Incidental Radiological Finding Research Articles

Oncology Capture of ED Patients with Incidental Radiologic Findings

Oncology Capture of ED Patients with Incidental Radiologic Findings

Catching Those Who Fall Through the Cracks: Integrating a Follow-Up Process for Emergency Department Patients with Incidental Radiologic Findings

Abnormal findings unrelated to the indication for testing are identified on emergency department (ED) imaging studies. We report the design and implementation of an electronic health record-based interdisciplinary referral system and our experience from the first 13 months of ensuring that patients with incidental radiology findings were connected with the appropriate outpatient surveillance. Our informatics team standardized the contemporaneous reporting of critical radiology alerts using our ED trackboard and created a companion follow-up request form for the treating ED clinicians to complete. The forms were routed to nurse case managers, who arranged follow-ups based on the findings and clinical significance. The primary outcome was the proportion of ED patient visits with identified incidental findings that had documented communication of the incidental findings and surveillance plans. Over the first 13 months after implementation, 932 ED patient visits had critical radiology alert referrals, for a total of 982 incidental findings. The primary outcome (confirmed post-ED communication and documented follow-up plan) was attained in 888 (95.3%, 95% confidence interval [CI] 93.9% to 96.6%) ED patient visits with confirmed post-ED communication and documented follow-up plans. The team was unable to contact or confirm follow-up with 44 (4.7%, 95% CI 3.4 to 6.1) patients by telephone or through the health care system's electronic communication tools. We report the implementation of a standardized notification and referral system for ED patients with incidental radiology findings. The development of a reliable notification and follow-up system is an important patient safety intervention given the opportunity to potentially identify undiagnosed malignancies.

CT KUB evaluation of suspected urolithiasis

Introduction: Non-contrasted computed tomography scan for kidney, ureter, and bladder (CT KUB) for diagnosis of urolithiasis is important for accurate diagnosis, followup, and management. Unlike USG, CT KUB has more diagnostic yield in urolithiasis and other incidental findings. This study aims to evaluate the use of the CT KUB in suspected urolithiasis, presented with severe flank pain.
 Method: A retrospective observational study was carried out in the Department of Radiology and Imaging, Patan Hospital, Nepal.TheCT KUB reports of patients with suspected urolithiasis from a period of 3 years from Jan 2017 to Jan 2020 were analyzed for evidence of urolithiasis and secondary signs of obstruction as ‘diagnostic’ of CT KUB. Other incidental radiological findings were further analysed and categorized into urinary and extra-urinary. Ethical approval was obtained.Association of USG and CT KUBwas analysed using Chi-square test,with p value<0.05considered statistically significant.
 Result: Total of 414 CT KUB reports were analysed, 230(55.6%) males, 314 patients had USG before CT KUB. Considering CT KUB as a gold standard for diagnois of urolithiasis, the accuracy of ultrasound was found to be 85.03% and sensitivity is 94.09% and specificity of 27.9%.
 Conclusion: Majority of the patients included in the study had ultrasound done before CT KUB. The sensitivity of ultrasound was significant considering CT KUB as a gold standard in diagnosis of urolithaisis.

Incidental findings on single-photon emission computed tomography/computed tomography (SPECT/CT) lymphoscintigraphy in breast cancer: the proposed Westmead SPECT/CT incidental findings classification.

