Chronic pancreatitis is a fibroinflammatory syndrome of the pancreas with a prevalence in children of approximately six per 100,000. Diagnosis of chronic pancreatitis in a child depends on the presence of imaging findings of chronic pancreatitis in the context of specific clinical features. Currently, a standardized reporting system for imaging findings of chronic pancreatitis in children is lacking, and imaging-based thresholds for abnormality have not been defined. Standardized reporting elements were defined for adults in 2019. Not all of the adult criteria are directly applicable to children due to changes in the pancreas with normal growth and development. To address the lack of accepted pediatric chronic pancreatitis reporting standards and encourage standardized communication of imaging findings, we convened a group of experienced pediatric radiologists and pediatric gastroenterologists with expertise in pancreatology and interventional endoscopy to define consensus reporting elements and interpretive criteria for findings of pediatric chronic pancreatitis. On the basis of the existing literature and panel opinion and leveraging a modified Delphi approach, we propose reporting standards for CT, MRI, and MRCP of pediatric chronic pancreatitis.

Kaposiform hemangioendothelioma (KHE) is a rare vascular tumor that typically presents in infancy and may be associated with the Kasabach-Merritt phenomenon (KMP). We present a challenging case of multifocal KHE on the leg of an infant, initially suspected at birth to be a reticulate port wine birthmark. Skin biopsy and imaging supported the rare diagnosis of multifocal KHE. Complicated by KMP, he was started on sirolimus monotherapy with significant improvement in his widespread disease.

Imaging plays an important role in the diagnosis and follow-up of children with acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP). Consensus is lacking for a minimum MRI protocol for the child with known or suspected ARP or CP. Lack of standardization contributes to variable diagnostic performance and hampers application of uniform interpretive criteria for clinical diagnosis and multicenter research studies. We convened a working group to achieve consensus for a minimum MRI protocol for children with suspected ARP or CP. The group included eight pediatric radiologists experienced in interpreting MRI for pediatric pancreatitis and one medical pancreatologist and functioned from November 2022 to March 2023. Existing clinical protocols were summarized across sites represented by group members, and commonly used sequences guided the group's discussion. The final consensus minimum MRI protocol includes five noncontrast sequences and two postcontrast sequences (which are required only in select clinical scenarios). The working group also provides recommended acquisition parameters, sequence-specific technical suggestions, and general recommendations for optimal imaging technique. We recommend that all sites imaging children with ARP and CP for clinical care, and particularly those engaged in cooperative group trials for pancreatitis, ensure that their local protocol includes these minimum sequences.

BACKGROUND. Imaging findings represent key criteria for diagnosing chronic pancreatitis in children. Understanding radiologists' agreement for imaging findings is critical to standardizing and optimizing diagnostic criteria. OBJECTIVE. The purpose of this study is to evaluate the interobserver agreement among experienced pediatric radiologists for subjective, quantitative, and semiquantitative imaging findings of chronic pancreatitis in children. METHODS. In this retrospective study, CT or MRI examinations performed in children with chronic pancreatitis were submitted by six sites participating in the INSPPIRE (International Study Group of Pediatric Pancreatitis: In Search for a Cure) Consortium. One pediatric radiologist from each of the six sites reviewed examinations; three of the radiologists independently reviewed all CT examinations, and the other three radiologists independently reviewed all MRI examinations. Reviewers recorded 13 categoric imaging findings of chronic pancreatitis and measured pancreas thickness and pancreatic duct diameter. Agreement was assessed using kappa coefficients for the categoric variables and intraclass correlation coefficients (ICCs) for the continuous variables. RESULTS. A total of 76 CT and 80 MRI examinations performed in 110 children (65 girls and 45 boys; mean age, 11.3 +/- 4.6 [SD] years) were reviewed. For CT, kappa coefficients for categoric findings ranged from -0.01 to 0.81, with relatively high kappa coefficients noted for parenchymal calcifications (kappa = 0.81), main pancreatic duct dilatation (kappa = 0.63), and atrophy (kappa = 0.52). ICCs for parenchymal thickness measurements ranged from 0.57 in the pancreas head to 0.80 in the body and tail. The ICC for duct diameter was 0.85. For MRI, kappa coefficients for categoric findings ranged from - 0.01 to 0.74, with relatively high kappa coefficients noted for main duct irregularity (kappa = 0.74), side branch dilatation (kappa = 0.70), number of dilated side branches (kappa = 0.65), and main duct dilatation (kappa = 0.64); kappa coefficient for atrophy was 0.52. ICCs for parenchymal thickness measurements ranged from 0.53 for the neck and body individually to 0.68 in the tail. ICC for duct diameter was 0.77. CONCLUSION. Interobserver agreement was fair to moderate for most CT and MRI findings of chronic pancreatitis in children. CLINICAL IMPACT. This study highlights challenges for the imaging diagnosis of pediatric chronic pancreatitis. Standardized and/or objective criteria are needed given the importance of imaging in diagnosis.

