switzerland). preceding hplc analysis, the residual extract of each sample was dissolved in water and filtered using a . lm filter. a ll aliquot of each sample extract was analysed via hplc at °c. the hplc system consisted of a waters hplc pump and a waters detector. the separation of glycyrrhizin was performed according to the method described previously (hurst et al., ) as an isocratic elution using methanolwater-acetic acid ( : : ) at a flow rate of ml/min through a rp column ( .  mm), followed by measurement of uv absorbance at nm. analysis of variance was performed on the data using spss software (version ), and significant differences compared to the control values were determined using duncan's multiple range test. enzymatic cyclization of squalene and oxidosqualene to sterols and triterpenes herbivore-induced responses in alfalfa (medicago sativa) licorice (glycyrrhiza glabra) bioactive terpenoids from roots and leaves of jatropha gaumeri meja-induced transcriptional changes in adventitious roots of bupleurum kaoi analysis of transcripts in methyl jasmonate-treated ginseng hairy roots to identify genes involved in the biosynthesis of ginsenosides and other secondary metabolites glycyrrhizin, an active component of liquorice roots, and replication of sarsassociated coronavirus triterpenoid saponins from pteleopsis suberosa stem bark involvement of antioxidants and lipid peroxidation in the adaptation of two cool-season grasses to localized drought stress glycyrrhiza in old and new perspectives molluscicidal saponins of polyscias dichroostachya salt and oxidative stress: similar and specific responses 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aculeatus and galphimia glauca cultured plants glycyrrhizin and related compounds down-regulate production of inflammatory chemokines il- and eotaxin in a human lung fibroblast cell line effect of water and temperature stress on the content of active constituents of hypericum brasiliense choisy the role of triterpenoid on reactive oxygen scavenging system: approach from the new chemiluminescence system (xyz system) saponins and plant defence -a soap story physiochemical and antioxidant responses of the perennial xerophyte capparis ovata desf. to drought effect of salt and drought stress on antioxidant enzymes activities and sod isoenzymes of liquorice (glycyrrhiza uralensis fisch) anti-allergic activity of beta-glycyrrhetinic acid- -o-beta-d-glucuronide influencing the product quality by deliberately applying drought stress during the cultivation of medicinal plants assessment of squalene synthase and beta-amyrin synthase gene expression in liquorice roots treated with methyl jasmonate and salicylic acid using real-time qpcr a drug over the millennia: pharmacognosy, chemistry, and pharmacology of liquorice plant-water relationships the role of active oxygen in the response of plants to water deficit and desiccation methyl jasmonate and yeast elicitor induce differential transcriptional and metabolic re-programming in cell suspension cultures of the model legume medicago truncatula effects of glycyrrhizin on hepatitis b surface antigen: a biochemical and morphological study saponins, classification and occurrence in the plant kingdom on the origins of triterpenoid skeletal diversity saikosaponin accumulation and antioxidative protection in drought-stressed bupleurum chinense dc. plants key: cord- -tv aakj authors: musolino, anna maria; supino, maria chiara; buonsenso, danilo; ferro, valentina; valentini, piero; magistrelli, andrea; lombardi, mary haywood; romani, lorenza; d'argenio, patrizia; campana, andrea title: lung ultrasound in children with covid- : preliminary findings date: - - journal: ultrasound med biol doi: . /j.ultrasmedbio. . . sha: doc_id: cord_uid: tv aakj abstract— recent evidence indicates the usefulness of lung ultrasound (lus) in detecting coronavirus disease (covid- ) pneumonia. however, no data are available on the use of lus in children with covid- pneumonia. in this report, we describe lus features of consecutively admitted children with covid- in two tertiary-level pediatric hospitals in rome. lus revealed signs of lung involvement during covid- infection. in particular, vertical artifacts ( %), pleural irregularities ( %), areas of white lung ( %) and subpleural consolidations ( %) were the main findings in patients with covid- . no cases of pleural effusions were found. according to our experience, the routine use of lus in the evaluation of children with suspected or confirmed covid- , when performed by clinicians with documented experience in lus, was useful in diagnosing and monitoring pediatric covid- pneumonia, reducing unnecessary radiation/sedation in children and exposure of health care workers to severe acute respiratory syndrome coronavirus (sars-cov- ). initially described in china in december , severe acute respiratory syndrome coronavirus (sars-cov- ) has spread all over the world, infecting more than million people and causing thousands of deaths (zhu et al. ) . humans of all age groups are susceptible, including the youngest. although currently pediatric coronavirus disease appears to be less severe compared with the adult form, children are by no means spared. several case series (dong et al. ; lu et al. b; qiu et al. ; tagarro et al. ) have documented that covid- can affect children of all ages, from newborns to adolescents. importantly, covid- pneumonia has also been described in asymptomatic or pauci-symptomatic children (dong et al. ; lu et al. a; qiu et al. ) . although a nasopharyngeal swab is required for a definitive etiologic diagnosis, this test has limitations, particularly because of its low sensitivity . for this reason, several authors have suggested the use of chest computed tomography (ct) not only for diagnosis of covid- pneumonia, but also as a screening tool for the diagnosis of covid- infection in epidemic settings, as ct has been reported to have better diagnostic sensitivity than nasopharyngeal swab (ai et al. ) . conversely, rubin et al. ( ) suggested an appropriate use of imaging, selecting those patients that might benefit from the adjunctive information contained in images. however, ct scan should not be routinely used in specific age groups, such as pregnant women (moro et al. ) and children. moreover, covid- has become a global disease, logistic difficulties or unavailability of ct scan in low-and medium-resource settings must be considered. on the other hand, chest x-ray does not have sufficient sensitivity and specificity for detecting covid- pneumonia to be considered as an alternative tool to ct scan. in this context, recent evidence has indicated the usefulness of lung ultrasound (lus) in detecting covid- pneumonia (buonsenso et al. a; kalafat et al. ; smith et al. ). in particular, both chinese (peng et al. ) and italian (soldati et al. a (soldati et al. , b task forces on the use of lus in covid- have provided the physical bases and lus patterns in covid- patients, suggesting that lus can be a useful tool to diagnose and monitor covid- pneumonia. however, no data are available on the use of lus in children with covid- pneumonia. for this reason, we performed this study with the aim of evaluating the role of lus in children with covid- . we conducted an observational study analyzing lus patterns in consecutively admitted children with covid- infection in two tertiary level pediatric hospitals in rome, beginning march , . all patients with swab-confirmed covid- infection who underwent lus within h from admission were included. the use of lus in the evaluation of children with respiratory infection has been approved by the ethics committees of our institutions. informed consent was obtained from each parent/guardian. lus was performed with a wireless pocket device connected to a probe, which were placed in single-use plastic covers (atl milano, milan, italy), as described by buonsenso et al. ( b) . lus was performed in patients in the sitting position, and all lung areas were scanned, as suggested by soldati et al. ( a) . the two operators responsible for lus are pediatricians with more than y of experience in point-of-care ultrasound and several publications in this setting (buonsenso et al. a (buonsenso et al. , b (buonsenso et al. , c (buonsenso et al. , d musolino et al. a musolino et al. , b . the lus patterns looked for were those described by soldati et al. ( a) : pleural irregularities, subpleural consolidations, vertical artifacts, patchy areas of white lung, pleural effusions. we evaluated consecutively admitted children with covid- with positive real-time polymerase chain reaction on nasopharyngeal swabs. lus was performed on admission when real-time polymerase chain reaction results were still pending. clinical, laboratory and imaging parameters and outcome data are summarized in table . the median age was y (interquartile range: y mo to y). previous medical history was unremarkable in all cases. all patients were symptomatic at the time of admission to the hospital, with fever in %, cough in % and diarrhea in % of cases. anosmia ( %), arthralgia ( %), chest pain ( %) and headache ( %) were also reported. results of laboratory investigations were within normal ranges according to patient age in all cases, with the exception of two children: one had leukopenia, and the other had a slightly altered c-reactive protein level. all children recovered, and none of them required pediatric intensive care admission. in all symptomatic cases, lus revealed signs of lung involvement during covid- infection. in particular, vertical artifacts, areas of white lung and subpleural consolidations and pleural irregularities were the main findings in pediatric covid- pneumonia. there were no cases of pleural effusions. in one case, ct scan was performed, and lus findings correlated well with chest ct (fig. ) . patient was admitted for complex afebrile seizures, so to minimize the child's movements and reduce the risk of nosocomial spread, the lung imaging of choice was magnetic resonance imaging (mri) as an extension of the brain mri dictated by his admitting diagnosis. his pulmonary mri revealed signs of pneumonia, confirming the lus findings. two patients underwent chest x-ray that revealed non-specific, diffuse interstitial thickening. in this study, we found that lus is able to detect lung pathology in children with confirmed covid- . in particular, lus patterns seen in our patients were mainly vertical artifacts, pleural irregularities, subpleural consolidations and patchy areas of white lung. since our proposal for more frequent use of lus in covid- patients (buonsenso et al. b ) and the first description of a patient with vertical artifacts, pleural irregularities and subpleural consolidations (buonsenso et al. d) , growing evidence in adults has revealed that lus is able to detect covid- . during sars-cov- infection is much more frequent in adults than in children; however, the main patterns are similar to those we described in children. both italian sonographers and the chinese critical care ultrasound study group (peng et al. ) described the same patterns in adults. importantly, lus has been documented as an important tool particularly in moderate to severe pneumonia (lu et al. ) and, mainly, in the monitoring of lung disease (moro et al. ). the finding that lus is able to detect covid- pneumonia in children has clinical implications. the chinese task force for pediatric covid- proposed a severity classification, defining children as asymptomatic, mild, moderate, severe or critical cases (dong et al. ) . in particular, the -moderate‖ stage is based on clinical criteria (pneumonia with fever and cough, in the absence of signs of hypoxemia) and/or radiologic criteria, as -some cases may have no clinical signs and symptoms, but chest ct shows lung lesions, which are subclinical‖ (dong et al. ) . in fact, in all the large series of pediatric covid- described in china (dong et al. ; lu et al. ; qiu et al. ) , the authors routinely used ct scan to determine the severity of the disease. this has caused clinicians and researchers from the rest of the world to overuse ct scan in children, even when they are asymptomatic or pauci-symptomatic. however, to date there is no evidence that diagnosis and treatment decisions based on ct scans improve outcomes in pediatric covid- infection. moreover, ct scanning should be used parsimoniously in the pediatric age group because of their increased sensitivity to radiation exposure and because it may require sedation. in fact, international guidelines state that history and examination are the main determinants of pneumonia severity and level of care, reserving imaging to compromised children requiring admission on clinical grounds (bradley et al. ) . importantly, the large number of asymptomatic and mild pediatric cases of covid- (dong et al. ; lu et al. ; qiu et al. ; tagarro et al. ) described so far confirms that radiologic imaging should not be routinely used. in our series, only in two cases were chest xray and ct scan were performed. the small number of patients undergoing traditional imaging is owing mainly to the long experience of our institutions in performing lus, which is currently routine practice in children with respiratory symptoms that we see in our centers. in this context, thanks to the already proven accuracy of lus in detecting pediatric pneumonia of any etiology (pereda et al. ; berce et al. ; musolino et al. ; supino et al. ; buonsenso et al. c) , and in the light of our observational findings, we suggest the routine use of bedside lus in children with suspected or confirmed covid- . as previously suggested (buonsenso et al. b ), lus would also allow the same pediatrician to both perform the physical examination and collect the lung images, with the advantage of reducing the exposure of other health care workers to infected patients. moreover, a multinational consensus statement from the fleischner society (rubin et al. ) provided five main and three additional recommendations intended to guide medical practitioners in the use of chest x-rays and ct in the management of covid- . they concluded, with current knowledge, that (i) imaging is not routinely indicated in patients with suspected covid- and mild clinical features unless they are at risk for disease progression; (ii) imaging is indicated in a patient with covid- and worsening respiratory status; and (iii) in a resource-constrained environment, imaging is indicated for medical triage of patients with suspected covid- who present with moderate-severe clinical features and a high pre-test probability of disease. these guidelines support the appropriate use of imaging and, in this context, point-of-care tools such as lus, particularly in children, who usually have milder manifestations of covid- . the routine use of lus in the evaluation of children with suspected or confirmed covid- , if performed by clinicians with documented experience in lus, could be a useful tool in diagnosing and monitoring covid- pneumonia, while reducing unnecessary radiation/sedation in children and exposure of health care workers to sars-cov- . correlation of chest ct and rt-pcr testing in coronavirus disease (covid- ) in china: a report of cases the usefulness of lung ultrasound for the aetiological diagnosis of community-acquired pneumonia in children pediatric infectious diseases society and the infectious diseases society of america. the management of community-acquired pneumonia in infants and children older than months of age: clinical practice guidelines by the pediatric infectious diseases society and the infectious diseases society of america point-of-care lung ultrasound findings in novel coronavirus disease- pnemoniae: a case report and potential applications during covid- outbreak covid- outbreak: less stethoscope, more ultrasound the use of lung ultrasound to monitor the antibiotic response of community-acquired pneumonia in children: a preliminary hypothesis point-ofcare lung ultrasound findings in novel coronavirus disease- pnemoniaea: a case report and potential applications during covid- outbreak epidemiology of covid- among children in china lung ultrasound and computed tomographic findings in pregnant woman with covid- chinese pediatric novel coronavirus study team. sars-cov- infection in children a clinical study of noninvasive assessment of lung lesions in patients with coronavirus disease- (covid- ) by bedside ultrasound how to perform lung ultrasound in pregnant women with suspected covid- infection lung ultrasound features of children with complicated and noncomplicated community acquired pneumonia: a prospective study lung ultrasound features of children with complicated and noncomplicated community acquired pneumonia: a prospective study chinese critical care ultrasound study group (ccusg). findings of lung ultrasonography of novel corona virus pneumonia during the - epidemic lung ultrasound for the diagnosis of pneumonia in children: a meta-analysis clinical and epidemiological features of children with coronavirus disease (covid- the role of chest imaging in patient management during the covid- pandemic: a multinational consensus statement from the point-of-care lung ultrasound in patients with covid- -a narrative review proposal for international standardization of the use of lung ultrasound for covid- patients: a simple, quantitative, reproducible method is there a role for lung ultrasound during the covid- pandemic [e-pub ahead of print point-of-care lung ultrasound in infants with bronchiolitis in the pediatric emergency department: a prospective study screening and severity of coronavirus disease (covid- ) in children in detection of sars-cov- in different types of clinical specimens china novel coronavirus investigating and research team. a novel coronavirus from patients with pneumonia in china chest x-ray reveals diffuse interstitial disease, with the left lobe more involved. (b) computed tomography scan reveals ground glass and subpleural consolidations. (c, d) lung ultrasound reveals patchy areas of white lung (c) and long, bright we are grateful to all pediatricians and radiologists who actively contributed with both clinical practice and research advice, the romulus covid team: alessia mesturino, barbara variables are expressed as a percentage or median (interquartile range).*this patient underwent lung mri, as brain mri was necessary because the child had complicated afebrile seizures. key: cord- - m f q r authors: brahier, thomas; meuwly, jean-yves; pantet, olivier; brochu vez, marie-josée; gerhard donnet, hélène; hartley, mary-anne; hugli, olivier; boillat-blanco, noémie title: lung ultrasonography for risk stratification in patients with covid- : a prospective observational cohort study date: - - journal: clin infect dis doi: . /cid/ciaa sha: doc_id: cord_uid: m f q r background: point-of-care lung ultrasound (lus) is a promising pragmatic risk stratification tool in covid- . this study describes and compares lus characteristics between patients with different clinical outcomes methods: prospective observational study of pcr-confirmed covid- adults with symptoms of lower respiratory tract infection in the emergency department (ed) of lausanne university hospital. a trained physician recorded lus images using a standardized protocol. two experts reviewed images blinded to patient outcome. we describe and compare early lus findings (acquired within hours of presentation to the ed) between patient groups based on their outcome at days after inclusion: ) outpatients, ) hospitalised and ) intubated/death. normalized lus score was used to discriminate between groups results: between march and april , we included patients ( outpatients, hospitalized and intubated/dead). patients ( %) had abnormal lus ( % outpatients, % hospitalised and % intubated/death; p= . ). the proportion of involved zones was lower in outpatients compared with other groups (median % [iqr - %], % [ - %] and % [ - %], p< . ). predominant abnormal patterns were bilateral and multifocal spread thickening of the pleura with pleural line irregularities ( %), confluent b lines ( %) and pathologic b lines ( %). posterior inferior zones were more often affected. median normalized lus score had a good level of discrimination between outpatients and others with area under the roc of . ( % ci . - . ) conclusions: systematic lus has potential as a reliable, cheap and easy-to-use triage tool for the early risk stratification in covid- patients presenting in eds the coronavirus disease pandemic has overwhelmed the health systems in several high-income settings ( ) , and is now spreading in the low-income countries. there is a critical need for accessible and low cost methods to stratify risk for evidence-based resource allocation ( ). while the majority of covid- patients have a paucisymptomatic or asymptomatic course, some may rapidly deteriorate leading to hospitalisation and the need for respiratory support. it has been suggested that early identification of patients at high risk of respiratory compromise is associated with lower mortality ( ) . several studies have shown the predictive value of ct imaging, where the extent and patterns of lung involvement correlated well with severity of covid- on admission to hospital. other studies have described a progression of lung anomalies on consecutive chest cts during the course of the disease, with rapid evolution from focal unilateral to diffuse bilateral ground-glass opacities and finally, consolidation ( ) . however, ct imaging has important limitations in triaging patients during the context of covid- , not only due to their limited availability, high cost and exposure to radiation, but more critically, due to their immobile nature, thus necessitating the movement of infectious patients ( ) . point-of-care ultrasound applied to lung is a promising alternative diagnostic tool, which can shorten time-to-diagnosis for the aetiology of acute dyspnoea, as well as stratify severity in the emergency department (ed) ( ) . it is widely used in routine practice of swiss eds, can be performed at the bedside without radiation exposure and is easy-to-use in patients requiring protective isolation. so far, the use of lung ultrasonography (lus) in covid- has only been described in cohorts of severe hospitalised patients ( ) ( ) ( ) ( ) . however, it has already shown excellent performance to detect non-covid- pneumonia, compared to ct as a reference standard ( ) , and matches the discriminative power of ct in patients with acute respiratory distress syndrome (ards) ( ) . a c c e p t e d m a n u s c r i p t lus has potential in the pragmatic triage of covid- patients especially in low-resource settings. this study aims to describe lus characteristics in a prospective cohort of patients with covid- and explore their predictive capacity for risk stratification. this study is nested in a prospective cohort study of patients with lower respiratory tract infections, which started on february th , in the ed of the lausanne university hospital, switzerland. we prospectively screened consecutive adult patients (age ≥ years) presenting in the ed with an acute lower respiratory tract infection (cough, sputum, dyspnoea or chest pain for < days) ( ) . patients with covid- confirmed by real time polymerase chain reaction (rt-pcr) for sars-cov- in a nasopharyngeal swab were included in this study. patients were excluded if lus could not be performed within hours of admission or if the patient was receiving therapeutic prone ventilation before the lus. the study team collected patient's data using a standardized electronic case report form in redcap® (research electronic data capture). we assessed day- outcome by checking the electronic health record and we classified patients in three groups: group (outpatients: absence of admission within days of inclusion); group (hospital admission within days of inclusion); group (intubation and/or death within days of inclusion). a c c e p t e d m a n u s c r i p t a trained physician (tb) in lung ultrasonography performed all lus at inclusion in the ed. acquisition was standardized according to the " -zone method" ( , ) . two images (sagittal and transverse) and second videos were systematically recorded in every zone with a butterfly iq tm , using the lung preset. the study physician (tb) and an expert radiologist (jym) standardized the reporting of pathological lus features based on covid- patterns (figure ) (e- figure , e- figure and video v in the online data supplement) ( , ) . for every zone, the following patterns were reported: ( ) normal appearance (a lines, < b lines), ( ) pathologic b lines (≥ b lines), ( ) confluent b lines, ( ) thickening of the pleura with pleural line irregularities (subpleural consolidation < cm) or ( ) consolidation (≥ cm). the presence of pleural effusion was also recorded. the lus score, used as a correlate of loss of lung tissue aeration, as well as a normalized lus score (nlus score) corrected for the number of examined zone, were calculated in every patient ( , , ) . blinded to patient outcome, both physicians independently filled the standardized report. discordance between the two readers was resolved by a third expert (op). supplementary table shows the potential correlation of visible features between ct and lus images based on physical explanations behind their generation in several retrospective human studies ( , ( ) ( ) ( ) ( ) an animal study ( ) and biomedical analysis ( ) . differences between the three groups was evaluated by one-way anova, kruskal-wallis or chi-squared test, as appropriate. a bilateral p value < . was considered indicative of a c c e p t e d m a n u s c r i p t statistical significance. the kappa coefficient was calculated to measure the inter-rater agreement between the two lus readers. the prognostic accuracy of the lus score, the nlus score and the proportion of lus affected zones to predict outcome was assessed by calculating the area under the receiver operating characteristic curve (auroc). we determined the optimal nlus score cut-off by choosing the value with the best sensitivity and a specificity superior to %. ethical approval was granted by the swiss ethics committee of the canton of vaud (cer-vd - ). table shows demographics, clinical characteristics and laboratory results of the study population by group. overall, the mean age was years (sd years), and ( %) patients were female. outpatients were significantly younger than patients in the other two groups (mean of years, p= . ). at inclusion, the median duration of symptoms was days (iqr - ) and not different between groups. the most common symptoms were cough ( %), fever ( %) and dyspnoea ( %). dyspnoea occurred with increasing frequency across severity groups (p= . ). heart and respiratory rates were lower in outpatients compared with patients in the other two groups (median /min vs /min, p= . and /min vs /min, p= . , respectively). leukocyte count and c-reactive protein were significantly and gradually higher with increasing severity. overall, eight patients ( %) had a ct scan and % had a chest x-ray. x-rays were abnormal in % and outpatients had fewer abnormal x-rays than patients in the other two groups ( . % versus %, p< . ). among patients with a normal chest x-ray ( in the hospitalized group, one in the intubated/death group), had lus abnormalities. at ed inclusion, patients ( %) had an abnormal lus, the proportion of which increased progressively across severity groups to reach % in intubated/death patients (p= . ) ( table ) . a total of lung zones were explored with lus in all patients. a median of zones were recorded for each patient (iqr , ); zones (iqr , ) in outpatients, zones (iqr , with increased severity, lung anomalies affected both apical and basal lung regions (e- figure in the online data supplement) and were more bilaterally distributed. figure ). in terms of the predominant abnormal lus pattern, outpatients mostly had a "non-confluent b lines" pattern, while the other two groups more frequently presented with "thickening of the pleura with pleural line irregularities" pattern (e- figure in the online data supplement). while the patterns of "pathologic b lines" and "confluent b lines" were more commonly the median lus score was (iqr , ) and the median nlus score was . (iqr . - the optimal nlus score cut-off to differentiate between outpatients and admitted patients including those who were intubated or died was . (sensitivity %, specificity %, positive predictive value %, negative predictive value %, positive likelihood ratio . , negative likelihood ratio . ). if this nlus score had been used at the first ed visit, it would have correctly recommended primary hospitalisation for the three patients who were initially discharged (later returning for secondary hospitalization). the lus score, the nlus score and the proportion of affected zones had a poor level of discrimination between patients who died or were intubated and the other two groups. the two observers showed good reproducibility for all explored zones with a kappa of . based on the standardized us report. the reproducibility was excellent to differentiate normal and abnormal zones with a kappa of . . despite the potential of lus as a cheap, portable and accessible point-of-care triage tool in acute respiratory disease (especially in low resource settings), a multinational consensus recently stated that the lack of studies limited specific recommendations for the management of covid- patients ( ) . using a standardized approach in a prospective ed cohort of patients, we described the characteristics of lus findings in covid- pneumonia. most a c c e p t e d m a n u s c r i p t patients presented abnormal lus with bilateral and multifocal involvement as previously shown in a large ct scan study ( ) . the most common patterns seen on lus in decreasing frequency were thickening of the pleura with pleural line irregularities, confluent b lines, pathologic b lines and rarely, consolidations and minor pleural effusions. abnormalities affected all lung regions but were more frequent in posterior and inferior zones. lus findings also evolved with increasing disease severity, both in anatomic scope (progressing from unilateral to bilateral and pan-lung involvement), and pathological type (progressing from the "non-confluent b lines" pattern to "irregular pleural thickening"). we also describe a risk gradient in lus findings that can be summarised in a simple ordinal scoring system (lus score) which was able to discriminate between outcome groups in ed a c c e p t e d m a n u s c r i p t triage. the lus score can be used to quantify the loss of lung aeration and is thus useful for monitoring patients with ards. this simple lus scoring method may help in assessing covid- disease severity and support ed triage to decide on admission or close monitoring. previous studies have evaluated the lus score in covid- patients. in the intensive care unit, the lus score was higher in patients with refractory respiratory failure compared with others ( ) . a good correlation existed between the lus score and a ct scan severity score. both scores correlated with clinical severity ( , ). in our study, lus score also increased progressively according to clinical severity. however, we did not have the power to predict intubation and/or death with a good accuracy. to our knowledge, our study is the first including the complete range of disease severity, i.e.outpatients and patients who were intubated or died. our findings provide additional evidence that the lus score could be used as a triage tool to decide on admission. the role of lus to evaluate several respiratory diseases such as pneumonia and ards has been widely documented ( , ) . lus has several advantages over chest ct such as its ease-of-use at point-of-care, low cost, absence of radiation, reproducibility and a reduced risk of nosocomial infection through its portability (reducing patient transport to imaging suites and lengthy disinfection protocol for the ct suite) ( , ). lus allows a rapid assessment of severity at presentation in the ed. this study also shows that physicians with basic training in us ( -day theoretical course and supervised acquisitions) are able to identify pathology with excellent concordance compared with experts: a critical proof of concept for its rapid deployment in covid- and for its general use in low resource settings. this study does not correlate lus with chest ct imaging. however, current recommendations specify that ct imaging should not be used for screening and is rather reserved for hospitalised, symptomatic patients, with specific indications ( ). interestingly, two studies showed that the lus and ct scan scores have good agreement in the assessment a c c e p t e d m a n u s c r i p t of clinical severity ( , ). excluding chest ct from the inclusion criteria eliminates a potential selection bias. on the other hand, we cannot propose a direct correlation between ct imaging and lus. acquisition of lus is dependent on the accessibility of anatomic sites, which is sometimes challenging in respiratory patients unable to mobilise. indeed, this study reported approximately % of missing values in posterior lung regions, which were mostly in severely ill patients. we mitigated this bias by normalising our score according to the number of available zones. regardless the discriminatory power of the score reveals that the predictive capacity of accessible zones is already highly informative. work is underway to identify the most informative zones and devise personalised imputations for such missing values. lus image interpretation is operator dependant, which is a potential disadvantage of this technique. however, in our study, we found a good agreement between the two observers. furthermore, using a standardized procedure and a pre-defined scoring method could minimize this limitation. in conclusion, lus is a promising tool for early risk stratification in covid- . lung involvement visualized with us correlates with disease severity and summarising this into a simple ordinal scoring system has potential to discriminate patients requiring hospitalisation in the ed and thus better allocate scarce resources. work is ongoing to confirm these findings in a larger outpatient cohort. glasgow coma scale < ; n (%) ( . ) ( ) ( ) ( ) . leukocyte count, g/l; median (iqr) . ( . , . ) ( . , . ) . ( . , . ) . ( . , ) < . :m . . who. home care for patients with covid- presenting with mild symptoms and management of their contact. the world health organisation lower mortality of covid- by early recognition and intervention: experience from jiangsu province clinical characteristics of coronavirus disease in china. the new england journal of medicine admission chest ct score predicts -day outcome in patients with covid- coronavirus disease (covid- ): a systematic review of imaging findings in patients radiological findings from patients with covid- pneumonia in wuhan, china: a descriptive study. the lancet infectious diseases clinical diagnostic value of ct imaging in covid- with multiple negative rt-pcr testing point-of-care ultrasonography for evaluation of acute dyspnea in the ed chinese critical care ultrasound study g. findings of lung ultrasonography of novel corona virus pneumonia during the - epidemic. intensive care medicine a clinical study of noninvasive assessment of lung lesions in patients with coronavirus disease- (covid- ) by bedside ultrasound can lung us help critical care clinicians in the early diagnosis of novel coronavirus (covid- ) pneumonia? radiology our italian experience using lung ultrasound for identification, grading and serial follow-up of severity of lung involvement for management of patients with covid- lung ultrasound in diagnosing pneumonia in the emergency department: a systematic review and meta-analysis thoracic ultrasonography: a narrative review guidelines for the management of adult lower respiratory tract infections--full version. clinical microbiology and infection : the official publication of the european society of clinical microbiology and infectious diseases thoracic ultrasound: technique, applications, and interpretation international evidence-based recommendations for point-of-care lung ultrasound proposal for international standardization of the use of lung ultrasound for patients with covid- : a simple, quantitative, reproducible method the value of lung ultrasound score on evaluating clinical severity and prognosis in patients with acute respiratory distress syndrome semiquantitative lung ultrasound scores in the evaluation and follow-up of critically ill patients with covid- : a single-center study covid- pneumonia manifestations at the admission on chest ultrasound, radiographs, and ct: single-center study and comprehensive radiologic literature review chest ct manifestations of new coronavirus disease (covid- ): a pictorial review comparative study of lung ultrasound and chest computed tomography scan in the assessment of severity of confirmed covid- pneumonia b-lines quantify the lung water content: a lung ultrasound versus lung gravimetry study in acute lung injury on the physical basis of pulmonary sonographic interstitial syndrome the role of chest imaging in patient management during the covid- pandemic: a multinational consensus statement from the fleischner society ct imaging features of patients with covid- : a meta-analysis frequency of abnormalities detected by point-of-care lung ultrasound in symptomatic covid- patients: systematic review and meta-analysis. the american journal of tropical medicine and hygiene early recognition of the pandemic influenza a (h n ) pneumonia by chest ultrasound lung ultrasound score in evaluating the severity of coronavirus disease (covid- ) pneumonia how to face the novel coronavirus infection during the - epidemic: the experience of sichuan provincial people's hospital. intensive care medicine iqr) ( , ) we thank all the patients who accepted to participate and make this study possible. we thank professor carron, head of the emergency department, who supported the study. we thank all healthcare workers of the emergency department, internal medicine ward, infectious disease service and intensive care unit of the university hospital of lausanne, who managed covid- a c c e p t e d m a n u s c r i p t a c c e p t e d m a n u s c r i p t key: cord- -jtouafgd authors: lu, xiao; zhang, mao; qian, anyu; tang, luping; xu, shanxiang title: lung ultrasound score in establishing the timing of intubation in covid- interstitial pneumonia: a preliminary retrospective observational study date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: jtouafgd purpose: to investigate the role of lung ultrasound score (lus) in assessing intubation timing for patients with severe acute respiratory syndrome coronavirus (sars-cov- ) pneumonia. materials and methods: seventy-two patients with critical coronavirus disease (covid- ) were admitted to a makeshift intensive care unit (icu). all patients underwent bedside lung ultrasonography one to two times per day. the patients were either intubated, treated with noninvasive ventilation (niv), or given high-flow nasal cannula (hfnc) after a discussion with the multidisciplinary group after their conditions worsened. bedside lung ultrasound was performed daily after intubation, and patients received mechanical ventilation. lung ultrasound was performed on days , , , , and after patients were admitted to the icu; if the patient was intubated, lus determination was performed before intubation within h (t ) and on days , , , and after intubation (t , t , t , and t , respectively).the goal of this study was to evaluate the severity of lung aeration loss in intubated and non-intubated patients with sars-cov- pneumonia by ultrasound at different time points within one week. results: a total of patients were included in this study, including nine who were intubated and mechanically ventilated and seven patients without intubation. the number of elderly individuals in the intubated group was higher than in the non-intubated group (p < . ). in addition, there were more male than female patients in both groups. patient characteristics (bmi, sofa, and pao( )/fio( ) value) were similar between the two groups (p > . ). the -day mortality rate of intubated patients was higher than that of non-intubated patients; six patients in the intubated group and two patients in the non-intubated group died. nine intubated patients showed changes in lus within seven days (n = ). the mean lus within h before intubation was . ± . . lus was significantly higher on t than on t (p < . ), and did not significantly differ from t to t . comparing lus between intubated and non-intubated patients on t showed that the lus of intubated patients was significantly higher than that of non-intubated patients (p < . ). between the two patient groups, oxygenation index was . ± . vs. . ± . on t , and the respiratory rate of the two groups was ± vs. ± breaths/min. neither oxygenation index nor rr significantly differed between the two groups. conclusion: lus may be an effective tool for assessing intubation timing in critically ill patients with covid- interstitial pneumonia. a total of patients were included in this study, including nine who were intubated and mechanically ventilated and seven patients without intubation. the number of elderly individuals in the intubated group was higher than in the non-intubated group (p < . ). in addition, there were more male than female patients in both groups. patient characteristics (bmi, sofa, and pao /fio value) were similar between the two groups (p > . ). the -day mortality rate of intubated patients was higher than that of non-intubated patients; six patients in the intubated group and two patients in the non-intubated group died. nine intubated patients showed changes in lus within seven days (n = ). the mean lus within the coronavirus disease (covid- ) outbreak began in december and rapidly spread to different areas of mainland china. on march , , who declared covid- a pandemic. the most common and severe complication in patients with covid- is acute hypoxemic respiratory failure or acute respiratory distress syndrome (ards), which requires oxygen and ventilation therapies [ ] . some critically ill patients require intubation and invasive ventilation [ ] . a number of patients with covid- present with "silent" or "happy hypoxia," in which the body's oxygen levels are well below %, yet patients are still able to breathe normally. for these patients, there is no shortness of breath, fast or shallow breathing, and likely no signs, symptoms, or sense that something may be wrong. few studies have addressed the timing of intubation for patients with severe acute respiratory syndrome coronavirus (sars-cov- ) pneumonia due to the high mortality of patients treated with invasive ventilation. the histopathology of initial covid- pneumonia is characterized by alveolar damage, which includes alveolar edema, while the inflammatory component is patchy and mild [ ] . the analysis of the available ct data from patients with covid- pneumonia [ ] shows largely bilateral lesions, which are patchy and confluent, with a ground glass or mixed consolidative and ground glass pattern. to date, current literature from china and italy doses not recommend the use of lung ultrasounds to diagnose covid- . however, lung ultrasounds are known to potentially assist in monitoring lung conditions [ ] . it has also been proven that lung ultrasound findings can be suggestive of a wide range of conditions, including pulmonary edema, pleural effusion, and pneumothorax [ ] . lung ultrasounds have also proven capable of detecting lung lesions before the development of hypoxemia in ards patients [ ] . ultrasounds can accurately quantify the loss of pulmonary aeration before, after, and during the weaning trial by calculating the lung ultrasound score (lus) [ ] . one prospective two-center study involving patients has demonstrated that the intensity of lung aeration loss occurring during the weaning trial is predictive of post-extubation respiratory distress within h of extubation. the study found that lus � could identify patients at high risk of developing post-extubation respiratory distress [ , ] . other studies recently found that patients weaned from mechanical ventilation showed a % reduction in respiratory distress during post-extubation [ , ] . however, these studies examined diseases similar to covid- , but their findings have not yet been proven in covid- . this study was designed to retrospectively analyze changes in lus for critically ill patients with covid- . our study examined covid- patients with interstitial pneumonia, using the clinical application of lus to assess intubation timing. a retrospective study was conducted in one makeshift icu in wuhan. from february , to march , , covid- patients were admitted in the icu of the cancer center of union hospital, tongji medical college, huazhong university of science and technology. a total of patients with critical covid- who were admitted to this icu within one month were included in this study. patients with severe covid- met any of the following criteria: . respiratory distress, rr � breaths/min; . pulse oxygen saturation (spo ) � % on room air in the resting state; . arterial partial pressure of oxygen (pao )/oxygen concentration (fio ) � mmhg ( mmhg = . kpa); and . > % lesion progression within and h on pulmonary imaging. routine bedside lung ultrasound (one to two times each day) was performed on patients who were treated via non-rebreather mask, non-invasive ventilator, or hfnc after admission to the icu. the patients were treated according to the guidance for corona virus disease of china (editions , ) for antiviral and proprietary chinese medicine. for patients with acute hypoxemic respiratory failure due to covid- , deciding whether to proceed with intubation and invasive ventilation can be challenging. in our icu, if the patient's condition became more severe during the treatment, the multidisciplinary discussion group (mdt) discussed whether to intubate that patient. after the patients received mechanical ventilation treatment, lung ultrasound assessment was performed daily. retrospective analysis of lus of patients at different time points was performed for one week. the patient's gender, age, body mass index (bmi index), sequential organ failure assessment (sofa score), and -day mortality rate were recorded; and the evolution of respiratory parameters between the two groups on time point t (lung ultrasound performed before intubation within h) were also recorded. this study was approved by the national health commission of china and ethics commission of second affiliated hospital, zhejiang university school of medicine (ky- - ). written informed consent was waived by the ethics commission of the designated hospital for emerging infectious diseases. a mindray m echography (mindray co, shenzhen, china) and a to mhz round-tipped or convex probe was used for the examination. for each patient, areas in the right and left lung were examined, and as delineated by a parasternal line, anterior axillary line, posterior axillary line, and paravertebral line, the anterosuperior, anteroinferior, laterosuperior, lateroinferior, posterosuperior, and posteroinferior lung regions were identified. scoring of each area was performed according to the most severe lung ultrasound detected in the corresponding intercostal spaces: ) normal aeration: presence of lung sliding with horizontal a lines or fewer than two isolated vertical b lines; ) moderate loss of lung aeration: either multiple welldefined and spaced b lines, issued from the pleural line or from small juxtapleural consolidations and corresponding to interstitial edema or coalescent b lines or issued from the pleural line or from small juxtapleural consolidations, present in a limited portion of the intercostal space and corresponding to localized alveolar edema; ) severe loss of lung aeration: multiple coalescent vertical b lines issued either from the pleural line or from juxta-pleural consolidations, detected in the whole area of one or several intercostal spaces and corresponding to diffuse alveolar edema; ) lung consolidation: the presence of a tissue pattern containing either hyperechoic punctiform images, which are representative of static air bronchograms, or hyperechoic tubular images, which are representative of dynamic air bronchograms, corresponding to the complete loss of aeration. lus was calculated as the sum of the points ranging from - . lung ultrasound was performed on days , , , , and after patients were admitted to the icu; these time points are called t , t , t , t , and t , respectively. if the patient was intubated, the lus scoring was performed before intubation within h (t ) and on days , , , and after intubation (t , t , t , and t , respectively). statistical analyses were performed using stata v (stata corp, college station, tx, usa). all statistical tests were performed at an α risk of % (excluding interim analysis). continuous variables are presented as the mean and standard deviation, subject to the normality of distribution (shapiro-wilk). in case of non-normality, these are presented as the median, quartiles, and extreme values. qualitative variables are expressed as numbers and associated percentages. graphic representations are associated with the analysis. comparisons between groups were conducted systematically: ( ) without adjustment, and ( ) adjusted by regression model based on factors whose distribution could be unbalanced between the groups despite randomization. during the study period, patients presented to the icu in wuhan with covid- within one month; patients were confirmed to be severe cases. twenty-seven patients were excluded for the following reasons: five patients were intubated before transferring to our icu, four patients died within h, and patients were not assessed by transthoracic lung ultrasound, and thus had no data. a total of patients were included this study, of whom nine were intubated within h after admission into the icu, and seven patients were not intubated and treated with a non-rebreather mask, non-invasive ventilator (niv), or high-flow nasal cannula oxygen therapy (hfnc). the demographics, clinical features, and outcomes of the sample are presented in table . the mean participant age was . ( . - . ) years old, with a higher proportion of older patients in the intubated group than in the non-intubated group (p < . ). there were more male patients than female patients in both groups. patient characteristics (bmi, sofa, and pao /fio value) were similar between the two groups (p > . ). the -day mortality rate of intubated patients was higher than that of non-intubated patients, and six patients in the intubated group and two patients in the non-intubated group died. table shows the evolution of respiratory parameters between the two groups on t ; no differences in respiratory rate, pulse rate, ph, paco , pao /fio , and spo were found between the two groups. . the average lus was . ± . on t and . ± . on t , and the lowest lus was . ± . on t . there was no significant difference in lus among time points. fig shows the changes in lus of intubated patients (n = ) at different time points. the lus within h before intubation was . ± . . lus was significantly higher at t than t (p < . ), but the scores did not significantly differ from t to t . fig shows that the lus of intubated patients, . ± . , was significantly higher than the lus of the non-intubated patients at t , . ± . (p < . ). fig shows a comparison of the oxygenation index of the two groups of patients: . ± . vs. . ± . on t . there was no significant differences in oxygenation index between the two groups. the high contagiousness of sarscov- and the risk of transporting unstable patients with hypoxemia and hemodynamic failure make chest ct a limited option for patients with suspected or established covid- . lung ultrasonography generates results that are similar to those of chest ct and superior to standard chest radiography when evaluating pneumonia and/or adult respiratory distress syndrome (ards), with the added advantages of ease of use at point of care, repeatability, absence of radiation exposure, and low cost [ ] . the most important clinical manifestations of respiratory failure in patients with covid- are hypoxemia and increased work of breathing. attention should be paid to the different effects of different oxygen therapy concentrations to avoid prolonged high-concentration oxygen therapy [ ] . during the treatment process, deciding when to switch from non-invasive ventilation or high-flow oxygen therapy to invasive mechanical ventilation and how to dynamically assess lung condition changes can be challenging. for critically ill patients with covid- , the difficulty of accurately assessing lung conditions is greatly increased due to the inability of doctors to use stethoscopes in protective clothing, as well as due to the use of lung ct to repeatedly evaluate patients' lung conditions in special circumstances. several studies on non-covid- patients have demonstrated that lung ultrasound is accurate for assessing positive end-expiratory pressure, prone position-induced lung recruitment, lung reaeration following antimicrobial therapy in ventilator-associated and community-acquired pneumonia, and lung reaeration data are presented as the number of patients, mean ± sd, or median and interquartile interval ( to %). https://doi.org/ . /journal.pone. .t table . evolution of respiratory parameters between the two groups on t . associated with the resolution of various forms of pulmonary edema [ ] [ ] [ ] . soummer et al. first proposed and successfully applied this method to assess the changes in lung ventilation for patients after offline extubation, and they confirmed that patients with lus > had a significant increase in intubation rate after offline extubation [ ] . an experienced sonographer can perform this examination within five min, and brief training and about supervised exams seem to be sufficient to achieve a basic ability to perform the task [ ] . a prior study showed lus's ability to influence clinical decisions in up to % of icu patients [ ] . in this study, the lus of the intubated group on t (within h before intubation) was higher than that of the non-intubated group. however, oxygenation index and respiratory rate, the conventional indicators to decide whether to intubate critical care patients, did not significantly differ between the two groups at the same time point. the obvious difference indicates that the lus may be a more accurate indicator of ideal intubation timing than the oxygenation index and respiratory rate. lus could dynamically assess the ventilation status of the two patient groups during treatment, and provided earlier prediction of pulmonary ventilation status and disease deterioration. an lus = may be a warning for intubation or exacerbations in critically ill covid- patients. clinicians need to closely observe the patient's condition and consider the possibility of tracheal intubation according to the patient's situation. a unique syndrome of hypoxic covid- patients has been described (labelled "the happy hypoxic") who are mentally alert and lack significant respiratory distress despite hypoxia that would usually prompt treatment, sometimes with profoundly low oxygen saturations [ ] . according to our experience in treating patients with severe covid- in wuhan, most patients are more tolerant to hypoxia, and patients with a low oxygenation index often have no obvious symptoms of chest tightness, shortness of breath, or mild symptoms, which are inconsistent with clinical indicators. there is no evidence that choosing early intubation instead of niv or hfnc improves outcome: early reports suggest intubated patients remain on ventilators for extended periods and mortality rates appear high. a retrospective cohort study of patients in wuhan showed that mortality rate was significantly increased after intubation; % of patients died after mechanical ventilation treatment, and patients often had complications such as septic shock, ventilator-associated pneumonia (vap), and deep vein thrombosis after intubation [ ] . intubated patients are thought to pose a lower risk of viral dispersion to staff. however, both the process of intubating and extubating are high risk to staff, and there are reports of accidental ventilator circuit disconnection when intubated. therefore, judging the timing of intubation and mechanical ventilation treatment is a concern for doctors in the emergency department and icu, but no recent study has found the best clinical indicators for evaluation. lung ultrasound is an ideal inspection method in addition to the gold standard ct examination, and may be one of the most effective tools for judging intubation time. according to our experience, the accuracy of bedside ultrasound in evaluating severe and critical covid- patients is significantly better than its accuracy in evaluating mild patients. the reason may be that the exudation of mild covid- patients is often not obvious, and the lesions are deep and/or pleural, and not accumulated. lung ultrasound's usefulness is limited, especially in cases of early or mild covid- . according to previous studies, lus is a semiquantitative assessment of lung ventilation by ultrasound. an lus of (scored out of ) may thus be an indicator for intubation in patients with respiratory failure. in this study, the lus before intubation was . ± . , which is lower than the score suggested by the previous study ( points) . the reason for this may be that the primary ct manifestation of the patients in the group was pulmonary exudation without obvious consolidation or atelectasis, which accounts for points in the lus. because the behavior of ards caused by covid- differs from that caused by other diseases, the patient's lus for covid- shows mainly a large number of b lines in both lungs, and is lower than normal ards patients, which show consolidation in some parts of the lung. most patients with mechanical ventilation have secondary bacterial infections or poor sputum drainage, which may cause some consolidation of the lungs and atelectasis, leading to a significant increase in lus after intubation [ ] [ ] [ ] . this study indicates that lus may be an effective tool for assessing the timing of intubation in patients with sars-cov- pneumonia/ards. the intubation of critically ill patients with covid- is mostly due to respiratory failure, but there is also a small number of patients who undergo intubation due to secondary acute heart failure or airway obstruction [ ] . thus, an ultrasound may be employed to evaluate cardiac function and other conditions as part of a comprehensive covid- assessment. as this study is a retrospective study, the number of patients included in this investigation is relatively small, and further large-scale prospective studies are needed to confirm our findings. supporting information s data. (xlsx) the novel coronavirus originating in wuhan, china: challenges for global health governance severe acute respiratory syndrome-related coronavirus: the species and its viruses-a statement of the coronavirus study group short term outcome and risk factors for adverse clinical outcomes in adults with severe acute respiratory syndrome (sars) early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia essentials for radiologists on covid- : an update-radiology scientific expert panel lung ultrasound: a useful tool in the assessment of the dyspnoeic patient in the emergency department. fact or fiction? lung ultrasound for daily monitoring and management of ards patients ultrasound assessment of antibiotic-induced pulmonary reaeration in ventilator-associated pneumonia bedside ultrasound assessment of positive end-expiratory pressure-induced lung recruitment lung ultrasound in acute respiratory distress syndrome and acute lung injury clinical review: bedside lung ultrasound in critical care practice comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome findings of lung ultrasonography of novel corona virus pneumonia during the - epidemic analysis of clinical features of patients with novel coronavirus pneumonia. zhonghua jie he hu xi za zhi ultrasound assessment of lung aeration loss during a successful weaning trial predicts postextubation distress* training for lung ultrasound score measurement in critically ill patients impact of lung ultrasound on clinical decision making in critically ill patients why covid- silent hypoxemia is baffling to physicians clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study our italian experience using lung ultrasound for identification, grading and serial follow-up of severity of lung involvement for management of patients with covid- epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study noninvasive positive-pressure ventilation for postextubation respiratory distress: a randomized controlled trial pathological findings of covid- associated with acute respiratory distress syndrome we thank letpub (www.letpub.com) for their linguistic assistance during the preparation of this manuscript. key: cord- -xwhxyy d authors: volpicelli, giovanni; lamorte, alessandro; villén, tomás title: what’s new in lung ultrasound during the covid- pandemic date: - - journal: intensive care med doi: . /s - - - sha: doc_id: cord_uid: xwhxyy d nan the sars-cov- pandemic is undermining the ability of many advanced healthcare systems worldwide to provide quality care [ , ] . covid- is the disease caused by infection with sars-cov- , a virus with specific tropism for the lower respiratory tract in the early disease stage [ ] . computed tomography scans of patients with covid- typically show a diffuse bilateral interstitial pneumonia, with asymmetric, patchy lesions distributed mainly in the periphery of the lung [ ] [ ] [ ] . in the context of a pandemic, rapid case identification, classification of disease severity and correct treatment allocation are crucial for increasing surge capacity. overtriage to admission and to intensive care by clinicians working in the department of emergency medicine (ed) will overwhelm system capacity. undertriage can lead to loss of life and cross infections. similarly, selection of those patients most likely to respond to specific treatments and determining the response to treatment in the intensive care unit (icu) can conserve scarce resources. lung ultrasound (lus) is well known for its feasibility and high accuracy when used at the bedside for diagnosing pulmonary diseases [ , ] . as the most striking manifestation of covid- disease is in the pulmonary system, lus performed by a trained and knowledgeable clinician may aid precisely in triage, classification of disease severity and treatment allocation in both the ed and the icu. in this paper, we describe the use of lus in treating patients with covid- . pending rt-pcr test results, other patients (or staff ) may be unnecessarily exposed to those carrying the disease. verifying that patients have covid- therefore remains the rate-limiting step in patient triage. alternatively, redundant implementation of precautions may lead to unnecessary resource consumption. the use of lus in this context could revolutionize patient triage. the lus technique described in this paper is detailed in the supplementary material (online resources supplementary file lus_technique.docx and figure_ - and video_ - ). the pretest probability of gaining useful information from lus is likely to be highest when the clinician seeks to correlate clinical findings with those seen in lus and knows what information to seek in order to do so. covid- presents with not only specific lus signs but also with typical patterns of lus findings. the signs seen in the lus of patients with covid- are similar to those extensively described in patients with other types of pneumonia [ ] . these include various forms of b-lines, an irregular or fragmented pleural line, consolidations, pleural effusions and absence of lung sliding (see online resources video_ - ) [ ] . the lus of patients with covid- usually shows an explosion of multiform vertical artifacts and separate and coalescent b-lines. the pleural line may be irregular or fragmented as is commonly observed in ards. as stated above none of these signs is pathognomonic to covid- pneumonia and their presence is variable. conversely, a typical artifact that we named "light beam" is being observed invariably in most patients with pneumonia from covid- . this artifact corresponds to the early appearance of "ground glass" alterations typical of the acute disease that may be detected in computed tomography. this broad, lucent, band-shaped, vertical artifact moves rapidly with sliding, at times creating an "on-off " effect as it appears and disappears from the screen. the bright artifact typically arises from an entirely regular pleural line interspersed within areas of normal pattern or with separated b-lines (online resources video_ ). at times it seems to cover the a-lines, concealing them entirely. at other times a-lines may still be visualized in the background as it is observed. the light beam is observed also in other conditions with ground glass alterations. nevertheless, the importance of this sign is given by the contingency of the terrible pandemic of covid- that we are experiencing in our eds. a multicenter study in progress is investigating the accuracy of this sign. to date, a pilot analysis of a monocenter series of patients suspected for covid- revealed the presence of multiple light beams in of the patients with confirmed disease and pneumonia. the same sign was never observed in patients with alternative pulmonary diagnoses and negative swab test (unpublished data). the lus findings of patients with covid- are unique in both combination and distribution. therefore, patients presenting to the ed may be classified into four broad categories based on the presence of specific patterns of lus findings (see table ). patients presenting with the pattern described in category a have little or no pulmonary involvement and are therefore unlikely to have covid- disease (i.e., asymptomatic sars-cov- carriers or patients with no lung disease). in patients table the presence of large consolidations with air bronchograms mainly in the bases of the lungs should always raise suspicion of bacterial cross-infection. as noted above, lus findings are always most informative when they are interpreted in light of the clinical context; some asymptomatic or mildly symptomatic patients may have surprisingly impressive high probability lus findings. conversely, in our experience, patients with covid- disease who suffer from severe respiratory failure are not likely to have no or mild lus alterations. there are several ways lus may be used to determine allocation of treatment resources to those patients most likely to respond. these include early quantification of the severity of lung involvement, periodic assessment for the appearance of findings suggestive of atelectasis or pneumonia and monitoring the effects of changes in mechanical ventilation and recruitment maneuvers on lung aeration. the use of lus to quantify and monitor changes in aeration has been described in critically ill patients with ards [ , ] . it is our impression that, contrary to what has been described in ards, interstitial patterns and consolidations contribute almost equally to lack of aeration in patients with covid- [ ] . rather, the severity of respiratory impairment seems to be related to the overall proportion of lung tissue showing groundglass alterations [ ] . early quantification of the severity of lung involvement in patients with covid- may be obtained by estimating the overall amount of lung areas detected as being pathological with ultrasound. documenting the ultrasound images obtained enables later assessment of lesion size and more precise calculation of the proportion of diseased lung. the diseased lung is identified by the presence of any pathological finding (e.g., separated and coalescent b-lines, light beams, consolidations) and the areas of diseased lung are measured. for each video clip, the proportion of involved lung is estimated ( - - - - %) and the overall proportion is then calculated. this method of semi-quantification may be used to estimate the extent of lung involvement which could serve to identify at least some of the patients more likely to require invasive ventilation. periodic assessment for the appearance of findings suggestive of atelectasis or pneumonia can be highly informative. identification of interstitial patterns or consolidations typical of pneumonia in patients with covid- should lead to a change in care. modifying ventilation parameters is simple but may not suffice for recruitment. we are adopting pronation guided mainly by lus detection of extended lesions in the dorsal areas both in patients treated with continuous positive airway pressure (cpap) and in invasively ventilated patients. in patients that are invasively ventilated we suggest following evidence-based suggestions for monitoring aeration changes [ , ] . the lung is studied in oblique scans in two anterior, two lateral and two posterior areas per side. each area is assigned a score ranging from to ( = normal a-lines, = multiple separated b-lines, = coalescent b-lines or light beam, = consolidation). the sum of all the areas represents the aeration score. the dynamic changes in aeration can then be quantified by reassigning a new score to re-aerated areas (see table ). new methods for automated computer-aided measurement of aeration could be considered when available, with the advantage of a more standardized quantitative approach for monitoring [ ] . in the setting of critically ill covid- patients with severe pneumonia, the possibility of thromboembolic disease should be considered [ ] . even if there are no published studies thus far, covid- patients are likely at increased risk for thromboembolism [ ] . critically ill patients should be treated accordingly and monitored by cardiac and venous ultrasound to diagnose deep venous thrombosis and cardiac signs of acute pulmonary embolism [ ] . we show a case of covid- with sudden deterioration and cardiac arrest due to acute pulmonary embolism with popliteal thrombosis (online resources video_ - ). hospital flooding of patients with covid- imposes a huge burden on the medical system. this burden can be somewhat mitigated with optimization of patient identification, triage and management. lus is noninvasive and can be performed very rapidly. lus may be used in the ed to identify likely covid- patients and to identify those patients with more extensive pulmonary involvement who should probably be referred to the icu. it may serve to differentiate between patients with acute signs of respiratory failure, patients with mild symptoms and normal respiratory function, patients with preexisting chronic cardiac or pulmonary diseases (see flow charts in online resources figure_ - ). in the icu, lus may be used to identify areas of poor lung aeration and to monitor the effect of changes in ventilation and recruitment maneuvers on lung aeration. the online version of this article (https ://doi.org/ . /s - - - ) contains supplementary material, which is available to authorized users. author details department of emergency medicine, san luigi gonzaga university hospital, torino, italy. emergency department and pre-hospital medicine, valle d' aosta general hospital, aosta, italy. school of medicine, universidad francisco de vitoria, madrid, spain. critical care crisis and some recommendations during the covid- epidemic in china covid- : a novel coronavirus and a novel challenge for critical care the novel coronavirus originating in wuhan, china: challenges for global health governance chest ct findings in patients with corona virus disease and its relationship with clinical features relation between chest ct findings and clinical conditions of coronavirus disease (covid- ) pneumonia: a multicenter study ct features of coronavirus disease (covid- ) pneumonia in patients in wuhan, china international evidencebased recommendations for point-of-care lung ultrasound accuracy of lung ultrasound for the diagnosis of consolidations when compared to chest computed tomography findings of lung ultrasonography of novel corona virus pneumonia during the - epidemic bedside ultrasound assessment of positive end-expiratory pressure-induced lung recruitment lung ultrasound for early diagnosis of ventilator-associated pneumonia covid- pneumonia: different respiratory treatment for different phenotypes? quantitative lung ultrasonography: a putative new algorithm for automatic detection and quantification of b-lines thrombotic events in sars-cov patients: an urgent call for ultrasound screening cardiovascular considerations for patients, health care workers, and healthsystems during the coronavirus disease (covid- ) pandemic diagnostic accuracy of focused cardiac and venous ultrasound examinations in patients with shock and suspected pulmonary embolism we sincerely thank prof. sharon einav (general intensive care, shaare zedek medical centre and hebrew university faculty of medicine, jerusalem, israel) for her fundamental contribution to the general revision of the manuscript and final editing. all the ultrasound videos in the section online resources have been recorded in the ed and icu of san luigi gonzaga university hospital. we thank the staff nurses and physicians who helped the collection of data. we thank the patients who gave their consent to publish the material. authors declare no conflict of interest with the subject matter. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.received: march accepted: april key: cord- -s neq x authors: arntfield, r.; vanberlo, b.; alaifan, t.; phelps, n.; white, m.; chaudhary, r.; ho, j.; wu, d. title: development of a deep learning classifier to accurately distinguish covid- from look-a-like pathology on lung ultrasound date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: s neq x objectives lung ultrasound (lus) is a portable, low cost respiratory imaging tool but is challenged by user dependence and lack of diagnostic specificity. it is unknown whether the advantages of lus implementation could be paired with deep learning techniques to match or exceed human-level, diagnostic specificity among similar appearing, pathological lus images. design a convolutional neural network was trained on lus images with b lines of different etiologies. cnn diagnostic performance, as validated using a % data holdback set was compared to surveyed lus-competent physicians. setting two tertiary canadian hospitals. participants lus videos ( , frames) of b lines from distinct patients with either ) covid- , non-covid acute respiratory distress syndrome (ncovid) and ) hydrostatic pulmonary edema (hpe). results the trained cnn performance on the independent dataset showed an ability to discriminate between covid (auc . ), ncovid (auc . ) and hpe (auc . ) pathologies. this was significantly better than physician ability (aucs of . , . , . for the covid, ncovid and hpe classes, respectively), p < . . conclusions a deep learning model can distinguish similar appearing lus pathology, including covid- , that cannot be distinguished by humans. the performance gap between humans and the model suggests that subvisible biomarkers within ultrasound images could exist and multi-center research is merited. lung ultrasound (lus) is an imaging technique deployed by clinicians at the point-of-care to aid in the diagnosis and management of acute respiratory failure. with accuracy matching or exceeding chest x-ray (cxr) for most acute respiratory illnesses, - lus additionally lacks the radiation and laborious workflow of computed tomography (ct). further, as a low cost, battery operated modality, lus can be delivered at large scale in any environment and is ideally suited for pandemic conditions. b lines are the characteristic pathological feature on lus, created by either pulmonary edema or non-cardiac causes of interstitial syndromes. the latter includes a broad list of conditions ranging from pneumonia, pneumonitis, acute respiratory distress syndrome (ards) or fibrosis. while an accompanying thick pleural line is helpful in differentiating cardiogenic from non-cardiogenic causes of b lines, reliable methods to differentiate noncardiogenic causes from one another on lus have not been established. additionally, user dependent interpretation of lus contributes to wide variation in disease classification, , creating urgency for techniques that improve diagnostic precision and reducing user-dependence. deep learning (dl), a foundational strategy within present-day artificial intelligence (ai) techniques, has been shown to meet or exceed clinician performance across most visual fields of medicine. [ ] [ ] [ ] without cognitive bias or reliance on spatial relationships between pixels, dl ingests images as numeric sequences and evaluates for quantitative patterns that may reveal information that is unavailable to human analysis. with ct and cxr research maturing, [ ] [ ] [ ] lus remains comparably understudied with dl due to a paucity of organized, well labelled lus data sets and the seeming lack of rich information in its minimalistic, artifact-based images. in this study, we trained a neural network using lus images of b lines from different etiologies (hydrostatic pulmonary edema (hpe), ards and covid- ). using lus-fluent physicians as comparison, we sought to determine if subvisible features in lus images are available to a dl model that would allow it to exceed human limits of interpretation. after university of western ontario research ethics board (reb ) approval, lus exams performed at london health sciences centre's tertiary hospitals were identified within our database of over , point-ofcare ultrasound exams. the curation and oversight of this archive have previously been described. the goal of this study was to determine if a deep neural network could distinguish between the b line profiles of different disease profiles, namely ) hydrostatic pulmonary edema (hpe); ) non-covid ards (ncovid) causes; and ) covid- ards (covid). these profiles were chosen deliberately to challenge the neural network to classify images with obvious qualitative differences (hpe vs ards) and with no obvious differences (ncovid vs covid) between their b lines patterns ( figure , videos , , ). the covid class consisted of confirmed cases of covid- via reverse-transcriptase polymerase chain reaction test. the ncovid class consisted of an assortment of causes: aspiration, community acquired pneumonia, hospital acquired pneumonia and viral pneumonias. exams were conducted as part of patient encounters in the emergency department, intensive care unit and medical wards across the hospitals. candidate exams for inclusion were identified using a sequential search by critical care physicians, ultrasound experts (ra, ta) from within the finalized clinical reports of our database of lus cases ( figure ). videos from our dataset represented a variety of ultrasound systems with phased array probe predominantly used for acquisition. videos of the costophrenic region (which included solid abdominal organs, diaphragm, or other pleural pathologies such as effusions or trans-lobar consolidations) were excluded as ) these regions did not contribute greatly to alveolar diagnoses, ) this would introduce heterogeneity into the still image data, and ) a trained clinician can easily distinguish between these pathologies and b lines. duplicate studies were discarded to avoid overfitting. from each encounter, de-identified mp loops of b lines, ranging from - seconds in length with a frame rate ranging from - /second (depending on the ultrasound system), were extracted. as covid was the newest class available to our database, its comparably smaller number of encounters governed the number of encounters we extracted from hpe and ncovid. a balanced volume of data for each class of image is important to avoid model over training on a single image class and/or overfitting. the images used to train the model were all frames from the extracted lus clips. hereafter, a clip refers to a lus video that consists of several frames. an encounter is considered to be a set of one or more clips that were acquired during the same lus examination. preprocessing of each frame consisted of a conversion to grayscale followed by a script written by one of our team (jh) to scrub the image of extraneous information (index marks, logos, and manufacturer-specific user interface). see supplementary appendix for full details. data augmentation techniques were applied to images to each batch of training data during training experiments to combat overfitting. augmentation transformations included random zooming in/out by ≤ %, horizontal flipping, horizontal stretching/contracting by ≤ %, vertical stretching/contracting (≤ %), and bi-directional rotation by ≤ °. in choosing an optimal architecture for our model, we investigated training from scratch on custom implementation of feedforward cnns, residual cnns as well as transfer learning methods. ultimately, xception architecture achieved the highest performance among the custom and common architectures evaluated. individual preprocessed images were fed into the network as a tensor with dimensions × × . although the images were originally greyscale, they were converted to rgb representation to ensure that the model input shape was compatible with the pre-trained weights. the output tensor of the final convolutional layer of the xception model was subject to d global average pooling, resulting in a -dimensional tensor. dropout at a rate of . was applied to introduce heavy regularization to the model and provided a noticeable reduction in overfitting. the final layer was a -node fully connected layer with softmax activation. the output of the model represents the probabilities that the model assigned to each of the classes, all summing to . . the argmax of this probability distribution was considered to be the model's decision. to further combat overfitting, early stopping was applied by halting training if the loss on the validation set did not decrease over the most recent epochs. for additional details on model selection, training, coding practice, our github repository and hardware used in this project, please see supplementary appendix. a modification of the holdout validation method was used to ensure that the model selection process was independent of the model validation. our holdout approach began with an initial split that randomly partitioned all . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . . encounters into a training set and test sets (henceforth referred to as test- set and test- set). the distribution of encounters and frames after this split are shown in table . it must be emphasized that all splits were conducted at the encounter level, not across all frames, thus ensuring that frames from the same clip did not appear in more than one partition. test- was used to evaluate all of the candidate models so that a final model architecture and set of hyperparameters could be chosen. test- was considered to be the holdout set, since it remained untouched throughout the model selection process and was only used during the final validation phase. a full account of validation methods can be found in the supplementary appendix. the final model performance was determined by its results on our hold-back, independent dataset (test- ). the results were analyzed both at the individual frame level and at the encounter level. the latter was achieved through averaging the classifier's predicted probabilities across all images from within that encounter. we assessed the model's performance by calculating the area under the receiver operating characteristic curve (auc), analyzing a confusion matrix, and calculating metrics derived from the confusion matrix. benchmarking human performance for comparison to our model was undertaken using a survey featuring a series of lung ultrasound clips, sourced and labelled with agreement from ultrasound fellowship trained physicians (mw, ta, ra, see supplementary appendix for complete survey). the survey was distributed to lus-trained acute care physicians from across canada. respondents were asked to identify the findings in a series of lus loops according to the presence b lines vs normal lung (a line pattern), the characteristics of the pleural line (smooth or irregular) as well as the cause of the lung ultrasound findings (hydrostatic pulmonary edema, non-covid pneumonia or covid pneumonia). responses were compared to the true, expert-defined labels consistent with our data curation process described above. since the data used for modelling did not include normal lungs, it was decided that those four clips were discarded from analysis. any normal diagnoses ( of diagnoses) for the remaining clips were replaced with uniformly randomly generated diagnoses for the remaining causes. we utilized the grad-cam method to visually explain the model's predictions. grad-cam involves visualizing the gradients of the prediction of a particular image with respect to the activations of the final convolutional layer of the cnn. a heatmap is produced that is upsampled to the original image dimensions and overlaid onto the original image. the resultant heatmap highlights the areas of the input image that were most contributory to the model's classification decision. the github link to the code used to generate the dl model and the full survey data results can be found in our supplementary appendix. patients or the public were not involved in the design, conduct, reporting or dissemination plans of this work. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint the data extraction process resulted in cases of covid which, as part of our effort to balance the groups for unbiased training, led to of ncovid and of hpe. further characteristics of the data are summarized in table . the benchmarking survey was completed by physicians with a median of - years of ultrasound experience the majority of whom had done at least a full, dedicated month of ultrasound training ( . %) and who described their comfort with lus use as "very comfortable" ( . %). see supplementary appendix for a full summary of survey data. the results of this survey highlight that the physicians were adept at distinguishing the hpe class of b lines from covid and ncovid causes of b lines. for the covid and ncovid cases, however, significant variation and uncertainty was demonstrated. see table and "comparing human and neural networks" section below. the model's predictions were evaluated at both the image and encounter level. the prediction for an image is the probability vector is the average predicted probability for class c over the predictions for all images within that encounter. encounter-level predictions were computed and presented to ( ) replicate the method through which real time interpretation (by clinician or machine) occurs with ultrasound by aggregating images within one or more clips to form an interpretation and ( ) closely simulate a physician's classification procedure, since the physicians who participated in our benchmarking survey were given entire clips to classify. three models fit with our chosen architecture and set of hyperparameters were evaluated on test- , achieving mean aucs on the encounter level of . (covid), . (ncovid), and . (hpe). the model's ultimate ability was to be determined on the . % of our images that constituted the holdback data (test- ) data. on this independent data, the model demonstrated a strong ability to distinguish between the relevant causes of b lines with aucs at the encounter level of . (covid), . (ncovid), and . (hpe), producing an overall auc of . for the classifier. confusion matrices on the test- set at the frame and encounter level (table ) show strong diagonals that form the basis of these results and the performance metrics seen in table . since auc measures a classifier's ability to rank observations, the raw survey data (in the form of classifications, not probabilities) was processed to permit an auc computation by considering physician-predicted probability of a lus belonging to a specific class as the proportion of physicians that assigned the lus to that class. the aucs for the physicians, at face value, were . (covid), . (ncovid), and . (hpe), leading to an overall auc of . (as compared to . for our model). a comparison of the human and model aucs is graphically displayed in figure . we took note of the the auc of approximately . for the physicians when the positive class is covid or ncovid, as distinguishing between these classes is not known to be possible by humans. in examining the raw confusion matrix data (table ) , this suggests near random classification (which corresponds to an auc of . ) between these classes -see supplementary appendix for a complete explanation. given the important implications of the performance gap observed, we employed an additional step of statistical validation for our findings through a monte carlo simulation (mcs, see supplementary appendix for full details) of human performance, based on our survey results, across one million exposures to our test- data. after simulating this . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint performance one million times, the mcs yielded an average auc of . across all three classes, with very few cases matching or exceeding the performance of the cnn. thus, we can conclude that our model exceeds human performance, and in particular that the model can distinguish between covid and ncovid (p < . ). the grad-cam explainability algorithm was applied to the output from the model on the holdback data. the results are conveyed by color on the heatmap, overlaid on the test- input images. blue and red regions correspond to highest and lowest prediction importance respectively. as the results seen in figure demonstrate, the key activation areas for all classes were centered around the pleura and the pleural line. in this study, a deep learning model was successfully trained to distinguish the underlying pathology in similar point-of-care lung ultrasound images containing b lines. the model was able to distinguish covid- from other causes of b lines and outperformed ultrasound trained clinician benchmarks across all categories. our results are the first of their kind to support that digital biomarker profiles may exist within lung ultrasound images. our model was developed using a data set of patients ( video loops/ , frames) which is modest by machine learning standards. owing to the scarcity of labelled lung ultrasound data, this data volume does compare favorably to other published lung ultrasound work. [ ] [ ] [ ] given the implications of successfully classifying lus images, it was essential for us to protect against overfitting. while many approaches exist to avoid an overfit model, we, in addition to multiple data augmentation techniques, reserved % of our data (test- ) as a hold-back set, not involved in model fitting or selection. this approach mimics the unbiased, generalizable performance desired of an image classifier and is familiar to other notable deep learning vision research in medicine. [ ] [ ] [ ] deep learning has shown similarly favorable results in recent cxr and ct studies of covid- . , given lus image creation is fundamentally different (producing artifacts, rather than anatomic images of the lung), it could not be expected that our work with lus would have yielded such similar results. the value of identifying such accuracy in a lus model rests in the ability of lus (unlike ct or cxr) to be delivered by limited personnel, at low cost and in any location. lung ultrasound artifact analysis has existed for several years in some commercially available ultrasound systems and has also been described using various methods in the literature. , , automating the detection of canonical findings of lus, these techniques are convenient and serve to achieve what clinicians may be trained to do with minimal training. with attention to covid- , lus has been shown to inform clinical course and outcome , creating some further momentum toward broader lus competence. as our work opens the door toward plausible early, automated covid identification using lus, dl techniques to auto-generate clinical severity score for covid has also recently been described. the eventual integration of various dl models into ultrasound hardware seems plausible as a method to achieve real time, point-of-care diagnosis and prognosis of covid or other specific respiratory illnesses. the implications of our work, at time of writing, are strongly attached to the current challenges and importance of covid- diagnosis. our results point to a unique, pixel-level signature within the covid- image. though the exact mechanism of distinction is unknown, the heat map results suggest that subvisible variations in the pleural line itself is most active in driving the model's performance. the precise taxonomical implications of our findings, whether they are driven by covid- , coronaviruses or viruses a whole, will require additional research. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . . our study has some important limitations. the first relates to the opaqueness that is implicit to deep neural networks. despite using grad-cam, the decisions by the trained model are not outwardly justified and we are unable to critique its methods and must trust its predictions. our benchmarking survey did not exactly replicate the questions posed to our neural network which made our statistical analysis more complex than it might have needed to be otherwise. the other limitations of our study related to the data size and sources. though our model performance signal was strong, the addition of further training data can only aid with generalizability of the model. future work will focus on validation through multi-center collation of covid lus encounters. lastly, our data were all from hospitalized patients and our results may not generalize to those who are less ill. with strong performance in distinguishing lung ultrasound images of covid- from mimicking pathologies, a trained neural network exceeded human interpretation ability and raises the possibility of disease-specific, subvisible features contained within lung ultrasound images. further research using well-labelled, multi-center data is indicated. all we declare no competing interests. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october , . