Point-of-Care Ultrasound May Reduce Misdiagnosis of Pediatric Intussusception.

Aim: Intussusception, the most common abdominal emergency in early childhood, is frequently misdiagnosed at initial presentation. The effect of using point-of-care ultrasonography (POCUS) by emergency medicine physicians on pediatric intussusception misdiagnosis rate remains unclear. Here, we summarize outcomes and misdiagnoses before and after training junior and senior physicians on using POCUS for diagnosing intussusception and compared their performance levels. Materials and Methods: This observational cohort analysis included patients with suspected intussusception who visited a pediatric emergency department (ED) between January 2017 and December 2019. All enrolled patients were evaluated by junior (<10-year experience) or senior attending physicians. Misdiagnosis was defined as a finding of negative air reduction or confirmation of diagnosis on ED revisit or admission. The misdiagnosis rates and outcomes before and after POCUS training for intussusception diagnosis were evaluated and performance of the junior and senior physicians was compared. Results: Of the 167 enrolled patients, 130 were confirmed to have intussusception by air reduction. Misdiagnosis rate was significantly lower in the post-training patient group after training than in the pre-training patient group (43.7 vs. 12.7%, P < 0.001). After training, fewer misdiagnoses were made by the junior (59.1 vs. 25.9%, P = 0.003) and senior (31.7 vs. 0%, P < 0.001) physicians. In the post-training patient group, the door-to-reduction time and rate of ultrasonography consultation with an expert also decreased significantly (118.2 ± 124.5 vs. 198 ± 250.2 min, P = 0.006). Abdominal pain (80.9%) was the most common symptom of intussusception, followed by vomiting (58.3%), fever (17.8%), bloody stool (15.4%), and diarrhea (14.2%). Even after training, the presenting symptoms of intussusception often leading junior physicians to misdiagnosis were diarrhea and fever. Conclusions: A brief POCUS training leads to decreased misdiagnosis rates in both the senior and junior physicians. Junior physicians should increase their awareness regarding diarrhea and fever being the presenting symptoms of intussusception, particularly in early childhood. Combining clinical judgment and POCUS results forms the core principle of the evaluation of children with intussusception.

Esophagography after pneumomediastinum without CT findings of esophageal perforation: is it necessary?

OBJECTIVE: The purpose of our study was to determine the necessity of fluoroscopic esophagography in patients with pneumomediastinum on CT but without CT findings of esophageal perforation. MATERIALS AND METHODS: From January 1, 2006, through December 31, 2010, there were 4305 fluoroscopic esophagography examinations including 533 with CT identified from a search of our PACS. Patients with pneumomediastinum on CT who were subsequently referred for emergent fluoroscopic esophagography to exclude esophageal perforation were enrolled. Fluoroscopic esophagography examinations performed within 3 days of CT were included. Patients with a history of esophageal disease were excluded. As a result, 103 patients were enrolled in the study; patients were divided into groups on the basis of whether there was additional clinical history of esophageal damage (trauma group) or not (nontrauma group). Images were reviewed by two board-certified radiologists blinded to the clinical data and radiologic reports for the presence or absence of esophageal perforation. A positive result on CT was defined as esophageal injury or periesophageal infiltration that coexisted with periesophageal air. A positive fluoroscopic esophagography result was defined as oral contrast medium leakage from the esophagus. RESULTS: Esophageal perforation was diagnosed in 15 of the 103 patients. The CT findings were significantly correlated with esophageal perforation (p < 0.001 in the trauma group, and p = 0.001 in the nontrauma group). The respective sensitivity and negative predictive value (NPV) of CT versus fluoroscopic esophagography in the trauma group were 100% versus 66.7% and 100% versus 87.9%; in the nontrauma group, the sensitivity and NPV were 100% for CT and fluoroscopic esophagography. Thus, the sensitivity and NPV of CT were either superior or equal to those of fluoroscopic esophagography. CONCLUSION: The results of our study suggest that performing fluoroscopic esophagography in patients with pneumomediastinum is unnecessary when CT is negative for esophageal perforation.

Evaluating pediatric intussusception using 24-hour ultrasound.