Capillary malformation-arteriovenous malformation (CM-AVM) syndrome is an autosomal dominant condition characterized by multifocal, noncontiguous pink patches on the skin that often have a surrounding pale halo. In some cases, an association with a fast flow, arteriovenous malformation (AVM) can be identified. Here, we describe a case report of a 16-year-old woman with CM-AVM syndrome and significant cardiac compromise successfully treated with trametinib, a mitogen-activated protein kinase (MEK) inhibitor.

While still uncommon, the incidence of acute pancreatitis in children has been increasing over the last two decades. The Atlanta classification for acute pancreatitis, developed for adults, stratifies cases of acute pancreatitis based on imaging and clinical criteria. This classification scheme allows for standardized use of terminology to facilitate treatment and prognostication. Although US and CT should be used in critical or unstable patients, MRI is an ideal imaging modality in pediatric patients with acute pancreatitis because of its ability to characterize tissue without ionizing radiation. We review MRI examples specific to Atlanta classification terminology in pediatric patients. Chronic pancreatitis has also been increasingly diagnosed in children, and imaging plays a key role in the diagnosis and management of this insidious disease. MRI with magnetic resonance cholangiopancreatography is the optimal modality for assessing the pancreas in a child with known or suspected chronic pancreatitis because it provides tissue characterization and high-contrast imaging of the pancreatic duct without the use of invasive instrumentation or ionizing radiation. We also review and demonstrate accepted MRI findings of chronic pancreatitis.

Pancreatitis is as common in children as it is in adults, though causes and accepted imaging strategies differ in children. In this narrative review we discuss the epidemiology of childhood pancreatitis and key imaging features for pediatric acute, acute recurrent, and chronic pancreatitis. We rely heavily on our collective experience in discussing advantages and disadvantages of different imaging modalities; practical tips for optimization of ultrasound, CT, and MRI with MRCP in children; and image interpretation pearls. Challenges and considerations unique to imaging pediatric pancreatitis are discussed, including timing of imaging, role of secretin-enhanced MRCP, utility of urgent MRI, severity prediction, autoimmune pancreatitis, and best methods for serial imaging. We suggest a methodical approach to pancreatic MRI interpretation in children and have included a sample structured report, and we provide consensus statements according to our experience imaging children with pancreatitis.

A 7-year-old female presented to our university children's emergency department with 3 weeks of right shoulder pain, worse after falling from a bunk bed at summer camp 2 days before. Three weeks earlier, her brother accidentally shot a pistol crossbow bolt that grazed her right lateral chest. At that time, she had no immediate symptoms apart from a bleeding laceration. After evaluation in the clinic for shoulder pain, she was diagnosed with muscle strain and resumed activities, including sports. In our emergency department (ED), examination revealed normal vital signs, right shoulder pain on abduction, and a well-healed 2 cm thoracic laceration. X-rays and computed tomography imaging identified a 10 cm bolt fully embedded in her chest (Figures 1-4). Missed penetrating thoracic trauma. Although trauma is the leading cause of mortality in children, penetrating chest trauma is uncommon. This case was unique in its mild initial symptoms, potential for life-threatening consequences, and remarkably delayed presentation. Delayed diagnosis of injury in pediatric trauma increases the risk of morbidity and mortality.1 Thoracic walls in children are notably compliant, making serious intrathoracic trauma possible without obvious external injury.2 Although arrow injuries are infrequent, pistol crossbows are easily accessible and easy to use with little training.3, 4 Crossbow bolts have high penetration force that can cause little to no surface lacerations or crushing defects.5 The head of this bolt was a field point, a tip widely used for target practice or hunting small game that can cause circular or slit-like external defects, as in our patient. In contrast, broadhead tips can cause more obvious radiating incisions owing to their multisided blades.6 Physicians must fully evaluate suspicious penetrating trauma, even with minimal surface abnormalities. Our patient was admitted to trauma surgery. Fortunately, the bolt was removed without complications under fluoroscopic guidance, and she has continued to do well.

We present a 9-day-old girl with multifocal cutaneous and hepatic infantile hemangiomas as well as a hepatic rapidly involuting congenital hemangioma. These two distinct vascular tumors have rarely been reported to co-occur. We additionally review the sonographic features that distinguish a hepatic congenital hemangioma from the hepatic infantile hemangioma.