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint lung ultrasound for the diagnosis of pneumonia in adults: a meta-analysis relevance of lung ultrasound in the diagnosis of acute respiratory failure the blue protocol trauma ultrasound examination versus chest radiography in the detection of hemothorax covid- outbreak: less stethoscope, more ultrasound lung b-line artefacts and their use chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. cardiovasc ultrasound lung ultrasound and b-lines quantification inaccuracy: b sure to have the right solution expert agreement in the interpretation of lung ultrasound studies performed on mechanically ventilated patients deep learning algorithms for detection of critical findings in head ct scans: a retrospective study development and validation of a deep learning algorithm for detection of diabetic retinopathy in retinal fundus photographs deep learning outperformed of dermatologists in a head-to-head dermoscopic melanoma image classification task prediction of cardiovascular risk factors from retinal fundus photographs via deep learning real-time electronic interpretation of digital chest images using artificial intelligence in emergency department patients suspected of pneumonia artificial intelligence distinguishes covid- from community acquired pneumonia on chest ct deep learning enables accurate diagnosis of novel coronavirus (covid- ) with ct images. medrxiv [internet the utility of remote supervision with feedback as a method to deliver high-volume critical care ultrasound training transfer learning with deep convolutional neural network for liver steatosis assessment in ultrasound images xception: deep learning with depthwise separable convolutions imagenet: a large-scale hierarchical image database early stopping -but when? visual explanations from deep networks via gradient-based localization an introduction to mcmc for machine learning automated lung ultrasound b-line assessment using a deep learning algorithm deep learning for classification and localization of covid- markers in point-of-care lung ultrasound automatic detection of covid- from a new lung ultrasound imaging dataset (pocus). arxiv [internet covid- : automatic detection from x-ray images utilizing transfer learning with convolutional neural networks lung ultrasound in covid- pneumonia: correlations with chest ct on hospital admission. respiration quantitative lung ultrasonography: a putative new algorithm for automatic detection and quantification of b-lines. crit care computer-aided quantitative ultrasonography for detection of pulmonary edema in mechanically ventilated cardiac surgery patients can limited education of lung ultrasound be conducted to medical students properly? a pilot study the authors would like to acknowledge the computational and technical support from cengn (canada's centre of excellence in next generation networks), mr. matt ross from the city of london, mrs. kristine van arsen from the division of emergency medicine and the clinician-sonographers at london health sciences centre who faithfully record and annotate their lung ultrasound studies. ncovid ( ) ( ) key: cord- -auk hpk authors: ji, li; cao, chunyan; lv, qing; li, yuman; xie, mingxing title: serial bedside lung ultrasonography in a critically ill covid- patient date: - - journal: qjm doi: . /qjmed/hcaa sha: doc_id: cord_uid: auk hpk nan during covid- pandemic, chest ct has played a crucial role in the rapid diagnosis of this disease . while the increasing risk of contagiousness and moving unstable patients make chest ct a limited choice for critically ill patients with covid- pneumonia. more recently, lung ultrasonography (lus) has been identified as a sensitive and semi-quantitative tool in the assessment of pneumonia, especially in the intensive care unit. herein we reported a case to describe serial bedside lus findings in a critically ill covid- patient. a -year-old woman living in wuhan was admitted to a fever clinic on feb , , with symptoms of fever (up to . ℃), chills, dry cough, fatigue and dyspnea. at admission, her body temperature was . ℃( . °f), respiratory rate was breaths per min, and oxygen saturation was % on room air and % under the condition of nasal ventilation. she had a medical history of hypertension and system lupus erythematosus. laboratory tests showed an elevated erythrocyte sedimentation rate ( mm/h) and c-reactive protein ( . mg/l) levels. real-time pcr of the patient's throat swab was positive for covid- nucleic acid. chest ct showed multiple bilateral and peripheral ground-glass opacities ( fig a) . bedside lus examination including all intercostal spaces was performed subsequently, which revealed multiple b-lines (b-lines total number: ), small consolidations and pleural line thickening ( fig b and c) . the extent of lesion on lus was consistent with the ct findings. after the patient received days of treatment, combined with respiratory support and interferon inhalation, real-time pcr of the patient's pharyngeal swab became negative. chest ct showed decreasing ground-glass opacities (fig d) . lus demonstrated decreased b-lines (b-lines total number: ) and the consolidation was disappeared (fig e and f) . https://mc.manuscriptcentral.com/qjm discussion covid- pneumonia is a new disease outbreak which has become a global health concern , and this disease shares ct features of bilateral lung involvement, with lesions mainly located peripherally and subpleurally . therefore, bedside lus can identify the pulmonary lesions timely and sensitively. moreover, ultrasound is the sole imaging modality accessible to the bedside of patients for timely identification of pulmonary complications and tracking disease changes . b-lines are hyperechoic artifacts on lus which appear as vertical lines that arise from the pleural surface, and pulmonary consolidation is defined as an isoechoic tissue-like structure, which is caused by the loss of lung aeration , . in our case, characteristic findings of this patient included multiple b-lines and thickening of the pleural line, with the presence of small consolidation. lus findings improve rapidly in response to covid- pneumonia therapy, which is consistent with chest ct features. bedside lus may present a useful and non-invasive method to monitor serial changes in covid- pneumonia. the patient's consent for the case report was obtained after well informed. a new coronavirus associated with human respiratory disease in china radiological findings from patients with covid- pneumonia in wuhan, china: a descriptive study dynamic changes and prognostic value of pulmonary congestion by lung ultrasound in acute and chronic heart failure: a systematic review diagnostic value of bedside lung ultrasonography in pneumonia https://mc.manuscriptcentral.com/qjm key: cord- -q nq f authors: reisinger, nathaniel; koratala, abhilash title: lung ultrasound: a valuable tool for the assessment of dialysis patients with covid- date: - - journal: clin exp nephrol doi: . /s - - -x sha: doc_id: cord_uid: q nq f nan patients on maintenance hemodialysis face unique challenges during coronavirus disease (covid- ) pandemic due to frequent contact with health care facilities as well as high comorbidity burden subjecting them to increased risk of serious complications from the disease. with an ongoing surge in covid-related hospitalizations exhausting resources, outpatient dialysis units are preparing to manage patients suspected to have or tested positive for covid- with mild symptoms. in addition to exploring the options to safely dialyze these patients, timely recognition of clinical deterioration and referral to the hospital are crucial [ ] . symptom recognition is not straightforward as these patients often have multiple etiologies for dyspnea especially given concomitant pulmonary congestion due to fluid overload. in some of the severely affected parts of the world, triage protocols have been developed using computed tomography (ct) scan of the chest as the primary imaging modality to identify dialysis patients that need hospitalization. repeated studies were often performed in those with positive findings, exposing patients to significant ionizing radiation [ ] . in contrast, lung ultrasound (lus) is a bedside diagnostic tool that emits no ionizing radiation and has comparable diagnostic accuracy to that of ct scan in detecting most lung pathologies. moreover, lus has a proven track record in dialysis patients to assess extravascular lung water, and nephrologists at some centers use it routinely for this purpose [ ] . lung imaging findings of covid- are non-specific on both ct scan and lus and cannot differentiate among viral pneumonias. preliminary data suggest that the sonographic features of this disease correlate well with chest ct features. in fact, the detection of focal b-lines on lus may be more sensitive than ct findings in early disease [ ] . other characteristic features of covid- disease on lus include a thickened or irregular pleural line, subpleural consolidations, and multifocal or confluent b-lines. translobar consolidation and pleural effusions are relatively uncommon [ ] . we herein present a brief case study to illustrate the role of lus in this context. a -year-old woman with a history of end-stage kidney disease on maintenance hemodialysis and hypertension was found to be hypoxemic with an oxygen saturation of % on room air. bedside lus demonstrated patchy areas of pleural thickening and irregularity as well as confluent b-lines and scattered consolidations consistent with viral pneumonia (fig. , supplemental video ) . focused cardiac ultrasound did not reveal any overt signs of fluid overload. she was tested positive for covid- and subsequently improved with supportive care. the patient continued to receive dialysis during a separate shift dedicated to covid- -positive patients. from the standpoint of infection control, using lus instead of ct limits staff exposure to the virus during transportation and avoids the downtime for radiology room decontamination, which takes about an hour after each scan. the key advantages of lus in this setting are summarized in fig. . we propose that dialysis units adopt lus as a bedside tool to diagnose and monitor the extent of pulmonary involvement in patients with covid- and differentiate from other causes of dyspnea. with the availability of cheaper ultra-portable hand-held ultrasound devices, lus is even more practical. ct scan can be reserved for those with equivocal lus findings or underlying chronic lung disease that interferes with interpretation. the online version of this article (https ://doi.org/ . /s - - -x) contains supplementary material, which is available to authorized users. right now, dialysis units lack trained staff for performing and interpreting lus. however, most medical professionals can be taught to perform 'goal-directed' lus quickly. web-based and remote-mentored training protocols demonstrate high inter-observer agreement for pathologic findings after a short training period [ ] . adding to this, numerous free resources exist for online training and remote mentoring. further, cloud-based image archiving platforms allow for immediate remote quality assurance easier with expert physicians reviewing images generated by novice users remotely. the time is now to act to prepare for the crisis and provide best possible care to our patients. author contributions both the authors have made substantial contribution to the preparation of this manuscript. funding none. the authors have declared that no conflict of interest exists. this article does not contain any studies with human participants or animals performed by any of the authors. permissions human body images in fig. were created using biorender ® . mitigating risk of covid- in dialysis facilities lessons from the experience in wuhan to reduce risk of covid- infection in patients undergoing long-term hemodialysis the promising role of lung ultrasound in assessment of volume status for patients receiving maintenance renal replacement therapy chinese critical care ultrasound study group (ccusg). findings of lung ultrasonography of novel corona virus pneumonia during the - epidemic a preliminary study on the ultrasonic manifestations of peripulmonary lesions of noncritical novel coronavirus pneumonia efficacy of a remote web-based lung ultrasound training for nephrologists and cardiologists: a lust trial sub-project key: cord- - d eq y authors: nan title: espr date: - - journal: pediatr radiol doi: . /s - - - sha: doc_id: cord_uid: d eq y nan prof. michael riccabona undertook his medical school & university training at the university of innsbruck, tirol, austria, completing his md at karl franzens university in graz, austria. following an internship in neurology, surgery and internal medicine he then specialized in paediatrics at the dept. of paediatrics, university hospital in graz. there he took charge of the paediatric radiology and sonography sections at university hospital in graz, as associate professor of paediatrics. in he additionally started to specialise in radiology, becoming associate professor of radiology in -then taking charge of the subsection of paediatric sonography at the dept. of radiology, university hospital in graz, where in march he was appointed full univ. prof at the medical university graz, austria. he has a distinguished academic career and written over papers, more than chapters and several textbooks, and is a very popular international speaker, delivering numerous lectures at many high profile scientific meetings. he is an active member of several reputable international societies, has been chair of the paediatric ultrasound section of the austrian ultrasound society since , and president of the society of german speaking paediatric radiologists ( ) ( ) ( ) ( ) ( ) ( ) ( ) . he is a constant source of inspiration within his subspecialist areas of interest in ultrasound and abdominal radiology in children. he has been course director at several important meetings and served as president of espr in graz in and as lead of the paediatric subcommittee at ecr in . he has provided inspirational leadership as chair of the espr task force on uroradiology since writing state of the art guidelines and procedural recommendations to facilitate standardised best practice for imaging within paediatric uroradiology. he has been a reviewer for many international journals. he has on-going active roles in postgraduate education for medical colleagues from eastern europe, including basic ultrasound education and refresher courses, and workshops. michael riccabona is very deserving of honorary membership of espr, which reflects his seminal role within paediatric radiology in europe and his tireless dedication working for the good of children. & to discuss how to optimally adapt the various imaging techniques minimising radiation exposure and risks during diagnostic imaging in children. & to consider common restrictions, challenges, and possible solutions in paediatric radiology within the different settings in different countries, regions, continents and clinical scenarios -discussing all these aspects with colleagues, and to mingle with experts from all over the world learning from each other and fostering networking in paediatric radiology to try to grant optimal imaging for all children. an application for the rd annual meeting as well as for the th post graduate course has been submitted to the eaccme® for cme accreditation of this event. the eaccme is an institution of the uems (www.uems.net). the number of cme points will be announced at the espr congress website. each medical specialist should only claim those hours of credit that he/she actually spent in the educational activity. certificates of attendance will be available in the espr myuserarea after the meeting. the answers right away is: yes we can and we constantly have to. it is part of human nature to recognize problems and to find solutions. we define ideals but we also face reality. being aware of the gap in between we are constantly driven to improve. this overview will highlight some milestones and disputes throughout the years of development in the use of plain x-ray imaging. it will hint on scientific literature and sources of information. and it will hint on some swiss contributions as the espr meeting will be held in davos, switzerland. fighting the glow not the fire - years of x-ray imaging development and improvement: in the beginning of the clinical use of x-ray imaging, there was great enthusiasm in its potential without knowing the unfavorable dangers of uncontrolled use of x-ray. the dangers were recognized and the 'beast' was tamed and domesticated. in respect to radiation protection, the most significant achievements took place in the first half of that development. throughout the recent decades, some further considerable steps in dose reduction took place mainly by the improvement of film-screen systems and the recent introduction of computed (cr) and digitized radiography (dr). even if the early computerized x-ray imaging brought a slight increase in patient doses (which was overcompensated later on by direct digital radiography) a whole new world of further advantages launched the digital era in which we live today. as we all know new dangers arose with these techniques as the uncontrolled distribution of images and thereby confidential patient data over hospital departments and across borders throughout. also, the risk of an evitable overexposure in digital radiography is a significant issue. throughout the process of taming the radiation and controlling it, today's doses are attained within the lowest range of the danger scale. this range still is perceived as a black box within which we do not exactly know which concept reflects the potential harm best. the linear no-threshold model [lnt] is acknowledged as the concept which most reliably supports the idea of radiation protection. other concepts partly oppose the linear idea and question the relevance of that dose range because there lie so much greater health benefits in the appropriate use of diagnostic x-rays. several scientists even propagate the idea that very low levels are producing health benefits instead of physical harm [hormesis model]. nevertheless, the lnt model is widely accepted as the most helpful in the context of diagnostic radiology. some recent studies were able to support the idea of potential harm at very low dose levels as they were able to prove the induction of attributable cancers in the pediatric age group. so today we are fighting the glow, not the fire. as trained medical professionals we are fully aware of the fact that there is only little potential harm to the patient by using x-rays in the current state of the art. but on the other hand, we also have to be aware of the fact that our patients and their parents still fear the fire. one of our main tasks, therefore, is to explain the risks and benefits to the patients and their advocates and to educate the public. developed straight from the first radiographic technique's digital radiography today is state-of-the-art in plain d-imaging. throughout the last decade, it has replaced cr and conventional radiography in many institutions. in the united states of america, one of the most developed healthcare systems, healthcare authorities propagate incentives to abolish cr and older imaging systems by making them financially unattractive. the market is fully concentrated on the spread of dr systems. momentarily there are no real milestones but many refinements of existing systems such as tomosynthesis, dual energy subtraction and advanced auto-stitching, fluoroscopy capability, basic angiography applications and -d cone-beam ct images are made available. combinations of these features can be found in some recently designed x-ray machines. grid-less imaging software can reduce patient dose significantly. concerning detectors, there are cr retrofit systems which will support the easy upgrade of existing systems to dr capability. wireless detectors with large internal storage, different sizes and high resolutions of microns are available. dr is becoming a part of the system in the current era of full digitalization of our lives and big data, digital radiology is a cornerstone of our healthcare systems. ris and pacs as part of integrated healthcare (ihs) systems are widely disseminated. at the next step, all accessible data will be used for analyses. the major vendors of imaging systems, as well as pacs suppliers and independent companies, offer readymade software tools for reports and evaluations of all kind. the doses from different x-ray sources can be screened internally and be used for optimization purposes. they also can be sent to remote servers for dose monitoring, comparison and optimization in multi-hospital health care provider settings or to comprehensive databases like the american college of radiology dose index registry, cancer registries, or for central billing. has everything been invented? many technologies have been declared dead before a new transformation appeared. this was the case for example with single slice ct before the invention of spiral ct by willi kalender, germany and peter vock, switzerland in . often the plain x-ray image was meant to be needless or redundant as newer technologies like ct or mri approached. but it still is of value because of different reasons as the low dose, high availability, well known and easy interpretation to name a few. there are some new and sophisticated techniques on the way like the "smart x-ray source" which uses coherent beams of x-rays from an array of micronsized point sources, developed by scientists at the massachusetts institute of technology (mit). the developers promise less radiation, less weight of the equipment and a far better soft tissue resolution. another promising approach is phase contrast x-ray imaging which has the potential to reduce the dose up to / of the actual value. it also has its strengths in additional soft tissue information as recent experimental publications show (paul scherrer institute switzerland) e. g. in functional evaluation of lung fluid (munich, germany). functional imaging of the lungs can also be achieved without any radiation as the development of the known concept of electrical impedance tomography highlights. this functional imaging method usually is not within the modality spectrum of radiologists. dose control and reduction -local -regional -international the most effective measures to achieve significant dose reductions in your own department are still the same strategies which are based on the "eternal rules" as we know them from our teachers: avoiding unnecessary exposures by strictly controlling the appropriateness of a referral. justification is a shared responsibility between radiologists and clinicians. there are many tools available for justification like the appropriateness criteria, guidelines or rules (like wrist or ankle rules) of several national societies and different study groups. the process of optimization is mainly in the hands of the technicians. as many studies show, the proper collimation still has the greatest effect on dose reduction. other important factors are the positioning of the patient and the shielding of radiosensitive organs which are not relevant for image interpretation so that they may be covered by lead shields. the proper use of the grid in bigger children can now partially be replaced by software solutions. in digital radiography, a profound knowledge of postprocessing possibilities is mandatory as well as the active control of the exposure indices. dose limitation procedures should be regularly checked in a team-based approach to avoid overexposure by less experienced staff or "exposure creep". existing standards should be actively used to guarantee a constant satisfactory image quality. in , the image gently campaign released a safety checklist for performing digital radiography examinations on pediatric patients which is easily applicable to every radiology service. organizational improvements: at regional and national level, efforts should be made to check for best practice use in the departments and to compare and discuss imaging strategies. the establishment of national and international dose reference levels helps to keep the overall doses low and to protect the population from unnecessary overexposure. the pidrl project prepared the "european diagnostic reference levels for pediatric imaging" as part of the eurosafe project. momentarily the results of pidrl-workgroup are harmonized with international organizations. the european guidelines on drls for paediatric imaging can be accessed as a preliminary final for workshop drafts on the internet. on a worldwide basis, the world health organization has published a fundamental information brochure concerning radiation risks and the communication of health professionals and patients. health care professionals have a shared responsibility for communicating risks and benefits of imaging procedures to patients, especially in the case of pediatric patients. the document "communicating radiation risks in paediatric imaging-information to support health care discussions about benefit and risk" is intended to serve as a tool for health care providers, to communicate known or potential radiation risks associated with pediatric imaging procedures and to support risk-benefit dialogue in health care settings. as said before we are fighting the glow, not the fire. the paper of the swiss pediatric oncology group stirred a broad discussion. among other issues, there was a question if it shouldn't be a logical consequence to transfer kids from areas with higher background radiation to safer areas. the author's answers were clear: that swiss health authorities better concentrate their efforts more effectively and with greater benefit for more people by supporting prevention "toward modifiable environmental factors leading to larger numbers of deaths from several causes, such as exposure to radon, air pollution, and second-hand tobacco smoke". this leads to the conclusion that we as medical radiological professionals do have the obligation to make every effort to prevent our patients and personnel from harm of the usage or non-usage of radiation. as health specialists, we also should support the fields of prevention with broad mass effects as far as we have the opportunity. and as human beings, we are summoned to do so in respect to other beings, to our environment and to the resources we all share. radiation protection and quality improvement is just a small part of it all, but it is our field -and 'yes we can'. "communicating radiation risks in paediatric imaging. freely available at the who homepage." computed tomography: are we doing enough? e. sorantin; graz/at summary: already in the alara principle was publishedbut the implementation is still far from complete. according to the surveys of the ec tender project "pidrl -european diagnostic reference levels for paediatric imaging" the most frequent computed tomography (ct) examinations in children are, in descending order, head/neck, chest and abdomen thus counting for about % of all pediatric ct's. therefore it makes sense to optimize these examinations first. surveys of the "international atomic energy agency (iaea)" in countries have shown, there is considerable lack of organizationeg in about % of facilities protocols for children were missing, indication based protocols available only in %, ctdi values for head and chest two to five times of those for adults. all of these simple facts indicate we are not doing enough for radiation protection in pediatric ct. actions to lower dose in ct can be categorized in organisational, optimization and alternatives. the interdisciplinary implementation of international guidelines for ct in minor head trauma with trauma surgeons could serve as an example of organisational actions. for dose optimization knowledge about dose relevant factors according the "imaging chain" is mandatory as well as adjusting kv to pediatric needs. dose influence on image quality must be known, by exploiting the fact, that, if all ct parameters are kept constant but hte slice thickness is just halve there must be an increase in noisein particular about two times more. therefore if a standard examination is reconstructed at half slice thickness and image quality is still appropriate the amount of waste radiation is in the range of %. therefore if the next examination will be reduced with eg % mas setting less will be for sure in appropriate quality and the process can be started again. after a couple of examinations the optimal dose will be reached. thus the "half slice thickness" approach is easy to do, does not need special equipment or human resources and will help to find the appropriate dose. the third point is alternatives -ultrasound and mri being the candidates in the first row. new, radiation free, techniques like electrical impedance tomography and others are already developed and can be expected to be release soon. take home points: & we are not doing enough for ct dose savingeven more than years after release of alara principle & dose saving actions can be categorized inthe subtasks organisation, optimization and alternatives & "the half slice thickness approach" is an easy to do technique to elaborate the optimal dose on an particular ct machine. prenatal thoracic mr l. alamo; lausanne/ch the generalization of screening us has considerably increased the detection of congenital anomalies in utero. in the last years, important technological advances and especially, the development of fast heavily t -weighted sequences has led to an increasing use of prenatal mri as additional diagnostic imaging method. mri is increasingly used for evaluation of thoracic pathology, including tumours and vascular malformations as well as anomalies of the diaphragm, the lungs and more recently, even of the foetal heart: -thoracic tumours and vascular malformations: the diagnosis of a congenital tumor during pregnancy involves a tremendous emotional impact for a family. the most frequently observed thoracic tumours are teratoma, myocardial rhabdomyoma and exceptionally, pleuropulmonary blastomas. mri may provide relevant additional information concerning the origin of the lesion and its real anatomical extent. -diaphragmatic pathology: congenital hernia is by far the most commonly reported foetal diaphragmatic anomaly. the large field of view and the multiplanar possibilities of mri may help to clarify the position of the herniated organs and to evaluate the severity of lung hypoplasia, considered the most important parameter for predicting outcome. other rare pathologies include eventration, paralysis and diaphragmatic lung sequestrations. -lung anomalies: congenital lung abnormalities are a heterogeneous group of pathologies consisting of isolated bronchopulmonary or vascular anomalies or a combination of both of them. congenital pulmonary airway malformation, bronchopulmonary sequestration and bronchial atresia are the most often observed pathologies but they present significant overlap imaging findings. mri allows accurate information concerning the location and extension of the lesion and the volume of the normal and abnormal lung. -heart pathology: the evaluation of the foetal heart remains extremely difficult because of its small size and high rate of battements. the unpredictable foetal motions during data acquisition and the absence of a foetal ecg signal to synchronize data acquisition are additional problems. in the last years, different approaches have been made to overcome these challenges. radiologists should know the typical imaging findings of the thoracic pathology most often observed in foetuses. prenatal mri may provide additional relevant information in a wide spectrum of congenital thoracic anomalies, but in general, it should only be performed if it is considered that additional results might influence the management of the pregnancy and/or the therapeutic approach. therefore, it is important to know the right indications for mri and to recognize the limits of the method. interruptions during embryogenesis of the muellerian or wolffian ducts result in various, potentially complex genitourinary abnormalities of a wide spectrum or combinations. multiple imaging modalities are employed to evaluate patients with these abnormalities. ultrasound is the frontline imaging modality. mr imaging is mostly reserved for complex cases and may incorporate an mr urography, too. other imaging modalities are less frequently used or provide only ancillary information. this presentation will demonstrate the utility of ultrasound and mr imaging, in particular, in the routine diagnostic imaging of patients with the wide spectrum of muellerian and wolffian duct abnormalities. & mr imaging is reserved for more complex cases. neonatal hepatic tumors and vascular malformations d. pariente, s. franchi-abella; le kremlin bicêtre/fr neonatal hepatic tumours and vascular malformations are rare but imaging plays a key role in diagnosis and treatment. the most frequent hepatic tumour is haemangioma (fig ) which often is asymptomatic but may be complicated by cardiac failure, coagulopathy or compartment syndrome. the differential diagnosis mainly includes hepatoblastoma, hematoma (fig ), abscess, mesenchymal hamartoma, choriocarcinoma in the solitary form and metastatic neuroblastoma, cirrhosis, neonatal leukemia in the multifocal form. pertinent biological data are alpha-fetoprotein (but level may be normally high in neonate), betahcg, and urinary catechol amines. hepatic vascular malformations are rarer and include intra or extra porto-systemic shunts (pss), arterio-portal fistula or complex mixed forms. intrahepatic pss may be associated with haemangioma and regress in most cases rapidly (fig ). on the contrary the extrahepatic pss which are located below the portal vein, should be urgently closed to avoid occurrence of agenesis of the portal vein. the best imaging modality is us which must be performed with high frequency probes and colour doppler to identify hepatic vessels and assess patency, direction of flow, abnormal communication. mri and ct with contrast injection may also be useful. hepatic mass in a do neonate with increased crp and afp. us showing a hyperechoic mass with thrombosis of the left portal vein (black arrow) and a track (white) extending to the mass: hematoma due to malposition of an umbilical vein catheter. hemangioma of antenatal diagnosis on d . the mass is composed of a large anterior vascular lake corresponding to a porto-systemic shunt and a tissular hyperechoic part. the infant has remained asymptomatic. intrahepatic porto-systemic shunt between the left portal branch of segment (white arrow) and the left hepatic vein (black arrow) in a neonate. at months of age this shunt has completely resolved. haemangioma is the most frequent hepatic tumour in the neonate and is often asymptomatic with spontaneous resolution. levels of alphafetoprotein are physiologically high in the neonate, and can be misleading. hepatic hematoma can be secondary to traumatic delivery, to coagulation disorders or to umbilical vein catheterization. intrahepatic porto-hepatic shunts are the most frequent vascular malformations and regress in most of the cases in the first year of life. us with colour doppler remains the best imaging modality in the neonatal period. imaging in crohn disease: state of the art in diagnosis, prognosis and followup n. colavolpe, a. aschero, b. bourliere-najean, c. roman, f. khachab, h. pico, m. kheiri, g. gorincour, c. desvignes, p. petit; marseille/fr summary: during the past years the inflammatory bowed diseases (ibd) have increase in frequency ( ). less than twenty-five percent of them occur in children of less than years ( ) and crohn's disease (cd) is twice as frequent than ulcerative colitis (uc) in the pediatric age group. specific phenotypic and genotypic subtype of ibd occur in younger children. early onset (eo) pediatric ibd (before years of age) represent % of childhood ibd ( ) . uc and undetermined colitis are more frequent in this age group. eo cd showed a more frequent isolated colonic and upper gastrointestinal involvement than later-onset disease where locations are predominantly colic and terminal ileum later on childhood. some pediatric ibd specificities exist than can interfere with the imaging findings: -cd can be limited to the terminal ileum or to the colon in up to % of children ( ) . isolated jejunal involvement is reported to occur in - % of children. this location is more frequent in the youngest and is more at risk of complicated course of disease ( ) . for auvin et al. ( ) the small bowel is involved in % of cases with less involvement of the terminal ileum than in the adult population. -uc: the classical contiguous alteration of the bowel wall from the rectum to the caecum is inconstant. a macroscopic rectal sparing is reported from et % and the absence of continuous disease from rectum to caecum (caecal patch) described in % of children. transmural inflammation may be present in severe form as well as terminal ileitis without granulomata (backwash ileitis) ( ) . in order to assess these pathologies, and more specifically cd small bowel locations which are difficulty explored by others modalities, small bowel follow-through, barium enema, ultrasound, computed tomography and mr imaging have been widely used. among them, mr-enterography has gained worldwide acceptance due to multiple factors including: a high contrast resolution, a multiplanar ability, an absence of radiation, the possibility to explore in the same exploration the whole bowel and the extra-bowel diseases (perianal fistulae, sacroiliac joint, biliary tract), the ability to compare of side by side consecutive studies in a reproducible manner, a more easily understood exploration by the clinicians than ultrasound, and first of all for its performances. in order to technically harmonize this exploration a recent consensus statements on mre protocol has been published by the esgar and the espr societies ( ) . preparation: -depending on their age children must not have solid oral intake from to hours prior to the examination to reduce bowel wall motility. morning mr appointment is more favorable for this purpose. no gasless fluid restriction is recommended but is reabsorbed too quickly to distend enough the small bowel. none hyperosmolar non absorbable solution is superior to another. its ingestion must start to minutes prior to mre. the recommended volume is ml/kg with a maximum up to ml/kg. explanations long before the mre concerning the importance of such absorption and the use of a refreshed product mixed with aromatized flavors will facilitate the child's participation. -the use of spasmolytic agents is optional. however, there are recommended in adults by multiple societies including esgar ( ) , the society of abdominal radiology ( ) and the acr (www.acr.org/ quality-safety/standards-guidelines). but, mre without antiperistaltic agents result has reached a high diagnostic confidence and excellent agreement with ct enterography for the presence of cd ( ) . if used, they need to be administered immediately prior to motion sensitive sequence (t w dynamic enhanced sequences). if the pictures obtain with these medications are of better quality, there is no evidence that they change the final diagnosis and the children's therapeutic management ( ) . the use of these products increase the length of the exploration and their side effects are frequent (nausea > vomiting) which balance their visual benefice ( ) . if a spasmolytic agent is used, the recommended first line spasmolytic agent is i.v. hyoscine butylbromide ( . mg/kg i.v). the recommended second line agent is i.v. glucagon, . mg (< . kg) and mg (> . kg), given as a slow infusion with i.v. saline at an infusion rate at ml/s. -no rectal enema is needed. -exploration can be performed either at . tesla or testla. more chemical shift and susceptibility artifacts are present with the latter. prone position has been demonstrated to allow better small bowel distension than the supine one with reduction of the peristaltism but without better lesion detections ( , ) . large multi-elements coils are needed to cover with high resolution from the perineum up to the left colonic flexure. sequences: both morphologic steady state free precession gradient echo and d -t -weighted images are needed in the axial and coronal planes. fat saturation in one of this plane is recommended and maximal slice thickness of mm is required. nowadays, non-enhanced then enhanced d t -fat saturation weighted sequences are mandatory. slice thickness does not exceed mm. enhance sequence need to be acquired at the portal phase of injection. however, in recent studies the need for gadolinium has been questioned when dwi is added to the morphologic sequences. dwi sequences have been considered optional ( , ) but we consider their place essential in pediatric practice. they must be done with high b values, from up to in the coronal and axial planes with to mm contiguous cut in free breathing. axial plane is less prone to artefact than the coronal plane. interestingly enough shenoy et al ( ) report in pediatric patients that dwi does not perform as well as standard mre for detection of active crohn disease but the combination of dwi and mre increases imaging accuracy for determining disease activity compared with either technique alone. seo et al ( ) in young adults said that dwi mre was noninferior to contrast-enhanced mre for the evaluation of inflammation in cd. based on the exploration of cd adult and pediatric population, dwi proved to be efficient and would avoid gadolinium injection ( ) . sirin et al. ( ) report in children that dwi revealed lesions that were not detectable with mre done with gadolinium injection. finally, respectively dubron et al. ( ) in children and neubauer et al ( ) in children and young adults demonstrate better performance of dwi than gadolinium enhanced imaging. like the existing mr protocols for suspected appendicitis ( ) it will not be surprising to see fast mr ibd explorations becoming an alternative to emergency us as already proposed ( ) . this fast mr limited to a morphologic t sequence in two planes associated with dwi sequences will allow a positive diagnosis and the ibd work up. apart from bowel obstruction and its spontaneous bowel distension one of the limiting factors will be the need for an oral water agent uptake in a potential surgical patient. however, it has been published in the adult literature than an oral or rectal preparation was not necessary to rule out uc ( ) nor a cd ( ) . the other limiting factor is the length of exploration. mre can be shorten especially if the patient's positioning is easy to do (dorsal decubitus) ( ) and if there is no need for injection, either for spasmolotytic agent and for gadolinium chelates. the suppression of the iv line, the absence of potential side effects (nausea, vomiting) of paralytic agents and the decreased of repeated long apneas with no loss of significant information will be strong progresses toward the holy grail. -positive diagnosis, disease activity, prognosis and follow-up: mre has a better accuracy to detect inflammation for the small bowel than for the colon ( ) . one of its goal is to try to accurately identify features of active inflammation vs fibrotic disease. this is of paramount importance since the former may respond to medical treatment and the latter may need surgical resection. however, inflammation and fibrosis are associated within the same bowel segment and progress in a parallel way making the goal difficult to reach ( ) ( ) ( ) . in their study based on the analyze of children operated for cd strictures, barkmeier et al. ( ) report than strictures demonstrating > cm upstream dilatation with associated feces sign were highly associated with transmural fibrosis. the most severely fibrotic strictures were associated to the greatest amount of inflammation and there was no significant correlation between stricture length, mural thickness, degree of post-contrast enhancement (arterial and delayed venous phases), diffusion-weighted imaging apparent diffusion coefficient, pattern of post-contrast enhancement, or normalized t -weighted signal intensity and histological fibrosis or inflammation scores. however, correlation with histological specimens of cd done on a other series s ( ) (suppl ):s -s pediatr radiol demonstrated that the enhancement ratio of the wall is positively correlated with disease chronicity due to a possible increasing microvessels permeability and inversely correlated to acute disease ( ). on the other hand, several authors have tried to correlate the adc values to cd activity. fibrotic tissue does not restrict diffusion and presents a decrease of signal at high b values and high adc values whether acute inflammation shows decrease adc values. variable thresholds from . x - mm /s to . x - mm /s have been proposed to separate active vs non active disease ( ) . however, others authors have reported low adc value of fibrosis compare to histology ( ). even if promising results have been published with high correlation with the crohn disease endoscopic index of severity ( ) , adc measurements are associated with sever limitation factors including sample size overlap between the bowel wall and its atmosphere, lack of reproducibility between mri-units and mri-vendors, non-standardized sequence b-values parameters ( ) . two mre scores are available to quantify the activity of cd. one is using gadolinium injection ( ) and the other dwi ( ) . due to the complexity of the formula, both are difficult to use in daily practice and have not been evaluated in paediatric practice. interestingly enough if a simplify mre paediatric protocol appears to become a reality, us stays a good imaging challenger and ( ). in a recent meta-analysis, based on adult and pediatric series, calabrese et al ( ) reported that bowel us showed . % sensitivity and . % specificity for the diagnosis of suspected cd, and % sensitivity and . % specificity for initial assessment in established patients with cd. bowel us identified ileal cd with . % sensitivity, . % specificity, and colon cd with . % sensitivity, . % specificity, with lower accuracy for detecting proximal lesions. the absence of abnormal thickness wall would have a negative predictive value, high enough to exclude the need for further exploration, especially when cd is concerned ( , ). concordance between us and mre have been variably reported from excellent ( ) to just correct ( ). rosembaum and al ( ) report that the us findings present in children operated for cd include: bowel wall thickness above . mm (mean, . mm) and an increased frequency of loss of mural stratification and fibrofatty proliferation. others us technologies are used in children to better approach the disease activity. it includes, hydrosonograpy using specific oral agents (mannitol, sorbitol, polyethylene glycol, etc…), contrast-enhanced ultrasound and dynamic contrast-enhanced ultrasound (nowadays, contrast agent is offlabel in children) ( ) and elastography ( ). their enthusiastic results and their efficiency to assess disease activity need to be confirmed ( ). in conclusion, as we suspected years ago ( ), mre has dramatically modified our approach of pediatric ibd especially when considering its orientation toward a less invasive exploration and the increasing importance of dwi imaging. a cost benefice between mre and us remains to be done on this increasing disease. heterotaxy and isomerism c. lapierre; montreal/ca summary: objectives: to review the classification of visceroatrial situs to describe the associated cardiac and non-cardiac anomalies to illustrate typical findings in fetuses, neonates and children to discuss the surgical consideration and the long-term follow-up in these patients abstract: by definition, the type of situs is determined by the relationship between the atria and the adjacent organs. anatomically, the atrial chamber differentiation is based on the morphologic aspect of the atrial appendages, earlike extensions of the atria. three types of situs exist: solitus (normal), inversus (mirror image) and ambiguus. a single type of situs is present in a patient. when the situs is neither solitus nor inversus, it is referred to as situs ambiguus or heterotaxy. heterotaxy may manifest with various abnormal visceroatrial configurations that are associated with cardiac (in - % of cases) and extracardiac anomalies such as splenic abnormalities, biliary atresia and intestinal malrotation. two subsets of situs ambiguus are well-recognized: right isomerism (asplenia) and left isomerism (polysplenia). in heterotaxy, the venoatrial connections are frequently abnormal. left isomerism is usually indicated by bilateral bilobed lungs, interruption of the ivc and multiple spleens. the more likely found cardiac anomalies are: pulmonary or aortic stenosis, isolated atrial and ventricular septal defects, cardiac arrhythmia due to sinus node dysfunction as well as pulmonary veins that drain into both the right and the left atria. in the presence of right isomerism, bilateral trilobed lungs, a large symmetric liver, and absence of the spleen are frequently observed. at the cardiac level, patients are more likely to have a common atrioventricular defect, a double outlet right ventricle and pulmonary stenosis. total anomaly of the pulmonary venous return and absence of coronary sinus will always be present in right isomerism. heterotaxy can be diagnosed with high accuracy by prenatal echography. a diagnosis should be suggested in the presence of congenital heart disease, visceroatrial heterotaxy and interruption of inferior vena cava with azygos continuation for left isomerism or abnormally closed juxtaposition of inferior vena cava and descending aorta in right isomerism. the mortality in fetuses is high in the presence of heart block and hydrops whereas the cardiac anomalies influence the long-term outcome. as discussed in the literature, the clinical outcomes and long-term prognosis in these patients are relatively poor when compared with non-heterotaxy patients. the risk factors are cardiac (underlying anatomy and arrhythmia risk) and non-cardiac. based on the cardiac anatomy, one of the main determinants is left versus right isomerism. with right isomerism, the cardiac malformation is more severe and an univentricular correction is more frequent. another predictor of mortality is pulmonary vein stenosis/obstruction. whatever the severity of cardiac lesions, the postoperative or discharge mortality is higher in patients with heterotaxy. prenatal diagnosis seems not improve the survival. extracardiac anomalies also contribute to the increased morbidity and mortality. three of the more challenging entities are respiratory, immunologic and gastrointestinal. recurrent respiratory infections, failed extubation or chronic respiratory failure are frequently observed in patients with heterotaxy. recent studies revealed an association between heterotaxy and primary ciliary dyskinesia which can explain the increased postoperative respiratory complications. the spleen is important for the bacterial clearance. patients with asplenia or polysplenia are thought to have "functional asplenia". so, they are at risk for sepsis and severe bacterial infection. the incidence of intestinal malrotation is high, approximately % to %. observation versus prophylactic ladd procedure and screening for asymptomatic intestinal malrotation are a growing area of debate. the trend seems to go along conservative management and surveillance of malrotation. bronchopulmonary malformations, such as congenital pulmonary airway malformation (cpam), bronchopulmonary sequestration (bps), and congenital lobar emphysema (currently known as congenital lobar overinflation [clo] ), are common congenital lung diseases. these conditions are detected prenatally, usually in the second trimester, in countries where obstetric sonography is routinely performed. the malformations are seen as hyperechoic images with respect to normal fetal lung parenchyma, with a mass effect and homogenous appearance or with coexisting cysts. the lesions usually decrease in size along gestation. a residual mass is seen on postnatal chest radiography, the first imaging technique performed, in only % of cases. cpam and bps are predominantly located in the posterior lower chest and can be identified postnatally on ultrasound using a small vector probe and a subcostal and subxiphoid approach. potential feeding arteries can be visualized using color or power doppler. based on clinical and sonographic findings, the differential diagnosis between congenital lung malformations and tumors such as neuroblastoma, type i pleuropulmonary blastoma, and myofibroblastic tumor will be discussed. postnatal management and imaging of newborns with congenital lung malformations is controversial, particularly in asymptomatic patients (approximately % of cases). chest radiography is mandatory at birth and chest ultrasound is also recommended to confirm the prenatal diagnosis. computed tomography (ct) or magnetic resonance imaging (mri) using angiographic techniques should be performed some months ( months) after birth in asymptomatic patients. these techniques are also recommended in symptomatic newborns and before surgery to characterize the arterial supply and venous drainage in cpam and bps, as ultrasound is limited in this regard. in premature infants, sonography complements radiography in the study of prematurity-related lung diseases such as respiratory distress syndrome and its pulmonary complications (eg, pneumothorax), in predicting bronchopulmonary dysplasia, and in diagnosing transient tachypnea of the newborn when clinical and radiographic features are inconclusive. the main ultrasound finding in these conditions is visualization of numerous "b-lines", vertical narrow-based hyperechoic bands extending from the pleural surface to the end of the field of view, representing what is currently known as "sonographic interstitial syndrome". b-lines are artifacts originating from variations in the air-fluid relationship of the lung and are better seen using high-frequency linear probes . use of sonography for follow-up of these patients will reduce the number of the chest plain films performed, and therefore, the amount of radiation exposure in this vulnerable population. for proper interpretation of the sonographic findings in these conditions, the radiologist should be familiar with current related terms, such as lines a, lines b, comet tail artifact, interstitial-alveolar syndrome, septal syndrome, and white lung. trauma is the leading cause of mortality and morbidity in children after the first year of life. motor vehicle accidents are the leading cause of death from unintentional injury in children up to the age of . of these cases, the abdomen is the fourth most commonly injured area. in pediatric patients non-operative management of these injuries predominate, hence the importance of early radiologic assessment for appropriate clinical follow-up. anatomically, compared to adults, childrens' abdomens are more square, less muscular and with less intraperitoneal and subcutaneous fat to absorb impact. the diaphragm is more horizontal causing downward displacement of the liver and the spleen outside the protective casement of the ribs. the pelvis is smaller and hence the bladder is displaced upward, also resulting in more vulnerability to this organ. the organ surface area is larger in children and they have a smaller body mass-hence more force applied per-unit of body surface area. the ribs are flexible, and although we see fewer rib fractures, this results in more internal damage. physiologically, children maintain hemodynamic stability longer, often presenting with only mild tachycardia, even when in severe hemodynamic shock. decrease in blood pressure may not be evident before the loss of % blood volume. nevertheless, bleeding is less severe and operative intervention is rarely performed. mechanics of blunt abdominal trauma include organ compression from seat belt injury with the presence of erythema, ecchymossis or abrasion on the abdominal wall increasing the likelihood of internal organ injury ( % likelihood of injury). other common mechanisms include pedestrian-car collisions( % with intra-abdominal injuries), falls ( % with intra-abdominal injuries), or handle bar injuries ( % with intraabdominal injuries). after the child arrives in the hospital, a trauma algorithm is initiated. generally, for the unstable patient, algorithms are similar and require a rapid atls protocol, followed by a fast ultrasound to confirm free fluid prior to operation. in stable patients, institutional algorithms vary greatly between countries and in different centers. some rely solely on mechanism to determine the need for fast vs ct (not complete ultrasound), others will rely on clinical exam (in a conscious patient with reliable exam) and blood work to determine the need for imaging (ct or us) and others may chose to perform an initial us and complete the exam with a constrastenhanced us during work hours. in the literature many management prediction rules exist based on the history, physical examination, mechanism of injury and are supplemented by blood work and/or intial imaging. most are based on retrospective reviews, with only a few controlled clinical trials. however, the validity of these studies is limited because of different populations, institutional policies and variable radiological practices in terms of when imaging is performed, which modalities are most beneficial and which are less valuable, all the while, considering the utilization of the least irradiating techniques. a representative sample of such algorithms will be discussed. routine and extensive initial trauma panels are not required according to a number of studies. abdominal ultrasound and urinalysis together have been found to confirm % of all intra-abdominal injures, in some studies. serial haemoglobins/hematocrit is valuable for determining ongoing s ( ) (suppl ):s -s pediatr radiol blood loss and assists clinical surveillance. electrolyte abnormalities are uncommon in children unless severe shock is present (metabolic acidosis). liver function tests are elevated in most cases of blunt abdominal trauma, hence, are often performed for its high sensitivity, to avoid ct if the liver panel is negative. imaging, however, is needed for grading of the potential liver injury if the liver panel is positive. abdominal xray is not useful in blunt abdominal trauma, and is usually normal. ultrasound has an important role in the pediatric community, as a sensitive and non-irradiating modality. however, this sensitivity is dependent on the type of ultrasound performed (fast vs. complete abdominal ultrasound vs. contrast-enhanced ultrasound) but also on the qualifications and experience of the performing physician. a meta-analysis of fast in pediatrics demonstrates that it has a sensitivity of % (grade i-ii evidence) for identifying hemoperitoneum. a negative fast is not sufficient to rule out intra-abdominal trauma. one prospective observational trial demonstrasted that % of patients without free fluid on fast (performed by formally trained pediatric truama surgeons demonstrated at least grade iii liver or splenic injuries on ct). we know that pediatric ultrasound is operator-dependent, and generally an ultrasound performed by the skillful hand of a pediatric radiologist is more sensitive than that performed by surgeons or by adult radiologists. furthermore, we know that the benefits of contrast-enhanced ultrasound in pediatric trauma exist-highly accurate in visualising lesions, hence avoiding non-contributive ct imaging, however, the feasibility of providing -hr contrast-enhanced ultrasound by a qualified radiologist is resource intesive: both structurally and with respect to personnel. published indications for abdominal ct in stable pediatric patients included suspected mechanism of blunt abdominal trauma, significant fluid resusitation without apparant blood loss, hemoglobin < mg/l without obvious blood loss, multisystem trauma and unreliable abdominal exam. one series with children undergoing ct for blunt abdominal trauma demonstrate postive findings in ( %), of which all solid organ injuries and % of hollow viscus injuries were identified on ct. however, ct has its limitations: it was found to identify gastrointestinal perforation in only % of patients with known perforation, but with findings of free fluid, wall thickening and/or bowel dilatation. it is also less accurate in identifying pancreatic trauma, with normal scans in - % of children with pancreatic trauma. again, findings of pancreatic trauma can be non-specific: free fluid or, less commonly, thickening of the gerota's fascia, presence of mesenteric fluid or of fluid between the pancreas and the superior mesenteric vein. when and where to perform ct depends on the imaging algorithms established by individual centers. generally, unstable patients with very high grade visceral injuries are taken to surgery. the stable patients are treated with non-operative management. the literature on angiographic embolization in pediatric blunt trauma is limited to case series that demonstrate a limited utility in hemodynamically stable patients with ongoing blood loss or for the definitive treatment of traumatic pseudoanevryms. a dialogue with the interventional radiologist is imperative in such cases. common imaging findings and pitfalls will be illustrated with case examples. in conclusion, a child's anatomy and physiology must be taken into account when determing the level of urgency and appropriate imaging work-up in blunt abdominal trauma. imaging of these patients cannot follow a standard algorithm as institutions vary with respect to types of personel, training, frequency of trauma, emergency department trauma protocols and availability of an in-house pediatric radiologist. ultrasound and ct have their advantages and disadvantages with associated pitfalls that the pediatric radiologist must recognize to provide an optimal diagnostic workup with minium irradiation. take home points: a child's anatomy and physiology must be taken into account when determing the level of urgency and appropriate imaging work-up in blunt abdominal trauma. imaging of pediatric abdominal trauma cannot follow a standard algorithm as institutions vary with respect to types of personel, training, frequency of trauma, emergency department trauma protocols and availability of a pediatric radiologist. ultrasound and ct have their advantages and disadvantages with associated pitfalls that the pediatric radiologist must recognize to provide an optimal diagnostic workup with minium irradiation. sport injuries d. jaramillo; miami, fl/us the growing skeleton has unique vulnerabilities to acute and chronic injuries due to sports. the practice of intensive sports during puberty and adolescence has led to a great increase in the incidence of sportsrelated injuries. during the growth spurt of early adolescence, the physis becomes weak, and is the site of fractures and avulsions (particularly in the apophyses) and of physeal widening due to repeated stresses, such as the wrist in gymnasts or the proximal humerus of baseball pitchers. both lesions can result in growth arrest. the chondro-osseous junctions of the ossifying epiphyses and apophyses are also vulnerable to avulsions, and the avulsed fragment may be entirely cartilaginous and not visible radiographically (such as in the patellar sleeve fracture). repeated trauma to epiphyses or round bones can lead to osteonecrosis (panner's disease) but more often to osteochondritis dissecans (ocd). in adolescents, ocd occurs most frequently in the medial femoral condyle, the capitellum of the elbow and the talar dome. juvenile ocd has a better prognosis than the adult form. when the skeleton begins to mature, there are fractures unique to partially closing physes such as the triplane and tillaux fracture. some sturctures have propensity to unique injuries during adolescence. a stress on the anterior cruciate ligament (acl) can lead to a tibial eminence avulsion in puberty ( figure) , an incomplete acl tear in early adolescence or a complete acl tear later. meniscal tears are almost always vertical and often involve large meniscal fragments that can flip. patellar dislocations often result in osteochondral injuries. this review will cover the main types of sports-related injuries and the imaging modalities used to diagnose them. year-old with pain and popping sensation during a fall on a football game. ap radiograph is normal & it is important to take into account the specific sport in order to anticipate subtle injuries that may be difficult to detect. a. c. offiah; sheffield/uk the radiographs obtained when inflicted injury is suspected are collectively termed the "skeletal survey". a full skeletal survey should be performed in all children below years of age in whom abuse is suspected. the investigation is not complete until follow-up skeletal imaging has been performed in the to days following the initial survey. children below one year of age should also receive a ct brain. neurological imaging in older children will depend on the clinical scenario. ct chest/abdomen is indicated when visceral injury is suspected. in terms of imaging in suspected abuse, espr has adopted the rcr guidelines. in the absence of a history of significant trauma, fractures highly specific for abuse in pre-ambulatory children include rib, metaphyseal and diaphyseal fractures. simple linear skull fractures have a relatively low specificity for abuse. the combination of subdural haemorrhage, retinal haemorrhage and diffuse cerebral oedema/encephalopathy (the so-called, "triad") suggests shaking. whereas the presence of a skull fracture implies impact. visceral injury often results from direct blunt trauma and may therefore be accompanied by anterior and/or costochondral rib fractures. the posterior rib arcs are protected by soft tissue and posterior rib fractures result from compressive/squeezing forces rather than direct trauma. the dating of fractures has a subjective element and it is more important to recognise that fractures are in different stages of healing, rather than to assign a definite age/age range to the injuries. the major differential diagnoses are accidental trauma and osteogenesis imperfecta. if rickets is the cause of the fractures, then radiology and/or biochemistry will show evidence of rickets. a low vitamin d level, in the absence of rachitic features, is not the cause of fractures. close liaison between radiologists and paediatricians is vital and any siblings/children in the same household who are below years of age should also receive a skeletal survey. remember that the presence of injury does not always mean abuse and that the absence of injury does not always exclude abuse. scoliosis may be primitive, structural, particularly during adolescence; during this period, careful follow-up is mandatory, because worsening is frequent. clinical examination with evaluation of a hump (gibbosity) with a scoliometer is mandatory, with also neurological assessment. beside radiography, additional tools have been developed to avoid xray exposure: "spinal mouse", back surface topography systems, ultrasound and other computer-assisted systems. but scoliosis can also be secondary, and imaging is important to find a cause and adapt management. among the etiologies, radiologist must recognize spine malformations, dysplastic and neuromuscular scoliosis. in addition, scoliosis may also be in relation with a primitive lesion, tumor-related or not, whether the initial disease could be within the spinal canal, spinal or paravertebral. imaging studies lies first on pa and lateral full spine x-rays, if possible with a low dose device (flat panel, slot-scanning system), keeping in mind that follow-up with repetitive exposures may be necessary. reproducible measures of different curvatures help to assess the overall static spine and the importance of scoliosis with cobb angle. the assessment of axial rotation can be obtained through d simulations, with frontal and axial views (see figure) . morphologic evaluation of the s ( ) (suppl ):s -s pediatr radiol spine is mandatory: if a secondary scoliosis is suspected, the research to etiology needs to perform ct or mri, depending on the clinical signs and the results of plain x rays evaluation. similarly, these explorations are useful in the preoperative assessment when surgical treatment is necessary. girl scoliosis, pa and lateral views with eos®, d simulation, coronal and axial views take home points: clinical evaluation is always the first step in subject with suspected scoliosis radiation burning is quite low with new devices, but repetitive exposures for follow-up need to carefully respect justification for x-rays exposures new tools are available to appreciate d spinal deformation and evaluate prognosis and surgical procedures ct and/or mri are useful in presurgical assessment and to look for etiologies in suspected secondary scoliosis malformations of the spine and spinal cord a. rossi; genoa/it summary: embryology and classification: spinal cord development occurs through three consecutive periods: (i) gastrulation ( nd gestational week): the embryonic disk is converted from a bilaminar into a trilaminar arrangement, with formation of the intervening mesoderm; the notochord is laid down along the midline, identifying the craniocaudal embryonic axis; (ii) primary neurulation ( th - th day): under the induction of the notochord, the midline ectoderm specializes into neural ectoderm. the initially flat neural plate progressively bends and folds until it fuses in the midline to form the neural tube. the primary neural tube produces the uppermost / of spinal cord; (iii) secondary neurulation ( th - th day): a secondary neural tube is laid down caudad to the termination of the primary neural tube. retrogressive differentiation of the secondary neural tube results in the tip of the conus medullaris and filum terminale. defects in one of these three embryological steps produce spinal dysraphisms, characterized by anomalous differentiation and fusion of dorsal midline structures. spinal dysraphisms may be categorized clinically in two subsets: open and closed spinal dysraphisms. in open spinal dysraphisms (osd) the placode (non-neurulated neural tissue) is exposed to the environment through a cutaneous defect along the child's back. osd include myelomeningocele, myelocele, hemimyelomeningocele and hemimyelocele, and are associated with a chiari ii malformation. myelomeningocele is by far the most common of these forms; the placode protrudes through a posterior defect and is elevated above the skin surface due to concurrent dilatation of the subarachnoid spaces. closed spinal dysraphisms (csd) are covered by intact skin, although cutaneous stigmata usually indicate their presence. two subsets may be identified based on whether a subcutaneous mass is present. csd with tumefaction comprise lipomas with dural defect (lipomyelocele and lipomyelomeningocele), meningocele, and myelocystocele. lipomas with dural defect are more common; they are differentiated from one another based on the position of the cord-lipoma interface, that lies within the spinal canal in lipomyelocele, and outside the spinal canal (ie, into a meningocele) in lipomyelomeningocele. csd without tumefaction comprise complex dysraphic states (ranging from complete dorsal enteric fistula to neurenteric cysts, diastematomyelia, dermal sinuses, caudal agenesis, and spinal segmental dysgenesis), bony spina bifida, tight filum terminale, filar and intradural lipomas, and persisting terminal ventricle. the most complicated forms (complex dysraphic states), including diastematomyelia, caudal regression, and segmental spinal dysgenesis) are related to faulty gastrulation. diastematomyelia (literally, split cord) is caused by failure of midline notochordal integration, resulting into two separate hemineural plates. caudal agenesis and segmental spinal dysgenesis are related to defective notochordal formation, characterized by absence or hypoplasia of a segment of the notochord, in turn resulting into absence or hypoplasia of a corresponding segment of the spinal cord. functional neuroimaging of cns is a fast advancing field with frequent new developments in scanner's hardware, protocols, clinical indications, and post-processing techniques. for radiation safety reasons in the case of children, functional neuroimaging is mostly based on mr techniques especially designed to focus on the assessment of functional tissue characteristics, such as neuronal activity (fmri),, metabolism (mrs) and perfusion (dsc perfusion, asl). pediatric coils with multiple elements, multiple slice excitation, d spectroscopy, d asl, reduced fov (zoom) and improved motion compensation techniques are important tools available to meet the permanent challenges of pediatric mr functional imaging: fast motionless acquisitions and increased resolution. functional mri (fmri) reveals brain activation during performance of behavioral tasks, based on the blood oxygen level dependent (bold) mri signal, which is modulated by neural activity via a process of neurovascular coupling. for children, especially of younger age unable to follow a task, resting-state fmri (rfmri) can be performed and correlates brain areas with similar spontaneous fluctuations in the bold signalthereby enabling estimates of 'functional connectivity.' main clinical applications of fmri are the delineation of eloquent cortex near a space-occupying lesion and the determination of the "dominant hemisphere" for language. intense research is conducted in the areas of language organization and development, brain plasticity, and neurobehavioral disorders (e.g. adhd). magnetic resonance spectroscopy (mrs) is a noninvasive mr technique, that detects intracellular metabolites, and may provide neuroimaging biomarkers of normal biological and pathological processes or response to a therapeutic intervention. although the main field of application of mrs is the brain tumors, it has also been of particular ( ) (suppl ):s -s pediatr radiol usefulness in assessing ischemic or traumatic brain injury and neurometabolic disorders. perfusion mr imaging methods detect signal changes that accompany the passage of a tracer through the cerebrovascular system. a less invasive approach is arterial spin labeling (asl) that uses arterial water as an endogenous tracer to measure cbf and thus it is more suitable for pediatric studies. mr perfusion is applied in the evaluation of brain tumors, neurological diseases and developmental disorders. functional neuroimaging clinical applications are expected to expand greatly in the future due to the increasing availability of their techniques, as well as the continuous advancements in the field of pediatric research. good knowledge of these techniques will become more necessary for an effective clinical practice and will enhance the role of radiology in the healthcare system. functional neuroimaging advanced techniques based on mri allow us to study complex cns processes such as cerebral perfusion (dsc, asl), metabolic activity (mrs) and brain activation (fmri). functional neuroimaging techniques already have significant clinical pediatric applications and assisted by recent advances in mr technology are expected to become even more powerful in the near future. kidney: perfusion, excretion, obstruction k. darge; philadelphia/us the functional imaging of the urinary tract entails the evaluation of the renal perfusion and excretion. in this complex process the sites of the main abnormalities could be pre-renal, renal parenchymal, renal pelvicalyceal or post-renal or even a combination at different sites. functional mr urography (fmru) is an advanced tool that not only allows the exquisite morphological depiction of the urinary tract, but also makes it possible to generate comprehensive functional data. these provide information about the function of the kidney as well as the excretion of urine from the renal parenchyma into the pelvicalyces and ureter. the functional results are mainly divided into two groups: . transit timesthese are recorded in minutes and a side comparison gives idea how much time it takes for the contrast to go through the renal parenchymathe longer the more abnormal in general. . differential renal functionsthese can be based on the enhanced renal parenchymal volume or the patalk number generated from this area and provides in percentage the split renal function. this presentation will discuss in detail the functional aspect of mr urography and demonstrate its utility in routine pediatric uroradiologic imaging. in chronic childhood lung disease (e.g. cystic fibrosis) global pulmonary function tests (pft) can be normal although lung damage is already present. moreover, in comparison to imaging, pft is challenging in young children. thus, cross-sectional imaging became more important in the past two decades. regarding morphological evaluation, multidetector computed tomography (mdct) serves as the most sensitive and reproducible modality. for functional evaluation perfusion/ventilation scintigraphy remains the reference standard. although the individual radiation burden by a single chest ct has decreased significantly in the past, radiation doses can cumulate considerably when repeated examinations are performed in a longterm follow-up. pulmonary mri exists as an alternative method, especially for paediatric patients. however, standard h+mr sequences do not demonstrate small airway disease due to inherent limitations of low signal and rapid t * signal decay of lung tissue. for comprehensive diagnosis, functional mri offers the unique possibility to measure regional ventilation and perfusion, and mapping relaxation times and diffusion. focussing on research applications, a variety of methods are available for these purposes. in this context, ventilation imaging using inert fluorinated gas indicates to overcome the limitations of the expensive setting necessary for imaging with hyperpolarized noble gasses. regarding lung perfusion, dynamic contrast-enhanced mri (dce-mri) is the most established method in clinical practice. however, especially in children, techniques that are completely non-invasive and do not require i.v.-contrast agents administration or gas inhalation could be promising to achieve broad acceptance. concerning non-invasive methods, ventilation can be assessed by sequences with ultra-short echo times (ute), perfusion by arterial-spin-labeling (asl) and both by fourier decomposition mri (fd-mri). in conclusion, pulmonary mri offers both, the assessment of morphology and the unique possibility to measure regional ventilation and perfusion, and mapping relaxation times and diffusion. new mr techniques that are completely non-invasive are now available. however, further scientific evaluation is needed. ibd and related arthropaties d. jaramillo; miami, fl/us musculoskeletal diseases affect about % of patients with crohn's disease and are the most frequent extra-intestinal manifestation of inflammatory disease. the articular manifestations of inflammatory bowel disease (ibd) are one of the seronegative arthritides, although they have a lower incidence of hla -b than other seronegative arthritis such as ankylosing spondylitis. there are manifestations in the joints of the extremities, and findings in the pelvis, especially in the sacro-iliac joints, and spine. involvement of the extremities occurs in about % of patients with ibd related arthropathies, are more common with crohn's disease, and can have either manifestations related olygoarticular jia, or can have symmetrical involvement of smaller joints. the axial manifestations include ankylosing spondylitis and sacro-iliitis. sacroilliitis is typically bilateral (figure) and often has radiographic as well as mri abnormalities. enthesitis, tenosynovitis and dactylitis can occur with ibd just as they occur with other arthritides. it is important to differentiate ibd related arthritis from septic arthritis due to extension of an enteric fistula. deceased bone mineral density is a common finding in inflammatory disease. it occurs as a combination of malabsorption of vitamin d due to intestinal involvement and the effects of therapy, particularly corticosteroids. insufficiency fractures of the spine, sacrum and extremities can mimic the symptoms of arthritis. finally, ibd can be associated with chronic non-bacterial osteomyelitis, although this association is relatively rare. this review will illustrate several of the skeletal manifestations of ibd, focusing on the arthropathies. juvenile idiopathic arthritis (jia) can be defined as an arthritis of unknown cause occuring in children younger than years and of at least weeks duration. juvenile spondyloarthritis (jspa) is a subset of jia and is characterized by enthesitis (inflammation at the attachment of tendons, ligaments and the joint capsule), arthritis and an increased risk of axial disease. there is also a strong association with human leukocyte antigen b . jspa accounts for approximately - % of juveniles arthritis cases in europe and is the most common form of juvenile arthritis in asia. the condition is associated with significant long-term morbidity, high health-care costs and poorer outcomes compared with other forms of juvenile arthritis as well as its adult counterpart. up to % of patients continue to be at risk of developing ankylosing spondylitis (as) during the disease course. recognizing spondyloarthritis (spa) in children is challenging, particularly early in the course of disease, as the signs and symptoms at disease onset differ from those seen in adults. jspa typically presents with hip and lower limb arthritis in conjunction with enthesitis. inflammatory back pain as a presenting symptom is less common. as a consequence, jspa may be missed or confused with other juvenile arthritides and patients often experience prolonged delays in diagnosis. currently there is no single diagnostic or classification system that is representative of the jspa population. according to the international league of associations for rheumatology (ilar) classification system, most childhood spa's are classified as enthesitis-related arthritis (era), psoriatic arthritis or undifferentiated arthritis. recent studies indicate that there are two clinical phenotypes of era: those with early axial disease often associated with hip arthritis in addition to peripheral arthritis; and those who follow a more peripheral disease course with arthritis and enthesitis and do not develop axial disease. the ilar classification system places patients with both axial and peripheral involvement into the era subtype, and does not specifically address children who meet the criteria for as. the correct approach to the classification of era is uncertain, and this issue is confusing to both pediatric and adult rheumatologists. unlike other categories of juvenile arthritis, jspa affects boys more often than girls, and peak age of onset is early adolescence. enthesitis is a defining characteristic of jspa. it is more common and affects more sites in the paediatric population compared with the adult one. the most commonly tender entheses are the insertions of the patellar ligament at the inferior patella, plantar fascia at the calcaneus, and the achilles tendon. arthritis in jspa is typically asymmetrical, oligoarticular (< joints) and involves predominantely the weightbearing joints. isolated hip joint arthritis may be the presenting feature and predicts early axial disease. involvement of the small toe joints is common in jspa but rare in other forms of jia. midfoot arthritis and tarsitis (inflammation of the intertarsal bones, overlying tendons, entheses and soft tissue) is highly suggestive of spondyloarthritis. in adults, inflammatory back pain typically heralds the onset of sacroiliitis, whereas children seldom present with symptoms of axial disease. however, according to several studies, sacroilitis can be asymptomatic in jspa and only detectable by imaging. other axial manifestations in jspa are inflammation of the lumbar apophyseal joints and interspinous ligaments, corner lesions of the spine and other sites of axial enthesitis-osteitis including the various ligamentous and muscular attachments of the pelvis. extraarticular manifestations of jspa are highly associated with axial disease and include acute anterior uveitis, bowel inflammation, psoriasis, and cardiac disease. clinical diagnosis of jspa can be difficult and the role of imaging may be more critical than in adult disease. the major goal of imaging in jspa is to identify children with early signs of axial disease, as this group is at the greatest risk for progression to as. the presence of axial disease in spa has also major implications for treatment decisions, since traditional firstline therapies appear to have minimal effectiveness in the management of axial inflammation. in addition, recent studies in adults suggest that earlier initiation of biologic agents (anti-tnfs) may slow radiographic progression. x-rays are not sensitive to acute inflammatory changes and will only show advanced disease in the sacroiliac joints. for these reasons plain radiographs are not useful in children or adolescents. ultrasound is a non-invasive, non-ionizing and relatively inexpensive technique that can be performed in a clinical setting. it is emerging as a valid diagnostic tool in spa and can be used to visualize peripheral synovitis, tendonitis and enthesitis, but the method is heavily operator-dependent and there does not yet exist a clear definition for the diagnosis and grading of enthesitis in children. secondary changes (calcifications, enthesophytes) have been observed much less in children compared with adults. there is a need for better consensus on abnormal ultrasonographic findings that define enthesitis lesions and standardization of methods. magnetic resonance imaging (mri) is a radiation free and sensitive imaging modality for detection of synovitis as well as cartilage and bone destruction. mri of the sacroiliac joints is increasingly obtained for early detection of inflammatory changes, as it shows active inflammatory (bone marrow edema, osteitis, enthesitis and capsulitis) and structural (erosions, subchondral sclerosis, subchondral fatty change and bony ankylosis) lesions of sacroiliitis long before radiographic changes become evident. in adults, mri has become the gold standard imaging modality for detecting arthritis and enthesitis. consensus definitions of lesions indicating pathology on mri are now incorporated into diagnostic criteria for adult with spa. in children and adolescents there is no gold standard mri technique and it is therefore not clearly defined whether changes s ( ) (suppl ):s -s pediatr radiol seen in the sacroiliac joints are pathologic or part of normal maturation in the growing skeleton. the use of contrast enhanced imaging for the detection of active sacroiliitis on mri in jspa is a major controversy. synovial enhancement can be detected without accompanying bone marrow edema in children, and it can be argued that contrast should be administered in order not to miss the diagnosis. some authors argue that contrast administration does not change or add substantially to the mri findings made on non-enhanced scans. certainly, given the risks associated with gadolinium administration, contrast should be used with caution. perhaps the use of contrast agents should be limited to selected cases when high stir signal in the joint is the only finding in order to confirm the presence of synovitis, and when the differential diagnosis includes etiologies such as infection or tumor. the development of new mri techniques has made it possible to perform whole body mri scans (wbmri) that allow assessment of the full range of affected entheses and joints. there is limited data on the utility of wbmri in the pediatric population. it is worth noting that edema-like changes seen in the marrow of healthy children is an important potential pitfall to consider during interpretation and further studies are required in order to establish specific reference standards for mri of the pediatric skeleton. diffusion-weighted imaging (dwi) offers a new approach to detect inflammation. inflammation produces an increase in the apparent diffusion coefficient (adc) of water molecules in affected tissues. several studies in adults and a few recent studies in children have demonstrated that adc is elevated in sacroilitis versus controls and that diffusion scores correlates well with stir images. dwi is promising as a potential biomarker of disease activity in jia and presents a novel approach to contrast-free imaging of synovitis. however, further studies are needed before it can be implemented in clinical practice. jspa is distinct from adult spa and manifests more frequently as peripheral arthritis and enthesitis. symptoms involving the spine and sacroiliac joints often occures later in this population. clinical diagnosis of jspa can be difficult, and imaging therefore plays an important role in the diagnostic workup of disease. identifying early signs of axial disease has major implications for treatment decisions and mri of the sacroiliac joints is increasingly obtained for early detection of inflammatory changes. however, mri criteria for sacroilitis in children are lacking. a major controversy in imaging of sacroilitis in jspa is the use of contrast, as children can have sacroilitis without accompanying bone-marrow edema. dwi presents a novel approach to contrast-free imaging of synovitis but further studies are needed before it can be used in clinical practice.wbmri has been shown to be more sensitive than clinical examination in the assessment of both disease activity and extent, but there is limited data on wbmri in children. normal variants in the growing skeleton may mimic pathologic changes and potentially cause overdiagnosing and -staging of disease. hence, there is an urgent need to establish specific reference standards for mri of the pediatric skeleton and to develop a gold standard mri technique for the axial skeleton in children and adolescents. juvenile idiopathic arthritis o. olsen; london/uk summary: juvenile idiopathic arthritis (jia) is common (about : , children). diagnosis and classification are based on clinical criteria. these criteria are in flux depending on ) contemporaneous knowledge about aetiology and ) available treatment options. radiology has currently no role in establishing the diagnosis. the clinical classification rests on whether the child has few joints affected (oligo jia), many joints (poly jia), has a condition similar to adult spondyloarthritis (entesitis-related arthritis) or other clinical presentations (systemic-onset jia, psoriatic jia, etc). radiology can potentially assess expressions of jia, such as synovitis, tenosynovitis, systemic manifestations and permanent damage caused by inflammation. it is therefore thought to play a part in gauging the disease activity. the clinical care aims at optimising the child's everyday function, reducing acute symptoms (pain, swelling, joint restriction), allowing normal growth, minimising long-term sequelae (joint deformity) and minimising adverse effects of medical treatment. medical treatment in jia is systemic (immuno-modulation) and local (steroid injection to joints and tendon sheaths). both modes of therapy may to some degree be guided by imaging. however, there currently is no evidence that any form of whole-body imaging is efficacious for guiding treatment. this means that, in principle, indication for imaging should be ) specific clinical questions, e.g. uncertainty regarding active inflammation at specific sites, or ) a high pre-test likelihood of inflammation at a site which is difficult to assess clinically and where imaging offers reasonable accuracy. one example of the latter are the temporo-mandibular joints where destruction is frequently seen at an early stage, often without prior symptomatic warning. there is one fundamental challenge for imaging research in jia: what is the reference standard? for lack of anything better, a standardised clinical examination is often used as 'ground truth'. the dilemma is obvious. if clinical examination is reliable and accurate, then why bother with imaging? but we think imaging offers an improvement, then we cannot use an inferior method to set the standard. this problem is not unique to jia. as is often the case, radiology in jia is all about: knowing your clinicians (i.e. the pretest likelihood for disease) being technically eloquent (e.g. using high-resolution us probes, not delaying post-contrast mri acquisitions) knowing what is normal (e.g. normal undulations in the articular surface, focal bone marrow signal variation) not being dogmatic about individual observations or measurements interpreting your findings in a clinical context the lecture will demonstrate similarities and differences among joints and modalities in children with variable-severity jia. the following points will be made: focal areas in the bone marrow with high signal (t ) and corresponding enhancement are often seen in healthy children. in isolation, these do not signify active inflammation. active synovitis in children often is not associated with (much) effusion the combination of synovial thickening with hyperaemia (us)/abnormal contrast enhancement (mri) and surrounding softtissue swelling suggests active inflammation, however there is (yet) no established system for quantifying hyperaemia/enhancement focal pits in the carpal bones do not represent erosions unless there is an associated cartilage defect radiographs are useful for detection of destructive abnormality in mri, scan fairly soon after injecting contrast. gadolinium physiologically leaks into the synovial fluid making it difficult to delineate the synovium a few differential diagnoses to keep in mind when there is mass-like swelling within or adjacent to a joint: vascular and neoplastic lesion, pigmented villonodular synovitis, synovial chondromatosis, lipoma arborescens. synovial inflammation is not always primary. even when there is an established diagnosis of jia, do consider that it may be secondary to biomechanical abnormality (erosion, osteochondral lesion, deformity). focal areas in the bone marrow with high signal (t ) and corresponding enhancement are often seen in healthy children. in isolation, these do not signify active inflammation. active synovitis in children often is not associated with (much) effusion the combination of synovial thickening with hyperaemia (us)/abnormal contrast enhancement (mri) and surrounding soft-tissue swelling suggests active inflammation, however there is (yet) no established system for quantifying hyperaemia/enhancement focal pits in the carpal s ( ) (suppl ):s -s pediatr radiol bones do not represent erosions unless there is an associated cartilage defect radiographs are useful for detection of destructive abnormality in mri, scan fairly soon after injecting contrast. gadolinium physiologically leaks into the synovial fluid making it difficult to delineate the synovium pulmonary manifestation of connective tissue disorders c. m. owens; london/uk summary: connective tissue diseases are an important cause of morbidity and mortality in children with very varied presentations. nomenclature is confusing and a more appropriate descriptive term would be "multisystem inflammatory disorder +/-autoimmunity". it is important for the radiologist to be aware of the protean radiological appearances and clinical manifestations. take home points: different patterns of diffuse lung disease (eg, desquamative interstitial pneumonia, non specific interstitial pneumonia, lymphocytic interstitial pneumonia, organising pneumonia, diffuse alveolar damage) may be present in several forms of collagen vascular disease, (and indeed other rheumatological conditions such as jia) including scleroderma, systemic lupus erythematosis, juvenile dermato and polymyositis, sjogren's syndrome and mixed connective tissue disease. these will be discussed in detail with illustrations for thin section high resolution ct with histopathological correlation. the clinical presentation, prognosis and response to therapy vary depending on the histological pattern of diffuse lung disease, as well as on the underlying collagen vascular disease. whole body imaging in children: sonography, ct, mri, nuclear medicine -what and when? r. a. nievelstein; utrecht/nl there are several (benign and malignant) disease processes in children that frequently involve more than one organ system or body region. diagnostic imaging of children with such multifocal or multisystem diseases has been quite challenging, often requiring a combination of different imaging techniques for a whole body coverage. the recent technical developments in computed tomography (ct), magnetic resonance imaging (mri) and nuclear medicine (nm) have changed the role of imaging in these children revolutionary. in the past, imaging techniques have been mainly used as a tool to detect the cause of illness and to assess the extent of disease spread before, during and after therapy (i.e. structural imaging). but nowadays, it has also become possible to use imaging techniques to gain information on the biological behavior of diseases before and during therapy (i.e. functional imaging). plain radiography, ultrasonography (us) and computed tomography (ct) have been the structural imaging techniques of choice for many decades, more recently supplemented by functional imaging techniques like single-photon emission tomography (spect) and positron emission tomography (pet). a major disadvantage of most of these techniques is the use of ionizing radiation, which may be associated with induction of second cancers later during life. this small but not negligible health risk is of particular concern in children as their tissues are more radiosensitive than adults and they have more years ahead in which cancerous changes might occur. that is why there is an increasing interest in the use of alternative imaging techniques that do not use ionizing radiation. with mri it is nowadays possible to acquire images with a high spatial resolution and excellent soft tissue contrast throughout the body, which makes it an ideal radiation-free tool for the detection of pathology, especially in soft tissue, parenchymal and bone marrow locations. moreover, recent technological advances have resulted in fast diagnostic sequences for whole-body mr imaging (wb-mri), including functional techniques such as diffusion weighted imaging (dwi). as a result, wb-mri has become a clinically feasible imaging modality for diagnosis and follow-up of multifocal and multisystem diseases in children. in this scope, the recent development of integrated pet/mri systems is very interesting, combining the superior structural imaging of mri with the functional (molecular) information of both imaging techniques while decreasing the radiation dose. traditionally, whole body imaging techniques have been mainly used for oncological indications, such as staging of malignancies, and monitoring of the effectiveness of therapy. however, whole-body imaging techniques are increasingly used for the diagnostic imaging of other benign multisystem diseases and indications, including chronic recurrent multifocal osteomyelitis (crmo), rheumatological diseases, neuromuscular diseases, neurofibromatosis type , generalized vascular malformations, multifocal osteonecrosis after intensive chemotherapy, fever of unknown origin, and post-mortem imaging. finally, these imaging techniques may be used for the screening of children with a cancer predisposition syndrome. during this lecture, imaging protocols and indications of the different whole body imaging techniques will be discussed with a focus on their clinical application in children with benign and malignant multifocal or multisystem diseases. ( ) (suppl ):s -s pediatr radiol appearances is important for any radiologist involved in child imaging, because we have an important role in characterizing the lesions and guiding purposeful and minimally invasive but successful diagnostic procedures. most head and neck masses in children are benign and have an inflammatory, infective, vascular or congenital cause (cf. special presentation on vascular malformations). malignant lesions are less common, however, early diagnosis is paramount as many of these cancers are readily treatable and often curable. differential diagnosis is guided by patient age, clinical presentation, tumour localisation, and imaging characteristics. while some masses such as (epi-)dermoids, fibromatosis colli and swollen lymph nodes including atypical mycobacterial infections (mott) may be readily diagnosed by clinical inspection und ultrasound, others present special diagnostic challenges. fibromatosis, for example, is a benign lesion with an often complex and potentially destructive local spread. some malignant lesions tend to be localised such as the embryonal rhabdomyosarcoma, while others may be part of a systemic disease such as lymphoma and langerhans cell histiocytosis (lchc). in case of a suspected malignancy, patients should be referred to a specialized centre which will be able to provide the full spectrum of multidisciplinary evaluation and treatment according to the guidelines of an international oncology study group. this is also important for image guided or surgical biopsies as long term outcome and survival of many of the young patients are directly associated with these initial diagnostic and therapeutic strategies. with its excellent spatial resolution in the near field, ultrasound is the method of choice for all superficial masses. an experienced paediatric radiologist will be able to identify most of the benign lesions and in other cases will be able to guide further diagnostic decisions. tumours in the midline require thorough workup to exclude an encephalocele or a dermal sinus with connection to the intracranial space. high resolution mri is required if such an extension cannot be ruled out by ultrasound or if a tumour is larger than the transducer's scan area. soft tissue tumours in the deeper parts of face and neck as well as tumours of osseous origin are also best delineated by mri. in lesions adjacent to the skull base contrast enhanced and fat saturated mr images with high spatial resolution are of utmost importance to completely depict the tumour's extension through the foramina and along the meninges (fig. ) . ct can provide additional information on the involvement of osseous structures. embryonal rhabdomyosarcoma. high resolution mri with fat saturation after contrast injection depicts the tumour's extension through the foramen ovale (long arrow) and along the meninges (short arrows). skull base and face lesions are less frequent in children than in adults. symptoms may be subtle or unspecific. depending on their localization, clinical findings may be common (nasal obstruction, otitis…) or more disturbing (cranial nerves palsies, exophthalmos, vision loss …). clinical history and physical examination findings are important to reduce the spectrum of differential diagnosis, but imaging data are the key features to determine the nature of these lesions. ct and mri play an important role in diagnosis, treatment survey and surgery planning of skull base and face lesions. skull base and face bone lesions are either intrinsic lesions of the bone or secondary to soft-tissue tumors or pseudo tumors invasion. this lecture will focus on bone intrinsic lesions, and include soft-tissue and pseudo tumors only as differential diagnoses. computed tomography plays the role for skull base and face of plain radiograph for long bones. therefore, the same semiology may be used to determine if the lesion is slowly or rapidly growing, aggressive or looks benign. helical ct allows reconstructions with both soft-tissue and bone algorithms as well as multiplanar reformations. it gives a good visualization of the anatomy of the skull base and allows a good depiction of the bone architecture. ct is first used for the initial work up of the disease but also for surgery and therapeutic planning (endoscopic sinus surgery with navigation). however, ct analysis may be challenging in children due to growth changes: normal process of pneumatization according to age, sutures not yet fused has to be recognized. some variations in pneumatization must not be mistaken for pathology: asymmetrical pneumatization of the petrous apex and arrested pneumatization of the sphenoid mimicking intraosseous lesion are the most common. both ct and mr imaging are complementary: most preferably, contrast-enhanced mr is associated with non-contrast high resolution ct. mri allows a good delineation of bone involvement of skull base lesion due to bone marrow changes, whether ct can fail to detect subtle extension within the bone. in addition to t and t weighted sequences, the use of specific sequences and/or techniques such as fat-saturation, diffusion, dynamic-contrast-enhanced sequences, and mr angiography helps to characterize the lesions. t spin echo sequence is mandatory to appreciate bone marrow infiltration in adults and older children. but when red bone marrow has not yet be replaced by fatty bone marrow, in young children, this can be challenging. it is useful to know the bone marrow fatty conversion of the skull base chronology. cranial mr can also be associated to whole body mr to look for multifocal or metastatic disease. epidemiologic data concerning bone tumors of the skull base are scarce due the rarity of these lesions. they can be classified according to their location within anterior, middle or posterior cranial fossa or classified according to their origin: osteogenic (osteoblastoma, osteoma, osteosarcoma...), chondrogenic (chondroma, chondrosarcoma), fibrous ( fibrous dysplasia, fibro-s ( ) (suppl ):s -s pediatr radiol osseous lesions..), notochord (chordoma), hematopoietic (leukemia, histiocytosis ), vascular (hemangioma), neuro ectodermic ( ewing sarcoma) or unknown origin (aneurysmal cyst, giant cell tumor). the aim of this presentation is to draw attention to skull base growth changes that can mimic pathology and to describe the imaging specificities of the most common bone tumors of the skull base and face in children. because conflicted nomenclature can cause confusion, accurate diagnosis and classification of these anomalies is important for proper clinical evaluation and management. many of these patients require multidisciplinary care, consequently the usage of a correct nomenclature across all disciplines is a sine qua non. the international society for the study of vascular anomalies (issva) classification, updated in , offers a comprehensive classification accepted by many subspecialities. this approach/ classification has facilitated correct communication for all medical subspecialties involved in the care of these complex vascular anomalies. pediatric radiologists play a critical role in evaluating these patients since the majority present during childhood. in this presentation, we present a state of the art mri imaging protocol with exemplary cases of the most common types of vascular anomalies in the pediatric trunk and extremities, using the current issva classification. in addition, we discuss the common syndromes associated with vascular anomalies such as klippel-trenaunay and lumbar syndrome. genetic skeletal disorders (gsd's) are a heterogeneous group of syndromes characterized by an intrinsic abnormality in growth and (re-)modeling of cartilage and bone. a large sub-group of gsd's may have additional involvement of other structures/organs beside the skeleton, such as the central nervous system (cns). cns abnormalities have an important role in long-term prognosis of children with gsd's and should consequently not be missed. sensitive and specific identification of cns lesions while evaluating a child with a gsd requires a detailed knowledge of the possible associated cns abnormalities. here, we will present and discuss a pattern-recognition approach for identifying relevant neuroimaging findings in gsd's guided by the obvious skeletal manifestations of gsd. in particular, we will discuss which cns findings should be ruled out for the various gsd. to facilitate this diagnostic approach the multiple gsd are classified based on the pattern of skeletal involvement ( . abnormal metaphysis or epiphysis, ) abnormal size/number of bones, ) abnormal shape of bones and joints, and ) abnormal dynamic or structural changes). skeletal involvement is defined in accordance with online mendelian inheritance in man. the spectrum of co-existing cns involvement is extracted from an extensive literature search. selected examples will be shown based on prevalence of the diseases and significance of the cns involvement. cns involvement is common in gsd's. a wide spectrum of morphological abnormalities is associated with gsd's. early diagnosis of cns involvement is important in the management of children with gsd's. this pattern-recognition approach aims to assist and guide physicians in the diagnostic work-up of cns involvement in children with gsd's and their management. not infrequently the correct radiological differentiation of skeletal and/or central nervous system findings secondary to non-accidental injury versus inherited genetic and/or metabolic disorders may be challenging. imaging findings may be non-specific, can result in incorrect diagnosis and subsequently inadequate patient management or initiation of faulty treatment. the diagnostic work-up of children suspected of non-accidental injury or genetic/metabolic disorders requires a multi-disciplinary approach involving many key players including physicans of various disciplines, nurses, psychologists, social workers and many more. a proper and detailed medical history and physical examination of the patient, collection of the relevant family history, a metabolic and genetic work up, a detailed interview of care givers, friends and family are essential for the correct and comprehensive evaluation of imaging findings. in the current session, various exemplary and possibly confusing cases will be interactively discussed with the audience by a panel of experts (susan blaser, thierry a.g.m. huisman and andrea superti-furga). goal is to offer a case based approach to challenging patients with discussion of the best diagnostic approach including differential considerations. the zikv is transmitted mainly by the bite of female aedes aegypti and aedes albopictus mosquitoes. other forms of transmission, including through sexual intercourse, blood transfusion, and neonatal, are currently under evaluation, although more elements are still needed to assess the real importance of these transmission routes . the course of the zikv infection is self-limited. so far, no specific symptoms have been attributed to the disease, and a wide variety of manifestations ranging from absent to mild symptoms (in % of cases) have been described. when symptoms are present, they may lead to a misdiagnosis of other bacterial and viral infections, especially other arboviroses in endemic areas. the most frequently reported symptoms are mild fever, cutaneous rash, fatigue, arthralgia/myalgia, and conjunctivitis. dizziness, malaise, edema of the extremities, anorexia, retro orbital pain, photophobia, gastrointestinal disorders, sore throat, cough, sweating, and lymphadenopathy have also been reported. infection by the zikv in adults may be associated with autoimmune complications such as guillain-barré syndrome . the laboratory diagnosis of zikv infection is based on the demonstration of the virus in the urine and blood using real-time reverse transcription polymerase chain reaction (rt-pcr). the main limitation of this diagnostic method is a false-negative result after the viremia is resolved. the serological diagnosis of the disease is limited due to cross-reactivity of the zikv with other viruses of the flavivirus genus, especially those causing dengue and chikungunya. physicians should be aware of this fact when the diagnosis of zikv infection relies solely on serological results. the diagnosis is also possible by igm measurement in serum, urine, or cerebrospinal fluid using enzyme-linked immunosorbent assay (elisa) . the prevention against zikv infection is similar to that of other arboviroses, including vector control and mosquito bite prevention. the first major zikv epidemics were reported in the french polynesia in and . at that time, some neurological changes were observed in neonates of infected pregnant women but were not associated with a maternal-fetal transmission of the virus. the growing increase in the number of cases and the severity of the infection specific to this subpopulation then led to the evidence of a congenital disease . in brazil, the situation became alarming with the report of a high number of infected individuals in the second half of , . the brazilian ministry of health attributed to congenital zikv infection the -fold increase in cases of neonatal microcephaly in the northeastern part of the country, particularly in the state of pernambuco. this led the world health organization (who) to declare the zikv infection a "public health emergency of international concern" in february . the main challenge for radiologists practicing in regions of endemic zikv infection is to become familiarized with findings of congenital zikv infection in perinatal imaging studies; this is particularly important for the prenatal screening of pregnant women , . the diagnosis of zikv infection in the fetus by neuroimaging is based on prenatal ultrasound (us), especially in the third trimester, and complemented with magnetic resonance imaging (mri). postnatal imaging was obtained by transfontanellar us, ct or mri. the main imaging findings on ct are microcephaly, an exuberant external occipital protuberance, rectification of the frontonasal angle, and a redundant scalp skin. three-dimensional ( d) reconstruction of al skull permits a better evaluation of these findings and enhances the parents' understanding of the disease. moreover, ct scan data may yield a d virtual physical model that can maybe obtained from ct scan data and printed onto using thermoplastic acrylonitrile butadiene styrene . the aim of this study was to describe the perinatal imaging findings in cases of congenital zikv infection. we studied mothers diagnosed with zikv infection from october to november . they had all presented a maculopapular rash and fever during the first or second trimester of pregnancy, and their neonates presented neurological defects that were attributed to intrauterine transmission of the zikv. the maternal diagnosis of zikv infection was confirmed by serology (n= ) or rt-pcr (n= ). all patients were torch (toxoplasma, rubella, cytomegalovirus, herpes simplex) negative. prenatal us was performed every weeks after the first imaging findings, and fetal mri was obtained in all cases. microcephaly was considered present when the infant's head circumference was two standard deviations below the mean value for age and sex or below the second percentile. postnatal imaging follow-up was obtained in all cases by transfontanellar us, ct or mri. we found several cns malformations, including lissencephaly, pachygyria and/or polymicrogyria, cerebral atrophy (panel ), enlarged cisterna magna with abnormalities of the corpus callosum, ventriculomegaly, brainstem hypoplasia, malformation of the cortical development, and cortical and/or periventricular calcifications mainly in the junction between the cortical and subcortical white matter (panel ). the skull of the infants had a collapsed appearance, with overlapping sutures and redundant skinfolds (panel ). craniofacial disproportion was easily identifiable, and arthrogryposis was identified in one case. similar neurological findings were observed in the infected patients and seemed to differ from findings of other infectious diseases. the finding of microcephaly in neonates with congenital zikv infection seems to be only the tip of the iceberg, as several cns malformations have been identified in connection with the disease. in brazil, a spectrum of imaging findings associated with congenital zikv infection has been observed. such findings are useful in helping radiologists to identify suspected cases of the disease. panel : prenatal ultrasound ( weeks) shows calcifications (arrows) and microcephaly. axial and sagittal t shows relative smoothness of the brain surface (arrows) and assymmetric colpocephaly. panel :ax t -wi multiple cortical-subcortical fronto-parietal hyperintense foci (arrows) and markedly hypointense on swi. sagittal t : dysgenesis of the corpus callosum, with dilation of the posterior horns of the lateral ventricles (colpocephaly). pre-and postnatal imaging in zika virus: where are we? early insights into zika's microcephaly physiopathology, from the epicenter of the outbreak: a case for teratogenic apoptosis of central nervous system. p. jungmann; recife/br early insights into zika's microcephaly physiopathology, from the epicenter of the outbreak: a case for teratogenic apoptosis of central nervous system. in mid-october , intense interaction among surgical pathology and fetal medicine specialists from university of pernambuco was only focused on the dramatic and non explained ultrasonographic (us) findings and hopelessness due to lack of explanations on the odd us discoveries on the first gestational cases of zika's microcephaly. this is the field of our history of a physiopathological hypothesis on zika virus (zikv) related microcephaly when it first struck pernambuco state (pe), northeast brazil, the place that has been at the front line of the global response to the microcephaly and responsible for a large amount of data from affected children. the outbreak onset came with a sudden increase in microcephalic newborns being reported in pe state from august (panel, fig. ) . zikv was previously thought to cause a relatively mild disease, but was recently accepted to lead to severe and diverse neurologic conditions in s ( ) (suppl ):s -s pediatr radiol some children born from infected mothers and in adults . the scientific community is actively trying to uncover the extent of these disorders but little has been reported on the early days of the outbreak when doctors were approaching the unknown. while evidence that zikv is related to microcephaly in newborns is accumulating, the mechanisms of how the virus affects the fetus is still uncertain. in the outbreak onset we had to face daunting challenges to search the cause of microcephaly and the emotional toll on the families. we took a very early approach from microcephalic fetuses on gestation and microcephalic babies on clinical follow-up from different pe areas, evaluated between october and december in oswaldo cruz hospital, to propose the early physiopathologic hypothesis that, a viral-related brain developmental disruption could be the basic neuropathogenesis in zikv babies instead of a direct injurious process due to viral insult followed by active inflammation. the eight pregnant women were all in the rd gestational trimester and had had normal us follow-ups till week th . crucially, we were facing a temporal-geographic association of cases presenting an unanticipated pattern of us alterations. because of their late alarming findings they were re-examined and the us scans revealed sudden encephalic alterations after th gestational week. such devastating us clustering images were not seen here before, but are now considered as part of the "congenital zika syndrome". we observed late appearing severe dysmorphic encephalic changes in out of fetuses, including small skull, small brain, sub arachnoidal space enlargement, ventricular dilation, brain calcifications of varied shape and distribution, inclined frontal bone, progressive decline of head growth potential, early fontanels closure and redundant scalp (panel, figs. a, b). we had no clues on the causes and mechanisms responsible for this phenotype of severe alterations. thus, we had no explanation to offer to patients, in particular, or to the medical community. both as physicians and human beings, we were committed straightaway to continue the study of these victims of an unknown medical tragedy, engaging our expertise in fetal imaging and immunopathology. from beginning october, the first microcephalic babies were referred to the upe pediatric infectology service for initial investigation. strikingly, the newborns exhibited "healthy" appearance, excluded the microcephaly itself and motor sequels. we then looked for csf analysis of the microcephalic babies. for that, we obtained from dr. patricia travassos, a csf specialist at upe, a cohort of csf samples that have been studied for signs of meningitis or encephalitis. about % ( cases) of the csf analyzed looked normal for any signs of central nervous system ongoing inflammatory responses (panel, fig. ). the babies had been examined by outpatient clinic dr angela rocha, from the upe hospital infectology reference center that have stated that although small, the babies were near to full term gestation ( - weeks gestation), had good apgar scores and variable degrees of microcephaly and neurologic impairments, i.e. contractures, spasms, irritability and in some retinal macular atrophy. during the follow-up, the babies were cared at home, breastfeeding, gaining weight and having routine vaccines. none of them expressed signs of ongoing inflammatory reaction in the cns (panel, fig. ) or alterations on peripheral blood count and other routine laboratory tests up to months of age. despite the striking neurological phenotype, % of the babies were negative for torch agents, no deaths were recorded. furthermore only in january , the first evidence associating zikv to microcephaly from rt-pcr test on amniotic fluid was reported . astonishingly, a particular kind of physiopathological process linked to fetal brain development was arising without clinical manifestation of inflammatory reactions or necrotic processes in these babies. unfortunately, no necroscopic samples of affected