BackgroundThe aim of this study is to determine the prevalence of incidental radiological findings detected on SPECT/CT performed as part of pre‐operative lymphoscintigraphy for sentinel lymph node biopsy (SLNB) in patients undergoing breast cancer surgery and development of a modified classification to workup these lesions.MethodsA retrospective audit was performed of all SPECT/CT performed in combination with lymphoscintigrams in breast cancer patients presenting with clinically node negative axillae and operated on by breast surgeons at the Westmead Breast Cancer Institute over a 12‐month period.ResultsFour hundred and nineteen patients were included in the study. In 149 patients (35.6%), there was a total of 205 incidental findings. The most common findings were, pulmonary abnormalities (38.5%), abdominal findings (27.8%), thyroid nodules (14.6%), cardiac abnormalities (10.7%) and others (8.3%). Using our proposed Westmead SPECT/CT incidental findings (WSIF) classification, 7.8% were known, 17.6% were major findings, 48.3% were minor findings, 15.1% were minimal findings and 11.2% were equivocal findings. 17.6% (n = 36) underwent further workup and investigation and 3.4% of patients (n = 5) required therapeutic intervention, including chemotherapy for primary lung cancer(n = 1) and surgeries (thoracotomy, n = 1; thyroidectomy, n = 2; colonoscopy, n = 1). 93.8% (n = 393) had at least one SLN mapped, most commonly located in Level 1 of the axilla.ConclusionThe incidental findings on SPECT/CT in combination with lymphoscintigraphy is within the range of previous studies (27.3–59.5%). A small proportion of patients required significant major interventions (3.4%). We propose that all incidental findings should be assessed according to our WSIF classification to aid in triaging need for further investigation and management.

Contemporary narrative review: a clinically oriented interpretation of incidental radiological findings for common cardiovascular computed tomography scans

Contemporary narrative review: a clinically oriented interpretation of incidental radiological findings for common cardiovascular computed tomography scans

Central hypothyroidism related to antipsychotic and antidepressant medications: an observational study and literature review.

ObjectiveTo investigate the final diagnosis and clinical outcome of patients referred to endocrinology in our district general hospital with biochemical isolated central hypothyroidism (CeH), and whether there is an association between this biochemical picture and treatment with antidepressant and antipsychotic medications.MethodsWe performed a retrospective observational study of patients referred to endocrinology with unexplained biochemical isolated CeH over a 5-year period.ResultsOf the 29 patients included in the study, 4 were found to have a partially empty or empty sella and 1 to have a bulky pituitary gland which was deemed to be an incidental radiological finding. No patients had any clinically significant pathology. On reviewing their medications, 18/29 (62%) were found to be on psychotropic medications.ConclusionsOur study suggests a relationship between patients on psychotropic medications and biochemical isolated CeH, an association only described in a very limited amount of literature prior to this. The mechanism behind this may be suppression of TSH secretion via antagonism of the dopamine-serotoninergic pathway. Determining a correlation between psychotropic medications and isolated CeH could lead to the avoidance of further radiological investigations and unnecessary anxiety for patients. However, a larger observational study is needed to provide further evidence to support/refute our finding.

Incidental radiological findings suggestive of COVID-19 in asymptomatic patients.

Despite routine screening of patients for coronavirus disease 2019 (COVID-19) symptoms and signs at hospital entrances, patients may slip between the cracks and be incidentally discovered to have lung findings that could indicate COVID-19 infection on imaging obtained for other reasons. Multiple case reports and case series have been published to identify the pattern of this highly infectious disease. This article addresses the radiographic findings in different imaging modalities that may be incidentally seen in asymptomatic patients who carry COVID-19. In general, findings of COVID-19 infection may appear in computed tomography (CT), magnetic resonance imaging, positron emission tomography-CT, ultrasound, or plain X-rays that show lung or only apical or basal cuts. The identification of these characteristics by radiologists and clinicians is crucial because this would help in the early recognition of cases so that a rapid treatment protocol can be established, the immediate isolation to reduce community transmission, and the organization of close monitoring. Thus, it is important to both the patient and the physician that these findings are highlighted and reported.