BACKGROUND: Although ultrasound is often the preferred pediatric imaging modality for the evaluation of intussusception in children, many institutions lack access to ultrasound at night. This study characterized the day- and nighttime use of radiographic imaging for evaluation of intussusception. METHODS: The charts of pediatric patients evaluated for intussusception between January 2010 and December 2010 were reviewed retrospectively to evaluate the day- and nighttime use of radiographic imaging. Patients were stratified into day and night groups according to when the imaging studies were performed, and differences in the clinical characteristics, imaging studies, cost, and final diagnosis were compared. RESULTS: Pediatric consultations were performed for 86 suspected intussusceptions: 40 (46.5%) during the day [38 (95%) ultrasounds and 33 (82.5%) plain abdominal X-rays] and 46 at night [3 (6.5%) computed tomography and 39 (84.7%) plain abdominal X-rays]. The rate of positive enemas was significantly higher during the day than at night (97.5% vs. 52.2%, p < 0.001). The radiation dose during the initial survey was significantly lower during the day than at night (0.63 ± 0.48 vs. 2.06 ± 1.48 mSv, p < 0.001). CONCLUSION: Radiographic imaging at night results in higher radiation exposure and negative enema findings. Twenty-four-hour ultrasound availability would decrease the radiation exposure and unnecessary enemas for intussusceptions suspected clinically.

Value of CT in the discrimination of fatal from non-fatal stercoral colitis.

OBJECTIVE: Clinical presentation and physical signs may be unreliable in the diagnosis of stercoral colitis (SC). This study evaluates the value of computed tomography (CT) in distinguishing fatal from non-fatal SC. MATERIALS AND METHODS: Ten patients diagnosed as SC were obtained from inter-specialist conferences. Additional 13 patients with suspected SC were identified via the Radiology Information System (RIS). These patients were divided into two groups; fatal and non-fatal SCs. Their CT images are reviewed by two board-certified radiologists blinded to the clinical data and radiographic reports. RESULTS: SC occurred in older patients and displayed no gender predisposition. There was significant correlation between fatal SC and CT findings of dense mucosa (p = 0.017), perfusion defects (p = 0.026), ascites (p = 0.023), or abnormal gas (p = 0.033). The sensitivity, specificity, and accuracy of dense mucosa were 71%, 86%, and 81%, respectively. These figures were 75%, 79%, and 77% for perfusion defects; 75%, 80%, and 78% for ascites; and 50%, 93%, and 78% for abnormal gas, respectively. Each CT sign of mucosal sloughing and pericolonic abscess displayed high specificity of 100% and 93% for diagnosing fatal SC, respectively. However, this did not reach statistical significance in diagnosing fatal SC. CONCLUSION: CT appears to be valuable in discriminating fatal from non-fatal SC.

Rescue by hematopoietic progenitor cells derived from engrafted cord blood unit in a child with brain tumor after transplantation for T-cell acute lymphoblastic leukemia.

An 8-year-old boy with T-cell acute lymphoblastic leukemia received unrelated cord blood transplantation in April 2006. His course was uneventful until February 2007, when a hyperintense lesion was noted in the pons. A subsequent bone marrow examination confirmed that he was in remission with full donor chimerism. He was therefore diagnosed with an inoperable brain tumor after cord blood transplantation. Despite radiotherapy for the brain lesion, his neurological status worsened. High-dose chemotherapy with "autologous" progenitor cell rescue was adopted, although the fact that these cells were originally derived from engrafted umbilical cord unit. He was in apparent remission of his brain tumor for 3 years.

Discrimination of gangrenous from uncomplicated acute cholecystitis: accuracy of CT findings.