brain tissues were available to us to monitor the presence of putative neural dysgenesis and the very nature of brain calcifications background offering histological support for our hypothesis. nevertheless, with this restricted dataset we hypothesized that whatever the etiologic agent involved in these cases, its physiopathologic mechanism must trigger the cellular death programthe apoptotic process -at a particular development window on the cns, assuming clinically that the agent was not encephaalitogenic but silently tertogenic. if not, the clinical outcome of affected babies would not be so mild as far as signs of inflammation on cns was concerned. consequently, the inflammation-free clinical status of patients suggested us that a massive enhanced apoptotic cell death during the window of telencephalic expansion was the most probable physiopathologic process operating this microcephaly phenotype, with no direct direct lytic brain lesion or significant necrosis due to usual injury. furthermore, knowles and penn stated that this window is very active to select the "fittest" neural cells by a constitutive apoptotic pathway. we so hypothetized that during this developmental time window, the "fit or not fit" status of the rapid, transient amplifying neural progenitors cells facing zikv, would heavily shift the selective process toward the self-elimination of virusbearing cells through apoptotic pathways. thus, zikv-enhanced constitutive apoptotic mechanisms would lead a massive loss of developing telencephalic neuronal precursors and, consequently, provoking losses of dividing cells and the arrest of further brain development. this could be particularly inferred by the absence of the characteristic morphology of late stages structures of neocortex, according with our us images of zikv microcephalics in gestation. similar processo could also be inferred to neurocrest derivatives as deformities in the viscercrany always accompany the cephalic malformation. our initial understandings based on clinical examination on the field, when no specific laboratory test, necroscopic data or experimental evidence on the disease causality were available, conducted our physiopathological approach to the "apoptosis hypothesis" for zika microcephaly that is now gaining strong support. in february, mlarkar et al showed clear connection between zikv and microcephaly, presenting cns histopathologic analyses, revealing remnants of neural germinative matrix, intense gliosis, alterations in cortical ribbon, calcifications in gray and white matters without associated necrosis, encephalitis or meningitis and the presence of the virus, further supporting neurodevelopmental arrest. similar results were showed by driggers et al . the ct scans from microcephalic babies from hazin at al , have added details of brain development arrest with no radiological signs of brain destruction or active inflammation. finally, experimental models have provided a body of evidence f or neuroprogenitors permissiveness to zikv and viralinduced apoptotic process. tang et al demonstrated by icq that the zikv infection of cortical neural progenitors attenuates their growth and increases caspase- activation, calling for an apoptotic process. this finding was corroborated by the up regulations of caspase- genes by rna sequencing. nowakowsky et al demonstrated that zikv may hijack axl protein as an entryway to infection. interestingly, axl is highly abundant on the surface of neural stem cells but not on differentiated neurons in the developing brain. recently, cugola et al demonstrated that zikv was able to cause cns congenital brain dysgenesis upon vertical transmission in mice. in parallel, human brain organoids infected by zikv show a reduction of proliferative zones and disrupted cortical layers, so targeting cortical progenitors and inducing apoptotic cell death with impaired development. for babies born with zikv-related microcephaly, the many expected consequences besides the evolving congenital neurosequels, are the unanticipated pattern of persistence of zikv in cns host cells, unsafe maintenance of neuron genome stability on remaining arrested populations, implying risks for brain tumors, risks for impaired adult type neuron wiring and neuron survival in an affected neuronal circuitry. in brief, evolve life with a wide vulnerable brain. the outbreak of zikv in the americas will eventually decline as herd immunity increases, but the world remains at risk of further waves of infection in affected countries and spread into new territories . while experimental studies will be carried out to fully understand the pathophysiology of zikv infection in the developing fetus, our findings provide a coherent and testable physiopathological hypothesis for cns teratogenic phenotype linked to zikv congenital infection, which may be critical for the clinical care of pregnant mothers and their babies before and after birth. take home points: fetal dysmorphisms detected by ultrassonographic and mri images in congenital zika syndrome are late findings, usually after the th gestational week and requires acurate analyses. clinically, zika's virus microcephaly is an infectiuos congenital condition that is not encephalitogenic but primarily teratogenic on the nervous system. the most important process leading to zika's virus microcephaly is pathologically induced apoptosis in telencephalic neuroprecursosrs cells and neurocrest precurssors cells. viral induced autophagy and low antiviral responses during the fetal period are linked to zika virus persistence in the central nervous system of affected new borns and babies a. vossough; philadelphia/us summary: susceptibility-weighted imaging (swi) has proven to be a valuable mr imaging sequence in a variety of applications. pediatric imaging has also immensely benefitted from this technique. in this presentation we will review pediatric neuroimaging applications in trauma, arterial and venous vascular disorders, hypoxic-anoxic injury, congenital malformations, congenital heart disorders, neoplasms, and pediatric degenerative disease. use of swi in pediatrics other than demonstrating hemorrhage and calcification will be reviewed. challenges in the clinical use of swi in pediatrics, interpretive pitfalls, and sources of clinical misinterpretation of swi will also be explored. we will also briefly present ongoing research and clinical use of swi in pediatrics and potentials for future collaborative investigations. & swi is highly sensitive in detection of susceptibility effects on mri. & in many cases, but not all, swi processing can differentiate between calclium and blood products. & quantitation information can also be obtained from swi with further processing. state of the art imaging of the single ventricle d.m. biko; philadelphia/us there are many congenital heart defects that result in a functional single ventricle. this may be functional or anatomical as a result of a dysfunctional valve or absent or ineffective pumping chamber. the repair of single ventricle physiology most often involves a staged reconstruction due to changing physiology ultimately resulting in a total cavopulomonary connection or fontan procedure. to appropriately image the single ventricle throughout its stages of palliation, familiarity with the physiology of the various steps in surgical palliation of the single ventricle is essential although echocardiography is a mainstay of cardiac imaging, cross sectional imaging has a vital role in the evaluation of the single ventricle. the role of ct angiography is mostly for anatomic evaluation. although it is fast and has high spatial resolution for evaluation of vasculature, ct has lower temporal resolution than mri and is unable to quantify flow. ventricular performance along with quantification of flow can be performed with mri. systemic to pulmonary collateral flow, which has been shown to result in adverse outcomes after fontan, can be quantified. valvular insufficiency and myocardial scarring can also be assessed. additionally, high anatomic vascular detail can be obtained with mri, particularly with the recent investigational use of the blood pool agent ferumoxytol. mri also has the ability to assess the lymphatics either through non-contrast t weighted imaging and/or dynamic contrast mr lymphangiography as lymphatic pathology may play a role in postsurgical hemodynamics in single ventricle patients. this lecture will focus on the use of ct and mri in the evaluation of the single ventricle particularly concentrating on the developing use of mri for anatomic and physiologic assessment. take home points: in single ventricle physiology, there is only one effective pumping chamber. familiarity with the physiology of the various steps in surgical palliation of the single ventricle is essential in imaging this disorder ct angiography provides high anatomic detail but limited in its assessment of physiology since it cannot quantify flow and has lower temporal resolution than mri. mri can evaluate ventricular performance, quantify flow and valvular insufficiency, and assess myocardial scarring. high anatomic vascular detail can also be obtained with mri particularly with the emerging investigational use of ferumoxytol. with non-contrast t weighted mri and/or dynamic contrast mr lymphangiography, lymphatic evaluation can be performed which may play a role in post-surgical hemodynamics in single ventricle patients. neuroimaging in head trauma m. argyropoulou, g. alexiou; ioannina/gr summary: objective: head trauma in children is one of the most common reasons for visiting emergency department. however, only a small portion of patients will have a traumatic brain injury. patients with moderate or severe head trauma should undergo ct scan, however, a debate exists for the indication and yield of neuroimaging for minor head trauma. we performed a systematic literature review on the accuracy of symptoms and signs in children with minor head trauma in order to identify those with severe intracranial injuries. materials: a systematic literature search of medline ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) was performed to identify studies assessing the diagnosis of intracranial injuries in children. the authors independently performed critical appraisal and data extraction. results: we identified studies that evaluated the performance of findings for detecting intracranial injury using the reference standard of neuroimaging or follow-up examination. mechanism of injury, multiple vomiting episodes and decline in gcs score were more commonly associated with severe intracranial injury on ct. normal variations in the amount of joint fluid, ganglion cysts, bone marrow edema, and bony depressions that resemble erosions are frequent in the wrists of children. the results of a follow-up of a healthy cohort aged - will be presented. the cohort was examined twice with mr of the wrist, and the second time also with a cartilage sequence for better visualization of the bony depressions. knowledge of these normal variations is important because they can resemble disease. bone marrow edema, joint fluid more than mm, and bony depressions that can resemble erosion are frequent findings in the normal wrist. take home points: bone marrow edema, joint fluid more than mm, and bony depressions that can resemble erosion are frequent findings in the normal wrist. these findings can not be attributed to dissease without additional findings of synovitis. a cartilage sequence can be of use in the differentiation between true erosions and bony depressions. mri scoring of the wrist in patients with jia-current status and future perspectives c. nusman; amsterdam/nl the wrist is a frequently affected joint in patients with juvenile idiopathic arthritis. due to recent improvements in treatment strategies, permanent damage is not that common anymore. also, imaging has been playing a key role in monitoring the disease activity in the wrist of jia patients. the past years lots of efforts have been made to improve the assessment of acute and permanent changes of the jia wrist. requisites and recommendations for the mri protocol to use for of the jia wrist are available in literature. currently, the features of scoring the jia wrist are synovitis, tenosynovitis, bone marrow edema and bone erosions. the repeatability of the above-mentioned scoring features proved to be acceptable. recent studies showed that the appearance of the wrist in healthy children can mimic pathology. therefore, construct validity of the scoring features needs to be assessed by comparing wrists of healthy children with the wrists of jia patients. & construct validity of the scoring features needs to be assessed by comparing wrists of healthy children with the wrists of jia patients a novel radiographic scoring system for permanent hip involvement l. tanturri de horatio , p.l. di paolo , s.c. shelmerdine , p. toma , k. rosendahl ; rome/it, london/uk, approximately - % of children with jia, particularly those with systemic onset disease, will have hip-involvement within - years after disease onset. as scoring systems for radiographic changes in children with hip involvement are lacking, we aimed to examine the reliability of potential markers and suggest a novel scoring system. a set of hip-radiographs from children with jia and clinical hipinvolvement: seen at the outpatient clinic at great ormond street hospital (gosh), london, and seen at ospedale pediatrico bambino gesù, rome, was used. all hip radiographs were scored in a blinded fashion, once by an experienced paediatric radiologist and a paediatric radiologist with minor experience in musculo-skeletal imaging in rome, and twice by an experienced radiologist and a research fellow in bergen/ london. radiographic findings suggestive of ) destructive change (bone erosion, flattening of the femoral head, squaring of the femoral head contour, presence of sclerosis, joint space height, and ) growth abnormality (length and width of the femoral neck, varus/valgus deformity, the ccd angle and the trochanteric-femoral head height) were assessed. assessment of erosions of the femoral head, femoral neck and the acetabulum showed moderate to good agreement for the same reader. the inter-reader agreement was, however lower. there was a high to moderate ( ) (suppl ):s -s pediatr radiol agreement for the assessment of femoral head flattening using the mose' circle. the measurements of femoral neck length and width, the ccd and trochanteric-femoral head lengths were precise, with % limits of agreements within - % of the mean. we have identified a set of relative robust radiographic findings suggestive of growth abnormalities and destructive change in children with hip-jia, and suggested a novel scoring system. x-ray of a years-old jia patient with severe chronic hip involvement. x-ray of a years-old boy with growth abnormalities on hips (bilateral coxa magna). in jia hip involvement is often a predictor of a severe disease course. radiographic findings vary according to mode of onset and age: in younger children the initial findings may be developmental rather than destructive while children with later onset jia may have destruction/narrowed joint space as the first feature. several of the commonly used radiographic findings for chronic hipchange are inaccurate. we have identified a set of relative robust radiographic findings suggestive of growth abnormalities and destructive changes in children with hip-jia, and suggested a novel scoring system. bone age assessment -statement from the msk task force k. rosendahl; bergen/no summary: age assessment is an important, yet complex and challenging issue that authorities may need to perform to determine whether an individual is an adult or a child in circumstances where their age is unknown. there is currently no method which can identify the exact age of an individual and there are concerns about the invasiveness and accuracy of the methods in use, namely analysis of documentary evidence, interviews, physical or other form of medical examination such as imaging. the main imaging methods include carpal, collar bone and dental examinations. whilst many countries make use of these methods they do not apply them in the same way and often use different combinations and/or order. one of the main reasons for this is the fact that age assessment procedures remain to a large extent determined by national legislation, with procedures evolving through national jurisprudence (ref.: european asylum support office (easo age assessment practice in europe)). the ethical and legal aspects of using bone age to determine age will be addressed in a statement from the msk task force. the ethical and legal aspects of using bone age to determine age will be addressed in a statement from the msk task force. & the application of drls should be the responsibility of all providers of x-ray imaging. this means that drls should also be applied to imaging performed outside the radiology department. & the physical quantity used to establish drls should be an easily measurable quantity, usually directly obtainable from the x-ray equipment console, obtained either by manual recording or preferably by automatic recording and analysis. organ doses and effective dose are not considered feasible as a drl quantity because these cannot be easily determined. the ultimate mission of eurosafe imaging is to support and strengthen medical radiation protection across europe following a holistic, inclusive approach. most common imaging procedures in children and their contribution to collective dose e. sorantin , c. granata ; graz/at, genova/it summary: several countries have released "diagnostic reference levels (drl)" for imaging procedures using ionizing radiation. unfortunately those drl differ in types of procedures and granularity as well as information about the proportion of pediatric patients within the different examinations are sparse. therefore an more evidence based approach seems to be feasable -meaning releasing drl first for frequent and radiation burdened examinations. therefore a survey within europe was conducted and a questionnaire was sent to key persons of the european society of pediatric radiology (www.espr.org) as well to members of a large academic, interdisciplinary, international network within the ceepus programme (central european exchange programm for university studieswww.ceepus.info). alltogether centers were contacted and an response was received from ( . .%). from one center only frequencies for interventional radiology was sent. plain films: most frequent procedures are extremities ( . %), followed by chest films ( . %) -both account together for more than ¾. flouroscopy: voding cysto urethrography (vcu) . %, followed by upper gastro intestinal (gi) series with . % -again representing / of those examinations. computed tomography: head & neck . %, chest . %, abdomen . % -together almost %. interventional radiology and cardiac interventions: only limited data available and procedures quite hardly standardize and comparable. it seems adviseable, that only a few procedures are suitable for drl like peripheral insertion of vascular lines, occlusion of ductus arteriosus botalli or stent implantation for coarctation. in order to estimate the contribution to the relative collective dose all values were normalized to a chest xrays ( . ) and the following numbers could be calculated: abdominal plain film . , skull . , ct head . , ct chest . , ct abdomen . . the most frequent imaging procedures using on ionizing radiation are: in plain films extremities and chest xrays in flouroscopy vcu and upper gi series in ct head, chest and abdomen therefore eu wide drl should be released for those examinations. as it could be expected chest ct is the main contributor to the collective dose. since the espr abdominal (gi and gu) imaging task force has changed its name and agenda, extending from initially only genitourinary queries to also other abdominal imaging topics, new projects have been added such as for example imaging in anorectal and cloacal malformations, imaging in paediatric inflammatory bowel disease (ibd, a joint project with esgar), or paediatric abdominal ceus applications. results of these new projects will be presented in the upcoming talkshoping that again (as the last procedural recommendations and proposed imaging algorithms) our proposals and recommendations will help to standardise paediatric imaging, to reduce radiation burden, and to facilitate comparable imaging data for future research. other topics in this session are a proposal for a more standardised approach to gastrointestinal ultrasonography, and considerations on gadolinium applications in children in the light of new observations (i.e., gadolinium deposit in tissue even in children with normal renal function). the work goes ononly achievable with active participation of interested and competent members. many interesting topics for either recommendations or joint research are on the list such as addressing late decompensating pujo or specific imaging needs in ibd in early childhood; other new ones may be proposed by any task force member. thus all espr members are invited to join the group, work with us and share their expertise. ( ) (suppl ):s -s pediatr radiol contrast enhanced us in childhood -applications in children: literature review and results from the questionnaire c. bruno; verona/it in adults, following the characterization of focal liver lesions, several applications of contrast-enhanced ultrasound (ceus) have emerged in the last two decades, since second-generation contrast agents have been introduced and approved for use in most european countries. from many points of view, children represent an ideal population for ceus, because of the absence of radiation exposure and of need of sedation. moreover, due to the small body size many anatomical targets in children can be adequately explored with high-frequency ultrasound, obtaining images with higher spatial resolution than in adults. however, to date comparatively few data on pediatric ceus are available. although very rare and usually mild, possible adverse effects of contrast agents probably limit their use in many centers. in addition, the intravenous administration of ultrasound contrast agents in children is still off-label in europe, which makes informed consent necessary in every case. finally, for unclear reasons information on this topic does not flow easily. & from the comparison between the data available, similar or better results are likely to be obtained with ceus in children than in adults, and some specific pediatric indications might be proposed. imaging in ibd-joint recommendation statement with esgar f.e. avni , m. napolitano , p. petit ; brussels/be, milan/it, marseille/fr the first joint esgar/espr consensus statement on the technical performance of cross-sectional small bowel and colonic imaging ( ) objective: to develop guidelines describing a standardized approach to patient preparation and acquisition protocols for magnetic resonance imaging (mri), computed tomography (ct) and ultrasound (us) of the small bowel and colon, with an emphasis on imaging inflammatory bowel disease. methods: an expert consensus committee of members from the european society of gastrointestinal and abdominal radiology (esgar) and european society of paediatric radiology (espr) undertook a six-stage modified delphi process, including a detailed literature review, to create a series of consensus statements concerning patient preparation, imaging hardware and image acquisition protocols in pediatric and adult patients. the delphi process is constructed as follow: step questionnaire construction to includes all contents relevant to the guideline and set up of working groups; step questionnaire completed by all committee member, step literature search; step draft consensus produced by each wg based on the literature review and questionnaire responses; step committee members indicate agreement or otherwise for each individual draft consensus; step acceptance of agreed statements (more than % of members), face to face meeting to modify statements without agreement. committee members indicate agreement or otherwise for each modified consensus statement and final consensus statements. the questionnaire was split into four broad topics, each of them treated by a subgroup including in each of them a pediatric radiologist: ( ) patient preparation for mre/mr enteroclysis/cte/ct enteroclysis, ( ) mre/ mr enteroclysis technique and sequence selection, ( ) cte/ct enteroclysis technique, and ( ) enteric us patient preparation and technique. after an extensive literature research each member were instructed to always base their statements on the retrieved literature wherever possible, and to this end graded the strength of retrieved relevant publications from i (high) to v (low) using the criteria of the oxford centre for evidence based medicine ( ) during their review process. if no relevant literature was available for a particular item, members used expert opinion to construct the consensus statements. the pediatric guidelines were based on the opinion of pediatric radiologists and adult radiologists who have experience in pediatric practice. & it is recommended that children aged - should not eat any solid & it is recommended that the use of a spasmolytic agent is optional. unlike adult practice, the use of spasmolytic prior to mre is considered optional in paediatric patients and use is likely dependent on the age of the patient, with older children more likely to tolerate spasmolytic injection. there are data supporting the benefits of glucagon on image quality, at the expense of prolonged imaging time and precipitation of nausea in just under half of paediatric patients ( , ) . however, high diagnostic accuracy can also be achieved without spasmolytic ( ) . & it is recommended that children aged over years should be nil by mouth for carbonated and milk beverages for - h. ingestion of still water or non-carbonated fruit juice is recommended. & it is recommended that for dedicated colonic evaluation, a standard protocol without specific modification is used. & use of a spasmolytic agent is not recommended. & the use of i.v. us contrast is not recommended. & it is recommended that scan coverage should include an abdominal and pelvic examination, including the liver. there are no specific recommendations as to the use of hydro us in the paediatric patient as practice is not well developed. if oral contrast is given prior to us, it would seem sensible to follow the recommendations for mre in the paediatric population & it is recommended that if ct scanning is used in the paediatric population, no specific preparation is usually required although administration of positive oral contrast could be considered; for example, prior to percutaneous drainage of abscesses. limitations: there is little evidence in the literature to ascertain all these proposals. the recommendations were mainly based on expert opinion. no recommendations have been proposed for children before years of age. especially the benefice of mre under sedation ( ) in the younger compare to us doppler need to be explored. contrast media application is essential for a number of mri studies in children. there is some evidence that gadolinium-based contrast agents (gbca) are well tolerated in infants and children. the risk of adverse reaction is no higher in children than in adults. there are only few data available about pharamakokinetics in children, especially for the use of gbca in neonates. age-adapted reference values of the glomerular filtration rate (gfr) have to be used to identify children with a potential risk. in the past few years there was some attention toward the potential cellular toxicity of gadolinium and its role in the development of nephrogenic systemic fibrosis (nsf). there were only few children identified with proof of nsf. but, particulary renal insufficiency, poor hydration, acidosis and inflammation increase the risk for nsf. because the cases of nsf have been observed with linear componds the guidelines ( ) (suppl ):s -s pediatr radiol from the esur and the espr and others propose to avoid linear compounds and to prefer macrocyclic gbca. in the past year several studies have described observations about possible gadolinium retention in the brain; hyperintense brain structures in native t weighted sequences were verified -globus pallidum and dentate nucleaus -also in children undergoing multiple mri examinations with gbca application. so, repeated mr investigations within a short time should be avoided -the cumulative dose of gbca should be recorded. consider all these points, the benefit of a contrast-enhanced study should be weighted against the potential risks before administering a gbca for each child separately. but, never deny a child an indicated cemri study. use single dose application ( . - . ml/kg body weight), improve renal function and hydration, balance acidosis -and ask your pediatric nephrologist íf necessary. gadolinium-based contrast agents are safe. macrocyclic compounds should be used in children. avoid contrast media in neonates and be careful in infants. identify risk factors. avoid repetivite application. procedural recommendation: how to perform pediatric gastrointestinal us m.l. lobo , m. riccabona ; lisbon/pt, graz/at summary: ultrasound (us) is the first imaging modality applied in the investigation of abdominal complaints in children, and an increasingly valuable imaging tool in the assessment of the gastrointestinal (gi) tract in neonates, infants and children. a comprehensive us examination is a critical first-step to optimize the potential of us diagnostic yield in many paediatric gi conditions. using proper high resolution transducers and graded compression technique is an essential part of gi us examination. a methodical and systematic analysis is crucial to facilitate a thorough evaluation of the bowel segments as complete as possible: follow bowel in a cross section, complete by longitudinal and oblique views. for some bowel sections filling is essentialsuch as stomach for gastroesophageal reflux and pyloric function, and distensibility and size of the colon by enema (e.g. for query microcolon). modern us methods are valuable, but not a pre-requisite. proper documentation of abnormal size of the gi tract segments, their luminal content, peristalsis, bowel wall characteristics and its surroundings, as well as local tenderness should be noted. a proposal for recommendation on how to perform paediatric gastrointestinal us will be presented for public discussion. & careful and dedicated us examination is crucial to obtain maximum anatomic and functional information in many gastrointestinal disorders in children. & systematic and methodical analysis helps to assess the bowel as complete as possible. & satndardization of us technique is essential to optimize us diagnostic capabilities and to allow for comparable examinations wich is essential to improve future evidence-based knowledge. hominid evo-devo: reconstructing the evolution of human development c. zollikofer; zurich/ch from an evolutionary biologist's perspective, modern humans represent the only surviving species of a group of highly specialized "bipedal great apes". they evolved more than seven million years ago in africa and managed to spread over the entire globe. in this talk, i will trace the history of our species with an emphasis on key developmental innovations that underlie major evolutionary innovations. why are we born with brains that have the size of adult great ape brains? and why do we grow up so slowly and get so old? i will highlight how advanced biomedical imaging methods help addressing these questions, and show how combined fossil, clinical and great ape data yield surprising insights into the evolution of our development. to present our experience with innovative imaging in pediatric interventional radiology. imaging technologies presented will include: . use of bubble contrast (lumeson) for indicatons including; complex pleural effusion and abdominal collection assessment pre and post therapy, primary g tube placement, renal perfusion pre and post rena artery angioplasty, vascular patency during central venous line placement, vascular malformation therapy and biliary tube assessment. . intravascular us (ivus) in arterial intervention pre and post angioplasty and venous thrombolysis intervention. . optical coherence tomography pilot study assesssment for renal artery intervention -validation in normal subjects. currently this imagng which uses laser light technology to assess vascular mural detail at the micron level, is only validated in coronary artery intervention in adults. . mr overlay -a technology that fuses mr imaging with low dose fluoroscopy and can faciltate biopsy of mr positive/ct negative lesions in the ir suite. focus will be on bone lesion biopsy and vascular malformation therapy. critical structures to be avoided can be outlined on the mr and transposed onto the fluoroscopic image during biopsy. in our experience this technology has promise in the pediatric setting with significant dose reduction when compared to ct. . mr fusion and i guide fusion technology enables an mr positive/ct negative lesion that would require ct guided imaging to be biopsed, using low dose c -arm ct, with fusion of the ct and mri images performed using landmarks, facilitating fluoroscopically guided biopsy in the ir suite. critical landmarks/structures to be avoided can be outlined on the ct or mr and transposed onto the fluoroscopic image during biopsy path planning and orchestration. focus will be on bone lesion biopsy. . color parametric flow related imaging in vascular interventionthis software enables time to peak opacification of arterial or venous contrast to be color coded in time and can provide adjunctive information for assessent of perfusion change during vascular intervention such as renal artery angioplasty, dialysis access intervention and cerebral embolization. . mr guided intervention -this focus will be on the initial development of an mr interventional program and our initial experience with mr arthrography. discussion will also involve the use of this modality for vascular malformation sclerotherapy and other msk interventions such as biopsy and nerve injections. . high frequency us imaging-focus will be on the use of a mhz us probe in the ir suite for various indications including visualization of smaller targets such as neonatal central venous access, superficial vascular malformation therapy and thyroid fine needle biopsy. . participants will become more familiar with exisitng and emerging innovative imaging technologies for pediatric intervention. participants will learn about the various indications and limitations of these technologies. . participants will gain insight into the process of introducing new imaging modalities into their pediatric interventional practice. increasing evidence supports the notion that autism spectrum disorder is associated with anomalies of brain function and connectivity. it is also evident that there are atypicalities in development/maturation of brain systems. particular promise arises from findings of atypical electrophysiology -indexing brain neuronal activity in real time. in particular, this talk will address a characteristic electrophsyiologic signature of delayed auditory evoked response latency (at~ ms). this, and related timing anomalies, have been proposed as biomarkers for asd -with candidate use for diagnosis, prognosis, stratification and therapy monitoring. progress along each of these axes will be discussed. however, to justify the term "biomarker", we demonstrate converging evidence from spectrally-edited (megapress) mrs and diffusion-mri. mrs offers insights into neurotransmitter levels, especially gaba and glutamate, imbalance of which may be associated with anomalous electrophysiologic oscillations in the gamma band. diffusion offers insights into the white matter of the brain (auditory pathway will be illustrated) and an interpretation of diffusion parameters as an index of central conduction velocity will be offered. combining these mechanistic measures with the spectrospatio-temporal capabilities of magnetoencephalography (meg), this talk will present a state of the art review of multimodal biomarker development in asd. take home points: meg captures brain activity in space and time as well as showing sensitivity to activity at different frequencies (where, when and what) delays in cortical neuronal response latency are evidence in asd atypical coupling between diffusion evidence of conduction velocity and timing of cortical responses in shown in asd oscillatory activity is atypical in asd (elevated "noise", decreased "synchrony") diminished inhibitory neurotransmitter (gaba) levels are shown in asd disturbance of teh typical coupling between gaba and gamma-band oscillations in development leads to anomalous adult oscillatory activity (taken to index local circuit function). multimodal and longitudinal approaches may be required to tackjle the complex and heterogeneous landscape of asd the paediatric radiologist can play an important role in establishing vascular access in paediatric patients ranging from neonates to teenagers. a breadth of knowledge and skills are needed to deal with changing body morphology and varied pathology in this age range. some of the skills particular to performing and managing vascular access in children will be discussed. different devices which can be placed, their indications, advantages and disadvantages will be reviewed. choice of access vessel is important in children, because there are known long term complication such as central venous stenosis and thrombosis, which can have a huge impact for future venous procedures or potential creation of an arteriovenous fistula of the arm for dialysis. preserving venous access sites is a ( ) (suppl ):s -s pediatr radiol key responsibility especially in children with complex medical and surgical co-morbidities. because vascular access in children has associated morbidity it's important to manage and maintain devices that are placed. the risk of infection when repairing or exchanging a broken line will be highlighted. image guided biopsy is a very frequent procedure in pediatric patients. they range from random organ parenchyma for the diagnosis of medical disease up to tumor biopsies for histopathology analysis. different imaging modalities can be used for guidance as well as different biopsy devices and needles. ultrasound guidance is the most common modality used for this purpose in the pediatric population. the success of this procedure depends on multiple factors: from pain control up to choosing the correct device and area to sample. the radiologist performing the procedure also needs to be familiar with the potential complications of the intervention, how to prevent them and how to manage them. the intention is to perform the safer procedure as possible, obtaining the best quality of sample. the goal of this lecture is to present in a didactic way technical tips to perform safe and effective image guided pediatric biopsies, which may be applicable to different groups of operators, ranging from general pediatric radiologists performing occasional biopsies up to pediatric interventional radiologists. the objectives will be: to identify the safest approach to different types of biopsies; to describe ways to obtain the better quality of sample as possible; to demonstrate the use of different approaches in challenging clinical scenarios; to illustrate new devices currently used in specific applications; to discuss potential complications and its management and to show imaging modality integration applied to biopsy planning an performance. image guided biopsy is a frequent procedure in pediatric patients. a pre-procedure planning is fundamental in the success of the intervention. the operator must be aware of the aims of the biopsy and based on this choose the best approach, device and site for sampling. preparation and competency to manage complications is mandatory. pediatric interventional oncology: big cases in little people m. heran; vancouver/ca summary: the pediatric patient presents unique challenges in diagnosis and management of oncologic disorders. interventional radiology (ir) has a prominent role in the care of these children, with improvements in imaging and equipment offering better and safer options to traditional diagnostic and therapeutic procedures. as cancer can involve any organ system, consultations to the ir service can involve any part of the body, and can be non-vascular and vascular, simple and complex. the most common ir procedures in the pediatric oncology patient are enteric tube placement/change, vascular access, and percutaneous image-guided tissue/organ biopsy. however, with the explosion of interventional oncology in the adult setting, the variety and complexity of ir in pediatric oncology has begun to increase as well. ir techniques, such as thermal ablation, transarterial pharmacotherapy, and preoperative embolization, are now increasingly discussed in multi-disciplinary conferences as complementary or primary modes of treatment of oncologic disorders or related diseases/complications. however, although the principles of these diagnostic and therapeutic ir procedures remain essentially the same in their translation from adults to children, well recognized differences in pediatric physiology and metabolism, as well as the range in weight, size, and age of children, result in a practical question of "how do we do this?" the aim of this presentation is to provide an overview of the role of ir in the pediatric oncology patient, and to highlight areas of research and innovation. vascular anomalies encompass a spectrum of disorders including vascular tumours and vascular malformations. incorrect nomenclature and misdiagnoses resulting in inappropriate treatment are commonly experienced by patients with vascular anomalies. the currently accepted method for classification of vascular anomalies is straightforward and clinically relevant. vascular malformations can be divided into high flow lesions such as arteriovenous malformation or low flow lesions such as venous or lymphatic malformations. in children, a diagnosis can often be made with the history, examination and ultrasound. the classification of vascular anomalies will be briefly reviewed with examples of commonly encountered pathologies. a multidisciplinary team approach to the management of these conditions is vital. paediatric radiologists can play a key role not only in diagnosis but also in management, principally by injection sclerotherapy of low flow lesions and embolization of the much rarer arteriovenous malformation. many sclerotherapy agents are available with sodium tetradecyl sulphate the most commonly used for venous malformations and doxycycline for lymphatic malformations. different sclerotherapy agents have different characteristics and uses which will be covered. symptomatic relief is often achieved with treatment but multiple treatment episodes may be needed to achieve the desired outcome. ensuring the child and family understand this is vital to ensure they are satisfied with the management of the condition. contrast media is commonly used during imaging in children whatever their age and whatever the pathologic conditions. still, youngest patients are vulnerable and unstable. therefore, in neonates and infants the use of s ( ) (suppl ):s -s pediatr radiol contrast media should be carefully evaluated and customized putting in balance the risk versus the benefit of its use. when using contrast media in neonates and infants, several features should be highlighted: -prematures and neonates have rather immature kidneys and some contrast media might be difficult harmful -the thyroid gland in prematures may be (transitorily) depressed by iodinated contrast media -the use of high osmolar contrast may induce a fluid shift and dehydration especially in premature and neonates -most contrast media are used off label; almost none has obtained the authorization to be used in neonates. -there are very few studies evaluating the short and long term adverse reactions in neonates and infants below the age of two. fortunately these reactions seem very rare in these age groups. -using contrast extends the duration of the examination and the need for sedation different types of techniques will potentially need ingestion, instillation or injection of contrast media: ) opacification of the entire gi tract pre-and post-operatively ) retrograde uretro-cystography ) contrast enhanced ct ) contrast enhanced mr imaging ) contrast enhanced us ) angiography furthermore, different types of contrast media can be used to achieve these purposes ) barium (sulfate) ) iodinated water-soluble contrast media (hyper-, iso-or hypoosmolar) remarks regarding opacification of the upper gi tract: -the upper or lower gi tract should be opacified using water soluble contrast in the immediate postoperative period or whenever a bowel perforation is suspected. -air can be used to confirm esophageal atresia and duodenal atresia -barium should be preferred in case of t-e fistula -either barium or water soluble iodinate contrast can be used in order to opacify (sub)obstructed upper gi tract remarks regarding the opacification of the lower gi tract -iodinated iso/hypo osmolar contrast should be used to opacify the colon in case of obstruction -a higher osmolarity iodinated contrast can be used in case of suspected meconium ileus or plug; still this contrast should be used diluted and under close clinical surveillance and adequate hydration. -in some more specific cases, for instance whenever hirschprung disease or a stenosis post nectotizing enterocolitis are suspected, barium enema can be used remarks regarding ct scan -contrast enhancement may help for the global assessment of various pathologies especially in case of cardio-vascular malformations or for the evaluation of abdominal masses. any iodinate contrast among those available is acceptable in neonates. higher osmolality contrast allows to inject a lower volume -injected volumes of . ml/kg seem adequate using - gauge needles -power injectors are acceptable as long as adequate catheters can be used -allergic or side effects are very rare and should be managed similarly to adults. remarks regarding mr imaging -the use of gd chelates in neonates remains controversial as there is no data available on the long term effects of gd injected so early in life -gd should be used only when enhancement may provide additional information compared to the non-enhanced study (cns infections, tumors, cardiovascular imaging, abdominal tumors, uro-mr imaging...) -only gd with low nsf risk should be used -gd should not be used in children with renal failure remarks regarding contrast enhanced us -little is known about the use of ce-us in neonates -indications seem equal to older children -there are very few side or allergic effects -doses suggested are . ml/year of age children present varied histological types of brain tumours. it's now possible to combine different information and image techniques to improve the diagnosis of paediatric brain tumours. the multimodal approach has increased the diagnostic specificity and permits, in most cases, the pre-operative differentiation between low and grade tumours. children with low grade lesions, and in particular the less accessible tumours, would benefit the most from avoiding biopsy. in addition, preoperative spinal mri evaluation to rule out drop metastases should be performed in patients with suspected high grade tumours. in general paediatric brain tumours are less necrotic, i.e. aggressive tumours in paediatric patients tend to be more hypercellular and homogeneous. because of its ready availability and speed, computed tomography ( ) (suppl ):s -s pediatr radiol (ct) is the first investigation generally performed for a suspected brain tumour. ct can rule out haemorrhage or calcifications, but can also be used to evaluate tumour cellularity. a hyperdense tumour on ct reflects hypercellularity and is very often high grade. medulloblastoma are, for example, typically hyperdense on ct scans and paediatric low-grade astrocytomas are almost always hypodense. mri plays a major role in the evaluation of brain tumours. in conventional mri, the "general aspect" is the single most important parameter in predicting high-grade tumours in children. the same does not hold true for low-grade tumours, of which only % can be predicted using the general aspect. in our previous study, hyperintensity on t -w and the lack of diffusion changes were the most important single parameters with % positive prediction. embryonic tumours, such as medulloblastoma or pnet have high tumour cellularity with consequent very low adc and hypo/isointense t compared to the cortex. adc values derived from dwi have been shown to be decrease in highly cellular tumours. adc values cannot reliably be used in individual cases due to the substantial overlap between tumour types previously described in the literature. nevertheless, adc has a higher predictive value in children and increases the accuracy of preoperative differentiation between low grade and high grade paediatric tumours. the cut-off values for differentiating between low and high grade paediatric brain tumours are . x mm /s and . x mm /s for minimum adc and average adc values, respectively. perfusion with relative cerebral blood volume (rcbv) is considered a marker of angiogenesis and is helpful in distinguishing high and low grade tumours. however, perfusion can be difficult to perform in small children; small catheters with manual injection are therefore used in such cases (or, as an alternative, arterial labelling). it should however be taken into account that choroid plexus tumours can have high rcbvs resulting from highly leaky capillaries. mr spectroscopy (mrs) shows the metabolic profile of the tumour. high grade tumours show elevated choline (cho) -reflecting increase in cell membrane turnover -and decreased n-acetylaspartate (naa), which represents a neuronal marker. the absolute values of the mrs peaks are not used by us; we favour to normalize the signal intensities of metabolites to their values in contralateral brain tissue. mrs is helpful not only as guidance for stereotactic biopsy (cho hot spot) but also for determining whether the tumour is high or low grade. as a rule of thumb, a % increase of cho when compared to the contralateral brain tissue is highly suggestive of a high-grade tumour. however, in children, increased cho levels can also be found in pilocytic astrocytoma; in this case the typical aspect with cystic component and location can suggest the diagnosis, despite the mrs result. therefore, in children, high cho levels do not necessarily imply the presence of a malignant tumour. task based functional mri (fmri) can be used for pre-operative localization of the eloquent cortex together with the identification of the language and somatomotor function. in the future, small children who are unable to cooperate will probably profit from resting-state fmri. pet mri has the advantage of integrating structural mr imaging with physiologic pet. take home points: take home points although the histology of paediatric brain tumours is diverse, their general morphological aspect on mri has a very high diagnostic reliability. unlike adult grade iv brain tumours, malignant paediatric brain tumours are less necrotic, but are highly cellular with high nuclear-to-cytoplasmic ratios. adding information on signal intensities on t w and dwi further increases the diagnostic accuracy of conventional mri. the solid areas of high-grade tumours are iso-or hypointense on t w and hyperintense on dwi, whereas low-grade tumours show inverse signal characteristics. advanced mr techniques (perfusion and spectroscopy) provide important biological information which can be used to correctly identify grading (high vs. low) and to guide biopsy. in children high cho levels, although suggestive, do not necessarily mean a malignant tumour. experience with central review of paediatric renal tumours g. khanna; st louis/us summary: central imaging review of pediatric renal tumors has been performed in children's oncology group since . to date, more than cases of pediatric renal tumors have been centrally reviewed real time by the study radiologists. the mean time for central review was < days. discrepancies between local and central risk stratification were identified for detection of bilateral disease and pulmonary metastasis. in addition, central archiving of images has created a rich repository of cases for future research. the role of imaging in detection of key diagnostic features in pediatric renal tumors will be reviewed. the diagnostic performance of imaging for staging, detection of vascular invasion and tumor rupture will be discussed. real time central review of imaging is feasible in pediatric oncology wilms tumor remains the most common pediatric renal malignancy, followed by renal cell carcinoma cystic nephroma typically presents as a bosniak lesion, and has high association with dicer- mutations is there a role for dwi in nephroblastoma? a.s. littooij; utrecht/nl wilms tumour or nephroblastoma is the most common malignant renal tumour in children. ultrasound is usually the first line investigation. mri of the abdomen is often performed to further delineate the tumor and its surroundings. the addition of diffusion-weighted imaging (dwi) to the standard mri protocol may enable subtype characterisation and allows assessing treatment response beyond necrosis and volume change. overall, the survival rate in patients with nephroblastoma is relatively good and the current focus is on finding biomarkers to further improve outcomes while reducing therapy-related side effects in these children. therefore, identifying low-or high-risk type nephroblastoma might be relevant for treatment planning. diffuse anaplastic nephroblastoma and extensive blastema in residual tumour after preoperative chemotherapy may require more intensive treatment. the limited available literature suggest a linear relation between adc values and subtypes nephroblastoma at histopathology. furthermore, the addition of dwi to the standard mri protocol may detect lesions (e.g. nephrogenic rests of nephroblastomatosis) that remain undetected at post contrast t -weighted images. unfortunately, there is a considerable heterogeneity in acquisition techniques and methods of adc measurements. nephroblastoma often contains areas of necrosis and/or hemorrhage that can demonstrate very low adc values and consequently mimic highly cellular portions of tumours. therefore these areas should be excluded from further analysis. this lecture will highlight the potential additional benefit and limitations of dwi in children presenting with renal tumour. significantly lower radiation exposure even in comparison to low-dose pet/ct, (b) the higher diagnostic accuracy as compared to pet/ct even when using diagnostic contrast-enhanced ct, (c) the unique possibility to combine distinct mr-inherent contrasts (e.g. dwi) with specific pettracers (e.g. cu-labeled antibody imaging) for the evaluation of novel targeted therapies, and (d) the opportunity to stage local and systemic tumour burden within a single and highly resolved examination. on the other hand, many circumstances are challenging the extensive use of pet/mri in children. in general, the availability of pet/mri systems is low, particularly for children. thus, only a few sites in europe have experience with this technique in children, and therefore the generated scientific evidence is limited. moreover, whole-body-mri is still not a broadly adopted method for the combined assessment of local disease extent and whole-body staging, potentially replacing other whole-body modalities like the bone scan. in this context, especially the detection of pulmonary metastases is biased also against pet/mri. finally harmonized sequence protocols and specific recommendations for trace dosage are not available for pet/mri. in conclusion, further efforts are needed to keep the promises of pet-mri in the daily practice. common artefacts in paediatric mri-how to recognise, avoid or take advantage of them c. kellenberger; zurich/ch summary: while mri is a robust and radiation free imaging technique for assessing anatomy and pathology of most tissues and organs throughout the body, it is inherently prone to artefacts as no other imaging modality is. mri artefacts may impair image quality potentially leading to difficulties or errors in interpretation, but in some instances can contribute diagnostic information. main sources of image degradation are motion, disturbances of the local magnetic field and other factors inherent to image acquisition. strategies to reduce effects from various kinds of motion and adjustment of sequence parameters for eliminating artefacts will be discussed. & understanding the origin and effects of artefacts encountered in paediatric mri is essential for modification of mri protocols, so that artefacts and associated errors can be avoided. & for safely and successfully imaging children with implants and devices, the composition, location and functionality of the foreign body needs to be known. injuries to the central nervous system in abusive head trauma are responsible for the primary cause of morbidity and mortality in infants. neuroradiology has an important role in diagnosis but also in depicting injury and extent of brain damage of poor outcome. computerized tomography (ct) and magnetic resonance imaging (mri) are the primary imaging techniques. ct is usually performed in the acute phase while mri is performed the following days after injury. some injuries are better identified on mri such as diffuse axonal injury and cerebral edema with susceptibility and diffusion weighted images. abusive head trauma (aht) is the primary cause of morbidity and mortality in infancy, especially during the first year of life. aht is clinically characterized by a triad consisting of subdural hematoma, retinal hemorrhage and encephalopathy caused by brain swelling ( ). the most common mechanism responsible for brain damage is thought to be caused by whiplash shaking injury explaining that abusive head trauma is also referred as shaken baby syndrome. impaction, compression and penetrating injury are also possible mechanisms as well as strangulation. however because of the variability of types and severity of injury, clinical symptoms vary from subtle to severe such as alteration of consciousness or coma ( ) . the most common symptoms include vomiting, seizure, lethargy, poor feeding and apnea of which vomiting and respiratory pauses are non-specific ( ). poor feeding, irritability or lethargy is also nonspecific signs. however apnea and/or retinal hemorrhages seen in children with brain injury are strongly associated with inflicted trauma ( ) . in contrast to acute injury some children may manifest with increased head circumference related to chronic subdural hematomas. neuroimaging is therefore playing a crucial role to assess infants and children with a suspicion of abusive head trauma. computerized tomography (ct) and magnetic resonance imaging (mri) are the primary imaging techniques. ct is performed for the initial evaluation in cases with acute symptoms to look for hemorrhagic intracranial injury as subdural hematoma. mri is more often performed in the following days to further evaluate brain injury and to look for spine and spinal cord damage ( , ) or in the presence of normal or equivocal ct findings ( ) . however brain mri may be the first option in children presenting with increased head circumference. recently the study from flom et al showed the high sensitivity of mri for intracranial hemorrhage in well appearing infants at risk for abusive head trauma suggesting mri as a screening tool with pulse sequences (axial t , axial gradient recalled echo and coronal t weighted inversion recovery) ( ) . ct is generally performed without intravenous contrast injection with d volume rendering (vr) reconstructions for identification of fractures. in some cases postcontrast images are also obtained specially to rule out deep venous thrombosis especially when children present with nonspecific clinical symptoms. mri protocol should include axial t , t * or susceptibility weighted images, coronal t images, diffusion or diffusion tensor images, and postcontrast dt images including mip reconstructions to evaluate the venous structures. mr venography can also be performed. susceptibility-weighted images are usually preferred because they allow the depiction of smaller hemorrhagic dai lesions and greater number of lesions compared to gre t ( ) . it was also reported by colbert et al ( ) that the presence of micro-hemorrhages alone was useful for outcome prediction in abusive head trauma with significant poor long-term outcome. the sensitivity and specificity of microhemorrhages was also higher than the other clinical (such as retinal hemorrhages and glasgow coma scale score) and other imaging findings for prediction of outcome. diffusion tensor imaging (dti) measurements were reported in abusive head trauma by imagawa et al: decreased axial diffusivity related to axonal injury with consequent reduced mean diffusivity did correlate with poor outcomes ( ) . magnetic resonance spectroscopy (mrs) is usually not part of the standard protocol. however aaen et al ( ) showed that n-acetylaspartate/creatine and/or nacetylaspartate/choline ratios were decreased significantly in the corpus callosum, frontal white matter, parieto-occipital white matter, and parietooccipital gray matter in children with poor outcomes. this study mentioned above also reported that the prediction of outcome was accurate in % of patients by using a logistic regression model that include age, initial glasgow coma scale score, presence of retinal hemorrhage, lactate on mrs, and mean total n-acetylaspartate/creatine. functional mri, ( ) (suppl ):s -s pediatr radiol volumetry may be performed in long-term follow up of victims of child abuse. physical abuse is associated with altered emotion with greater activation in the salience network in response to negative stimuli, that includes amygdala, thalamus, putamen and anterior insula ( ) . increased responsiveness of the right amygdala to fearful and angry faces (negative stimuli) and structural changes as reduced hippocampal volume, are reported by dannlowski et al ( ) . impaired attention was also reported in patients with childhood abuse ( ) with reduced activation during attention tasks in the left hemispheric ventral and dorsolateral prefrontal regions. intracranial injuries include extracerebral hemorrhages and parenchymal damage as brain swelling and ischemia, venous infarction, diffuse axonal injury, contusions and intraparenchymal hematomas ( , ) . extracerebral hemorrhages subdural hematoma is a characteristic finding of inflicted traumatic brain injury, is generally multifocal and most commonly seen along the posterior interhemispheric scissure, over de convexities at the vertex level and/ or in the posterior fossa ( ) ( ) ( ) . subdural hematomas are most likely bilateral but may be unilateral. all locations are related to disruption of bridging veins. the identification of bridging vein rupture allows the diagnosis of traumatism in relation to acceleration/deceleration, rotational and shearing forces due to violent shaking ( ) . a mixed density appearance of subdural hematomas is frequent but is also seen in accidental traumatic brain injury ( ) ( ) ( ) . indeed this feature is often present in the very early hours following trauma and is thought to be secondary to early sedimentation of blood clots and supernatant serum. tubular high density is often seen on non-contrast ct over the convexities in abusive head trauma. this ct feature is related to a clot secondary to venous disruption ( , ) that can end up in thrombophlebitis. this tubular high density was reported more recently as tadpole sign ( ) and lollipop sign ( ) respectively seen in and % of abusive head trauma. this appearance is strongly associated to inflicted trauma and much less frequent in accidental trauma ( out of cases ( , %) of accidental trauma in our experience). associated venous infarction is reported in % of cases of abusive head trauma ( ) and often located in the parieto-occipital region, unilaterally at the site of venous disruption of bridging veins. subdural hemorrhages, when multiple, in the convexity and interhemispheric, or in the posterior fossa were found significantly associated with abusive head trauma in the meta-analysis reported by kemp et al ( ). in addition subdural hematoma, cerebral ischemia, skull fracture, retinal hemorrhage and intracranial injury were significantly associated with abusive head trauma in the review from piteau et al ( ). subarachnoid hemorrhages (sah) and epidural hematomas are also found in inflicted trauma and are not considered discriminant-imaging features. however epidural hemorrhages, isolated skull fracture and scalp swelling were reported as significantly associated with accidental traumatic brain injury ( ). sah in shaking injury is usually caused by tears of the vessels within the pia and arachnoid predominantly in the interhemispheric fissure and high convexity ( ). parenchymal injury parenchymal injury include brain swelling and ischemia, venous infarction (discussed above), diffuse axonal injury related to rotationallyinduced shear-strain injury with different inertia for grey and white matter due to their different specific gravities, contusions seen in deceleration trauma with friction between the skull and brain, and in blunt trauma and intraparenchymal hematomas related to lacerated vessels. brain swelling/ischemia may be related to increased blood volume (congestive swelling), increased presence of water in the nervous tissue, and the combination of both. increased water in the nervous tissue may manifest as vasogenic edema located in the white matter due to extravasation of plasma like fluid related to incompetent blood-brain-barrier and as cytotoxic edema located in the grey matter, related to ionic imbalance. cerebral edema can be recognize on ct within the hours following injury as loss of gray-white matter differentiation and decreased attenuation of grey and white matter. cytotoxic and vasogenic edema are better characterized on mri with diffusion-weighted imaging. brain swelling and edema occur early after trauma with consequent underestimation of subdural hematoma. therefore imaging should be repeated (ct or mri) especially when neurologic symptoms change rapidly. brain swelling/ edema may also involve the posterior fossa and is better identified on brain mri. two frequent patterns have been reported in abusive head trauma ( ). diffuse supratentorial brain swelling (infarction) involving the cortex and white matter was reported in % of cases and is considered as severe hypoxic-ischemic injury with poor outcome ( ). watershed infarction was reported in % of cases and considered a less severe form of hypoxia-ischemia. apparent diffusion coefficient (adc) values are strongly associated with poor neurodevelopmental outcomes in the acute phase (within days) especially basal ganglia, thalamus, brainstem, cerebral cortex, cerebellar vermis, cerebellar cortex and mean total brain ( ). during the early phase up to month adc values in fewer regions (basal ganglia, thalamus, brainstem and corpus callosum) were associated with poor outcome. when patients with and without parenchymal lesions are compared, the detection of diffuse lesions during the first months as well as beyond months is significantly associated with severe developmental outcome ( ). late mri (beyond months after injury) also showed that recovery depends on the extent of brain damage. patients with diffuse lesions show more severe motor and intellectual impairments and are more likely to have blindness and epilepsy than patients with focal or hemispheric lesions ( ). diffuse axonal injury (dai) is related to shear-strain injury of small medullary veins and was reported in % of cases of abusive head trauma ( ). it is encountered in trauma with sudden acceleration-deceleration associated with rotational angular forces and in shaking-impact trauma. the lesions may be hemorrhagic or non hemorrhagic (related to axonal swelling). dai is most often located in the subcortical white matter at the gray-white matter junction, corpus callosum, basal ganglia, brainstem and internal capsule. if the lesions are large enough and hemorrhagic dai may be seen on ct. however dai is usually better identified on mri with susceptibility and diffusion weighted images. the detection of changes in the basal ganglia or brainstem during the first days as well as during the first month after injury is significantly associated with poor long-term outcome in survivors ( ). the presence of intraparenchymal brain micro-haemorrhages detected on swi in children with abusive head trauma correlates with significantly poor long-term neurologic outcome ( ) contusion is also reported in abusive head trauma and is seen in blunt trauma with impact with or without contrecoup contusion. contusions are located at the surface of the brain (crest of gyri) and may be pial and haemorrhagic (disruption of cortical arteries). they are also found in the frontal and temporal regions related to impact of the brain on the roof of the orbit, middle cranial fossa and sphenoid wing. white matter tears are also seen in the frontal and temporal area related to the vulnerability of unmyelinated and soft white matter in infants. skull fractures are seen in blunt impact and are less frequent than long bones and rib fractures in non-accidental trauma. the most common site is the parietal bone (because of bulging of parietal bones below year of age). the fracture may be linear as in accidental trauma. radiologic features significant for inflicted trauma are multiple fractures, bilateral fractures and fractures that cross suture lines ( , ). focal underlying brain damage can be seen such as subdural hematoma and hemorrhagic contusion. hypoxic-ischemic encephalopathy is seen in strangulation injury with involvement of the territories of the internal carotid artery related to their anatomic vulnerability. neuroradiology (ct and mr) is crucial for the diagnosis of trauma, to predict outcome when showing edema and hypoxic-ischemic injury. this presentation will present an update on post mortem mri (pmmr) with relevance to clinical developments over the last years. in particular, reference will be made to diagnostic accuracy of pmmr across different body parts, the current limitations of post mortem mr, and protocol development at different field strengths. imaging correlates of post mortem interval are also being investigated. maceration (autolysis within intrauterine fluid) and perimortem hypoxic brain changes caused difficulties in image interpretation, which more advanced and quantitative techniques may be able to address. jawad take home points: below g, . -t pmmr shows a significant reduction in diagnostic yield, compared with conventional autopsy, and therefore its clinical usefulness in this setting will depend on individual circumstances. t pmmr performs better than . t particularly < weeks gestation, and particularly for the chest, heart and abdomen. diffusion characteristics in different fetal brain areas are multifactorial, with maceration the strongest predictor in most areas. international pm ct protocols c.y. gerrard , o.j. arthurs ; albuquerque, nm/us, london/uk the european society of pediatric radiology (espr) taskforce and the international society of forensic radiology and imaging (isfri) pediatric working group have combined efforts to establish best practice standards for performing perinatal and pediatric post mortem computed tomography (pmct) examinations. use of pmct in the investigation of pediatric death has increased significantly in the past decade. due to quick acquisition times and the ability to acquire thin slice, high detailed images of the whole body, ( ) (suppl ):s -s pediatr radiol many hospitals and forensic institutes have implemented pmct into daily practice. however, there lack an overall standardization of how cases are triaged and the acquisition methods when comparing institutes using pmct. in an effort to address inconsistencies in acquisition parameters, post processing, and case selection, pmct protocols were compiled from international institutes and centres currently performing pediatric imaging. this paper will describe both the uniform and divergent elements of image acquisition and procedural uses identified among the participating centres. the outcome is to provide a single source of information that can guide already established and new centres on the best practice standards for implementing pediatric pmct. take home points: describe how pediatric post mortem computed tomography (pmct) has increased in utility over the past decade. identify the differences in acquisition methods for clinical computed tomography versus post mortem computed tomography. discuss the overall consensus of case triage and scan acquisitions when comparing institutes in aggregate. provide comprehensive statement of best practice standards for pediatric pmct. post mortem imaging research: updates and future proposals o.j. arthurs; london/uk paediatric and perinatal post mortem imaging is a new and rapidly growing field, and the post mortem imaging taskforce was founded in graz at espr . the pmi taskforce aims to help reach consensus and guidance regarding imaging protocols and the potential yield of post mortem ultrasound, ct and mr. the key priorities are the themes of collaboration, image acquisition, best practice guidelines, training and education, raising awareness and access to imaging. this presentation will give updates on the latest developments in perinatal and paediatric imaging, with particular focus on where the pmi taskforce can help. in particular, protocol development is underway, and the espr meeting acts as an opportunity for collaborative working and network development, to facilitate best clinical practice and welcome new members. arthurs oj et al., espr post mortem imaging task force: where we begin. pediatr radiol ( ) ; : - take home points: post mortem imaging is an exciting sub-specialty which requires a combination of in depth fetal medicine, perinatal autopsy and pediatric imaging knowledge to help shape and grow the clinical and research arena. dedicated personnel have an opportunity to create the evidence-based behind a growing clinical service, with clear benefits to patients, families and referring clinicians. abstracts appear as submitted to the online submission system and have not been checked for correctness and completeness. sequences, are an emerging tool for evaluating intracranial vessel disease. improved survival due to emended treatment protocols results in an increasing number of long-term medulloblastoma survivors who experience delayed treatment effects. microbleedings, developement of cavernomas, vasculitis and atherosclerotic lesions are cerebrovascular structures affecting sequelae of the applied radiochemotherapy. this study evaluates radiation-induced intracranial vascular changes. twenty-two long-term pediatric medulloblastoma survivors (mean age . years, range - years; mean years after primary radiochemotherapy . years, range - years) underwent mri. the scan protocol included precontrast -dimensional time of flight (tof)magnetic resonance angiography (mra), precontrast d t -and d t -vwisequences and postcontrast d t -vwi-sequences of the medium and large intracranial arteries. vessel wall thickening, contrast enhancement and luminal narrowing were analyzed. additionally precontrast t -, t -swi and t -weighted images of the supra-and infratentorial brain were acquired. results: vwi-sequences: vessel wall changes could be found in ( %) and patients ( %) of the right and left ica, respectively. for the ba ( %) patients revealed vessel wall changes; for the left and right va ( %) patients were detected with vessel wall changes, respectively. in the tof angiography no alteration of the ica, ba or vas could be identified. in total vessel wall changes for the vertebrobasilar system and the icas could be found in ( %) patients. swi-sequences: all patients ( %) revealed swi lesions, the smallest lesion measuring less than mm, the biggest up to mm. sixteen patients ( %) were presented with lesions > mm, suspicious for cavernomas. to ensure quality of life in long term childhood medulloblastoma survivors, monitoring of long-term effects, like vascular changes after rct is gaining in importance. high resolution mri, including swi and vwisequences could be used here for. this study images, asymptomatic vessel wall alterations in former childhood medulloblastoma patients through vwi sequences and micro bleedings through swi sequences. vessel wall alterations, revealing rct induced arteriosclerosis, can lead to symptomatic intracranial stenosis which is associated with ischemia, furthermore micro bleedings and cavernomas can lead to intracranial hemorrhage. however further studies are needed to standardize mri sequence protocols to ensure a high standard follow up protocol, detecting clinically still asymptomatic vascular changes. fast "black-bone" mr imaging in evaluation of craniofacial abnormalities: comparison with high resolution ct z. habib, a. talib, c. parks, s. avula, l.j. abernethy; liverpool/uk to evaluate the feasibility and diagnostic value of a fast field echo, "black bone" mri sequence in children with craniofacial abnormalities. a fast "black bone" mri sequence has been used in addition to standard brain mri in children (mean age months, age range months to years and months) referred to the supra-regional craniofacial surgery unit at alder hey children's hospital, liverpool, uk. a subgroup of of these patients with complex craniofacial abnormalities additionally had high resolution volume ct performed at the same visit. "black bone" mr imaging was performed on philips ingenia t and . t scanners, using a d fast field echo sequence (tr= . ms, te= . ms, flip angle ). this sequence can be performed with an acquisition time of less than minutes. the "black bone" sequences were assessed for accuracy in evaluating the patency of the sagittal, coronal and lambdoid sutures, and, where applicable, were compared with high resolution ct. the fast "black bone" mri sequence was shown to be technically feasible in all cases. the resultant images successfully demonstrated both patent sutures, which were confidently seen, and prematurely fused sutures which were confidently not seen. visualisation of patent sutures was found to be further enhanced by the use of minimum intensity projection. in the subgroup of patients with complex craniofacial abnormalities, comparison with high resolution volume ct confirmed good sensitivity for patency of cranial sutures. there was complete agreement in out of sutures assessed. the "black bone" mr images were also found to produce good-quality surface-rendered images and were also suitable for -d printing of models for pre-operative planning. fast "black-bone" mri has proven to be technically feasible and to demonstrate cranial suture patency with good agreement with high resolution ct. additionally "black-bone" mri can be used to produce good quality surface-rendered images and -d printed models for surgical planning. main symptom of mucopolysaccharidosis type iva (mps iva) is progressive systemic skeletal dysplasia. this is routinely monitored by cerebral and spinal mri. the vascular system is generally not in the primary focus of interest. in our population of mps iva patients we observed vessel shape alterations of the vertebrobasilar arteries, which has not been described before materials: mri-datasets of patients with mps iva acquired between and were eligible for retrospective analysis of the vertebrobasilar arteries. the vessel length and angle of the basilar artery (ba) and both vertebral arteries (va) were analyzed. a deflection angle between °and °in the vessel course was defined as tortuosity, less than °as kinking. the results were compared to an matched control group of patients not suffering from mps. the deflection angle [°] of the va and ba was significantly decreased in the majority ( %) of mps iva patients (fig. ) mps iva is associated with significantly increased tortuosity of vertebrobasilar arteries. therefore the vascular system of mps iva patients should be monitored on routinely basis, as vessel shape alterations had been associated with dissections, leading to a higher risk of cerebrovascular events. in the pediatric population, intraspinal cysts (arachnoid or neurenteric cysts) are rare lesions mainly located in the thoracic region, whose acute onset is not well described in the literature. ( ) (suppl ):s -s pediatr radiol we present a series of four children seen in the last two years as spinal cord emergencies and discuss the clinical aspects, imaging diagnosis, and management approaches, particularly in the emergency setting. a comparison of our cases with those reported in the literature is also provided. as in other types of spinal cord lesions, mr imaging is the diagnostic procedure of choice, because of its potential to demonstrate the exact location and extent of the cyst and its relationship to the spinal cord, valuable information for planning surgical treatment. this is a retrospective review of cases of pediatric intraspinal cyst occurring in boys and girl, aged to years, treated at our institution between and . onset was sudden in all cases and mimicked transverse myelitis or infarction. all our affected patients had no preceding history of trauma and presented with signs of spinal cord compression-back pain and less commonly abdominal pain-followed by weakness. all patients underwent emergent mr imaging, including t , t , t *, d ciss, diffusion imaging and enhanced t sequences, mainly in the sagittal and axial planes. in each sequence, mr imaging showed a well-defined cystic lesion with signal intensity similar to cerebrospinal fluid, and secondary spinal cord compression that was severe in most cases. blood remnants were not visualized within or around the arachnoid cyst in any patient, which correlated with the absence of trauma antecedents. three of the four cysts were located in an anterior position relative to the spinal cord, and only one was located posteriorly; this latter had an associated subdural effusion. none of our patients had an associated neural tube defect. all patients were urgently treated with cyst wall fenestration or resection. the symptoms improved in all except one patient, whose symptoms did not abate, but ceased to progress. a prompt emergent diagnosis with mr imaging is important, as the symptoms can resolve if surgical treatment is performed before the spinal cord becomes irreversibly damaged. urgent surgery is essential in these cases, particularly if progressive neurological dysfunction develops over the course of spinal cord compression. the outcome following surgical fenestration or excision is excellent in most cases. nevertheless, a long-term imaging follow-up is recommended to detect possible recurrence. the objective of this study was to evaluate the usefulness of multiparametric quantitative mri model for myelination quantification in children. twenty-two children (age range: - , days) were scanned with multiparametric quantitative mri. total volume of myelin water fraction (mwf) (msum), the percentage of msum within the whole brain parenchyma (mbpv), and the percentage of msum within intracranial volume (micv) were obtained. mwf values of brain regions were acquired by drawing regions of interests. the values were fitted to representative models of myelin maturation. spatiotemporal pattern of mwf mapping was visually assessed. values of msum, mbpv, and micv well fitted to a developmental model of myelination. mwf of brain regions well fitted to a developmental model with high r values: pons (r = . ), middle cerebeller peduncle (r = . ), genu of corpus callosum (r = . ), splenium of corpus callosum (r = . ), thalamus (r = . ), frontal white matter (wm) (r = . ), parietal wm (r = . ), temporal wm (r = . ), occipital wm (r = . ), and centrum semiovale (r = . ). mwf mapping followed the known spatiotemporal pattern of myelination. multiparametric quantitative mri is a useful tool for mwf quantification in children. retinoblastoma is the most common intraocular tumour of childhood. it is a highly malignant. retinoblastoma is curable. if detected while still confined to the globe and if there are no metastatic risk factors, the child will nearly always survive following appropriate treatment. our aim is to assess diagnostic accuracy of preoperatively performed magnetic resonance (mr) imaging for detection of tumor extent in patients with histopathologically proved retinoblastoma. local ethics committee approval and informed consent were required for reviewing of patients' images and records. fifty-eight eyes in girls and boys with retinoblastoma (mean age at diagnosis was months ± . ) were reviewed on unenhanced t wi, t wi, and gadolinium-enhanced t -weighted mri with and without fat suppression. mri parameters such as anterior chamber hyperintensity, involvement of choroid, ciliary body, optic nerve, sclera, orbital fat, and pineal gland were determined. maximum tumor diameter was measured and correlated to metastatic risk factors. imaging and pathologic findings were compared. choroidal invasion was suspected with mr imaging in / eyes; findings were false-positive in eyes and false-negative in two (accuracy, . %; sensitivity, . %; specificity, %). mr imaging findings were true-positive in of eyes with proved prelaminar optic nerve invasion ( % sensitivity) and false-positive in ( . % specificity, . % accuracy). postlaminar optic nerve invasion was correctly detected in eyes; eyes were false positive, in other eyes, this metastatic risk factor was missed (accuracy, . %; sensitivity, . %; specificity, %). of nine eyes with histologically proven scleral invasion, eyes were true positive . in the other eyes, scleral involvement was missed on mri (accuracy, %; sensitivity, . %; specificity, %).extraocular fat invasion was suspected on mri in / eyes. of these, findings were truly positive in eyes ( %) and in eye ( %) was incorrect (false positive) (accuracy, . %; sensitivity, %; specificity, %).anterior chamber hyperintensity on t -weighted mr images obtained after contrast agent administration correlated well with main mri and histolopathology findings. tumor size (assessed in our study by the maximum diameter in mm) was statistically associated with postlaminar optic nerve invasion (ρ=. ) and choroidal invasion (ρ=. ). mr imaging shows promising role for tumor staging and detection of metastatic risk factors. tumor diameter, measured with mr imaging, is associated with postlaminar optic nerve and choroidal involvement. patterns of the cortical watershed continuum of term gestation hypoxic ischaemic injurythe "wish-bone sign" a. chacko , s. andronikou , s. vedajallam , j. thai ; east london/za, bristol/uk objective: background partial-prolonged term hypoxic ischaemic injury (hii) involves the cortical and subcortical watershed zones of the brain, which are visually difficult to conceive. new innovative methods of demonstrating watershed cortical atrophy using flattened maps of the brain surface gives added insight into distribution of the watershed zone by demonstrating the entire brain surface. aim determining and validating patterns of hii sustained at birth in term infants using cross-sectional mri and the innovative mercator and scroll map views of cortical surface anatomy, to define the distribution of the watershed zones in children with partial-prolonged injury. one hundred paediatric mri brain scans with an mri and clinical diagnosis of chronic term hypoxic injury were read by radiologists independently. all sites of abnormality were recorded and patterns classified. ( ) (suppl ):s -s pediatr radiol patients with partial-prolonged and combined patterns were evaluated using mercator and scroll map reconstructions, generating schematics of the watershed zone. predominant patterns of disease were partial-prolonged and acuteprofound types. the watershed zone was demonstrated, on the derived maps, representing a continuum of involvement in the shape of a 'wish-bone' extending bilateral from frontal lobes to posterior parietal lobes in band-like fashion along the para-falcine cortex and intersected by another band of atrophy in the peri-rolandic regions extending along peri-sylvian cortices. this is defined in schematics as a visual aid. predominant patterns of injury in term hypoxic ischaemic injury are described and quantified, with the 'wish-bone sign' introduced to describe the typical distribution pattern of partial-prolonged hii in the watershed zone. correlation of brain edema degree and biochemical parameters in pediatric posterior reversible encephalopathy syndrome with hematologic/oncologic diseases t. akbas , s. ulus , b. karagun , t. arpaci , c. kalayci , b. antmen ; adana/tr, istanbul/tr posterior reversible encephalopathy syndrome (pres) often associated with hypertension is characterized by typical transient parietooccipital predominantly brain edema on magnetic resonance imaging (mri) with neurological symptoms such as seizures, headache and visual disturbances. even if endothelial dysfunction, increased blood-brain barrier permeability and hyper-hypoperfusion remain as controversial mechanisms to explain, the pathophysiology of pres is unremain. the aim of our study was to investigate the correlation between brain edema degree on mri and serum biochemical parameters such as lactate dehydrogenase (ldh), albumin (alb), creatinine, uric acid (ua) and urea. a total of pediatric hematology and oncology patients ( male, female, aged - , mean age: years months) diagnosed with pres during treatment and after hematopoietic stem cell transplantation (hsct) were included in this retrospective study. underlying diseases were beta thalassemia (n: ), aplastic anemia (n: ), acute lymphoblastic leukemia (n: ), acute myeloid leukemia (n: ), lymphoid leukemia (n: ) and burkitt's lymphoma (n: ). pres was seen after undergoing hsct in patients. the brain edema degree according to specified anatomical regions on fluid attenuation inversion recovery (flair) mri sequence was scored by two radiologists blinded to patients' records. the levels of serum biochemical parameters at onset of symptoms were correlated with score of brain edema degree on mri. serum ldh concentration was statistically correlated with the score of brain edema degree (spearman's rho correlation, r= . , p= . ). no relationship was found between other biochemical parameters and the score of brain edema degree. our results suggest that increased serum ldh as a marker of endothelial dysfunction is the main biomarker for development of brain edema in pediatric pres patients under treatment and after hsct with underlying hematologic and oncologic diseases. objective: gadolinium based contrast agents (gbcas) have been associated with increasing signal intensities in deep brain nuclei on unenhanced t -weighted brain imaging. until now, most studies have been performed in adults, while results on pediatric patients are sparse. therefore, the aim of this study was to evaluate if there is any difference between signs of gadolinium retention in pediatric and adult patients. in this irb-approved, single center retrospective study, we extracted all patients with at least contrast-enhanced mris archived on pacs between - . all patients with gadobenate dimeglumine only enhanced mris were reviewed. seventy-six pediatric patients with the most injections and adult patients with the most injections were included in the final evaluation. therapies were documented. t signal intensity measurements for the initial and last unenhanced brain mris were performed for dentate nucleus, pons, globus pallidus and thalamus. signal intensity ratios for dentate-to-pons (dnp) and globus pallidus-to-thalamus (gpt) were calculated and correlated with number of injections and time interval as well as therapy. differences between adults and pediatrics were assessed. mean age for the pediatric group was . years compared to . years in the adults. no significant difference was found for gender distribution ( vs. % females) and follow up time ( . vs. years). there was no difference concerning the signal intensities on first and last mri in children and adults (p= . / . , respectively). for each additional year of follow-up the change in ratio increases by . for adults but only . for peds (p= . ). comparing therapies, in children a statistically significant difference between patients with and without former radiation was found (p< . ) while there was no difference in adult patients with and without therapy (p= . ). children and adults show a similar increase in t signal in deep brain nuclei ascribed to gadolinium deposition. in children, radiation and chemotherapy) seem to have a higher influence on gadolinium deposition. this correlation cannot be found in our adult cohort, indicating therapies have no (additional) influence. kearns-sayre syndrome (kss) is a rare mitochondrial dna-deletion syndrome characterized by early onset (< years), progressive external ophthalmoplegia and pigmentary retinopathy, often associated with cerebellar ataxia, muscle weakness, bilateral sensorineural hearing loss and cardiomyopathy. pyramidal symptoms may be present in kss, but they are poorly reported in the literature. through this case series, we aim to evaluate the concordance with the imaging patterns proposed by literature, correlating them with clinical and laboratory data, and to investigate possible microstructural damage with diffusion tensor imaging (dti) and magnetic resonance spectroscopy (mrs). we evaluated eight patients ( - years of age) with genetically confirmed diagnosis of kss. all pts. were studied with t/ . t mri. in / pts. the study was completed by mrs and in / by dti imaging with reconstruction of cortico-spinal tracts (cst) using a -rois approach. a t-test comparative study between mean fractional anisotropy (fa) of cst in the kss patients with dti and a group of healthy controls was performed. cst reconstruction in a patient suffering from kss (images a-c), compared to an healthy control (images d-f). the dti study showed significantly reduced fa values, pointing out a possible microstructural damage. the disease showed an mr pattern of mixed white and gray matter signal abnormality, with periventricular and/or subcortical white matter hyperintense lesions, which in / patient presented a "tigroid pattern" (fig. ) three patients displayed a disease extension to the cervical spinal cord. (fig. ) dwi images demonstrated restricted diffusivity in almost all lesions (fig. ) , with persistence of low adc values. mrs study documented a high lactate peak in / pts. and a naa reduction in / pts; an increment of gsh was noted in one patient (fig. ) . the t-test comparative study of cst showed a significant reduction of mean fa value in kss patients compared to healthy controls (p= , ). involvement of the spinal cord (a-c, yellow arrows). comorbidity was suspected in "a" (myelitis). below (d-f): pale nuclei (d, green arrows) and subcortical white matter (e) alterations. right image displays the "tigroid pattern" (purple arrow). mrs showing the presence of a gsh peak, which may suggest an augmented antioxidative activity within the encephalic tissue. below: dwi hyperintensity in many regions of the brain in patients suffering from kss, due to diffusion resctriction. the integration of neuroimaging with clinical data can implement the diagnosis of mitochondrial diseases such as kss. according to our experience, comorbidities can delay the achievement of a correct diagnosis. the finding of an altered signal in the spinal cord of / pts. may suggest a new possible localization of the disease, while in one patient was referable to myelitis (fig. , a) the evidence of a "tigroid patter" in should be taken in count in the differential diagnosis with lysosomal disorders. the presence of a prominent gsh peak may represent an augmented antioxidant activity, which may correlate with a more favorable outcome. an involvment of cst can be speculated even if pyramidal symptoms are poorly represented in kss. remotely distractible, magnetically controlled growing rod (mcgr, fig. ) system has been developed to allow for gradual lengthening on an outpatient basis. this allows for safe spinal lengthening with continuous neurologic monitoring and real-time feedback by the patient. this study aims to evaluate retrospectively our ultrasound (us) geometric method and his accuracy compared with the plain radiograph (gold standard) for assessing mcgr distractions. this is a retrospective study that includes patients with early-onset scoliosis undergoing multiple consecutive distractions after mcgr implant. the rods length was measured for with us, for each distraction ( -months interval), and compared with plain radiograph follow-up ( -year interval). all patients included were treated with dual-rod systems. distraction length was monitored by a senior radiologist with us at each visit, one rod at a ( ) (suppl ):s -s pediatr radiol time, before and after magnetic lengthening, with our geometric measurement method (fig. ) . low-dose upright two-projections radiograph were taken immediately after surgery and at -year intervals and measured by two radiologists ( and years of experience respectfully) (fig. ) . we compared measurements with the wilcoxon signed-rank test. from january to october , a total of patients ( females and male), which diagnoses included mitochondrial encephalopathy syndrome (n= ), spina bifida (n= ), ataxia of unknown cause (n= ), juvenile idiopathic scoliosis (n= ) and trisomy (n= ), with a mean of distractions per patient (standard deviation [sd] ± , ), were recruited. fifty distractions for each system ( measurements in total) were performed, targeting different lengths of distraction (from - . mm to + . mm) on each occasion. a total of sets of plain radiographs were taken. from these, sets of data points were used for correlation analysis. the mean distracted length per year on plain radiographs was , mm (sd ± , mm) and the mean distracted length on us per -months interval was , mm (sd ± , mm). excellent correlation was observed between radiographic and ultrasound measurements. in particular, correlation between rx measurements and ultrasound was excellent both for junior ( . <p< . , w= ) and senior radiologist (p< . , w= , ). there were no rod's breaches identified neither in ultrasound or radiographs in this series. the measured changes in rod length between the two imaging modalities were highly correlated. thus, ultrasonography is at least as accurate as radiographs in measuring changes in rod length. our geometric measurement method adds reproducibility to an effective, non-ionizing and lowcost procedure for monitoring distraction of mcgr in children population. refuting child abuse denialistshealing rickets is clearly different from child abuse metaphyseal fracture a.e. oestreich; cincinnati/us objective: child abuse denialists, who testify against the diagnosis of child abuse, often claim that radiographic findings generally recognized by pediatric radiologists as likely due to abusive trauma are instead a consequence of rickets, including healing rickets. in particular, bucket handle transverse bony density at metaphyses are declared by some denialists to be identical to the pattern of healing rickets. i demonstrate by reviewing the details of these different patterns that this is an incorrect declaration. additionally, concave distal ulna margins alone are not a sign of rickets. rickets is radiologically distinct from classic metaphyseal fractures. i reviewed medicolegal documents and published articles by several well known physicians who claim that certain children suspected of having suffered child abuse instead demonstrate rachitic bone disease. their statements and images in support of their opinions are critically reviewed and contrasted with known examples of rickets, including healing rickets. at the physeal region of long bones in rickets, the zone of provisional calcification (zpc) is not calcified and the normal metaphyseal collar shaftward from that zone is not maintained. in metaphyseal fractures from abuse, the zpc and collar are maintained. in early healing rickets, the zone of provisional calcification calcifies first, giving a transverse calcification separated from the already ossified metaphysis. this calcification is different from a bucket handle fracture pattern without signs of rickets. moreover, concave distal margin of the ulna without other signs of rickets is seen in about % of normal infants. repeatedly, denialists have testified against the diagnosis of child abuse, claiming rickets in the absence of radiographic evidence -i critique one well known child abuse is a serious diagnosisclaiming by denialists of an alternate diagnosis, such as rickets, when radiographically no rickets is present, should be refuted. a clear understanding of the differences between abuse fractures and rickets is obligatory. when no rickets is seen at other growth sites, including seeing the presence of zones of provisional calcification, rickets is not present. simultaneous multi-slice turbo spin echo: a -fold time-saving alternative to conventional tse in mr imaging of the pediatric knee s. benali, a. gholipour, p.r. johnston, s.d. bixby; boston/us objective: simultaneous multi-slice (sms) is a novel iteration of parallel imaging in mri that reduces acquisition time at least two-fold over conventional turbo spin echo (tse) acquisitions. the aim of this study is to determine whether -dimensional ( d) sms tse can replace conventional d tse in imaging of the knee in pediatric patients without compromising diagnostic quality. this was an irb-approved retrospective study. subjects included all pediatric patients referred for routine -tesla mri of the knee between october through december . mri examination consisted of institutional basic protocol with both traditional t tse and sms t tse in axial and sagittal planes with fat suppression. two anonymized study folders were created for each subject, one containing all basic sequences (basic exam), and one in which t tse sequences were substituted with t sms sequences (sms exam). two pediatric radiologists independently and blindly reviewed each study and noted presence or absence of pre-determined abnormalities (table ) . discrepancies between radiologists were settled by consensus. qualitative assessment was performed using a likert scale to evaluate edge blurring, contrast resolution, image noise, and flow artifact. thirty-five subjects comprised the study population (mean age . years, range - , female, male). diagnostic performance was assessed by comparing findings (table ) from basic exam to sms exam based on absolute agreement and cohen's kappa statistic. for all findings, the proportion of absolute agreements between basic and sms exam was > . for reader , > . for reader , and . for consensus between readers. kappas for consensus reads were . on all structures (p< . , lower % confidence limit > . ). for reader , kappas were . for / structures (p< . ) and . for pcl. for reader , kappas were . for / structures (p< . ) and . for cartilage defects. paired t-test was used to compare mean likert scores for image quality characteristics. for both readers, sms was preferred for flow artifacts whereas tse was preferred for the three remaining image quality characteristics (p< . ). our primary assessment suggests that sms t tse is comparable to standard tse in terms of diagnostic performance in the evaluation of the pediatric knee despite modest decrease in overall image quality. the -fold decreased acquisition time of sms is a significant advantage which is felt to offset the mild decrease in image quality, particularly as it increases the likelihood that children will tolerate the examination without motion. mri for sacroiliitis in children: panel findings and inter-observer evaluation using standardised reporting k.e. orr , m.j. bramham , s. andronikou ; plymouth/uk, bristol/uk there is little evidence regarding mri for diagnosing sacroiliitis in children with juvenile idiopathic arthritis (jia). the limited literature presents varied opinions but no published recommendations for standardisation of reporting. axial disease in jia responds poorly to conventional first-line treatments but identifying these children using history and examination findings is unreliable. standardised mri reporting ( ) (suppl ):s -s pediatr radiol may improve diagnosis and selection of patients in whom newer biologic treatments are indicated. the aim was to use a standardised reporting proforma based on published definitions for recording mri findings in suspected sacroiliitis to evaluate inter-observer agreement and determine the reliability of findings according to specific sequences. ninety-nine sacroiliac joint mris ( joints) were included, were initial examinations and were follow-up mris. the age range was between . and . years (mean age . years). three readers retrospectively reported all mris using the standardised proforma. 