Pancreatic steatosis: A frequent finding in a Chilean population

Introduction and aimsPancreatic steatosis is an incidental radiologic finding in asymptomatic patients, and its clinical importance is unclear. Primary aim: to study the prevalence of pancreatic steatosis (PS) in consecutive patients registered at our hospital, that underwent computed axial tomography (CAT) scanning of the abdomen and pelvis, excluding known pancreatic diseases. Secondary aim: to review the association of PS with the demographic and clinical data of the patients, as well as with hepatic steatosis (HS). Materials and methodsAn observational study was conducted on adult patients that had CAT scans of the abdomen and pelvis. Definitions: a) tissue density was measured in Hounsfield units (HU) in five 1 cm2 areas of the pancreas, three areas of the spleen, and in segments VI and VII of the liver; b) fatty pancreas: a difference < –10 HU between the mean pancreas and mean spleen densities; and c) fatty liver: density < 40 HU. We registered the epidemiologic and laboratory data of the patients. The association of those factors with the presence of PS was analyzed using SPSS version 24.0 software, and statistical significance was set at a p < 0.05. ResultsOf the 203 patients, PS was found in 61 (30%). The patients with PS were significantly older and had a higher body mass index. We found no significant association with the rest of the parameters studied, nor with HS (55 patients). None of the patients had symptoms attributable to a disease of the exocrine pancreas. ConclusionsFatty infiltration of the pancreas is a frequent finding in CAT scans, and its clinical importance is unclear. Aging of the population and the increase in obesity underline the need for future studies on PS.

English

Carcinoid is an uncommon tumour in ovary comprising 0.1 % of primary ovarian neoplasms and 1 % of all carcinoid tumours. It was first described by Stewart et al. in 1939 following which many case reports have come out.1They usually occur in the peri-menopausal age. Primary ovarian carcinoids are usually unilateral, but can show a cystic teratoma or mucinous neoplasm in the same or opposite ovary. Histological variants include insular, stromal, trabecular, and mucinous among which insular is the most common type, and around 30 % of them are associated with a carcinoid syndrome. Insular type is reported to be more common in western countries, whereas trabecular / stromal cases are more reported in Asian countries. Most carcinoids in ovary are diagnosed as an incidental radiological finding as an abdominal or pelvic mass or they may present with typical carcinoid syndrome - diarrhoea, flushing, bronchospasm, oedema, increase skin pigmentation, carcinoid heart disease. Another uncommon presentation is severe constipation associated with peptide YY production in the tumour. The clinical behaviour of carcinoid ranges from indolent unrecognisable to highly active metastatic secretory tumours. Carcinoid ovary being an uncommon tumour presenting in an uncommon site with varied presenting features, clinical confusion may lead to delayed diagnosis and management for patient. This case report aims to describe the clinicopathologic features of primary carcinoid ovary presenting in a female with severe constipation.

Esteatosis pancreática: hallazgo frecuente en población chilena

Introduction and aimsPancreatic steatosis is an incidental radiologic finding in asymptomatic patients, and its clinical importance is unclear. Primary aim: to study the prevalence of pancreatic steatosis (PS) in consecutive patients registered at our hospital, that underwent computed axial tomography (CAT) scanning of the abdomen and pelvis, excluding known pancreatic diseases. Secondary aim: to review the association of PS with the demographic and clinical data of the patients, as well as with hepatic steatosis (HS). Materials and methodsAn observational study was conducted on adult patients that had CAT scans of the abdomen and pelvis. Definitions: a) tissue density was measured in Hounsfield units (HU) in five 1cm2 areas of the pancreas, three areas of the spleen, and in segments VI and VII of the liver; b) fatty pancreas: a difference <–10 HU between the mean pancreas and mean spleen densities; and c) fatty liver: density <40 HU. We registered the epidemiologic and laboratory data of the patients. The association of those factors with the presence of PS was analyzed using SPSS version 24.0 software, and statistical significance was set at a p<0.05. ResultsOf the 203 patients, PS was found in 61 (30%). The patients with PS were significantly older and had a higher body mass index. We found no significant association with the rest of the parameters studied, nor with HS (55 patients). None of the patients had symptoms attributable to a disease of the exocrine pancreas. ConclusionsFatty infiltration of the pancreas is a frequent finding in CAT scans, and its clinical importance is unclear. Aging of the population and the increase in obesity underline the need for future studies on PS.