In acute cholecystitis, the presence of gangrene is associated with higher morbidity and mortality and necessitates open surgical intervention rather than laparoscopic cholecystectomy. As Murphy's sign may be absent, gangrene may not be detected ultrasonographically. This retrospective study evaluated indications of acute gangrenous cholecystitis on computed tomography (CT) in 25 patients, who were proven as having acute cholecysitis surgically and pathologically within 3 days of pre-operative CT. The CT images were reviewed by two board-certified radiologists blind to the initial CT report. Acute gangrenous cholecystitis was significantly correlated with the CT signs of perfusion defect (PD) of the gallbladder wall (P = 0.02), pericholecystic stranding (PS) (P = 0.028), and no-gallstone condition (No-ST) (P = 0.026). The presence of PD was associated with acute gangrenous cholecystitis with a relatively high accuracy (80%), a sensitivity of 70.6%, a specificity of 100%, a positive predictive value (PPV) of 100%, and a negative predictive value (NPV) of 61.5%. The combination CT signs of PD or No-ST improved the accuracy for acute gangrenous cholecystitis to 92%, with a sensitivity, specificity, PPV, and NPV of 88.2%, 100%, 100%, and 80%, respectively. Other CT signs were highly specific for acute gangrenous cholecystitis but of low sensitivity, including mucosal hemorrhage, mucosal sloughing, wall irregularity, pericholecystic abscess, gas formation, and portal venous thrombosis. CT was found to accurately diagnose acute cholecystitis, with the presence of PD, PS, or No-ST significantly correlated with that of gangrenous change. Thus, CT is useful in the preoperative detection of acute gangrenous cholecystitis.

Renal abscess in children: a 10-year clinical and radiologic experience in a tertiary medical center.

Renal abscess is a rare disease in childhood and early diagnosis is essential to minimize the renal damages. Experiences gained from this 10-year study on patients with CT-proved diagnosis include the varied clinical presentations and use of sonographic-marked nephromegaly and focal mass as indications for further CT diagnosis.

Staphylococcus aureus pericardial abscess in a child with beta-thalassemia major following double-unit unrelated cord blood transplantation.

The authors describe a 10-year-old boy with beta-thalassemia major who received double-unit unrelated cord blood transplantation and had a rocky post-transplantation course that included an episode of massive pericardial effusion. Pericardial tube drainage was performed for evacuating fluid. Results showed hemorrhagic pericardial effusion. A Staphylococcus aureus pericardial abscess eventually developed despite antibiotics coverage. Temporary drain placement was unsuccessful and the patient underwent radical pericardiectomy. Although cyclosporine therapy had to be stopped before the 6-month withdrawal, the patient did well with full donor chimerism 14 months post-transplant.

Primary intraspinal mesenchymal chondrosarcoma: report of one case.

We report a case of primary intraspinal mesenchymal chondrosarcoma in an 11-year-old boy. Contrast-enhanced MRI revealed a hyperintense, sausage-shaped mass extending from C7 to T2. The lesion located anterolaterally on the left side, pushing the spinal cord to the right and posterior. Microscopic examination and immunohistochemical studies confirmed the diagnosis of mesenchymal chondrosarcoma. Follow-up studies have shown no tumor recurrence for 2 years. This tumor is rare but should be considered for differential diagnosis in spinal tumors.

Magnetic resonance abnormalities of bone marrow in a case of acute lymphoblastic leukemia.

Although magnetic resonance imaging (MRI) is not performed routinely in the diagnostic work-up of children with leukemia, patients may present with a normal peripheral blood cell count and osteological manifestations. For such cases, MRI may be requested in the early workup for a diagnosis. This situation illustrates that a delay in appropriate diagnosis may occur, with the classic features of the disease being uniformly absent. We present a child illustrating the salient features of acute leukemia upon MRI with limb pain and an initial normal peripheral blood cell count.

Extramedullary relapse in the left proximal femur with Philadelphia chromosome positive acute lymphoblastic leukemia after allogeneic bone marrow transplantation.

We describe a rare presentation of extra-medullary relapse in an adolescent boy with Philadelphia chromosome-positive acute lymphoblastic leukemia who had undergone allogeneic bone marrow transplantation after first remission. In spite of enduring bone marrow remission, the patient experienced a local relapse in the left proximal femur within 3 years of the transplant. The findings from radiography, bone scintigraphy, and chimerism analysis with short tandem repeats as well as bone marrow aspirates taken via the iliac crests were indeterminate. Magnetic resonance imaging at the onset of hip pain was characterized by decreased signal intensity of the left proximal femur, a finding characteristic of bone marrow edema. Confirmation of extra-medullary relapse of the proximal femur was delayed until histologic proof of the computed tomography-guided biopsy samples was obtained. Overt bone marrow relapse was identified 14 months later. Reestablishment of normal donor hematopoiesis was achieved with reinduction chemotherapy.