'reader ' was the study group panel while readers and were specialist paediatric radiology consultants working in the united kingdom. readers were blinded to additional clinical information and other imaging. inter-reader variation was evaluated for the presence of bone marrow oedema, erosions, effusions, ankylosis, sclerosis and enhancement, as well as the presence or absence of sacroiliitis. the quality of mri examinations was evaluated, including presence and adequacy of sequences performed and alignment of the coronal/oblique studies. mri findings were correlated with clinical details and final diagnosis. there is significant variability in sacroiliac joint mri protocols. refinement of these to include only necessary sequences based on inter-reader reliability and reinforcement of good positioning will improve reporting and result in universal standardisation. there is inconsistency in current reporting practice of sacroiliac joint mri in children but increasingly, clinicians rely on imaging to select patients with sacroiliitis and guide appropriate treatment. using a standardised reporting proforma may improve the quality and consistency of reporting. ultrasound-guided steroid tendon sheath injections in juvenile idiopathic arthritis s. peters, d.a. parra; toronto/ca objective: juvenile idiopathic arthritis (jia) is the most common chronic rheumatic disease in childhood. tenosynovitis is one of the manifestations of jia, which can explain the absence of response to treatment when adjacent joints are injected. steroid injection is one of the treatment options for tenosynovitis and it has been shown to be effective in the literature. utilizing ultrasound (us) guidance for injections into tendon sheaths has shown clinical advantage to conventional blind injections in the adult rheumatoid arthritis population. the aims of this study are to: (a) identify tendon sheaths most commonly treated in our patient population with jia referred for steroid injections; (b) describe technical aspects of the procedure; (c) characterize sonographic appearance of tenosynovitis in jia; (d) assess agreement between clinical request and sites injected. this was a year single-center retrospective study ( may -april in which we recruited patients with jia referred by rheumatology for us-guided tendon sheath injections. we collected patient demographics, clinical assessment information, sonographic appearance of the tendons and technical aspects of the intervention from the procedure records. we collected data from visits of patients ( % female, mean age years months) with a total of injections. the ankle region was most commonly injected ( %), specifically the tendon sheaths of tibialis posterior ( %), peroneus longus ( %) and brevis ( %). % of the procedures were performed under general anesthesia and triamcinolone hexacetonide was used in % of the injections. an "out of plane" approach was used in % of the interventions and the mhz "hockey stick" us probe was preferred for guidance ( %). we found minor intra-procedure complications without sequelae. the majority of treated sites ( %) showed peritendinous fluid and sheath thickening on us. other findings were increased color-doppler signal and echogenic peritendinous fluid. a strong agreement between clinical request and sites injected was observed and most patients required one visit ( %). us-guided tendon sheath injections 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 area most commonly injected in this cohort of patients. the most common sonographic finding is peritendinous fluid and sheath thickening. these findings might assist radiologists and rheumatologists to characterize and more effectively manage tenosynovitis in patients with jia. to evaluate the accuracy of the software for automatic bone age (ba) estimation based on deep learning technique, and to validate the feasibility of this system in clinical practice. the software for automatic ba estimation was developed based on deep learning technique using , left hand radiographs and estimated ba of each radiograph based on greulich-pyle method. ba estimation was done for left hand radiographs of consecutive patients ( months - years; boys and girls) in three methods: ( ) ai bone age (assessed by the software), ( ) ai-assisted ba (assessed by two radiologists with the assistance of the software), ( ) gp atlas-assisted ba (assessed by two radiologists with only gp atlas but the software). the reference ba was determined by two radiologists by consensus. the accuracy of the estimated ba by each method was assessed using concordance rate (%), pearson's correlation analysis, the root mean square error (rmse), and bland-altman plot. reading time for ba estimation by each method was evaluated. ai bone age showed % of concordance rate, and a significant correlation with reference ba (r = . , p< . ). the bland-altman plot of agreement between the reference ba and ai bone age showed the mean difference of - . years ( % limit of agreement, ± . years). rmse was . years. in reviewer , concordance rates were same between both gp atlasassisted ba and ai-assisted ba ( %), and rmse of ai-assisted ba ( . ) was slightly lower than that of gp atlas-assisted ba s ( ) (suppl ):s -s pediatr radiol ( . ). in reviewer , concordance rate was slightly higher in aiassisted ba ( %) than gp atlas-assisted ba ( %), and rmse was almost the same ( . in ai-assisted ba, . in gp atlasassisted ba). the reading time was reduced . % in reviewer and . % in reviewer . the software for automatic ba estimation based on deep learning technique showed high accuracy and may enhance work efficiency in ba estimation by allowing radiologists to save reading time and to improve accuracy. temporomandibular joint mri findings in adolescents with primary disk displacement in comparison to those in juvenile idiopathic arthritis j. bucheli, d. ettlin, c. kellenberger; zurich/ch to investigate potential differences of morphology and degree of inflammation in temporomandibular joints (tmjs) affected by primary anterior disk displacement (add) and juvenile idiopathic arthritis (jia). in adolescents ( female, age ± y), contrast enhanced magnetic resonance images (fig. a) of tmjs with add were retrospectively compared to those of age-and gender-matched controls with jia. morphology of articular disk and bony structures were described. osseous deformity and inflammation were qualitatively scored with progressive -grade scales and compared between groups with mann-whitney-u test. mandibular ramus length, measured on gradient echo minimum intensity projection images (fig. b) , was compared between groups and to normal values with independent samples t-test. in the add-group, / disks were dislocated anteriorly and showed thickening of the posterior band ( / ). in contrast, tmj disks of jia patients were mainly flattened (n= ) and/or centrally perforated (n= ) and rarely dislocated (n= ). tmjs with add showed similar overall grades of inflammation (p= . ) and osseous deformation (p= . ) as tmjs in the jia group. while erosions were frequent in both groups (add / ; jia / , p= . ), the mandibular condyle (p< . ) and glenoid fossa (p< . ) were less flattened in tmjs with add. in add tmjs, bone marrow oedema was less frequent (p= . ) and grades of joint enhancement slightly lower (p= . ), but presence of synovial thickening (p= . ) and degree of effusion (p= . ) were not significantly different between groups. mandibular ramus length was not significantly different (p= . ) between groups, but in both groups clearly decreased compared to mean normal values (p< . ). articular disks in tmjs affected by jia are rarely dislocated. surprisingly, tmjs with primary add show considerable inflammatory change including condylar erosions. still, chronic systemic inflammation in jia joints results in considerable higher deformity of the mandibular condyle and the temporal joint surface. observation of the mostly preserved normal shape of the temporal bone may help differentiating primary add from jia. retrospective magnetic resonance imaging (mri) study of consecutive jia patients ( female, median age y) with at least two consecutive tmj mri examinations ≥ y apart and no csi. degree of tmj inflammation was determined on t -weighted and contrast-enhanced t weighted fast spin echo images (fig. a) , and degree of osseous deformity on gradient echo images (fig. b) by progressive -grade scales ( - ). change of respective grades was assessed with wilcoxon test. mandibular growth was determined by ramus length change and compared to normal values. over a median period of . y (interquartile range, . - . y), degree of tmj inflammation improved (p< . ) with decrease in frequency of grade ( . % to %) and grade ( . % to . %). inflammatory grades improved both in patients with (n= , p= . ) and without (n= , p= . ) systemic disease modifying medication. the degree of osseous deformation slightly improved (p= . ), with decrease in frequency of grade ( . % to . %) and grade ( . % to . %), and increase of grade ( % to . %). overall growth rates of mandibular ramus (median, . mm/y) were not significantly different from normal growth rates (p= . ) (fig. c) . growth rates of tmjs from patients only receiving non-steroidal anti-inflammatory drugs (median, . mm/y) were not significantly different (p= . ) compared to patients treated with systemic disease modifying drugs (median, . mm/y). in patients with systemic treatment of jia, both the degree of tmj inflammation and osseous deformity as seen on mri improved at midterm follow-up. normal growth of the mandibular ramus was maintained. these results are in contrast to those from an earlier cohort treated with csi, in which on average deformities deteriorated and growth was impaired. objective: pediatric ileocolic intussusception, ici, is a common abdominal condition for which pediatric radiologists are asked to attempt emergency pneumatic reduction. because of the high success and low complication rates of pneumatic reductions, radiologists are able to make several attempts at reduction in stable patients if the initial enema attempt is unsuccessful. we have observed patients with successful reductions with rather long periods between initial symptoms of ici and performance of the air enema. we hypothesize that successful pneumatic reduction rates are independent of length of symptoms and in stable patients, repeated reduction attempts can be performed with the expectation of successful reduction. we performed an irb-approved retrospective review of all ici with a pneumatic reduction attempt between - at xxx. clinical, imaging and surgical data was reviewed. time to enema was defined as the time from first symptom to first air enema attempt. linear and second order polynomial statistical analysis was performed to assess the relationship between time to enema and enema outcome. results: ici were identified in patients. air enema was successful in ici, %. the mean time to enema was . hours, range - hours with sd of . hours for successfully reduced ici and . hours, range - hours with sd of . hours for unsuccessfully reduced ici. surgical resection was required in patients with ischemic bowel including one with an irreducible meckel's diverticulum as lead point. there was no correlation between time to enema and successful reduction, fig . no patient with a successful pneumatic reduction of a ici required subsequent bowel resection. conclusions: air enema for ici can be safely performed despite prolonged time to enema with the anticipation of a successful reduction. the lack of correlation of pneumatic reducibility and time to enema suggests that in surgically cleared patients with ici, the pneumatic reduction attempt may not be a true emergency and that repeated attempts at reduction are safe. additionally, though our numbers are small, they suggest that an ici is reducible or not from the beginning and do not "become irreducible" with prolongation of the time to enema. evaluation of splenic stiffness measurements for the diagnosis and the follow-up of portal stenosis after paediatric liver transplantation c. escalard , a. dabadie , s. chapeliere , d. pariente , c. adamsbaum , s. franchi ; le kremlin-bicêtre, paris/fr, la timone, marseille/fr to report our preliminary findings about the role of splenic and hepatic supersonic shear-wave elastography (sswe) in the diagnosis and followup after treatment of portal stenosis in paediatric liver graft recipients. all paediatric liver recipients with portal stenosis treated by the interventional radiology procedure, and who underwent splenic and hepatic sswe pre and post interventional procedures, were retrospectively reviewed. demographics, data about the portal stenosis (delay post transplantation, clinical presentation, initial radiological findings, hemoglobin and platelet counts), ir procedure performed, clinical and ultrasonographic follow-up and spleen stiffness pre and post ir procedure were collected. four patients were included, median age , years (range , months to years) and median delay post transplantation , years (range month to . years). two patients presented with anemia, associated in one case with progressive splenomegaly. one patient had liver test abnormalities, and one had decreased portal flow found on systematic doppler followup. spleen stiffness was elevated pre-procedure in all patients, from to kpa (normal < kpa), and liver stiffness was normal or mildly elevated in all. portal stenosis was successfully treated by ir in patients. spleen stiffness decreased rapidly, ranging from to % (figure ) . however, the size of the spleen remained unchanged. in the last patient, angioplasty of the portal stenosis failed leading to portal thrombosis. spleen stiffness increased on the subsequent ultrasound ( figure ). mr elastography (mre) is a novel imaging technique that provides a non-invasive evaluation of liver fibrosis. the standard sequence used for this purpose on a siemens scanner has been gradient echo (gre). we also implemented echo planar imaging (epi) available as a work-in-progress (wip). our aim is to compare the liver elastogram values between gre and epi in children. after consent from both research and referred clinical subjects, a dedicated mre of the liver was performed on a t mr scanner (magnetom® skyra, siemens) with a pediatric mechanical driver over the right upper quadrant. an axial t blade with fat saturation, coronal t vibe dixon and axial diffusion weighted imaging (dwi) were obtained. elastograms were obtained using both standard gre and epi, in the axial plane. for the gre sequence, different slices were selected and each scanned sequentially. the epi sequence incorporated different slices in just one series. images were post-processed placing regions-of-interest (roi) and measuring the stiffness in kilopascals (kpa). for each sequence and each slice the mean stiffness and then the average of the means was calculated. a spleen elastogram was simultaneously generated, without changing the mechanical driver location, and the mean stiffness was also calculated. increased stiffness was defined as > . kpa in the liver and > . kpa in the spleen. we focused on a technical comparison between the sequences without clinical or histological correlation of findings. we included subjects that had elastogram measurements of liver and of them spleen stiffness on both gre and epi sequences. mean liver stiffness on gre was . (sd+/- . ) and on epi was . (sd+/- . ), with a pearson's correlation of r= . (p< . ). increased liver stiffness was found in / ( . %) of the cases in gre and / ( %) of the cases in epi. mean spleen stiffness on gre was . (sd+/- . ) and on epi was . (sd +/- . ) with a pearson's correlation of r= . (p= . ). epi reported consistently higher values than gre in both liver and spleen stiffness. our preliminary data shows a moderate to high correlation between gre and epi sequences; however, the epi values were higher in both liver and spleen. in the future, larger studies are needed to validate these thresholds and patterns among different sequences. were also reviewed if done. patient's medical & surgical treatment, and clinical progress were also reviewed. active telephone follow-up days after cevus was performed. results: patients giving a total of pelviureteric units were referred for vus study during the study period, with age ranging from month to years old. no contrast-related complication was encountered. except cases with failed catheterization, were investigations of urinary tract infection (uti), antenatal hydronephrosis and congenital anomalies etc., and remaining were follow up studies of known reflux. of all cases of uti, refluxing units were picked up by vus, ranging from grade i to v. of the refluxing units diagnosed by cevus, were missed on mcu, among which were high grade refluxes (grade iii to v) requiring treatment; whereas cevus only missed one grade i refluxing unit detected by mcu. besides, one grade iv refluxing unit identified on vus was under graded by mcu to grade i. regarding patient outcomes, one patient with mcu-missed refluxing unit presented with breakthrough uti on follow up. two refluxing units that were missed on mcu but detected on cevus demonstrated scarring on dmsa. conclusion: cevus is shown to be more sensitive in detecting vesicoureteric reflux than mcu. the fact that mcu-missed refluxes detected by cevus were associated with breakthrough urinary tract infection and scarring on dmsa indicated that the extra sensitivity brought by cevus did translate to clinical significance. difficulty in visualizing low-grade reflux is a potential limitation of this technique. with favourable diagnostic performance and safety profile, cevus can be further applied in this community in the era of radiation reduction. percutaneous transbiliary needle or forceps biopsy in hepatic masses with biliary dilatation a. dabadie , s. franchi , d. pariente ; la timone, marseille/fr, le kremlin-bicêtre, paris/fr hepatic masses with biliary dilatation are rare in children and mainly include rhabdomyosarcoma of the biliary ducts, but also other masses or pseudo-masses compressing the hepatic hilum. in these patients histological diagnosis of the lesion as well as temporary biliary drainage are warranted. the objective of this study is to report our experience in percutaneous transbiliary biopsy performed simultaneously and using the same access as the percutaneous biliary drainage in children with hepatic mass obstructing the biliary ducts. children presenting with a hepatic mass causing biliary obstruction, with need for biliary drainage, were considered candidates for percutaneous transbiliary biopsy of the lesion performed at the same time. the biopsy was performed under ultrasound guidance, through a sheath introduced in the dilated biliary system, using a semi-automatic gauge needle or the transluminal biliary biopsy forceps set (cook medical, bloomington, usa). between and , four patients were included, three females and one male, median age . years (range . - . ). all presented with jaundice and were diagnosed with a hepatic mass with secondary biliary obstruction. percutaneous transbiliary biopsy was performed in all patients using the gauge needle. in one patient, the biopsy did not demonstrate any tumoral cells and a second biopsy was performed using the forceps device through the same biliary access. the samples deemed adequate for analysis by the pathology department in all patients, however the samples were larger when using the needle. a retrospective -prospective study included patients of both sexes ( , +/- , y), in a two-year span. patients were divided into two groups according to the used diagnostic method (positivegroup a on us and a on mri, with intestine mural thickness above mm, and negativegroup b on us and b on mri, with mural thickness below mm). overall sensitivity and specificity of us and mri in diagnosing ibd was calculated in comparison to pathohistological (ph) findings. us examination showed an average intestinal mural thickness of . ± . mm and . + . mm in group a ( patients) and group b ( patients) respectively. mri examination showed an average intestinal mural thickness of . ± . mm and , + , mm in group a ( patients) and group b ( patients) respectively. out of patients from group a, ( %) had irregular mural architecture, contrary to group b in which mural architecture irregularities have not been observed. in groups a and b ( . %) and ( . %) patients had irregular mural architecture respectively. average length of affected intestinal segment on us and mri was mm and mm respectively. five patients from group a and four from group a had signs of fibrosis. color doppler showed hyperemia in and patients of group a and a respectively. transmural signs of inflammation were found in % of patients on us, and . % of patients on mri. average longer diameter of mesentery lymph nodes measured by us and mri was . ± . mm and . ± . mm, respectively. overall sensitivity of us and mri was . % and . % respectively. both us and mri showed a specificity of %. us and mri are reliable and compatible methods in diagnosing ibd, with mri being slightly more accurate. us is an extremely valuable and widely available imaging modality in every-day clinical work, both in diagnosing and follow-up of therapy effects in children with ibd. findings in percutaneous transhepatic cholecysto-cholangiography in neonates and young infants presenting with conjugated hyperbilirubinemia d.a. parra, s. peters, j. amaral; toronto/ca objective: conjugated hyperbilirubinemia is a concerning finding in neonates and young infants, biliary atresia (ba) being one of the main diagnostic considerations. ba is a rare disease characterized by fibrosis of the biliary tree. the obliteration of the biliary system leads to cholestasis and ultimately liver parenchymal injury, cirrhosis and death. an early diagnosis of ba along with a kasai portoenterostomy operation significantly improves the long-term prognosis. percutaneous transhepatic cholecysto-cholangiography (ptcc) is one of the options described in the diagnostic algorithm of ba. the aims of this study are to: (a) describe ptcc findings in patients with conjugated hyperbilirubinemia; (b) identify the abnormal patterns encountered that justify further investigations; (c) analyze technical aspects of the procedure. this is a year single-center retrospective study ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) in which we recruited patients with the diagnosis of cholestasis (less than months old) referred for ptcc. we collected patient demographics, clinical information, findings in ptcc, post-procedure management and long term clinical outcome. eigthy-nine patients were referred for ptcc in the study period. the procedure was technically feasible and successfully performed in patients ( % male, mean age . months). forty-one had a pre-procedure hida scan suggestive of ba. fifty-nine patients had an ultrasound-guided biopsy in conjunction with the ptcc and in all of them the cholangiography was performed through a needle placed using ultrasound guidance in the gallbladder. % ( ) of the patients had a normal ptcc. abnormal patterns encountered were: ) variable degrees of hypoplastic bile ducts seen in %; ) atretic gallbladder without demonstration of communication with bile ducts seen in %; and ) gallbladder communication with a cystic structure not communicated with the biliary ducts (cystic biliary atresia) seen in %. the most common diagnosis in the abnormal group was ba ( %). alagille's syndrome, alpha- antitrypsin deficiency and progressive familial intrahepatic cholestasis were other diagnoses in this group. no complications related to the procedure were observed. ptcc is a safe and effective option in the diagnostic algorithm of patients presenting with cholestasis early in life. visualization of the gallbladder is fundamental to perform the procedure. the majority of studies were normal in our patient population preventing further invasive investigations. three types of abnormal ptcc patters were encountered, with ba being the most common diagnosis in this group of patients. to evaluate the additive role of shear wave elastography in the sonographic distinction of biliary atresia from other causes of neonatal/ infantile cholestatic liver disease. neonates and infants with clinical and biochemical diagnosis of cholestatic jaundice were enrolled in our study after obtaining informed written consent from the parents. grey scale, doppler and shear wave elastographic findings were recorded after hours of fasting using aixplorer® ultrasound system (supersonic imagine, aix en provence, france). sedation was not needed during the study. for obtaining elastographic values, linear transducer ( - hz) was used and after image stabilization a q-box measuring mm was placed in the most homogenous vessel free area. the mean of three elastographic values were recorded. hida scan, liver biopsy, intra-operative cholangiogram and histopathological evaluation of resected specimens was done wherever feasible and clinically indicated. the prospectively obtained elastographic values were retrospectively evaluated. eleven of patients included in our study were proven to be biliary atresia (ba) by intra operative cholangiogram and histopathological reports. the diagnosis in the remaining patients included other causes of infantile cholestatic jaundice like infantile choledochal cyst, neonatal idiopathic hepatitis, progressive familial intrahepatic cholestasis, abernathy malformation, cmv hepatitis etc. the elastographic values of ba and non-ba patients were compared. six of infants were younger than days which included four patients with ba and their elastographic values ( . ± . kpa) were significantly different from that of non-biliary atresia ( ± kpa) in the same age group (p value < . ). similarly, for patients aged > days also we had a significant difference (p value < . ) in elastographic stiffness between ba ( . ± kpa; n= ) and non-ba ( . ± . kpa; n= ) groups. the mean echogenic area anterior to right portal vein (earpv) was . ± . mm in ba and . ± . mm in non-ba group (p value < . ). the mean gall bladder (gb) length was . ± . mm in biliary atresia group in contrast to . ± . mm in the rest (p value < . ). the roc plot for earpv and gb length gave a youden index cut off value of > . mm (sensitivity . & specificity . %) and < . cm (sensitivity & specificity . %) respectively. infants with biliary atresia have a significantly higher elastographic value when compared to age matched patients with other causes of neonatal cholestasis. we expect to validate the findings in our ongoing study with a larger sample size. to retrospectively define in a large pediatric population the association between testicular microlithiasis and testicular neoplasia. retrospective multicenter study of scrotal ultrasounds performed between january and april in subjects < years of age. all unique subject scrotal ultrasound reports from each institution were reviewed for mention of microlithiasis. for subjects with serial exams, the most recent exam performed was included in the analysis. all exams mentioning microlithiasis were reviewed by site-specific investigators to confirm the presence of ≥ punctate calcifications in the testicle on a single image. the presence of testicular germ cell and stromal tumors were determined for subjects with and without microlithiasis through review of institutional pathology and imaging databases. the risk of testicular neoplasia in the context of microlithiasis was expressed in terms of odds ratios with (a-or) and without adjustment (u-or) for fixed study site (institution) effects by logistic regression. the study population included , unique subjects with confirmed microlithiasis in , ( . %). mean subject age was . ± . years for subjects with microlithiasis and . ± . years for subjects without (p< . ). one hundred thirty-nine subjects ( . this large, multicenter study confirms that there is a significant, strong association between testicular microlithiasis and testicular neoplasia, particularly malignant germ cell tumors. children with microlithiasis have approximately x greater odds of having a malignant germ cell tumor than children without microlithiasis. this reinforces the need for a large prospective study assessing the risk of developing testicular neoplasia in children with incidentally identified diffuse microlithiasis. do adc-values reflect renal function or obstruction in children with uretero-pelvic-junction obstruction? p. grehten, a.c. eichenberger, c. kellenberger; zurich/ch the use of diffusion weighted imaging (dwi) in renal mri is increasing. in adults as well as in infants a positive linear correlation between adcvalues and glomerular filtration rate has been demonstrated. the aim of our study was to assess whether renal dwi can provide information on the grade of urinary tract obstruction or renal function in children with uretero-pelvic-junction (upj)-obstruction. retrospective analysis of children (age . +/- . y) with unilateral upj-obstruction who underwent pre-and postoperative mri at . t and normal controls (age . +/- . y). functional mr-urography and multiple b-value dwi were part of the mr-protocol. renal adc-values were correlated to measures of obstruction and function, and compared between obstructed and non-obstructed kidneys and between pre-and postoperative studies. no correlation was found between mean parenchymal, cortical or medullary adc-values and calyceal transit time (ctt), renal transit time (rtt) and measures of differential renal function (%parenchymal s ( ) (suppl ):s -s pediatr radiol volume, vdrf, pdrf). there was moderate correlation with absolute parenchymal volume and total kidney volume, and low correlation with pelvic volume. adc-values showed high correlation with age and patient's weight. adc-values normalized for age or weight showed low correlation with rtt and ctt, but no correlation with functional measures. adc-values were not significantly different between obstructed and contralateral normal kidneys (p= . - . ) or between pre-and postoperative studies (p= . - ). renal adc is dependent on age and weight in young children and does not correlate with differential renal function. for assessing urinary tract obstruction with adc normative values need to be established. to determine the level of knowledge and awareness of medical staff, medical students and parents concerning possible risks associated with ionizing radiation. a prospective study has been conducted at children's hospital, center for adult's radiology, and medical faculty, by filling out two anonymous questionnaires (questionnaire medical staff and medical students, questionnaire parents of the children exposed to x-ray based procedures), and it included participants. statistical analysis was performed using the spss . . the majority of examinees assessed their knowledge about ionizing radiation as moderate. knowledge level was statistically significantly higher only in the group of medical students who passed the course of radiology, in comparison to the group of those who have not attended the course yet. only % of radiologists and up to . % of pediatricians, pediatric surgeons and anesthesiologists are informed about "image gently" campaign. up to % of radiologists, and up to % of clinicians, both specialists and residents, are aware of alara principle. over % of medical doctors think that diagnostic radiology procedures are very often performed unnecessarily among children, while only . % of parents share this opinion. most of the radiologists and clinicians consider it necessary to inform parents about potentially harmful effects of ionizing radiation, but even though - % of clinicians claim they do inform parents in every-day clinical practice, over % of parents affirm that they had never been informed about effects of ionizing radiation before diagnostic procedures were performed on their children. only % of pediatric surgeons and pediatricians, but . % of radiologist and % of anesthesiologists are concerned that informing parents about ionizing radiation would cause problems in every-day work. nearly % of parents claimed that they would not refuse to expose their child to x-ray based diagnostic procedure, after the given information about potential harmful effects. over % of radiologists and less than % of pediatric surgeons and pediatricians support the initiative to calculate the total effective dose child was exposed to during hospitalization, and place it on the discharge list. between % and % of pediatricians and pediatric surgeons greatly underestimated the effective doses in ct and fluoroscopy procedures. there are - % of clinicians who are aware that ct increases the risk of carcinoma development. this study showed that general knowledge about ionizing radiation, potential risks and effective doses in pediatric population is poor, and that organized education is required. fluoroscopy in pediatric radiology -how important is an individual impact to radiation exposure of children? j. lovrenski, i. varga; novi sad/rs to determine whether there are differences between different pediatric radiologists and radiology residents in exposure of pediatric population to ionizing radiation during fluoroscopy procedures. a retrospective study has been conducted at the regional children's hospital, and included all the diagnostic fluoroscopy examinations performed within a one-year period. the fluoroscopic data along with the names of pediatric radiologists/radiology residents performing these examinations were retrieved from the evidentiary notebooks, and included: dose-area product (dap), skin dose, and fluoroscopy time. there were radiologists (r -r ), and radiology residents (r -r ) involved in fluoroscopic examinations. we found all the fluoroscopic findings in the hospital's data base, which enabled a differentiation between positive and negative findings. statistical analysis was performed using the spss . . a p-value less than . was considered statistically significant. a total of fluoroscopy procedures in children (mean age , y, males and females) have been performed within a one-year period, most of which were voiding cystourethrograms (vcug) - , and an upper gastrointestinal (gi) series - examinations. radiology residents and radiologists carried out and examinations respectively. duration of fluoroscopy procedures performed by residents (av. . s) was statistically significantly shorter in comparison with duration of fluoroscopy examinations performed by radiologists (av. s). dap and skin dose did not show statistically significant difference between these two groups, as well as the number of positive and negative fluoroscopic findings in groups of examinations performed by radiologists and radiology residents. mean dap value ranged from . μgym (r ) to . μgym (r ) when performing vcugs, and from . μgym (r ) to . μgym (r ) for upper gi series. mean skin dose ranged from . mgy (r ) to . mgy (r ) for vcugs, and from . mgy (r ) to . mgy (r ) for upper gi series. mean fluoroscopy time ranged from . s (r ) to . s (r ) for vcug, and from . s (r ) to . s (r ) for upper gi series. statistically significant difference was shown only between radiologists r and r for dap and skin dose values in performing vcug, and for fluoroscopy time in performing an upper gi series. for all examinations dap and skin dose were statistically significantly higher in the group of positive fluoroscopic findings. this study has shown that exposure of children to ionizing radiation during fluoroscopy procedures significantly depends on radiologist/ radiology resident and the nature of fluoroscopic finding. to evaluate image quality and radiation exposure of non-contrast pediatric chest ct with automated tube voltage selection (atvs), in combination with automated tube current modulation (atcm). non-contrast chest ct scans of children ( male and female; mean age, . ± . years) were analysed retrospectively with regard to radiation exposure and image quality before and after the implementation of an automated tube voltage selection. correlations of volume ct dose index (ctdi vol ) and the effective diameter (edm), before and after the implementation of atvs were compared, and confidence intervals related to the change in correlations with and without atvs were determined using fisher's z-transformation. image quality was assessed by mean signal-difference-tonoise ratios (snrs) in the aorta and in the left principal bronchus with the independent samples t-test. subjective image quality was rated by two pediatric radiologists and a general radiologist on a point scale. agreement between the readers was assessed using weighted kappa coefficients. a p< . were considered significant. automated tube voltage selection, in combination with an automated tube current modulation, resulted in optimization of scan protocols, homogeneity of image quality, and reduction of radiation exposure for pediatric patients. advantages and disadvantages of cone beam ct for pediatric interventions l. dance, r.b. towbin, d. aria, c. schaefer, r. kaye; phoenix/us objective: illustrate the advantages and disadvantages of cone beam ct (cbct) as an alternative to conventional ct guidance and an adjunct to angiography. there is a steep learning curve to optimize utilization of cbct. we found that cbct reliably identifies high-contrast lesions. however, the lower dose and decreased penetration of cbct resulted in poorer visualization of low-contrast lesions. also cbct can be degraded by streak artifact from hardware or dense contrast. the relatively narrow field of view can be restrictive for peripherally located lesions in larger patients. however, the anatomic display is adequate for guidance in most instances. these findings are illustrated in a series of cbct-guided cases including pulmonary nodule localization, osteoid osteoma ablation, abc sclerotherapy, renal av fistula embolization, and liver lesion biopsy. the advent of cbct as an adjunct modality in the ir suite has significantly decreased the use of conventional ct guidance and significantly decreased the radiation dose in children. we have found cbct to be a practice changer. the aim of this study is to review our local drl in pediatric fluoroscopy and to compare them to values proposed by pidrl guidelines and recent international litterature. data were prospectively collected on consecutive procedures ( total) performed from january to december on different fluoroscopy units (siemens iconos r , luminos drf). of each procedure patients data (name, weight and birth date), examination-data (kind of procedure, date, dap [cgy*cm ], total fluoroscopy time, number of images) were recorded. data from micturating-cystourethrography(mcu), barium meal/swallow(bs) and most commonly performed procedures were divided into weight-groups (< kg, - kg, - kg, - kg) and of each one th-percentile was calculated. data were compared to europeandrl and recent literature data (by age:newborn, -, -, years old). weight-groups are considered a representative sample if at least -patients per procedure-type and per patient-group are included. our local-drl for mcu are (< kg), ( - kg), ( - kg) and ( - kg). they results to be lower than pidrls values ( , , , ) but higher if compared to a previous local survey of ( , , , ) . bs data are (< kg), ( - kg), ( - kg); these data are lower than that of a previous local survey of ( , , ) . the update of local-drl is helpful in daily practice to identify (and solve) critical issues such as incorrect technique or poor practice with new flat-panel equipment. pidrl guidelines: a review of local drl for pediatric head, thorax and abdomen ct in a italian referral center a. magistrelli, v. cannatà, e. genovese, m. cirillo, r. lombardi, p. toma; rome/it the aim of this study is to review our local drl in pediatric ct and to compare them to values proposed by pidrl guidelines and recent international litterature. data were prospectively collected on consecutive procedures ( total) performed from january to june on a somatom definition flash siemens. of each procedure patients data (name, weight and birth date), examination-data (kind of procedure, clincal question, date, ctdivol / and dlp / ) were recorded. ctdivo/dlp from head ct were divided into age-groups (< weeks, weeks- y, - y,≥ y) and of each one th-percentile was calculated. ctdivol/dlp from thorax (chest, cardiovascular ct angiography) and abdomen+pelvis ct examination were divided into weightgroups (< kg, - kg, - kg, - kg,> kg) and of each one th-percentile was calculated. data were compared to europeandrl and recent literature data. weight-groups are considered a representative sample if at least patients per procedure-type and per patient-group are included. our local drl are substantially lower than that proposed by pidrl guidelines. specifically ctdivol/dlp for chest ct are / (< kg), , / ( - kg), , / ( - kg), , / ( - kg), , / (> kg) respectively. for cardiovascular ct angiography are , / (< kg), , / ( - kg), , / ( - kg), , / ( - kg), , / (> kg). while for abdomen+pelvis ct are , / (< kg), , / ( - kg), , / ( - kg), , / ( - kg), , / (> kg). data for trunk sere not collected. for head ct local drl are higher in age-group and but lower in other age-group if compared to routine head ct pidrl ones. the update of local-drl allowed us to identify (and solve) some critical issues such as incorrect technique. drl-curve in optimization of pediatric body ct r. seuri , p. laarne , a. nikkola-sihto , k. nygaard bolstad , m.s. perhomaa , a. thilander klang , k. rosendahl , j. ruohonen , e. tyrvainen ; helsinki/fi, tampere/fi, seinäjoki/fi, bergen/no, oulu/fi, gothenburg/se, kuopio/fi objective: diagnostic reference levels (drls) in medical imaging represent valuable tools to study dose optimization in clinical practice. this is particularly important in pediatric computed tomography (ct) as the number of the examinations in many institutions is low. drls are typically given as a percentile point, usually as % or rd quartile of the observed distribution of patient dose. in pediatric practice drls are often given for each age-or weight group separately. we present continuous drl-curve as a feasible way to compare dose levels in pediatric body ct. during - a selected group of nordic hospitals collected dose values (ct dose index by volume, ctdi vol , and dose-length product, dlp) from pediatric body ct examinations on children aged - years. the dose values were imported into a dynamic excel table, previously established by the radiation and nuclear safety authority in finland, stuk (fig ) . the stuk-table includes a graphic presentation of a continuous drl-curve presented as a function of body weight, and the program automatically calculates a dose curve and compares it to the established reference level (fig ) . the dose values were easily exported to the excel tables, and the graphic presentation and comparison with an established drl-curve was clear and readily understandable for both radiologists and radiographers. in some of the institutions included in the present study, the weight of the patient was not recorded routinely. this represents a challenge for the use of the drl-curves provided by stuk. the drl-curves provided by stuk were feasible for clinical practice. the automatic calculation of the dose curve and graphic presentation were helpful to interpret the results. the drl-curve also allows relevant comparison even with a smaller number of patients. fifty randomly selected ct chest studies performed over years to assess diffuse lung disease were included in the study sample ( females, males; mean age . years + . years), comprising disorders. two pediatric radiologists and a pediatric radiology fellow blinded to the results of the cts evaluated four subsets of complete chest cts ( slices, every third slice, every other slice, and all images below the thyroid) and compared the subsets with the entire chest ct, interpreted as the control. accuracy of evaluating the primary diagnosis and determination if significant diagnoses were missed in the reduced slice ct subsets were rendered. we assume linear distribution of dose across the anatomy to estimate dose reduction on reduced slice subsets. most significant findings were present on all reduced slice ct subsets. all relevant findings were present in % of subthyroid, % of every other slice, % of every rd slice, and % of regional slice subsets respectively. excluded findings included small foci of ground glass opacity, consolidation, focal mosaic attenuation, and linear parenchymal bands; peribronchial thickening, dextrocardia vs dextropositioning, tree-in-bud opacities, extent of mild bronchiectasis. with the exception of consolidation in of the studies, these findings were not thought to inhibit diagnostic assessment. the underlying diagnosis was correctly identified in most of the subsets: % subthyroid and every other slice, % every rd slice, and % of regional slice subsets. dose is significantly decreased by using any of these methods. while some findings are excluded with increasing gaps between slices, equivalent diagnostic information can be provided on reduced slice ct and can serve as a viable strategy to reduce lifetime radiation dose to children and young adults with diffuse lung disease imaged for routine follow-up. as findings are missed with larger gaps, this strategy should be used with caution in patients presenting with acute symptoms . to extrapolate the significance of early diagnosis which will compliment to treatment planning and management. case presentation: types a and b niemann-pick disease are lysosomal storage disorders that result from deficient acid sphingomyelinase activity and lead to the accumulation of sphingomyelin, primarily in tissues of the reticuloendothelial system. type b niemann-pick disease manifestations are hepatosplenomegaly, excess bleeding and bruising, growth retardation, and recurrent respiratory infections. features of hrct include thickened peribronchovascular and interlobular septal thickening, ground-glass opacities. the intermixed regions could be characterized as showing crazy paving, although this is not the predominant pattern. type b niemann-pick disease should be added to the list of clinical entities that can demonstrate crazy paving. our patient is a sevenyear old girl, presented with dry cough and fever. physical examination revealed hepato splenomegaly. radiological work up included abdominal ultrasound examination, which showed mild hepatosplenomegaly. chest radiography revealed diffuse reticulonodular infiltration in both lungs. chest hrct was done for more comprehensive evaluation which showed multilobar bilateral peribronchovascular interstitial thickening and interlobular septal thickening with ground-glass opacities and crazy paving appearance. no honeycomb pattern was seen. no sizable pulmonary nodule or sizable mediastinal lymphadenopathy was seen. no pleural effusion was seen. finding were indicating extensive pulmonary intestitial disease. a corroborative analysis along with lab tests and genetic studies revealed the diagnosis of type b niemann pick disease. . the spectra of hrct features including crazy paving pattern may be encountered; though not frequent. hence should be included in the differential diagnosis of crazy paving pattern. blast from the past: lemierre's syndrome in adolescents with sore throat o. kvist; stockholm/se a minor ailment such as a sore throat could prove to be a severe disorder known as lemierre's syndrome. this syndrome mostly affects previously healthy adolescents and young adults and in its classical form should meet four diagnostic criteria; primary infection of the oropharynx, septicemia, clinical-or radiographic evidence of thrombosis of the internal jugular vein (ijv) plus secondary metastatic abscesses. the infection is caused by fusobacterium necrophorum, a species of obligate anaerobe bacteria forming part of the normal human flora. the syndrome should be suspected in any patient with pharyngitis, cervicalgia and pulmonary symptoms. the incidence of lemierre's syndrome decreased dramatically after the introduction of antibiotics but has, of unknown reasons, increased over the past years. we will present four patients diagnosed with lemierre's syndrome in our department during the last years. the purpose of this case report is to raise awareness of this "forgotten disease". of the four patients diagnosed with lemierre's syndrome two fulfilled all criteria while two fulfilled out of . (table ). the first two presented at the emergency department with one week's history of a sore throat, left sided cervical lymphadenopathy, erythematous tonsils, leukocytosis and elevated crp. in both cases the clinical condition deteriorated and they were referred to the icu. one developed ards and required initiation of ecmo. in both patients, chest ct revealed multiple pulmonary consolidations with cavitations, findings consistent with septic emboli (image , and ). incidentally ct-neck revealed thrombosis in the left ejvand ijv (image ). ultrasound of the neck veins confirmed the finding (image and ). blood cultures taken on admission later proved positive to f. necrophorum. the third and fourth case, with similar clinical histories but with a less aggressive development, had positive blood cultures but no thrombosis and vice versa. (table and all four patients recovered and could be discharged with oral antibiotics and anticoagulants. unique teaching points: in conclusion, lemierre's syndrome is less common today thanks to antibiotics but may still occur in previously healthy adolescents and may lead to a fatal outcome. the pediatric radiologist should be aware of typical findings like septic emboli in the lungs and thrombosis in the ijv. unicameral bone cyst associated with secondary aneurysmal bone cyst of clavicle i. dasic, g.j. djuricic, s. ducic; belgrade/rs objective: aneurysmal bone cyst (abc) accounts for , % of all bone tumors. they are benign but locally destructive lesion of the bone characterized by presence of spongy or multiloculated cystic tissue filled with blood. abcs are metaphyseal, excentric, bulging, fluid-filled and multicameral, and may develop in all bones of the skeleton. most common locations include the proximal humerus, distal femur, proximal tibia, and spine. clavicle is a very rare site for aneurysmal bone cyst with only few cases reported in literature. a -year-old boy reported to the university children's hospital for detailed examination of swelling of right shoulder. - days before admission parents noticed tumefaction of right shoulder. there was no history of trauma or fever. physical examination revealed tumefaction of the right shoulder, in projection of acromial end of clavicle, measuring approximately x cm, which was tender and fixed. the swelling was not hot to the touch, and there was no skin discoloration over that area. regional lymph nodes were not palpable. (fig. a) x-ray revealed osteolytic, expansible lesion in the lateral end of clavicle and there was no pathological fracture. (fig. b) laboratory analyzes were within normal limits. blood cultures remained sterile. chest x ray and abdominal ultrasound were normal. computed tomography (ct) revealed a thinwalled multiloculate lesion in lateral end of right clavicle. (fig. a) there was no extension in the soft tissues on magnetic resonance imaging (mri). mri shows the multiloculate cavities and fluid levels. (fig. b) . the open biopsy was done. histopathological examination confirmed the secondary aneurysmal bone cyst on the field of simple bone cyst of clavicle. the clavicle is an uncommon site for bone tumors. review of literature shows clavicle accounts for less than % of all bone tumors. the patient with an aneurysmal bone cyst generally presents with pain and swelling, which may vary in duration from weeks to several years. up to % of bone tumors occur in less than years of age with peak incidence in second decade. radiologically, lesion is lytic and may have a soap-bubble appearance with ballooned distension of the periosteum. the differential diagnosis for aneurysmal bone cyst include giant cell tumor, chondromyxoid fibroma and telangiectatic osteosarcoma. distinction from telangiectatic osteosarcoma is difficult because the conditions have overlapping clinical and radiologic features. the differentiation is made from the histologic features. imaging of glomus tumor of liver in a child (case report) n. tewattanarat, j. srinakarind, j. wongwiwatchai, p. komvilaisak, s. areemit, p. ungarereevittaya, p. intarawichian; khonkaen/th objective: glomus tumors occur preferentially in subcutaneous tissue of fingers and toes, but extremely rare in visceral organs. most cases of the tumors are diagnosed in adults. several cases of glomus tumors in liver have been reported in adults. a literature review, no case of glomus tumor in liver in children was published. therefore, we present clinical, imaging findings of the first case of pediatric patient with glomus tumor in liver and also histopathological features. a previously healthy year-old-girl was admitted with a twoweek history of progressive dyspnea on exertion and vomiting. family history was unremarkable. physical examination revealed hypertension and smooth and firm mass at epigastrium. systolic apical murmur on heart examination was noted. liver function test ( ) (suppl ):s -s pediatr radiol showed elevated cholesterol ( mg/dl). other laboratory tests (complete blood count, blood chemistry, renal and liver function test, coagulation test, hepatitis profiles and alpha-fetoprotein) were within normal limits. echocardiogram found mitral and tricuspid regurgitation and poor left ventricular systolic dysfunction. abdominal mri demonstrated a -cm well-defined exophytic hypervascular mass with intratumoral hemorrhage at segment / b of the liver. there were no other suspicious lesions in other organs. the biopsy was done and revealed glomus tumor. patient underwent preoperative embolization and the liver mass revealed decreased size to -cm after -month follow up with ultrasound. after that, exploratory laparotomy with left lateral segmentectomy was performed. the pathological results showed dilated vascular channels surrounded by uniform neoplastic cells, uniform with round nuclei, fine chromatin, inconspicuous nucleoli, and pale eosinophilic cytoplasm, and well-defined cytoplasmic border. no mitotic figures and necrosis are identified. immunohistochemical (ihc) staining of tumor was positive for cd , smooth muscle actin (sma) and h-caldesmon. others ihc including ae /ae , heppar , cd , desmin and myogenin were negative. from these findings, the tumor was finally diagnosed as glomus tumor of uncertain malignant potential due to deep location and large size. primary glomus tumor is a rare entity of liver tumor diagnosed in children. however, it should be considered in the differential diagnosis of a hypervascular liver mass. most of these tumors are benign, however tumor in liver have malignant potential due to deep seated position. therefore, tumor removal with pre-operative embolization should be considered. brain mri in a pediatric patient with linear scleroderma en coup de sabre m. mortilla, a. rosati, e. canale, c. filippi; florence/it objective: linear scleroderma "en coup de sabre" (ecds) is a rare subset of localized scleroderma. affected individuals typically have a characteristic atrophic skin lesion involving the fronto-parietal scalp. the disease usually has a benign course but rare neurologic symptoms can be seen associated: the most common described is epilepsy. intracranial mri findings described in the literature include: focal brain atrophy, calcifications and t -hyperintense white matter lesions that may demonstrate contrast enhancement. white matter lesions and calcifications are found in the cerebral hemisphere ipsilateral to the skin abnormality. in the literature only a few pediatric cases have been described. a yrs. old girl was hospitalized at our institution for evaluation of a lesion of the frontal skin associated to a history of febrile seizures and mri alterations. she presented febrile seizures at the age of on april . on january parents noted a frontal cutaneous lesion that was defined as "linear scleroderma, port-wine stain type". on november she performed an mri at another institution showing a diffuse white matter alteration in the left emisphere with focal lesions with high susceptibility and mild contrast enhancement. she was addressed to immunosuppresive therapy with steroids and methotrexate, with steroids stopped after months. a clinical cutaneous improvement was noted. on july a second mri showed a worsening of the findings. we describe a case of a little girl with ecds with no neurologic deficits or symptoms that shows extensive and progressive neuroradiologic alterations. only a few pediatric cases have been described, but it has to be known that also in absence of symptoms, patients with linear scleroderma should be screened with mri to look for cns involvement in this immune disease. brain mri can also be used to monitor the progression of the disease and the response to therapy. mals is a vascular compression syndrome which symptoms can overlap chronic functional abdominal pain. in mals the proximal part of the celiac artery is compressed by the too low located median arcuate ligament during expiration resulting in hemodynamically significant symptoms. we report two cases with mals diagnosed primarily by ultrasonography. case -year-old girl was admitted to tartu university children's clinic (tucc) due to recurrent acute epigastric pain episodes with nausea and loss of appetite during years. previous analyses were normal, abdominal uss and gastroscopy did not show any abnormalities. she was referred to paediatric radiology department for doppler us (dus) which showed narrowed proximal celiac artery (ca) with turbulent flow, increased peak-systolic and end-diastolic velocities on deep inspiration and expiration, and positive ca deflexion angle on expiration. superior mesenteric artery (sma) was markedly widened, indicating possible collateral blood-supply due to severe ca stenosis. according us findings mals was suspected. abdominal mra showed proximal ca kinking, stenosis and poststenotic dilatation and confirmed diagnosis. during dsa collateral blood-supply from sma via pancreaticoduodenale arcade (pda) was seen. laparoscopic release of mal resulted in relief of patient's symptoms, she has been pain-free for two years. case -year-old girl applied to tucc due to recurrent abdominal pain episodes for - years. usually, pain occurred - times per week about minutes after the start of intense cycling training or competitions, and passed about minutes resting in squat position. mild mid-epigastric bruit was audible at physical examination. dus showed two-fold increase in expiratory peak-systolic and enddiastolic blood flow velocities compared to inspiratory velocities which indicated to the hemodynamically significant worsening of ca compression by mal during expiration. mra showed proximal ca compression, upward angulation and poststenotic dilatation. preoperative ct-angiography depicted collateral supply via pda. during laparoscopic surgery ca was released by transecting mal and surrounding fibrous tissue. after surgery the girl has been pain-free for one year except single pain episode during intense competition. the diagnosis of median arcuate ligament syndrome should be considered in patients with postprandial abdominal pain that does not have other clearly established etiology. colour doppler us should be the first choice imaging method. to confirm diagnosis in pediatric patients abdominal mra is preferred in our institution, but as mra may still have a tendency to movement artifacts and inadequate spatial resolution for smaller blood vessels, in these two cases mra was followed by cta or dsa. understand the unique predilection of infantile malignancies to metastasize and present as skin-based masses, most commonly lymphoma/leukemia. case presentation: an otherwise healthy day old male presented to dermatology with a pedunculated, friable red glabellar mass (centered between the eyes). first noticed as a flat, bluish lesion at days, its subsequent rapid growth led to an emergency department visit where dermatology diagnosed a hemangioma and initiated propranolol treatment. despite this, the mass continued to grow rapidly, encroaching upon the patient's right eye. the patient was admitted for further workup. an elevated beta hcg, anemia ( . mg/dl), and thrombocytopenia ( , ) suggested an alternate diagnosis. an mri and ultrasound led to a percutaneous biopsy; pathology was consistent with choriocarcinoma. pet ct found fdg-avid glabellar, liver and lung lesions. maternal and placental testing was negative for choriocarcinoma. ultrasound demonstrates a hypoechoic hypervascular mass. mri brain demonstrates cutaneous confinement of the solid avidly enhancing glabellar mass. ct shows a peripherally enhancing liver mass with a masslike area of consolidation in the right lung. initial pet/ct demonstrated fdg avid liver and lung metastases with a small focus of residual activity at the glabella consistent with incomplete resection. follow-up pet/ct showed astoundingly rapid re-growth of the glabellar mass and enlargement of the hepatic and pulmonary masses just days later demonstrating the extremely aggressive nature of this cancer. month follow-up pet/ct showed significantly decreased size and activity of the metastases consistent with a treatment response. in a series of infants with cutaneous metastases, the following diseases presented with cutaneous involvement (ordered most to least common): leukemia, langerhans cell histiocytosis, neuroblastoma, rhabdoid tumor, rhabdomyosarcoma, primitive neuroectodermal tumor, choriocarcinoma, and adrenocortical carcinoma. pathology slides ( ) (suppl ):s -s pediatr radiol unique teaching points: considered one of the fastest growing tumors, infantile choriocarcinoma classically presents with hepatomegaly, anemia, failure to thrive, and precocious puberty between days and months of life. left untreated, the disease is usually fatal within weeks of presentation. a solitary cutaneous metastasis can be mistaken for infantile hemangioma both clinically and radiographically. atypical mri appearance is one important clue that can suggest an alternative diagnosis. pet/ct may be useful for staging and follow-up. a rare case of ovarian juvenile granulosa cell tumor associated with ollier's disease -generalised mesodermal dysplasia p. joshi; pune/in to demonstrate a rare case of mesodermal dysplasia -association of ovarian granulosa cell tumour with enchondromatosis case presentation: two year month old girl presented with precocious puberty i.e thelarche. left hand radiograph showed the radiological age corresponding to chronological age, suggestive of peripheral precious puberty. the patient subsequently underwent a sonography which revealed a pelvic mass probably arising from the right ovary ? sex cord stromal tumour. a mri of the abdomen and pelvis confirmed the pelvic mass and revealed multiple bone lesions in the right hemipelvis -on the side of the tumour she was later operated. hpe of pelvis mass revealed juvenile granulosa cell tumour. ultrasound pelvis images reveal a solid pelvic mass, probably ovarian in etiology mri pelvis also reveals multiple bone lesions unique teaching points: the aim of the poster is to create awareness about this association. the bone lesions should not be mistaken for metastasis juvenile granulosa cell tumour of the ovary (jgct) is a well-known sexcord stromal ovarian neoplasm. ollier's disease is a rare, non hereditary mesosermal dysplasia consisting of multiple enchondromas. the association of granulosa call tumour with asymmetric ipsilateral hemiskeletal distribution may indicate generalised mesodermal dysplasia as there is also association of jgct with maffucci's syndrome, other dysplastic conditions such as microcephaly, facial asymmetry,' and potter's syndrome. review of literature showed previous cases of juvenile granulosa cell tumor associated with enchondromatosis, three associated with maffucci's syndrome, and the rest with ollier's disease goldbloom's syndrome is a paediatric idiopathic disease characterized by transient bone marrow oedema with recurrent crisis of bone pain, periosteal hyperostosis, fever, increased inflammatory markers and dysproteinaemia. a case series of wbmr studies in goldbloom's syndrome is reported and differential diagnosis discussed. case presentation: a -year-old female girl was admitted to our paediatric department because of daily crisis of bone pain of the lower limbs, associated with fever spikes, limping and nocturnal awakenings. no history of trauma was reported. laboratory tests showed mild anaemia (hb . g/dl), thrombocytosis (plt /mmc), increased inflammatory markers (ers mm/h, crp mg/dl), high streptolysine o and dnase-b antibody levels (aso iu/ml and adn-b ui/ml, respectively). throat swab was positive for group a β-haemolytic streptococcus (gas). unusual dysproteinaemia, characterized by hypoalbuminemia ( . g/dl) with increased a , a and g globulinaemia, was noted. x-ray examinations of both legs resulted normal. wbmri showed markedly delineated, high and homogeneous hyper-hypointensity respectively in stir/t of the distal tibialperoneal meta-diaphysis of both legs (fig a,b). distal metaphysis of femur, humerus, radius-ulna and proximal tibia were also homogeneously mildly hyperintense on stir sequences bilaterally (fig a). bone biopsy revealed signs of chronic inflammation. infectious and neoplastic diseases were ruled out and the diagnosis of gs with dysproteinaemia seemed conceivable. steroid treatment was started in association with indomethacin, leading to a prompt resolution of the clinical picture within a few days. the follow-up stir total body mri, performed after months, showed the complete resolution of bone oedema. (fig a,b) the sock sign is a pathognomonic whole-body magnetic resonance imaging (wbmri) feature of goldbloom's syndrome (gs).it is a well marked, symmetric, homogeneous and high bone marrow hyperintensity, localized both at the distal tibial and peroneal meta-diaphysis, which looks like a pair of socks. objective: left ventricle hypoplasia is generally thought as a part of hypoplastic left ventricle syndrome or aortic hypoplasia. it is estimated that about - ml/m left ventricle volume is needed in order to support systemic circulation. less than that volume generally precludes biventricular repair. however conditions associated with severe preload decrease such as total anomolous pulmonary venous return (tapvr) should be considered in the differential diagnosis. tapvr presenting as hypoplastic left ventricle syndrome is presented in this study. six month old female patient admitted to emergency service with symptoms of fever, dyspnea and coughing. emergency staff started intravenous antibiotic theraphy and from medical records learned that she has been followed for partial anomolous pulmonary venous return (papvr) and atrial septal defect (asd). lung x-rays revealed pulmonary edema. echocardiography was performed and revealed very small left ventricle, papvr and mm wide asd. ecg gated cardiac ct was requested with the prediagnosis of hypoplastic left ventricle syndrome. ct images revealed dilated right cavities, very small left ventricle, pulmonary edema, tapvd and peritoneal fluid plus hepatomegaly. we then retrospectively searched our archive and found she was diagnosed as papvr when she was days old. all the cavities that time, were normal sized. according to these we confirmed our diagnosis as tapvr and hypoplastic appearing cavities due to reduced preload and right chamber dilatation due pulmonary overcirculation. surgical team decided to perform corrective operation and they confirmed our diagnosis unique teaching points: small left ventricle cavity in an infant need not to be due to intrinsic hypoplasia. whenever we experience such a situtation we should search for other reasons of pseudohypoplasia in order to give a chance for corrective surgery instead of palliative procesures. we present a case report of kimura disease, a rare benign chronic inflammatory disease that involves the deep subcutaneous tissues and lymph nodes of the head and neck. we report the case of a thirteen year old male who presented with a right sided facial mass which had been present for two years but had enlarged rapidly in the preceding three months. us and mr were interpreted locally as an arteriovenous malformation. review of these examinations and catheter angiography performed at this quaternary referral centre favoured a vascular tumour. subsequent percutaneous biopsy demonstrated angiolymphoid hyperplasia with eosinophilia and blood tests showed a serum eosinophilia, consistent with kimura disease. us shows a mass consisting of scattered heterogenous foci within the fat with multiple large feeding vessels. contrast enhanced mri demonstrated a solid, homogenously enhancing, mass with multiple vascular flow voids from the right external carotid artery branches. catheter angiography showed tumour blood supply from branches of the right transverse facial artery and distal right ima. the dominant supply arose superficially from the transverse facial artery. kimura disease is a rare chronic inflammatory disorder of unknown aetiology that involves the deep subcutaneous tissues and lymph nodes of the head and neck region, most common in asian men in the third decade and sporadic in the non-asian population. the histopathological and biochemical characteristics are eosinophilic lymphfolliculoid granuloma, increased eosinophils in the peripheral blood and increased ige levels. whilst ultrasound and mri are effective imaging modalities, imaging alone does not allow confident differentiation from malignant lesions and biopsy is necessitated. kimura disease has a benign indolent course with an excellent prognosis following surgical excision although local recurrence has been reported. increased naa: is it surely canavan disease? e. varga, p. barsi, g. rudas; budapest/hu leukodystrophies are a group of rare genetic, metabolic diseases that affect the central nervous system, mainly the brain. each type of them is caused by a specific gene abnormality that leads to abnormal development or destruction of the white matter of the brain. the differential diagnosis are made on the basis of clinical and neuroradiological signs. there are some diseases which show typical changes on mr spectroscopy. we present a case of a year-old boy, who has been investigated due to somatomental retardation and muscle dystrophy since his six months of age. his perinatal period was normal except of a nystagmus visible from his birth. the child has muscle dystrophy, spastic quadriparesis, contractures, scoliosis, truncal hypotonia and ataxia and mental retardation. we started examinations to find out the background pathology of his idiopathic encephalo-myopathy. the brain mri showed a bilateral, symmetrical white matter signal alteration, which referred to some kind of metabolic ( ) (suppl ):s -s pediatr radiol disease. the mr spectroscopy revealed decreased cholin and increased naa levels, which are typical of canavan disease. despite of this, the clinical aspects and the location of the involved brain areas were more typical of pelizaeus-merzbacher disease (pmd). the pmd is a genetic disorder, which is originated of the mutation of the proteolipid protein gene (plp ) located on long arm of x-chromosome (xq - ) . this gene has an impact on growth of the myelin sheath. various types of mutations (deletion, duplication, point mutation, insertion) of plp gene lead to various severity of clinical picture. all form of mutations show decreased naa level on spectroscopy, except the duplication of plp gene. in connection with our case, we present briefly the clinical and neuroradiological differences between the two entities. magnetic resonance imaging findings in medium-chain acyl-coenzyme a dehydrogenase (mcad) deficiency l. talamanca, d. narese, m.c. rossi espagnet, l. pasquini, d. longo; rome/it we report serial brain magnetic resonance (mri) in a patient with medium-chain acyl-coenzyme a dehydrogenase (mcad) deficiency who developed acute encephalopathy. a -months-old girl was admitted in the emergency department of our hospital with sudden onset of acute encephalopathy with drowsiness. baseline laboratory investigations revealed severe hypoglycemia, hyperammonemia, hyperchloremic metabolic acidosis and hyperuricemia. the patient was treated with glucose solution infusion that resulted in a gradual resolution of symptoms. the first brain mri, performed within hours of onset of symptoms showed bilateral symmetric restricted diffusion on diffusion-weighted imaging (dwi) in the middle cerebellar peduncle, nucleus caudatus, putamen and periventricular white matter; the adc map showed reduced diffusivity (fig ) . the second mri, at hours after the onset, revealed bilateral and symmetric hyperintensity on t -weighted images in the middle cerebellar peduncle, nucleus caudatus, putamen and periventricular white matter. dwi showed restricted diffusion in both globus pallidus (fig ) . a single voxel h-mrs study performed by placing a roi in the right nucleus lenticularis revealed increased values of gaba and glutamine (fig ) . a further mri was performed weeks after the first neuroimaging and indicated widespread atrophy and the appearance of a hyperintense signal in t -wi in both globus pallidus while dwi did not reveal any remarkable signal abnormality. single-voxel mrs of the same region showed a normalization of gaba and glutamine values. brain mri showed bilateral symmetric restricted diffusion on diffusionweighted imaging (dwi) in the middle cerebellar peduncle, nucleus caudatus, putamen and periventricular white matter; the adc map showed reduced diffusivity the second mri, at hours after the onset, revealed bilateral symmetric restricted diffusion on diffusion-weighted imaging (dwi) in both globus pallidus. a single voxel h-mrs study performed by placing a roi in the right nucleus lenticularis revealed increased values of gaba and glutamine. mcad is an enzyme of the mitochondrial b-oxidation of fatty acids, an essential source of energy for cells during stress. mcad deficiency is the most common genetic disorder of fatty acid oxidation. the clinical manifestation of the disorder is typically precipitated by stress due to fasting, vomiting, fever or muscular exertion and occurs in the majority of cases before the age of with the onset of acute hypoketotic hypoglycemia. clinical features of this decompensated state include seizures and lethargy proceeding to coma and death in the absence of prompt treatment with intravenous dextrose infusion. mcad deficiency usually appears in an acute form and has high morbidity and mortality rates; early diagnosis is therefore extremely important in order to promptly begin treatment and obtain a complete recovery from symptoms. mr can play a significant role in the early diagnosis of the decompensated state of the disease; in our case dwi revealed the presence of lesions with a bilateral symmetric topographic distribution that strongly suggested a metabolic disease leading to acute encephalopathy. a full-term male neonate ( days old) with external perineal anomalies was referred to our hospital. the physical perineal examination revealed a bifid scrotum containing palpable testis and a normal configured penis located at the bottom of the bifid scrotum. two soft masses of and cm respectively, divided from a cutaneous notch, were located below the bifid scrotum and on the right of the midline. the rear biggest mass was normal epithelized, instead the other one was a rugged pigmented mass, which resembled the scrotum (figure ). there were no additional abnormalities of the external genitalia. the other peduncolar mass, located between the right scrotum and the posterior mass, had fluid content. a mild hydrocele in the right scrotum and a sliding testis on the left side were also revealed. us examination showed a hyperechoic solid tissue, corresponding to the rear biggest perineal mass. the other peduncolar mass, located between the right scrotum and the posterior mass, had fluid content (figure ) . a mild hydrocele in the right scrotum and a sliding testis on the left side were also revealed. mri also confirmed two perineal peduncolar masses: the biggest and posterior one, was made up by homogeneous fatty matter without contrast-enhancement after intravenous gadolinium injection (figure ). the patient underwent excision of perineal masses and no complications occurred in the surgery. the histopathological examination of the perineal masses revealed two areas with different histological features: the first one was characterized by the presence of smooth muscle bundles dispersed in the dermal collagen, instead the other contiguous area showed abundant mature adipose tissue in the deep dermis and hypodermis ( figure ). at last the rugged swelling mass was definitively diagnosed as as without testis tissue inside, and the rear mass was diagnosed as lipoma. the physical perineal examination revealed a bifid scrotum containing palpable testis. two soft masses of and cm respectively, divided from a cutaneous notch, were located below the bifid scrotum. us examination showed a hyperechoic solid tissue, corresponding to the rear biggest perineal mass. the other peduncolar mass, located between the right scrotum and the posterior mass, had fluid content mri confirmed the presence of two perineal peduncolar masses: the biggest and posterior one, was made up by homogeneous fatty matter without contrast-enhancement after intravenous gadolinium injection. neonates presenting with perineal masses are uncommon. these anomalies can occur isolated or more rarely in combination with other abnormalities such as uro-genital or ano-rectal anomalies or with contiguous subcutaneous tumors. when perineal masses are found, with prenatal diagnosis or during a newborn physical examination, it is important to look for any associated congenital anomalies or subcutaneous tumors by using imaging. to describe and emphasize the significance of the "half-moon" sign in pelvic mri. a -year-old adolescent, karate athlete, was submitted with left hip pain, decreased range of movement and asymmetry in thigh circumference. markers for infection or inflammation were negative. frog-leg radiograph was negative for hip effusion, slipped epiphysis and equivocal for a left trochanteric abnormality. mri demonstrated a half-moon pattern of bone marrow edema at the left intertrochanteric area and at the major trochanter, surrounding an apophyseal low-intensity lesion. ap radiograph and limited ct confirmed the presence of a lytic lesion with sclerotic margins, containing calcified chondroid matrix. chondroblastoma was histologically confirmed following excision. mri, coronal stir sequence, demonstrates semilunar-shaped hyperintense area abutting the growth plate and the cortex of the femoral neck, consistent with the half-moon sign. note edema surrounding an apophyseal low-intensity lesion and soft-tissue edema. ct confirms a typical apophyseal lesion with sclerotic margins containing chondroid matrix. unique teaching points: "half-moon" sign refers to a semilunar shape of bone marrow edema at the intertrochanteric area of the hip with its base located at the cortex of the femoral neck. this distribution differs from the distribution of edema in metaphyseal and metaphyseal-equivalent osteomyelitis. "half-moon" sign has been described in patients with stress fractures and osteoid osteomas. to our knowledge, this is the first case of chondroblastoma exhibiting this sign. whenever the "half-moon" pattern of edema is identified at pelvic mri scans, a thorough search for an occult fracture line or a nidus corresponding to an osteoid osteoma or a chondroblastoma is mandatory. mr elastography (mre) is a noninvasive imaging technique that quantitatively measures liver stiffness and provides an estimate of the degree of fibrosis. our aim was to evaluate the feasibility of performing mre using both gradient echo (gre) and echo planar (epi) sequences on siemens scanners. a dedicated mre of the liver was performed on a t mr scanner (magnetom® skyra, siemens) with a pediatric mechanical ( ) (suppl ):s -s pediatr radiol driver (courtesy of mayo clinic) over the right upper quadrant. an axial t blade with fat saturation, a coronal t vibe dixon and axial diffusion weighted imaging (dwi) were obtained. elastograms were obtained using both an axial standard gre and a works in-progress (wip) epi sequence. for the gre sequence, different slices were selected and each scanned sequentially. the epi sequence incorporated different slices in just one series. images were post-processed placing regions-of-interest (roi) and measuring the stiffness in kilopascals (kpa). for each sequence and each slice the stiffness mean was measured and then the average of the means was obtained. a spleen elastogram was simultaneously generated, without changing the mechanical driver location, and mean stiffness was also calculated. based on cutoffs in the literature, values were considered abnormal if liver stiffness > . kpa and spleen stiffness > . kpa. our initial experience shows that mre is feasible on siemens scanners using both gre and epi sequences. epi sequences are a promising addition to standard gre. prone versus supine ultrasound positioning for evaluation of urinary tract dilation (utd) in children c. maya , y. gorfu , e. dunn , k. darge , s. back ; philadelphia/us, addis ababa/et objective: ultrasound (us) is used in the initial evaluation and surveillance of utd in children. utd classification systems, including the multidisciplinary consensus, assess anterior-posterior renal pelvic diameter (aprpd) and calyceal dilation. there is currently no consensus regarding optimal patient positioning-prone versus supine-during us assessment of utd. this study was performed to determine if there is a significant difference in the measurement of the aprpd, presence of calyceal dilation, or resulting utd consensus score obtained between supine and prone positions. two raters retrospectively reviewed renal bladder ultrasounds of patients with utd of one or both kidneys. technically adequate ultrasound examinations of orthotopic kidneys that were imaged in both supine and prone positions were included. those with renal anomalies or prior surgery were excluded. aprpd measurements, as well as central and peripheral calyceal dilation, were documented in both prone and supine positions. a postnatal utd consensus score was assigned to each kidney based only on these features. kidneys ( left) in subjects had utd in either the supine or prone position. mean age was . years (range: . - . y). female to male ratio was : ( / ). the interclass correlation (icc) of the aprpd between raters was . and . in the supine and prone positions respectively (ps< . ). central calyceal dilation was found in / supine kidneys and / prone kidneys by rater and / supine and / prone kidneys by rater (kappa . ). peripheral calyceal dilation was found in / supine kidneys and / prone kidneys by rater and / supine kidneys and / prone kidneys by rater (kappa . ). as such the results are presented as one. the aprpd tended to be greater when prone with a strong correlation between prone and supine measurements ( . , p< . ). the mean difference between supine and prone aprpd was . mm (p< . ). in kidneys, calyceal dilation was seen in the prone position and not supine while kidney had central calyceal dilation only when supine. the utd score differed between supine and prone in / kidneys, with all but one higher when prone. in other kidneys, the aprpd differed between positions however concurrent calyceal dilation resulted in no change in utd class. as a screening tool, performing ultrasounds in the prone position may help identify more kidneys with utd. further research is needed to determine if these differences are clinically significant. during the evaluation of magnetic resonance enterography (mre), diffusion restriction (dr) has been utilized as a marker for bowel inflammation, but in our practice we commonly see dr in otherwise normal segments of jejunum. the purpose of this article is to assess the dr in normal loops of jejunum on mre and to determine if there is a correlation between dr and luminal distention, age, magnet field strength, and bowel segment location. a retrospective analysis of subjects with a normal mre and normal clinical work up (based on available clinical history, endoscopy reports, serum white blood cell count and inflammatory markers, and stool samples) was performed. the abdomen was divided into quadrants. if available, loops of jejunum were randomly chosen in each quadrant. two radiologists independently evaluated these same loops of jejunum for the following: luminal distension, wall thickness, and enhancement pattern. additionally, the loops were then evaluated for the presence or absence of dr. inter-rater reliability was determined. disagreement was resolved by consensus. presence or absence of dr was correlated with luminal distension, age, magnet field strength ( . versus tesla), and abdominal quadrant. one hundred ninety-seven loops of jejunum were evaluated in patients. not all subjects had jejunal loops in all quadrants. sixteen subjects ( %) had jejunal loops with dr for a total of loops. one loop had increased wall thickness and another increased enhancement but both did not demonstrate dr. no other loops demonstrate increased enhancement or wall thickening. for the presence or absence of dr, inter-rater reliability was fair (kappa= . ). there was no correlation between the presence/ absence of dr in relation to luminal distension, age, magnet field strength, or quadrant location. of the subjects who had a single loop with dr, a nd loop with dr was found in %. year old who presented with nausea. mr enterography demonstrates no bowel thickening or abnormal enhancement. a. coronal haste demonstrates the craniocaudal position of the axial diffusion sequence for reference (line). year old who presented with nausea. mr enterography demonstrates no bowel thickening or abnormal enhancement. b. axial diffusion weighted seqeunce (b= ) shows diffusion restriction within loops of jejunum (arrow) within the anterior abdomen. year old who presented with nausea. mr enterography demonstrates no bowel thickening or abnormal enhancement. c. corresponding adc map demonstrates low signal within the jejunal wall consistent with diffusion restriction (arrow). diffusion restriction in normal loops of jejunum on mre was present in % of patients. if dr is seen in an otherwise normal segment of jejunum, this can be considered non-pathologic. a patient with a loop of jejunum with dr is likely to have an additional loop of jejunum demonstrating dr. there is no correlation with dr of normal jejunum with luminal distension, magnet field strength, or patient age. our data may help reduce overestimation of disease burden when clinically applied. imaging findings in the newborn with meconium peritonitis that require surgery p. caro dominguez , a. zani , a. daneman ; cordoba/es, toronto/ca objective: meconium peritonitis is a rare condition caused by an in-utero bowel perforation resulting in spillage of meconium into the peritoneal cavity and subsequent calcification. the role of prenatal and postnatal imaging is to identify infants who require surgery. the aim of this study was to evaluate the role of postnatal imaging in meconium peritonitis and to correlate the radiologic and sonographic patterns with the need for surgery. imaging studies in infants with meconium peritonitis performed between and at our institution were reviewed separately by a pediatric radiologist, a pediatric radiology fellow and a pediatric surgeon. patients were divided in a surgical and a non-surgical group. clinical, surgical and pathology reports were reviewed to validate the diagnosis. statistical analysis: comparisons between sonographic and radiographic findings and patterns in the surgical and non-surgical groups were performed using unpaired t-test and chi-square. during the study period, there were infants with meconium peritonitis managed at our institution. in the ( %) who needed surgery, the most frequent surgical findings were idiopathic perforation, jejunal and ileal atresia. ultrasound identified more cases with hepatic calcifications, meconium pseudocyst, ascites and pneumoperitoneum than radiography and radiography more cases of small bowel obstruction. ascites identified with ultrasound (p= . ) [fig ] and bowel obstruction [fig ] diagnosed either with ultrasound (p= . ) or radiography (p= . ) were associated with the need for surgical intervention. one third of children with meconium pseudocysts ( / ) [fig ] , did not require surgery. diffuse peritoneal or hepatic calcifications as an isolated postnatal finding were not associated with the need for surgery. both radiography and ultrasonography give valuable information to the surgeon to take the decision for surgery. dilatation of bowel loops and ascites detected postnatally with radiography and/or ultrasound require surgical intervention in children with meconium peritonitis. interestingly, a large proportion of infants with meconium peritonitis can be managed conservatively. . - . ) . those included had complete fmru analysis, dti (b= and b= , directions), and upjo configuration in at least kidney. cases with motion artifact (n= ), post-pyeloplasty (n= ) or duplex collecting systems (n= ) were excluded. pelvicalyceal dilation grade (pcd), corticomedullary differentiation (cmd), and functional parameters were included. pyeloplasty following fmru was recorded. dti tractography was reconstructed using a fractional anisotropy (fa) and an angle threshold of . and °, respectively (figure ) . user-defined regions-of-interest (roi) of the renal parenchyma, excluding the collecting system, were drawn to quantify dti parameters: mean fa, apparent diffusion coefficient (adc), tract length and tract volume. the relationships between dti quantitative parameters and fmru parameters were analyzed. age and adc (roi) (p< . , r = . ), tract volume (p< . , r = . ) and tract length (p< . , r = . ) were positively correlated. age and fa (roi) (p< . , r = . ) were negatively correlated. there was a correlation between fmru parenchymal volume and tract volume (p< . , r = . ), but median volumes were higher on dti (tractography= . cm vs. fmru= . cm ; p< . ). of the children, had pyeloplasty, had nephrectomy, were managed conservatively and was lost to follow-up. fa was significantly lower in kidneys that went on to have pyeloplasty in comparison to those without pyeloplasty, but the %ci and the iqr overlapped (table ) . the adc, tract length and tract volume were similar between these groups (table ) . there was no difference between the adc of fa values in kidneys with and without pcd or cmd (p> . ). linear hierarchical regressions controlling the age did not show a significant relation between adc and cortical or renal transit times (p> . ), but lower fa values were related to a higher renal transit time (p< . , r = . ). table . quantitative dti parameters between kidneys with and without pyeloplasty following fmru. renal adc, fa, tract volume and tract length change with age but tractography overestimates renal parenchymal volume. there was a tendency towards a lower fa in kidneys that went on to pyeloplasty. otherwise, none of the quantitative parameters evaluated in this study differentiated degrees of upjo. echo-enhanced voiding urosonography (eevus) has become an important imaging tool in urodiagnostics; however, it has been observed that during eevus the premature destruction of ultrasound contrast agent microbubbles might occur. the purpose of this study was to evaluate the possible causes of contrast vanishing during investigations and propose the protocol to avoid false negative results. eevus was performed in children from april to december . sonovue mixed with saline solution in a plastic bottle is applied by continuous flow through the urine catheter. the collected data according to the protocol in this prospective study was completed in children, aged from weeks to . years. the protocol included general patient information, indication for eevus, duration of eevus in minutes, and the presence of vesicoureteric reflux. extensive data about sonovue were recorded: charge number, expiration date, time since opening, amount of initially administered contrast (ml sonovue/ml saline solution), grading of the initial contrast opacification of the bladder, the need for immediate readministration of contrast (dose), grading of contrast opacification during examination, and the need for readministration of contrast later in the course of the examination (dose). in addition, the data regarding bladder (ratio real/predicted bladder volume, wall thickness, ureter dilatation), saline solution, the size of urine catheter (french), and the type of antibiotic prophylaxis were collected. child observation included grading of crying and muscle stiffness. normal contrast opacification of urinary tract during examination was found in / children, while in / ( . %) the contrast opacification was insufficient. in / ( . %) microbubble destruction occurred during the first minute, in ( . %) in minutes, and in in minutes after the beginning of contrast administration. the reason for unsatisfactory contrast opacification at the beginning of the eevus is probably due to small urine catheter size ( % of children with fr catheter had insufficient opacification compared to . % with fr in whole cohort), time since the contrast is opened (more than hours in children), and insufficient bladder emptying at the beginning of the procedure. the reason for microbubble destruction later in the course of the examination is bladder overfilling in combination with increased muscle stiffness and strong crying, which led to increased bladder pressure. there was no correlation between the type of antibiotics and microbubble destruction. we should be aware of possible false negative vur results during eevus caused by premature microbubble destruction. patients with fontan-type palliation of univentricular congenital heart disease have elevated central venous pressure due to their passive pulmonary flow. the altered circulation has a negative impact on several visceral organs, and these patients have chronic liver congestion. they are at risk of developing hepatic fibrosis and cirrhosis with potential malignant transformation. these changes can occur from only a few years after fontan palliation, making early detection and grading of major importance. the patchy pattern of hepatic changes makes liver biopsy an unreliable diagnostic tool. magnetic resonance imaging (mri) t mapping has been suggested as a technique for non-invasive assessment and quantification of hepatic fibrosis/cirrhosis. the aim of this study was to compare two different t mapping sequences of the liver in adolescents with fontan palliation, and in healthy controls. materials: adolescents ( - y) with fontan circulation and young healthy adults ( - y) were included as a part of an ongoing national population-based study. all underwent mri ( . tesla) pre-and post-gadolinium contrast, including two types of t mapping of the liver. a d t volumetric interpolated breath-hold examination ( d vibe) sequence with dual flips with b correction and a modified look-locker inversion recovery (molli) sequence. t relaxation times (ms) were measured by placing five standardized circular regions of interest (roi) in the mid-section of the liver and one in the spleen (fig ) . statistical analysis was performed comparing measurements pre-and post-contrast, between sequences, and patients and controls. there was a significant difference in the measurements between molli and d vibe with increased values for the latter. within each sequence there were small, but significant regional differences in relaxation times (table ). the same pattern was seen in pre-and post-contrast images in both groups. there were significantly increased native t times on both sequences in all regions in the fontan group as compared to the controls, but not post contrast. t relaxation times differ between the t mapping sequences, molli and d vibe, pre-and post-contrast. t mapping of the liver revealed significantly increased native t times in adolescents with fontan palliation compared to healthy slightly older controls. these findings suggest hepatic fibrosis/cirrhosis, but may also represent a component of congestion. diagnostic accuracy of ultrasound, computed tomography and wedge portography in the work-up for mesenterico-rex bypass in children with extrahepatic portal hypertension s. toso, r. breguet, m. annoshiravani, s. terraz; geneva/ch to identify the diagnostic accuracy of ultrasound (us), computed tomography (ct) scan and portography (wedge hepatic vein portography or direct portography) in the pre-operative work-up of mesenterico-rex bypass performed for extrahepatic portal hypertension in children. we conducted a retrospective analysis of pre-operative imaging for mesenterico-rex bypass in our tertiary hospital over the last years. we analyzed all patients between the ages of - years, with extrahepatic portal hypertension necessitating surgical treatment that underwent us, ct and portography. three reviewers independently analysed the patency of the left portal vein, mesenteric vein, splenic vein and the presence of communication between the left and right portal vein on preoperative imaging with correlation to surgical findings. statistical analysis of diagnostic accuracy was performed. eleven patients underwent mesenterico-rex bypass for portal hypertension secondary to portal vein thrombosis. two patients had partial liver transplant. ct with ultrasound correlation was sufficient in responding to the preoperative criteria in % ( / ) cases. portography was useful in the % ( / ) cases where ct could not respond to preoperative criteria, in particular the presence of left-right communication. there was good inter-rater correlation for each modality and good correlation of findings between modalities. in the majority of cases the use of ultrasound and ct is sufficient for preoperative planning for mesentrico-rex bypass. portography is mandatory in cases with large intra-hepatic cavernoma, where the left-right communication could not be confirmed on ct. contemporaneous clinical data was reviewed where available, and a clinical decision on disease severity and activity on a likert scale made with and without imaging. fifty-three patients underwent mre and bowel us in the specified timeframe ( male; median age . years, range - years). twenty patients had sufficient contemporaneous clinical information to be analysed. inter-observer variability for the imaging scores was assessed using bland-altman plots. where variability was beyond pre-determined limits, the studies were consensus reviewed. mean scores were used for the studies within accepted limits of variability. there was no significant difference between total mre and us scores (wilcoxon signed-rank test z= . , p= . ). at the bowel segment level, there was no significant difference between the mre and us segment scores for the ileum and terminal ileum (wilcoxon-signed rank test, z= . , p= . ), but significant differences were present between the imaging scores for other bowel segments, with mre identifying more abnormalities. there is a significant positive correlation between mre and clinical consensus scores (spearman's rho= . , p= . ) and between us and clinical consensus scores (spearman's rho = . , p= . ). imaging caused a refinement to the original clinical assessment in of the cases, with jejunal and ileal disease the most common reason for 'upgrading' a score and absence of any detectable abnormality on us and mre the most common reason for 'downgrading' a score. we found good agreement between mre and us for total patient imaging scores, ileal and terminal ileal scores. both mre and us scores correlated well with the gold standard clinical consensus, with imaging altering the original clinical decision in % of cases. although us detected fewer abnormalities than mr, it correlates marginally better with the clinical consensus, suggesting it is at least equally clinically valuable. background: differentiating between acute osteomyelitis (om) and acute bone infarct (bi) in children with sickle cell disease (scd) is a challenge for clinicians and radiologists, particularly when blood cultures are negative. although bone aspiration is the gold standard test for om diagnosis, it is an invasive procedure and infrequently performed. magnetic resonance imaging (mri) has shown a potential role in differentiating between acute bi and acute om. the goal of this case series is to evaluate the utility of fluid signal on unenhanced fat-suppressed (fs) t -weighted mr sequence in distinguishing acute bi and om in children with scd. methods: we reviewed a total of children with scd admitted with long bone pain during the one -year study period - attributed to either an acute bi or an acute om. twelve of patients with available bone aspiration, blood culture, and mri data were evaluated for fluid signal, marrow signal and other criteria. of patients, nine patients were diagnosed as acute bi and two patients had acute om and one with coexisting bi and om. the diagnosis was based on the fluid signal on t unenhanced t fs mr images as compared to aspiration cytology in which eight of nine patients with bi had hyperintense fluid signal on non-contrast t fs mr images while one of two patients with om demonstrated hypointense fluid signal. the last patient was diagnosed as a probable coexisting lesion (om&bi) based on a giant well demarcated hypointense marrow signal with an extraosseous hyperintense fluid signal. in acute bi, an abnormal hyperintense subperiosteal or paraosteal fluid signal is frequently observed on unenhanced t -fs weighted images. this finding was present in the majority of cases in our study population regardless of age, sex or site in the appendicular skeleton. mri fluid signal characteristic on unenhanced t fs shows promise as a criterion to differentiate between acute bi and om. role of mri to assess skeletal age in pediatric celiac disease s. bernardo, m. martino, a. laghi, e. tomei; rome/it objective: coeliac children are often subject to weight loss and lower somatic growth rate, compared to healthy children of the same age. the purpose of this study was to asses the feasibility of magnetic resonance imaging (mri) of the hand and the wrist to assess skeletal age and growth delay. we enrolled in our study coeliac children ( males and females) affected by histological proven coeliac disease, with a chronological age ranged between years and month and years and months (mean age of years, +/ years and months standard deviation). a single mri sequence (t d se, acquisition time: minute seconds) of the hand and wrist in coronal plane was performed of each patient to estimate the skeletal age. patients' data were compared with a population of normal subjects. the preliminary results showed a delay in skeletal age in children affected by coeliac disease in , % of the simple study, with a delay of maturity of . years (+/- , years of sd). only children showed advance mri skeletal age when compared to normal subjects. mri of hand/wrist to assess skeletal age may be considered as a reliable indicator of somatic growth. mri, without radiation exposure, can be an used as a diagnostic tool in skeletal delay. it could play an important role in the follow up of coeliac children, after glutenfree diet. the prevalence of metaphyseal injury and its mimickers in otherwise healthy children under two years of age p. eide, Å. djuve, r.e. gjøsaeter, k.f. forseth, a. nøttveit, c. brudvik, k. rosendahl; bergen/no objective: metaphyseal lesions in infants and toddlers are believed to have a high specificity for inflicted injury, however, normal metaphyseal irregularities may mimic pathology and lead to overdiagnosis. during the period - all children between and years, seen at the a&e department in bergen (bergen legevakt) due to an injury, and who had radiographs taken, were included. data on previous injury, age, sex and injury mechanism were drawn from the medical notes and pacs archive. all radiographs were reviewed by two researchers and an experienced paediatric radiologist, registering the following: number, site and type of fractures, signs of healing (yes, no), bone structure (normal, pathological) and metaphyseal appearances (shape (normal, metaphyseal collar, metaphyseal irregularity), injury). the study was approved by the institutional review board. six hundred one children ( girls) between and months of age (mean . months) were included, of whom ( girls) had a total of fractures. one hundred eight of the fractures ( . %) involved the forearm, followed by leg-fractures ( / , . %) and fractures to the clavicle ( / , . %). one epiphyseal separation and one metaphyseal lesion (without a history of trauma) were seen. one thousand three hundred twenty metaphysis were analysed, of which ( . %) were defined as either irregular ( / , . %) or demonstrating a metaphyseal collar ( / , . %). metaphyseal lesions with a history of trauma did not occur in otherwise healthy neonates and infants under years of age, indicating that this type of fracture has a particular mechanism. metaphyseal irregularities are frequent, particularly around the knee, and should not be mistaken for clms to evaluate whether mri might be used for age estimation, based on greulich-pyle (gp) atlas criteria. . tesla mri of the left hand was conducted in adolescents, and subjectively evaluated by two blinded radiologists. for sequence optimization, coronal mri sequences (t tirm, t vibe- d-we, and t se) and a left hand x-ray were compared in ten patients (eight male, two female; mean age, . years). the ages of healthy volunteers ( s ( ) (suppl ):s -s pediatr radiol male, female; mean age, years) were assessed from coronal t vibe- d-we. bland-altman plots, intraclass correlation coefficients (icc), and logistic regression models were calculated. coronal t vibe- d-we achieved the best image quality. the correlation between estimated patients' ages on x-ray and mri was high. icc showed high inter-observer agreement ( . for x-ray, . for mri). the estimated age of the healthy volunteers tended to be older than their chronological age. the probability of overestimation was higher in girls than in boys. coronal t vibe- d-we of the left hand is feasible for skeletal age estimation by gp criteria with a high readers' agreement. the likelihood of overestimation of healthy children makes it necessary to develop a new hand atlas representing changes since the s. to assess the relationship between the radiographic findings of metabolic bone disease (mbd) and serum biochemical markers in preterm infants. preterm infants in our neonatal intensive care unit between january and september were included. two readers retrospectively reviewed the wrist radiography for grading according to mbd severity. we recorded the levels of alkaline phosphatase (alp) and phosphorous (p) immediately after birth, on the same day of the first wrist radiography (alp-s, p-s), the highest alp levels before the first wrist radiography (alp-hb) and during follow-up (alp-h), and the lowest p levels before the first wrist radiography (p-lb) and during follow-up (p-l). patients were subdivided into four groups according to mbd severity determined by wrist radiography for the first analysis, and were divided into two groups according to mbd presence for the second analysis. one-way analysis of variance with a tukey multiple comparison and the student's t-test were used for statistical comparisons in the two analyses, respectively. a receiver operator characteristic (roc) curve was constructed to determine the optimal cut-off values of the biochemical markers for the radiological prediction of mbd. of the patients, , , , and infants were classified into grades , , and , respectively. in the first analysis, alp-s, alp-hb, and alp-h were significantly different between grades - and - (all p< . ). plb was significantly different between grades and (p= . ) and p-l was significantly different between grades and or (p< . or p= . ). in the second analysis, alp-s, alp-hb, alp-h, p-s, p-lb, and p-l were all significantly different between the two groups (p< . ). the roc curve of alp-h showed the largest area under the curve values ( . , % confidence interval= . - . ; p= . ) for detection of a radiographic change. the optimal cut-off value of alp-h was . u/l, and the sensitivity and specificity were . % and . %, respectively. the first wrist radiography was obtained at . ± . weeks after birth, and alp-h was measured at . ± . weeks after birth. the cut-off value of alp for the prediction of abnormal radiological changes in wrist radiography was determined to be was . u/l. our findings indicate that the highest alp level at around . weeks after birth could be a valuable predictor of radiological mbd in preterm infants, including those with very low and extremely low birth weights. quantitative grading of tmj synovitis in children with jia-influence of mr-coil, timing after contrast-injection and location of measurements on joint-to-muscle enhancement ratio a. hamardzumyan schmid, c. kellenberger; zurich/ch objective: assessment of signal intensity ratio between joint space and longus capitis muscle on contrast-enhanced mri has been proposed as reliable method across different mr-scanners and protocols for grading temporomandibular joint (tmj) arthritis in juvenile idiopathic arthritis (jia) with a cut-off of . for diagnosing synovitis. the aim of this study was to investigate potential influences on such enhancement ratios (er). retrospective evaluation of contrast-enhanced mr-studies of tmjs in girls with jia (age . ± . y) obtained at two occasions with two different coils on a . t scanner. joint-to-muscle er were calculated from signal intensity measurements in different joint compartments, muscles and sequences obtained with varying delay after contrast-injection, and compared with paired sample t-test. er of tmjs without synovitis (n= ) and tmjs with synovitis (n= ), determined by qualitative criteria, were compared to er reported in the literature. superior and inferior joint space to longus capitis muscle er for normal tmjs ( . ± . ; . ± . respectively) exceeded . in all but one case (figure) and for tmjs with synovitis ( . ± . , . ± . ) were significantly higher than in cases with synovitis from the literature ( . ± . , p≤ ). the same er were higher when obtained with dual-ring coil ( . ± . ; . ± . ) than with multichannel surface coil ( . ± . ; . ± . ; p≤ . ). while er to longus capitis muscle were higher than those to pterygoideus muscle for both coils (p≤ . ), er to pterygoideus muscle did not differ between coils (p> . ). not considering the timing of the scan, er to pterygoideus muscle were highest in the inferior joint space ( . ± . ), followed by the anterior joint recess ( . ± . ) and superior joint space ( . ± . ). comparing images acquired immediately after contrast injection to later images (median delay min, range - min), pterygoideus muscle er in the superior ( . ± . to . ± . ) and inferior ( . ± . to . ± . ) joint space increased substantially (p< . ), while er in anterior recess showed no significant increase ( . ± . to . ± . , p= . ). conclusion: joint-to-muscle er are clearly dependent on ) the signal profile of the mr coil with muscles located further away from the coil providing higher er, ) the time of image acquisition after contrast-injection with later obtained images providing higher er, and ) where the joint signal intensity is measured. as these factors need to be accounted for, the described normal and pathologic ranges of joint to longus capitis muscle er cannot be generalised for every mr-system and imaging protocol. integration of d c-arm ct images with navigational software provides real-time fluoroscopic guidance during percutaneous interventions in the interventional radiology (ir) suite. a trajectory, drawn from skin entry point to the target lesion on the d c-arm ct data, is overlaid on intraprocedural fluoroscopy for real-time needle guidance. this study describes our experience with syngo iguide (siemens) needle guidance software in a range of clinical applications in the pediatric ir suite, including technical success, radiation dose and procedure time. in this irb approved study, all percutaneous interventions performed in the ir suite using syngo iguide over a -year period were included. cases were classified by procedure type; for each type, mean effective radiation dose (msv) was estimated using pcxmc program (v . . . , stuk) and procedure times were evaluated. forty-five patients ( male, female; mean age: ± years) underwent iguide-assisted interventions including: bone biopsies - / ( pelvic, lumbar, and lower extremity), intra-articular steroid injections - / ( sacroiliac, and temporomandibular joint), lumbar punctures - / , percutaneous catheter placements - / (cecostomy, and chest tube placement) and bone biopsy with radiofrequency (rf) ablation - / . iguide was used in particular for the cecostomy procedure due to high sub-hepatic cecal pole position, and in the chest tube procedure due to the presence of loculated pneumothoraces. all procedures were technically successful. the diagnostic bone biopsy rate was . %. the mean estimated dose and procedure times for each procedure type are listed in table . sonography of neonatal spine (sus) is a simple, non-invasive, quick, relatively inexpensive method to evaluate lumbar spine anomalies in infants less than months of age. unossified posterior neural arches allow beam penetration to obtain high-resolution images of the intra-spinal contents. sus is carried out at the bedside, does not utilize radiation & requires no sedation. linear array transducers with extended field-of-view permit diagnostic sensitivity equal to mri. factors affecting mri resolution like patient movement, pulsation & vascular flow do not affect sus. we use sus as first-line screening test in neonates with lumbosacral cutaneous stigmata & spinal dysraphism (sd) associated syndromes. this was a prospective study approved by the institutional ethics committee. thirty five children (age range of to years) with clinically suspected and complicated pulmonary tb were enrolled in the study. lung mri and ct scan was performed in all the patients. the sensitivity, specificity, positive predictive value (ppv), and negative predictive value (npv) of lung mri in detection of radiological findings that were considered highly suggestive or diagnostic for tb, were calculated, with ct as the standard of reference. lung mri performed equivalent to ct in detection of pleural effusion, mediastinal/hilar lymphadenopathy and lung cavitation with sensitivity and specificity of %. agreement between ct and mri in detection of each finding was almost perfect (k: . - ). lung mri was found to be comparable to ct scan for detecting various radiological abnormalities which were highly suggestive for tuberculosis. being a radiation free imaging modality, it has the potential, particularly in children, to replace chest radiographs and ct scan in the coming years. to evaluate differences of myocardial strain assessed by feature tracking using ssfp cardiac mri sequences between pectus excavatum (pe) patients and healthy volunteers. in this prospective study, cardiac mri was performed in pe patients (with a pathologic haller-index above . ) and healthy volunteers ( males and females, respectively; age range - years) including short-and long-axis cine-ssfp sequences on a t scanner. post-examination analysis included standard cardiac volumetry with measurements of the biventricular ejection fractions (ef). additionally, manual biventricular contouring by an experienced radiologist, and subsequent automated strain assessment using dedicated software (circle cvi ®) was performed. longitudinal, radial, and circumferential peak systolic strain and strain rates were analyzed for both ventricles. left-ventricular ef was normal in all patients. five pe patients had a normal right-ventricular ef, in pe patients rvef was slightly impaired ( - %), all healthy volunteers had a normal rvef. compared with healthy volunteers, pe patients showed a significantly higher apical left-ventricular strain (radial: ± . vs. ± %, p< . ; circumferential: - . ± . vs. - . ± %, p= . ) and strain rate (radial: . ± . vs . ± . s - , p< . ; circumferential: - . ± . vs. - . ± . s - , p= . ). mid right-ventricular strain (radial: . ± . vs. . ± . %, p= . ; circumferential: - . ± . vs. - . ± . %, p= . ) and strain rate (radial: . ± . vs. . ± . s - , p= . ; circumferential: - . ± . vs. - . ± . s - , p= . ), as well as apical right-ventricular strain (radial: . ± . vs. . ± . %, p= . ; circumferential: - . ± . vs. - . ± %, p= . ) and circumferential strain rate (- ± . vs. - . ± . s - , p= . ) were also significantly higher in pe patients than in healthy volunteers. left-and especially right-ventricular radial and circumferential strain and strain rate increased from the bases to apices in pe patients. longitudinal strain and strain rate did not differ significantly between pe patients and healthy volunteers. myocardial strain assessed by cardiac mri differs significantly between pe patients and healthy volunteers. as the chest wall deformity usually leads to a compression of the basal parts of the ventricles, higher values of myocardial strain in the mid and apical ventricles in pe patients might indicate a compensation mechanism to enhance especially right ventricular output against sternal compression. to determine the normal range of the haller index (hi) value, and its dependence on the age, sex, and respiratory phase. evaluate the possibility of reduction of the effective dose (ed) of ionizing radiation using a single-slice ct scan technique. the retrospective-prospective study included patients (av. y, sd y). it consisted of parts. the prospective study included evaluation of ct scans performed by single-slice technique in patients with pectus excavatum both in inspiratory and expiratory phase, without topogram. hi was measured in each patient in both respiratory phases. in retrospective study, ct scans of the chest in children without pectus excavatum were analyzed to determine normal range of hi values depending on the age ( - y, - y, - y, - y) and gender. the retrospective study also included the analysis of another ct scans in patients who were operated or diagnosed with pectus excavatum. in the latter group of patients the average value of ed of ionizing radiation was calculated, and the values were compared with the average ed obtained using low-dose ct examinations applied in the new protocol (single-slice technique). the normal value of hi was . ± . . a significant positive correlation between age and value of hi was found. older patients had higher hi ( - y: . ± . , - y: . ± . ). results of mann-whitney test did not demonstrate any difference between gender in the observed group, however girls had generally higher hi in all age groups. in the group of patients who were operated/diagnosed with pectus excavatum, hi was . ± . . the average value of hi in inspirium in children with diagnosed deformity was . ± . , while in expirium it was . ± . . only / ( %) patients had hi value over . (a boundary value for surgical treatment) during inspirium, while / ( %) patients had it in expirium, which showed statistically significant difference (p= . ). single-slice ct technique during the inspiratory and expiratory phase showed average ed of . msv, which is an equivalent of chest xray. it reduced ed more than times in comparison with low-dose whole chest ct. the value of haller index increases with the age and in expiratory phase. we propose the single-slice ct technique without topogram in expiratory phase, as a sufficient and reliable technique in evaluation of haller index and preoperative preparation. mps iva is a lysosomal storage disorder caused by a deficiency of nacetylgalactosamine-sulfatase. main symptom is a systemic skeletal dysplasia. affection of the vascular system has not been described yet. our goal is the analysis of the vascular system in patients with mps iva, based on the example of the aorta. in a retrospective study, patients with mps iva were included. the aorta in its course from th thoracic vertebrae to th was analyzed on the basis of craniospinal mr and ct examinations. to describe the course of the aorta, the area around the vertebral body was devided into equal parts (fig. ) . high buckled arteries in relation to the length of the affected aortal part were indicated as aortal kinking, and a moderate twist in relation to the length of the affected aortal part as aortal tortuosity. results: twelve of patients had an aortal kinking, of patients an aortal tortuosity, of these had moderate and strongly tortuous aortae. seven patients had a normal aortal course, couldn't be analyzed. one patient revealed both, aortal kinking and tortuosity. this study reveals the occurrence of aortic tortuosity in patients with mps iva. we suggest that this complication could be due to glycosaminoglycane deposition in the aortic intima, which may be s ( ) (suppl ):s -s pediatr radiol associated with an increased vulnerability of the vascular wall. we conclude that the examination of the vascular system should be included in regular follow-up protocols. lung ultrasound in the diagnosis and follow-up of pneumonia in children -is it really as reliable as chest x-ray? s. balj-barbir, j. lovrenski, s. petrović; novi sad/rs to investigate the role of lung ultrasound (lus) both in the diagnosis and follow-up of pneumonia in children. a prospective study was carried out in the regional children's hospital, and included children (av. . y, sd . y) with clinically suspected pneumonia, in whom initial lus and subsequent chest x-ray (cxr) were performed within h. the final diagnosis of pneumonia at discharge was used as a reference test to determine the reliability of lus, cxr, clinical and laboratory findings in the diagnosis of pneumonia. children with pneumonia formed a study group, while the control group consisted of children without diagnosed pneumonia. lus finding of subpleural lung consolidation was considered a diagnostic sign for pneumonia. the children with lus signs of pneumonia were followed-up until complete resolution of the lus findings. there were from one to five follow-up lus examinations performed. a final diagnosis of pneumonia was confirmed in / ( . %) patients, and / ( . %) were hospitalized (av. . , sd . hospital days). in diagnosis of pneumonia lus, cxr, auscultation, elevated crp, and tachypnea showed sensitivity of . %, . %, %, % and . %, and specificity of %, %, %, % and % respectively. lus detected lung consolidations in of children with final diagnosis of pneumonia, and in / patients lus showed air-bronchogram (figures , ) . lus was superior to cxr in the detection of lung consolidations smaller than mm. interstitial lung changes were detected by lus in / ( . %) patients, and by cxr in / ( %). lus and cxr detected pleural effusion in / ( . %) and / ( . %) patients respectively. mcnemar's test showed no statistically significant difference, and cohen's kappa coefficient showed almost perfect agreement ( . ) between us diagnosis of pneumonia and final diagnosis of pneumonia. during the follow-ups, moderate to substantial agreement between lus and clinical evaluation of the course of the disease was obtained (k= . - . ). in children with complete clinical and incomplete us regression of pneumonia, consolidations of less than mm were the most prevalent finding. the average time period until complete resolution of the lus findings was . ± . days. children with us detected pulmonary consolidations larger than mm were statistically significantly longer hospitalized than others. lung ultrasound in the diagnosis of pneumonia in children is just as reliable as radiography, and should be included in the standard diagnostic protocol. the latest uk nice guidelines for childhood tb contact screening require that a chest x-ray (cxr) be requested only when mantoux or igra testing is positive or if there is a documented reason e.g. clinical concern. nice clarifies the role of cxr in determining treatment choice. we aimed to review cxr referral and treatment in the current climate of european migrant screening. retrospective review of paediatric referrals to the infectious diseases clinic for tb contact screening of whom had cxrs, from october to august and correlation with the medical notes. a panel of paediatric radiologists independently interpreted radiographs in the clinical context of tb contact screening and a majority decision was reached. of patients referred to the infectious diseases unit, underwent cxr in addition to a mantoux and igra test. of those cxr's, were reported as having features of pulmonary tb but only / ( %) were treated as active tb. eighteen of the ( %) cxr's which were reported as having no features of pulmonary tb, were treated as active tb. of those , only / ( . %) had a clearly documented reason. review of the radiographs (mean age years) by the panel of radiologists noted that all were of readable quality, radiographs were in keeping with a diagnosis of tb, were inconclusive and were normal. the diagnosis of tb was based on lymphadenopathy in and ( ) (suppl ):s -s pediatr radiol milliary nodules in . parenchymal abnormality was seen in patients [one was the milliary] and effusion was seen in . this correlated well with the initial radiology reports of duty radiologists. of the who underwent cxr, referral information was available in . ( . %) of these had been appropriately referred because of a +ve mantoux/igra. only out of ( . %) of those who had cxr despite a -ve mantoux or igra, had a documented reason. according to nice guidelines, % of cxr reported positive for tb were not treated for active tb. this may represent a lack of clarity regarding the definition of 'latent tb'. furthermore, only a third of the % of patients who received treatment despite negative radiographs had a documented reason. the current migrant crisis requires clarity of x-ray definitions of latent tb to avoid the % under-treatment and % overtreatment identified in our population. is there really no cardiac problem for performing sports Ö.