Background Skull fractures are commonly seen after both accidental and nonaccidental head injuries in young children. A history of recent trauma may be lacking in either an accidental or nonaccidental head injury event. Furthermore, skull fractures do not offer an indication of the stage of healing on radiologic studies because they do not heal with callus formation as seen with long bone fractures. Thus, a better understanding on the timing of skull fracture resolution may provide guidance on the medical evaluation for accidental or nonaccidental head injury. Objective The aim of the study was to determine the time required for radiographic skull fracture resolution in children younger than 24 months. Methods This was a retrospective observational analysis of children younger than 24 months referred with skull fractures between January 2008 and December 2012. Analysis included children with accidental head injuries with a known time interval since injury and a negative skeletal survey who underwent serial radiographic studies. Complete healing of a skull fracture was defined as resolution of fracture lucency by radiograph. Results Of the 26 children who met inclusion criteria, 11 (42.3%) demonstrated resolution of skull fracture(s) on follow-up imaging. Fracture resolution on radiologic studies ranged from 2 to 18 weeks. Twelve fractures in 10 children demonstrated fracture resolution at 10 or more weeks after injury. Conclusions Healing or resolution of a skull fracture can take months in children younger than 24 months. With the high variability in skull fracture presentation and large window to fracture resolution, unexplained or multiple skull fractures in children younger than 24 months may be the result of a single or multiple events of head trauma.

Fibrous hamartoma of infancy (FHI) is a benign, poorly demarcated, unencapsulated hamartoma contiguous with surrounding fat. This case highlights pronounced bony remodeling and muscle atrophy associated with FHI in a 6-week-old girl. Emphasis is placed on pathologic diagnosis and mechanisms, treatment considerations, and the multidisciplinary approach utilized in the management of the disorder.

Arthritis & RheumatologyVolume 72, Issue 2 p. 315-315 Clinical Image Teenaged Boy With Lipoma Arborescens of the Knee and Elbow and Presumed Juvenile Idiopathic Arthritis Cody S. Dail, Cody S. Dail University of Minnesota Medical School, Minneapolis, MNSearch for more papers by this authorKelly R. Dietz, Kelly R. Dietz orcid.org/0000-0003-3670-2912 University of Minnesota Medical School, Minneapolis, MNSearch for more papers by this authorMichael A. Murati, Michael A. Murati orcid.org/0000-0002-2943-7084 University of Minnesota Medical School, Minneapolis, MNSearch for more papers by this authorColleen K. Correll, Colleen K. Correll orcid.org/0000-0002-5451-1936 University of Minnesota Medical School, Minneapolis, MNSearch for more papers by this author Cody S. Dail, Cody S. Dail University of Minnesota Medical School, Minneapolis, MNSearch for more papers by this authorKelly R. Dietz, Kelly R. Dietz orcid.org/0000-0003-3670-2912 University of Minnesota Medical School, Minneapolis, MNSearch for more papers by this authorMichael A. Murati, Michael A. Murati orcid.org/0000-0002-2943-7084 University of Minnesota Medical School, Minneapolis, MNSearch for more papers by this authorColleen K. Correll, Colleen K. Correll orcid.org/0000-0002-5451-1936 University of Minnesota Medical School, Minneapolis, MNSearch for more papers by this author First published: 14 November 2019 https://doi.org/10.1002/art.41167Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume72, Issue2February 2020Pages 315-315 RelatedInformation

Visual disturbances are an uncommon pediatric chief complaint. Usually, after a complete ocular exam including visual acuity, most causes are benign and not life-threatening. Children with abnormal visual complaints who have underlying medical conditions, such as SLE or other autoimmune conditions, a recipient of a transplant, renal disease, and even eclampsia require closer scrutiny. We report a 10-year-old female with a history of systemic lupus erythematosus complicated by hypertension and cardiomyopathy secondary to lupus who presented to the emergency department with a history of vision loss and headache. Head computer tomography demonstrated findings of posterior reversible encephalopathy syndrome (PRES). PRES is a clinical disease associated with cranial radiological findings of heterogenous etiologies that is often reversible. Prompt recognition and treatment are important in preventing permanent damage, long term morbidity and even death.

This study was intended to establish normal values for velocities in the hepatic artery and portal veins in pediatric patients after total pancreatectomy and islet autotransplantation (TPIAT).