P-BN37 Audit of the Management of Gall Bladder (GB) Polyps according to European Joint Guidelines (EJG), 2017

Abstract Background Gall Bladder (GB) polyps are abnormal growths of the inner lining that project into the lumen. They are a rare incidental radiological finding, with prevalence ranging from 0.3% to 9.5%. The majority of these frequently turn out to be pseudopolyps, however, correct follow up and management is essential as to ensure that true polyps, which may be malignant or have malignant potential, are not missed. EJG on the subject, published in 2017, tried to address controversial issues including which patients require cholecystectomy, which patients require follow up and how frequently this should be. We carried out an audit assessing adherence of our center’s management of GB polyps to the EJGs. Methods Patients were identified for this retrospective ten year cohort study bv identifying patients listed under ‘International Statistical Classification of Diseases and Related Health Problems (ICD 10) code K 82.8, other specified diseases of gall bladder’ on our database. Patients with other diagnoses, such as gall bladder dysfunction were excluded after review of electronic patient record (EPR) (Sunrise, Allscripts). EPRs facilitated review of emergency attendances, clinic letters, investigations and histological results for those diagnosed with a gall bladder polyp. Analysis was performed with Microsoft Excel. Results Since publication of the guidelines, 71 patients were diagnosed with a polyp. Of these, 73% were diagnosed by general surgeons and only 36% were managed according to the guidelines. We did, however, identify a strong positive trend (0.9) in improved adherence to guidelines over time. We found that guidance was more likely to be followed if the polyp was &amp;gt;10mm versus smaller (p &amp;lt; 0.01). 18% of patients (50% of those adherent to guidelines) were booked straight for laparoscopic cholecystectomy but there was a much poorer adherence to guidance concerning surveillance of polyps. There was no statistically significant difference (p = 0.32) in adherence to guidance when comparing management by surgeons versus non-surgeons. Conclusions Adherence to EJG’s overall is poor in our cohort. The adherence has improved over time, and at 3 years post introduction is 62% compared to an average of 35%. The guidance is also best followed when laparoscopic cholecystectomy is indicated straight from diagnosis compared to patients who meet the criteria for surveillance. Initial diagnosis by a non-surgical specialty does not affect adherence to guidance. Better local education amongst junior surgical grades about GB polyps, as well as increased awareness of the EJG’s may improve adherence to guidance. Further research into risk stratification and the optimal follow up of GB polyps may make surveillance guidance easier to follow and further improve compliance.

P-BN36 Trends in Management of Gall Bladder Polyps Over 10 Years

Abstract Background Gall Bladder (GB) polyps are abnormal growths on the inner lining that project into the lumen of the GB. They are a rare incidental radiological finding, with a prevalence ranging from 0.3% to 9.5%. The majority of these turn out to be pseudopolyps, however, correct follow up and management is essential to ensure that true polyps, which may be malignant or have malignant potential, are not missed. We hypothesised that a lack of familiarity and poor understanding of the significance of GB polyps, along with the fact that they are frequently noted as an incidental finding by non-surgical specialties, has led to variable management of GB polyps. In order to investigate this, we carried out a retrospective analysis of the management of GB polyps at our large district general hospital over the last 10 years. Methods Patients were identified for this retrospective ten-year cohort study from our database by identifying all patients coded under the ‘International Statistical Classification of Diseases and Related Health Problems (ICD 10) code K 82.8, other specified diseases of gall bladder’. Patients with other diagnoses, such as gall bladder dysfunction, were excluded after review of electronic patient record (EPR) (Sunrise, Allscripts). These records facilitated review of emergency attendances, clinic letters, investigations, and histological results for those diagnosed with a gall bladder polyp. Analysis was performed using Microsoft Excel. Results A total of 154 GB polyps were identified, of which general surgeons diagnosed 63% and 74% went on to have further management. 11% of patients in our cohort proceeded straight to laparoscopic cholecystectomy, 33% underwent planned surveillance, 20% had unplanned scans and 12% were either followed up with the GP or referred back to clinic. A further 26% were discharged. In total, 35% of patients ultimately had a laparoscopic cholecystectomy and the average time from diagnosis to operation was 19 months. There was a strong negative correlation (-0.72) in reduction in time to operation over the 10-year study period. We also identified a decline in patients being followed up over time (-0.14) and in patients receiving no further management post diagnosis (-0.19). Conclusions Management of GB polyps has historically been and continues to be very variable, however, over our 10-year study period we have identified a trend towards operating earlier, with more patients being listed for surgery straight from diagnosis, and more having a shorter period of surveillance. In our cohort there has been no change in number of patients who have further planned surveillance imaging after diagnosis or in numbers of patients discharged with no further investigation or management. We postulate that this variability in management may be due to the fact that GB polyps are often identified as an incidental finding by non-surgical specialists, together with a general lack of awareness of current guidelines and a poor understanding of the pathophysiology.