İ. koska, p. bayindir, h. alper; izmir/tr objective: sudden death in young is a rare condition excluding known anomalies and sudden infant death sydrome; but its consequences are devastating because they are so unexpected. % of them occur in a context of sports event. everyday parents of millions of children admit hospitals in order to get permission for participating in sports events. and after physical examination and ecg, physicians are expected to decide such an important issue. however there are a number of silent reasons that may lead to child to sudden death. altough we don't perform ct scans for such indications, we have encountered several cases with abnormalities that can lead to sudden child death and while reporting an examination, awareness of these devastating conditions may be usefull. we searched our database from . . to . . in order to see how often we diagnosed such a silent reason from the ct images that are performed for some reasons. as our center is a tertiary center we have performed cardiac ct examinations in that period that are mainly for excluding or defining complex cardiac anomalies. in order to prepare a pictorial review of unexpected but ct detectable sudden cardiac death reasons, we excluded congenital heart diseases (namely obstructive, shunting or complex anomalies) and ecg detectable arrhytmic diseases. the non arrhytmic, non traumatic reasons for sudden cardiac death excluding congenital heart diseases in the papers are: hypertrophic cardiomyopathy (cmp) (% ), some coronary artery path and origin anomalies (mainly abnormal left coronary artery from pulmonary artery (alcapa), and interarterial path)(% ), increased cardiac mass (% ), dilated cmp (% ), marfan disease (% ), myocarditis (% ), ischemic heart disease (% ). we detected examinations according to our inclusion criteria and selected one cases of each; rca path anomaly, alcapa, dilated cmp, hypertrophic cmp, subaortic discrete membrane and increased cardiac mass for presentation although sudden cardiac death is rare in young children it is a so devastating condition that it must be taken into account for every situation. awareness of silent conditions and active search of them may protect professionals from medicolegal issues and unpleasent results. to describe the spectrum of chest ct scan findings of pulmonary involvement in childhood langerhans cell histiocytosis (lch) and propose a simple scoring system to evaluate the profusion and distribution of the main lung lesions. one hundred forty-six chest ct scans of the pediatric patients with pulmonary lch enrolled in the french national database for lch until april , could be retrospectively and independently reviewed by pediatric radiologists. for each ct scan a semi-quantitative analysis was performed for nodular opacities and cystic abnormalities. the chest was divided in fields (upper, medium and lower field of the left and the right lung) and for each field, both for the nodules and the cysts the score was =no lesion, = lesions involving up to % of the parenchyma, = - %, = - % and =more than %. of patients evaluated at diagnosis, patients ( %) presented with nodules, patients ( %) presented with cysts and patients ( %) presented a combination of both nodular and cystic lesions. on the initial ct scan, median nodules total score was and median cysts total score was . during subsequent ct scans almost the same percentage of patients with nodules ( patients, %) was found but we observed an increase number of patients with cysts ( patients, %), median nodules total score was and median cysts total score was . the distribution of nodules and cysts was symmetric in the upper, medium and lower fields with an involvement of costo-phrenic angles in % of the cases. patients with pneumothorax ( patients, %) had a higher cysts median score ( ) than patients without pneumothorax ( ). we found alveolar condensation in patients ( %). none of them showed signs of infection at bal examination or any improvement after a treatment with a standard antibiotic therapy while they did show regression under the lch standard regimen of chemotherapy. we proposed a score for semiquantitative analysis of distribution and profusion of nodular and cystic lesions on chest ct scans that can be a useful tool in pediatric population to monitor lung involvement. we found a significant correlation between pneumothorax and a high cysts median score. alveolar condensation could be considered as a possible manifestation of plch in children. lung bases involvement was found in % of the cases, representing an important different imaging feature from adult plch. high resolution computed tomography for chronic small airway disease in hiv infected adolescents a.-m. du plessis , s. andronikou , h. zar ; cape town/za, bristol/uk early treatment with antiretroviral therapy (art) and decline in infected infants due to prevention of mother-to-child transmission has resulted in an increase in the population of hiv-infected adolescents. pulmonary disease is common among them. cxr is considered insensitive and terminology inconsistent. therefore, despite concerns related to radiation dose in paediatric patients, high resolution computed tomography (hrct) is the modality of choice for the evaluation of small and large airway pathology, prominent in chronic pulmonary disease. hrct findings are used for prognosis, treatment decisions and defining anatomic extent of bronchiectasis for surgical intervention. the aim of this paper is to demonstrate the spectrum, frequency and extent of airway pathology in hiv-infected adolescents using hrct. a nested sub study was undertaken within the cape town adolescent antiretroviral cohort (ctaac); a prospective, descriptive cohort study of hiv-infected adolescents on art and age matched hiv-s ( ) (suppl ):s -s pediatr radiol negative controls. hrct was performed on patients who demonstrated abnormal lung function (defined by forced expiratory volume in second (fev ) of < % and/or low lung diffusion capacity (dlco)). single phase, contrasted multi-detector volume acquisitions were performed from the thoracic inlet to the diaphragms at full inspiration and image data postprocessed to yield thin ( , mm) and thicker slice images ( mm). three mm slices at cm intervals were performed in full expiration. three radiologists interpreted the c t scans independently, with strict imaging definitions, and a majority decision was generated for each finding. ages of patients ranged from between to years with a mean of , . there were females and males with a ratio of : , . bronchiolitis obliterans was seen in % of patients and bronchiectasis was demonstrated in %, % of which was classified as severe (involving either an entire lobe or more than % of at least lobes). there was an absence of lymphadenopathy (a sign of primary tuberculosis (tb)), lymphocytic interstitial pneumonitis (lip) and post tuberculous apical architechtural distortion. miliary tb was identified in a single patient. ground glass was seen in % and consolidation in %. the majority of hiv infected adolescents with poor lung function demonstrated bronchiolitis obliterans strongly emphasizing the use of hrct for confirming small airways disease. hrct was also useful for demonstrating extent of associated bronchiectasis in %. hrct allows classification of patients into those with diffuse small airways disease requiring medical management and those with local disease requiring surgery. background: chronic recurrent multifocal osteomyelitis (crmo) is an autoinflammatory paediatric non-infectious bone disease. presenting symptoms are non-specific, prolonging diagnosis, and leading to deformity, morbidity and unnecessary procedures. imaging is critical to diagnosis, with whole-body mri (wbmri) commonly used in all stages of care. in our institution, a baseline whole-body coronal stir sequence is routinely obtained. aim: to determine lesion distribution and extent on baseline wbmri via retrospective panel review of all patients clinically diagnosed with crmo, and to determine any patterns of involvement that could facilitate earlier radiological diagnosis. method: all patients diagnosed with crmo since december using published bristol criteria were identified and baseline whole body mris reviewed. the reviewing radiologists were blinded to the original report and previous investigations. each mri was reviewed for focal lesions consistent with crmo. the extent of metaphyseal and epiphyseal lesions was categorized into involvement of thirds of the width of the structure. the wbmri of forty children ( girls, boys), averaging years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) were reviewed by the panel using a majority decision rule. three hundred three lesions were recorded, averaging . lesions ( - ). the tibia was most affected ( lesions), most commonly the distal tibial metaphysis ( lesions in patients, bilateral). rib, metatarsals and distal femoral epiphyseals lesions were common. humeral, hand and skull lesions were few. complete metaphyseal involvement, the 'smouldering physis', was most prevalent within the proximal and distal tibial metaphyses. although ranked seventh, the reportedly more common clavicular lesions were the site of the most florid lesions, demonstrating bone expansion and periosteal reactions. two clear patterns of involvement emerged. in patients with clavicular lesions, fewer overall lesions were observed (average . ), mainly affecting the axial skeleton and feet. patients with tibial involvement had a higher number of overall lesions (average . ), but few lesions outside the lower limbs. only four patients had a both clavicular and tibial lesions. twelve vertebral lesions and four cases of spodylo-discitis were identified; two at t / level, one at t / level, and one involving both t / and t / . our series of cases of crmo with baseline wbmri, one of the largest in the published literature, identifies the common sites that should be interrogated for involvement. this study also demonstrates potential as-yet undescribed patterns of skeletal involvement that can be used to aid radiological diagnosis and highlights a non-infective cause for spondylo-discitis. hepatic hemangiomas (hh) are the most common benign vascular tumors encountered in the pediatric population. two main types have been described congenital and infantile, which both display distinct clinical courses and biological features. hemangioendothelioma in differential diagnosis of hh is controversy. recent literature suggests that congenital hepatic hemangiomas present in a focal form, whereas infantile hepatic hemangiomas present in either a multifocal or diffuse form. the goal of this study is to evaluate the features associated with focal and multifocal hh. the records of patients diagnosed with a hepatic hemangioma at a tertiary pediatric hospital from to were reviewed. we divided our series into groups: focal or multifocal including diffuse form. clinical endpoints are: age of diagnosis, presence of cutaneous hemangioma, alpha-fetoprotein, thrombocytopenia, cardiac insufficiency. imaging endpoints were echogenicity on us (hypoechoic, hyperechoic or mixed), vessels density on color doppler (< ; - , > cm ). presence of calcifications, venous lakes, visible vessels and aortic tapering were assessed on us, ct-scan, mr and angio. treatment and outcome were analyzed. univariate and bivariate analysis were done. this study included focal ( m, f) and multifocal ( m, f) hh. antenatal diagnosis was done in focal and multifocal hh. focal lesions were associated with the presence of cutaneous hemangiomas (p< . ) and calcifications (p< . ). no other variable was significant. conservative management was decided in focal and multifocal hh. steroids (focal: , multifocal: ), steroid-interferon (focal: , multifocal: ), propranolol-steroid (focal: , multifocal: ) and surgery in one focal form. complete regression was observed in most lesions (focal: n= , multifocal n= ), whereas incomplete regression < % was observed in patients (focal: n= , multifocal: n= ) and patients in the focal group with the pathology diagnosis of hemangioendothelioma. hepatic hemangiomas demonstrate a wide range of radiological features, with important overlaps in focal, multifocal or diffuse forms. focal and multifocal hh can be seen in congenital hemangioma, infantile hemangioma or hemangioendothelioma. the association of cutaneous infantile hemangioma in the focal group confirmed that the focal lesion can be seen in infantile hemangioma. however, calcifications are more frequent in focal hh which is described in congenital hemangioma or hemangioendothelioma. ( ) (suppl ):s -s pediatr radiol symptomatic and asymptomatic meckel's diverticulum in the pediatric population -a retrospective analysis of imaging findings with histopathologic correlation n. abu ata, r. cytter-kuint, j. bar-ziv, i. hadas-halpern; jerusalem/il objective: though meckel's diverticulum (md) is a relatively common gastrointestinal anomaly, many of the symptomatic and most of the asymptomatic md's are often missed on abdominal imaging. our purpose is to describe the radiologic appearance of symptomatic and asymptomatic md in the pediatric population and to correlate the radiologic findings with histopathology. a retrospective analysis of all children diagnosed with md between / - / and had relevant imaging (n= ) was done. imaging studies-ultrasound (us), computed tomography (ct) and magnetic resonance imaging (mri) were retrospectively reviewed and evaluated for visualization of md in symptomatic and asymptomatic patients. findings were compared with the preoperative radiology report and the pathology specimen. symptomatic group (n= ): mean age . ± years, nineteen males. md presented with abdominal pain in patients, small bowel obstruction (sbo) in patients, gastrointestinal bleeding or anemia in patients and intussusception in cases. md was identified in preoperative reports ( . %) and retrospectively identified in more cases (overall patients, . %). in cases, an inflamed or perforated md were found. in cases, mucosal lining resembling gastric folds was seen. inverted meckel and prominent tissue surrounding the diverticula were seen in patients. in a single case md was misdiagnosed as a duplication cyst. asymptomatic group (n= ): mean age . ± , eight males. md was not mentioned in any of the original reports and only md's were identified retrospectively ( . %). no mucosal abnormality or irregularity were noted. histopathology: ectopic gastric mucosa was found in / ( . %) of the symptomatic patients vs. / ( . %) in the asymptomatic group. all patients with sonographic appearance of gastric mucosa had gastric mucosa in pathology (specificity- %, positive predictive value- %). md has a variety of radiologic appearances. it can be detected in most of the symptomatic patients but is almost undetectable in asymptomatic patients. heterotopic gastric mucosa is more common in the symptomatic group. inflamed gastric mucosa may have a typical appearance resembling a small stomach, a sign that was not described before and has both high specificity and high positive predictive value for gastric mucosa within a meckel diverticulum. preliminary results on dna damage from ct irradiation in pediatric patients i. dilevska, e. nagy, w. schwinger, e. sorantin; graz/at the increased radiation sensitivity in children, compared to adults, is a well-recognised fact in the pediatric radiology community. the high-dose irradiation induced dna damage has been well established, however the dosages that are clinically used in everyday ct procedures are so low, that it remains unclear how this severely affects the dna and can induce cancer in the long run. the aim of this study is to assess the effects of lowdose ionizing radiation from ct in children by establishing a standardization curve ranging from the high to the low, medically significant ctdi values. this is done by measuring the phosphorylation of the h ax histone (γh ax), which is considered a biomarker for quantification of radiation induced dna double-strand breaks (ddsbs). the detection of the γh ax histone was done by two methods: immunofluorescence microscopy (im), which is an established method for detection and quantification of this histone and the new, promising flow cytometry technique (facs). for this study, leucocyte samples ("buffy coats") were provided by the local transfusion department and these samples were irradiated with a clinical ct scanner (aqilionone, tmse) with values ranging from , to , mgy ctdi. afterwards the samples were processed with both methods. for the immunofluorescence, twostep immunostaining was used with two different antibodies and the cell and foci counting were done on an olympus xc microscope, while the facs staining was done with a one-step antibody and the samples were measured on a navios flow cytometer (beckman coulter). comparable results were detected with both methods, with a good correlation between the facs and im, with a linear incline (r > . ) in the high and in the low dosages from , to . mgy ctdi. however, in the samples irradiated with doses below . mgy ctdi, there seems to be less phosphorylated h ax than in the native samples. two possible explanations arise: a) low dose irradiation initiates repair that extends to ddsbs occurring naturally or b) low dose irradiation doesn´t cause phosphorylation of this histone, but affects other dna damage and repair pathways. the preliminary findings show that the facs analysis can be used as a valid replacement method for the labor-intensive if method in the higher dosages. however more analysis should be done to establish its accuracy in the lower regions since underlying mechanisms are not clear yet. a. turkaj , g. cicero , e. sorantin , r. coroiu ; graz/at, mesina/it, cluj-napoca/ro there is only little information available regarding imaging procedures in the trauma setting of pediatric patients. such data can serve as a rational basis for running pediatric trauma units. the purpose of the paper is to investigate the number, types and distribution of imaging procedures in a tertiary pediatric trauma center serving children of about . million inhabitants with approximately . children. all trauma-caused admission to the emergency room and their imaging procedures were analyzed retrospectively occurring within a period of months. a cohort of patients (m:f= . : ) were analyzed. patients were grouped according to age into the following categories: neonates, infants, middle childhood, early adolescence, late adolescence. imaging procedures were classified into plain films, us, ct and mri. furthermore, the time of admission was noted and categorized in time slots : - : , : - : , : - : and : - : . referral cause was divided in domestic accidents, motor-scooter-bicycle accidents, car accidents, sport injuries, falls from height and others. the average age was . ± . years, aligned in the following age-groups neonates ( %), infants ( %), middle childhood ( %), early adolescence ( %), late adolescence ( %). a total of imaging procedures were performed, of which plain films ( %), us ( %), ct ( %) and mri ( %). there was a statistically significant difference of imaging procedures due to age in particular in us and ct. regarding the timeslots: : - : ; patients ( %), : - : ; patients ( %), : - : ; patients ( %), : - : ; patients ( %). domestic accidents were the leading referral cause with cases ( %) prevailed age groups were infants and middle childhoods corresponding for more than %. motorscooter/bicycle accidents accounted for cases ( %) of which most were early and late adolescence (more than %), s ( ) (suppl ):s -s pediatr radiol sport's accidents ( . %) equally shared among middle childhood, early and late adolescences. car accidents ( . %) cases and fall from height ( , %) did not show any prevalence according to the age groups. for the first time detailed data about imaging procedures at the emergency room for pediatric patients are now available. over half of the admissions ( %) occur outside regular work hours thus representing a challenge for the staff in duty and this fact should be considered in working schedules. due to strict interdisciplinary developed diagnostic pathways the number of ct examinations was reasonable low. head ct in a regional children's hospital without mri -effective doses and justification of clinical indications j. lovrenski, n. milenković; novi sad/rs to calculate effective doses (ed) for pediatric head computed tomography (ct), to determine the most common referral diagnoses, and the share of normal and pathological ct findings. a retrospectiveprospective study comprised all the children with performed ct examination ( -slice scanner) within a one-year period. pediatric ct protocols were used. the values of ed for head cts were calculated based on the two different models (shrimpton's and icrp publication ). average ed for different age groups was expressed as the number of chest x-rays (cxrs) ( cxr . msv). the most common non-traumatic referral diagnoses for head cts were determined, as well as percentage and type of pathological ct findings. a share of pathological ct findings was also determined for trauma as a referral diagnosis. head cts were represented with ( %) in total number of ct examinations within a one-year period. the different calculation models have shown the difference in ed values of up to . %. eds for head cts were equivalent of ( years of age and older) to (younger than months of age) cxrs for one sequence of scanning. the most common non-traumatic referral diagnoses for head cts were: loss of consciousness, epilepsy, headache, convulsions, and vertigo. in this group of patients, % of completely normal ct findings were found. pathological findings in this group consisted of the patients with the most common non-traumatic referral diagnoses were as follows: cortical atrophy ( patients), arachnoid cyst ( ), ischemia ( ), porencephalic cyst ( ), agenesis of the corpus callosum ( ), chiari malformation -type i ( ), open-lip schizencephaly ( ), and tumor of the posterior cranial fossa ( ). most common incidental, extracerebral pathology discovered included sinusitis and otomastoiditis. in patients with trauma as referral diagnosis, the share of pathological ct findings was . %. it is necessary to get clinicians familiar with the extent of ionizing radiation that children are exposed to during the head ct examinations. a more careful selection of children for head cts is necessary in an every-day clinical practice, especially for patients with non-traumatic referral diagnoses. diffuse and symmetric diffusion restriction involving the white matter of the brain in patients with neonatal seizures j.-y. hwang , y.j. lee , y.-w. kim ; yangsan-si, gyeongsangnam-do/ kr, yangsan-si/kr this study aimed to evaluate magnetic resonance (mr) imaging findings in patients with neonatal seizures focused on the diffuse white matter lesions on diffusion weighted image (dwi) in addition to clinical manifestations. a total of neonates aged less than -week old underwent brain mr imaging for evaluation of neonatal seizures between november and december . among them, patients showed diffuse and symmetric pattern of high signal intensity on dwi. clinical, laboratory, and mr images were analyzed retrospectively. nine patients were males and three patients were females. patient age was . ± . days (range, - days). all the patients were born at full term. the most frequent month of the hospital visit was march (n= ) and january (n= ). eight patients showed generalized clonic seizure and four patients showed partial clonic seizure. stool viral test was performed in nine patients. among them, five patients were positive for the rotavirus and one patient was positive for the astrovirus. nine patients underwent cerebrospinal fluid analysis, however, all showed negative results. mr imaging was performed at . ± . days after onset of seizures. diffuse and symmetric diffusion restriction were distributed along the cerebral white matter tracts and both thalami (fig ) accompanied with high signal intensity on either t -weighted images or on the fluid-attenuated inversion recovery (flair) sequence. multiple foci of high signal intensity on t -weighted images at the centrum semiovale that was affected on dwi were also observed. follow-up period was . ± . months (range, . - . months) and developmental delay was encountered in three patients. six patients underwent follow-up mr imaging at the age of . ± . months (median, . months; range, . - months). five patients showed volume loss in cerebral white matter on both sides of the brain and four patients showed high signal intensity of the periventricular white matter on either t weighted images or flair sequences (fig ) . myelination delay was not observed in follow-up mr images. diffuse and symmetric diffusion restriction involving the cerebral white matters can be seen in patients with neonatal seizures on mr imaging. our study shows that rotavirus is commonly encountered, but not exclusively detected in these patients. nevertheless, viral infection-associated encephalopathy should be considered when a patient is presented with characteristic clinical and mr findings. whole body mri on diagnosis and follow-up of neurofibromatosis type d. grassi, v. tostes, e. caran, h.m. lederman; sao paulo/br demonstrate that whole body mri is effective on showing neurofibromatosis type involvement of different regions of the body not known by the clinicians. review of patients with neurofibromatosis type (nf ) who underwent whole body mri throughout their follow-up with the majority of them had only brain and spine imaging studies. it was possible to demonstrate that whole body mri provides an overview of nf systemic manifestations and neurofibroma's extension beyond the clinic expectation. despite being rare, sarcomatous degeneration was suspected when there was any difference on the characteristics of the neurofibromas. whole body overview where its possible to see the neurofibroma's extension in right cervical region, scoliosis and multiple plexiform neurofibromas. only the biggest neurofibroma was detected by clinical exam. however it is possible to identify two others neurofibromas. whole body view of multiple plexiform neurofibromas. whole body mri is a radiation-free exam and it is useful on the diagnosis of nf and on patient's follow-up. it provides an overview of the systemic s ( ) (suppl ):s -s pediatr radiol involvement and neurofibroma's extension beyond the clinical expectation. during patients follow up, it could also show tumor's characteristics modification, which was considered as a possible sarcomatous degeneration. accuracy of non-radiologists and lay-persons for identifying children with cerebral cortical atrophy from 'mercator map' curved reconstructions of the brain s. vedajallam , a. chacko , s. andronikou , e. simpson , j. thai ; east london/za, bristol/uk objective: background: communication of cortical brain atrophy in children with term hypoxic ischaemic injury (hii) to parents and the legal fraternity contesting compensation rights can be very difficult using text and standard cross-sectional images. when demonstrating the cortex in hii, a single image of the brain surface, much like the way a map of the earth is derived from a globe, can be generated from curved reconstruction of coronal magnetic resonance imaging (mri) scans i.e. a mercator map. lay people's ability to identify abnormal scans from such maps without prior training requires evaluation before routine use. aim: to determine the sensitivity and specificity of lay people in detecting abnormal brain scans through review of mercator flat-earth maps of the brain, without prior training. ten mercator map images were provided to participants with a distribution of hii, cortical dysplasia and reported normal. participants were required to identify abnormal scans. sensitivity and specificity overall and for sub-groups were derived by averaging true positives and negatives; false positives and negatives. the results show a strong ability for lay-people to identify normal versus abnormal mri brain studies using mercator maps. the sensitivity and specificity in this group is % and % respectively. non-radiologist physicians and radiographers performed slightly better than lay people as expected. radiologists of course had very high sensitivity and specificity of % and %. the mercator map is therefore a viable tool in the communication of complex mr imaging to the lay-person. safety and efficacy of sphenopalatine ganglion blockade in childreninitial experience l. dance, c. schaefer, d. aria, r. kaye, r.b. towbin; phoenix/us objective: sphenopalatine ganglion (spg) blockade is known to be a safe and effective migraine headache treatment among adults. this paper will report the initial experience in the pediatric population with spg blockade. one hundred thirty-three procedures were performed in patients ages to from february through november . pre-intervention headache scores were recorded on a scale of to . the procedure was performed supine with neck in hyperextension. anesthesia of the bilateral nares was accomplished with lidocaine spray and gel. contrast was injected using a sphenocath confirming catheter position. % lidocaine was injected. patients remained supine with neck in hyperextension for minutes. post-intervention headache scores were recorded. mean pre-treatment score of . decreased to . post-treatment (Δ . , % ci . - . , p< . ). there were no complications. spg blockade is a safe and effective treatment for migraine headaches in children which results in decreased reliance on intravenous drug therapy. orbital masses represent a spectrum of benign and malignant lesions in children that can be challenging to diagnose and treat. imaging plays an important role in diagnosis, due to a potentially limited clinical examination and risks associated with biopsy. mr imaging is a powerful tool for imaging the orbit, due to the excellent tissue contrast it provides. yet conventional mri has a limitation in discriminate the benign from malignant lesions. diffusion-weighted imaging (dwi) is non-invasive rapid technique uses the water diffusibility to produce contrast among different kinds of tissues. our propose was to assess the role of dwi and calculated apparent diffusion coefficient (adc) values in characterization of the pediatric orbital masses regarding benignancy or malignancy. one hundred and thirty patients with recently diagnosed orbital masses and who underwent preoperative conventional mri and dwi were included in this study. the orbit was divided into six compartments: the eye globe, retroocular fat, optic nerve, lacrimal system, bony boundaries and extra-ocular muscles. the average adc obtained from each tumor was compared with the histopathological diagnosis determined from subsequent surgical sample. seventy girls and sixty boys with orbital masses were included in this study. their age was ranged from month to years. the globe is the seat of lesions in / cases, optic nerve in / case. seven cases have lesions in the lacrimal gland. forty-five of cases was diagnosed as having benign masses & of cases have malignant lesions. there is a statistically significant difference between the mean adc value of the benign lesions ( . ± . x - mm /s) and the mean adc value of the malignant lesions ( . ± . x - mm /s) (p< . ). the optimal adc cutoff value that was determined for discrimination between these lesions is: . x - mm /s), with sensitivity of . % and specificity of %. using conventional mri alone in predicting benign and malignant lesions has the sensitivity of % and specificity of % with % positive predictive value and % negative predicative value. combining dwi and conventional mri has increased accuracy, as the sensitivity and specificity were %, % respectively with % positive predictive value and % negative predicative value. ( ) (suppl ):s -s pediatr radiol adc values provide an accurate, sensitive, fast, and non-invasive mean of characterization of pediatric orbital tumors. a priori tumor characterization is useful in timing and treatment planning for orbital tumors. utiliy of resting state fmri in children for preoperative language mapping l.-m. leiber, m. delion, a. ter minassian; angers/fr to assess if resting state fmri is able to detect language eloquent areas in childrens. six children, from to years old suffering from brain lesions were enrolled in this study. they underwent mri with one dt morphology session and three minutes fmri sessions, including one resting state fmri and two language task induced activity fmri sessions. analysis was performed using a generalized linear model for the first one and a spatial independent component analysis approach for the two others. language maps were compared with cortical mapping obtained by intraoperative direct stimulation. language network was identified systematically by resting state session but not by task induced activity sessions. moreover, in two of the six patients, resting state fmri was able to detect eloquent areas found during intraoperative cortical mapping that were not present in task induced activity sessions. resting state fmri appears superior to task induced activity fmri in detecting language eloquent areas. is sclerotherapy an effective treatment option for ranulas or thyroglossal duct cysts in children? d. aria, l. dance, c. schaefer, r. kaye, r.b. towbin; phoenix/us to assess the utility of sclerotherapy in the treatment of ranulas and thyroglossal duct cysts materials: from - , patients varying in age from months to years were referred to the ir department for sclerotherapy. of the patients, had a diagnosis of ranula while had the diagnosis of thyroglossal duct cyst by either mr, ct, or us. sclerotherapy treatments were performed with standard sclerosing agents, i.e. sotradecol % foam, absolute ethanol, and bleomycin. in the subset of patients with ranulas, sclerotherapy was commonly performed in accordance with salivary (submandibular and/or sublingual) gland botox injection or ethanol ablation. -gauge or f sheathed needles were used for us-guided access to the lesions, with ranula sclerotherapy being performed after placement of side-hole drainage catheters ( - f) due to their increased viscosity. the preferred sclerosing agent was injected with dwell times ranging from mins to hours. salivary gland injection/ablation was performed under usguidance using a -gauge needle with volume injection targeted centrally within the gland or in the portion of the gland abutting the ranula. after treatment, all patients were scheduled for follow-up ultrasounds at a minimum of weeks to assess lesion response or residual disease. a total of sclerotherapy treatments were performed. of the patients, were lost to follow-up after single sessions for ranula and thyroglossal duct cyst. the other patients all had follow-up ultrasounds after each of the remaining sclerotherapy sessions. four of these patients showed initial improvement with either decreased size of lesion or lesion resolution while the other showed no improvement with either stable or increased size on initial follow-up. the patients who initially showed promising response unfortunately had recurrence on follow-up imaging and ultimately, demonstrated no favorable response to sclerotherapy after subsequent treatments regardless of whether treatment was combined with ethanol/botox salivary gland injection. in summary, all patients who were successfully followed show no appreciable response to treatment for ranula or thyroglossal duct cyst. despite the emergence of clinical requests for sclerotherapy of ranulas and thyroglossal duct cysts, in our case series, sclerotherapy has not proven to be an effective treatment option using our current drug regimen. role of the susceptibility-weighted imaging (swi) in the neuroimaging of term newborns g. rudas, e. varga, p. barsi, l. kozák, Ü. méder; budapest/hu objective: susceptibility-weighted imaging (swi) was introduced in the neonatal neuroimaging only a few years ago. we can find only a few publications about its advantages and disadvantages. according to our experience, swi is extremely useful not only for detecting bleedings but for the diagnosis of other diseases as well. during the last year we had mri examinations on term newborns ( - days of life) and the swi gave additional information in cases. we used a t philips insignia scanner. in the case of the questionable hypoxic-ischemic-encephalopathy ( cases) and the metabolic diseases ( cases) we could find increased signal intensity in the cortex; in the case of stroke we could find the thrombus itself in cases; the avm were much clearer using the swi in cases; at the pvl in cases we could visualize the cysts better using swi; in the case of congenital heart disease ( cases) and in the case of sinus thrombosis ( ) we could find microbleedings and/or dilated veins; in cases the position of the lateral ventricle drain or shunt was much clearer using the swi. the swi gave important additional information in / ( %). the swi is a strongly recommended new sequence at the mri examination of the term newborns' brain. a disadvantage of swi is that it requires ca. three minutes examination time (in contrast to t * which is only minute long). mechanical birth-related trauma: imaging of the "accidents of birth" a. chaturvedi, j.g. blickman; rochester/us objective: . to discuss definition, incidence and risk factors leading to "mechanical birth-related trauma" and compare these with existing literature. offer an organ-system based classification scheme encompassing the varied manifestations of birth-related trauma and describing the implications on care decisions. materials: the hospital imaging department database was searched for neonates who presented with history of difficult/traumatic birth at our obstetric center between january , -june , . search software used was primordial customised radiology solutions, san mateo, ca. the search terms used were "macrosomia", "shoulder dystocia", "instrumental delivery", "malpresentation", "cephalopelvic disproportion", "forceps" and "vacuum". initial and follow-up imaging and clinical data on these neonates was reviewed and compiled by two board-certified pediatric radiologists. the relevant literature was reviewed and findings compared. organ-system based classification scheme for birth-realted trauma. in our study, mechanical trauma of birth was seen to manifest within different organ systems, which have been listed below in the order of occurrence within our sample. injuries to the skull (sutural overlap, dents and fractures), scalp hemorrhages (subgaleal hematoma, cephalhematoma, caput). intracranial intraand extra-axial hemorrhages (subdural, subarachnoid, epidural, intraparenchymal). clavicle fractures neonatal brachial plexus injury. sternocleidomastoid hematomas. adrenal hemorrhages. cervical spinal cord contusions. schematic diagram depicting intra-and extracranial hemorrhages by location. -year-old with history of calvarial fracture at birth-fracture did not heal but enlarged secondary to leptomeningeal entrapment at the fracture sitean entity called "growing fracture" or "leptomeningeal cyst". multiple newborn organ systems can be injured from mechanical trauma of birth. our numbers compare favourably with the existing literature. mechanical birth-related trauma can occur simultaneously with hypoxic-ischemic birth injury. although most of these injuries spontaneously and completely resolve, long-term complications can be seen in some cases. few of these injuries are life-threatening. imaging plays a crucial role in diagnosis and follow-up, and can assist in decision making as well as in counselling the parents. ewing sarcoma of tibia in an infant girl a. seehofnerova, j. skotáková, i. Červinková; brno/cz objective: ewing sarcoma (es) is the second most common primary bone malignancy in children. it histologically originates from neuroectodermal tissue and consists of small round blue cells. ewing tumour family is very close to primitive neuroectoderm tumour (pnet) family with diverse stage of differentiation, ewing sarcoma being less differentiated. approximately % of the cases occur between ten and twenty years of age with slightly higher prevalence in male gender. nine-month-old caucasian girl presented to local surgery department after she had wedged her lower leg in a bed. the right lower leg was swollen and painful. she was initially diagnosed with a ligament injury and underwent standard treatment. oedema gradually disappeared, but swelling and pain increased after three weeks. she also suffered from a fever of . °c ( . o f). at that point x-ray of her right lower leg was performed with report describing pathologically changed structure of tibia and she was referred to our university centre. ( ) (suppl ):s -s pediatr radiol we made a second reading of the plain film, reporting sclerotic heterogeneous bone structure of the right tibial diaphysis and distal metaphysis, onion-like periosteal reaction with sunburst spiculation and cortical bone destruction. her laboratory results were: crp . mg/l, ld . μkat/l, nse . μg/l, ferritin μg/l. crp has been raising for a week to mg/ l, then decreased to normal level. differential diagnosis was established as a primary bone malignancy (especially es) or, less likely, an osteomyelitis. mri revealed pathological signal of bone marrow of diaphysis of the whole tibia with cortical scalloping and periosteal spiculated apposition. epiphyses were spared. dorsal cortical bone was interrupted with extraosseal spread of the process. intraosseal part enhanced heterogeneously, whereas extraosseal component enhanced almost homogeneously after contrast medium administration. total size of the tumour was assessed as x . x mm ( . ml) . adjacent muscles were oedematous with post-contrast enhancement. there were also few enlarged lymph nodes in popliteal region. results from the biopsy confirmed ews with positive ews/fli gene. tumour was assessed as a localized disease, enneking iib. patient underwent chemotherapy according to aews doc protocol and a knee-exarticulation with no traces of tumour in resection lines. nowadays she is in the first complete remission. x-ray: ap view mri: etw _tse postcontrast, sagittal view, pre-treatment mri: etw _tse postcontrast, sagittal view, after initial treatment unique teaching points: ewing sarcoma belongs to common primary bone tumours in children but is a very rare unit in infants. despite the age predilection it is necessary to consider this diagnosis even in children younger than one year of age. scimitar syndrome together with pulmonary sequestration and horseshoe lung: congenital pulmonary venolobar syndrome b.e. derinkuyu, h.n. Özcan, y. tasci-yildiz, h g. cınar, u.a. orun; ankara/tr objective: congenital pulmonary venolobar syndrome (cpvls) comprises of a spectrum of pulmonary developmental anomalies. the main components of cpvls are hypogenetic lung partial anomalous pulmonary venous return, absence of pulmonary artery, pulmonary sequestration, systemic arterialization of lung, absence of inferior vena cava. minor components of cpvls include tracheal trifurcation, eventration and partial absence of the diaphragm, phrenic cyst, horseshoe lung, esophageal and gastric lung, anomalous superior vena cava, and absence of the pericardium. in this case presentation, we present a baby with scimitar syndrome, pulmonary sequestration, horseshoe lung and right aberran subclavian artery. a month-old girl was admitted to our hospital with the suspicion of scimitar syndrome from a different hospital. she did not have any symptoms. the physical examination was unremarkable. on plain radiograph, the baby had dextrocardia. there was a doubtful tubular structure with the shape of scimitar and a nodular radioopacity behind the heart (figure ). transthoracic echocardiography demonstrated the dextrocardia, atrial septal defect and the right pulmonary artery hypoplasia. afterwards, the ct angiography was done for confirmation of scimitar syndrome and other accompanying abnormalities. on the ct angiography, there was a partial anomalous pulmonary venous return to the suprahepatic inferior vena cava known as scimitar syndrome. besides this, there was a right pulmonary extralobar sequestration in the lung base. the arterial supply was arising from the celiac trunk, while the venous drainage was going directly to the inferior vena cava. therefore, the right lung was hypoplastic of which the tongue of the right pulmonary parenchyma passing between the aorta and heart, appearing confluent with the left lung in a horseshoe configuration. there was dextrocardia and right aberran s ( ) (suppl ):s -s pediatr radiol subclavian artery. the patient was subjected to catheterization and angiography for treatment. on plain radiograph, the baby had dextrocardia. there was a doubtful tubular structure with the shape of scimitar and a nodular radioopacity behind the heart unique teaching points: the term cpvls is an umbrella to a group of pulmonary parenchymal and vascular anomalies that may present in combination. mdct is a helpful diagnostic tool in the preoperative evaluation for delineation of the components of this syndrome. congenital pulmonary venolobar syndrome refers to a wide spectrum of pulmonary developmental anomalies that may appear single or in combination. the main components of congenital pulmonary venolobar syndrome are hypogenetic lung (including lobar agenesis, aplasia, or hypoplasia), partial anomalous pulmonary venous return, absence of pulmonary artery, pulmonary sequestration, systemic arterialization of lung, absence of inferior vena cava, and accessory diaphragm. in this case presentation, we describe a child with scimitar syndrome, bilateral sequestration, hypogenetic lung (single lobed left lung) and right aberran subclavian artery. an year-old syrian girl was admitted to our hospital with the history of heart defect. she did not have syncope or ciyanosis whereas she has easy fatigue and palpitation. on plain radiograph the anomalous draining vein was seen as a tubular structure paralleling the right heart border in the shape of a turkish sword ("scimitar") ( figure ) . transthoracic echocardiography demonstrated the scimitar vein as well as large patent ductus arteriosus (pda), atrial septal defect and left pulmonary hypoplasia. afterwards, the ct angiography was done for confirmation of scimitar syndrome and other accompanying abnormalities. on the ct angiography, there was a partial anomalous pulmonary venous return to the suprahepatic inferior vena cava known as scimitar syndrome. besides this, there was a bilateral intralobar pulmonary sequestration in the lung bases. the arterial supply of the right side was arising from the celiac trunk, while the left side feeding artery was originating directly from the descending aorta. therefore, the left lung had a single lobe with single pulmonary vein draining to left atrium. there was a large pda and right aberran subclavian artery. the patient was subjected to catheterization and angiography for treatment. the right sided anomalous draining pulmonary vein and the feeding artery of the right sequestration were closed in the first session. the procedure was completed without any complication. afterwards, the closure of the feeding artery of the left pulmonary sequestration and the pda were planned in the next sessions. on plain radiograph the anomalous draining vein was seen as a tubular structure paralleling the right heart border in the shape of a turkish sword ("scimitar") unique teaching points: congenital pulmonary venolobar syndrome comprises a heterogeneous group of uncommon abnormalities that may occur in combination. diagnosis of congenital pulmonary venolobar syndrome can be confirmed by ct angiography that allows detailed evaluation of vascular, tracheobronchial, and pulmonary parenchymal abnormalities with a single short, noninvasive procedure. neck infection disclosing diagnosis of congenital fourth branchial arc anomaly in a girl h.n. Özcan, z. aycan, b. ardıclı, m. haliloglu; ankara/tr objective: congenital branchial arc anomalies are rare entities. herein, we describe the imaging findings of acute suppurative infection of the neck caused by fourth branchial fistula in a child. case presentation: an -year-old girl presented to our pediatric emergency department with fever, left sided neck swelling and redness. her complaints were started five days ago. on her physical examination, there was a x cm, stiff, painful mass lesion with redness on the left side of the neck. blood count and thyroid function tests were in normal range; however, c-reactive protein level and erythrocyte sedimentation rate were elevated. neck ultrasonography revealed diffuse soft tissue swelling, a hypoechoic mass consistent with abscess in the left thyroid lobe and perithyroid tissue. the left lobe of the thyroid gland had poorly defined margin and a focus of air. contrast-enhanced neck mr imaging demonstrated an abscess in the left thyroid and perithyroid tissue ( figure ) and enhancement of the soft tissue plane around the left pyriform fossa (figure ). barium swallow revealed the sinus tract originating from the left pyriform sinus apex. the patient was operated after antibiotic treatment and sinus tract was surgically excised. the aim of this report is to describe three cases of right kidney wilms' tumor with cavoatrial tumor extension, referred to our institution between january and september . case presentation: three children, two girls ( and years old) and one boy ( years old) were admitted at the emergency service with cardiac failure symptoms; the latter had also liver failure. echocardiography showed right atrial thrombus in all three patients, as an extension of massive obstructive thrombosis of the inferior vena cava (ivc). abdominal ultrasonography revealed in all patients a right renal mass, associated to right renal vein thrombosis that extended to the ivc and to the right hepatic vein. contrast enhenced computed tomography confirmed findings. patients were treated primarily with chemotherapy before surgery, with partial regression of the thrombus in two patients and no response in one. ( ) (suppl ):s -s pediatr radiol unique teaching points: wilms' tumor is the most common renal malignancy in children and its intravascular extension is a well-recognized event. incidence of tumor extension to inferior vena cava (ivc) is reported to be of - % and intra-atrial extension of , - , %. it occurs most commonly in tumors located in the right kidney (probably due to the shorter path of the right renal vein compared to the left one). this complication does not directly influence the prognosis of malignancy, but the degree of intravascular extension determines technical surgical strategy and increases difficulty of the surgical procedure, especially when there is intracardiac involvement, which increases morbidity. several classifications have been proposed in the adult age group, but due to the similarity of the degree of intraoperative difficulty, the same classifications are used in children. pritchett et al. ( ) described the relation between thrombus and hepatic vessels: level i -intrahepatic intravascular extension; level iiintrahepatic extension; and level iii -suprahepatic or atrial extension. staehler et al. ( ) proposed a different classification that was posteriorly modified and detailed by daum ( ) : stage i -small extension (thrombus size within ivc < cm); stage iilarge thrombus (> cm within the ivc), but still below the hepatic vessels; stage iii -thrombus extending to the level and above the hepatic vessels; stage iv -intra-atrial thrombus. a year old boy presented with a soft tissue mass in his forearm which appeared to have grown quickly in size over a period of three to four months. physical examination demonstrated a welldefined mass in the dorsal aspect of the forearm with no pulsatile bruit. intial differentials included a vascular anomaly or a sarcomatous lesion. the patient proceeded to have an ultrasound examination which revealed a very well-defined heterogenous subcutaneous mass, mostly solid in substance. the lesion measured . cm x . cm x . cm (transverse x length x depth). there was no evidence of muscle invasion. prominent internal arterial vascularisation was demonstrated and the mass was classed as inderminate in nature. subsequent mr findings demonstrated a mass with t signal isointense to muscle, hyperintense t signal and marked homogenous enhancement. small foci of intralesional t hyperintensity and larger areas of t * gradient hypointensity were noted, in keeping with small areas of intralesional blood. vessels were seen to extend from the subcutaneous fat into the lesion. the mass slightly distorted the underlying extensor muscles and tendons of the forearm but there was no deep extension across the fascia. findings deemed the lesion to be more malignant in nature. the patient underwent incisional biopsy and histological findings confirmed a diagnosis of angiomatous fibrous histiocytoma. these tumours are rare soft tissue tumours which most commonly occur in children, adolescents and young adults. while it is rare, there is a potential for local recurrence and metastasis. therefore, it is essential to identify these tumours where possible or at least consider them as a differential for a soft tissue mass in a child. the surgeon commented that the imaging findings and report were essential in making the initial decision about whether to perform an incisional or excisional biopsy as the best treatment for the tumour is wide surgical excision with clearance of margins. unique teaching points: angiomatous fibrous histiocytomas are rare lesions with potential for recurrence and metastasis and therefore should be identified and managed appropriately as a malignant tumour. they are often confused as soft tissue haemangiomas or complex haematomas. it is very important to be aware of the presentation and imaging findings, remembering this form of tumour as a key differential for a soft tissue mass. nasopharyngeal anlage tumor in a neonate with the initial presentation of respiratory difficulty: correlation between imaging and clinicopathologic findings p.-s. tsai, d.-c. lin, s.-l. shih; taipei/tw the etiologies of nasal or nasopharygeal obstruction are variable in neonates. the respiratory symptoms are varied in these cases. mass lesions in nasal cavity or nasopharynx are extremely rare during the neonatal period. however, we must keep it in mind when respiratory problems occur in the neonatal period. here, we report a case presenting with sleep apnea resulting from nasal obstruction by a rare benign salivary anlage tumor in nasopharynx and discuss the imaging findings as well as clinicopathologic characteristics. the -day-old female infant had loud breathing sound, slow feeding and sleep apnea since birth. nasal endoscope and laryngoscope disclosed a polypoid tumor in nasopharyngeal cavity with a stalk connecting with posterior nasal septum. further magnetic resonance imaging (mri) revealed a lobulated mass about . cm in greatest diameter occupying posterior nasal cavity to the nasopharynx that was intermediate signal intensity on t -weighted/t -weighted images and heterogeneous gadolinium enhancement. the patient then received endoscopic resection. the tumor was shown locating in nasopharyngeal cavity and having a stalk from posterior nasal septum, partially occluding the choanae as well. resected tissue fragments displayed tan and whitish in color grossly. microscopic examination demonstrated duct-like structures and mesenchymal elements in a nodular pattern which are typical features of salivary gland anlage tumor. until now, there is no tumor recurrence for four years. unique teaching points: "salivary gland anlage tumor (sgat)" was firstly introduced in a report by dehner et al in . the tumor that has histologic resemblance to the developing salivary gland, is believed to be a hamartoma originating from minor salivary gland rather than a true neoplasm. congenital sgat displays male predilection and is a rare cause of neonatal airway obstruction. the mass is usual in the midline and attached to the posterior nasal septum or posterior nasopharygeal wall by a delicate pedicle. favorable results with simple excision are obtained. once massrelated airway obstruction is established, further examination with computed tomography (ct) or mri is helpful in anatomic evaluation, size measurement, characteristics definition and intracranial involvement. if mass induced airway obstruction is suspected in a neonate and sgat is considered based on imaging studies, invasive procedure should be careful due to the potential of tumor dislodgement from its fine pedicle resulting in complete airway obstruction. the association of intussusception with malrotation is referred to as waugh syndrome. [ ] malrotation occurs in approximately in live births. [ ] the incidence of malrotation amongchildren with intussusception is %. we hereby present a case report of waugh's syndrome associated with midgut volvulus. case presentation: a month old male child reported to the emergency department with the clinical history of vomiting, abdominal distension, bloody mucoid stools and incessant cry. routine blood examination revealed hb: . gm%, tlc: /cu mm, plt- . lac/cu. mm. ultrasound (us) examination was performed and it revealed dilated fluid-filled small bowel loops with moderate amount of free fluid, right iliac fossa showed bowel within bowel appearance suggestive of target/pseudo kidney sign of bowel intussusception. no pathologic lead point was identified. transverse ultrasound image through the upper abdomen showed superior mesenteric vein noted to the left of the superior mesenteric artery hence malrotation should be considered. in view of surgical emergency non contrast enhanced ct was done and axial image showed target/sausage shaped soft tissue density mass it had alternating areas of low and high attenuation due to bowel wall and mesentry. on emergency laparotomy patient was found to have intestinal malrotation with duodenojejunal junction on the right of the midline and mid gut volvulus in clockwise direction. intussusception with terminal ileum (gangrenous), caecum, appendix, whole of ascending colon, transverse colon were telescoping into descending and sigmoid colon. the volvulus was derotated and the in tussusceptum was reduced. the gangrenous terminal ileum and appendix was resected and ladd's procedure was done, a diverting ileostomy was created. the patient recovered uneventfully after which an ileo-colonic anastomosis was created transverse ultrasound shows a mass with a swirled appearance of alternating hypoechoic and hyperechoic "bowel-within-bowel" appearance (target sign) unique teaching points: on ultrasonography multiple, concentric, target like appearance of wall layers of invaginated segments (target sign) on axial scan, as well as pseudokidney sign (sandwich sign) on longitudinal scans were accepted as diagnostic criteria for intussusception. [ ] it can assess the relative positions of the smv and sma which are mostly abnormal in malrotation. upper gastrointestinal contrast study is the imaging reference standard for diagnosis of malrotation with or without volvulus. abnormal position of the duodeno-jejunal junction. spiral, "corkscrew" or z-shaped course of the distal duodenum and proximal jejunum, and location of the proximal jejunum in the right abdomen. [ ] a high degree of clinical suspicion and radiologist's awareness of this entity is helpful in guiding the surgeons towards diagnosis and prevention of morbidity and mortality. a rare case of epidermal naevus syndrome p. joshi; pune/in to acquaint the radiologists with the entity of epidermal nevus syndromes (enss) which are a group of rare complex disorders characterized by the presence of skin lesions known as epidermal nevi associated with additional extra-cutaneous abnormalities, most often affecting the brain, eye and skeletal systems case presentation: this one and a half year old child was referred to us for neuroimaging. he had multiple hairy naevi over his face, limbs including the palms, since birth, associated with blackish discolouration of his entire trunk. unique teaching points: epidermal nevi are overgrowths of structures and tissue of the epidermis, the outermost layer of the skin. the different types of epidermal nevi can vary in size, number, location, distribution and appearance. neurological abnormalities that can be associated with enss can include seizures, cognitive impairment, developmental delays and paralysis of one side of the body (hemiparesis). skeletal abnormalities can include abnormal curvature of the spine, the term "epidermal nevus syndrome" has generated significant controversy and confusion in the medical literature. originally, the term was used to denote a disorder that was actually several different disorders erroneously grouped together. in the recent past, the term was used to denote a specific disorder now known as schimmelpenning syndrome. however, the term epidermal nevus syndrome could be correctly applied to several different disorders. therefore, the umbrella term "epidermal nevus syndromes" now represents a group of distinct disorders that have in common the presence of one of the various types of epidermal nevi. however, there is so far no general agreement how to classify the types of this diverse group of disorders, adding to the confusion within the medical literature. these disorders are quite different from one another and are not "variants" of each other as is sometimes mistakenly stated in the medical literature. in the future, as the genetic molecular basis of these disorders is better understood, the classification may change or expand. bilateral axillary lump in a newborn diagnosed as hematoma h.n. Özcan, u. aydingoz, m. haliloglu; ankara/tr objective: most birth traumas are self-limiting and have a favorable outcome. injuries to the infant that result from mechanical forces during the birth process are not uncommon. they occur most commonly on head and neck after vaginal breech delivery. however, soft tissue hematomas can be rarely seen after caesarian section (c/s). herein, we describe imaging findings of a newborn with bilateral axillary lump diagnosed as hematoma. case presentation: a -year-old woman was admitted to an outside hospital at weeks' gestation for c/s due to prior caesarean operation. it was her fourth pregnancy (g p ). the pregnancy was unremarkable and she had normal ultrasounds at gestation. there was no history of trauma or fall during antenatal period. according to the c/s reports, the process of operation was uneventful any undue prolongation and without having used any other instrumentation. the weight of the female baby was . kg at birth. on the rd postnatal day, her mother noticed a left axillary swelling, then admitted to a tertiary children's hospital. her physical examination revealed, bilateral axillary asymmetry with a fluctuant, nontender swellings. there was no redness or discoloration of the skin. there was no clinical feature suggestive of trauma or bleeding diathesis. a superficial ultrasonography showed solid heterogeneous, hyperechogenic masses x mm in the left axillary region and x mm in the right side. doppler study did not reveal any flow in the masses. contrast enhanced mr imaging demonstrated, bilateral axillary mass lesions with fluid levels and smooth contours (figure and ) . t w images demonstrated hyperintense component suggesting hemorrhage. after the administration of the gadolinium-based contrast material, lesions showed peripheral enhancement (figure ) . a diagnosis of hematoma was entertained. the child was managed non-operatively. she was monitored clinically and radiologically. follow-up ultrasounds scan revealed significant regression of the swellings. unique teaching points: soft tissue hematomas can be rarely seen in newborns. the formation of axillary hematoma on the background of c/s is a rare complication, which, to the best of our knowledge, has not been previously reported. ultrasonography and mr imaging readily depicts hematoma and aids in the differential diagnosis. colorectal carcinoma (crc) is extremely rare in pediatric age, with an estimated annual incidence of approximately case per million individuals. the majority of reported cases occur in adolescence, while the incidence is further lower for children under years. the distribution between males and females is not equal, with higher prevalence in males (ratio of : ). the etiology in children is unclear as these tumors are often sporadic and not linked to a preexisting adenomatous polyp, unlike adults. predisposing factors such as familial polyposis of the colon, other polyposis syndromes, ulcerative colitis and familial multiple cancer syndromes were reported in % of cases. advanced stage at diagnosis, aggressive histologic subtypes (poorly differentiated, signet ring and mucinous adenocarcinoma) and poor survival are the hallmarks of pediatric crc. case presentation: a -year-old male presented with a history of dyspeptic symptoms (recurrent epigastric-right flank colic pain and heartburn) for the last eight months, without evidence of irregular bowel function. after a prior diagnosis of esophagitis secondary to a gastroesophageal reflux disease, physical and laboratory examinations revealed anorexia, progressive body weight loss, microcytic iron deficiency anemia and positive fecal occult blood test. during an emergency access, abdominal ultrasound identified rounded target liver lesions and circumferential heterogeneous mural thickening of the ascending colon. contrast-enhanced computed tomography scan (cect) demonstrated a marked circumferential wall thickening of the ascending colon and cecum with a longitudinal extension of mm and thickness of mm; the mass contained lowdensity areas and calcifications. furthermore hypovascular hepatic lesions along with lymph node metastases containing calcifications were identified. no lung metastases were found. histopathological analysis confirmed the diagnosis of metastatic colon adenocarcinoma. after chemo-and radio-therapy, only the hepatic lesions showed reduction in size and number. the patient subsequently underwent right hemicolectomy. one month after surgery he is in a rigorous follow-up through ultrasonographic evaluation of pleural effusion and ascites and cect. unique teaching points: crc, although rare, should be suspected in children presenting with unexplained persistent abdominal pain, progressive body weight loss and positive fecal occult blood test. ultrasound imaging can be appropriate in the preliminary detection of abnormal bowel wall thickening, lymph node and liver metastases; cect is mandatory to confirm the radiological diagnosis and complete the staging. to increase awareness of this rare syndrome and its varied presentation in order to facilitate its early diagnosis and treatment to prevent poor prognostic outcomes. case presentation: lemierre syndrome is a rare disease characterized by an initial infection of the head and neck leading to the development of a septic thrombophlebitis which has a propensity to spread and involve the jugular and facial veins. this progressive infection then leads to the development of metastatic septic emboli to the respiratory tract. we present the case of a year old boy who attended with a week history of fever and a cough. initial imaging on admission demonstrated a large left sided hydropneumothorax with multiple cavitating lesions throughout the lung parenchyma in addition to thrombosis of some of the segmental pulmonary veins. the hydropneumothorax was surgically drained and the patient was transferred to the paediatric intensive care unit after further deterioration with the development of a broncho-pleural fistula. following a short course of antibiotics there was no clinical or radiological improvement and sputum cultures grew coliform organisms which raised suspicion for a more distant source. when pus was noted to be discharging from the left ear, a contrast enhanced ct of the head and neck revealed a left mastoiditis with multiple cerebral abscesses and occlusive thrombi in the left jugular vein, transverse venous sinus, sagittal and straight sinuses. following this diagnosis antibiotic therapy was modified and targeted at anaerobes, which was vital in assisting the patients recovery and successful discharge home. unique teaching points: clasically the majority of lemierres syndrome begins in the oropharynxinvolving the palantine tonsils and peritonsillar tissue often presenting with fever, sore throat and neck pain. our case demonstrates an atypical presentation with sepsis and respiratory symptoms as a result of the septic emboli which delayed diagnosis. we have learnt from this case the importance of considering lemierres syndrome in patients presenting with signs of a respiratory infectionin particular cavitating pulmonary lesions-that have not improved with conventional therapy and to have a low threshold to investigate the head and neck as a potential source of infection. when the working hypothesis of meningitis could not help e. kovacs , n. pinter , g. balázs , a. machovitsch , a. arany , z. liptai , l. fonyad , p. benke ; budapest/hu, amherst/us objective: neuroinfection still represents a diagnostic challenge in the everyday practice, where clinical evaluation, imaging, laboratory and pathological workup and treatment goes hand in hand under the pressure of time. we summarized a case in which, despite the extensive multilateral collaboration the battle was lost, to bring attention to the possible causes. a two year old, previously healthy female was taken to the emergency department for altered state of consciousness and fever. she also suffered from gingivitis. the unconscious child underwent an emergency ct scan: hydrocephalus with signs of raised intraventricular pressure was detected. subsequently mri of the head and spine was performed, and showed signs of diffuse leptomeningeal enhancement with basal predominance. multiple dwi restricted parenchymal lesions with basal predominance were also found. repeated csf and blood tests did not reveal any causative organism, although the gradually increasing crp suggested infection. two weeks after the onset of symptoms a follow up mri study showed extensive cerebral and spinal swelling with no focal lesion. the child passed away three days later due to cardiac failure. autopsy and neuropathological evaluation could not reveal the cause of the disease, which was identified only weeks after the child died, by culturing sputum and csf. unique teaching points: an overview of the clinical and radiological presentation of meningitis basilaris is carried out. attention is given to the circumstances, when tuberculotic infection should be suspected, and antituberculotic treatment should be started, even before the confirmation of the presence of mycobacteria can be obtained. to describe the clinical, laboratory and mri findings of chronic nonbacterial osteomyelitis(cno) in a patient with a negative radiograph and emphasize useful imaging findings, including an unusual radial pattern of edema in both femoral heads. case presentation: a -year-old adolescent, was referred with progressive debilitating hip pain and inability to walk since days, that was unsuccessfully treated with non-steroidal anti-inflammatory drugs. during hospitalization he developed fever up to ο with normal full blood count and smear, elevated esr ( mm/h) and crp ( . mg/dl), positive serologic markers for streptococcus (asto) and ebv and received antibiotics with relative good response. blood cultures did not grow any pathogens, the rest of serology was negative for acute infection, tuberculin skin test was negative and immunological investigation was unremarkable. pelvic radiographs were negative. mri showed a symmetric pattern of bone marrow involvement around both triradiate cartillages, at both femoral heads and ( ) (suppl ):s -s pediatr radiol major trochanters. complementary evaluation of tibial areas with a limited protocol disclosed asymptomatic involvement of tibial epiphyses and apophyses. a radial pattern of edema was seen at the femoral heads with alternating stripes of involved and uninvolved areas. clinical course and imaging appearances were highly suggestive of cno. rapid clinical improvement occurred during hospitalization while a repeat mri months later showed complete resolution of hip findings and the patient was free of any symptoms or signs. coronal stir sequence at presentation showing the radial pattern of bone marrow edema (arrowheads) alternating with stripes of normal marrow (*) at both femoral epiphyses. note hyperinense edema (arrows) around triradial cartillages. coronal stir sequence showing the predilection of bone marrow edema symmetrically around triradial cartillages (arrows) and at major and minor trochanters (arrowheads). coronal stir sequence at -months follow-up shows resolution of edema. unique teaching points: cno is a not well known chronic autoinflammatory bone disorder affecting primarily children and adolescents. positive serology for streptococcus or other infectious agents has been previously reported as in our case and may be a triggering factor. striking mri findings with a negative radiograph may occur at initial stages. symmetrical distribution of non-specific bone marrow edema around epiphyses and apophyses is highly suggestive of the diagnosis in the appropriate clinical setting and following exclusion of suppurative bone infections as well as bone or hematologic malignancies. the radial pattern of edema in our patient is unusual and considered to comply with the direction of main trabecular systems in femoral heads. in / chest cts, nodules (median size . mm) were detected. display mode a with mm mip yielded the best interreader variability (κ= . ) and the highest sensitivity ( . %) compared to mode b and c (κ= . , sensitivity . % and κ= . , sensitivity . %, respectively). perifissural nodules were detected in all subgroups. conclusion: mip improves the detection of pulmonary nodules in chest cts of young children, but overall interreader agreement is only fair. nodules, including perifissural nodules, occur in children with and without malignancy. images were subsequently read and interpreted by board-certified radiologists and nuclear medicine physicians in communal reading. in case of identifying suspicious lesions in cect additional imaging (mri) or biopsy was performed. compared to pet/ct employing only low dose ct (ldct), the use of cect resulted in the identification of additional suspicious lesions in patients. furthermore the use of cect allowed us to qualify lesions as benign/ physiologic which in pet/ldct were identified as suspicious and lesions suspect for metastases or tumor. in those patients who received combined integrated fdg pet/ct including both ldct and cect the ctdi ranged in between , - . mgy (n= . mgy) and the dose length product (dlp) ranged in between . - mgy *cm (n= . mgy *cm) specificity was significantly higher combining pet and ct compared to stand-alone ct and pet. our study showed that the acquisition of cect in combined integrated pet/ct leads to an increased specificity and thus represents an essential component of a good fdg pet/ct in pediatric oncology. in assessment of lymph nodes, inflammatory foci and liver lesions diagnostic contrast enhanced ct is essential. comparison of the detectability of ubos in neurofibromatosis type i patients with proton density-weighted and flair sequences in t mri l. porto, s. lescher, n. hillenbrand; frankfurt/de objective: neurofibromatosis type (nf ) is an autosomal-dominant congenital disease. in nf patients, significant numbers of so-called unidentified bright objects (ubos) can be found in brain imaging, with predilection sites at the basal ganglia and the dentate nucleus. ubos seem to develop at a very early age, contrary to other criteria leading to diagnosis. the detection of ubos might therefore prove helpful in the early diagnosis of nf , complementing the clinical diagnosis based on criteria of the "national institutes of health consensus development conference". the aim of the study was to investigate whether the detectability of ubos increases at t by comparing proton density-weighted images (pdw) with fluid-attenuated inversion recovery (flair) sequences. a total of nf patients ( male, female, between and years old, mean age . years) were examined by a t magnetic resonance scanner. the presence of ubos was evaluated on pd-w and flair images by evaluators ( experienced neuroradiologists, junior radiologist and student in his final year). detectability was rated by a three-point scoring system for dedicated regions: lesions which were "well defined/detectable", "suspicious" or "detected after a second look". the wilcoxon signed-rank test was used for comparisons between the raters. the level of significance was p< . . significantly more lesions were marked as "well defined/detectable" in the pd-w sequence compared to flair (p< , for all four evaluators together, as well as for each evaluator separately). in particular, pd-w proved to be superior for detecting ubos located in the medulla oblongata (p= , ) dentate nucleus (p= , ) and hippocampal region (p= , ), regardless of the level of the raters' experience. this is the first study that compares flair and pd-w at t for the diagnosis of ubos in nf . significantly more ubos are detected in the pd-w compared to flair sequences, especially for the infratentorial regions. as ubos occur at very early stages of the disease in patients with suspected nf , pd-w might aid an early diagnosis in these patients. assessment of radiation doses from diagnostic imaging in the followup of paediatric oncology patients p. logan , r. harbron , k. mchugh ; london/uk, newcastle-upon-tyne/uk objective: previous literature ( , ) has suggested paediatric oncology patients accumulate a large radiation burden as a consequence of routine diagnostic imaging examinations during therapy. we retrospectively looked at the effective doses from routine ct and nuclear medicine in three cohorts of children, namely patients with hepatoblastoma, wilms' tumours and rhabdomyosarcoma (rms). of note, in our centre we rely on repeated mris of the primary site for many tumours. effective doses (e), in millisieverts (msv), were estimated using the ncict dose estimation tool (lee et al ) , based on details specific to each procedure: patient age, scan region, scanner type and ct dose index (ctdi -an indicator of radiation exposure recorded at the time of each scan). doses for general radiography were estimated using pcxmc v . monte carlo simulations, assuming standard exposure factors and field size. there were patients in total ( hepatoblastoma, wilms', rms). there were boys. the mean age was years months (ranging from days - years months). the mean and median cumulative effective doses from ct for the whole cohort were . msv and . msv respectively. four patients in the wilms' cohort had a dmsa nuclear scintigram ( . - . msv), no hepatoblastoma patient had any nuclear medicine imaging, and patients with rms received a bone scan ( - . msv) or a pet scan (approximately msv). cumulative radiation doses from routine radiological investigations in paediatric oncology can be kept in a much lower range than reported in the literature ( , ). in our institution, the followup of solid intra-abdominal tumours with mri, with additional ct or nuclear medicine only when clinically justified, has resulted in a significantly low radiation exposure in these patient cohorts. mri of the primary tumour site should be implemented as a replacement for ct imaging when there is no significant detriment to the diagnostic information obtained. ( ) (suppl ):s -s pediatr radiol mri-based evaluation of multiorgan iron overload is a predictor of adverse outcomes in pediatric patients undergoing allogeneic hematopoietic stem cell transplantation f. zennaro , d. zanon , r. simeone , g. boz , f. degrassi , m. gregori , g. schillani , c. boyer , n. maximova ; nice/fr, trieste/it objective: iron overload is associated with poor clinical outcomes in patients undergoing allogeneic hematopoietic stem cell transplantation (hsct). although the effects of hepatic and cardiac siderosis on patient outcomes have been extensively studied, less is known about the effects of siderosis in other organs. the medical records of consecutive pediatric patients who underwent allogeneic hsct in our institute from to were retrospectively reviewed. mri was used to measure iron concentrations in the liver, spleen, pancreas and bone. these patients were divided into two groups, with non-elevated (< μmol/g; group ) and with elevated (> μmol/g; group ) liver iron concentration (lic) at baseline. in group , only two patients had normal iron concentrations in all organs. none of the patients of group presented with pathological iron concentrations in only two organs. comparisons of baseline data with results of the first follow-up mri performed - months after hsct, showed a general worsening of iron accumulation. in group , none of the patients showed complete absence of iron overload in a single organ. in group , none of the patients showed a total absence of siderosis involving fewer than three organs. this study confirms the correlations between iron overload and the risks of transplant-related complications, such as transplant related mortality, sinusoidal obstruction syndrome, infections, pancreatic insufficiency, and metabolic syndrome, in transplant recipients with systemic siderosis. another important finding of this study was the close correlations between pre-transplant bic and times to neutrophil and platelet engraftment (p< . each). ( ), ganglioneuromas (gn, ) and ganglioneuroblastoma (gnb, ), examined by t mri were retrospectively grouped according to tumor entity, risk factors (bone marrow metastasis, mycn amplification or p deletion) and therapeutic regime (observation versus chemotherapy). dw (b values , and ) and conventional mri images (t , t pre and post contrast) were analyzed for tumor size, relative si-and absolute adc-values at baseline (base; no therapy), and after (fu ) and (fu ) months. adc values in nb were lower than in gnb and gn ( . * - mm /s versus . * - mm /s; p< . ). there was a tendency towards lower adc values in tumors with risk factors (n= ) versus no risk factors (n= ) at baseline, which did not reach statistical significance (p= . ). during follow-up shrinkage of tumor volume was noted (baseline ml, fu ml, fu ml; p< . baseline vs. fu ; p= . baseline vs. fu ). in the observation group, tumor adc values rose without relapse ( . * - to . * - mm /s). only in eventually relapsing tumors adc values tended to decrease further ( . * - to . * - mm /s, p= . ), despite initial reduction in tumor size. to establish inter and intra-observer variability in the radiological detection and assessment of pulmonary nodules at diagnosis in children with wilms tumours. a test set of ct thoraxes at diagnosis from patients enrolled in the multicentre 'improving population outcomes of renal tumours of childhood' (import) study in the uk were assessed. five radiologists ( chest, paediatric) from different centres ( uk, netherlands) completed a scoring sheet for nodule assessment on the same studies on two occasions, months apart. the readers were blinded to patient respiratory symptoms, the original radiology reports and also that they were scoring identical cases. descriptive statistics, modified bland altman graph and fleiss kappa scores were used for statistical assessment. in total, different pulmonary nodules across the ct thoraces at both rounds were scored by at least one reader. ( %) were seen by at least one reader in round and ( %) in round , ( . %) nodules were seen by at least one reader in both rounds. only ( %) nodules were scored by all readers in round , ( %) by all readers in round , and ( %) nodules by all readers in both rounds. of the nodules seen in the first round, were measured to be > mm in at least one dimension and of these, were classified as malignant by all readers. the limits of agreement for mean difference in nodule size in anterior-posterior, transverse and longitudinal measurements were ± . mm, ± . mm and ± . mm respectively. the fleiss kappa scores ranked from poor to fair agreement for nodule border smoothness ( . ), nodule shape ( . ), solidity ( . ) and impression of malignancy ( . ). within the same readers for both rounds, nodule detection rates of agreement were between . - . %. the average intra-reader percentage of observed agreements for nodule border smoothness, shape, solidity and impression of malignancy were . %, . %, . % and . % respectively. conclusion: detection and characterisation of pulmonary nodules on ct thorax shows both intra-and inter-observer variability. this has important implications for the interpretation of metastatic disease at presentation. fever without a focus is defined as febrile illness without an initial obvious cause or localizing signs. our aim is to assess the diagnostic value of whole-body mri (wb-mri) in the diagnostic work-up of children with fever without a focus. we retrospectively searched for subjects who underwent wb-mri for fever without a focus. a total of children (m= , f= ), mean age . years (range: . - . ) were included. / ( . %) subjects were immunosuppressed and / ( . %) subjects were hospitalized at onset of fever. the reference standard was based on positive cultures, biopsy or surgery. when this was not possible, a probable diagnosis was made based on clinical follow-up or serology. initially, the wb-mri images were reviewed independently by pediatric radiologists blinded to all clinical information. at the end of each case the final diagnosis and the diagnostic category ( categories: a. normal, b. infection, c. oncologic, d. rheumatologic, e. miscellaneous) was recorded. this was followed by a consensus read for comparison with the reference standard. for statistical analyses all subjects were treated as fever without a focus. results: reference standard: the diagnostic category of the reference standard was as follows: infectious / ( . %), oncologic / ( . %), rheumatologic / ( . %), miscellaneous. / ( . %). even after extensive work-up in / ( . %) no clear cause for the fever was found table . wb-mri: wb-mri diagnosed the cause of fever without a focus in / subjects ( . %) ( table ). in subjects ( . %) wb-mri results were falsely positive ( jia and myositis), and in the remaining subjects no imaging findings compatible a cause of febrile disease were found. interobserver agreement was fair (kappa . ). in children with fever without a focus wb-mri provided the diagnosis in in almost a quarter of the cases. given the multiplicity of causes of fever without a focus, some of them not possible to visualize on mr imaging, wb-mri may be considered in routine imaging practice when evaluating pediatric patients with fever without a focus. to compare linear measurement/volume to direct volumetric measurements using dimensional( d) post-processing software. for this irb approved study initial diagnostic ct or mr exams in patients( mo- yr) with solid tumors were reviewed by radiologists and technologists. radiologists recorded measurements in axes in their routine method, described tumor shape (sphere, ellipse, cone) and surface texture (smooth, almost smooth, or mildly, moderately, markedly irregular). three technologists individually, and radiologists by consensus, used d processing software (intellispace portal, philips, cleveland, oh) to directly measure tumor volume. tumor volume (v) was calculated from linear measuments using the following equations: sphere v= / πr , ellipsoid v= πr or πr , conicalv= πr or πr , and cuboid v=(xyz). inter-reader variability in tumor measurement in all tumors and for tumors divided by surface characteristics was assessed amongst radiologists and technologists, and radiologist consensus using coefficient of variation (cov). tumor shape analysis was reported as sphere, ellipse, cone, and surface texture smooth, almost smooth, mildly irregular, moderately irregular, markedly irregular. inter-reader variability of as much as , cc above to cc below the mean tumor volume was found when using radiologist determined linear measurements, with standard deviation (sd), range . - . inter-reader variability amongst technologist derived volumes was considerably less, range cc above to cc below the mean, with sd, range . - . cov analysis shows a greater degree of variation in tumor volume calculated from linear measurements [smooth( %), almost smooth( %), mildly( %), moderately( %), markedly( %) irregular] than direct volume determination [smooth( %), almost smooth( %), mildly( %), moderately( %), markedly( %) irregular]. variation was significant only for tumor with irregular surface texture [smooth (p= . ), almost smooth (p= . ), mildly (p= . ), moderately (p= . ), or markedly (p= . ) irregular]. variation in linear/volume measurements in very irregular tumors. light blue=middle % tumor volume measurements by pediatric radiologists. whiskers mark limits of range. ▲♦ • markers =measurements by technologists. note broad degree of variation. ( ) (suppl ):s -s pediatr radiol variation in linear/volume measurements in almost smooth tumors. light blue=middle % tumor volume measurements by pediatric radiologists. whiskers mark limits of range. ▲♦ • markers =measurements by technologists. note narrow degree of variation. both graphs show the same informationthe % relative variation in tumor volume measurements determined by dimensional linear measurements ( pediatric radiologists) v. volumetric processing (technologists & consensus group). radiologist generated measurements are subjective and unreliable. variation in measurement technique leads to differences in calculated tumor volume which significantly over or under estimate volume in tumors with irregular texture and is not significant in smooth tumors. quail-quantitative mri-based evaluation of pancreatic iron overload in pediatric patients undergoing allogeneic hematopoietic stem cell transplantation f. zennaro , m. gregori , f. degrassi , e. cattaruzzi , y. diascorn , c. boyer , n. maximova ; trieste/it, muggia/it, nice/fr objective: iron overload (io) is a relatively common but often neglected transplantrelated complication and has been associated with poor prognosis in patients undergoing allogeneic hsct for hemato-oncological disease. pancreatic io is frequent among patients with transfusion-dependent anemias, but is uncommon among patients with hematologic malignancies. the causes of pancreatic io and the potential effects of pancreas iron deposits on transplant outcomes or on the risk of developing significant late effects in long-term hsct survivors have not been yet determined. our institute routinely uses magnetic resonance imaging (mri) with various gradient-recalled-echo (gre) sequences to quantitatively measure the iron concentration in abdominal parenchymal organs in all pediatric patients before and after allogeneic hsct. this study retrospectively analyzes the correlations of pancreas io with the type of conditioning regimen and pretransplant liver iron concentration (lic) in pediatric patients who underwent allogeneic hsct in our transplant unit over the last years. we enrolled patients, age - years. pre-transplant mean lic was , μmol/g (normal values μmol/g). ( %) patients had mild liver io and ( %) had moderate or severe io. pretransplant mean pancreatic iron concentration (pic) was , μmol/g, whose only ( %) had mild pancreatic io and none had severe io. post-transplant mean lic was , μmol/g, only one patient had mild liver io but patients ( %) had moderate or severe io. post-transplant mean pic was , μmol/g, ( %) patients had moderate or severe io. mean pre-transplant pancreatic volume was , cm , while mean post-transplant pancreatic volume (evaluated days after transplantation) was , cm . ( , %, p< , ) patients with post-transplant moderate or severe pancreatic io underwent tbi-based conditioning. mean reduction of pancreas volume in tbi group was , cm (p< , ). no pancreatic volume reduction was observed in chemotherapy-based group. all patients with pancreatic io have had exocrine pancreatic insufficiency and ( , %) patients have had metabolic syndrome. volume reduction well correlate (mean , %, p< , ) with pancreatic io. this study confirms that pancreatic iron overload is not so rare in patients with hematologic malignancy underwent allogeneic hsct, with increased risk of metabolic syndrome and total deficit of exocrine pancreatic activity, but not of endocrine activity. iron overload monitoring allows for chelation therapy optimization. mr is fast, reproducible and more reliable compared to serum ferritin and transfusional history and allows a multi organ evaluation. pulmonary tb is common in south africa, with many children affected. diagnosis can be challenging and chest x-ray remains fundamental for diagnosis. interpretation is difficult and shown to have wide inter-reader variability. no study however has compared cxr findings and interreader agreement between ambulatory and hospitalised patients. this study compares the frequency of