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Cranial ultrasound is an invaluable tool in assessing neonatal brain anatomy and pathology. It is accessible, relatively quick, inexpensive, safe, portable and generally well-tolerated. This pictorial review focuses on the use of cranial ultrasound in evaluating the premature brain. We illustrate the different grades of intraventricular haemorrhage, the most common sequela of prematurity, its evolution and potential complications, as well as periventricular leukomalacia. Anatomical variants and benign findings that mimic preterm brain injury are also discussed. Critical relevance statement Cranial US is an invaluable tool for assessing neonatal brain anatomy and pathology and can be used in preterm infants to diagnose, monitor and assess for complications of intraventricular haemorrhage and periventricular leukomalacia. Key Points Cranial US (CUS) is an invaluable tool for assessing the neonatal brain and has many advantages over MRI. CUS can detect intraventricular haemorrhage and periventricular leukomalacia, the most important sequelae of prematurity. Knowledge of optimal CUS technique, normal anatomy, and variants/benign sonographic findings that mimic pathology is crucial to avoid misdiagnosis and unnecessary concern. Graphical Abstract

Cranial ultrasound is a critical screening tool in the detection of cerebral abnormalities in term neonates and infants, and is complementary to other imaging modalities. This pictorial review illustrates the diverse central nervous system pathologies which can affect the term neonatal and infantile brain, including vascular abnormalities (hypoxic ischaemic injury, perinatal arterial ischaemic stroke, cerebral sinovenous thrombosis, vein of Galen aneurysmal malformations, subpial haemorrhage, and dural sinus malformations); infections (congenital (cytomegalovirus and toxoplasmosis) and bacterial meningoencephalitis); genetic disorders and malformations (callosal agenesis, tuberous sclerosis, developmental megalencephaly, lissencephaly-pachygyria, and grey matter heterotopia); tumours (choroid plexus papilloma, atypical teratoid/rhabdoid tumour, and desmoplastic infantile glioma) and trauma (birth-related, inflicted injury). Each condition is explored with a focus on its sonographic characteristics—some have rarely, if ever, been described on ultrasound. Critical relevance statement Through this case review, we illustrate various pathologies affecting the term neonatal and infantile brain, including vascular lesions, infection, genetic disorders/malformations, tumours and trauma: some of these pathologies have rarely, if ever, been described on CUS. Key Points Cranial ultrasound (CUS) is a critical screening tool for the term brain. Many term neonatal and infantile pathologies can be detected on CUS. Some of the pathologies illustrated in this paper have rarely been described on US. Graphical Abstract

ObjectiveThe notion that osteogenesis imperfecta (OI) predisposes children to metaphyseal fractures is controversial. This review aimed to ascertain the prevalence of metaphyseal fractures in children with OI less than 2 years of age.Materials and methodsMedline, CINAHL and Web of Science were searched for studies reporting metaphyseal fractures in children with OI less than 2 years of age. Articles not retrievable, not published in English, or where ‘metaphyseal’ fracture was not defined/illustrated, were excluded. Article quality was independently assessed using the Critical Appraisal Skills Programme and Case Reports tools.ResultsOf 298 retrieved abstracts, 82 were duplicates: 216 articles were screened by title and abstract, excluding 186. Hand search of the remaining 30 articles identified two further articles. Only four articles were included: (1) 4/41 children with OI aged between 1 day and 3 years with ‘metaphyseal’ fractures; (2) a case series including a 16-month-old boy with three ‘metaphyseal’ fractures. Abuse concerns remained despite a type IV OI diagnosis (not genetically confirmed); (3) a 7-month-old girl with two ‘corner’ fractures suspected to have OI and to have been abused; and (4) a pair of siblings with ‘metaphyseal’ fractures and type XI OI (FKBP10 mutation).ConclusionsThere is limited evidence that OI predisposes infants and young children to metaphyseal fractures. The two diagnoses are not mutually exclusive and until further large studies are conducted, physical abuse should always be considered in infants and young children with metaphyseal fractures, even in those with confirmed OI.