P-BN38 Patient Outcomes Following Laparoscopic Cholecystectomy after a Diagnosis of Gall Bladder (GB) Polyp over 10 Years

Abstract Background Gall Bladder (GB) polyps are elevations of the GB wall that project into the lumen. They are a rare incidental radiological finding with prevalence of 0.3% to 9.5%. Although the majority of these may be pseudopolyps correct follow up and management is essential as to ensure that true polyps, which may be malignant or have malignant potential, are not missed. We conducted a retrospective study assessing patient factors that may predispose to the finding of true polyps. Patient outcomes including histological findings as well as ongoing symptoms and further investigations or emergency attendances were also assessed. Methods Patients were identified for this retrospective ten year cohort study using International Statistical Classification of Diseases and Related Health Problems (ICD 10) code K 82.8, other specified diseases of gall bladder. Patients with other diagnoses such as gall bladder dysfunction were excluded after review of electronic patient record (EPR) (Sunrise, Allscripts). EPR allowed for review of emergency attendances, clinic letters, investigations and histological results for those diagnosed with a gall bladder polyp. Analysis was performed with Microsoft Excel. Results 35% patients had a laparoscopic cholecystectomy and the average wait time for surgery was 19 months but only 11% of patients were found to have true GB polyps on histology. Other histological findings included chronic cholecystitis (96%), cholesterolsis (33%) and stones 35%. Only 12% of those booked straight to laparoscopic cholecystectomy re-presented post operatively compared to 37% of those operated on after a period of surveillance. Patients booked straight for laparoscopic cholecystectomy, or diagnosed with polyps &amp;gt;10mm in size, were statistically more likely to have a true GB polyp (P &amp;lt; 0.05), however, gender, ethnicity, and whether an isolated polyp or multiple were diagnosed made no statistical difference to detection of a true polyp (P &amp;gt; 0.05). Conclusions From this series of patients true polyps are most likely to be identified if it is larger than 10mm at diagnosis and operated on straight away. 96% of all patients, however, displayed histological features of chronic cholecystitis. This suggests that proceeding to laparoscopic cholecystectomy straight from diagnosis of a GB polyp can be justified. Only 1patient in our cohort returned normal GB histology.. Following diagnosis of a GB polyp, the option of operation versus surveillance should be discussed wirth individual patients and decisions based on assessment of risks and benefits should be made. Further research will help identify those with a predisposition to high-risk true polyps.

A Comprehensive Update of the Incidence and Demographics of Laryngoceles in Adults.

To provide updated data on the incidence, types, and demographics of laryngoceles in the adult population. We searched the medical archives of our institute for computed tomography (CT) studies acquired between January 1, 2007 and December 31, 2017 in which the term "laryngocele" appeared in the radiology reports. Two of the authors reviewed relevant images for the presence, type, distribution, and laterality of true laryngoceles. Demographic and clinical data were extracted from medical records and the incidence was calculated. Laryngoceles were detected in 53 out of the 79 893 patients with relevant CT data, which equates to an incidence of 151 per 2.5 million (0.06:1000) patients per year. The male:female ratio was 3:1, average age was 60 (±18) years, and incidence peaked among patients in the sixth decade of life. Nine patients (17%) had known laryngeal cancer; however, the majority of the cohort did not have follow up clinic visits. Our study demonstrates that the incidence of laryngoceles is much greater than previously reported. In most cases, the diagnosis of a laryngocele was an incidental radiological finding. Male gender predilection and age at presentation are in agreement with previous reports. Association of laryngoceles with laryngeal cancer could not be calculated due to low rates of follow ups. 3.