cxr changes, as well as interreader agreement in ambulatory compared to hospitalised children with suspected tb. from nolungile clinic and red cross children's hospital respectively was done. each sample contained % proven tb and % negative controls. two paediatric radiologists and one paediatrician served as blinded, independent readers for the database using standardised ticksheets. our study demonstrated no significant difference in lymphadenopathy, but an increase in parenchymal change in the hospitalised group. we otherwise showed similar results to literature regarding finding frequency, but poor inter-observer agreement. if the least expert reader were removed, results were comparable with available literature. this highlights the need for development and study of explicit cxr criteria for lymphadenopathy to improve the value of cxr for paediatric tb in all settings. lung ultrasound in pediatric pneumonia -why is it necessary to use the additional trans-abdominal approach? j. lovrenski; novi sad/rs objective: to emphasize the need of lung ultrasound (lus) technique modification, which enables detection of pneumonia in children not visualized by using solely the standard trans-thoracic approach. a prospective study was carried out in the regional children's hospital, and comprised a -year period. the inclusion criterion was us finding of pneumonia detected by trans-abdominal, and not with trans-thoracic approach. lus examinations were performed using a combined, trans-abdominal and trans-thoracic approach. longitudinal, transversal (intercostal), and oblique sections were used. trans-abdominal examination included transhepatic and trans-splenic approach. the ultrasound probe was angulated from the most anterior to the most posterior sections while examining the lung bases by trans-abdominal approach. a pneumonia-positive lus finding included subpleural consolidation with air-bronchogram, or with an adjacent area of interstitial/ alveolar-interstitial edema. lus was always performed before the other diagnostic modalities (chest x-ray (cxr) and computed tomography (ct)), if they were indicated by pediatrician or radiologist. within a -year period in children (mean age . y, sd . y) the pneumonic focus was discovered using the trans-abdominal approach, while the trans-thoracic approach showed a normal lus pattern. all the children had the clinical symptoms of pneumonia (fever and cough, with or without dyspnea/tachypnea). the auscultatory finding was positive in children. cxr was performed in three children, showed a right-sided pneumonia in two, and was negative in one patient. one child had a contrastenhanced chest ct, which confirmed a left-sided pulmonary base abscess detected during lus examination by trans-splenic approach only (figures , ) . apart from pulmonary symptoms, there has not been any other associated diseases found, apart from otitis media in two children. each child responded to the antibiotics treatment with resolution of infection and us signs of pneumonia. in this oral presentation we will explain and give anatomical and technical reasons for pneumonia-positive us findings within lung bases, that remained undetected by the trans-thoracic approach. left-sided abscess abutted on the spleen (s), and was detected by trans-splenic us approach. it did not contact the pleural surface approachable by trans-thoracic ultrasound (black semi-lunar mark). l-liver. conclusion: trans-abdominal (trans-hepatic and trans-splenic) approach should become an inseparable part of each lus examination, along with a standard trans-thoracic approach. this modification of technique is expected to result in a further increase of lus sensitivity in diagnosing pneumonia. is thoracic ultrasound really competitive to computed tomography in children -a two-year retrospective study j. lovrenski, k. antolović; novi sad/rs to compare diagnostic accuracy of thoracic ultrasound (us) and computed tomography (ct) in children. a retrospective study was conducted in the regional children's hospital, and comprised a -year period. the inclusion criteria were: chest ct performed within h after the us examination of thorax, and us and ct examinations in the same patient performed by different pediatric radiologists. all us examinations were performed using a combined transabdominal-transthoracic approach. ct examinations were done ( ) (suppl ):s -s pediatr radiol according to the body mass based pediatric ct protocols. each hemithorax was analyzed separately in terms of comparison between us and ct findings. statistical analysis included the calculation of sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) of ultrasound in diagnosis of pulmonary pathological entities. out of children with chest ct, of them (mean age , y, sd , y) fulfilled the criteria to enter the study group. lung us showed sensitivity, specificity, ppv and npv in diagnosis of pleural effusion: %, , %, %, %; lung consolidation: %, %, %, %; lung abscess: %, %, %, %; and interstitial lung disease: %, %, %, %, respectively. within hemithoraces multiseptation of pleural effusion was observed by us only. air bronchogram within lung consolidation was observed in hemithoraces both by us and ct examinations. necrotic areas within pulmonary consolidations were detected by us in hemithoraces, which was later confirmed by ct examination. lung abscesses were diagnosed in hemithoraces by both us and ct. two small lung abscesses filled with air ( hemithorax) and bronchiectasis ( hemithoraces) were detected only by ct examinations. other pathological findings detected both by us and ct examinations were: congenital pulmonary airway malformation (cpam) ( hemithorax), pulmonary sequestration ( hemithorax), partial pneumothorax ( hemithoraces), hidropneumotorax ( hemithorax), inflamed pneumatocele ( hemithorax), hydatid cyst ( hemithorax), pericardial effusion ( patients), soft tissue masses of thoracic wall with initial bone destruction ( patients), and lymphomas ( patients) (figures - ) . in one patient us and ct revealed cysts and an extremely dilated bronchus within lung consolidation (pathohistological finding: cpam type combined with subsegmental bronchial atresia, and extensive bronchopneumonia). us examination, unlike ct, could not differentiate between eventration of the left hemidiaphragm and diaphragmatic hernia in one patient. to determine and compare the accuracy of frontal cxrs alone and 'combination frontal-lateral' set of cxrs for diagnosing lymphadenopathy in children with tb using patients with confirmed tb and controls without tb, and to compare findings in hiv-infected and hiv-uninfected children. a total of children (ie: children with gene xpert confirmed tb and control patients admitted with lower respiratory tract infections), which were part of a larger south african study, who had both frontal and lateral cxrs, were included. three qualified radiologists read the cxrs in separate sittings one month apart (one for the frontal x-ray alone and one for the 'combination frontal-lateral' cxrs) for the presence of lymphadenopathy. odds ratios and % confidence intervals were calculated to determine the presence of lymphadenopathy using a consensus reading on the frontal cxr and frontal-lateral cxr combination according to the final diagnosis of tb. inter reader agreement was determined using the kappa statistic. lymphadenopathy was reported in ( %) patients on the frontal cxr alone and in ( %) patients on the frontal-lateral cxr combination. ( %) of the patients with lymphadenopathy on the frontal cxr alone were gene xpert positive versus ( %) of the patients with lymphadenopathy on the frontal-lateral cxr combination. in all patients, the consensus reading using a frontal-lateral cxr combination resulted in a -fold increase (or , ; % ci , ) in calling lymphadenopathy compared to using a frontal cxr only in the gene xpert positive group, the consensus reading using a frontal and lateral cxr combination resulted in a fold increase (or , ; % ci , - , ) in calling lymphadenopathy compared to a frontal cxr only. overall inter reader agreement for all readers when evaluating for lymphadenopathy was 'fair' on both the frontal cxr (k= , ) and the frontal-lateral cxr combination (k= , ). the addition of a lateral view to the standard frontal cxr increased the rate of calling lymphadenopathy. however, the accuracy of diagnosing lymphadenopathy on chest x-ray as a marker for tb was poor. this poor accuracy was further hampered by only 'fair' inter reader agreement for the presence of lymphadenopathy on chest x-ray. dynamic d ct imaging in children has significant advantages over routine ct scanning, bronchography and bronchoscopy for diagnosing trachebronchomalacia because it can be performed during free breathing without anaesthesia or invasive airwayaccess.itcanalsodemonstratevascularcausesoftracheo-bronchomalaciain the same sitting. the technique is currently performed in paediatric center in the uk. we aimed to report pitfalls encountered while setting up a dynamic d ct imaging service for children and report the findings of studies performed. materials: dynamic d ctscanning was introduced after installation of a large array ( slice) ct scanner, applications specialist training and review of the literature. imaging parameters in use by greenberg and colleagues (arkansas children's hospital, usa) were applied. referral indications, pitfalls encountered, quality of scanning and imaging findings/diagnoses were reviewed and enumerated. results: nineteen paediatric dynamic d ct scans ( females, males; days - years months; mean months) were performed over months. the first studies were performed without ivi contrast due to lack of experience and subsequent studies were performed with contrast ( figure major pitfalls included initial failure to perform contrasted studies for simultaneous evaluation of vessels, initial failure to withdraw the endotracheal tube, patient motion under care of nurses and clinicians, failure to appreciate the value of imaging the full lung volume while trying to keep dose length product to a minimum and failure to appreciate that collapse of the airway is often in the ap plane and not appreciated on coronal slab projections -rotating d volume rendered images is a requirement ( figure ). additional obstacles were initial clinician and radiologist lack of support after early failures and colleague concerns regarding the radiation dose. objective: diagnosis of pulmonary tuberculosis (ptb) in children relies on chest radiography, however there is wide inter-observer agreement in detecting lymphadenopathy, the hallmark of ptb. paediatric airways are pliable, thus detection of airway compression may be a more objective criterion for the presence of lymphadenopathy. thus the objctive was to assess the usefulness of airway compression on chest radiographs for diagnosis of ptb in children. chest radiographs of children admitted to red cross children's hospital with suspected ptb were read by two readers according to a standardised format and a rd when there was disagreement. radiographs of children with definite ptb were compared to those with lower respiratory tract infection (lrti) from another cause. the prevalence and location of airway compression was evaluated. findings were correlated with hiv status and age. inter-observer agreement was assessed using kappa statistic. . % in older children (or . ; %ci . - . ). no association with airway compression and hiv infection was found. inter-observer agreement ranged from . - . . eighteen-month-old male patient diagnosed with ptb; hiv negative. majority agreement of airway compression at lmb indicative of lymphadenopathy. left upper lobe opacity is in keeping with a ghon focus. there is a strong association between airway compression on chest radiographs and confirmed ptb, particularly in infants, irrespective of hiv status. however, clinical use is limited by poor inter-observer agreement. paediatric ultrasound-guided biopsies in a tertiary oncology centre: five years experience n. parvizi, m. smedley, s. chakraborty; oxford/uk objective: histological diagnosis is almost always essential to guide appropriate therapy for children diagnosed with cancer. tissue can either be obtained by surgical/open or image-guided percutaneous biopsy. the aim of this study is to assess the safety and diagnostic accuracy of ultrasound-guided biopsies in a tertiary oncology referral centre. a retrospective analysis of clinical data, imaging findings and histological diagnosis of patients aged to years between january and december was carried out. a total of ultrasound-guided biopsies were performed in our institution on patients. most of the biopsies were performed in theatre with the patient under general anesthetic and with an -gauge spring-loaded core biopsy needle with a minimum of two cores per patient. in % of lesions the needle biopsy was diagnostic. the single nondiagnostic case did not have sufficient material to make a full diagnosis and a surgical biopsy was required. eighty-two of the biopsied lesions were malignant and were benign. in no cases was a repeat biopsy required. the vast majority of the biopsies were performed within one week of request with over half performed within days. all biopsies were performed without complication and in the majority of cases the patients were discharged the same day or following an overnight stay. ultrasound-guided percutaneous biopsy is an accurate and safe technique in order to acquire tissue from suspected malignant lesions in children. these can be performed instead of or in addition to open biopsy and will often result in a shorter hospital admission and recovery time. the role of imaging in the diagnosis of thymoma in paediatric patients with myasthenia gravis j. adu, t. a. watson; london/uk thymomas are exceedingly rare tumours in the paediatric age group, with only very few cases having been reported in the literature. thymomas are commonly associated with myasthenia gravis (mg), with thymectomy being potentially curative. ct is the mainstay imaging modality for thymoma diagnosis in the adult population. while, chemical shift mr imaging can be helpful to distinguish thymoma from other anterior mediastinal abnormalities. currently, there is no consensus on the imaging pathway for children with mg with suspected thymoma. our aim is to review the imaging of patients who were referred to our institution for management of mg, and suggest an imaging pathway in cases where thymoma is suspected. we performed a retrospective search of the local pacs system of cases between and using the search terms "thymoma" and "myasthenia gravis" in the clinical indication for the study and the body of the final report. forty-three cases were identified using the search criteria. eight cases were excluded owing to an absence of cardiothoracic imaging. / of all cases ( %) had chest x-rays (cxr's), of these / ( %) were normal. the three remaining patients who had abnormal cxr's went on to have ct scans, which confirmed an anterior mediastinal mass (amm) in all three cases. / of all cases ( %) had cross-sectional imaging (mri / cases, ct / cases). of those, / of cases ( %) had normal studies. specifically, all mri studies ( % of cases) were normal, while only / ct scans ( %) demonstrated an anterior mediastinal abnormality. / of all cases ( %) had both cxr and cross sectional studies. / of these cases ( %) had a normal ct or mri. in the remaining three cases, the amm was clearly demonstrated on both cxr and the crosssectional imaging. in our series, radiography, ct and mri studies were normal in the vast majority of cases. however, given that thymectomy is potentially s ( ) (suppl ):s -s pediatr radiol curative, it is appreciated that clinicians may still be keen to radiologically investigate paediatric patients with myasthenia gravis. cxr is not an efficacious imaging modality in this context, as patients with a normal cxr may be falsely negative, and patients with an abnormal cxr may undergo cross-sectional imaging regardless. we propose that mri should be used as first line investigation for patients in this population. this approach will negate the need for ionizing radiation, maximize diagnostic yield, and facilitate surgical planning if deemed clinically appropriate. increased risk of venous thrombosis of the arm with multiple peripherally inserted central catheters insertion in paediatric patients r. gnannt , n. waespe , j. donnellan , k. liu , l. brandao , b. connolly ; zurich/ch, toronto/ca objective: peripherally inserted central catheters (piccs) are associated with superficial and deep venous thrombosis of the arm. the impact on the incidence of developing a thrombosis of the arm when inserting a subsequent picc remains unclear. the purpose of this study was to analyze the incidence of deep, upper limb thrombosis of repeated upper limb piccs in children. the study population included all patients who underwent their first successful arm picc insertion between january and december . subsequent ipsilateral arm piccs were included in the analysis. patients were followed until march or until any alternative central venous line insertion (jugular, femoral, saphenous or umbilical vein lines -because of their thrombogenic effect). for each picc insertion the following data were collected: date of insertion and removal, weight of the patient, type of picc ( . fr, . fr, fr, fr, fr), left or right arm, and vein cannulated (basilic, brachial, cephalic). all symptomatic deep and superficial thrombosis of the arm were correlated with the picc database. four thousand one hundred thirty-eight piccs were inserted. applying inclusion and exclusion criteria, piccs remained for analysis. first, nd , rd , and th picc insertions in the same arm were identified in , , and patients, respectively. in total there were upper body deep symptomatic thrombotic events diagnosed with ultrasound. a st , nd , rd , and th picc insertion was associated with / (incidence . %), / ( . %), / ( . %), and / ( . %) thrombotic events, respectively. an increasing hazard ratio was seen with higher numbers of picc insertions, which was significant when comparing the st with the rd picc insertion in the same arm (hr . , ci % . - . , p= . ). after excluding any confounder, double lumen piccs were associated with a significantly higher risk of thrombosis than single lumen (or . , ci . - . , p= . ). repetitive picc insertions in the same arm are associated with an increased risk of thrombosis. double lumen piccs are associated with a higher risk of thrombosis compared to single lumen lines. diagnostic performance of lung ultrasound for the detection of community acquired pneumonia in children j.a.m. stadler , s. androunikou , h. zar ; paarl/za, bristol/uk, cape town/za objective: chest radiographs (cxr) are considered the first line imaging modality when investigating cases of suspected community acquired pneumonia (cap) in children. however, cxr interpretation is limited by moderate sensitivity and specificity and poor inter-and intra-rater reliability and expose children to potentially harmful ionizing radiation. point-of-care lung ultrasound (lus) has been proposed as alternative to cxr for diagnosis of pneumonia in children and some published data suggest accuracy and reliability as good as or better than cxr. most of these studies however, were performed in in-hospital settings creating a bias for selceting more severe disease and consequently more overt radiological findings. the mean age of children in most of these studies were also well above one year, while the highest incidence and risk of complicated pneumonia occurs during the first year of life. the purpose of our study was to assess the diagnostic performance of lus for the diagnosis of pneumonia in both hospitalised and non-hospitalised children in an age group representative of the most at risk segment of the population. we performed a lus on children who presented with clinical signs consistent with the who case definition for childhood pneumonia. one hundred of these patients also had chest radiographs performed as part of routine clinical care. inter-rater reliability (irr) between a general practitioner and an expert paediatric radiologist were assessed for the interpretation of lus findings consistent with pneumonia. where radiographs were available concordance between lus and cxr findings of pneumonia were also assessed. results: seventy-four hospitalised and non-hospitalised clinically defined pneumonia cases were included with a median age of . years. our general practitioner reported lus findings consistent with pneumonia in / ( %) compared with / ( %) by the paediatric radiologist. substantial overall agreement between the reporters was found with an overall agreement proportion of . and kappa= . . agreement for the presence of lung consolidation or for a normal scan was also substantial with kappa of . and . respectively. agreement on the finding of interstitial syndrome was moderate with kappa= . . agreement was higher in hospitalised than in non-hospitalised cases with kappa of . and . for the respective categories. results showing concordance between lus and cxr findings are pending. conclusion: lus shows substantial irr for the diagnosis of pneumonia in children. irr are higher for the detection of consolidation or for no pathology than for interstitial syndrome. irr also appears to be lower in clinically less severe disease. 'white-out' on plain chest radiograph-a late presentation of congenital diaphragmatic hernia a. fagan , c. stewart , k. halliday , s. rao , d.t. chang kwok ; peterborough/uk, lincoln/uk, objective: awareness of the limitations of plain radiograph and computed tomography in diagnosis of late presentation of congenital diaphragmatic hernia. case presentation: a year old boy presented with a day history of pyrexia, vomiting and respiratory distress. he was haemodynamically stable, and had no audible air entry over his upper left thorax with occasional wheeze over the left base. he had bronchiolitis previously but did not require ventilatory support. he was otherwise well with unremarkable antenatal scans. initial chest x-ray showed a large air collection with fluid or soft tissue density within the left hemi-thorax and mediastinal shift to the right. repeat x-ray (figure ) demonstrated the nasogastric tube below the diaphragm. complicated pneumonia was suspected but as the findings were atypical a non-contrast ct was performed. this was interpreted as showing a large hydropneumothorax. (figure ) . a chest drain was inserted which drained only a small volume of fluid, and a repeat chest film showed no change. ct chest and abdomen with oral and intravenous contrast revealed a bochdalek diaphragmatic hernia (figure ) . fortunately the chest drain had not entered the herniated stomach. the hernia was surgically corrected and the child recovered well. ( ) (suppl ):s -s pediatr radiol bochdalek is the most common congenital diaphragmatic hernia (cdh). it is often diagnosed on prenatal ultrasound, with mri used for confirmation. cdh which is not diagnosed in the perinatal period may be asymptomatic and imaging findings can be confusing. postnatal x-ray typically shows an opacified hemi-thorax with or without gas bubbles. there can be mass effect with mediastinal shift. the position of an ng tube can be helpful in localising the stomach, but in this case the infradiaphragmatic position of the tube gave false reassurance. in neonates, the position of an umbilical venous catheter may demonstrate abnormal location of the liver. computed tomography generally demonstrates a posterolateral defect (foramen of bochdalek), which is located on the left in % of cases. ct is useful for excluding lung masses or bronchopulmonary foregut malformations, which may appear similar to cdh on x-ray. ct can also identify anatomical abnormalities associated with cdh. late presenting cdh is often misdiagnosed as pleural effusion or pneumothorax. there are other case reports published where chest drains were inserted before cdh was diagnosed. it is important to keep cdh in mind as a potential cause of unilateral hemithorax opacification, even in previously asymptomatic older children. ct with oral contrast can be useful in diagnosis. ovarian tuberculosis with peritoneal dissemination mimicking ovarian tumor with peritoneal seeding d. grassi, v. tostes, a. duarte, s. abib, h.m. lederman; sao paulo/br consider tuberculosis (tb) as a differential diagnosis whenever the case enrolls in an endemic region. case presentation: female, years old adolescent, who presents with abdominal pain and weight loss. abdominal sonography was performed in a public family practice location and bilateral ovarian masses were detected. she was referred to an oncology pediatric facility for further investigation. abdominal mri and chest ct were performed where dissemination through the peritoneal and mesenteric lymph nodes could be detected; chest ct was normal. the patient underwent surgical intervention for diagnosis and on pathology the findings in the bilateral ovarian masses were secondary to tb involvement. sonography showing bilateral pelvic masses. t -weighted coronal overview bilateral ovarian masses. unique teaching points: whenever a case enrolls in an endemic region of tuberculosis, it is important to consider it as a possible differential diagnosis. in this case, the initial presentation mimicked ovarian tumor with mesenteric seeding. however, only after surgical approach was possible to diagnose ovarian tuberculosis with mesenteric lymph nodes and peritoneal involvement. retrospectively, patient's uncle was discovered as having pulmonary tb. langerhans'-cell histiocytosis with thoracic involvement in infant and young child: ct findings s.-l. shih , k. tsai , w. huang , f.-s. yang ; taipei/tw, taitung/tw the purpose of the study was to evaluate the ct changes of thorax in the patients with langerhans'-cell histiocytosis. the -month-old female infant presented with generalized hemorrhagic macular rash over the skin for months. the laboratory findings showed hemoglobin . gm/dl (normal . ~ . gm/dl). the chest radiograph showed bilateral reticulonodular infiltration. high-resolution computed tomography (hrct) of chest showed multiple cystic-like lesions ( - mm) in the right middle and bilateral lower lobes. the pathological report was langerhans'-cell histiocytosis after skin biopsy from upper chest. then she was on scheduled chemotherapy. she was in remission after one-year treatment. the y m-old girl presented with fever for months. the physical examination revealed hemorrhagic-macular rash over the skin in the anterior chest wall and hepatosplenomegaly. the laboratory findings revealed albumin . g/dl (normal . - . g/dl) and hemoglobin . g/dl (normal . - . g/dl). hrct of chest showed multiple cystic-like lesions ( - mm) in the bilateral lower lobes with left pleural effusion as well as multiple osteolytic lesions in the vertebral bodies of t , t , t and t . the pathological report was langerhans'-cell histiocytosis after skin biopy from anterior chest wall. then she was on scheduled chemotherapy. she was doing well years after treatment. the y m-old girl presented with yellowish discoloration of skin for one month. the laboratory findings revealed direct/total bilirubin . / . mg/dl (normal . - . / . - . mg/dl), got iu/l ( - iu/l) and gpt iu/l ( - iu/l). the chest radiograph revealed enlargement of upper mediastinum. the ct scan of chest and upper abdomen showed punctuate calcification with heterogeneous enhancement in the upper mediastinum and several minute cysts in the lower lobes of lung (hrct) as well as dilatation of bilateral intrahepatic bile ducts in the liver. the pathological report was langerhans'-cell histiocytosis after biopsy from thymus and liver. then she was on scheduled chemotherapy and got initial response. unique teaching points: langerhans'-cell histiocytosis affecting the lungs and thymus may be in isolation or as part of a multiorgan disease. the pulmonary changes on ct scan may not have corresponding respiratory symptoms. ct scan of thorax may have multiple minute cysts ( - mm) in the lungs, pleural effusion, calcification in the thymus and osteolytic lesions in the thoracic spine. case of fungal infection of the soft tissue in a child with acute myeloid leukemia (ultrasound aspects of diagnosis) i. begun, s. kondaurova; minsk region/by objective: early diagnosis of fungal infections of the tissues is essential for a successful and complete recovery. we describe a clinical case of fungal infection of the soft tissue in a child with acute myeloid leukemia (aml). ultrasound were made for the characteristics of the structural changes in the area of interest to perform biopsies followed by bacteriological culture studies. case presentation: patient k., years old, diagnosed with aml, from which after a course of induction chemotherapy with neutropenia about weeks on the skin of the foreskin appeared removable hard white coating. cultures of plaque it possible to establish the presence of fungi of the genus trichosporon spp. after days, there were hyperemia, compaction and ulceration of the glans penis, which led to extensive tissue defects. with help ultrasound were determined the structural deformation of the glans penis with the pronounced around changed tissues vascularization. after days in the rear surface projection of the left thigh and the lateral surface of the left calf were defined erythematous papules which progressed to ulceration with central black scab. by standard ultrasound were visualized: subcutaneous nodal education oval , х , sm on hip and echogenic skin thickened portion having an average degree of severity of dorsal acoustic shadow on the lower leg (weakening of the signal behind scab). in cultures of biopsies of subcutaneous foci were revealed fungi of the genus trichosporon spp too. the patient received the combination treatment (intravenous liposomal amphotericin b and surgical rehabilitation of lesions of glans and corpus cavernosum of penis). after the stabilization of patient state the treatment of the underlying disease was continued. unique teaching points: for some patients, lesions of superficial tissues may be the only sign of systemic fungal infections, and rapid recognition of these lesions may contribute to early diagnosis and treatment. ultrasound examination in such a situation naturally becomes an main imaging tool and by choice method. the scanning high-resolution of foci of the thigh of the patient k. in grayscale made possibility to determine the configuration consisting of the central echogenic focus surrounded by a hypoechoic rim (fig. ) with peripheral changes in the type of "infiltrative" according by the active fungal infection at the exit of cytopenia. duplex and triplex ultrasound scanning were indicating to the perifocal vascularization with low level vascular resistance around of the affected area (see fig. - ) . to increase knowledge and awareness of rare cases and diseases in order to be able to better manage and treat patients in the future. case presentation: an -month-old female was presented to our hospital with abdominal distention that increased in the past months associated with low-grade fever, loss of weight and mild respiratory distress. abdominal ultrasonography revealed an enlarged liver with multifocal hypoechoic lesions scattered all over the liver (fig ) . a ct scan with iv contrast (mri was not available at that time in our district) revealed severe hepatomegaly with the presence of multiple, variable in size, hepatic hypodense lesions which had peripheral (ring) enhancement after contrast injection in the arterial phase (fig ) . progressive centripetal filling in portal phase is seen and in the delayed images many of the lesions were completely filled (fig ) . reduction in the aortic caliber (mid-aortic syndrome) below the level of celiac branch was noted. a diagnosis of hemangioendothelioma was made although liver biopsy was not done due to fear of hemorrhage. alternative diagnosis to infantile hemangioendothelioma in this age group is hepatoblastoma, mesenchymal hamartoma and metastatic neuroblastoma. the patient was transferred to another city to a hospital with pediatric oncology department for follow up and treatment. unfortunately the lack of experience and knowledge of such rare cases led to mismanagement and delayed treatment and after less than months the patient was brought back to our hospital to the pediatric icu due to deterioration of her status due to congestive heart failure. unfortunately the patient died shortly afterwards. hemangioendothelioma is twice as common in girls and can have complications due to high output chf secondary to arteriovenous shunting hemangioendotheliomas tend to involute spontaneously without therapy over a course of months to years. they are followed with sequential ultrasounds. medical therapy is reserved for severely symptomatic lesions (e.g. anemia, consumptive coagulopathy, high-output chf) and includes high-dose steroids or alpha-interferon. in cases of failed medical management, surgical resection should be performed. if partial hepatectomy is not technically achievable, transarterial embolization should be used either as definitive therapy or as a temporizing measure until liver transplantation is possible. the sad outcome of this case was mainly due to mismanagment due to lack of medical experience and knowledge of such rare cases so we suggest that such rare cases should be catalogued in a national data bank for future consultation and teaching purposes. fatal outcome of acute gastric dilatation causing acute abdomen compartment syndrome in a child: a case review c.s. yoon; seoul/kr to describe and review presumed acute abdominal compartment syndrome in a child. case presentation: a years and months old boy was admitted to emergency room due to abdominal distention. he suffered abdominal pain and vomited since yesterday after lunch. on physical examination, his abdomen was rigid and distended. body temperature is . °c. the white cell count was increased ( , /μl). esr is mm/hr and c-reactive protein was . mg/l. creatinine was increased ( . mg/dl). amylase and lipase were increased ( u/l and u/l respectively). prothrombin time was prolonged ( . sec). plain abdomen radiograph shows markedly distended stomach with air-fluid level (fig. ) . first trial of nasogastric tube insertion was failed due to kinking of tube at gastroesophageal junction. contrast-enhanced abdomen ctscan shows marked distensionofstomachwithlargeamountoffoodmaterialsandintraluminalairwith prominent external compression in the duodenal rd- th junction. esophageal air distention is also markedly noted with l-tube insertion. no opacification of large vessel with contrast media, without contrast enhancement of spleen, pancreas and left kidney is noted (fig. ) . prob. markedly compressed and poorly defined lower abdominal aorta with faintly visible both common iliac arteries and femoral arteries. after ctscan, nasogastric tube exchange was performed due to poor drainage of gastric fluid. about cc of gastric fluid was drained. however, sudden cardiac arrest of the patient was developed. although vigorous cardiopulmonary resuscitation was performed, the patient was died. ( ) (suppl ):s -s pediatr radiol unique teaching points: acute abdomen compartment syndrome is a very serious and lifethreatening disease. as soon as possible, rapid diagnosis and adequate treatment are necessary for good prognosis. delayed diagnosis and treatment may result in fatal outcome. pleuroperitoneal fistula in a pediatric patient with primary hyperoxaluria type w.p. chu; hang hau/hk to illustrate the imaging features of pleuroperitoneal fistula in a pediatric patient suffering from primary hyperoxaluria type case presentation: an -year-old girl with the history of primary hyperoxaluria type was repeatedly admitted to the hospital for recurrent right pleural effusion despite chest drain insertion. the right pleural fluid was transudative in nature and the microbiological cultures for bacteria and mycobacterial species were negative. the radiographic examination [ figure ] showed moderate right pleural effusion a n d f e a t u r e s o f o x a l o s i s i n c l u d i n g b i l a t e r a l c o r t i c a l nephrocalcinosis and generalized increased in bone sclerosis. delayed planar images of the peritoneal scinitigraphy [ figure ] obtained and hours after injection of technetium- m suphlur colloid found diffuse tracer activity at the right hemithorax, suggestive of pleuro-peritoneal fistula. the patient subsequently required thoracoscopy and surgical decortication at the right hemithorax and renal transplantation. primary hyperoxaluria is due to defective glyoxylate metabolism and results in increased synthesis of oxalic acid. cortical nephrocalcinosis and diffusely increased bone sclerosis are characteristic radiographic features. pleuroperitoneal fistula is unusual in patients without peritoneal dialysis. possible cause in this patient is increased intra-abdominal pressure related to portal hypertension and cirrhosis. osteosarcoma with pulmonary intra-arterial tumor embolism metastasis a. alzaher, f. alzaher; dammam/sa objective: osteosarcoma rarely invade the veins and small number of cases has been reported with venous invasion at the presentation. however, to our knowledge, no case has been reported with venous invasion and isolated distal metastasis as intra-arterial pulmonary embolisms. we are presenting a case of pediatric pelvic osteosarcoma with venous invasion and pulmonary arterial tumor embolisms as isolated distant metastasis at the presentation. the purpose of this case report is to describe the rare presentation of distant metastasis as isolated pulmonary arterial embolism that might be overlooked radiological. additionally, such tumor embolism might cause respiratory symptoms and differentiating tumor emblism from pulmonary thromboembolism is crucial to avoid the unnecessary anticoagulation. case presentation: fourteen year old boy who presented with months history of right hip and lower limb pain after trauma. this was associated with lower limb swelling. the plain radiography showed right pelvic iliac bone aggressive mass, along with lobulated, soft-tissue components, extensive areas of osseous matrix, and malignant periosteal reaction. the patient could not tolerate the mri and ct scan was performed and it showed that the mass was invading the right external and internal iliac vein with imaging appearance was most consistent with osteosarcoma. patient staging was then carried on with mri under anesthesia and chest, abdomen and pelvic ct scan. the unenhanced and iv contrast enhanced chest ct scan showed multiple beaded expansion of sub segmental pulmonary arteries with soft tissue destinies and calcification suggestive of intra-arterial pulmonary tumor embolisms. there was no isolated pulmonary nodule or any other site of distant metastasis. unique teaching points: we present this case to increase the awareness of isolated intra-arterial pulmonary tumor embolisms as osteosarcoma metastasis especially with the present of venous invasion. additionally, such condition might be with respiratory symptoms and differentiating the tumor embolism from pulmonary thromboembolism is crucial to avoid the unnecessary anticoagulation. case presentation: a -year old boy with acute myelodysplastic syndrome presented with recurrent, acute severe anemia (hemoglobin g/dl) and melena. his past history was significant for bone marrow transplant twice followed by graft-versus-host-disease of intestines, bilateral lung transplants for bronchiolitis obliterans, renal failure, scleroderma and acute pancreatitis. ct angiography performed previously did not identify active extravasation. several days before, upper gi endoscopy had demonstrated ulceration of the greater curvature of the gastric wall that was initially treated with epinephrine injection and surgical clip placement. at the time of referral, endoscopic interventions were unsuccessful leading to progressive clinical deterioration. a decision was taken to proceed to angiography to isolate the arterial source of hemorrhage, with an intention to embolize, if feasible. catheter angiography via transfemoral fr access revealed a left gastric artery pseudoaneurysm with active extravasation into the gastric lumen through the ulcer. after selecting the feeding pedicle of the left gastric artery with a microcatheter, the pseudoaneurysm was embolized using % nbca in lipiodol, resulting in complete angiographic obliteration of the bleeding source. on repeat cbc hours post-procedure, the hemoglobin had increased from to g/dl. the patient remained hemodynamically stable in the intensive care unit. there is no evidence of bleeding recurrence days later. unique teaching points: catheter angiography can define the bleeding source with greater accuracy than cta in children. there should be a low threshold to perform catheter angiography, with an intention to proceed to treatment. nbca embolization is a feasible and effective option for treatment of acute gi bleeding in children. case presentation: an infant born by cesarean section at weeks of gestation, after nonreassuring cardiotocoghraphy, with meconium aspiration at birth, severe hepatocellular failure with hyperbilirubinemia, signs of hemorrhage, edema, ascites, hypoglycemia, increased ferritin values, and lactic acidosis was referred for ultrasound and magnetic resonance. both examinations showed signs of liver cirrhosis with portal hypertension; in addition, on t -weighted images and gradient-echo images, the signal intensity of the liver and the pancreas was lower than that of the spleen and skeletal muscle, a finding consistent with abnormal iron deposition in those organs. a biopsy of the lower lip confirmed the diagnosis of neonatal hemochromatosis. unique teaching points: although the diagnosis may be suspected clinically, it must be confirmed by demonstrating the generalized iron overload affecting, among other organs, the salivary glands, liver and pancreas, with sparing of the reticuloendothelial system. the underlying cause may be associated with an an alloimmune mechanism; thus, intravenous immunoglobulin during gestation is administered in selected cases to prevent the severity of neonatal hemochromatosis. diagnosis is then crucial not only for management of the affected infant, but also for prevention in the future offspring. fishing for the answer -a rare case of paediatric exogenous lipoid pneumonia secondary to fish oil aspiration h. moodley, d. white, g.d. baker; johannesburg/za objective: lipoid pneumonia is a rare condition caused by the intrapulmonary accumulation of endogenous or exogenous fat containing substances. in the acute exogenous form secondary to aspiration of oil, it is important to make the diagnosis and remove the causative agent to prevent or arrest the progression of pulmonary fibrosis. radiopathological findings usually prompt the diagnosis, as aspiration of mineral oils is usually unnoticed due to the lack of reactive airway symptoms and patients present with vague chronic respiratory symptoms. case presentation: we present the clinical, radiological and pathological correlation of exogenous lipoid pneumonia in a -month-old male patient with recurrent respiratory tract infections. a ct chest demonstrated an extensive crazy paving pattern of the dependent lung segments bilaterally. the lung biopsy findings of occasional intra -alveolar macrophages with larger ( ) (suppl ):s -s pediatr radiol foamy cytoplasmic vacuoles, raised the possibility of an exogenous lipoid pneumonia secondary to aspiration. on further history, the patient was found to have been fed fish oil by his mother, confirming the diagnosis. unique teaching points: the rare diagnosis of exogenous lipoid pneumonia can be confirmed on ct chest by measuring the hounsfield units in the most hyperdense components of consolidation (typically - to - hu). histopathological confirmation can be obtained provided that the specimens are not embedded in paraffin. the possible role of visual evaluation of dwibs in childhood renal masses based on our five cases e. varga, g. rudas; budapest/hu objective: nowadays, the diffusion-weighted mri has a great importance not only in the differential diagnosis and follow-ups of childhood renal tumors, but in the early detection of recurrence of the disease as well. the dwibs with appropriate b-values and the adc calculation can be helpful in distinguishing between benign and malignant processes. however, the adc calculation is a time consuming method and in addition, there are cases when we cannot use this technique, but we can still apply the visual evaluation of diffusion. case presentation: between - , we had cases in which the visual assessment of dwibs was the best method which helped to make the appropriate therapeutic decisions. left kidney of an infant with nephroblastomatosis was removed because of an arising wilms tumor. , years later, in the contralateral kidney, a small area of diffusion restriction appeared on the dwibs in one of the cystic residual lesions, but the anatomic sequences haven't showed any changes comparing with the previous examinations. in another patient with beckwidt-wiedemann syndrome, the follow-up ultrasound examination showed a little bulging of the surface of the left kidney. accordingly, the mri showed a barely distinguishable nodule, but the dwibs referred to a wilms tumor. in a -month-old child, more nodules were visible in both kidney on the dwibs than on other sequences. with the help of visual evaluation of dwibs, we were able to detect the malignant lesion easily and quickly, among a lot of cystic and solid nodules of the kidneys in a seven years old patient with sclerosis tuberosa. an -month-old infant was followed with a benign cystic renal disease and a new small solid nodule was found on the last ultrasound examination. instead, the visual assessment of dwibs indicated a multilocular cystic wilms' tumor. unique teaching points: the diffusion-weighted mri is suitable for differentiate benign and malignant renal lesions in children. the dwibs (with appropriate b-values) and the adc calculation are very sensitive methods in pediatric oncoradiology. the adc calculation is a long process andas our cases demonstrated -we cannot apply in every cases. the visual evaluation of dwibs is a time saving method which is spared from limitations of adc histogram-based assessment, so it may become very useful in the everyday practice. we can use it in the differential diagnosis and follow-ups of childhood renal tumors and we can detect the recurrence of the malgnancy very early and easily. mr urography in a -years-old female with unusual urinary dribbling m.c. terranova, c. tudisca, d. narese, g. li voti, s. salerno; palermo/it objective: congenital anomalies of kidney and urinary tract (cakut) occurs in up to . % of infants, and clinically they can range from asymptomatic patients, in which anomaly is detected incidentally even in adulthood, to ante-natal or post-natal mortality due to bilateral kidney agenesis or acute renal failure. dmsa renal scintigraphy is considered gold standard, for evaluation of those cases electable for surgery, in order to assess renal function, depict and locate ectopic kidney and guide surgical management, but has the important limit of radiation exposure and may undetect poorly functional renal moieties. the advent of modern magnetic resonance technics proven to be able to assess anatomical malformations and renal function, overcoming the limits of dmsa scintigraphy, may be used as a valid alternative, especially in vulnerable pediatric population. we herein describe a case of a young girl with small left renal bud and ectopic ureter, draining in vagina, discovered by mr and undetected by previous dsma scintigraphy. case presentation: a years old girl was referred for continuous urinary dribbling, after starting toilet training, with normal bladder voiding pattern, unrelated to any physical and psychological events, and no history of urinary tract infections. physical examination revealed vaginal septa and micturition training was practiced, with no symptoms improvement. abdominal us study was performed, reporting empty left renal fossa and hypertrophic right kidney; no ectopic kidney nor sign of urine stasis or other urogenital anomalies were detected, and dmsa renal scintigraphy was planned. it depicted only normal right kidney radionuclide uptake but no evidence of left renal or ectopic renal tissues activity. patient then underwent mr evaluation for suspected genito urinary malformation, that revealed a small cystic formation, with a slight cortex, at the level of the iv lumbar vertebra -that represented the left immature renal bud -supplied by a short fluid-filled tubular structure, located postero-medially to the bladder -that configured the left ectopic ureter, draining in left vaginal wall. bladder was normal, and regularly connected with the right orthotopic ureter (fig ) . pre-surgical cystoscopy and vaginoscopy, followed by left ascending urethrogram were performed, confirmed previous mr findings, and patient underwent successfull laparoscopic left nephron-ureterectomy. unique teaching points: mr urography has proven to be a rapid, safe, radiation free, systematic diagnostic tool especially in the evaluation of poorly functioning renal systems, and of collecting system, bladder and ureteral abnormalities, overcoming the limits of conventional imaging technics agenesis of the dorsal pancreas: case report c. lanza, g. pieroni, l. amici, a. giovagnoni; ancona/it objective: agenesis of the dorsal pancreas (adp) is a rare malformation. since and until , cases have been reported. majority of the patients with this anomaly are asymptomatic or associated with abdominal pain, hyperglycemia, diabetes mellitus, and acute or chronic pancreatitis. case presentation: we present a case report of a -year-old girl with adp, diagnosed incidentally during radiological evaluation for abdominal pain. she was hospitalized in the pediatric department for recurrent abdominal pain for the past months. there was no history of nausea, vomiting or trauma. biochemical investigations showed a normal random serum glucose, serum amylase levels slightly increased ( u/l; reference value - u/l) and slightly elevated serum pancreatic lipase levels ( u/l; reference value - u/l). the day after serum amylase levels decresed up to u/l and lipase levels to u/l. us revealed increased -size pancreatic head with normal contour and echotexture with no parenchymal calcification or duct dilatation. the body and the tail of the pancreas were poorly visualized. mr imaging examinations revealed only a partial visualization of the pancreas: the pancreatic head and the uncinate process were visualized with defined margins with peripancreatic fat stranding, but the distal neck, body, and tail of the pancreas were absent. on mrcp, the dorsal pancreatic duct of santorini and the minor duodenal papilla could not be visualized. the ventral pancreatic duct of wirsung and the common bile duct were normal and clearly visualized. these findings were compatible with complete adp, eliminating the need for ercp. unique teaching points: the clinical presentation of dpa varies greatly ranging from incidental detection on x-ray, surgery or autopsy through to the development of a ductal adenocarcinoma of the pancreas. abdominal pain and diabetes are the most frequent clinical manifestations reflecting exocrine and endocrine insufficiency as most of the islands of langerhans are located in the tail of the pancreas. there have also been reports of an increase in the size of the remnant pancreas and recurrent acute pancreatitis as a form of presentation. diagnosis requires confirmation of the absence of the neck, body and tail of the pancreas and duct of wirsung using endoscopic retrograde cholangiopancreatography (ercp) or mrcp. one hundred four mr images of foetal cns with a us suspicion of acc were retrospectively reviewed. foetal mri was performed at . t magnetom avanto (siemens, erlangen, germany) without motherfoetal sedation. polymicrogyria, lissencephaly, schizencephaly, subependymal heterotopias and migration disorders were evaluated. cortical findings were compared to three types of acc (complete agenesis, partial agenesis and hypoplasia). genetic tests were collected. postnatal mri or foetopsy for diagnostic confirmation were collected. on foetuses, fetal mri was able to detect cortical malformations in cases even in early gestational ages (< gw). the mean gestational weeks (gw) at mr diagnosis was (range: - gw). mr imaging found / polymicrogyria, / lissencephaly, / schizencephaly, / subependymal heterotopias and / neuronal migration disorders. / had complete acc, / had partial acc and / had cc hypoplasia. statistically significant correlations (p< . ) between complete acc, focal polymicrogyria and cortical dysmorphism affecting frontal lobes were found. fetal cns mri can detect cortical development malformations in complex acc, providing further information for the clinician to assess the severity of perinatal outcome. mri is a useful tool in improving obstetrical genetic prenatal counselling to predict pregnancy and foetal prognosis. clinical signs of the neonatal lymphatic flow disorder (nlfd) are a combination of the congenital chylothorax, chylous ascites and body edema. it can present as neonatal chylothorax (nc), neonatal chylous ascites, or congenital lymphatic dysplasia (cld). the prenatal appearance of lymphangiectasia has been described as nutmeg lung. the purpose of this study is to describe prenatal and postnatal imaging features and outcomes of neonates with nlfd. materials: this is a retrospective case series of neonates in our institution that had pre-and postnatal lymphatic imaging and nlfd. all patients had prenatal imaging (fetal mri and us) and underwent postnatal dynamic contrast mr lymphangiography (dcmrl) with a three-dimensional ( d) t space. conventional lymphangiography (cl) when performed was also reviewed. six patients with nlfd were identified ( with nc and with cld). one patient had congenital heart disease. nutmeg lung was seen in all patients on fetal mri and patients on fetal us. / patients had pleural effusions, / had ascites and / had body wall edema prenatally. postnatal mri with d t space revealed soft tissue edema in the upper chest and neck ( / patients), mediastinal edema ( / patients), interstitial lung edema ( / patients), retroperitoneal edema ( / patients), and ascites ( / patients). dcmrl demonstrated lymphatic flow to the pleural space ( / patients) and to the abdominal cavity ( / patients) and dermal backflow ( / patients). cl was performed in patients, all of which had collateral lymphatic flow to the lung. lymphatic intervention was performed in patients, lipiodol injection for patients with nc and thoracic duct embolization (tde) for patient with cld. mean hospital duration in the first months of life was days (range - ) for nc and days (range - ) for cld. all patients with cld died after months of age due to respiratory distress including the patient that had tde and both with findings of dermal backflow. the pleural effusions in the patients with nc resolved post lipiodol injection and in the other patient with nc it resolved with conservative therapy. conclusion: nlfd is a disorder that can be recognized on prenatal and postnatal imaging. in this small series, nutmeg lung was present in all patients with nlfd and may be easier to recognize with fetal mr than us. dermal backflow on dcmrl suggests a poor prognosis. both prenatal and postnatal imaging may guide treatment and interventions in nlfd. fetal mri and postnatal ct scans of prenatally diagnosed bpms from patients with available histology were analyzed retrospectively. the fetal mri and ct images were reviewed by two radiologists blinded to histological findings. specific diagnosis was assigned based on predetermined criteria. the accuracy of fetal mri was evaluated. the agreement rate in fetal mri diagnosis between two radiologists was %. an overlap of % in fetal mri and histopathological diagnosis was reached. when comparing fetal mri and postnatal ct examinations, the agreement of the results was also %. the least matching histological diagnosis was bronchopulmonary sequestration (bps). fetal mri is very accurate in characterizing the bpm spectrum and provides important information on lesion type and structure when compared with histology. with relatively small number of patients high correlation between prenatal mri and postnatal ct was reached. therefore, further investigation with more patients is needed. we hypotethise that fetal mri in late pregnancy could in the future replace early (neonatal) ct examinations if fetal mri provides sufficient inforfmation for clinical management. real time virtual sonography: a new integrated approach for the evaluation of fetal cerebral pathologies? s. bernardo, a. antonelli, v. vinci, m. saldari, c. catalano, l. manganaro; rome/it objective: real-time virtual sonography (rvs) is a new technique that uses magnetic navigation and computer software for the synchronized display of real-time us and multiplanar reconstruction mri images. the purpose of this study was to evaluate the feasibility and ability of rvs to assess the main cerebral pathologies in fetuses with suspected us anomalies. materials: this is a prospective study. fusion imaging (hitachi hi vision ascendus) was offered to patients undergone fetal mri for a us suspicion of cerebral pathology. the mri image dataset acquired was loaded into the fusion system using a cd support and displayed together with the us image. both sets of images were then manually synchronized and images were registered. the possibility to record the images in a video format allowed, however, the possibility to re-evaluated the examination. results: rvs was technically possible in all cases. data registration, matching and fusion imaging were performed in minutes at the beginning and in less than - minutes after practice. the ability of rvs imaging to assess the main anatomical sites and fetal anomalies was evaluated and compared with standard us and mri images. the principal application of rvs was the study of midline, cerebral gyration and vascular malformations because it also allowed adding a real time doppler signal on mri images. fusion imaging helped the diagnosis in %. in the / cases of encephalic pathology, fusion imaging improved the diagnosis; in the other cases mri was superior to us even using the rvs. this is a preliminary study on the feasibility and practical use of a fetal mri-us real-time fusion imaging. both techniques are complementary but still independent and the retrospective synthesis of these exams allows optimal analysis of fetal cerebral anomalies. this technique has many advantages especially on the pedagogic plan. however, rvs is currently limited to the research area. role of foetal mri in the evaluation of ischaemic-haemorrhagic lesions of the foetal brain s. bernardo, a. antonelli, v. vinci, m. saldari, c. catalano, l. manganaro; rome/it the aim of this study was to define the role of fetal magnetic resonance imaging in the evaluation of cerebral ischaemic-haemorrhagic lesions and the extension of parenchymal injuries. from september to december we performed fetal mri of cerebral region in foetuses with suspected abnormalities on ultrasound or cmv infection and toxoplasma serum conversion. fetal mri was performed with a . -t magnet system without materno-fetal sedation. fetal mri detected ischaemic-haemorrhagic lesions in / fetuses, revealing a % pathology incidence. mri confirmed the diagnosis in / cases with us suspect of ischaemic-haemorrhagic lesions associated with ventriculomegaly. in / cases with us findings of cerebellar haemorrhage, mri confirmed and provided additional information regarding the parenchymal ischaemic injury. in / cases with us suspect of ventriculomegaly (n= ), corpus callosum agenesis ( ), cerebellar vermis hypoplasia ( ), holoprosencephaly ( ), spina bifida ( ) mri detected ischaemic and haemorrhagic lesions unidentified at us examination. in / fetuses with us suspicion of intracerebral tissue space-occupying lesion, mri modified the diagnosis to extra-axial haematoma associated with dural sinus malformation. results were compared to fetopsy or after-birth follow up. fetal mri is an additional imaging modality in the diagnosis of cerebral ischaemic-haemorrhagic lesions and it is useful in providing further information on the extension of parenchyma injury and associated abnormalities and in improving delivery management. the contribution of mid-trimester virtual autopsy with mr imaging a. d'hondt, n. d'haene, j. rommens, m. cassart, f.e. avni; brussels/be the aim of the study was to assess the potential contribution of fetal virtopsy (post-mortem mr imaging (pm-mri)) in the second trimester of pregnancy. during a one-year period, post-mortem mr imaging (pm-mri) was performed in all fetuses who died in utero or whose pregnancy was interrupted due to major malformations. the study was performed in agreement with the local ethical committee. fetuses of < weeks that underwent obstetrical ultrasound and pm-mr were included. mr imaging examination was performed on a . tesla magnet with a standardized protocol. the findings on pm-mri were compared to obstetrical sonographic findings (and to pathology when available). we have analyzed separately the findings in the central nervous system and those in the rest of the fetus (chest, abdomen and skeleton). the results were classified in three categories according to the diagnostic accuracy: ultrasound>pm-mri, ultrasound=pm-mri and pm-mri>ultrasound. the us and pm-mri data of ten fetuses were analyzed. their gestational age ranged from . - weeks and their bodyweight ranged from - g. for the cns malformation: pm-mri offered a better diagnostic accuracy than us in cases ( %) (e.g. agenesis of the corpus callosum and holoprosencephaly). in cases ( %) us offered the same information than pm-mri. there was no case where us was more accurate than pm-mri. for the rest of the body malformations: pm-mri offered a better diagnostic accuracy in cases ( %) (e.g. heterotaxy anomalies or vertebral segmentation anomalies). in cases ( %), us offered the same information as pm-mri. there were cases ( %) where us showed major malformations that were not diagnosed on the pm-mri (two cases of cardiac malformation). post mortem mr imaging is more accurate than obstetrical ultrasound in detecting major malformations in the cns as well as in the rest of the body. the present exceptions are cardiac malformations. the examination offers an easy evaluation of the deceased fetus. it provides, in most cases, important additional information. diffusion coefficient and perfusion fraction parameters correlate with gestational age in normal human in vivo placenta: a preliminary study a. antonelli, m. guerreri, s. bernardo, s. capuani, c. catalano, l. manganaro; rome/it to investigate the potential of diffusion parameters derived from a biexponential analysis as marker to evaluate the perfusion quality of normal in vivo placenta. eighteen normal pregnancies, fulfilling the study inclusion criteria, have been analysed at . t magnetom avanto (siemens, erlangen, germany) without mother-foetal sedation. dw imaging was collected using seven b values: , , , , , , (s/mm ). three regions of interest (rois) have been considered -central (c), peripheral (p) and umbilical (u) regions. a bi-exponential model was used to obtain perfusion fraction (f), pseudo-perfusion (d*) and apparent diffusion (d) coefficients. pearson test was performed to investigate correlation between diffusion parameters and gestation weeks (gw), body mass index (bmi) and basal glycaemia (bg). the average values on all rois were d= . ± . • - (mm /s), d*= . ± . • - (mm /s), f= . ± . • - , in good agreement with the literature. in the c roi, a positive correlation (p< . ) was observed between f and gw. after gw in the p roi a positive correlation between f and gw (p< . ) and a negative correlation between d and gw (p< . ) were found. no correlation was found between d, d*, f, bmi and bg. conclusion: the f increase reflects normal placenta perfusion physiology. on the other hand, the decrease of d highlights placental parenchyma maturation becoming more fibrotic during late gestational age. bi-exponential model provides more and useful information about placental morphological changes compared to mono-exponential diffusion model. to demonstrate the diagnostic value of fetal mri in the detection of fetal central nervous system (cns) impairment in prenatally echocardiographic diagnosed congenital heart diseases. we retrospectively examined fetuses between gestational weeks and gestational weeks who performed a fetal mri in our institution after a second-line ultrasonography, between april and october . fetal heart and cns studies were performed with a . tesla magnet (siemens magnetm avanto) without maternal sedation. prenatal findings were compared to fetopsy results, fetal mri after gw or postnatal mri. in our sample of cases, / had interatrial septal defect (iasd),intervertricular septal defect (ivsd), and atrioventricular canal defect (cavc), / had cardiac rhabdomyomas, / had hypoplastic left heart syndrome and hypoplastic aorta, / had transposition of the great vessels, / had fallot tetralogy, / had aorta coartation and / had intracardiac masses of uncertain significance. magnetic resonance imaging was able to detect cns impairment: we recognize / corpus callosum (cc) dysgenesis ( / cc hypoplasia, / complete cc agenesis, / partial cc agenesis), / ventriculomegalies or hydrocephalus, / subtentorial anomalies (dandy-walker, vermian hypoplasia and vermian malrotation) and / gyration anomalies. due to the high risk of cns involvement in prenatal congenital heart diseases, it is essential to suggest an mri study of the evolving fetal brain especially in complexes forms that suggest a syndromic background. fetal mri of the cns is mandatory in the study of congenital heart disease due to the high rate of encephalic anomalies associated, particularly in iasd, ivsd and cavc. first experiences and diagnostic utility of micro-ct for fetal autopsy j.c. hutchinson , x. kang , s.c. shelmerdine , m. cannie , v. segers , n. sebire , j. jani , o.j. arthurs ; newcastle upon tyne/uk, brussels/ be, london/uk perinatal autopsy remains poorly accepted by parents, despite yielding information that affects the management of future pregnancies in around % of cases. microcomputed tomography (micro-ct) has shown promising results in the examination of ex-vivo fetal organs, and may provide diagnostic imaging in cases where traditional autopsy is challenging, and s ( ) (suppl ):s -s pediatr radiol existing post mortem imaging techniques (ct and mri) provide insufficient diagnostic resolution. our objective was to examine whole fetuses non-invasively using micro-ct, and compare the findings with standard autopsy as the gold standard. in this ethically approved double blinded study, terminated fetuses or miscarriages underwent iodinated micro-ct examination followed by conventional autopsy. images were acquired using a nikon xth st microfocus-ct scanner with individual specimen image optimisation. forty indices normally assessed at perinatal autopsy were evaluated for each imaging dataset by two independent reporters and a consensus report produced. autopsies were performed blinded to the imaging findings by one of two perinatal pathologists. we examined fetuses, with a gestational age range of - gestational weeks. / indices were non-diagnostic ( %), but there was agreement for / diagnostic indices (overall concordance of . % ( % ci . , . %). in seven out of eight fetuses ( . %), the same final diagnosis was made following micro-ct examination and autopsy examination; in one case, micro-ct was non-diagnostic. ten false negatives indices included a vsd, laryngeal anomaly, ambiguous genitalia and incomplete bowel rotation, none of which changed the overall diagnosis. three apparent false positives on micro ct were a cloacal anomaly, incidental cystic neck lesion and thymic atrophy, which were not detected at autopsy. micro-ct of early gestation whole fetuses can provide highly accurate datasets with three-dimensional renderings of complex disease processes. this approach confirms the potential of this technology for non-invasive examination of small fetuses. investigation of perinatal body organ diffusion-weighted post mortem mri s.c. shelmerdine , m. cheryl , j.c. hutchinson , n. sebire , o.j. arthurs ; london/uk, southampton/uk objective: diffusion weighted magnetic resonance imaging (dwi) uses water molecule diffusion to generate mr contrast images, and can reveal microstructural or functional changes in tissues, quantified by measuring the apparent diffusion coefficient (adc). the application of dwi to the post mortem setting is appealing as it does not require the administration of an exogenous contrast agent. a recent pilot study of paediatric cases suggested that lung adc values at pm mri may be a useful marker of post mortem interval (time since death; pmi) which has forensic relevance, but other body organs have not been comprehensively evaluated. the aim of this study was therefore to evaluate the relationship between pmi and body organ adc values in a larger cohort of subjects across a wider gestational range in the setting of perinatal death. whole body perinatal postmortem mri with dwi sequences were performed at . t, with b values of , , mm /s. mean adc values were calculated from regions of interest (rois) placed in the lungs, myocardium, spleen, renal cortex, liver and psoas muscle. the values were measured by two independent readers, correlated against gestational age and post mortem interval (pmi) using the pearson product-moment correlation coefficient. bland-altman plots were created, and the limits of agreement used to assess the inter-observer agreement of mean adc values. results: eighty fetal deaths and stillbirths were imaged with mean gestational age . weeks (range: - weeks). the mean pmi was . days (range - days). there was a weakly positive correlation between pmi and mean lung adc (r = . ) and spleen adc (r = . ). no correlation was found with between adc and pmi for the other body organs. there was reasonable inter-observer agreement between the two readers, with mean adc difference . mm /s (+/- . mm /s). perinatal lung and splenic adc values show a mild increase with increasing pmi. together with other imaging parameters, this may be useful to evaluate organ-specific changes which occur in the post mortem period, particularly in a forensic setting. further research is needed to understand the organ-specific changes which occur in the post-mortem period. usefulness of combined grey-scale and color doppler ultrasonography(us) findings in the evaluation of acute pyelonephritis in children k. lee, j.h. lee; anyang/kr objective: us diagnosis of apn in children can give a valuable information to the clinicians for the early treatment. but the problem of us in the diagnosis of apn is wide range of sensitivity, which is - %. the purpose of this presentation is to evaluate the usefulness of grey-scale us and color doppler us in the diagnosis of acute pyelonephritis in children. from march to february , children( kidneys), boys and girls, aged weeks to years (mean age, . months) underwent kidney us as an initial diagnostic tool for acute pyelonephritis and follow up dmsa scintigraphy within a week. criteria for acute pyelonephritis on grey-scale image were focal/diffusely increased/decreased echogenicity or loss of corticomedullary differentiation. on color doppler sonography, the criterion was decreased color flow. we classified the us diagnosis of apn into categories. definite, suggestive, possible and normal. when above two grey-scale us criteria and color doppler us criterion are seen, we classified it as 'definite'. when one of greyscale us and color doppler us finding are seen, it was classified as 'suggestive' of apn. 'possible' apn was abnormal finding either on grey-scale or color doppler us. 'normal' was no abnormal findings on grey-scale and color doppler us. we compared above findings with dmsa scan, which is considered as gold standard for diagnosing apn. statistical analysis was performed on all kidneys. the overall sensitivity of our study was %( / ) and specificity was %( / ). the positive predictive value for each definite, suggestive, possible groups were %, %, and % respectively. the negative predictive value for normal group was %, which means the false ppv was %. the p-value of the definite and suggestive was statistically significant, but the possible was statistically insignificant. in the diagnosis of apn in children, abnormal us finding either on greyscale or color doppler us is not optimal. abnormal us findings both grey-scale us and color doppler us showed good association with dmsa scan and statistically significant. combined grey-scale and color doppler us findings can give a more reliable information in the diagnosis of apn in children. the greater degree of gastric and/or duodenal wall thickening and increased echogenicity are helpful sonographic features in differentiating congenital duodenal anomalies from malrotation. our findings confirm the superiority of us vs ugi for evaluation of duodenal obstruction in neonates and evaluation of gastric and duodenal wall must be added to the constellation of other features to be assessed on us examinations. a measure of renal morphology as an indicator for potential renal failure a.c. eichenberger, p. grehten, c. kellenberger; zurich/ch this study introduces a measure of renal morphology, herein labelled split renal volume (srv), that should be applied as an indicator for potential renal failure and eventual surgical treatment of obstructive uropathy in children. current practice applies dynamic contrast enhanced functional renal imaging (fri) with complex post-processing methods. fri generates a measure of split renal function (srf). reduced values of srf under % are currently considered to be an indicator for surgical treatment. this retrospective study compares the accuracy of srv with the accuracy of srf as methods for assessing potential renal failure. materials: srv is a quotient of volumetric measurements. total renal volume is described by the sum of parenchymal volume and intra-renal collecting system volume. srv is designated in this study as the quotient of two ratios: first, the ratio of total renal volume to parenchymal volume of the left kidney; and second, the ratio of total renal volume to parenchymal volume of the right kidney. twenty-two children were studied: (age . ± . y) with unilateral asymptomatic intrinsic uretero-pelvic-junction obstruction (upjo), and normal controls (age . ± . y). all subjects underwent mr urography at . t, which provided estimates of srf and srv for each of the examined kidneys. the sensitivity and specificity of both srf and srv for predicting surgical management were determined by comparing the indicators with an expert review panel's decision to operate. the panel was blinded to values of srv. results: when a cut-off value of % for srf was used, the resultant sensitivity and specificity of srf for the detection of kidneys at risk were found to be % and %. the values of srv ranged between . and . . it was found that a value greater than . indicated kidneys at risk. when the cut-off value of . for srv was used, the resultant sensitivity and specificity of srv for the detection of kidneys at risk were both %. in this small population, srv proved to be % accurate and is superior to srf for detecting kidneys at risk of failure due to obstruction. routine application of srv promises to simplify mr urography by obviating dynamic contrast enhanced imaging studies. further prospective studies are necessary in order to select an optimal cut-off value of srv. factors that can distort the dj flexure mimicking malrotation v. bhalla , s. mohan , k.a. bradshaw , m. thyagarajan ; stoke-on-trent/uk, birmingham/uk to highlight the varied radiological appearances and position of the duodenal-jejunal flexure in children and to discuss its importance in assessing for malrotation materials: retrospective analysis of the multiple fluoroscopic examinations performed in the assessment for malrotation over the past years in a busy tertiary centre results: the classic position of the dj flexure is to the left of left pedicle of l and at the level of the duodenal bulb on frontal views and posterior (retroperitoneal) on lateral views. however variations of the normal location can appear, particularly on frontal views, in the upper gi series that can mimic malrotation which has shown to be more common in neonates. we present cases with examples to illustrate the variability in position due to various causes and its implications in the diagnosis of malrotation and volvulus. our case mix includes patients with excessively distended stomachs, large bowel obstruction, renal pelvic dilatation, repeated naso-jejunal and gastro-jejunal tube insertion and in patients post liver transplantation. malrotation and its assessment have serious management and prognostic implications. this presentation demonstrates that the imaging features can be varied, and knowledge about factors distorting the position of the dj flexure is vital in the accurate management of neonates presenting with bilious vomits. retrospective study of prospectively collected data performed at a single tertiary paediatric institution over a . year period. a total of consecutive patients, aged < years, were reviewed who underwent native renal biopsy. all biopsies were performed within the interventional radiology department. all patients had renal disease requiring a renal biopsy for diagnosis. outcome measures include technical success, early and late complications and the adequacy of histological samples. in addition, age, body weight, glomeruli number, histological data, number of cores, size of the biopsy needle, use of co-axial needle and the rate of tract embolisation/plugging were recorded. results: from september to april , patients (mean age: . years +/- . ; range . - . years) underwent native renal biopsy. one hundred ninety-one patients were < years of age. nine hundred forty-six patients ( . %) had a biopsy of the right kidney, patients ( . %) had a biopsy of the left kidney and patient ( . %) had a biopsy of a horseshoe kidney. five hundred fifteen patients were female ( . %). seven hundred sixtynine patients ( . %) had the procedure performed under general anaes-thetic and of patients ( . %) had the procedure performed under local anaesthetic (+/-sedation/entonox). mean number of passes of the core biopsy needle through the renal capsule was . . a gauge core biopsy needle was used in % of the patients. . % of the patients had three or less passes of the biopsy needle though the renal capsule. the overall complication rate was . % (n= ). . % (n= ) of patients had a non-diagnostic biopsy. fifty-five patients underwent a post biopsy ultrasound due to clinical concerns. twenty patients developed perinephric haematoma ( were treated conservatively; one underwent embolisation and subsequent nephrectomy). four patients developed arteriovenous fistulas. two patients developed post procedure infections (one at the skin site and one a perinephric collection). histology results were reviewed in all patients. the mean number of glomeruli obtained was . (range - ). glomerulonephritis was the most common histological diagnosis (n= ; . %) conclusion: renal biopsy is an extremely useful diagnostic tool for renal disease. there is no published data of this size assessing the outcome of native renal biopsies in the paediatric population. jr usa a. lassrich germany j. sauvegrain france c. fauré france a. giedion switzerland e. willich germany r. astley united kingdom ringertz sweden d.g. shaw united kingdom r. lebowitz usa b. lombay hungary pena spain gold medallists london/united kingdom the dutch group of paediatric radiologists, the hague/the netherlands g. stake ringertz (espr) & d. kirks (spr) chicago/united states future espr meeting italy european courses of paediatric radiology (ecpr) genoa/italy (neuroradiology) r.fotter, graz/austria (abdomen) brussels/belgium (thorax) j-n. dacher paediatric musculoskeletal imaging) references: . -stellungnahme-lnt-modell.pdf [internet]. [zitiert an evaluation of paediatric projection radiography in ireland contrast imaging -> application -dectris background ionizing radiation and the risk of childhood cancer: a census-based nationwide cohort study best practices in digital radiography communicating radiation risks in paediatric imaging kinderradiologie-besonderheiten des strahlenschutzes diagnostic imaging and ionizing radiation -canadian nuclear safety commission epidemiology without biology: false paradigms, unfounded assumptions, and specious statistics in radiation science (with commentaries by inge schmitz-feuerhake and christopher busby and a reply by the authors) european guidelines for ap/pa chest x-rays: routinely satisfiable in a paediatric radiology division? eurosafe imaging together -for patient safety image gently campaign back to basics initiative: ten steps to help manage radiation dose in pediatric digital radiography hostens j, u. a. in-vivo dark-field and phase-contrast x-ray imaging safety commission cn. linear-non-threshold model optimisation of paediatric chest radiography optimizing digital radiography of children radiation exposure in diagnostic imaging: wisdom and prudence, but still a lot to understand radiation shielding for diagnostic radiology strahlenhygienische aspekte bei der röntgenuntersuchung des thorax the image gently pediatric digital radiography safety checklist: tools for improving pediatric radiography the standardized exposure index for digital radiography: an opportunity for optimization of radiation dose to the pediatric population gastroenterology and radiology records were searched to identify ibd patients with colonic strictures. all patients underwent an mre within months of colonoscopy. the following colonic parameters were evaluated: bowel wall thickening with luminal narrowing, pre-stenotic bowel dilatation, bowel wall enhancement, and diffusion restriction (if performed). colonoscopy and operative notes were correlated. results: fourteen patients met the inclusion criteria, one with colonic strictures. bowel wall thickening with luminal narrowing at the site of the reported stricture was present in all cases. pre-stenotic bowel dilatation (> . cm) proximal to the reported stricture was present in / cases. using luminal narrowing and prestenotic dilatation as criteria for diagnosis of a colonic stricture, / cases were therefore positive on mre. when comparing to colonoscopy, mre diagnosed colonic strictures in / cases ( %). in the six patients who had surgery, mre accurately diagnosed colonic strictures in / cases ( %). conclusion: mre is not the primary modality for colonic evaluation, yet diagnosing colonic pathology on mre, particularly strictures, may be beneficial for the referring gastroenterologist in the assessment of these patients. potential strictures on colonoscopy did not agree with mre in all cases, but when correlating with surgery % of colonic strictures were accurately diagnosed in a small subset. although mre is not optimized for the evaluation of the colon, colonic strictures can be recongnized in children with crohn's disease.disorders of sexual differentiations in neonates: standardized sonographic evaluation and proposal of a reading grid h. lerisson, e. amzallag -bellenger, f.e. avni, m. cartigny; lille/fr to propose a systematic and structured sonographic approach in neonates with disorders of sexual differentiation (dsd) materials: review of the us pelvic, external genital and adrenal findings in consecutive patients with clinical suspicion of dsd evaluated in the neonatal period. the us survey included: the uterus (absent or visible -with or without hormonal impregnation), the vagina (absent or present (complete or partial)), the gonads (ovaries, testis or unsetermineddysgenetic ) as well as the adrenals (normal, too small or enlarged). the us conclusions were correlated with the endocrinological and genetical work-up of each patient results: twenty cases of dsd have been included us had correctly identified the presence of a uterus in patients. there was one false positive case; among the patients did not show the physiological hormonal impregnation. the vaginal anomalies were correctly evaluated. the gonads were defined correctly as normal testis in patients, normal ovaries in and dysgenetic gonads in . they could not be visualized in patients. adrenals were considered normal in patients (one false negative), hypertrophied in and small in one patient. to compare hepatic d shear wave elastography ( d swe) in children between free-breathing and breath-hold conditions, in terms of measurement agreement and time expenditure. a cohort of children ( . ± . years) who underwent standardized d swe between may and october were retrospectively evaluated. liver elastograms were obtained under free-breathing and breath-hold conditions and time expenditure was measured. median stiffness, interquartile range (iqr), and iqr/median ratio were calculated based on , six, and three elastograms. results were compared using pearson correlation coefficient, intraclass correlation coefficient (icc), bland-altman analysis, and student's t. median liver stiffness under free-breathing and breath-hold conditions correlated strongly ( . ± . kpa vs. . ± . kpa; r= . , p< . ). time to acquire elastograms with free-breathing was lower than that with breath-holding ( . ± . sec vs. . ± . sec, p< . ). results for median liver stiffness based of , six, and three elastograms demonstrated very high agreement for free-breathing (icc . ) and for breath-hold conditions (icc . ). hepatic d swe performed with free-breathing yields results similar to the breath-hold condition. with a substantially lower time requirement, which can be further reduced by lowering the number of elastograms, the free-breathing technique may be suitable for infants and less cooperative children not capable of breath-holding. abstract: pelvi-ureteric junction obstruction (pujo), classified into intrinsic and estrinsic is one of the most frequent urological diseases affecting the pediatric population. extrinsic causes include the presence of crossing vessels, kinks or adhesions. in cases with extrinsic obstruction of puj, colour doppler ultrasound (cd-us) can detect the presence of crossing vessels. in presence of crossing vessels pyeloplasty or vascular hitch can be performed. the aim of the study is to analyze the sensitivity of cd-us and magnetic resonance urography (mru) in visualizing crossing vessels in extrinsic pediatric hydronephrosis in order to decide the correct diagnostic pathway and evaluate in the pre-operative phase which surgical technique and approach (open, laparoscopic or robotic) is the ideal to be performed. a retrospective review of medical records for patients who underwent surgical treatment for hydronephrosis from august to february was performed. a descriptive statistical analysis was performed. the presence of crossing vessels at surgery was considered the gold standard. the sensitivity was calculated for both the imaging techniques as a measure of accuracy, evaluating the ratio between the positive cases divided by the those with aberrant vessels identified at surgery. results clinical charts were reviewed. crossing vessels identified at surgery were ( , % of pujo). the median age was higher in the group with crossing vessels compared to the group without crossing vessels (p< , ). the sensitivity of cd-us was higher compared to mru ( , % vs , %). before the surgical time knowing which technique and approach have to be managed in hydronephrotic patients with crossing vessels could be very important. according to our preliminary datacollection cd-us has got a higher sensitivity and could be the gold standard technique. study limitations include the absence of specificity, positive and negative predictive values. in the future it could be useful to perform a double blind trial in which children with moderate-severe hydronephrosis will be subjected to both imaging techniques to evaluate not only the sensitivity, but also the specificity, the positive predictive value and the negative predictive value conclusion: conclusions in the pre-operative phase, cd-us could be sufficient for the surgeon to discern between pujo with the presence or the absence of crossing vessels, as it has a higher sensitivity and lower costs compared to mru.urosonography -nonradiant alternative for voiding cystourethrography o.m. fufezan, c.a. asavoaie, s. tatar; cluj-napoca/ro voiding cystourethrography (vcug) was considered the gold standard in the diagnosis and monitoring of vesicoureteric reflux (vur). this method is invasive due to the radiation exposure. in the present the diagnosis of vur can also be established by contrast ultrasound examination, also known as voiding urosnography (vus). the authors will present the role of vus in the diagnosis and grading of the vur and the role of patient position in the detection of vur. the infants and children with congenital anomalies of the urinary tract and/or urinary tract infection have been evaluated with vus. iatrogenic vur, neurogenic bladder and urogenital sinus anomalies were excluded. the presence and the degree of the vur were evaluated. vus has been performed using a protocol similar to the one used for vcug. in conditions of sterile urine, . ml sonovue and saline solution have been introduced into the bladder until voiding started. the patients were examined both in a supine and an upright position and the following structures have been scanned: urinary bladder, distal part of the ureters and both pelvicaliceal systems during bladder filling, during and after voiding. the visualisation of the ultrasound contrast agent in the upper urinary tract represented a positive vur diagnosis. the grading of the vur has been established based on the same criteria as in vcug. sixty five patients ( renal units), ages between weeks and years were evaluated (median age ± sd: years ± years and months) through vus. vcug was performed in patients in a maximum of hours after vus. vur has been identified in patients ( . % renal units). a high vur grade (iv-v) was identified in . % of renal units. for the patients investigated with both methods, the results were concordant in patients. in two patients vur has not been identified by vcug, but was detected during vus. the upright position (in addition to decubitus) revealed vur in renal units in which the reflux was not detected in decubitus. conclusion: vus is extremely useful and reliable in diagnosing and grading vur in pediatrics. the changing of the patient position during examination can improve vur detection.new sonographic features useful in differentiating congenital duodenal anomalies from malrotation: gastric and duodenal wall thickening and hyperechogenicity p. caro dominguez , s. hameed , a. zani , r. moineddin , o.m. navarro kunstmann , a. daneman ; cordoba/es, london/uk, toronto/ca the clinical and plain radiographic differentiation of congenital duodenal anomalies (atresia, web, stenosis) and intestinal malrotation is not always clear. although sonography has been documented as an important diagnostic tool to differentiate these two entities, its role is still not widely appreciated. the purpose of this study was to assess the sonographic features of the gastric and duodenal wall in a large series of neonates with congenital duodenal obstruction as these have not been reported previously. neonates who had surgically proven congenital duodenal anomalies or malrotation were identified from the surgical database in a tertiary pediatric hospital in a period of years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . those with an ultrasound performed within hours of surgery were included in the study. imaging was retrospectively and independently reviewed by two readers in chronological order blinded to final diagnosis. a wall thickness of ≥ mm of a distended loop was considered abnormal. hyperechogenicity was recorded when the wall of the stomach or duodenum was brighter than liver or splenic parenchyma. imaging findings in the group with congenital duodenal anomalies was compared to the group with malrotation using fisher's exact test. one hundred eight neonates were included in the study, with a congenital duodenal anomaly, with malrotation ( with volvulus) and with both. ugi was performed in neonates who had us. the correct diagnosis was provided only by us in of these newborns ( %), only by ugi in ( %), by both in ( %) and by neither in ( %). ugi was performed in children with malrotation and volvulus, eight were diagnosed only by us, four only by ugi and nine by both. the gastric and/or duodenal wall was significantly thicker and more hyperechoic in neonates with congenital duodenal anomalies than those with malrotation (p< . ) [fig , table ]. conversely an abnormal relationship between the superior mesenteric artery and vein, abnormal position of the third part of the duodenum and the whirlpool sign were found more commonly in neonates with malrotation than those with congenital anomalies (p< . ). key: cord- -k aapnx authors: manivel, vijay; lesnewski, andrew; shamim, simin; carbonatto, genevieve; govindan, thiru title: clue: covid‐ lung ultrasound in emergency department. date: - - journal: emerg med australas doi: . / - . sha: doc_id: cord_uid: k aapnx nan lung ultrasound (lus) is a vital part of critical care evaluation of multiple lung pathologies, like pneumothorax, acute respiratory distress syndrome (ards), pulmonary oedema, interstitial lung disease (ild) and pneumonia ( ) . as sars-cov- infection causes interstitial pneumonitis, there is an extensive use of lus in covid- patients in china ( ) and italy ( ) . detection of covid- by rt-pcr testing of nasopharyngeal swabs, considered as the gold-standard test, lacks sensitivity compared to ct chest, % vs % respectively( ). ultrasound has an excellent correlation to ct chest findings ( ) and could be an alternative to ionising radiation imaging ( ) . poor sensitivity of % for cxr to detect covid- changes ( ) and superiority of ultrasound in similar ild ( ), makes it an attractive imaging option. performance of lus at bedside also allows concurrent execution of clinical examination and lung imaging by the same clinician, expedites clinical decision making ( ) . a step-by-step approach to safely performing lus in table . we recommend chest be scanned systematically as zones, six zones for the right lung (r to r ) and six zones for the left lung (l to l , figure ). scanning the posterior lung zones (r , r , l , l ) will improve the sensitivity of lus, as most changes are in the posterior lung ( ) . for safe scanning, the patient to sit facing away from the clinician and posterior, lateral (r , r , l , l ) and even anterior (r , r , l , l ) zones scanned by the clinician positioned behind the patient. if the patient is in the supine position (unwell to move or sedated), the posterior lung zones replaced by scanning areas slightly posterior to the posterior axillary line. in our limited experience with covid- patients, it takes less than minutes to perform lus, excluding cleaning time. coronavirus being a lipid-based enveloped virus, is susceptible to low-level alcohol based disinfectant wipes ( ) but strongly recommend involvement of the infection-control department and the ultrasound manufacturer in disinfection planning and guideline development. this article is protected by copyright. all rights reserved. an appropriately optimised image of a normal lus will feature a-lines and few b-lines (< b-lines per intercostal space) and smooth thin pleural line ( ) . sonographic features of covid- pneumonitis are ( ) luss is a valid tool to assess regional and global lung aeration in ards ( , ) and can be used in covid- pneumonitis with several similar sonographic features( ). at each zone, luss points range from to , with higher points allocated to severe lung changes ( figure ). based on the total score from lung zones, the severity classified as mild (score - ), moderate (> - ) and severe (> ). a normal lung will have a total score of . a clinician's decision on the need for supplemental oxygen is a complex process, involving factors like oxygen saturation, work of breathing, respiratory rate and pre-existing medical conditions (i.e. copd, heart disease). a single parameter like oxygen saturation or respiratory rate, may not represent real-time clinical practice. this article is protected by copyright. all rights reserved. clue protocol only provides a foundation, which is easy to use and flexible to accommodate complex clinical presentations. some of the patients in the mild and moderate severity group could safely go home from the ed, provided a proper self-isolation facility, and adequate community follow-up ensured. in patients, who are depicted in cells with dotted borders in the table "clue protocol" in figure , consider in-hospital management if no pulse-oximetry monitoring or home-oxygen support provided. while australia and new zealand prepare for a figurative tsunami of highly infectious patients, we anticipate that a protocolised use of bedside lus by emergency clinicians in covid- patients could alleviate some of the radiological resource burden expected. existing evidence supports lus in covid- , but none has a clear objective scoring system or incorporates clinician's assessment in decision making. clue protocol aims to addresses this gap and provide the emergency clinician with an appropriate disposition plan. clue protocol will provide instant, objective information of the severity of the disease and may avoid further imaging like cxr and ct chest. absence of ionising radiation with ultrasound makes it an ideal imaging modality for serial assessments, providing an objective measure of disease progression. ultrasound performed by the treating clinician during the clinical examination may minimise the number of staff encounters, potentially minimise healthcare worker infection rate and cross-contamination among patients. we anticipate several limitations. firstly, luss and clue protocol has never been tested for use in covid- viral pneumonitis and currently a multicentre trial in australia and new zealand eds in progress, to evaluate this scoring system. secondly, lus findings are not specific to covid- and may not correlate to clinical outcome. thirdly, using ultrasound in covid- involves meticulous infection control practice. finally, lus requires an operator with a certain degree of training, and we strongly emphasise that beginners to lus are not to train on these highly infectious patients. this article is protected by copyright. all rights reserved. page of clue protocol which incorporates lung ultrasound scoring system and supplemental oxygen requirement at the time of examination, when performed by a trained emergency clinician, can help risk-stratify suspected covid- patients. this protocol will aid the clinician to make rapid and appropriate bedside clinical decisions, potentially decrease reliance on chest x-rays or ct chest and aid disposition planning from the emergency department. this article is protected by copyright. all rights reserved. thoracic ultrasonography: a narrative review findings of lung ultrasonography of novel corona virus pneumonia during - epidemic can lung ultrasound help critical care clinicians in the early diagnosis of novel coronavirus (covid- ) pneumonia? radiology correlation of chest ct and rt-pcr testing in coronavirus disease (covid- ) in china: a report of cases clinical characteristics of coronavirus disease in china integrated use of lung ultrasound and chest x-ray in the detection of interstitial lung disease covid- outbreak: less stethoscope, more ultrasound. the lancet a preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia wfumb position statement: how to perform a safe ultrasound examination and clean equipment in the context of covid- assessment of lung aeration and recruitment by ct scan and ultrasound in acute respiratory distress syndrome patients key: cord- -ifbpz a authors: cho, young-jae; song, kyoung-ho; lee, yunghee; yoon, joo heung; park, ji young; jung, jongtak; lim, sung yoon; lee, hyunju; yoon, ho il; park, kyoung un; kim, hong bin; kim, eu suk title: lung ultrasound for early diagnosis and severity assessment of pneumonia in patients with coronavirus disease date: - - journal: korean j intern med doi: . /kjim. . sha: doc_id: cord_uid: ifbpz a background/aims: current evidence supports lung ultrasound as a point-of-care alternative diagnostic tool for various respiratory diseases. we sought to determine the utility of lung ultrasound for early detection of pneumonia and for assessment of respiratory failure among patients with coronavirus disease (covid- ). methods: six patients with confirmed covid- by reverse transcription-polymerase chain reaction were enrolled. all had undergone chest x-ray and chest computed tomography (ct) on the day of admission and underwent multiple point-of-care lung ultrasound scans over the course of their hospitalization. results: lung ultrasound detected early abnormal findings of representative b-lines in a patient with a normal chest x-ray, corresponding to ground-glass opacities on the chest ct scan. the ultrasound findings improved as her clinical condition improved and her viral load decreased. in another minimally symptomatic patient without significant chest x-ray findings, the ultrasound showed b-lines, an early sign of pneumonia before abnormalities were detected on the chest ct scan. in two critically ill patients, ultrasound was performed to assess for evaluation of disease severity. in both patients, the clinicians conducted emergency rapid sequence intubation based on the ultrasound findings without awaiting the laboratory results and radiological reports. in two children, ultrasound was used to assess the improvement in their pneumonia, thus avoiding further imaging tests such as chest ct. conclusions: lung ultrasound is feasible and useful as a rapid, sensitive, and affordable point-of-care screening tool to detect pneumonia and assess the severity of respiratory failure in patients hospitalized with covid- . the world is currently experiencing a novel coronavirus disease (covid- ) pandemic [ ] . in south korea, there have been multiple confirmed cases related to local outbreak clusters, but there are no rapid, sensitive, affordable screening tools available to assess the presence of pneumonia, disease severity, or risk of respiratory fail-the korean journal of internal medicine. vol. , no. , july ure. chest computed tomography (ct) is a useful method for diagnosing covid- [ ] . however, the highly transmittable nature of covid- through droplets or fomites, and the risk associated with radiation exposure, has hindered routine use of traditional diagnostic modalities such as computed tomography (ct) [ ] [ ] [ ] . lung ultrasound (lus) is increasingly performed at the bedside for clinical assessment of the patients with acute respiratory failure [ ] . the normal lung surface associate lung sliding with horizontal repetitions of the pleural line, called a-lines. 