Pre-hospital focused assessment with sonography in trauma (FAST) has been effectively used to improve patient care in multiple mass casualty events throughout the world. Although requisite FAST knowledge may now be learned remotely by disaster response team members, traditional live instructor and model hands-on FAST skills training remains logistically challenging. The objective of this pilot study was to compare the effectiveness of a novel portable ultrasound (US) simulator with traditional FAST skills training for a deployed mixed provider disaster response team. We randomized participants into one of three training groups stratified by provider role: Group A. Traditional Skills Training, Group B. US Simulator Skills Training, and Group C. Traditional Skills Training Plus US Simulator Skills Training. After skills training, we measured participants' FAST image acquisition and interpretation skills using a standardized direct observation tool (SDOT) with healthy models and review of FAST patient images. Pre- and post-course US and FAST knowledge were also assessed using a previously validated multiple-choice evaluation. We used the ANOVA procedure to determine the statistical significance of differences between the means of each group's skills scores. Paired sample t-tests were used to determine the statistical significance of pre- and post-course mean knowledge scores within groups. We enrolled 36 participants, 12 randomized to each training group. Randomization resulted in similar distribution of participants between training groups with respect to provider role, age, sex, and prior US training. For the FAST SDOT image acquisition and interpretation mean skills scores, there was no statistically significant difference between training groups. For US and FAST mean knowledge scores, there was a statistically significant improvement between pre- and post-course scores within each group, but again there was not a statistically significant difference between training groups. This pilot study of a deployed mixed-provider disaster response team suggests that a novel portable US simulator may provide equivalent skills training in comparison to traditional live instructor and model training. Further studies with a larger sample size and other measures of short- and long-term clinical performance are warranted.

While many infrastructure projects fail, many succeed.  Unfortunately, we may never learn the important lessons to be gained because we fail to evaluate them many years after implementation.  This study assesses two engineering projects implemented by the Engineers Without Borders USA, Marquette University Chapter projects: 1) a vehicular bridge that enhances access to health care, education and markets; and 2) a potable water distribution system that provides clean water to 1300 community members. The community’s primary goal for the program was to improve the health of its citizens, which they self-identified as “a crisis”. The assessment reviewed the pre-implementation and ten-year post implementation data for infant mortality, maternal mortality and school absences due to water borne diseases. The results show dramatic improvements in all three areas with the infant mortality rate per 1000 births being reduced from 38 to 2; the maternal mortality rate per 1000 births being reduced from 15 to 0 and the school absences per month moving from 310 to 2. The “best practices” of the program’s implementation and 10-year review are documented to assist other organizations implementing similar programs. 

Introduction: Pre-hospital focused assessment with sonography in trauma (FAST) has been effectively used to improve patient care in multiple mass casualty events throughout the world. Although requisite FAST knowledge may now be learned remotely by disaster response team members, traditional live instructor and model hands-on FAST skills training remains logistically challenging. The objective of this pilot study was to compare the effectiveness of a novel portable ultrasound (US) simulator with traditional FAST skills training for a deployed mixed provider disaster response team. Methods: We randomized participants into one of three training groups stratified by provider role: Group A. Traditional Skills Training, Group B. US Simulator Skills Training, and Group C. Traditional Skills Training Plus US Simulator Skills Training. After skills training, we measured participants’ FAST image acquisition and interpretation skills using a standardized direct observation tool (SDOT) with healthy models and review of FAST patient images. Pre- and post-course US and FAST knowledge were also assessed using a previously validated multiple-choice evaluation. We used the ANOVA procedure to determine the statistical significance of differences between the means of each group’s skills scores. Paired sample t-tests were used to determine the statistical significance of pre- and post-course mean knowledge scores within groups.Results: We enrolled 36 participants, 12 randomized to each training group. Randomization resulted in similar distribution of participants between training groups with respect to provider role, age, sex, and prior US training. For the FAST SDOT image acquisition and interpretation mean skills scores, there was no statistically significant difference between training groups. For US and FAST mean knowledge scores, there was a statistically significant improvement between pre- and post-course scores within each group, but again there was not a statistically significant difference between training groups.Conclusion: This pilot study of a deployed mixed-provider disaster response team suggests that a novel portable US simulator may provide equivalent skills training in comparison to traditional live instructor and model training. Further studies with a larger sample size and other measures of short- and long-term clinical performance are warranted. [West J Emerg Med. 2015;16(2):325–330.]

We present the case of an 11-year-old girl who was presented to the Emergency Department with right elbow pain and swelling following a fall. Radiography demonstrated intra-articular displacement of an avulsed medial epicondyle ossification centre, which was not readily identified at presentation. She proceeded to an uncomplicated open reduction and internal fixation.

We report an unusual complication of COVID-19 infection in a 53-year-old Caucasian man. He presented with shortness of breath, fever and pleuritic chest pain. A CT pulmonary angiogram (CTPA) demonstrated acute bilateral pulmonary embolism and bilateral multifocal parenchymal ground glass change consistent with COVID-19 (SARS-CoV-2) infection. Right adrenal haemorrhage was suspected on the CTPA which was confirmed on triple-phase abdominal CT imaging. A short Synacthen test revealed normal adrenal function. He was treated initially with an intravenous heparin infusion, which was changed to apixaban with a planned outpatient review in 3 months’ time. He made an uncomplicated recovery and was discharged. Follow-up imaging nearly 5 months later showed near complete resolution of the right adrenal haemorrhage with no CT evidence of an underlying adrenal lesion.