Pindborg tumour: A case report

The calcifying epithelial odontogenic tumor (CEOT) is a benign epithelial odontogenic lesion that accounts for less than 1% of all odontogenic tumors. CEOT is usually asymptomatic and an incidental radiological finding, often presenting as a mandibular radiolucency with flecks of calcified material. We report a case of CEOT in the right posterior maxilla of a 24-year-old female that was associated with an ectopic unerupted tooth. The tumour in this case caused mild pain and appeared radiographically similar to an odontoma or Ameloblastic fibro-odontome, due to its dense calcified contents. Diagnosis was confirmed through histopathology. This case report highlights the unusual clinical and radiographic appearence of Pindborg tumor.

SCIMITAR SYNDROME IN A PATIENT WITH NON-HODGKIN'S LYMPHOMA: A RARE CASE REPORT IN THE BRAZILIAN AMAZON

Non-Hodgkin's Lymphoma is a neoplasm that originates from mutations in the lymphatic tissue in the B and T progenitor cells, whose clinical manifestation is characterized by the enlargement of lymph nodes and general systemic symptoms. Otherwise, scimitar syndrome (SS) is a rare variant of a group of congenital cardiovascular disorders known as partial anomalous pulmonary venous return, in which the pulmonary venous flow ends in the right atrium rather than the left atrium. This report describes a 60-year-old patient, born in Santarém (PA), who was diagnosed with diffuse large-cell non-Hodgkin's Lymphoma with immunophenotype B, with a germinal center type IIIB pattern - CD20, CD10, BCL2 and BCL6 positively diffuse and Kl -67 positive around 60 to 70%. After diagnosis, she received systemic infusion chemotherapy with R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisone) according to current guidelines. During the tomographic scan, the diagnosis of associated Scimitar Syndrome was made. Radiographic findings such as hypoplastic right lung, anomalous pulmonary venous drainage through the inferior vena cava, anomalous pulmonary irrigation through a branch of the descending aorta, dextrocardia (deviation of the heart to the right side of the body) characterize the Scimitar Syndrome, have been described in the literature and identified in the referred clinical case. The absence of identifiable symptoms in the clinical history attributed to the syndrome may justify its identification by an incidental radiological finding in an imaging scan of Non-Hodgkin's Lymphoma. After the diagnosis of lymphoma, according to current guidelines, he completed the proposed chemotherapy regimen with a complete response and remains in outpatient follow-up. Furthermore, the association of the syndrome with the occurrence of malignant neoplasms gives scientific relevance and rare character to the aforementioned case report.

S1887 A Rare and Late Complication of COVID-19 Infection: Pneumatosis Intestinalis