'b-lines' indicate loss of lung aeration. the bedside lung ultrasound in an emergency (blue) protocol is a fast protocol (< minutes), which combines these signs, resulting in several aeration patterns: moderate loss of lung aeration (b lines); severe loss of lung aeration (b lines); pulmonary consolidation (c). herein, we describe some of the key lus findings in six patients with confirmed covid- infection with normal to minimal radiographic changes; and covid- pneumonia along their clinical course, to demonstrate the feasibility and utility of the lus in early detection of pneumonia and clinical guidance on the management of the acute respiratory failure. we retrospectively reviewed the records of six consecutive patients with confirmed covid- who underwent serial lus. all patients had routine clinical admission evaluation with repeated reverse transcription-polymerase chain reaction (rt-pcr) tests for severe acute respiratory syndrome coronavirus (sars-cov- ) in samples obtained from their upper or lower respiratory tract during their hospitalisation. the patients' treatment differed according to the decision of the primary attending physician, who is an infectious disease specialist. all lus were conducted by one independent pulmonary and critical care specialist using a point-of-care ultrasound. for lus examination ( supplementary fig. ), an c-rs microconvex probe ( mhz, venue, ge healthcare, milwaukee, wi, usa), which directly applied to the intercostal space was used. the use of bedside ultrasound by the international consensus conference was not considered in the report [ ] . patients were examined in sitting or semi-recumbent position, with the probe applied perpendicularly to the chest surface, as the patient's clinical condition allowed [ ] . six areas per each hemithorax were examined, as recommended [ , ] . at least two central intercostal spaces per area were investigated with longitudinal or transversal scans. first, the scan was done to correctly identify the pleura; a video clip at least one respiratory cycle length was stored for offline analysis. then, the following data were recorded for each scan: the length of pleural line, presence of a-lines, number and coalescence of b-lines, subpleural echo-poor regions (subpleural con- solidations), and tissue-like patterns (consolidations). to quantify b-lines, we employed a machine learning system embedded in the venue device, which included "auto-gain" and "auto b-lines" functions [ ] . the "auto b-lines" function automatically distinguishes between real b-lines and all other artefacts [ ] . the lung review screen provided the overall lus score, by adding the scores from segments. each b-line was counted and the count per zone was given as one of the following numbers: , , , , , or ≥ . the score for each segment was defined as follows: counts ≤ were given a score of ; counts of or were given a score of (b lines); counts ≥ were given a score of (b -lines); and if consolidation was present a score of (c) was given (the finding of consolidation was not automatically recorded and had to be entered manually). the "auto b-lines" tool highlighted b-lines while scanning, and at the end of the sweep the line tool jumped image to the frame with the most b-lines. some of these key features included the brightness of the b-lines relative to its surroundings, the depth of b-lines (whether the b-lines extended to the bottom of the image), and the deletion of a-lines. the study protocol was approved by institutional review board of seoul national university, bundang hospital (b- - - ). the institutional review board waived the need for informed consent because the study was based on a retrospective analysis of electronic medical records. the records of six patients (four adults and two children) were analysed retrospectively. five patients showed positive rt-pcr for sars-cov- in upper and lower respiratory tract specimens, and one -month-old girl was only positive in the upper respiratory tract as a lower respiratory tract specimen was not able to be obtained. the clinical characteristics of the enrolled patients are shown in table . of the four adults, the first was a -year-old woman who had a sore throat and a fever which had started days previously, and the second was a -year-old man with a cough. the two critically ill patients were a -year-old woman and an -year-old man, both with dyspnoea, and transferred from other hospital for critical care. of the two children, the first was a -year-old girl who had a small amount of sputum for days. the second was a -month-old girl who had tested positive for sars-cov- but had no respiratory symptoms. of the four adults, lus use in two cases led to the with early detection of pneumonia, and two cases with severity assessment for acute respiratory failure. lus was followed by the results of chest x-ray (cxr) and chest ct results focusing on abnormal findings in the index cases, and then followed by lus prospectively. case a -year-old woman was referred and admitted following a positive sars-cov- test at a community health screening, which she attended days after the onset of a sore throat and fever. she had had contact with a family member with a confirmed covid- . she did not have symptoms of a lower respiratory tract infection. the cxr performed on the day of visit was normal (fig. a) , but her chest ct ( right upper lung field, which corresponded with normal ct findings on the right. she developed dry cough and fever on day and began treatment with lopinavir/ritonavir. contrary to near minimal changes of serial cxr (supplementary fig. a a -year-old man was admitted to the hospital following a positive sars-cov- test, with a -day history of cough, chills, and myalgia. he had been exposed to a colleague with sars-cov- infection, who had experienced similar symptoms days before the onset of his symptoms. at the time of hospitalisation, he did not use of lung ultrasound for severity assessment for acute respiratory failure case an -year-old man was transferred from another hospital with ongoing respiratory problems. he had been diagnosed with confirmed covid- at the other hospital, days before being transferred to our hospital. immediately before transfer, the patient had rapid, shallowing breathing despite oxygen supplementation. copies of cxrs taken days, and day before being transferred to our hospital are shown in fig. a . lus was immediately performed to assess the extent of lung infiltration. the lus showed multiple b-lines in the entire anterior bilateral upper and lower lung fields (fig. b) , and the lung aeration score according to the automated protocol was (fig. c ). based on these findings, we immediately decided to initiate mechanical ventilation with rapid sequence intubation. a post-intubation cxr and chest ct showed typical findings of adult respiratory distress syndrome (ards) (fig. d) . a -year-old woman was transferred from another hos-pital after being diagnosed with covid- . she had been admitted to the other hospital after days of fever, when she developed respiratory distress occurred during isolation. at the time of her transfer to our hospital she was being treated with empirical antibiotics and oseltamivir and was receiving l/min of supplemental oxygen via nasal prongs. her cxr and ct findings at the previous hospital are shown in supplementary fig. a . the lus was performed with the patient in the supine position. multiple b-lines were observed in the anterior right upper lung field, and both anterior lower lung fields, but not the anterior left upper lung field. her lung aeration score was points (supplementary fig. b ), based on the lus findings in both anterior areas. although lopinavir/ ritonavir was started immediately after transfer to our hospital, she was intubated on day after her respiratory symptoms became more severe. lus performed on day showed a worsening of her pneumonia, with the lung aeration score of points (supplementary fig. c ). after mechanical ventilation, the patient's cxr and lus aeration score improved from to , but her hypoxia remained severe (ratio of arterial oxygen partial pressure to fractional inspired oxygen [p/f ratio] on day ). as a rescue therapy for ards, methylprednisolone ( mg/ kg intravenously) and inhaled nitric oxide were administered. despite these interventions, the patient continued to deteriorate, and veno-venous extracorporeal membrane oxygenation (ecmo) support was started on day . her cxr showed worsening of her pneumonia, and a lus performed on day ( days after ecmo application) showed a lung aeration score of points (supplementary fig. d) , which was worse than it had been on day (the day of intubation). (table ) the patient was subsequently diagnosed with hospital-acquired pneumonia caused by carbapenem-resistant acinetobacter baumannii cultured from a respiratory sample. under the ecmo support, lus was performed before and after an alveolar recruitment manoeuvre to assess proper positive end-expiratory pressure (peep) on the ventilator. the lus performed after the recruitment maneuver revealed improved aeration of the right lower lung field and lowering of the diaphragm level followed by lung expansion (fig. ) . based on that findings on the lus, we were able to decide on the optimal peep settings and performed a follow-up cxr to confirm improved lung recruitment. case a -year-old girl had confirmed sars-cov- infection after being exposed to a family member with covid- and was hospitalised for evaluation and monitoring of her symptoms. the initial cxr after admission was normal. however, her chest ct scan on day showed focal consolidation with multiple ggos in the right lower lung field (supplementary fig. ). as in case , the lus (performed on day ), showed typical b-lines (consolidations and ggos) in the right lung field (fig. a) , and contralateral a-lines (normal aeration) in the left lower lung field. she developed a small amount of sputum the korean journal of internal medicine. vol. , no. , july but was not administered medication for pneumonia because her condition was stable. follow-up cxrs and lus were performed and days, respectively, after the first lus. as her symptoms improved, lus showed evolution from b -lines to b -lines and then a-lines, indicating progressive improvement in her lung aeration ( fig. b and c, video ; https://www.kjim.org). since there was no evidence of worsening symptoms during the hospitalisation, the patient was transferred to the step-down facility. the final lung aeration score was and her symptoms also disappeared at that time. a -month-old girl was hospitalised with sars-cov- infection after contracting infection from a member of her family. she had no symptoms of covid- and was clinically stable. the initial cxr also showed normal findings ( supplementary fig. a ). to further rule out the presence of pneumonia, lus and cxr was carefully performed on her back area at the bedside with the support of her father on day . the lus showed a-lines throughout her lungs, and no b-lines ( supplementary fig. b ). chest ct was not performed because of her stable clinical condition and normal cxr and lus findings. the cxr (supplementary fig. c ) and lus were repeated on day and remained normal. the patient was later discharged without requiring treatment. this is the first lus case series performed for covid- patients in south korea. in cases and , lus showed important early findings of pneumonia, which corresponded to the findings on chest ct, while cxr did not reveal abnormalities. lus is an especially useful tool for covid- patients because performing conventional auscultation can be challenging when wearing personal protection equipment. lus helped to assess the severity assessment for respiratory failure in cases and as well as the recovery phase. in addition, lus was a useful alternative to chest ct in children to whom radiation exposure can cause harm and in those who need sedation to perform chest ct [ , ] . previous studies have stressed the accuracy and the diagnostic value of chest ct in managing patients with covid- [ , , ] . this case series illustrates the accuracy and the diagnostic value of lus in managing patients with covid or asymptomatic sars-cov- infection. the goal of lus in intensive care medicine and emergency medicine is to detect and manage the pathophysiological changes of cardiopulmonary diseases with an emphasis on point-of-care, rather than simply as a tool to reveal underlying anatomical abnormalities [ , [ ] [ ] [ ] . while recent studies have emphasised the accuracy and the diagnostic value of chest ct in patients with covid- [ , , ] , lus may be a good alternative test for ct scan, and it carries less risk of breaking airborne isolation and transmission of sars-cov- infection to others. currently, a ct scan had been difficult because of keeping a covid- patient in the negatively pressured mobile bed from the quarantine area to the examination room. besides, more health care workers should accompany critically ill covid- patients for their safety, which inevitably increases the risk of exposure to the virus during transportation. also, in this study lus was more sensitive than cxr and sometimes detected b-lines, indicative of subpleural lesions despite the absence of obvious changes on cxr. in an attempt to quantify the lus findings, we adopted the machine's built-in algorithm of analysing characteristics of lesions, focused on interpreting b-lines and the lung aeration score. the automated quantification process helped to overcome the limitations of lus, particularly its intra-operative variability and patient-related factors such as obesity and position [ , ] . in the first adult and the first child patients (cases and ), the lus findings of improvement or deterioration during the period in which the patient was under observation agreed with the ct findings and with changes in the sars-cov- rt-pcr cycle threshold (ct) values for rna-dependent rna polymerase (rdrp) gene (supplementary fig. a and b ). this suggests that lus might be a very useful tool for monitoring disease progression in covid- patients [ ] . currently in south korea, many asymptomatic or mildly symptomatic individuals are confirmed as having sars-cov- infection due to extensive use of rt-pcr testing and thorough epidemiologic investigation of close contacts of individuals with confirmed infection. due to outbreaks among members of religious organisations and inmates of psychiatric institutions in certain geographic areas including the city of daegu and gyeongbuk province, the number of individuals with confirmed infection overwhelmed the medical system, which limited the ability of medical staff to assess the severity of the covid- in some patients during the first few weeks of the epidemic. as in other countries, there were many early deaths due to rapidly progressive disease in those regions. in such situations, using lus for early detection of pulmonary involvement in patients with covid- could be lifesaving, because it is very difficult to recognise patients developing acute respiratory failure with hypoxia in advance, especially within hours after hospitalization. there is an urgent need for a rapid, reliable, and low-risk everyday pointof-care clinical tool that can be used to triage patients with sars-cov- infection and identify those at risk of respiratory failure [ , , ] . as ultrasound examinations in the intensive care unit have been covered by national insurance in south korea, it is also affordable especially for critically ill patients such as severe covid- . we propose the use of an lus screening protocol as shown in fig. . there are some limitations to this study. first, we performed the chest ct prior to lus for the index pa- tient, who did not have significant symptoms suggesting lower respiratory tract pathology. therefore, there is a possibility that lesions cannot be detected if lus was performed without knowing the ct results, given that the initial findings for covid- are only focal ggo lesions. in other cases of acute respiratory distress syndrome, however, lus could identify b-lines, ultrasound evidence of peripherally located ggo, or infiltrations on covid- patients that corresponded to initial symptoms, even before the cxr. we believe that that lus could be performed for confirmed covid- patients without obvious lower respiratory tract symptoms, to guide very early clinical decisions. second, the radiographic findings obtained by ct scan and lus could be at different stage of covid- progress, as there was a time difference between those two measures. there was a time difference between ct scans and lus from a few hours up to days, depending on the hospital logistics and patients' condition, as well as the call schedule of the operator. however, with serial cxrs performed during the gap period, obvious changes were able to be recorded, and clinically estimated to some extent. third, the study was conducted by one ultrasound examiner and was a case series of six patients. as mentioned, inter-operative or even intra-operative variations can be of concern with lus, and we were not able to address or calculate inter-operative variations with current study. however, with using built-in machine learning algorism for image standardisation and processing, we were able to quantify and characterise b-lines for all six case patients. given the pandemic outbreaks occurring around the world, we hope the insufficient number of this research subjects could be overcome by subsequent large-scale studies. especially, we hope the methodologies of longitudinal follow-up lus on covid- patients could be adopted by other researchers and clinicians, to reduce the risk of breaking isolations as well as radiation exposures. this could be especially valuable in children, who need mostly sedation, where it is difficult to repeat chest ct. in conclusion, lus was feasible and useful for a rapid, sensitive, affordable point-of-care screening tool to detect pneumonia without radiation hazard and suggest the severity of respiratory failure for covid- patients. no potential conflict of interest relevant to this article was reported. . lung ultrasound is feasible and useful for screening tool to detect pneumonia in early phase without radiation hazard. characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention coronavirus disease (covid- ): role of chest ct in diagnosis and management correlation of chest ct and rt-pcr testing in coronavirus 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undifferentiated hypotension in the emergency department diagnostic bedside ultrasonography for acute respiratory failure and severe hypoxemia in the medical intensive care unit: basics and comprehensive approaches the characteristics and clinical value of chest ct images of novel coronavirus pneumonia clinical features and chest ct findings of coronavirus disease in infants and young children lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis lung ultrasound for the diagnosis of pneumonia in children: a meta-analysis semiquantitative ultrasound assessment of lung aeration correlates with lung tissue inflammation staff safety during emergency airway management for covid- in hong kong time course of lung changes at we would like to thank editage (www.editage.co.kr) for english language editing. key: cord- - y la authors: agricola, eustachio; beneduce, alessandro; esposito, antonio; ingallina, giacomo; palumbo, diego; palmisano, anna; ancona, francesco; baldetti, luca; pagnesi, matteo; melisurgo, giulio; zangrillo, alberto; de cobelli, francesco title: heart and lung multimodality imaging in covid- date: - - journal: jacc cardiovasc imaging doi: . /j.jcmg. . . sha: doc_id: cord_uid: y la abstract sars-cov- outbreak has rapidly reached a pandemic proportion and has become a major threaten to global health. although the predominant clinical feature of covid- is an acute respiratory syndrome of varying severity, ranging from mild symptomatic interstitial pneumonia to acute respiratory distress syndrome, the cardiovascular system can be involved with several facets. as many as % hospitalized patients presenting with covid- have pre-existing history of cardiovascular disease and current estimates report a proportion of myocardial injury in covid- patients ranging up to %. multiple pathways have been advocated to explain this finding and the related clinical scenarios, encompassing local and systemic inflammatory response and oxygen supply-demand imbalance. from a clinical point of view, cardiac involvement during covid- may present a wide spectrum of severity ranging from subclinical myocardial injury to well-defined clinical entities (myocarditis, myocardial infarction, pulmonary embolism and heart failure), whose incidence and prognostic implications are currently largely unknown due to a significant lack of imaging data. the use of integrated heart and lung multimodality imaging plays a central role in different clinical settings and is essential in diagnosis, risk stratification and management of covid- patients. aim of this review is to summarize imaging-oriented pathophysiological mechanisms of lung and cardiac involvement in covid- and to provide a guide for an integrated imaging assessment in these patients. the severe acute respiratory syndrome coronavirus (sars-cov- ) outbreak arisen in central china at the end of december has rapidly reached a pandemic proportion and the associated disease (covid- ) has become a major threaten to global health ( ) . as the pandemic grows, treating physicians are challenged with different and complex clinical scenarios. the most prominent feature of covid- is an acute respiratory syndrome of varying severity, ranging from mild symptomatic interstitial pneumonia to acute respiratory distress syndrome (ards). however, several reports have stirred the attention to possible cardiovascular involvement during sars-cov- infection: as many as % hospitalized patients presenting with covid- have pre-existing history of cardiovascular disease and current estimates report a proportion of myocardial injury in covid- patients ranging up to % ( ) ( ) ( ) . identification of myocardial injury is associated to a dismal prognosis independently and on top of coexisting previous cardiovascular diseases, therefore recognition of its underlying mechanisms may offer a therapeutic opportunity ( ) . in this context, the use of multiple diagnostic imaging techniques may apply to both heart and lung to provide an integrated assessment of cardiac and pulmonary function and to refine diagnosis, risk stratification and management of covid- patients. the pathogenesis of covid- is characterized by two distinctive but synergistic mechanisms, the first related to viral replication and the second to host immune response ( ) . the disease primarily involves the lungs and progresses through three stages with increasing severity, corresponding to distinct histopathological, imaging and clinical findings( - ). . the first stage involves incubation period, sars-cov- replication in the respiratory system and potential spread to target organs. during this phase alveolar and interstitial inflammation is mild, patchy and usually shows bilateral, peripheral and lower distribution, with patients presenting mild respiratory and systemic symptoms. . the second stage is characterized by localized lung inflammation, that shows different grades of severity, ranging from severe interstitial inflammation and thickening to air space consolidation. patients develop symptoms of viral pneumonia and eventually hypoxia, leading to clinical deterioration and need for hospitalization. . in a subgroup of patients transition to the third stage occurs. this phase is dominated by widespread lung inflammation and systemic inflammatory syndrome triggered by dysregulated host immune response and cytokine storm, causing hyperinflammation, ards, shock and multi-organ damage. clinical features of covid- are variable. while the majority of patients present with only mild respiratory and systemic symptoms, some progress to severe forms of viral pneumonia and eventually develop severe systemic inflammatory manifestations, with an increasingly higher case-fatality rate ( ) . cardiovascular adverse events may occur at different stages complicating the course of the disease and leading to unfavorable outcomes (central illustration). definition of cardiac involvement in covid- is challenging, as sars-cov- infection has multifaceted effects. from a clinical point of view, cardiac involvement during covid- may present a wide spectrum of severity ranging from subclinical myocardial injury to well-defined clinical entities. in a comprehensive understanding, the following clinical scenarios may be encountered: a) primary cardiac involvement; b) secondary cardiac involvement; c) worsening of previous cardiovascular diseases ( table ) . primary cardiac involvement. this may be the consequence of viral tropism for the endothelium and (presumably) for the myocardium. a link between the respiratory syndrome and the pleomorphic cardiovascular manifestations associated with covid- could be identified in the angiotensin converting enzyme (ace- ), a membrane-bound enzyme that serves as cell-entry receptor for the sars-cov- ( ). this receptor is expressed in a variety of tissues, including lung alveolar epithelial cells and enterocytes of the small intestine, as well as arterial smooth muscle cells and endothelial cells ( ) . based on previous data from the sars-cov epidemic, myocardial infection by coronavirus is a possibility: in an autopsy series, sars-cov rna was found in % sampled hearts, along with macrophage infiltration and myocardial damage ( ) . the extent to which these finding may also apply to sars-cov- is unknown. to date, no cases of sars-cov- nucleic acid isolation from myocardial specimens have been described. however, several cases reported on the occurrence of severe myocarditis during laboratory-proven covid- ( ) ( ) ( ) ( ) ( ) . in all these cases myocarditis caused severe left ventricular dysfunction, but showed some degree of systolic function recovery following medical therapy, ranging from progressive improvement to complete myocardial function restoration. a single case of myo-pericarditis complicated by life-threatening cardiac tamponade has been reported, again without direct isolation of sars-cov- from the drained pericardial fluid ( ) . in the absence of proven sars-cov- viral infection of the myocardium, the clinical picture overlap of these case reports with other possible differential diagnoses calls for prudence in diagnosing sars-cov- virus-related myocarditis. secondary cardiac involvement. this is the result of indirect myocardial damage during sars-cov- infection. of note, it may represent the convergence of multiple different mechanisms. in a post-mortem examination from a covid- patient who developed ards, interstitial mononuclear inflammatory cells were noted in heart specimens without structural damage ( ) . hyperinflammatory response in advanced stage of the disease elicits a cytokine storm, chiefly mediated by il- and il- pathways closely resembling hemophagocytic lymphohistiocytosis, a life-threatening hematologic disorder characterized by uncontrolled proliferation of activated lymphocytes and macrophages, with massive release of inflammatory cytokines ( ) . these cytokines have been implied in myocardial injury and adverse remodeling in clinical and experimental models of acute coronary syndromes (acs) and may exhibit direct negative inotropic and metabolic effect onto cardiomyocytes in sepsis-like settings ( ) . in addition, il- plays a proven role in atherothrombosis and the resulting hyperinflammatory milieu may provoke atherosclerotic plaque instability and a pro-coagulant state with increased risk of arterial and venous acute thrombotic events, including type myocardial infarction (mi) and pulmonary embolism (pe). indeed, there is raising concern that covid- patients are more prone to develop thromboembolic venous events and disseminated intravascular coagulation ( , ) . secondary cardiac involvement may also be the consequence of hypoxia-induced myocardial damage that could lead to type mi. this condition could either unmask underlaying obstructive coronary artery disease, or present as myocardial infarction with non-obstructive coronary arteries (minoca) in case of intense oxygen supply-demand imbalance ( ) . moreover, altered pulmonary hemodynamics may play a role in secondary cardiac involvement. in severe covid- pneumonia, use of higher positive end-expiratory pressure may be associated with increased right ventricular (rv) afterload and strain due to higher pulmonary arterial pressure and pulmonary vascular resistance. pulmonary circulation hypoxic vasoconstriction and superimposed pulmonary thromboembolic events may further precipitate these effects. worsening of previously existing cardiovascular diseases. this is frequently observed during covid- and may explain the higher prevalence of patients with pre-existing cardiovascular comorbidities in the non-survivor cohorts ( , , ) . indeed, patients with heart failure (hf) are particularly vulnerable to hemodynamic decompensation during viral infections ( ) . furthermore, in predisposed patients, arrhythmias may ensue as a result of multiple mechanisms, including hypoxia, systemic inflammation and side effects of drugs used in the treatment of covid- (i.e. hydroxychloroquine often combined with azithromycin) ( ) . chest x-ray. the recent covid- radiological literature has been molded by the chinese experience, with the vast majority of reports focusing on the role of chest computed tomography (ct), almost neglecting chest x-ray (cxr) contribution. on the other hand, european hospitals have drawn diagnostic algorithms in which cxr is described as a first line triage tool, mainly due to its availability and feasibility and to long reverse transcription polymerase chain reaction (rt-pcr) turnaround times. furthermore, the american college of radiology points out that ct room decontamination after scanning covid- patients may disrupt radiological service availability, and suggests that portable chest cxr might be considered the optimal tool to minimize the risk of cross infection ( ) . as recently reported, cxr demonstrates typical radiographic features in the vast majority of covid- patients, including ground-glass opacities and consolidation, while pleural effusion is not common (table and figure ). in a retrospective cohort of patients, wong et al. found that the common ct findings of bilateral involvement, peripheral distribution, and lower zone dominance can also be assessed on cxr and that severity of cxr findings peaked at - days after symptoms onset, consistently with previous ct reports ( ) . despite the fact that out of patients demonstrated cxr abnormalities before eventually testing positive on rt-pcr, baseline cxr sensitivity resulted %, being significantly lower than that reported for initial rt-pcr and baseline ct ( ) . moreover, differently from what has been previously reported about chest ct, radiographic and virologic recovery times were not significantly different, thus reducing the role of cxr in clinical monitoring ( ) . a retrospective analysis of south korean patients who underwent both chest ct and cxr further decreased the sensitivity of cxr imaging in detecting covid- pneumonia to . % ( ) . however, the significance of this result is limited by the small sample size. recently, bandirali et al. proposed a role for cxr in asymptomatic or minimally symptomatic patients in epidemic regions, which may have positive radiographic findings even after days of quarantine ( ) . up to date, there is no consistent report accurately depicting the course of disease on serial cxr images. chest computed tomography. chest ct is a highly accurate imaging modality for pneumonia identification and characterization. as recently reported, chest ct demonstrates typical imaging features in covid- patients, including bilateral ground-glass opacities (ggos), crazy paving pattern (ggos with superimposed inter/intralobular septal thickening) and/or consolidations, predominantly in subpleural locations in the lower lobes; typically, discrete pulmonary nodules, lung cavitation, pleural effusion and lymphadenopathies are not present( , )(table and figure ). pan et al. demonstrated that multiple ct scans could accurately depict the course of disease, summarized in ct-based stages ( ) . the typical covid- pneumonia often starts as small subpleural ggos, mainly affecting the lower lobes (early stage, - days after symptoms' onset), which then rapidly develops into crazy paving pattern and consolidation areas, typically affecting both lungs (progressive stage, - days after symptoms' onset). thereafter, dense consolidation become the most frequent finding (peak stage, - days after symptoms' onset). when infection resolves the consolidation areas are gradually absorbed with residual ggos and subpleural fibrotic parenchymal bands (absorption stage, > weeks after symptoms' onset) (figure ) . ai et al. found that with rt-pcr as a reference, the sensitivity of chest ct imaging for covid- is % ( ) . interestingly, these radiological findings are also observed in patients with clinical symptoms but negative rt-pcr results and that almost % and % of these patients have been respectively reconsidered as highly likely cases and as probable cases by a comprehensive evaluation ( ) . furthermore, % to % of patients had initial positive chest ct consistent with covid- before the initial positive rt-pcr results ( ) . finally, % of patients showed improvement of follow-up chest ct scans before the rt-pcr results turning negative ( ) . nevertheless, it is worth emphasizing that patients with rt-pcr confirmed covid- infection might have normal chest ct findings at admission, when disease is still subtle ( ) . additionally, chest ct can be used for characterization of covid- pneumonia severity. yang et al. proposed a ct-based severity score defined by summing up individual scores from lung regions: the individual scores in each lung, as well as the global severity score, were found to be higher in severe covid- when compared with mild cases (sensitivity: . %, specificity: %)( ). for lung evaluation presenting features that make it very attractive for assessment of patients affected by covid- ( ) ( ) ( ) . lus can be performed with any two dimensional scanner, including portable ones, using linear, convex or phase array probes. specifically, highfrequency linear probe is recommended to assess the pleural line, phase array low-frequency probe is suggested to evaluate deep consolidation, while micro convex probe with small footprint is useful for evaluating posterior fields in supine patients. the entire chest can be scanned with the probe oriented longitudinally or obliquely along the intercostal spaces. the scanning protocol consists in -zone examination with regions per hemithorax: upper and lower parts of anterior, lateral, and posterior chest wall demarcated by the anterior and posterior axillary line ( , ) . covid- pneumonia is characterized by initial interstitial damage with a bilateral, peripheral and posterior distribution followed by parenchymal involvement ( ) . lus effectively detects the areas affected by subpleural interstitial syndrome with the appearance of b-lines, which increase in number as the pathology spreads up covering most of the pleural line. these findings correspond to ggos and reticular pattern at ct scan ( table ) . the characteristics of the b-lines help to distinguish within interstitial syndrome between pneumonia or ards and cardiogenic pulmonary edema. specifically, inflammatory patterns are characterized by the presence of bilateral, irregularly distributed b-lines with spared areas and coalescent b-lines mostly in posterior fields; furthermore, the pleural line appears typically thickened and irregular with reduced or absent lung sliding ( ) . as the disease progresses, lung consolidations become frequent. the subpleural consolidation areas are identified as anechoic hemispheric areas close to the pleural line with a hyperechogenic base. extensive consolidation appears as non-translobar and translobar consolidation with hepatization of lung tissue and air bronchogram which distinguish them from consolidations in resorptive atelectasis (figure ) . however, lus also presents limits since it is operator dependent and abnormalities affecting the central regions surrounded by aerated lung are not detectable. with the aim of increasing the reproducibility it would be convenient to establish a scanning model and a severity score. the lus score, validated with the chest ct comparison, provides a numerical assessment of regional loss of aeration that can be used to assess the response to treatments( ) (figure ). echocardiography. even though echocardiography should not routinely be performed in patients with covid- and restricted to those in whom it is likely to result in a change in management, bedside echocardiography is a clinically useful tool in different clinical settings in emergency department (ed), intensive care unit (icu) and non-icu wards ( ) . compact and highly mobile machines should be the ideal ultrasound system to adopt, privileging dedicated probes and machines in infected areas. a miniaturized handheld ultrasound equipment that can be easily protected and cleaned may be an alternative option ( , ) . a pragmatic strategy based on the use of focused cardiac ultrasound (focus) seems the most reasonable approach ( ) . focus should be combined with lus for the evaluation of patients with respiratory failure. the covid- crisis highlights the need for imagers to be cross-trained (lus and focus) and be more nimble: sonographers, cardiologists, and emergency physicians who are not familiar with lus can learn quickly with initial support of expert colleagues and web resources ( ) . however, since focus is not being performed as the definitive diagnostic test, if no usable information is obtained, comprehensive echocardiogram and/or other diagnostic testing have to be considered ( ) . the aim of echocardiography is to reliably identify cardiac abnormalities and coexisting heart disease in order to facilitate triage and guide patient management. echocardiography is also recommended for the evaluation of patients who develop symptoms consistent with a cardiac etiology. information must quickly include biventricular function, gross valvular abnormalities, wall motion abnormalities, pericardial effusions and surrogates of a patient's volume status, including inferior vena cava collapsibility and ventricular size ( ) . transthoracic echocardiography (tte) is the standard technique, while transoesophageal echocardiography (toe) should be avoided due to the high risk of equipment and personnel contamination, unless there is a clearly defined indication that requires toe imaging or inadequate tte imaging quality due to patient-specific factors (intubated patients, poor image quality, inability to position the critically ill patient for optimal image acquisition) ( ) . the most common echocardiographic abnormalities encountered in our experience on covid- patients in the non-icu setting are reported in table . acute worsening of respiratory symptoms is a leading indication for performing echocardiography in these patients, frequently depicting a picture of acute cor pulmonale: rv dilatation, paradoxical septal motion and pulmonary hypertension. in this clinical setting pe seems relatively frequent (figure ) . echocardiography may expedite diagnosis of this condition. ct coronary angiography is a well-established tool to effectively and safely rule-out cad in the setting of acute chest pain, thanks to its excellent negative predictive value ( - %) ( ) . of note, ct angiography can combine coronary arteries, pulmonary arteries and thoracic aorta assessment using dedicated "triple rule-out" (tro) protocols. in selected patients with variable degrees of respiratory symptoms, showing cardiac enzyme and ddimer elevation, a dedicated tro approach, with lung parenchyma instead of thoracic aorta as the third focus of the examination, may solve different clinical questions in one sitting ( ) . although most of the currently available ct scanners allow to image coronary arteries with high-resolution and limited motion artifacts, clinical judgement is advised, since dedicated scanners can improve image quality. additionally, ct angiography could rule-out left atrial appendage thrombus, allowing direct-current cardioversion in patients with atrial fibrillation, thereby limiting operator exposure deriving from toe examination. moreover, cardiac ct could provide advanced diagnostic assessment through myocardial characterization ( ) . indeed, ct examination can be completed with a delayed iodine-enhanced scan to identify areas of myocardial necrosis or fibrosis. this further evaluation may result especially useful in patients with minoca, allowing to differentiate myocardial infarction from stresscardiomyopathy, which is typically characterized by absence of myocardial late enhancement, and to diagnose acute myocarditis, detecting myocardial scar with typical nonischemic pattern. in this case, one can speak of "quadruple rule-out" having a single examination looking for lung involvement, coronary and pulmonary artery patency and myocardial scar ( ) . however, cardiac ct remains limited in the detection of myocardial edema, which represents the hallmark of acute myocardial inflammation ( ) . cardiac magnetic resonance (cmr) is the imaging of choice for the diagnosis of acute myocarditis, revealing with high sensitivity focal or diffuse myocardial edema through shorttau inversion recovery (stir) sequences and mapping techniques (t and native-t ), potentially associated to necrotic foci visible with late gadolinium enhancement (lge), diffuse expansion of extracellular volume fraction (ecv) and hyperemia ( , ) (figure ) . the recent introduction of parametric mapping enables cmr to reveal diffuse myocardial edema that can be missed by conventional sequences, increasing its accuracy in the diagnosis of inflammatory cardiomyopathies. currently, few case reports showed cmr findings consistent with acute myocarditis in patients with laboratory-proven sars-cov- infection ( ) ( ) ( ) . myocardial edema was the key for cmr diagnosis in all of these cases, underscoring the importance of including mapping techniques in cmr protocols adopted in covid- patients with suspected myocarditis ( ) . therefore, in selected covid- patients not requiring icu, when clinical presentation and biomarker alterations suggest acute-onset myocardial inflammation, if the diagnosis is likely to impact on management, cmr may be considered to confirm acute myocarditis, after exclusion of alternative relevant clinical conditions, including acs and hf, by means of other rapidly available imaging modalities (i.e. cardiac ct scan or tte). nuclear cardiology imaging. nuclear cardiology encompasses several non-invasive imaging modalities and techniques that can be used for myocardial perfusion and viability assessment, as well as for the diagnosis of infective endocarditis, cardiac sarcoidosis and amyloidosis. however, most of these conditions can be proficiently and safely evaluated with other imaging modalities after covid- clinical resolution. therefore, in covid- patients, the use of nuclear cardiology tests should be restricted to very specific indications when they may yield diagnosis or directly influence the clinical management and no alternative imaging modalities can be performed (i.e. suspected infective endocarditis of prosthetic valves or intracardiac devices), in order to reduce healthcare personnel exposure related to long protocols and imaging acquisition times ( ) . invasive cardiac imaging. when evaluating the role of invasive cardiac imaging modalities in covid- patients, several aspects deserve consideration. in the complex rearrangement of the healthcare service, all the efforts should be directed to ensure the standard-of-care and timely access to the catheterization laboratory for patients with acute cardiovascular conditions, irrespectively of sars-cov- infection. therefore, the use of ica in covid- patients should be restricted to those presenting with clinical or hemodynamic instability, including acute myocardial infarction, myocarditis, cardiogenic shock or cardiac arrest (figure ). in these cases an invasive strategy is pivotal to ensure diagnosis and interventional treatment ( ) . in addition, ica eventually combined with coronary intravascular imaging or left ventriculography plays an important role in identification and differential diagnosis of minoca ( ) . basing on our direct experience, minoca accounts for > % of acs in covid- patients. notwithstanding, patient status, severity of respiratory compromise, comorbidities and the risk of futility should be carefully evaluated when considering indication to invasive strategies in covid- patients. some clinical and laboratory risk factors for in-hospital death have already been identified in covid- patients ( , ) . the quantification of lung and cardiac involvement by multimodality imaging could effectively delineate the severity of the disease and eventually the prognosis, providing a base for further clinical decision making. quantification of lung damage using a chest ct severity score (ct-ss) has been proposed to identify patients who need hospital admission ( ) . this score was defined summing up individual scores from lung regions: scores of , , and were respectively assigned if parenchymal opacification involved %, < %, or ≥ % of each region (ct-ss range - ). the individual scores for each lung as well as the total score resulted significantly higher in patients with clinically severe covid- as compared to mild cases. a ct-ss < . was highly effective in severe covid- pneumonia rule-out, with a npv of . %( ). in the same way lus could be effective in evaluating covid- pneumonia severity and monitor its modifications over time. for this purpose the numerical assessment of regional loss of aeration measured by global lus score could represent a useful tool ( ) . the global lus score can be calculated as the sum of regional aeration scores attributed to each lung region during a standard -zone examination scanning: if a-lines or < b-lines are visualized; if ≥ b-lines involving ≤ % of the pleura; if b-lines becoming coalescent or involving > % of the pleura; if tissue-like pattern( ) (figure ) . the global lus score showed good correlation with lung density as assessed by ct scan and has been applied in the icu setting to quantify and monitor lung aeration in weaning from mechanical ventilation and in ards patients on extracorporeal membrane oxygenation (ecmo) ( ) . so far, the implementation of the global lus score to monitor disease evolution and to guide decision making in covid- patients has not been systematically investigated. similarly, despite growing evidence pointing at the negative prognostic impact of cardiovascular involvement in covid- , no specific risk scores have been developed and validated. interestingly, although great emphasis has been posed on the link between myocardial injury and mortality, the actual incidence of specific cardiovascular clinical conditions (myocarditis, mi, pe and hf) and the respective prognostic implications in different stages of covid- is largely unknown due to a significant lack of imaging data ( ) . a systematic approach with the use of multimodality imaging to precisely characterize covid- -related cardiovascular manifestations should be warranted to provide clinicians with comprehensive risk stratification tools. the imaging modalities are useful in the management of covid- patients in different clinical settings, from triage in the ed to icu and non-icu wards (figure ) . emergency department/triage. a rapid and efficient diagnosis of covid- is of paramount importance to accurately manage the high number of patients presenting to the ed with suspected sars-cov- infection. considering the high probability of covid- among patients currently accessing ed with fever and respiratory symptoms, the main goal is to stratify patients with positive sars-cov- rt-pcr test (or with clinically highly suspected infection despite a negative test) in order to discharge those with mild symptoms and admit to non-icu or icu departments those with severe or life-threatening infection. a simultaneous clinical evaluation and lus performed by the same visiting physician (reducing the number of operators exposed), combined with laboratory testing and cxr, allow a fast diagnosis, risk stratification and decision-making regarding patient destination. in this context, lus has the potential to rapidly discriminate initial forms of covid- from advanced presentations ( ) . focus is an adjunct to recognize specific ultrasound signs in patients with or suspected cardiac symptoms ( ) . this quick stratification could be subsequently confirmed by cxr, trying to limit the number of ct scans performed in the ed setting, reserving ct for cases with uncertain diagnosis or to rule-out other causes of illness such as pe. of note, several patients have a severe form at ed presentation, rapidly becoming non-invasive ventilation (niv)-dependent and, therefore, cannot easily undergo ct scan; in these patients, lus is of paramount importance for rapid diagnosis and stratification. despite its potential diagnostic utility, no unequivocal advantage has been demonstrated for a lus-guided strategy over standard cxr and (if appropriate) ct scan evaluation in patients with suspected or confirmed covid- . furthermore, lus requires closer contact with the patient, potentially exposing clinicians to higher risk of aerosolized particles inhalation, mandates use of more protective personal protection equipment (ppe) and should be performed by trained personnel. in this context, lus application is a promising technique, although its role should not be overemphasized in the absence of solid evidence; on the contrary, cxr and clinical evaluation remain pivotal for initial patient assessment. beyond ed evaluation, an important approach to take care of patients and prevent transmission is the application of telemedicine ( ) . telemedicine/e-visits could be combined with home triage for patients reporting worsening symptoms or self-monitored parameters, the latter being ideally performed by dedicated teams providing both clinical evaluation and lus at the patient's home, thus more accurately differentiating patients who could continue remote monitoring and medical therapy at home from those who need hospitalization. covid- departments is currently based on supportive care (i.e. oxygen therapy, niv if necessary) and a combination of empirically prescribed drugs (i.e. hydroxychloroquine, antibiotics, antivirals, glucocorticoids or anti-cytokine therapies). along with clinical and laboratory evaluation, imaging is fundamental to assess covid- evolution and response to therapy, both in daily clinical activity and in the context of controlled pharmacological/interventional trials. baseline ct scan is frequently used to confirm diagnosis and to obtain detailed information on disease extension and severity, thus becoming also a reference for subsequent imaging follow-up ( ) . of note, considering its known advantages (portability, bed-side evaluation, safety), lus seems particularly useful for serial assessments during hospital stay and may be useful to determine timing of ct imaging ( ) . alongside with lung imaging, focus could be useful to assess volume status and concomitant cardiac involvement, reserving cardiac ct, ica and cmr only for selected cases, including suspected concomitant mi, pe or myocarditis ( ) . icu represents the most challenging setting in the management of covid- patients. ideally, a baseline ct scan is needed in all critically ill patients requiring icu admission, in order to precisely describe morphological lung involvement. as in the previously described clinical settings, serial lus and cxr are fundamental to monitor disease evolution in icu patients, while ct scan could be used when clinical changes are observed, substantial modifications in morphological lung damage are suspected, or ventilator-related complications need to be excluded ( ) . echocardiography could be useful to rule out concomitant cardiogenic causes of respiratory manifestations ( ) . furthermore, focus allows a non-invasive hemodynamic monitoring in the icu setting: assessment of biventricular function, estimated stroke volume, filling pressures, pulmonary pressures, and central venous pressure ( ) . similarly, tte helps in identifying patients at high risk of ventilator weaning failure and guides tailored therapeutic strategy. finally, when mechanical respiratory and circulation support with ecmo is needed, both tte and toe are important to guide device selection (veno-venous vs. veno-arterial) based on concomitant cardiogenic cause, assist during device placement (cannulation), and monitor cardiac function and devicerelated complications during support ( ) . negative rt-pcr test deserve special consideration. as medical systems are overwhelmed, accurate balance between infection prevention and adequate healthcare assistance delivery should be pursued. beside clinical disease probability assessment, while serology tests are under development, current strategies to reduce in-hospital sars-cov- spread from asymptomatic patients rely on rt-pcr nasopharyngeal swab test, with important limitations ( ) . therefore, adherence to international guidelines recommendations, and restriction of imaging tests to those really impacting on patients' clinical management are advocated ( , ) . triaging protocols should differentiate between patients requiring nondeferrable but schedulable imaging examinations, who can be appropriately managed after rt-pcr test result is available, and those with urgent or emergent acute cardiovascular conditions, who should be considered sars-cov- positive until proven otherwise. optimization of healthcare network and patient pathways is required to avoid contamination between infected individuals and sars-cov- negative patients, while maintaining adequate health assistance. both patients and healthcare workers should be provided with standard ppe and keep social distance when possible. basing on our experience, rt-pcr test should be performed according to local resources in selected patients requiring hospitalization or undergoing aerosol-generating high-risk procedures, after body temperature measurement and a clinical triaging questionnaire evaluating history of fever, dyspnea or cough and sars-cov- exposure in the last weeks ( ) . current covid- pandemic, sharply increased the examination workload of the imaging departments. the in-hospital infection rate was about % in one of chinese experience: % hospital staff and . % inpatients ( ) . in italy, up to % of overall cases were reported among healthcare workers with an estimated in-hospital infection rate of . % ( ) . sars-cov- transmission occurs through direct inhalation of droplets but also by touching eyes, nose or mouth after hand contact with contaminated surfaces. imagers, nurses and technicians are at high risk especially due to the close patient contact performing imaging studies. in order to prevent and mitigate the transmission, preventive measures must be implemented encompassing facilities, imaging equipment, ppe and machine disinfection procedures ( ) . specific in-hospital routes between imaging department and covid- wards should be defined. the special environment for covid- dedicated imaging should include a contaminated equipment area, a separated report room and a staff cleaning room. the use of mobile equipment and dedicated scanners, ultrasound probes and machines for infected patients should be encouraged ( ) . staff must undergo rigorous nosocomial infection training and equipped with highquality ppe ( table ) , balancing the risk of transmission with the potential for scarcity of ppe, considering in some cases their re-using, with adequate precautions. the use of a checklist and a step-by-step process to ensure proper wearing (donning) and removing (doffing) are recommended. imaging personnel not directly involved should avoid any contact, and the distance between the technician and patients must be, preferably, > - meters. all patients should wear a surgical mask during imaging. left-lateral patient positioning with the scanner on the right side of the bench may ensure the longest distance between patient's face and the echocardiographer during tte examination. personnel involved in toe examinations should wear full ppe as this procedure is aerosol-generating. while cuffed endotracheal tube and close-circuit ventilation could reduce the risk of aerosol generation in intubated patients, niv carries a higher risk of droplets spreading. the level of protection during toe should be full both in icu or non-icu context ( ) . as sars-cov- is sensitive to most standard viricidal disinfectant solutions, imaging machines should be thoroughly cleaned. it is recommended to use soft cloth dipped in mg/l chlorine-containing disinfectant or % ethanol for scanners disinfection ( ) . generally, for echocardiographic probes it is advised to immerse them for ≤ hour without using hot steam, cold gas, or abrasive agents, as ethylene-oxide or glutaraldehyde-based methods. automated disinfection solutions should be available. air, object surfaces and floor disinfection in the covid- dedicated imaging department should be carried out according to the daily operation specifications. in reading rooms social distancing should be remembered and all non-essential items removed ( ) . as of today, none of the healthcare workers in the cardiac imaging department of our hospital, have been infected with sars-cov- , underscoring the relevance of adequate ppe use and adherence to a rigorous safety protocol ( ) . since ppe availability could be a significant issue especially in hard-hit areas, the use of clinical judgement should be emphasized to avoid additional staff exposure deriving from performing imaging tests unlikely to yield clinically important information on covid- positive or suspected positive patients. thus, the need for procedures requiring stringent ppe (i.e. toe or nuclear imaging) and the possibility to perform alternative imaging modalities (i.e. cardiac ct) or no procedure at all should be thoroughly assessed in order to optimize ppe use. sars-cov- outbreak has rapidly reached a pandemic proportion and has become a major threaten to global health. although the predominant clinical feature of covid- is an acute respiratory syndrome of varying severity, the cardiovascular system can be involved with several facets. heart and lung multimodality imaging plays a central role in different clinical settings and is essential in diagnosis, risk stratification and management of covid- patients. in order to prevent and mitigate the transmission, key preventive measures must be adopted encompassing the equipment, the facilities, the healthcare personnel and the disinfection procedures. -year-old woman with sars-cov- positive rt-pcr swab test presenting with sudden severe dyspnoea associated with significant d-dimer increase: ct pulmonary angiography shows gross filling defect in right pulmonary artery lobar branch for right upper lobe (a); lung parenchyma windowing demonstrates bilateral, subpleural ggos and consolidation areas, typical for covid- pneumonia (b); tte shows rv dilatation and septal shifting, indirect signs of severe pulmonary hypertension (c-d). -year-old woman with sars-cov- positive rt-pcr swab test presenting after week of fever ( . °c), cough, diarrhea with recent onset of typical chest pain, elevated cardiac markers (hs-tnt ng/l), st-segment depression in inferior and lateral leads at ecg, and inferior septum hypokinesia at tte. triple rule-out ct shows peripheral lung opacities (a-b) characterized by crazy paving pattern involving both the inferior lobes, with posterior distribution, suggestive for covid- interstitial pneumonia (boxes), and demonstrates absence of pulmonary embolism (c) or coronary disease (d). cmr shows slight diffuse myocardial hyperintensity on t stir image (e) consistent with a slight increase of t relaxation time on t mapping: mean value of ms (normal value ≤ ms) with a peak of ms in the inferior septum (g); ir images do not show significant lge foci. viral replication and host immune response synergistically determine covid- pathogenesis. as the disease progresses through its three stages, different chest imaging modalities (lus, cxr and ct) demonstrate worsening lung involvement. in case of severe pneumonia tte can identify increasing pulmonary hypertension and rv impairment. cardiovascular complications related to viral infection or to systemic inflammation can occur at different 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in acute respiratory distress syndrome patients* is there a role for lung ultrasound during the covid- pandemic? covid- pandemic and cardiac imaging: eacvi recommendations on precautions, indications, prioritization, and protection for patients and healthcare personnel ase statement on protection of patients and echocardiography service providers during the novel coronavirus outbreak focused cardiac ultrasonography echocardiography in the time of covid- coronary ct angiography versus standard evaluation in acute chest pain triple rule out versus coronary ct angiography in patients with acute chest pain results from the acic consortium cardiac computed tomography in troponin-positive chest pain: sometimes the answer lies in the late iodine enhancement or extracellular volume fraction map quadruple rule out" with cardiac computed tomography in covid- patient with equivocal acute coronary syndrome presentation cardiovascular magnetic resonance in nonischemic myocardial inflammation: expert recommendations early t myocardial mri mapping: value in detecting myocardial hyperemia in acute myocarditis guidance and best practices for nuclear cardiology laboratories during the coronavirus disease (covid- ) pandemic: an information statement from asnc management of acute myocardial infarction during the covid- pandemic virtually perfect? telemedicine for covid- cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease (covid- ) pandemic presymptomatic sars-cov- infections and transmission in a skilled nursing facility echo in pandemic: front line perspective, expanding role of ultrasound and ethics of resource allocation istituto superiore di sanità covid- integrated survelliance: key national data death from covid- of health care workers in china key: cord- -nr akd k authors: aziz, r.; kaminstein, d. title: essential notes: the use of lung ultrasound for covid- in the intensive care unit date: - - journal: bja educ doi: . /j.bjae. . . sha: doc_id: cord_uid: nr akd k nan thoracic imaging is a key component of managing respiratory failure in patients with . timely access to routine chest x-rays (cxr) and computed tomography (ct) scans can however be challenging in a pandemic. furthermore, resource utilisation is critical, and the safety of the patient and staff must be balanced carefully with the necessity of obtaining images. point-of-care lung ultrasound (lus) is a dynamic technique routinely used in intensive care to answer targeted questions and aid in practical procedures. whilst lus has its limitations, and in isolation cannot provide a definitive diagnosis, it can be useful where resources are scarce. in this article we explore the use of lus specifically in critically ill patients with covid - , outlining both essential aspects for new practitioners of lus and points of high diagnostic yield. when using any imaging technology in the face of an infectious disease the equipment itself must not be allowed to become a vector for further spread. ideally a dedicated ultrasound machine is required for the "red zone", as was the case during the ebola virus outbreak in . , basic principles of hygiene to minimise contamination include: the removal of organic debris from the probe and machine; disinfection with probe-compatible material; the use of sachets rather than bottled ultrasound gel; and clear documentation of the cleaning process. portable handheld machines are preferable, being easier both to cover during scanning and to clean. j o u r n a l p r e -p r o o f there is currently no validated systematic approach for performing lus in patients with covid- pneumonitis, although the intensive care society has made some recommendations. there are several different techniques and choices of probe, including the blue protocol. the optimal approach where resources are limited must balance the following: • the need to answering the clinical question; • the workload in icu; • the risks of disturbing the patient's position, particularly when there is cardiovascular instability. lus protocols for icu assume users have a degree of expertise, time and appropriate resources. during a pandemic, providers may find themselves in temporary hospital structures with large numbers of critically ill patients. protocols designed for normal working conditions may not address the context of a strained and overwhelmed system. we believe the following key points determine the highest yield approach to lus in patients with covid- : • the changes seen are not homogenous, with normal areas interspaced between areas of abnormality (in contrast to bilateral, homogenous changes seen with cardiogenic pulmonary oedema). • abnormal lung findings predominate in the posterolateral aspect of the chest. we therefore recommend the following approach for those new to thoracic ultrasound. • begin with a "survey" of the lungs in general using a probe that offers a wide field of view and maximises tissue penetration. the curvilinear (abdominal) probe allows a rapid survey of the lung fields but shadowing from the ribs can obscure much of the image. the cardiac probe provides superior views between ribs, and evaluation of cardiac function, but the narrower field of view prolongs the duration of the scan. either is suitable, with the aim being to gain a rapid sense of the extent of disease. • start at the lung bases as posteriorly as possible, accounting for the patient's position and severity of illness. this allows identification of a dependent pleural effusion, and any involvement of the lower lung zones. • then move systematically to the apex anteriorly, looking for any abnormalities at the pleural interface suggestive of a large pneumothorax, and reviewing as much of each lung as possible as you scan to gauge the extent of lung involvement. if any abnormalities are detected the higher resolution linear probe ( - mhz) should be used to examine these areas in more detail for characteristic findings. lus does not rely primarily on visualising actual pathology but instead uses artefacts generated by density changes at air/water or air/tissue interfaces. terminology and definitions are important. b-line patterns are frequently referred to in patients with covid- . by definition b-lines must arise from the pleura and erase a-lines. in covid- the vertical lines often originate however from subpleural consolidations and not from the pleura itself. whilst similar, these are not strictly b-lines but instead c-lines, which are defined as originating below the pleura from consolidations or defects on the pleural surface (figure ; supplementary videos and ). the 'light-beam artefact' that has also been described may be a confluence of c lines leading to a different appearance than that seen in pulmonary oedema or bacterial pneumonia. the key difference between c-lines and b-lines is that clines are artefacts caused by viral-induced irregularities of the pleural surface and not caused by alveolar oedema, which gives rise to b-lines. this is similar to the ring-down pattern in tuberculosis, which affects the pleural interface causing defects and artefacts that arise from the pleura itself ( supervised practice during the early stages of learning may not be possible during a pandemic setting. during the ebola pandemic physicians were trained to obtain images which were reviewed remotely by an expert for detailed analysis and quality assurance. this 'telemedicine' approach is used extensively in providing ultrasound training to front-line providers throughout the world and could also be used for patients with covid- . both images are taken with the same ultrasound machine using phased array probe with similar settings. probe in both cases is positioned in the mid axillary line at the base of the lung in the lower lung zone just above the diaphragm. figure a is from a patient with known covid- pulmonary disease. ring-down artefacts are seen as c-lines (solid arrow) originating from a thickened pleura (thin arrow) and do not erase the underlying a-lines (hollow arrow). figure b demonstrates lung ultrasound in the critically ill isolation unit : the emory university hospital experience imaging an outbreak -ultrasound in an ebola treatment unit prevention of pathogen transmission during ultrasound use in the intensive care unit: recommendations from the college of intensive care society. guidance for lung ultrasound during covid- practical approach to lung ultrasound chest ct manifestations of new coronavirus disease (covid- ): a pictorial review findings of lung ultrasonography of novel corona virus pneumonia during the - epidemic lung ultrasound in the critically ill sonographic signs and patterns of covid- pneumonia lung ultrasonography in pulmonary key: cord- -p jx authors: lopes, agnaldo josé; mafort, thiago thomaz; da costa, cláudia henrique; rufino, rogério; de cássia firmida, mônica; kirk, kennedy martins; cobo, carolina gianella; da costa, hanna da silva bessa; da cruz, carlos miguel brum queiroz; mogami, roberto title: comparison between lung ultrasound and computed tomographic findings in patients with covid‐ pneumonia date: - - journal: j ultrasound med doi: . /jum. sha: doc_id: cord_uid: p jx objectives: the aim of this study was to describe findings from lung ultrasound (lus) and computed tomography (ct) in health professionals with coronavirus disease pneumonia and to evaluate the associations of the findings of both tests. methods: this cross‐sectional observational study evaluated health professionals who were initially seen in screening tents and had a diagnosis of coronavirus disease as confirmed by a reverse transcription polymerase chain reaction and lung involvement diagnosed by lus. subsequently, these individuals were admitted to the hospital, where chest ct was performed. aeration scores were obtained for the lus examinations based on the following findings: more than b‐lines, coalescent b‐lines, and subpleural consolidations. a subjective assessment of the extent of lung disease on ct was performed on the basis of the percentage of lung parenchyma involvement as follows: % or less, % to %, and greater than %. results: regarding lus signs, more than b‐lines, coalescent b‐lines, and subpleural consolidations were present in . %, . %, and . % of cases, respectively. the main findings on ct were ground glass opacities, a crazy‐paving pattern, and consolidations ( . %, %, and % of cases); . % of cases had examinations without abnormalities. patients with more than b‐lines on lus had more ground glass opacity areas on ct (p = . ), whereas patients with subpleural consolidations on lus had more consolidations on ct (p < . ). in addition, patients with higher lus aeration scores had more extensive disease on ct (p < . ). conclusions: lung ultrasound can detect lung injury even in the presence of normal ct results. there are associations between the abnormalities detected by both methods, and a relationship also exists between lus aeration scores and the disease extent on ct. respiratory syndrome. severe acute respiratory syndrome coronavirus has a tropism specific to the lower respiratory tract in the initial stage of the disease, although it causes severe pneumonia in a low percentage of cases. thus, the identification of individuals with suspected covid- as early as possible is crucial in the attempt to interrupt the transmission route and thus control the spread of the pandemic. some chest imaging modalities, including lung ultrasound (lus) and computed tomography (ct), have gained prominence in evaluating lung involvement in covid- in patients with respiratory manifestations. however, the benefits and potential risks of each modality should be considered according to the context in which the patient is evaluated and the stage of disease progression. in the current state, ct is the imaging modality of choice for the imaging diagnosis of covid- pneumonia, which is characterized by the preponderance of ground glass opacity (ggo) abnormalities at disease onset, followed by the development of the crazy-paving pattern and, finally, an increase in the areas of consolidation in a more advanced disease course. [ ] [ ] [ ] despite its usefulness, chest ct is not available in many institutions, and the disinfection of the ct scanner after use by a patient under investigation or with covid- results in a delay in the care of other patients who require ct. furthermore, exposure to radiation and the limited mobility of the ct scanner may restrict the usefulness of ct scans, especially during this public health emergency with limited medical resources. thus, in a pandemic situation, lus may represent a valuable option to reduce the pressure on radiodiagnostic services that offer ct, especially in the context of screening patients in temporary-care structures, taking into account the imbalance between demand and imaging method availability. coronavirus disease pneumonia is a common complication in sars-cov- infection and can be assessed by lus in the treatment of patients with suspected lung injury. , lung ultrasound has the advantages of being a mobile, fast, and noninvasive technology; it does not expose the patient to radiation, has the possibility of repeatability, and can be used in screening tents or campaign hospitals. , moreover, in the covid- context, an lus examination can be performed by a clinician next to the patient, which reduces the exposure of health professionals to sars-cov- and avoids transmission of the virus during transport to other areas. although lus signs are nonspecific when considered in isolation, the observation of some aspects may increase the diagnostic power of this modality in high-prevalence areas, and some asymptomatic or slightly symptomatic patients may have notable lus findings, with a high probability of those findings indicating covid- . , because lus can identify changes in lung tissue that correlate both with histopathologic lesions and with ct findings, its role may be relevant in the context of the covid- pandemic. despite the numerous advantages of lus, there is still not sufficiently clear information to determine its diagnostic value in covid- , especially when comparing ultrasound (us) signs with chest ct findings. thus, the purpose of this study was to describe lus and ct findings in health professionals with covid- pneumonia and to evaluate the associations of the findings of both tests. this cross-sectional observational study evaluated health professionals aged years or older with a diagnosis of covid- confirmed by a reverse transcription polymerase chain reaction (rt-pcr) and lung involvement diagnosed by lus. these individuals were initially seen in screening tents set up at the piquet carneiro policlinic, state university of rio de janeiro, where an rt-pcr was performed for all individuals, and an lus examination was performed for those with at least respiratory symptom, persistent fever in the last days, pulse oximetry (oxygen saturation) below %, or a combination of these signs. depending on the medical evaluation results, patients were admitted to the pedro ernesto university hospital, state university of rio de janeiro, where chest ct was performed. we only included patients who underwent both lus and chest ct examinations with an interval between the examinations of hours or less in the study (n = ). the study was approved by the national research ethics commission under number caae- . . . . all of the participants signed an informed consent form. lung ultrasound examinations were performed using an aplio xg device (toshiba medical systems, tokyo, japan) equipped with a . - -mhz multifrequency linear transducer or . - -mhz convex transducer in the b-mode. the transducer used in all analyses was a low-frequency convex device; this transducer was selected because it allows evaluations of patients with different body shapes and standardization of the results. these examinations were performed by a team of clinicians with experience in the method ( with years of experience, with years of experience, and with years of experience). each examination was performed by physicians, who were blinded to each other's initial findings. these examinations were performed sequentially by each of physicians and, after the us examinations were completed, a consensus among them was reached in cases of disagreement. the us examinations were performed in areas of each hemithorax ( anterior, lateral, and posterior). the examinations were performed with the patients in a standing position. the lus images were examined for the following signs: more than b-lines, coalescent b-lines, and subpleural consolidations. to classify lung injury by lus, weights ranging from to were assigned for each of the areas and for each lus finding as follows: , more than b-lines; , coalescent b-lines; and , subpleural consolidations. the sum of all areas evaluated in the lus represented the aeration score. computed tomography chest ct scans were performed with a helical ct scanner with channels (brilliance ; philips healthcare, cleveland, oh). the scanning time was set at seconds, with a current of ma in the x-ray generator and a voltage of kv. the examination was performed with the patient in the supine position and during inspiratory apnea. each acquisition consisted of a block with to cross sections ( mm thick), with a distance of mm between sections. the images were represented in a square matrix of rows and columns. the gantry was maintained without any inclination, and an iodinated contrast medium was not used. the ct scans were independently evaluated by radiologists (all with > years of experience with the method), and a consensus was reached in cases of disagreement. the tomographic patterns of disease probability were evaluated according to the classification previously described by the consensus of the radiological society of north america : typical for viral infection (including covid- ), indeterminate, atypical, and negative for lung disease. the ct scans were also temporally evaluated by the categories described by pan et al, who estimated the stage of disease progression as follows: stage ( - days), initial; stage ( -- days), progression; stage ( - days), peak; and stage (≥ days), absorption. in addition, a subjective evaluation of the extent of lung disease was performed on the basis of the percentage of lung parenchyma involvement as follows: % or less (a), % to % (b), and greater than % (c). the normality of the data distribution was assessed by the shapiro-wilk test, and because a substantial number of variables did not have a normal distribution, nonparametric tests were selected. the median and interquartile range or frequency values and percentages were used to express the results. the inferential analysis consisted of the kruskal-wallis analysis of variance for comparisons between subgroups or the mann-whitney test for comparisons between subgroups. the dunn multiple-comparison test was applied to identify which subgroups differed significantly from each other. categorical data were compared by the χ or fisher exact test. the significance level adopted was %. the statistical analysis was performed with sas version . software (sas institute inc, cary, nc). among the participants who were initially evaluated by lus and who were admitted to the hospital and underwent a chest ct examination within hours after undergoing the lus examination, ( . %) were men, and ( . %) were women, with a median age of (interquartile range, - ) years; ( . %) were older than years. respiratory symptoms were present in ( . %) participants, while ( . %) had diagnosed comorbidities (including diabetes, cardiovascular disease, and chronic lung disease). in our sample, ( . %) patients required supplemental oxygen, and ( . %) had respiratory failure or a sufficiently severe presentation to be admitted to the intensive care unit. regarding lus signs, more than b-lines were present in ( . %) cases; coalescent b-lines were present in ( . %) cases; and subpleural consolidations were present in ( . %) cases. the median sum of all areas evaluated by lus represented an aeration score of ( - ). when lus signs were compared with clinical data, we observed that patients with respiratory symptoms had higher aeration scores than those without respiratory symptoms ( [ - ] versus [ ] [ ] [ ] [ ] ; p < . ). we observed that patients with comorbidities had more areas of subpleural consolidation on lus and higher aeration scores than those without comorbidities ( . % versus . %; p = . ; [ ] [ ] [ ] [ ] [ ] [ ] versus . [ ] [ ] [ ] [ ] [ ] [ ] ; p < . , respectively). we also observed that patients with respiratory failure or a sufficiently severe presentation to be admitted to the intensive care unit had more areas of subpleural consolidation on lus and higher aeration scores than those without these characteristics ( % versus . %; p < . ; . [ - . ] versus [ ] [ ] [ ] ; p < . ). the ct scan findings were classified as typical and indeterminate for lung disease in ( . %) and ( . %) participants, respectively. interestingly, ( . %) patients had normal ct findings, despite changes observed with lus. when the abnormal ct scans (n = ) were categorized on the basis of the classification of pan et al, ( . %) cases were stage , and ( . %) were stages and ; no cases were stage . ground glass opacities, the crazy-paving pattern, and parenchymal bands were observed in ( . %), ( %), and ( . %) cases. in these ct examinations, consolidations, the halo sign, and subpleural lines were observed in ( %), ( . %), and ( . %) cases. regarding disease extent on ct, ( . %), ( . %), and ( . %) cases were classified as a, b, and c. when the ct findings were compared with the clinical data, we observed that a higher percentage of patients with respiratory symptoms, compared with those without respiratory symptoms, had a lung disease extent of greater than % on ct ( . % versus %; p < . ). we also observed that patients with comorbidities, compared with those without comorbidities, had a lung disease extent of greater than % on ct ( . % versus . %; p < . ). we also evaluated the relationship between lus signs and ct findings. in this analysis, patients with more than b-lines on lus had more ggo areas on ct than those without more than b-lines on lus (figures and ) . patients with subpleural consolidations on lus had more areas of consolidation on ct than those without subpleural consolidations on lus (figure ) . in this study, confluent b-lines on lus were not associated with any specific ct finding. finally, we evaluated the associations between the lus aeration score and the various classifications by chest ct (table ) . interestingly, patients with higher lus aeration scores had more extensive and more advanced disease on ct. additionally, we evaluated the lus findings of the patients who underwent lus examinations without ct scans. in this sample, more than b-lines were present in ( . %) patients; coalescent b-lines were present in ( . %) patients; and subpleural consolidations were present in ( . %) patients. the median sum of all areas evaluated by lus corresponded to an aeration score of ( - ). when compared with patients undergoing ct, we observed that patients without ct scans had fewer coalescent b-lines, fewer areas of subpleural consolidation, and lower aeration scores on lus ( . % versus . %; p < . ; . % versus . %; p = . ; [ - ] versus [ - ]; p < . , respectively). because of the spread and extremely rapid advancement of covid- , early screening, comprehensive detection, and infection monitoring by imaging methods are required, especially with regard to covid- pneumonia caused by sars-cov- . in this context, lus has been increasingly used as a promising tool for the evaluation of covid- pneumonia lesions, as these lesions show a predominantly peripheral distribution, rendering detection by lus more appropriate. , in this study, the following were the main findings: in health professionals with covid- pneumonia, lus was a very sensitive test for the detection of lung lesions; almost % of our cases involved normal ct results despite changes on lus. patients with respiratory symptoms or comorbidities had more extensive disease on both lus and ct. there was a relationship between the lus aeration score and the extent of lung disease on ct. in addition, we observed an association between more than b-lines on lus and ggo areas on ct as well as between subpleural consolidations on lus and consolidation areas on ct. to our knowledge, this was the first study that evaluated the associations between lus and ct findings in detail, considering the extent of lung involvement in a more representative sample. the combination of us signs within certain patterns and their correlation with sars-cov- identification methods in different covid- phenotypes may allow effective characterization of lung involvement and assist in patient screening and admission. in this sense, we used lus together with clinical evaluations and rt-pcr assays in screening tents to detect covid- pneumonia in patients who had at least respiratory symptom, persistent fever in the last days, oxygen saturation below %, or a combination of these signs. in fact, lus can help inform clinical decision making for patients with covid- and the management of their associated lung injury. in individuals with respiratory symptoms in highprevalence areas, the combination of clinical and anamnestic data with lus signs may represent an important aid to assess pulmonary involvement by sars-cov- , especially in places where ct is not available. importantly, almost % of our participants had normal ct findings within the first hours after undergoing lus examinations, with high sensitivity of lus for the detection of covid- pneumonia. in line with our findings, bernheim et al observed that ( %) of symptomatic patients with covid- evaluated in the initial phase ( - days) had normal chest ct findings. these authors observed that with the progression of time after symptom onset, chest ct findings consistent with covid- were more frequent, including a greater extent of lung involvement. by evaluating patients with covid- pneumonia using lus and ct divided into regions (interval between tests ≤ hours), yang et al observed that in a total of lung regions, ( %) had abnormal signs on lus, whereas only ( . %) had abnormal findings on ct. by evaluating patients with confirmed or highly clinically suspected covid- , tung-chen et al observed radiologic signs compatible with covid- pneumonia in patients on lus and in patients on chest ct. other studies have also shown the high sensitivity of lus in the detection of lung lesions caused by sars-cov- at different times during disease progression. , in covid- pneumonia, histopathologic lesions involve the distal regions of the lung, with characteristics including edema, alveolar damage, interstitial thickening, and gravitational consolidations. therefore, the imaging diagnosis of covid- pneumonia is facilitated by a surface imaging technique. thus, the greater sensitivity of lus relative to ct can be explained at least in part by the fact that sars-cov- induces lesions in the lung periphery, rendering such lesions particularly suitable for lus investigations. in fact, the lung characteristics of patients with covid- pneumonia are ideal for lus, since the manifestations are visible in the posterior and inferior areas of the lung and in the subpleural areas, which can be reached by us. furthermore, lus is highly sensitive to variations in the balance between air and fluids in the lung, and because covid- pneumonia is characterized by alveolar-interstitial damage with inflammatory exudation and edema, it can be clearly detected by lus. although lus is highly sensitive for the detection of multiple lung disorders, including covid- pneumonia, this method does not depict pathognomonic signs related to sars-cov- in the lungs; therefore, abnormal signs in covid- pneumonia should be interpreted with caution. in fact, abnormal lus signs in covid- pneumonia such as b-lines and consolidations are present in many other interstitial and alveolar-interstitial lung diseases, including viral pneumonia of different etiologies (eg, h n and h n influenza viruses), pneumocystis jirovecii pneumonia, idiopathic or secondary pulmonary fibrosis, hypersensitivity pneumonitis, congestive heart failure, and diffuse alveolar hemorrhage. , , integration of clinical data, epidemiologic findings, and lus signs is necessary for the differential diagnosis between covid- pneumonia and other conditions with similar us manifestations. thus, lus signs must be considered in the context of the pandemic, and laboratory tests to confirm covid- are still required to support clinical decision making. in this study, the most common signs on lus were focal b-lines, which were present in almost twothirds of the cases. because lus examinations were performed during the first approach to patients, it is possible that focal b-lines are among the main characteristics in the initial stage of covid- . our findings are in agreement with a study by yasukawa and minami, who observed that all patients had thick irregular pleural lines and b-lines. the histopathologic aspect of initial covid- pneumonia is characterized by alveolar damage and irregular inflammatory components, which correlate with b-lines on lus in several ways. , in our sample, subpleural consolidations on lus were observed in less than % of cases, unlike in the sample studied by xing et al, who observed this finding in % of cases. however, it is important to note that these authors evaluated patients with covid- pneumonia at different stages of the disease, most of whom were in critical condition, whereas the patients in our study were evaluated by lus at an earlier time point, even before hospitalization. it is also worth noting that patients with respiratory symptoms or comorbidities had higher aeration scores and more subpleural consolidations on lus, which indicates that there may be a relationship between clinical findings and lus signs. although chest ct findings may be normal or indeterminate during the very early stage of covid- , the initial findings usually include only ggo areas, and then areas of consolidation appear in the lungs with disease progression. the most common finding in our sample was ggos, observed in almost % of cases; this indicated a characteristic of our sample, which predominantly involved cases still in an early phase of covid- . this fact was corroborated by the classification of pan et al ; . % of the cases were stage when the classification method was applied to our sample. we observed consolidation areas in only % of cases; these lesions are more frequent and have a greater extent in critically ill patients and indicate that the alveoli are filled with inflammatory exudation. importantly, patients with respiratory symptoms or comorbidities had more extensive disease on ct, which supports the importance of evaluating tomographic data in light of clinical findings. a relationship exists between lus and chest ct findings in patients with covid- . in fact, in our study, there was an association between more than b-lines on lus and ggo areas on ct as well as between subpleural consolidations on lus and consolidation areas on ct, which was in agreement with the previous observations by peng et al and lomoro et al. in covid- , early-diagnosed b-lines may be a sign of the acute phase of ggo lesions during the early dissemination of active disease, when limited areas of lesions alternate with preserved lung parenchyma. , the presence of consolidations, whether on lus or ct, probably correlates with the disease progression and severity based on previous studies of tomographic findings in patients with covid- . as most patients with covid- develop ggo-like lesions with a peripheral distribution that progress over time to form more consolidated changes, lus may detect many symptomatic patients who require hospitalization. , finally, we observed associations between the lus aeration score and the types of patterns/percentage of involvement on ct, which demonstrates that the methods are complementary when lesions are analyzed in their entirety. the strengths of this study included the prospective evaluations with both lus and ct within hours of each other as well as the independent reviews of images by more than a single physician. however, similar to other studies, ours also had limitations. first, the study included only health professionals, thus presenting the possibility of a sampling bias; however, our institution has developed a program to exclusively evaluate health professionals because of the considerable vulnerability of this population to sars-cov- infection. second, our sample consisted of patients known to have covid- , limiting the lus evaluation as a screening modality. additionally, similar to almost all studies evaluating the role of lus in covid- pneumonia, our study was potentially subject to a selection bias, given that lus examinations were performed only in patients known to have positive rt-pcr results for sars-cov- . third, we did not evaluate the evolution of lus and chest ct images of the study population. finally, although lus has several advantages over other imaging modalities, it cannot detect deeper lung lesions because aerated lungs block us transmission, and lus is more operator dependent; thus, the correlation between lus signs and ct findings is of great interest. despite these limitations, we think that our study can serve as a theoretical framework for the design of studies aiming to evaluate lus as a screening test. accordingly, inclusion of all patients suspected of having covid- , including those with negative test results, which to our knowledge has not yet been rigorously reported in the literature, will be important. furthermore, our study may serve as a foundation for future longitudinal studies to further explore lus and chest ct findings in patients with covid- . in conclusion, this study showed that in a sample of health professionals with covid- pneumonia still at an early stage, lus detected lung lesions even in the presence of normal ct findings. patients with respiratory symptoms or comorbidities tended to have more changes on lus and more extensive disease on ct. there was a relationship between the abnormalities detected by the imaging modalities, especially between the presence of more than b-lines on lus and ggo areas on ct and between subpleural consolidations on lus and consolidation areas on ct. in addition, there was an association between the lus aeration score and the extent of the disease on ct. clinical, laboratory and imaging features of covid- : a systematic review and meta-analysis the epidemiology and pathogenesis of coronavirus disease (covid- ) outbreak sonographic signs and patterns of covid- pneumonia covid- patients' clinical characteristics, discharge rate, and fatality rate of meta-analysis time course of lung changes at chest ct during recovery from coronavirus disease (covid- ) chest ct features of covid- in ct imaging features of novel coronavirus ( -ncov) point-of-care lung ultrasound findings in patients with novel coronavirus disease (covid- ) pneumonia duarte-neto an; brazilian image autopsy study group. histologicalultrasonographical correlation of pulmonary involvement in severe covid- ultrasound on the frontlines of covid- : report from an international webinar what's new in lung ultrasound during the covid- pandemic is there a role for lung ultrasound during the covid- pandemic? ultrasound of the pleurae and lungs radiological society of north america expert consensus statement on reporting chest ct findings related to covid- : endorsed by the society of thoracic radiology, the american college of radiology, and rsna lung ultrasonography versus chest ct in covid- pneumonia: a two-centered retrospective comparison study from china the role of imaging in the detection and management of covid- : a review point-of-care lung ultrasound in patients with covid- : a narrative review lung ultrasound in covid- pneumonia: correlations with chest ct on hospital admission the "pandemic" increase in lung ultrasound use in response to covid- : can we complement computed tomography findings? a narrative review chest ct findings in coronavirus disease- (covid- ): relationship to duration of infection correlation between chest computed tomography and lung ultrasonography in patients with coronavirus disease (covid- ) comparative study of lung ultrasound and chest computed tomography scan in the assessment of severity of confirmed covid- pneumonia point of care and intensive care lung ultrasound: a reference guide for practitioners during covid- lung ultrasound as a triage tool in an emergency setting during the covid- outbreak: comparison with ct findings lung ultrasound findings in patients with covid- pneumonia chinese critical care ultrasound study group (ccusg). findings of lung ultrasonography of novel corona virus pneumonia during the - epidemic the clinical and chest ct features associated with severe and critical covid- pneumonia covid- pneumonia manifestations at the admission on chest ultrasound, radiographs, and ct: single-center study and comprehensive radiologic literature review can lung us help critical care clinicians in the early diagnosis of novel coronavirus (covid- ) pneumonia? our italian experience using lung ultrasound for identification, grading and serial follow-up of severity of lung involvement for management of patients with covid- key: cord- -lr roxej authors: vieira, ana luisa silveira; pazeli júnior, josé muniz; bastos, marcus gomes title: role of point-of-care ultrasound during the covid- pandemic: our recommendations in the management of dialytic patients date: - - journal: ultrasound j doi: . /s - - - sha: doc_id: cord_uid: lr roxej covid- is a viral disease due to the infection of the novel corona virus sars-cov- , that has rapidly spread in many countries until the world health organization declared the pandemic from march , . elderly patients and those affected by hypertension, diabetes mellitus, and chronic pulmonary and cardiovascular conditions are more susceptible to present more severe forms of covid- . these conditions are often represented in dialytic renal end-stage patients. moreover, dialysis patients are more vulnerable to infection due to suppression of the immune system. growing evidences, although still supported by few publications, are showing the potential utility of ultrasound in patients with covid- . in this review, we share our experience in using point-of-care ultrasound, particularly lung ultrasound, to indicate the probability of covid- in patients with end-stage renal disease treated by hemodialysis. we also propose recommendations for the application of lung ultrasound, focused echocardiography and inferior vena cava ultrasound in the management of patients in hemodialysis. the world is currently facing a pandemic disease caused by a novel coronavirus (sars-cov- ) and called covid- (coronavirus disease- , described in ). this viral infection showed rapid dissemination and potential harm due to complications in the respiratory system characterized by a severe form of pneumonia with respiratory failure. only a minority of patients are at risk of developing the severe form of the disease, but the extremely high number of infected patients is causing a surge that is creating a serious crisis even in the most advanced medical organizations [ ] . the big challenge is to recognize, efficiently and quickly, those patients with covid- pneumonia who need isolation, hospitalization and intensive care management. the chinese experience shows that clinical symptoms at presentation are not able to predict the severity of the disease and that transmission is frequent from asymptomatic infected subjects [ ] . chest radiography, despite its wide availability and low cost, has low diagnostic sensitivity for pneumonia in cases of covid- [ ] . on the other hand, lung computed tomography (ct) is considered to be the best image modality for early identification of pulmonary involvement in patients infected with sars-cov- [ ] . in a recent study, the sensitivity of ct was reported to be superior to reverse transcription polymerase chain reaction (rt-pcr) ( % vs. %, respectively, p < . ) in the diagnosis of covid- [ ] . however, a role of ct imaging in the diagnosis of covid- is ambiguous and this latter study has been heavily criticized [ ] . moreover, it is difficult to imagine a scenario where ct is systematically performed in all suspected cases of covid- because of costs, time consumption, exposure to radiation, possibility of crossinfections, and even non-availability in scarce resource areas. patients with end-stage renal disease (esrd) are at increased risk of infection with sars-cov- virus. reports from health services around the world have indicated that patients with diabetes mellitus and hypertension, two of the main causes of esrd worldwide, and also advanced age and cardiovascular complications, two frequent accompanying conditions in dialysis patients, are more susceptible to sars-cov- infection and more prone to develop severe covid- pneumonia, eventually requiring intensive care treatment [ , , ] . moreover, the logistical characteristics of hemodialytic procedures, performed three times a week in closed areas to group of patients, are at increased risk of disease transmission [ ] . so far, epidemiological data in patients on ambulatorial hemodialysis with covid- are limited. during the outbreak in a hemodialysis unit of wuhan, it was reported that out of patients ( . %) and out of staff personal ( . %) were diagnosed with covid- [ ] . during the days of follow-up, seven of those patients died. lung ultrasound (lus) shows superior sensitivity when compared to x-ray in patients with acute respiratory failure [ ] . moreover, lus has been experienced during the chinese outbreak of covid- [ , ] . nonetheless, lus may be a more feasible and practical alternative since it can be quickly done at the bedside, is repeatable and reduces the possibility of cross-infections. in italy, lus has been proposed as an alternative to ct for suspected cases of covid- [ ] [ ] [ ] [ ] . based on our experience and supported by the existing literature, we suggest the use of lus in dialysis patients to allow the early recognition of the disease as well as to indicate the severity of pulmonary involvement, allowing a safer allocation of dialysis patients during the covid- pandemic. the role of lus to evaluate several respiratory conditions is nowadays widely documented [ ] . the lesions observed in ct scan of patients with covid- are generally peripheral and subpleural, perhaps due to the fact that sars-cov- is a novel virus with an average diameter of only about nm, which allows it to be easily inhaled down to the peripheric airways and alveoli without immune barrier [ ] . lus is an image method that classically allows the evaluation of the pulmonary periphery which makes it an excellent technique in the assessment of covid- . the same physician in charge of the patient can obtain pulmonary images by lus performed at bedside, thus minimizing the number of health professionals potentially exposed to the virus. this is a crucial point, considering that data from italy and spain, two of countries with the highest rate of covid- , show that approximately to % of health workers became infected and were quarantined [ ] . the technology of modern ultrasound machines (portable and ultra-portable) currently available has many favorable characteristics. the easy portability at the bedside, the long battery life and the possibility to be connected to smartphones and tablets make them suitable even in remote areas. the small dimension is also a favorable characteristic to allow an easy procedure for disinfection, which is crucial in the context of the current pandemic. the application of lus by portable machines allows the examination without the need to move the patient to radiology facilities, which would increase the risk of cross-infections. another important advantage of modern technology is connectivity that allows the possibility of image sharing through social media and other internet systems, making telemedicine a possible help to local medical staffs. however, not always handheld machines are available in the medical units. lus is becoming critical in the front door of this covid- outbreak. thus, any ultrasound machine should be used based on the availability. carriable ultrasound machines can be dedicated to specific areas where patients suspected for covid- are examined. anyway, we recommend an accurate disinfection of the probes after each exam using alcohol solutions to avoid contamination. in case of use of the ultrasound machine during invasive procedures at risk of aerosol dispersion, we also recommend using transparent covers on the keyboard and a full disinfection of the screen and other parts at the end of the maneuver. lus is a relatively new technique that has been used increasingly since the pioneering work of lichtenstein and axler, published in the early s [ ] . nowadays, lus is frequently used in the emergency departments and intensive care units in the diagnosis of several lung diseases [ ] . more recently, nephrologists also discovered lus as a great tool to evaluate their dialytic patients [ , ] . the images obtained with lus most of the time are not anatomical. they are based on artifacts generated by the interaction of the ultrasound beam with the acoustic interface between the tissues of the chest wall and the air in the alveoli distributed in the pulmonary surface. indeed, lus can only study lung diseases that abut the pleura [ , ] . patients can be examined either in supine/ semi-recumbent (with arm abducted over the head) or in sitting position, as similarly done during the standard physical examination [ ] . each hemithorax is generally divided into three areas: anterior (between parasternal and anterior axillary lines), lateral (between anterior and posterior axillary lines) ( fig. ) and posterior (between posterior axillary line and the spine) (fig. ) . each area is further divided into superior and inferior [ ] . in the case of critical care patients who cannot collaborate and lie down in the supine position, the dorsal region of both lungs can be assessed by slightly moving the patient in lateral decubitus [ ] . the lungs can be scanned using a high-frequency probe (linear) or by a low-frequency probe (convex, microconvex and phased array). the higher the frequency, the greater is the image resolution, even though penetration is reduced. on the other hand, low-frequency transducers can reach greater depths, but at the expense of a lower image resolution. in the context of this pandemic, we recommend using a probe with a large surface of emission and a technique for lus that allows a quick examination of the whole chest surface. also, the probe should transmit at a low frequency to allow enough penetration and evaluate pleural surface and vertical artifacts at the same time. this description corresponds to the convex probe. the transducer should be positioned longitudinally to the chest and perpendicular to the ribs. on occasion, the probe can be turned to obtain an oblique scan along the intercostal space to visualize more in detail the lus pattern in a wider portion of the pleural surface. lus allows a dynamic examination in real time and the transducer must be handled with continuous slow movements of tilting, sliding and rotating to optimize the image. during the insonation, it is also helpful to adjust the image gain and depth (around to cm) and position the focus (when available) at the level of the pleural line. as lus is based on artifacts, it is important to disable the "multi beam", "tissue harmonic imaging" features and filters that optimize the real images and decrease artifacts [ ] . lus is a technique mainly based on the visualization of artifacts originating by the acoustic mismatch between tissue and air in the surface of the lung [ ] . normally, in the periphery of the lung, there is basically alveolifilled with air. when the ultrasound beam encounters the interface between two structures with opposite values of acoustic impedance, it is completely reflected back to the transducer. thus, during the chest insonation, the ultrasound beam will pass through skin, subcutaneous tissue, muscles, until it reaches the pleura. this latter corresponds to the interface where the maximum acoustic tissue/air mismatch is encountered and will be visualized as an echoic horizontal linear artifact, the pleural line. below the pleural line, the examiner may see echoes that reproduce the pleural line at regular equidistant intervals echoing more times the distance between the probe and the pleura. these horizontal artifacts, indicated as a-lines, are visualized when the lung is well aerated (fig. ) (additional file ) [ ] . accumulation of subpleural interstitial exudate, transudate, collagen, and blood causes loss of aeration and changes the air-liquid balance. also, the fibrotic thickenings of the interlobular septa create a similar deaeration. in these pathologic conditions, the pulmonary surface will not be a strong reflector of the ultrasound beams. the first grade of loss of aeration causes a partial penetration of the ultrasound creating vertical artifacts on the images displayed on the screen. nowadays, these artifacts are called b-lines [ ] . b-lines are defined as discrete laserlike vertical hyperechoic reverberation artifacts that arise from the pleural line, extend to the bottom of the screen without fading, and move synchronously with lung sliding [ ] (fig. ) (additional file ) . when the accumulation of fluid raises, the b-lines proportionally increase in number and intensity until tend to coalesce, originating a pattern called white lung [ ] (fig. ) (additional file ) . in this progression, the final step of loss of aeration and increase in density gives the pattern of a consolidated lung parenchyma [ ] (fig. ) (additional file ) . lus allows a first screening of patients admitted at the dialysis unit presenting symptoms that raise suspicion of covid- . it can help triaging between low-risk patients (patients clinically stable who do not present pathologic lus changes) and those who show signs of pneumonia and high risk for severe forms of the disease. thus, lus allows us to diagnose pneumonia in covid- and differentiate the severity of the disease at presentation, useful to select who requires hospitalization and limit unnecessary nosocomial exposure. however, it is important to highlight that in case of abnormal lus pattern suggestive of viral pneumonia, ruling out alternative conditions may represent a challenge. indeed, b-lines and consolidations are not enough specific and cannot easily differentiate hydrostatic/cardiogenic edema or other pathologic conditions [ ] . the interstitial pneumonia in covid- is typically peripheral, bilateral, diffuse but asymmetric [ ] . for this reason, the lus exam in the suspected patient must be performed all over the chest surface [ ] . the typical patterns detected by lus in patients with covid- pneumonia are characterized by b-lines in different forms, both separated and coalescent, an irregular and/or fragmented pleural line, peripheral small consolidations, and large consolidations with dynamic air bronchograms [ ] (fig. ) (additional file ). these patterns are usually intercalated with "spared areas" (a-lines) [ ] . a large pleural effusion is not a common finding [ ] . detection of the typical signs, described above combined in a pattern with a typical bilateral and patchy distribution, raises the high probability of the presence of the disease in a symptomatic patient. however, in dialytic patients the interpretation of the artifacts is more challenging, due to the fact that these frequently are affected by cardiovascular complications and quite frequently present a status of hypervolemia [ ] . it is especially critical to differentiate the characteristics of the b-lines in dialytic patients admitted with dyspnea, since these artifacts are the most frequent findings in covid- pneumonia and also typically found in hypervolemic patients with lung congestion. b-lines due to hypervolemia are symmetrically distributed in both lungs and initially well separated. the symmetric distribution is gravity related and the anterior superior areas are the last part of the lung to be involved in the process of progression of the severity of lung congestion. thus, correlation of the severity of the b-lines representation and the severity of the symptoms