Insulin pumps are common in the management of type 1 diabetes (T1D). We report two cases of metal insulin infusion set needles which broke off the tubing and remained embedded in the soft tissue of two boys with T1D (five needles in one case, and one needle in the other). The patient with five retained needles was asymptomatic and had a normal physical examination, and the missing needles were only detected using pelvic X-ray; the second patient had only mild discomfort. While these are the first such cases reported in the medical literature, there may be other cases which have gone unnoticed, suggesting the potential need to explore the safety of this product further.

Objectives:Fear of diabetes and major surgery may prohibit referral of young children severely affected by pancreatitis for total pancreatectomy with islet autotransplant (TPIAT). We evaluated outcomes in our youngest TPIAT recipients, 3 to 8 years of age at surgery.Methods:Medical records were reviewed for 17 children (9 girls) ages 8 years or younger undergoing TPIAT from 2000 to 2014. Most (14/17) had genetic risk factors for pancreatitis. Since 2006, TPIAT recipients were followed prospectively with health questionnaires including assessments of pain and narcotic use, and scheduled hemoglobin A1c (HbA1c) and mixed-meal tolerance tests (6 mL/kg Boost HP) before surgery, and at regular intervals after. Patients are 1 to 11 years post-TPIAT (median 2.2 years). Data are reported as median (25th, 75th percentile).Results:All had relief of pain, with all 17 patients off narcotics at most recent follow-up. Hospitalization rates decreased from 5.0 hospitalization episodes per person-year of follow-up before TPIAT, to 0.35 episodes per person-year of follow-up after TPIAT. Fourteen (82%) discontinued insulin, higher than the observed insulin independence rate of 41% in 399 patients older than 8 years of age undergoing TPIAT over the same interval (P=0.004). Median post-TPIAT HbA1c was 5.9% (5.6%, 6.3%), and within patient post-TPIAT mean HbA1c was 6.5% for all but 2 patients.Conclusions:Young children with severe refractory chronic pancreatitis may be good candidates for TPIAT, with high rates of pain relief and insulin independence, and excellent glycemic control in the majority.

Proceedings: AACR 102nd Annual Meeting 2011‐‐ Apr 2‐6, 2011; Orlando, FL Major and minor congenital anomalies are found more often in children with cancer than in those without. Rib abnormalities (RAs) are common anomalies which have been associated with childhood cancer in three studies; however the studies differed in the specific type of RAs (abnormal rib number or cervical ribs) implicated. This study sought to clarify the literature using the clinical population of the University of Minnesota. Methods: RAs were assessed in a hospital based case-control study. Cases consisted of cancer patients aged 0-19 years old treated at the University of Minnesota during 2003-2009. Controls were randomly selected pediatric patients who received a chest X-ray at a community hospital during 2003-2008. Data collected from medical records were sex, ethnicity, date of birth, date of radiograph, indication for chest radiograph, and ZIP code of residence. Cancer type and date of diagnosis was also collected for cases. Two radiologists oversaw one radiology resident's evaluation of rib number, cervical, bifid, and post-surgical rib anomalies, predominantly by X-ray. Pearson's Chi-square test was used to assess categorical data differences between cases and controls. Dichotomous variables were created for normal (24) or abnormal (>24, <24) rib number and cervical ribs. Logistic regression was used to calculate the odds ratios and 95% CI adjusting for age and sex. All statistical analyses were performed using SAS® 9.2. Results: Images were available for 76.5% (478/625) of cases and 93.2% (1398/1499 = 93.2%) of controls. Of the available images, 96.0% (459/478) and 81.2% (1135/1398) were evaluable. There were significant differences between childhood cancer cases and controls for age at imaging (cases =5.57 years, controls = 9.45 years, p<0.0001), residence within the state of Minnesota (controls = 97.9% and cases = 67.4% were residents, p<0.0001). Gender was not significantly different (cases = 56.4% male, controls =59.7%, p=0.23). Data on ethnicity was missing in over 20% of controls and 50% of cases and was not included in the analysis. There was a significant difference in the number of abnormal ribs in cases versus controls after controlling for age and sex (OR = 1.66 (95%CI 1.00, 2.74), p=0.05). The presence of cervical ribs was not significantly associated with overall childhood cancer (p-value = 0.38). Collectively renal tumors had a significantly increased number of abnormal ribs (OR = 4.15 (95%CI 1.17, 14.80) p-value = 0.03). Conclusions: The results of this study support previous reports that there is an association of RAs with childhood cancer. Children with renal malignancies had a significantly higher prevalence of RAs. There was no association between childhood cancer and cervical ribs. Further research is warranted to investigate the significance of the association of RAs and childhood cancer. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 873. doi:10.1158/1538-7445.AM2011-873