Introduction: Pneumatosis intestinalis (PI) is a rare incidental radiologic or endoscopic finding characterized by the presence of gas in the bowel wall. Primarily it happens due to ischemia of bowel. Intestinal ischemia has been reported in association with COVD-19 infection. From literature review, it is commonly seen in patient with severe illness and happens in the first 1- 3 weeks of the illness. Late presentation of COVID-19 associated PI is even very rare. We present a patient with no significant medical history presented with abdominal discomfort 6 months post COVID-19 illness, and he was found to have PI. Case description/methods: A46-year old male patient with no significant medical history presented with on and off left sided abdominal discomfort/pain 4 months after COVID-19 illness. The pain became more frequent over the next 2-3 months, and patient came to GI clinic for evaluation. During his COVID illness, patient had low grade fever, fatigue, significant visual acuity issues. Patient denies shortness of breath, diarrhea or constipation. He did not require hospital admission, but patient took dexamethasone, Ivermectin for 3-5 days. Patient was evaluated by gastroenterologist, and it was decided to do colonoscopy which showed typical PI (Figure). This patient was found to have PI 6 months after his COVID illness. He is healthy person with no other risk factors for PI. Patient is not diabetic and does not have any pulmonary, cardiac or autoimmune disease. His pain was not associated with eating. No significant laboratory abnormality was found. Patient had CT scan of abdomen/pelvis 1 week after colonoscopy which showed resolution of the PI. On follow up appointment, symptom has improved well. Discussion: Late presentation of pneumatosis intestinalis associated with COVID- 19 is very rare. Parthenogenesis can be due to direct injury of GI mucosa through attachment to angiotensin converting enzyme receptors of enterocytes, disruption of normal colonic flora or due to COVID-19 induced thromboembolic complications. It is important that clinicians are aware of this late complication. In general, most cases of PI are asymptomatic and may be incidental finding on imaging or endoscopy. Treatment varies but most cases does not need surgical treatment. Steroid treatment, bowel rest and hyperbaric oxygen therapy can resolve the problem. In our patient, he had good bowel rest, bowel preparation for colonoscopy which might contributed for the resolution on his CT scan.Figure 1.: Colonoscopy showing Pneumatosis intestinalis in descending colon.

Polyostotic Fibrous Dysplasia of Ribs

34 yr old female presenting with pain lower part of left side chest was found to have incidental radiological finding which revealed a rare genetic condition of ribs.

Management of Bone Cyst of Talar Body by Endoscopic Curettage, Nanofracture, and Bone Graft Substitute

Large bone cyst of the talar body is frequently associated with an osteochondral lesion. The talar bone cyst can be an incidental radiologic finding. However, when the talus is extensively destroyed, there is a risk of pathologic fracture and damage to the articular cartilage, leading to persistent swelling and pain of the subtalar joint and ankle joint. Open debridement and bone grafting frequently requires extensive soft-tissue dissection or even different types of malleolar osteotomy for proper access to the lesion. The purpose of this Technical Note is to describes the technique of endoscopic curettage, nanofracture, and filling the cyst with injectable bone graft substitute. This minimally invasive approach has minimal disruption of the normal cartilage surface.

Pulmonary embolism in pediatric age: A retrospective study from a tertiary center.

Pediatric pulmonary embolism (PE) is rare but associated with adverse outcomes. We aimed to characterize PE cases admitted in a tertiary hospital and to evaluate sensitivity of selected PE diagnostic prediction tools. Retrospective, descriptive study of PE cases admitted from 2008 to 2020 using data collected from hospital records. Patients were grouped according to PE severity and setting (outpatients vs. inpatients). Links and correlation with demographic characteristics, risk factors, clinical presentation, management, and outcomes were analyzed. PE diagnostic prediction tools were applied. Twenty-nine PE episodes occurred in 27 patients, 62.9% female, mean age 14.1 years. Most PE were central and split between massive or submassive. One was diagnosed in autopsy. Twenty outpatients, all adolescents, were admitted for classic PE symptoms; in half of them the diagnosis had been previously missed. Risk factors included contraceptives (65%), thrombophilia (35%), obesity (20%) and auto-immunity (20%). Eight inpatients, diagnosed during cardiorespiratory deterioration (n = 5), or through incidental radiological findings (n = 3), were younger and had immobilization (87.5%), complex chronic diseases (75%), infections (75%) and central venous catheter (62.5%) as risk factors. Retrospectively, d -dimer testing and adult scores performed better than pediatric scores (sensitivity 92.9%-96% vs. 85.7%-92.9%). Both pediatric scores missed a case with a positive family history. Pediatric PE diagnosis is often delayed or missed. Development of pediatric prediction tools from validated adult scores merits being explored. We argue clinical presentation and risk factors may be different in inpatients and outpatients and propose broader reliance on family history.