of the patient becomes critical. furthermore, the pleural line is usually diffusely regular, and lung consolidations are not detected. another differential characteristic is that the pleural effusion is a common finding in hypervolemia. on the other hand, although b-lines due to covid- are also typically bilateral, they have a different distribution. in pneumonia during the course of covid- , it is typical the visualization of clusters of b-lines, both in separated and coalescent forms. moreover, other authors described an intense "shining bandform artifact spreading down from a large portion of a regular pleura, often appearing and disappearing with an on-off effect in the context of a normal a-lines lung pattern visible on the background" [ ] (fig. ) . this sign has been called "light beam" artifact (additional file ). this band may also originate from an irregular pleural line or from small subpleural consolidations. the "light beam" is not only observed in covid- pneumonia but it is highly frequent in this disease. the combination of the light beam with the other artifacts in clusters alternating abruptly with spared a-lines areas, with the typical [ , ] . this is particularly effective when lus is applied in patients presenting with the typical symptoms of covid- , in this specific moment of outbreak with a high prevalence of the disease. if the b-lines pattern that can be observed by lus in dialytic patients does not fully respect the typical characteristics of a covid- pneumonia and cannot allow a definitive conclusion, we suggest to extend the ultrasound scan to the heart and the inferior vena cava (ivc). esrd patients frequently present cardiovascular complications, giving combined or separated diastolic and systolic dysfunctions. these dysfunctions frequently are associated and even favor hypervolemia, and may easily result in pulmonary congestion [ ] . fluid congestion of the pulmonary interstitium is represented with high sensitivity by multiple and diffuse b-lines at lus. not only lus is highly sensitive in the detection of pulmonary congestion, but also it can indicate the effectiveness of a treatment that reduces the congestion. thus, if monitoring the patients during the dialysis session the number of b-lines decreases after the ultrafiltration, it is a reliable indicator that the origin of the lus pattern is hypervolemia and not the infection [ ] . the ultrasound evaluation of the diameter and the respiro-phasic change of ivc can also be helpful in a scenario where differential interpretation of b-lines is a challenge. a collapsing or close to collapsing ivc before the dialysis session is not compatible with a condition of hypervolemia. on the other hand, a plethoric ivc shortly after dialysis implies a still filled intravascular space. however, the ultrasound examination of the ivc poses always the necessity to consider possible confounding factors. it is essential to consider the clinical settings. for instance, there are situations when the decrease of ivc diameter is not related to progression to hypovolemia, but may be linked to increased abdominal pressure, an abnormal inspiratory effort, and others. at the same time, situations revealing increase in the ivc diameter may be not necessarily related to hypervolemia, like it is observed in some specific cardiac conditions determining an obstacle to the venous return or in pulmonary conditions with alveolar hyperinflation, and so on [ ] . as seen previously in this article, it is clear that dialysis patients are at a greater risk of developing the most severe forms of covid- , in addition to being potential vectors of the disease; since due to the specificities of their treatment, they cannot fully adhere to the social distancing, recommended by the world health organization [ ] . based on current evidence and our experience with point-of-care ultrasound in nephrology, we suggest the following recommendations in the management of dialytic patients during the pandemic (fig. ): . the creation of different allocations, whenever possible, for patients who arrive and leave the clinic, thus reducing contacts between patients; . immediate supply of surgical masks as soon as patients arrive to the unit for the dialysis session. the mask must be kept by the patient for the entire stay in the clinic. during triage, a health professional, also wearing a surgical mask, should investigate about any suspected symptom of covid- infection, such as fever, cough and dyspnea, and possibility of any contact with confirmed cases of covid- or permanence in areas with diffuse presence of the disease. in addition, the temperature must be checked using an infrared thermometer, minimizing contacts with the patient; . if the patient is asymptomatic and does not confirm any contact with confirmed cases, the patient can be referred to his/her dialysis session, as usual; . if the patient is asymptomatic but confirms any contact with positive covid- cases or provenience from an area of strong epidemic, he/she should preferably be referred to an isolated room dedicated to suspected cases, where patients remain separated with a minimum distance of . m [ ] . in this room, particular care should be reserved to allow isolation from contact and protection of the dialysis personnel, who should wear full protective gear such as waterproof disposable gown, cap, gloves, face shield, and at least n face mask, and proceed with more rigorous cleaning and disinfection. complementary tests admission should be strongly considered. if saturation is above %, the cost-benefit ratio of hospitalization should be considered. other factors, like adequate family support, comorbidities and socioeconomic conditions, are important conditions that need to be investigated and considered. in the case a patient with positive signs of covid- pneumonia is discharged to home, frequent clinical re-assessment should be programmed; . if the patient shows a pattern of b-lines not typical and hydrostatic edema remains a possible alternative, ideally, a more detailed ultrasound assessment should be performed, by extending the examination to the heart and ivc. if the ultrasound findings are compatible with hydrostatic edema, the patient should be submitted to dialysis with ultrafiltration and reassessed clinically and with ultrasound at the end of the procedure. if the clinical status and the lus pattern improve significantly in terms of resolution of dyspnea and reduction in the number of b-lines, the possibility that the lus pattern observed at triage was secondary to hypervolemia is reinforced. if there is no change in clinical and lus parameters, the possibility of an infective origin of b-lines increases; . in the context of the pandemic that we are experiencing, it is essential to pay attention to measures of individual protection and the accurate cleaning and disinfection of the device and transducers after their use. the examiner must wear an apron, gloves (three pairs), glasses and n mask. the patient must wear a surgical mask during the examination [ ] . to avoid contamination of the us device, it is recommended to cover the equipment keyboard with transparent plastic films to be changed after each use. it is also recommended to clean the device with gauze or similar material soaked in % alcohol and the transducers according to the manufacturer's guidelines (in general, compounds based on quaternary ammonia are recommended). the first pair of gloves should be removed after examining the patient, the second pair after disinfecting the equipment and the third pair together with the removal of the garment [ ] . the world is witnessing a pandemic with disastrous effects due to the rapid spread of the sars-cov- virus and the huge demand for resources needed to contain covid- . in this context, lus performed by the attending physician represents a safe, inexpensive, easily reproducible technique with a great potential in allowing to differentiate patients with signs of covid- pneumonia. the screening performed by the lus at the bedside allows defining the immediate management of dialysis patients, seen in dialysis units, where other propaedeutic resources are often not available. a strategy based on triaging suspected patients for covid- pneumonia is potentially useful to prevent the dissemination of the virus and also to impact positively the prognosis of vulnerable dialytic patients. clinical characteristics of novel coronavirus infection in china clinical characteristics of fatal and recovered cases of coronavirus disease (covid- ) in wuhan, china: a retrospective study findings of lung ultrasonography of novel corona virus pneumonia during the - epidemic sensitivity of chest ct for covid- : comparison to rt-pcr chest computed tomography for detection medicine 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guideline on covid- : ultrasound machine and transducer cleaning publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we sincerely thank dr. giovanni volpicelli for image courtesy ("light beam" video) and for sharing his knowledge. supplementary information accompanies this paper at https ://doi. org/ . /s - - - . all the authors of the article are responsible for concept and writing. all authors read and approved the final manuscript. no funding has been received. availability of data is not applicable to this article. ethics approval is not applicable to this article. we receive the signed consent form any conscious patient cared in our institution to collect and publish anonymous data on point-of-care ultrasound that is performed to diagnose their condition. license agreementin submitting an article to any of the journals published by springeropen i certify that: i am authorized by my co-authors to 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they have no competing interests with the subject key: cord- - m rdhy authors: buda, natalia; segura-grau, elena; cylwik, jolanta; wełnicki, marcin title: lung ultrasound in the diagnosis of covid- infection - a case series and review of the literature date: - - journal: adv med sci doi: . /j.advms. . . sha: doc_id: cord_uid: m rdhy covid- pandemic caused by severe acute respiratory syndrome coronavirus (sars-cov- ) and spreading worldwide has become a serious challenge for the entire health care system as regards infection prevention, rapid diagnosis, and treatment. lung ultrasound (lus) is a dynamically developing diagnostic method used in intensive care, cardiology and nephrology, it can also be helpful in diagnosing and monitoring pneumonia. interstitial pneumonia appears to be the most common clinical manifestation of coronavirus infection. we present case reports of covid- involving the lungs, in which transthoracic lung ultrasound was successfully utilized as a constituent of bedside diagnostics and a review of the literature concerning potential use of lus in covid- diagnostics. the possibility to perform this examination repeatedly, its non-invasiveness and high sensitivity make it an important element of care provided for patients with viral pneumonia. an outbreak of epidemic caused by an unknown sars-cov- belonging to the coronavirus family began in december in china. coronavirus disease caused by this newly discovered virus has very quickly spread all over the world. considering the rapidly increasing number of cases the world health organization (who) declared a pandemic on th march . the incubation period of this disease transmitted by droplets ranges from to days, usually between and [ , ] . its course is varied -the majority of patients (about %) are asymptomatic or present with mild symptoms of a respiratory tract infection (fever, cough, weakness) [ ] . approximately % of patients have severe symptoms, and % require treatment at intensive care units due to pneumonia requiring mechanical ventilation ( . %), the development of acute respiratory distress syndrome (ards), sepsis or multiple organ failure (mof) [ , ] . covid- mortality rate has been estimated as . % [ , ] . considering the epidemic context, it is essential to diagnose the disease quickly. the basic diagnostic method is a reverse transcription polymerase chain reaction (rt-pcr) test of a nasopharyngeal swab or sputum sample, with a sensitivity of - %, but the result may be sometimes available only after h. the infection is manifested by the following abnormalities in laboratory test results: leukopenia, lymphocytopenia, increased levels of ldh and crp [ ] . imaging techniques are important tools in the diagnosis of sars-cov- infections -chest computed tomography (ct) is presently recommended by experts as a screening examination [ ] . the hallmarks of covid- revealed by ct are bilateral, mostly peripheral, lesions. characteristic imaging features include ground glass opacities (over % of patients) with areas of consolidation. lymphadenopathy, pleural effusions, and pulmonary nodules are rare [ ] . ct imaging is characterized by high sensitivity, however, it has some limitations. it may be impossible to perform ct for a patient with hypoxemia, who is mechanically ventilated with high levels of oxygen or for hemodynamically unstable patients. transthoracic lung ultrasound (lus) is characterized with a sensitivity and specificity of . - . (depending on the duration of the disease) for the diagnosis of ards [ ] . this tool appears very attractive for the implementation in the diagnosis of patients with suspicions of covid- , especially because it can be performed at any stage of the diagnostic and therapeutic process and does not require transportation that might be risky for the patient [ ] . we present case reports of covid- involving the lungs, in which lung ultrasound was successfully utilized as a constituent of bedside diagnostics. lus was performed on admission when real-time polymerase chain reaction results were still pending. symptoms, laboratory results, chest x-ray and lung ultrasound parameters are summarized in table . a -year-old male without previous medical history, complaining of fever of . ºc and cough for days. on admission, the patient had dyspnea with modestly lower blood saturation (sato %), but with marked hypoxemia (po mmhg) and modest rise of blood ph ( . ) and lower pco ( mmhg). the arterial-blood gas test was performed without oxygen therapy. in other laboratory tests, crp, procalcitonin and d-dimers measurements were normal. the chest x-ray was also normal. because of inconclusive results of the other tests, lus was performed, revealing multifocal minor sub-pleural consolidations accompanied by strengthening behind the lower margin of the lesion (the so-called c-line artifact), short vertical artifacts (the so-called z-lines) and segmental pleural irregularity ( fig. a and b ). considering all information obtained and clinical data, a suspicion of covid- infection was put forward, confirmed by the rt-pcr test. an -year-old man with many comorbidities involving the cardiovascular system, including persistent atrial fibrillation and pulmonary hypertension, admitted to hospital due to fever of . ºc. primary diagnosis was a urinary tract infection and concomitant respiratory infection. however, no abnormality was found in the general urine test. crp and procalcitonin levels were not elevated; however, pancytopenia and reduced oxygen partial pressure (po mmhg) were noteworthy. chest x-ray revealed features of lung congestion. the results of laboratory and imaging tests did not explain the high fever, so covid- was suspected, and then confirmed by rt-pcr. in the course of diagnostics, an ultrasound examination of the lungs was also performed, revealing the following abnormalities: segmentally irregular pleural line and single focally located b-lines ( fig. a and b). an -year-old female with many comorbidities, including cirrhosis and chronic kidney disease (ckd g ), and a history of ischemic stroke and episode of deep vein thrombosis, was admitted to the clinic due to acute dyspnea. on admission, the patient was in a serious condition -blood pressure was / mmhg, there was tachypnoea of breaths/min., blood saturation could not by measured, and an attempt to collect arterial blood for an arterial-blood gas test was unsuccessful. laboratory tests performed during the first hours after admission revealed: crp . mg/l (< . ); ldh u/l (< ); procalcitonin . ng/ml (< . ); wbc . g/l; rbc . t/l, hb . g/dl; ht - %, plt /l. in a control peripheral blood sample, wbc decreased to . g/l; there was no neutropenia, though. flu and rsv swabs (rt-pcr) were negative. the result of the chest x-ray examination was inconclusive: congestive lesions to be differentiated with inflammatory lesions were described. in the physical examination, massive crackles and rales on both sides of the chest were revealed. to complete the diagnostic process, a bedside lus examination was performed. profile a ( a -year-old female admitted to the emergency department due to fever, cough and dyspnea. the patient had no previous medical history of comorbidities. fever and cough started days earlier. on admission, desaturation was noticed -sato was % without oxygen therapy. an arterial-blood gas test revealed po decreased to mmhg and pco to mmhg, ph was . . additionally, leukopenia was found in a peripheral blood sample. moreover, ldh activity was markedly elevated to u/l (normal activity < u/l) and so was pcr concentration. procalcitonin concentration was normal. the chest x-ray examination showed small bilateral infiltrates. in the subsequent days of hospitalization, lus was performed, revealing confluent b-lines in anterior, lateral and posterior regions in the lower and upper fields and small consolidations in both lower fields ( fig. a and b) . unfortunately the patient's condition worsened, in a control arterial-blood gas test po was low (approximately mmhg) despite the oxygen therapy (fio %). the patient was transferred to an intermediate care unit in order to obtain better monitoring. lus may be performed with any ultrasound device available at the work place. a normally aerated lung constitutes a barrier that strongly reflects the ultrasound beam. consequently, although ultrasonography has been used in clinical diagnostics for many years, it has not been employed for the assessment of the lungs [ ] [ ] [ ] [ ] . a normal utrasonographic image is characterized by a smooth, regular, echogenic, continuous pleural line, the presence of lung sliding (the movement of the pleural line consistent with the respiratory activity), aline artifacts (horizontal artifacts that occur beneath the pleural line at multiples of the distance between the ultrasound transducer and the pleural line) [ ] [ ] [ ] [ ] (fig. .) it should be noted, however, that although these features indicate a normally aerated lung, this is not equivocal with the exclusion of some pulmonary diseases, for instance, asthma, chronic obstructive pulmonary disease (copd), and pulmonary embolism without subpleural consolidations. consequently, it is essential to refer the result of the ultrasound examination to clinical information (medical interview, other additional examinations) [ - ]. [ ] [ ] [ ] . in this case, similar to interstitial pneumonia of a viral etiology, the more b-line artifacts are visible, the more significantly the interstitial tissue is affected [ ] . in the context of the sars-cov- pandemic, a rapid diagnosis of covid- is particularly significant since the identification and isolation of infected patients limits the pace of spreading the infection in the general population [ , ] . the epidemiological interview, important when the first cases occurred in a given area, presently, with more than . million of confirmed cases (data as of th june ), loses its significance considering the likelihood of getting infected [ , ] . the clinical picture -fever, cough, dyspnea, and weakness -may indicate the coronavirus infection, but similar symptoms may appear also in common acute conditions (including viral infections of a different etiology), or during exacerbation of chronic diseases. commonly used diagnostic procedures for sars-cov- infection, i.e., ct and the rt-pcr test, are available in hospital conditions, yet the waiting time for the result, especially as regards the genetic test, may be prolonged [ ] [ ] [ ] . it appears that the use of transthoracic lus would be an ideal solution since this examination can be performed at the patient's bedside at any stage of the diagnostic and therapeutic process. the presence of specific (but not pathognomic) abnormalities in the lus scan, combined with concordant clinical information obtained during the medical and epidemiologic interview, may estimate with a high probability the risk of covid- in the examined patient and customize further treatment [ , ] . due to the common use of portable ultrasound devices, point of care diagnostics is available at the emergency departments, in the emergency medical services, in gp surgeries, or at a patient's home [ , ] . the advantages of ultrasonography, apart from the possibility of the bedside examination without the necessity of transporting the patient, include non-invasiveness and lack of exposure to x-rays. consequently, this examination can be performed as often as is clinically necessary. this may be particularly important for patients in very serious clinical conditions, who require advanced therapeutic techniques at intensive care units (invasive mechanical ventilation, renal replacement therapy, extracorporeal membrane oxygenation -ecmo). transportation of such patients to tomography units to assess the development of pulmonary lesions and its pace may be risky or actually impossible. in this patient group, chest ultrasound, extended with basic echocardiography, assessment of the abdominal cavity and inferior vena cava (ivc) may be very useful in treatment monitoring and optimization. it should also be stressed, that multiple organ ultrasound assessment is performed by one operator thus minimizing the contamination of the equipment and exposure of additional medical staff to infection. an additional advantage, in the group of most critically ill patients, particularly those mechanically ventilated, may be the use of ultrasound to monitor the efficiency of recruitment maneuvers and to detect complications such as pneumothorax or pleural effusion [ ] [ ] [ ] [ ] [ ] [ ] . lus may be useful in the diagnosis of patients suspected of covid- (at the department, in a tent adjacent to the department, at a patient's home, etc.). moreover, it may be utilized for monitoring of the disease at intensive care units. an ultrasound examination is relatively uncomplicated and can be performed repeatedly at any place, depending on clinical needs. the low cost and safety of an ultrasound examination (absence of ionizing radiation) encourages clinicians to utilize ultrasonography in the diagnosis of pulmonary diseases. we believe, that in condition of inconclusive clinical data, incorrect lus results may sensitize us to the possibility of covid- coexistence. moreover, if a person has negative rt-pcr test and positive transthoracic ultrasound it seems reasonable to repeat the rt-pcr test and then, if negative, to search for causes of interstitial changes other than covid- . however, in order to prove the efficiency of this imaging technique for the diagnosis of covid- further multi-center studies are necessary. the authors have no funding to disclose the authors declare no conflict of interests table . summary of symptoms, laboratory results, chest x-ray and lung ultrasound parameters in the patients with covid- . abbreviations: crp -c-reactive protein; n -normal; h -high. a pneumonia outbreak associated with a new coronavirus of probable bat origin severe acute respiratory syndrome coronavirus (sars-cov- ) and coronavirus disease- (covid- ): the epidemic and the challenges epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study who feb; - clinical characteristics of coronavirus disease in china a novel coronavirus outbreak of global health concern a rapid advice guideline for the diagnosis and treatment of novel coronavirus ( -ncov) infected pneumonia chest ct findings in coronavirus disease- (covid- ): relationship to duration of infection ultrasound patterns of pulmonary edema thoracic ultrasonography: a narrative review the comet-tail artifact is there a role for lung ultrasound during the covid- pandemic? how to perform lung ultrasound in pregnant women with suspected covid- chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. cardiovasc ultrasound lung ultrasonography in the evaluation of interstitial lung disease in systemic connective tissue diseases: criteria and severity of pulmonary fibrosis -analysis of patients on the physical basis of pulmonary sonographic interstitial syndrome transthoracic lung ultrasound in the monitoring of interstitial lung disease: a case of scleroderma laboratory diagnosis of emerging human coronavirus infections -the state of the art. emerg microbes infect point-of-care lung ultrasound findings in novel coronavirus disease- pnemoniae: a case report and potential applications during covid- outbreak is there a role for lung ultrasound during the covid- pandemic? feasibility of paramedic performed prehospital lung ultrasound in medical patients with respiratory distress international evidence-based recommendations for point-of-care lung ultrasound ultrasound diagnosis of occult pneumothorax lung ultrasound in the critically ill. ann intensive care whole body ultrasonography in the critically ill. ebook ultrasonography for the assessment of lung recruitment maneuvers recruitment maneuvers and peep titration. respir care the authors have no funding to disclose the authors declare no conflict of interests key: cord- -kbkvk k authors: deng, qing; zhang, yao; wang, hao; chen, liao; yang, zhaohui; peng, zhoufeng; liu, ya; feng, chuangli; huang, xin; jiang, nan; wang, yijia; guo, juan; sun, bin; zhou, qing title: semiquantitative lung ultrasound scores in the evaluation and follow-up of critically ill patients with covid- : a single-center study date: - - journal: acad radiol doi: . /j.acra. . . sha: doc_id: cord_uid: kbkvk k rationale and objectives: chest ct is not suitable for critically ill patients with covid- and lung ultrasound (lus) may play an important role for these patients. in this study, we summarized the findings of lus and explore the value of semiquantitative lus scores in evaluation and follow-up of covid- pneumonia. materials and methods: retrospectively studied the lus and chest ct imaging of critically ill patients with covid- . the imaging data were reviewed to acquire the lus and ct scores. the correlation between lus scores and ct scores were made to evaluate the accuracy of lus. a cut-off point of lus score was calculated to distinguish critical-type patients from severe-type patients. lus follow-up of patients were compared with the gold standard chest ct. results: the most common lus features of covid- pneumonia were crowded or coalescent b-lines with multifocal small consolidations in multi-zone. the mean lus score was . points in severe-type patients and . points in critical-type patients (p< . ). the correlation between lus scores and ct scores was high (r= . , p< . ) and it was higher in critical-type patients than that in severe-type patients. the lus score higher than . points had a . % sensitivity and . % specificity to distinguish critical-type patients. the consistency of lus and chest ct in follow-up was . , with higher consistency in diagnosis of lesion progression (kappa values was . ). conclusion: our scoring system provides a more quantitative use of lus findings and accurate evaluation of lung damage for critically ill patients with covid- . coronavirus disease (covid- ) is caused by severe acute respiratory syndrome coronavirus (sars-cov- ), which first appeared in wuhan in december ( ) ( ) . as of may , , there have been more than . million confirmed cases in more than countries and territories around the world ( ) . given the rapid spread of this virus, the world health organization declared that covid- should be characterized as a pandemic on march , ( ) . although the incidence rate of severe cases of covid- was lower than that of severe acute respiratory syndrome (sars) in , covid- is more infectious, and it led to a large number of severe cases in a short amount of time ( ) . at the peak of the pandemic, there were patients with severe illness in wuhan ( ) . the main clinical manifestations of those critical patients were respiratory distress, fever and other severe systemic symptoms ( ) . many critical patients required mechanical ventilation or even extracorporeal membrane oxygenation (ecmo) support ( ) . the timely and accurate evaluation of lung lesions is very important in the treatment of patients with covid- , and chest computed tomography (ct) is considered the 'gold-standard' imaging technique ( ) . however, ct is not suitable as a follow-up tool for critically ill patients because of the risks of patient transport and infecting others. bedside chest radiography has many restrictions and may lead to poor-quality x-ray films with low sensitivity, which has been well described ( ) . therefore, it is necessary to devise a novel imaging technique to evaluate lung lesions. lung ultrasound (lus) is a highly useful apparatus in the intensive care unit (icu). it offers a quick, reliable, inexpensive and radiation-free monitoring tool at the patient's bedside ( ) . lus is used to evaluate lung disease through the findings obtained when ultrasound waves cross tissues with a varying air/fluid ratio. many researchers have further highlighted the advantages of lus in icus for the evaluation of patients with respiratory distress ( ) ( ) ( ) . however, there have been only a few case reports of bedside lus application in critical patients with covid- ( ) ( ) ( ) . in this study, by analyzing ultrasonic data in cases, we aimed to summarize the findings of lus and to explore the value of semiquantitative lus scores in the evaluation and follow-up of critically ill patients with covid- . this is a subgroup analysis of patients enrolled in a larger ultrasound research project on covid- . our study was approved by the clinical research ethics committee of the hospital (no. wdry -k ) and has been carried out in accordance with the code of ethics of the world medical association. the data were collected and analyzed to facilitate better clinical decisions and treatment. a total of consecutive critically ill patients who were admitted to the hospital from february , to march , and had a confirmed diagnosis of covid- before their hospitalization were included in the study. the diagnostic criterion was defined as real-time fluorescence polymerase chain reaction revealing the positive detection of covid- in throat swabs or the lower respiratory tract. according to the diagnosis and treatment guidelines for covid- ( th edition) issued by the national health commission of china, the severity of the disease was classified into categories. mild-type patients had mild clinical symptoms and no pulmonary changes on ct imaging. common-type patients had symptoms of fever and signs of respiratory infection with pneumonia changes on ct imaging. severe-type patients presented with any one of the following: a. respiratory distress and respiratory rate ≥ /min, b. fingertip blood oxygen saturation ≤ % in resting conditions, or c. arterial partial pressure of oxygen (pao )/oxygen concentration (fio ) ≤ mmhg ( mmhg= . kpa). finally, critical-type patients met any one of the following criteria: a. respiratory failure requiring mechanical ventilation, b. shock, and c. icu admission requirement due to multiple organ failure. patients with severe and critical type were enrolled in our study and defined as critically ill patients. patients with a history of lung carcinoma, tuberculosis, congenital lung diseases or recent chest surgery were excluded from the study. to rule out the effects of acute heart failure on the lungs, patients with reduced left ventricular ejection fraction (< %) were also excluded from the study. the demographics and baseline characteristics that we collected consisted of gender, age, clinical signs and symptoms (such as fever, cough, shortness of breath, chest pain, fatigue, and loss of appetite), body mass index, blood oxygen saturation and coexisting conditions. after thorough clinical assessment, blood samples were taken to evaluate c-reactive protein (crp), leucocytes and procalcitonin. all enrolled patients underwent chest ct examination within hours after hospitalization. the extent of lung lesions was evaluated using the ct scoring system adopted by pan et al ( ) . each of the lung lobes was visually scored from to : no involvement, scored ; < % involvement, scored ; %- % involvement, scored ; %- % involvement, scored ; %- % involvement, scored ; and > % involvement, scored . the total ct score was the sum of the individual lobar scores (the maximum score= ). all images were interpreted and scored by two senior radiological specialists. these investigators were blinded to the clinical data. all enrolled patients underwent bedside lus evaluation within hours after hospitalization. the bedside lus were performed by sonographers with to years' experience in ultrasound. the machine used was a ge vivid™ iq ultrasonography (ge healthcare, china) equipped with a convex c - -rs probe. the frequency was set at . mhz, the depth was set at cm, and the gain was adjusted to obtain the best possible image so that the reverberation artifact (lung comet) could be clearly detected even if the patient were obese. according to international evidence-based recommendations for point-of-care lus in the emergency setting ( ) , the complete eight-zone lus examination was performed with patients in the supine or near-to-supine position. the chest wall was divided into zones: anterior and lateral zones per side. the anterior chest wall was delineated from the parasternal line to the anterior axillary line, and the lateral chest walls were delineated between the axillary anterior and posterior lines. superior and inferior zones were divided by the third intercostal space (figure ). videoclips were recorded throughout the respiratory cycle for subsequent off-line analysis. each zone was scored according to the lus pattern as follows ( ) ( ) : a normal lung pattern was identified by the presence of normal lung sliding with a-lines or fewer than two isolated b-lines and was scored as ; the presence of or more well-spaced b-lines presented in a single intercostal space was scored as ; the presence of crowded b-lines (more than % range in a view) with or without consolidation limited to the subpleural space was scored as ; and the presence of confluent b-lines (approaching % range in a view) or a tissue pattern characterized by dynamic air bronchograms that was defined as lung consolidation was scored as . the most severe ultrasound finding can be considered representative of the entire zone. the most severe ultrasound finding observed in each zone was recorded and used to calculate the sum of the scores (the maximum score= ). the lus score characteristics are summarized in figure . in addition, pneumothorax was defined as the presence of a lung point and absence of lung sliding and b-lines. pleural effusion was defined as intrapleural anechoic collection. the ultrasound images were analyzed and scored by doctors with to years' experience in lus. all doctors were blinded to each other and the clinical data. random ultrasound images of twenty patients were digitally transferred to a computer and analyzed by two independent observers to assess interobserver variability. the two observers were blinded to each other and neither of them were participated in the lung ultrasound examination. interobserver consistency was defined as the same patient acquired the same lung ultrasound score from two independent observers. to dynamically assess lung lesions, a follow-up of bedside lus was performed on all patients every two days after admission or at any time the doctors deemed it necessary. chest ct was performed again after admission when doctors considered the patient's condition to have deteriorated significantly, when accurate assessment of the lung lesion was needed, or when the patient's condition improved significantly and the patient no longer required care in the icu. if the ct follow-up was performed more than twice, only the first follow-up was selected for evaluation. patients with ct scores that had increased ≥ points compared with that at admission were defined as having disease progression. similarly, a reduction of ≥ points in the ct score compared with that at admission or a reduction of lung lesion density was defined as disease resolution. changes in the ct score within point were defined as no change. the bedside lus scores within hours before the ct examination were compared with those at admission. similar to the definition of ct, if the lus score increased or decreased ≥ points compared with that at admission, it was defined as progression or improvement; otherwise, it was defined as no change. the results of lus in follow-up were evaluated by comparison with the gold standard chest ct to evaluate the accuracy. continuous numeric variables are expressed as the mean value ± standard deviation, and dichotomous variables are expressed as the frequency number (%) or median [interquartile range]. variables were compared between groups using an unpaired student's t test if the data were normally distributed or the wilcoxon rank sum test if the data were not normally distributed. the intragroup correlation coefficient (icc) was used to test the consistency of ct scores and ultrasound scores between two observers, and icc values > . represent good repeatability. the distribution of involved lobes and the number of involved lobes in different clinical types were compared by the chi-squared test or fisher's exact test when sample sizes were small. the relationship between lus scores and ct scores was studied with pearson correlations. a receiver operating characteristic curve (roc) was used to test the ability of ct scores and lus scores to distinguish critical-type patients from severe-type patients. a kappa consistency check was used to evaluate the consistency of lus and chest ct in follow-up. statistical significance was defined at a level of p＜ . . all statistical tests were analyzed with spss software (version . ). the demographic and clinical characteristics are shown in table all patients were given oxygen therapy. thirty-eight patients used noninvasive mechanical ventilation, patients used invasive mechanical ventilators, patients used ecmo, and patients were sent to the icu. as of april th , , patients remained in the hospital, had been discharged, and patients had died. the ct characteristics and lesion distribution on admission are summarized in table . the median interval between symptom onset and ct examination was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) days. the most frequent ct features were ground-glass opacity ( . %), followed by consolidation ( . %) and crazy-paving pattern (ground-glass opacity with superimposed inter-and intralobular septal thickening, . %). most patients had bilateral and multifocal involvement. the involvement of the peripheral lung was observed in all patients. in severe-type patients, an average of . lobes were involved, while in critical-type patients, an average of . lobes were involved. the mean ct score was . points in severe-type patients and . points in critical-type patients, and there was a significant difference between patients of different types (p< . ). the consistency of ct quantitative scores between two observers showed good repeatability, with an icc of . ( % confidence interval . - . ). the lus findings were positive in all patients, but the degree of severity varied among patients. typical lus findings included the following: thickening and irregularity of the pleural line, an increase in b lines to different degrees and different extents, small multifocal consolidation limited to the subpleural space, and mass consolidations with dynamic air bronchograms. pleural effusions were uncommon, and pneumothoraxes were rare in this study. the findings and scores of bedside lus are summarized in table we used an lus score for the first time, to our knowledge, to evaluate and follow-up pneumonia in critically ill patients with covid- . we found that the lus of these patients showed certain characteristics, including the thickening and irregularity of the pleural line, increase in b lines, small multifocal consolidation limited to the subpleural space and mass consolidations with dynamic air bronchograms. these characteristics can be clearly seen on ultrasound and can be easily calculated to form semiquantitative scores. our study showed that semiquantitative lus scores were highly correlated with chest ct scores and could be effectively used to evaluate the lung lesions of patients with severe pneumonia. an lus score higher than . points highly suggested that the patient was in critical condition. there was a high consistency between lus scores and chest ct scores in the follow-up of critically ill patients, especially for patients with lesion progression. the discovery that sars-cov- (severe acute respiratory syndrome coronavirus ) binds to angiotensin converting enzyme (ace)- , which is highly expressed in the lower airways, explained why sars-cov- causes acute respiratory distress syndrome (ards) and respiratory failure ( ) . severe respiratory distress caused by lung damage is the leading cause of death in patients with covid- . the timely and accurate evaluation of lung lesions is very important for the clinical management of these patients. for critically ill patients, available modalities today mainly include chest radiographs and the gold-standard chest ct. the choice of modality is based not only on the clinic need but also on local resources and patient condition. some realities that have to be considered, such as the high contagiousness of sars-cov- and the risk of transporting unstable patients with hypoxemia and hemodynamic failure, may greatly affect the feasibility of lung disease investigation ( ) . lus is a convenient imaging modality that is simple, noninvasive, repeatable, cost-effective and independent of the operator's experience. its increasing popularity and supporting research data substantiate its role as an emerging technique for bedside chest imaging in critical care ( ) . many studies have confirmed the important role of lus in the icu ( , , ) . our study showed that lus is an excellent monitoring tool for patients with covid- , especially critically ill patients. first, all patients had confirmed sars-cov- infection before admission, and the role of bedside lus for these patients was in evaluating the severity of lung lesions rather than forming a diagnosis. second, most covid- pneumonia cases present with peripulmonary and subpleural involvement in the early stage ( ) . this pathological feature makes it easy to detect by ultrasound. these characteristics of covid- pneumonia provide an ideal application condition for lus. our study confirmed that the positive rate of bedside lus in critically ill patients with covid- was %. the crowding of b lines was observed in all patients, and consolidation in a variety of patterns were observed in most patients. in this study, we used semiquantitative ultrasound scores to represent the involvement of both lungs. at present, there is no uniform standard of lus scores for adult applications. the chest wall has been divided into points (blue protocol), zones, zones, zones, or zones in different studies on the basis of the specific circumstances ( , ( ) ( ) . the blue protocol only selects six points to represent the condition of both lungs, which will miss many lesions. the -zone protocol is too complicated for bedside application. in our study, all patients were critically ill, and it was difficult to change their position for lus examination of the back. therefore, we chose the -zone protocol recommended for critical patients by the world interactive network focused on critical ultrasound (winfocus). it was interesting that there was a good linear correlation between the lus scores based on the -zone protocol and the ct scores based on the -lung-lobe protocol. although the lus results are related to the degree of aeration of the lung's outer and subpleural layers and are completely different from the chest ct results, they can also effectively reflect the condition of lung involvement. our study indicated that the more severe the lung damage was, the more accurate the lus scores. this result was mainly related to the pathological characteristics of severe covid- pneumonia-diffuse distribution of lesions and extensive peripheral involvement. the more severe the lung lesion, the more likely it is to involve the surrounding areas, and the less likely it is to be missed by ultrasound evaluation. further roc analysis showed that lus scores higher than . points could effectively distinguish critical-type patients from severe-type patients. in addition, we found the clinical diagnosis of critical-type usually lagged behind lus findings. in cases of severe-type patients, they did not have critical clinical symptoms while their lus scores were higher than . points. there were cases of them suddenly deteriorated into critical-type within days. the high lus score was valuable for early warning of critical-type patients. bedside lus has a significant advantage over gold-standard chest ct for convenient patient follow-up. ultrasound has no radiation, and the examination can be performed anytime and anywhere. more importantly, lus follow-up does not necessitate the transport of the patient or a change in the patient's body position, which can ensure the safety of critically ill patients. however, the accuracy of ultrasonic follow-up in covid- pneumonia has not been reported. our results showed that the follow-up of lus and chest ct had different reliability in patients with different clinical outcomes. there was a high consistency between lus and ct in the diagnosis of lesion progression (kappa values . ), though there was moderate and poor consistency in the diagnoses of lesion improvement and no change (kappa values were . and . , respectively). in some patients whose clinical symptoms were significantly improved after active treatment, although the density of the lesion was reduced on ct, the scope of the lesion was not significantly changed in the short time period. therefore, lus scores may not be sensitive enough to detect these subtle improvements. this study indicated that lus scores were more accurate in suggesting disease progression than in measuring improvement and stabilization. an increase of points in the lus scores had a high sensitivity and specificity to predict the progression of lung lesions. whereas our study shows the advantages of bedside lus, it must be acknowledged that our research may have some limitations. first, it should be recognized that lus is a surface imaging technique, it owes its accuracy to the fact that nearly all lung pathologies relevant to the critically ill have a peripheral manifestation [ ] . covid- is a highly contagious disease, and its treatment has been coordinated by the government. the patients transferred to our hospital usually were in a more serious condition than other patients with covid- . the more severe the pneumonia was, the more accurate the lus evaluation. the inclusion of a larger number of critically ill patients might affect the representativeness of a study with a less seriously ill patient population. second, the lus examinations were all performed in the supine position, and it was difficult to change the position of critical patients, which would certainly lead to the lesions located in the posterior lung being missed. third, to verify the consistency of lus and ct in follow-up, we only analyzed the patients who underwent ct follow-up, which could not reflect the follow-up effect of lus in the whole population over the whole course of the disease. in conclusion, our scoring system allows the more quantitative use of lus findings and provides promising applications in critically ill patients with covid- . the lus scores were well correlated with the ct findings and could effectively distinguish critical-type patients from severe-type patients. the follow-up of lus and chest ct had high consistency in patients with progressive disease. bedside lus has the potential to become a reliable tool for dynamic lung monitoring in intensive care and to play 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with covid- : a simple, quantitative, reproducible method potential harmful effects of discontinuing ace-inhibitors and arbs in covid- patients lung ultrasound in the icu: from diagnostic instrument to respiratory monitoring tool imaging and clinical features of patients with novel coronavirus sars-cov- blue-protocol and falls-protocol: two applications of lung ultrasound in the critically ill accuracy of several lung ultrasound methods for the diagnosis of acute heart failure in the ed: a multicenter prospective study key: cord- - g nue s authors: kirkpatrick, andrew w.; mckee, jessica l. title: re: “proposal for international standardization of the use of lung ultrasound for patients with covid‐ : a simple, quantitative, reproducible method”—could telementoring of lung ultrasound reduce health care provider risks, especially for paucisymptomatic home‐isolating patients? date: - - journal: j ultrasound med doi: . /jum. sha: doc_id: cord_uid: g nue s nan to the editor: we pay tribute to the efforts of dr soldati and colleagues, both for their front-line clinical care and in also making the extra efforts to study the potentially invaluable technique of point-of-care lung ultrasound (lus), and especially their efforts to standardize and warehouse data to aid in research. the authors duly note that lus could be used in a variety of global settings, including low-and middle-income countries, as well as during multiple times of disease progression, including the paucisymptomatic phase of coronavirus disease (covid- ) pneumonia. we repeat our admiration of our colleagues, who took such great personal risks to obtain the ultrasound (us) images required to permit the development and subsequent validation of the lus scoring system proposed by the authors. more than other imaging modalities, point-of-care us involves a return to the bedside by health care providers, who are more often becoming sick themselves. for infection control, the authors recommend that wireless us transducers wrapped in single-use plastic covers be used to physically contact the patient, although the smart device connected to the wireless us was often in proximity to the patient as well. we note that to actually conduct the examinations, one or even two health care providers were physically next to the patient. it was suggested that if one of these providers could be "distanced" from the patient, while controlling image acquisition, that this would reduce the operator dependence of us. we would humbly like to extend the authors' suggestions to propose that with current off-the-shelf informatics, both health care providers could potentially be physically isolated from the patient, thus reducing the exposure risk for any particular us examination to zero. this concept is most applicable to the majority of covid- -positive and potentially exposed patients, who will not develop severe respiratory failure requiring hospitalization and life support. as the authors note, lus is easily able to detect interstitial lung disease, subpleural consolidations, and acute respiratory distress from any etiologic cause; thus in those with preexisting lung disease, the examination may be less useful in detecting early changes warning of worsening covid pneumonia than in a young, previously healthy patient with completely normal lungs to begin with. for more than years, we have confirmed that us-naïve nonphysicians can be remotely mentored by experts to obtain diagnostic-quality images , that can be remotely interpreted, using a treatment paradigm originally devised to support medical care in low earth orbit. early chest computed tomography has been recommended for early detection of suspected covid- pneumonia, with better sensitivity than a polymerase chain reaction. however, this is clearly impossible for home-isolated patients wondering whether to self-triage into the formal medical system. however, lus may have comparable results to chest computed tomography with markedly reduced logistic challenges. we thus propose that most at-risk but otherwise well paucisymptomatic potential patients could have their screening augmented through remotely telementored lus, following the standardized protocols and scores outlined by soldati and colleagues. on the basis of previous studies, we believe that any other intelligent family member could be mentored to obtain interpretable images. in the case of a self-isolated individual with no family, a self-mentored examination would also be feasible, although in terms of technique, we would suggest that any mentored self-assessment begin from landmark (excluding the back), as it would be unreasonable to expect average humans to be able to hold a transducer to their back. finally, we declare that dedicated research examining the practicalities of mentored home lus self-assessment be urgently studied, which we are planning to do. in a world in which health care providers seem to be inordinately at risk and with a potential crisis in personal protective equipment availability, anything else seems irresponsible. proposal for international standardization of the use of lung ultrasound for patients with covid- : a simple, quantitative, reproducible method the feasibility of nurse practitioner-performed, telementored lung telesonography with remote physician guidance: "a remote virtual mentor just-in-time costeffective off-the-shelf remote telementoring of paramedical personnel in bedside lung sonography: a technical case study fast at mach : clinical ultrasound aboard the international space station sensitivity of chest ct for covid- : comparison to rt-pcr. radiology chinese critical care ultrasound study group. findings of lung ultrasonography of novel corona virus pneumonia during the - epidemic key: cord- - h w ty authors: yun, debo; cui, yan; geng, yuan; yang, yujiao title: use of lung ultrasound for diagnosis and monitoring of coronavirus disease pneumonia: a case report date: - - journal: sage open med case rep doi: . / x sha: doc_id: cord_uid: h w ty knowledge of lung ultrasound characteristics of coronavirus disease pneumonia might be useful for early diagnosis and clinical monitoring of patients, and lung ultrasound can help to control the spread of infection in healthcare settings. in this case report, a -year-old man with severe acute respiratory syndrome coronavirus infection was diagnosed by reverse transcription-polymerase chain reaction testing of a nasopharyngeal swab. the lung ultrasound findings for this patient were the interstitial-alveolar damage showing bilateral, diffuse pleural line abnormalities, subpleural consolidations, white lung areas and thick, irregular vertical artifacts. when the patient recovered from the severe acute respiratory syndrome coronavirus infection, lung ultrasound images showed a normal pleural line with a-lines regularly reverberating. performing lung ultrasound at the bedside minimizes the need to move the patient, thus reducing the risk of spreading infection among healthcare staff. lung ultrasound is useful for early diagnosis and evaluation of the severity of coronavirus disease pneumonia and for monitoring its progress over the course of the disease. an outbreak of the novel coronavirus disease (covid- ) that began in wuhan, china, in december , has spread in over different countries in the world. since then ( june ), the severe acute respiratory syndrome coronavirus (sars-cov- ) has caused , , people infected with , deaths (https://www.who.int/emergencies/diseases/novel-coronavirus- /situation-reports/). the sars-cov- has a coronavirus envelope, is highly infectious and can cause a variety of symptoms such as headache, dry cough, dyspnea, myalgia, fatigue and fever. , the imaging of covid- pneumonia mainly involves computed tomography (ct) and chest x-ray. the characteristic feature is a development of pneumonia that is seen as groundglass opacity in the peripheric parts of the lungs as the main finding on chest ct. several studies have shown that lus is useful for diagnosing covid- pneumonia. [ ] [ ] [ ] moreover, advantages of lus, such as reduced healthcare worker exposure to infected patients, repeatability during follow-up, lowcost and ease of application in limited-resource settings, makes lus a valuable and accessible clinical tool. a -year-old man presented to our fever clinic on february in nanchong, sichuan, china, with a dry cough, headache, asthenia and fever, which had started days previously. he denied any recent travel, but reported a history of contact with a family member from wuhan, china (who had not been diagnosed with sars-cov- infection), which was considered a high-risk area for covid- infection by the chinese health authorities at the time. the patient did not have any chronic medical problems and was a non-smoker. the physical examination revealed that body temperature of . °c, respiratory rate of breaths per minute, pulse of beats per minute, blood pressure of / mmhg, and his oxygen saturation was % in room air. the thoracic ct image (figure (a) and (b)) showed bilateral lesions, patchy, also confluent and ground glass with the mixed consolidation. blood tests showed lymphocytopenia, thrombocytopenia and high levels of lactate dehydrogenase (ldh) and other inflammatory markers. a nasopharyngeal swab sample was collected and tested for sars-cov- . the test result was positive. the patient was isolated and was provided with symptomatic support and antiviral treatment (recombinant human interferon, lopinavir/ritonavir oral solution, diammonium glycyrrhizinate injection and methylprednisolone). the ethics committee of north sichuan medical college approved this study. informed consent was obtained before the lus procedure. the lus examinations were performed using a portable device (mindray/umt- , china) with a -mhz convex probe. settings were set to penetration mode with a low center frequency and a single focus zone at the level of pleura, and compound scan technology was used in the diagnosis of consolidation. in order to reduce the exposure risk, only one emergency department (ed) physician (y.c.) entered the isolation room, observing all the standard preventive measures for respiratory, droplet and contact isolation provided by the national health commission of the people's republic of china for the covid- outbreak. the ultrasound probe was enclosed in a sterile, plastic probe cover. the patient was scanned in the supine position following the lus examination method described in a previous study. each hemithorax was divided into six regions using three longitudinal lines (parasternal, anterior and posterior axillary) and two axial lines (one above the diaphragm and the other cm above the nipples). the ultrasound device was sterilized in a dedicated area and put enclosed in a new sterile plastic bag at the end of the procedure. during the hospitalization, the patient conducted a total of four ultrasound examinations, which were first, fifth, tenth, and fifteenth days of admission, respectively. the lus was performed by the same ed physician using the same ultrasound device. the specific lus findings for this patient were the interstitial-alveolar damage showing bilateral, diffuse pleural line abnormalities, subpleural consolidations, white lung areas and thick, irregular vertical artifacts (figure (c)-(h) ). when the patient recovered from the sars-cov- infection, lus images showed a normal pleural line with a-lines regularly reverberating (figure (i) and (j) ). detailed report of lus findings at each examination are shown in table . this report describes the use of lus in a -year-old man with covid- pneumonia who was admitted to our hospital in nanchong in sichuan province in china. our hospital has a policy of performing serial lus examinations on the patients with covid- , so we performed lus on this patients with covid- and use this as a basis for a broader discussion of the benefits of lus. we believe that our study makes a significant contribution to the literature because lus is a potentially very useful clinical tool for the diagnosis and management of covid- , but it has not been recommended by the guide- the use of lus in the evaluation of a suspected covid- patient has several implications. first, lus images can be obtained instantly at bedside by one clinician, therefore reducing the number of health workers potentially exposed to the patient. currently, the use of traditional imaging, such as chest x-ray or ct scan, require that the patient to be moved to the radiology unit, potentially exposing several healthcare workers and other patients to the risk of sars-cov- infection. while using lus, the same evaluating clinician can do other essential tests such as blood tests, intravenous feeding and injections and respiratory support. this is a primary advantage of lus as sars-cov- is very contagious, and reducing exposure is the most effective way to prevent infection. second, lus can be used to perform an initial screening of lung pathology in individuals diagnosed as positive for sars-cov- infection in order to distinguish low-risk patients from high-risk patients. patients with negative lung images can wait for second-level imaging if clinically stable and, thereby, reduce the risk of nosocomial transmission. third, routine use of ct scan has certain implications especially a potential high-risk of radiation. while lus has the advantages of being easy to use, reliable, radiation-free, and it can be performed repeatedly in real time. finally, the portable devices are easier to sterilize than ct scanners and radiography equipment due to their smaller surface area. in case of a massive spread of this pandemic, traditional imaging is much more difficult to perform than lus. we therefore recommend that clinicians working in countries affected by the covid- pandemic use and further evaluate the role of lus in patients with covid- pneumonia. the lus images of patients with covid- pneumonia are quite characteristic. performing lus at the bedside minimizes the need to move patients within the hospital, thus reducing the risk of transmitting infection. lus might be useful for early detection and evaluation of severity of covid- pneumonia. table . lus images at each examination. the first day of admission (early stage of the disease) thickened pleural line with a small amount of b-line the fifth day of admission (progression stage) a large number of discrete b-lines, more visible small consolidations and areas of white lung the tenth day of admission (early recovery) confluent b-lines, less small consolidations and less areas of white lung the fifteenth day of admission (late recovery) lung ultrasound shows normal images, the bat sign and the a-lines lus: lung ultrasound. covid- assessment with bedside lung ultrasound in a population of intensive care patients treated with mechanical ventilation and ecmo relation between chest ct findings and clinical conditions of coronavirus disease (covid- ) pneumonia: a multicenter study the role of ultrasound lung artifacts in the diagnosis of respiratory diseases coronavirus disease (covid- ): role of chest ct in diagnosis and management clue: covid- lung ultrasound in emergency department frequency of abnormalities detected by point-of-care lung ultrasound in symptomatic covid- patients: systematic review and meta-analysis performance of lung ultrasound in detecting peri-operative atelectasis after general anesthesia point-of-care lung ultrasound findings in novel coronavirus disease- pneumonia: a case report and potential applications during covid- outbreak clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study correlation between chest computed tomography and lung ultrasonography in patients with coronavirus disease (covid- ) the authors would like to thank editage (www.editage.com) for english language editing. y.y. and d.y. were involved in conceptualization; y.c. and y.g. were involved in data curation; y.y. was involved in formal analysis, funding acquisition, investigation, and writing-review and editing; y.y. and y.c. were involved in project administration; and d.y. was involved in writing-original draft. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. all procedures performed in this case involving the patient were in accordance with the ethical standards of the institutional and/or national research committee and with the helsinki declaration and its later amendments or comparable ethical standards. the author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this work was supported by the project of north sichuan medical college (cby -a-yb ). informed consent was obtained from the patient included in the study. written informed consent was obtained from the patient for publication of this case report and accompanying images. yujiao yang https://orcid.org/ - - - key: cord- - emzxu authors: nouvenne, antonio; zani, marco davìd; milanese, gianluca; parise, alberto; baciarello, marco; bignami, elena giovanna; odone, anna; sverzellati, nicola; meschi, tiziana; ticinesi, andrea title: lung ultrasound in covid- pneumonia: correlations with chest ct on hospital admission date: - - journal: respiration doi: . / sha: doc_id: cord_uid: emzxu background: lung ultrasound (lus) is an accurate, safe, and cheap tool assisting in the diagnosis of several acute respiratory diseases. the diagnostic value of lus in the workup of coronavirus disease- (covid- ) in the hospital setting is still uncertain. objectives: the aim of this observational study was to explore correlations of the lus appearance of covid- -related pneumonia with ct findings. methods: twenty-six patients ( males, age ± years) urgently hospitalized for covid- pneumonia, who underwent chest ct and bedside lus on the day of admission, were enrolled in this observational study. ct images were reviewed by expert chest radiologists, who calculated a visual ct score based on extension and distribution of ground-glass opacities and consolidations. lus was performed by clinicians with certified competency in thoracic ultrasonography, blind to ct findings, following a systematic approach recommended by ultrasound guidelines. lus score was calculated according to presence, distribution, and severity of abnormalities. results: all participants had ct findings suggestive of bilateral covid- pneumonia, with an average visual scoring of ± %. lus identified different possible ­abnormalities, with bilateral distribution (average lus score ± ): focal areas of nonconfluent b lines, diffuse confluent b lines, small subpleural microconsolidations with pleural line irregularities, and large parenchymal consolidations with air bronchograms. lus score was significantly correlated with ct visual scoring (r = . , p < . ) and oxygen saturation in room air (r = − . , p < . ). conclusion: when integrated with clinical data, lus could represent a valid diagnostic aid in patients with suspect covid- pneumonia, which reflects ct findings. thoracic imaging, either with chest x-ray (cxr) or computed tomography (ct), is an essential part of the diagnostic route of coronavirus disease- in patients admitted to hospital with fever or respiratory nouvenne et al. respiration doi: . / symptoms [ ] . ground-glass opacities (ggo), local or bilateral patchy shadowing, and interstitial abnormalities are the most common alterations described in cxrs and cts [ ] . the sensitivity of ct for diagnosing covid- pneumonia is % considering the results of reverse-transcription polymerase-chain reaction (rt-pcr) tests as gold standard [ ] . despite potential lack of specificity of the covid- pneumonia-related ct findings, the specific epidemic contingency makes ct an accurate tool to stratify patients based on imaging patterns [ ] [ ] [ ] [ ] , predicting poor outcomes and the need for ventilation [ ] . however, the use of ct scanning in the context of the covid- pandemic strictly relies on local resources and expertise. bedside lung ultrasound (lus) is a widely available diagnostic tool, complementary to physical examination, that can provide a large amount of diagnostic information in several respiratory diseases and settings [ ] . in the hands of experienced clinicians, lus diagnostic accuracy for bacterial pneumonia is similar to chest ct [ , ] . the advantages of lus are more obvious in older patients with multimorbidity and restricted mobility, for whom high-quality cxr and ct scans are difficult to obtain [ ] . recently, it has been suggested that point-of-care lus can be useful for both diagnosing and monitoring covid- patients [ , ] . covid- pneumonia-related pulmonary abnormalities are often located in the subpleural regions of the lung, thus increasing the likelihood of insonation during ultrasound examinations. as reported by studies in mall case series, covid- pneumonia can be associated with multifocal b lines, bilateral subpleural consolidations, and pleural thickening [ ] [ ] [ ] , which reflect abnormalities detectable on chest ct [ ] . however, a correlation between lus and ct findings in patients urgently hospitalized for severe covid- pneumonia remains to be determined [ ] . the primary aim of this observational study was to describe lus patterns in a group of patients with severe covid- pneumonia admitted to an acute-care hospital and to explore correlations of these findings with both chest ct and clinical features. the study population included patients admitted to the internal medicine and critical subacute care unit of the university hospital of parma, italy, for suspect covid- pneumonia in march . only patients who underwent both chest ct and bedside lus within h after admission were included. critical con-ditions, need for intensive care support at the time of admission, and presence of severe cardiorespiratory illness other than covid- were considered as exclusion criteria. all patients included in the study underwent high-resolution ct (hrct) immediately before ward admission as part of the emergency department evaluation route of suspect covid- cases set at the university hospital of parma [ ] . hrcts were performed with either a -row scanner (somatom definition edge; siemens healthineers, erlangen, germany) or a -row scanner (somatom emotion; siemens healthineers). all hrct scans were performed in supine position at end inspiration without intravenous administration of contrast media. the acquisition parameters were set at - kvp on the -row scanner (automatic selection of tube voltage by carekv, siemens healthineers) and fixed at kvp on the -row scanner, reference mas, pitch . - . , and collimation . - . mm. reconstruction parameters for lung images were: slice thickness . mm, increment . - . mm, sharp reconstruction algorithm (bl or b s, respectively), and lung window (width, , hu; level, − hu). reconstruction parameters for mediastinal images were: slice thickness . mm, increment . mm, medium reconstruction algorithm (br or b s, respectively), and mediastinal window (width, hu; level, hu). images were reconstructed by advanced modeled iterative reconstruction (admire) strength on the -row scanner and filtered back projection on a -row scanner. a chest radiologist with years of experience in chest imaging retrospectively reviewed the hrct scans, and defined the presence and extent of thoracic abnormalities. notably, extent of ggo and consolidation was visually scored to the nearest % on the whole lungs. the distribution was described as follows: (a) axial distribution: predominantly peripheral (within the outer third of the lung), predominantly central, or mixed; (b) craniocaudal distribution: predominantly upper (above the carina), middle (between the carina and the right inferior pulmonary vein), or lower (below the inferior pulmonary vein) [ ] ; (c) bilateral or unilateral involvement; (d) lobar involvement was assessed over lobes (lingula was considered as a single lobe). description of the pattern was tabulated into the various hrct categories of our local covid- protocol [ ] . ct images were also classified according to the covid- reporting and data system (co-rads) score, which is based on the level of suspicion of pulmonary involvement in sars-cov- infection [ ] . within h from ward admission and ct scanning, bedside lus was performed as part of the routine diagnostic evaluation, adopted in our medical unit even before the emergence of the covid- outbreak, by an ultrasound-certified expert clinician with > years of experience in lung ultrasonography, who was blind to chest ct findings. lus was performed as a complement to physical examination, and operators wore adequate personal protective equipment. a portable ultrasound system (esaote mylab alpha tm , esaote, genova, italy) with convex . examinations were performed in compliance with expert recommendations [ ] with the patient in the sitting position, systematically scanning the front and the back side of each hemithorax. a convex probe was first used to provide a panoramic view of the pleural line and ultrasound artifacts associated with lung parenchyma status (a lines, comet-tail artifacts such as b lines, and consolidations). a linear probe was then used for a more detailed study of pleural line appearance and subpleural abnormalities. each hemithorax was split into anterior-lateral sectors and posterior sectors, and each sector was then divided into upper and lower halves using the third intercostal space as reference to obtain areas for each hemithorax according to our previously published research [ ] . images were saved using ultrasound software and reviewed by operators after the exam to avoid unnecessary prolonged contact with patients. the presence, site, and distribution of abnormalities, such as b lines, pleural line thickening or breaks, consolidations, and air bronchograms, were evaluated. abnormal findings in each scan were also graded according to the scoring system (lus score) proposed by soldati et al. [ ] ( = regular pleural line, a lines present; = indented pleural line, focal b lines; = broken pleural line, subpleural consolidations; and = white lung with or without consolidations). clinical information on each patient, including vital signs and oxygen saturation in room air at the moment of ward admission, sars-cov- testing, timing of symptom onset, and main comorbidities, was also retrieved from each clinical record. data were analyzed with stata v. (statacorp llc, college station, tx, usa). data were expressed as means ± sd or percentages. the correlation of the lus score with the ct visual score and oxygen saturation in room air was calculated with spearman correlation index. abnormalities detectable on hrct were grouped into categories, namely a first group showing either consolidations or diffuse ggo and a second group where only patchy ggo could be detected. comparison tests were used for continuous variables as appropriate: student t test for independent variables or mann-whitney u test. twenty-six patients ( males, females; mean age ± years) were included in the study. the most frequent symptoms of presentation were fever ( % of cases), cough ( %), and dyspnea ( %). on admission, the duration of symptoms was on average ± days. seventeen patients ( %) required oxygen support, including ( %) with high flows (≥ l/min). twenty-two patients were positive for sars-cov- rt-pcr on admission. the remaining patients had covid- diagnosis confirmed with rt-pcr testing later during their hospital stay. baseline clinical characteristics of the patients are summarized in table . twenty-one patients had ct findings typical of covid- pneumonia (co-rads score ), while patients had equivocal findings for pulmonary involvement of covid- (co-rads score ). the extension of parenchymal involvement, measured by visual scoring, was on average ± %. bilateral involvement was detected in % of cases, with abnormal findings involving all pulmonary lobes in % of cases. ggo, subpleural lines, fat vessel sign, and crazy paving pattern were the most frequent abnormalities (table ) . lus showed bilateral abnormalities in all patients, with an average lus score of ± . diffuse b lines, focal b lines with spared areas, and interstitial involvement with multiple subpleural microconsolidations were the most frequently detected patterns ( table ; fig. ). in % of cases, larger consolidations were also detected, and dynamic air bronchogram sign could also be documented in cases. pleural effusion of mild severity could be detected in only patient, while all other examinations revealed no pleural effusion. the lus score showed a significant positive correlation with ct visual score (r = . , p < . ) (fig. a) and a negative correlation with oxygen saturation on admission (r = - . , p < . ). no significant correlation could be found between lus score and duration of symptoms before assessment. after stratification of lus scores in groups, namely above and below average, the former showed a higher extent of hrct abnormalities than individuals whose lus scores were below average (p = . ) (fig. b) . patients with hrct depicting either consolidation or diffuse ggo showed higher lus scores than those individuals with hrcts showing only patchy ggo abnormalities (p = . ) (fig. c) . nine of patients ( %) died during hospital stay. compared with survivors, they were older (age ± vs. on hospital admission, covid- -related alveolarinterstitial pneumonia was associated with lus abnormalities reflecting chest ct alterations. the most frequent ultrasound presentations were focal areas of the interstitial syndrome (either nonconfluent or confluent b lines) with possible presence of small, multiple, subpleural consolidations and indentation of the pleural line. in some cases, overt consolidations with air bronchograms could be detected, while pleural effusion was present in only few cases. the lus score, calculated according to type, extension, and severity of ultrasound abnormalities, showed a statistically significant correlation with analogous ct severity score and oxygen saturation in room air. these findings are coherent with expert opinions and case series previously published in the literature [ ] [ ] [ ] [ ] [ ] [ ] . however, the significant correlation between ultrasound and ct scores allows to make a step forward in defining a role for lus in the clinical management of covid- pneumonia. in patients urgently admitted with respira-tory symptoms and fever, the integration of clinical and anamnestic data with lus findings could represent an important aid for diagnosis of covid- and for addressing patients to the most appropriated care path, especially in situations where ct diagnostics are not immediately available. soldati et al. [ ] recently suggested the use of lus for triaging patients with symptoms compatible with pneumonia in the prehospital setting or at the moment of first emergency department evaluation. this application of lus could be particularly useful considering that, during the pandemic peak, many covid- patients, especially if older and multimorbid, may have atypical clinical presentation and no evident history of a contact with individuals who tested positive for sars-cov- [ ] [ ] . recent data also suggest that early lus evaluation of patients with respiratory symptoms in the emergency department can result in significant changes in patient management [ ] , and this could be particularly useful in the covid- pandemic, where misdiagnoses may have relevant consequences in terms of infection spread. the use of ultraportable handheld devices could be of particular interest in this emergency setting, as recently demonstrated for interventional applications [ ] . the correlation between lus and ct visual scores in covid- supports the implementation of this technique and the design of larger, prospective studies eval- the ultrasound imaging findings of covid- pneumonia are similar to those previously described in cases of viral pneumonia of different etiology, including h n and h n influenza viruses [ ] [ ] [ ] [ ] [ ] [ ] . in that situations, lus was effectively used for the diagnosis of the acute respiratory distress syndrome, monitoring of the response to intensive care treatments, and for the detection of bacterial superinfections [ ] [ ] [ ] [ ] [ ] [ ] . such applications could also be useful in the context of covid- pneumonia [ , ] and should be carefully evaluated in future studies. notably, we observed higher lus scores in patients with consolidation or diffuse ggo abnormalities detectable on hrct than in individuals showing patchy ggo. although the findings of our study support the use of bedside lus in the evaluation of patients with suspect covid- , ultrasound should not be considered as a substitute for chest ct for several reasons. first, the correlation between the severity of ultrasound abnormalities and ct visual score was suboptimal, albeit statistically significant. this suggests that ultrasound may be less accurate than ct for the stratification of the severity of lung involvement in covid- . moreover, the false-negative and false-positive rates of lus findings in covid- pneumonia in comparison with ct have not been elucidated yet. the interobserver agreement of lus is also uncertain in covid- pneumonia, although it was demonstrated as good to excellent in several other respiratory diseases [ , ] . the limited availability of ultrasound equipment dedicated to isolated patients may also be an important barrier for the use of this technique in the context of covid- patients [ ] . we must also acknowledge that the ultrasonographic signs of covid- pneumonia can be present in other respiratory and cardiovascular diseases, including pulmonary fibrosis and congestive heart failure [ , ] . confluent or nonconfluent b lines with pleural line thickening and subpleural nodules are the key abnormalities associated with idiopathic or secondary pulmonary fibrosis [ , ] . diffuse b lines also represent a well-known index of pulmonary congestion usually responding to diuretic treatment [ , ] . the integration of the clinical and epidemiological context with ultrasound findings is therefore necessary for the differential diagnosis between covid- pneumonia and other conditions with similar ultrasonographic appearance. the detection of pleural effusion, which is rare in covid- (< % of cases according to a recent meta-analysis of ct findings [ ] ) and very frequent in congestive heart failure, may represent an important element for the formulation of a correct diagnosis. from this perspective, lus represents a technologic complement to physical examination to evaluate the diagnostic suspicion in patients with a clinical history compatible with covid- pneumonia [ , ] . this is the framework in which lus examinations were performed in the present study. lus should therefore be considered as a guide, and not a substitute, for the prescription of more consolidated diagnostic techniques, such as cxr and ct. it is also noteworthy that neither lus nor traditional imaging can be able to detect sars-cov- infection when pulmonary involvement is not present [ ] . similarly, none of these diagnostic techniques can help to distinguish viral pneumonia caused by other respiratory viruses from covid- pneumonia [ ] . thus, integration of imaging with clinical and anamnestic data is al- spearman correlation between lung ultrasound (lus) score and ct visual scoring (a). the ct visual score was significantly different (p = . ) between patients with lus score below and above the median value (b). the lus score was also significantly different (p = . ) in patients who exhibited consolidation and/ or diffuse ground-glass opacities (ggo) at chest ct versus those who had a patchy ggo pattern (c). respiration doi: . / ways mandatory to reach a correct diagnosis even in the context of a pandemic [ ] . lus could also represent a promising tool for monitoring the evolution of pulmonary involvement of covid- after baseline traditional imaging (cxr or ct). some limitations of our study should be considered. the small sample size and absence of prospective evaluation of lus during the clinical course of covid- pneumonia are the most obvious ones. lus may in fact be very useful for monitoring the evolution of pulmonary lesions following treatment [ ] . recent data also suggest that ct findings are able to predict adverse outcomes in covid- pneumonia [ ] . the small size of the present study population prevented to explore whether the extension and severity of abnormal lus findings can provide some prognostic information in covid- pneumonia. finally, the ultrasound evaluation was not performed exactly at the same time of hrct, albeit during the same day, which generates a possible bias in the correlation of both imaging techniques. however, this study represents one of the first clear demonstrations that a significant correlation between chest ct and lus exists in covid- pneumonia, supporting the use of lus for early detection and clinical management of this disease. future studies should clarify the impact of lus implementation in the clinical management of covid- in different settings, including community care, emergency department triage, intensive care units, and follow-up of recovering patients. in patients urgently hospitalized for suspect covid- pneumonia, lus is associated with distinct patterns, including focal areas of confluent or nonconfluent b lines, multiple bilateral subpleural consolidations, and pleural line indentation. these abnormalities reflect chest ct findings, and their severity correlates with chest ct visual score in a positive way. when integrated with clinical data, lus 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n ) pneumonia by chest ultrasound the value of lung ultrasound monitoring in h n acute respiratory distress syndrome lung ultrasound imaging in avian influenza a (h n ) respiratory failure lung ultrasonography for the diagnosis of patients with acute respiratory distress syndrome due to bird flu h n infection prospective application of clinician-performed lung ultrasonography during the h n influenza a pandemic: distinguishing viral from bacterial pneumonia interobserver agreement in the evaluation of b-lines using bedside ultrasound lung ultrasound in internal medicine: training and clinical practice adet study group. clinical use and barriers of thoracic ultrasound: a survey of italian pulmonologists ultrasound signs of pulmonary fibrosis in systemic sclerosis as timely indicators for chest computed tomography ultrasound of extravascular lung water: a new standard for pulmonary congestion ultrasound b-lines in the evaluation of interstitial lung disease in patients with systemic sclerosis: cut-off point definition for the presence of significant pulmonary fibrosis lung ultrasound in internal medicine efficiently drives the management of patients with heart failure and speeds up the discharge time coronavirus disease (covid- ) ct findings: a systematic review and meta-analysis the role of chest imaging in patient management during the covid- pandemic: a multinational consensus statement from the fleischner society the authors wish to thank dr. ilaria zanichelli for assistance in definition and writing of the study protocol, and dr. nicoletta cerundolo for advice in manuscript writing. the authors also thank the fondazione cariparma for the support in the implementation of bedside ultrasonography projects at the geriatric-rehabilitation department of the university hospital of parma. the study protocol was approved by the ethics committee of area vasta emilia nord, emilia-romagna region (id / / oss/aoupr). due to the retrospective design of the study, informed consent signature was waived, in compliance with the italian law. the study was conducted in accordance with the declaration of helsinki. the authors have no conflict of interest to declare. no specific funding must be reported for the present study. key: cord- - xkug authors: smargiassi, andrea; soldati, gino; borghetti, alberto; scoppettuolo, giancarlo; tamburrini, enrica; testa, antonia carla; moro, francesca; natale, luigi; larici, anna rita; buonsenso, danilo; valentini, piero; draisci, gaetano; zanfini, bruno antonio; pompili, maurizio; scambia, giovanni; lanzone, antonio; franceschi, francesco; rapaccini, gian ludovico; gasbarrini, antonio; giorgini, paolo; richeldi, luca; demi, libertario; inchingolo, riccardo title: lung ultrasonography for early management of patients with respiratory symptoms during covid- pandemic date: - - journal: j ultrasound doi: . /s - - - sha: doc_id: cord_uid: xkug covid- pandemic is representing a serious challenge to worldwide public health. lung ultrasonography (lus) has been signaled as a potential useful tool in this pandemic contest either to intercept viral pneumonia or to foster alternative paths. lus could be useful in determining early lung involvement suggestive or not of covid- pneumonia and potentially plays a role in managing decisions for hospitalization in isolation or admission in general ward. in order to face pandemic, in a period in which a large number of emergency room accesses with suspicious symptoms are expected, physicians need a standardized ultrasonographic approach, fast educational processes in order to be able to recognize both suggestive and not suggestive echographic signs and shared algorithms for lus role in early management of patients. the recent pandemic caused by sars-cov- , spreading from wuhan, china, in december is representing a serious challenge to worldwide public health and healthcare structures. the global emergency needs a unified approach to better early manage patients when, in a pandemic context, a large number of emergency room accesses are expected with a symptomatology characterized by cough, dyspnea and fever [ , ] . novel coronavirus disease (covid- ) has a very heterogeneous clinical behaviour ranging from asymptomatic cases, different degrees of flu-like symptomatology until to cases of pneumonia with possible evolution into severe respiratory failure [ , ] . lung ultrasonography (lus) has been signaled as a potential useful tool in this pandemic context in which the common and dangerous complication of covid- symptomatology is represented by viral pneumonia [ , ] . viral pneumonia by sars-cov- is characterized by alveolar exudation and damage, interstitial thickening with patchy distribution with centrifugal extension and subpleural involvement. in advanced phases also consolidations and ards histologic pattern are observed [ ] . coagulation disorders and embolic/ischemic damages on lungs may explain, at least in part, the origin of some subpleural consolidations and a severe progression of respiratory failure [ , ] . one of the characteristics of lus is to intercept alterations affecting tissue/air content in peripheral lung parenchyma [ ] [ ] [ ] [ ] . normally, peripheral airspace geometry of lung hampers ultrasound incident waves thus determining a complete back reflection. in this healthy contest ultrasound (us) images are characterized by horizontal artifacts beyond the pleural plane [ , ] . when peripheral airspace (pas) geometry of lung is subverted from any cause (tissue/air ratio is reduced), ultrasound incident waves, in relations to their wavelength, could enter acoustic channels and be trapped in acoustic microholes on pleural plane. vertical artifacts are visible in us images, resulting in the so-called sonographic interstitial syndrome (sis) indicative of a hyperdense preconsolidated state of lungs [ ] [ ] [ ] [ ] [ ] [ ] [ ] . moreover, it has been described how some characteristics of sis could be indicative either of pneumogenic primary pathology or secondary involvement, like in case of cardiogenic pulmonary edema. therefore, lus could be useful, being performed during diagnostic processes, in determining early lung involvement and potentially playing a role in managing decisions both intercepting cases of suspected covid- pneumonia and suggesting alternative diagnosis. this could foster and speed up hospitalization in general ward when applicable. a standardized ultrasonographic approach and fast educational processes are needed to have most of physicians able to recognize lus signs and to build shared algorithms for lus role in early management of patients. in our experience in performing lus in suspected covid- patients, both pocket and wireless devices [ ] than standard ultrasound machines can be used better if dedicated exclusively to covid- patients to reduce healthcare operator/patients infection. in any case maximum care for sterilization is necessary following last recommendations [ ] . lus can be performed using a standardized acquisition protocol with standardized setting conditions: using low mi, avoiding harmonic images and cosmetic filters, keeping one focal point on pleural line, avoiding saturation phenomena of pleural line and using the highest frame rate possible. for patients able to maintain the sitting position a standard sequence of evaluations (three posterior, two lateral and two anterior for each hemithorax) has been proposed in peculiar anatomic landmarks using a progressive numbering starting from right posterior basal regions. a modified acquisition protocol has been proposed in case of patients that are not able to keep the sitting position such as in critical care settings [ ] . in these cases, it might be difficult to evaluate the posterior areas, currently considered a "hot-area" for covid- pneumonia. operators should try to have a partial view of the posterior basal areas by moving patients on both lateral sides and then, continue echographic assessment from right basal region on mid-axillary line below the internipple line in supine position [ ] . a scoring system of lus findings in covid- patients has been proposed, ranging from to [ , ] . this scoring system is based on characteristics of pleural line and vertical artifacts. score : pleural line is regular. horizontal reverberant artifacts and mirror effects are present. score : pleural line has slight alterations with sporadic vertical artifacts due to alteration of pas geometry. score : pleural line has relevant alterations. progression of subversion of pas geometry causes a predominance of vertical artifacts. small subpleural consolidations can be present. score : pleural line is irregular and cobbled. white lung with or without larger consolidations may be present. in order to exploit lus as useful tool to face covid viral pneumonia, hospitals need to have most of physicians involved in covid management able to recognize us suspicious patterns. short educational programs should be performed to train physicians to standardize acquisition protocols and to recognize us patterns in patients with symptoms compatible with viral pneumonia. features that need to be identified are [ , , , ] : characteristics of pleural line: normally the pleural line is regular and smooth. the same in case of cardiogenic pulmonary edema, especially in early interstitial phase. pneumogenic pathological findings are irregularities and coarse-cobbled aspect. horizontal artifacts beyond the pleural line: conventionally called a-lines representing reverberant artifacts of pleural line. mirror effects of acoustic interfaces of structures of chest wall can be present between reverberations of pleural lines. mirror effects and reverberant artifacts of pleural line are associated to normal disposition of peripheral airspace geometry in inflated lungs. vertical artifacts beyond the pleural plane: conventionally called b-lines representing the openings of acoustic channels (shrunk and folded alveoli, water, tissue, fluids) on pleural plane due to alterations of peripheral airspace geometry by pathological conditions. white lung: completely white artifactual field beyond the pleural plane without horizontal phenomena. severe alterations of peripheral airspace geometry, with small airspaces randomly distributed. sonographic interstitial syndrome (sis): the presence of vertical artifacts or/and white lung in echographic scans. it is indicative of hyperdense pre-consolidated state of lung on its parenchymal periphery. lung consolidations: multi-shaped hypoechoic areas emerging on pleural plane. pleural effusions: intrathoracic fluid collection. the presence of alterations of pleural line and sis with patchy bilateral distribution in a symptomatic context compatible with covid- is a suspicious us pattern [ ] ; similarly, white lung with bilateral patchy distribution associated or not with small subpleural consolidations, in the same symptomatic context is highly suggestive of covid- pneumonia, but not definitively specific (fig. ) [ , , ] . sonographic interstitial syndrome with a homogeneous bilateral distribution without spared areas, pleural line smooth and regular, bright vertical artifacts with gravitational distribution, is suggestive of secondary involvement of lungs in cardiogenic pulmonary edema. moreover, large unilateral consolidations usually are not a compatible pattern as well as large pleural effusions [ ] . pneumologists, infectiologists, internists, emergency room doctors, radiologists, obstetricians/gynecologists and pediatricians might be potential targets of these educational programs. some of these specialists usually are already sonographers with long-time experience. in our hospital physicians of previously mentioned medical specialties, have been trained with a h lesson, tailored on acquisition protocol and echographic patterns. experiences of application of this program, in obstetricians/gynecological area, have been published [ , ] . lus can have a pivotal role in early management of patients admitted to the emergency room with aspecific respiratory symptoms, but suspected of covid- in pandemic contest (fever, dry cough and dyspnea). patients should undergo lus to better define subsequent management paths. in fact, in these patients, whatever will be the results of a chest x-ray (cxr), if performed, lus findings characterized by patchy bilateral sis/white lung with or without small bilateral patchy subpleural consolidations can be compatible with covid- pneumonia, although not definitively specific. patients should be kept isolated and should quickly undergo both microbiological tests (both sars-cov- swab, intended as nasal/throat samples, and rapid serologic test for igm antibodies) and high-resolution computed tomography scan of the chest (hrct) with or without administration of iodinated contrast, depending on each clinical case and according to local protocols. patients should be hospitalized in isolation if: patients could be hospitalized in general ward, according to local procedures, where a second swab will be performed, if: instead, if lus is negative or showing findings not suggestive for a diffuse pneumogenic sis, patients should be kept in isolation, because of the presence of suspected symptoms, waiting for results of microbiological tests (both nasal/ throat swab and rapid serologic tests). at least one positivity of these tests indicates hospitalization in isolation. hrct and/or contrast ct scan should be indicated in order to either rule out or rule in pulmonary lesions missed by lus, especially in case of alteration of intrapulmonary gas exchanges (pao /fio < or change of usual, for chronic respiratory patients) detected by arterial blood gas (abg) analysis. instead, if both microbiological test are negative, lus not suggestive findings could foster an alternative diagnosis in combination with abg analysis and panoramic cxr (which may add relevant information for pathologies not detectable by lus): ) lus pattern suggestive of cardiogenic sis: patients should undergo echocardiography to confirm diagnosis ) lus pattern and cxr pattern suggestive of alternative diagnosis (for example focal pneumonia, pleural effusions, mediastinal pathology, central lung consolidations etc.) with conserved intrapulmonary gas exchanges. in these cases, patients could be hospitalized in general ward, according to local procedures, where a second swab will be performed. however, as far as for the point is concerned, an alteration of intrapulmonary gas exchanges (pao /fio < or change of usual, for chronic respiratory patients) should indicate hrct and/or contrast ct scan in order to better explain the causes. again, if ct scans are suspected for viral pneumonia, patients should be hospitalized in isolation, waiting for confirmation from other microbiologic tests (second swab test and serology for igg, iga/m antibodies). figure shows the proposed algorithm to early manage patients with symptoms compatible with covid- admitted to the emergency room. pregnant women admitted to emergency room with symptomatology compatible with covid- are managed in a dedicated covid- -path, hospitalized in isolation and should immediately receive lus to define subsequent management paths. pregnant women should have a normal lus pattern, except for few rare particular cases. sometimes, in advanced time of gestation, a mild posterior bilateral basal homogenous sis is detectable for volume reduction of inferior lung lobes. therefore, if lus findings are suggestive of patchy bilateral sis with or without small bilateral patchy subpleural consolidations in a symptomatic context compatible with covid- , patients must keep isolation waiting for results of microbiological tests (both nasal/throat swab and rapid serologic tests). these lus findings are highly suggestive of covid- pneumonia, although not definitively specific. indeed, lus suggestive findings could foster therapeutic decisions [ , ] . patients need to be strictly monitored for worsening of symptoms and alteration of gas exchanges indicating icu admission and wait for confirmation from other microbiologic tests (second swab test and serology for igg, iga/m antibodies) in case of fist microbiological tests both negative. instead, if lus is not suggestive of suspicious patterns, it is important to focus on intrapulmonary gas exchanges detected by arterial blood gas (abg) analysis. if pao / fio ratio is altered in these young women (< ), patients should be however kept in isolation, because of the presence of symptoms, waiting for microbiological tests (both nasal/throat swab and rapid serologic tests): ) at least one positivity of these tests indicates hospitalization in isolations. it is very important to focus on worsening of symptoms, occurrence of relevant alteration of intrapulmonary gas exchanges (pao /fio < ) detected by arterial blood gas (abg) analysis (a second lus could show the appearance of a suggestive pattern). in these cases, icu should be considered. in this context, gas exchanges data have to be considered with the final goal to achieve higher maternal oxygen (target arterial pressure of oxygen pao > mmhg) and lower carbon dioxide levels (target arterial pressure of carbon dioxide paco - mmhg) to maintain placental perfusion and prevent fetal hypoxemia and acidosis. this is mandatory in pregnancy independently from the time of gestation [ ] . ) in case of both negative results from microbiological tests: lus could be indicative of an alternative diagnosis and a panoramic chest x-ray could add information useful to better stratify patients for alternative diagnosis not detectable by lus (mediastinal pathology, focal consolidations not reaching visceral pleura etc.), while waiting for second sars-cov- swab results and admission to obstetric general ward. in case of both lus with no signs of suspected covid- pneumonia and normal intrapulmonary gas exchanges (pao /fio > ), pregnant women undergo maternal and fetal monitoring until microbiological test results. at least one positivity requires that the patient should be kept in hospitalization in isolation. if both microbiological tests are negative and pao / fio > the patient might be isolated at home and kept in contact either in case of worsening symptoms for hospital admission or in case of mild and stable symptoms for continuing home isolation waiting for the results of second sars-cov- swab test. figure shows the proposed algorithm to early manage pregnant patients with symptoms compatible with covid- , admitted to the obstetric emergency room. the role of lus for pediatric patients has been already widely reported in literature [ ] [ ] [ ] . in case of pediatric patients admitted to emergency room with symptomatology suspected for covid- , lus should be early performed. as for pregnant woman, pediatric patients in basal conditions should have a normal lus pattern. therefore, a lus pattern suggestive for pulmonary involvement in patients with symptomatology compatible with covid- in a pandemic context, is highly indicative of viral pneumonia. patients should be kept hospitalized in isolation and strictly followed while waiting for results of microbiological tests (both nasal/throat swab and rapid serologic tests). instead, if lus is not suggestive of suspicious patterns, it is important to focus on oxygen peripheral hemoglobin saturation (spo ). in presence of spo ≤ % or of need for o therapy, patients should be kept in isolation waiting for microbiological tests results: ) at least one positivity of these tests indicates hospitalization in isolations. in case of worsening of symptoms or of gas exchanges with spo < % (a second lus could show the appearance of a suggestive pattern), admission to pediatric icu (picu) and hrct should be considered according to local protocols. ) in case of both negative results from microbiological tests: lus could be indicative of an alternative diagnosis and a panoramic chest x-ray could add information useful to better stratify patients for alternative diagnosis not detectable by lus, while waiting for second sars-cov- swab results and admission to pediatric general ward. the last clinical scenario is the one in which first lus pattern is not compatible with covid- pneumonia and there are normal values of spo . according to local protocols patients should undergo microbiological tests and could be isolated at home or hospitalized waiting for results. figure shows the proposed algorithm to manage pediatric patients with symptoms compatible with covid- , admitted to the pediatric emergency room. this paper aims to identify a role for lus for early management of patients with symptoms suspected for covid- admitted to emergency room in a pandemic context. moreover, it tries to invite the medical community, operating in different specializations, to perform lus with a standardized approach. being able to recognize lus patterns suggestive or not suggestive of covid- pneumonia can be fig. a proposed algorithm to early manage pregnant patients with symptoms compatible with covid- , admitted to the obstetric emergency room very useful and simplify diagnostic processes. proposals of management algorithms are also reported to ameliorate daily clinical practice in a period of huge difficulties for healthcare workers in emergency department to face patients with suggestive but aspecific symptoms. finally, we encourage also operators to collect echographic videos and images from covid- patients and upload to a protected internationally available database allowing both the development and testing performances of automated algorithms dedicated to patterns recognition [ ] . we invite our colleagues to link to our website (https ://iclus -web.bluet ensor .ai/ to upload images and videos to the database, to attend teaching 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examinations in the time of covid- deep learning for classification and localization of covid- markers in point-of-care lung ultrasound authors' contributions all authors contributed to study conception and design. the first draft of the manuscript was written by andrea smargiassi and all authors commented on previous versions of the manuscript. authors give all permissions to journal of ultrasound to publish this work. all authors read and approved the final manuscript funding not applicable. code availability not applicable.ethics approval not applicable for review papers. none of the authors has to disclose conflicts of interest in relation to this work.