A 14-year single-center experience evaluating sclerotherapy efficacy in lymphatic malformations.

OBJECTIVE: The aim of this study is to share our experience in treating patients with lymphatic malformations (LMs) over a span of 14 years, evaluating its efficacy and safety, particularly with the use of ethanol as sclerosant of choice. METHODS: A retrospective review of pediatric patients diagnosed and later treated for LMs between 2008 and 2022 was conducted. We collected patient demographics, LM characteristics, treatment strategies, and outcomes, including response to treatment and complications. RESULTS: The cohort included 36 patients (24 male patients), first presenting clinically at a median age of 5 months (range: 0-12 years). LMs were macrocystic (17), microcystic (3), and mixed types (16). In most patients (22), the malformation involved the cervicofacial area. Twenty-five patients underwent 54 procedures, averaging 2 procedures per patient (range: 1-13). Sclerotherapy resulted in 90% of patients exhibiting some response of the LM (P = .005). Ethanol was used in most procedures (31) and proved most efficacious, facilitating partial or complete response of the malformations in all cases compared with 72% with other sclerosants (P = .06). Sclerotherapy exhibited low complication rates among all sclerosants used (7%, P = .74). CONCLUSIONS: Sclerotherapy is a safe and effective intervention for pediatric LMs. Ethanol demonstrated comparable efficacy and safety to other sclerosants, highlighting its potential as a preferred treatment option. This study supports the tailored use of sclerotherapy, guided by a thorough understanding of the risks and benefits, to provide optimized care for patients with LMs.

Assessment of glymphatic dysfunction in pediatric idiopathic intracranial hypertension: insights from quantitative diffusivity and perivascular spaces analysis-a case-control study.

Background: The impaired drainage of cerebrospinal fluid through the glymphatic system is thought to play a role in the idiopathic intracranial hypertension (IIH) pathophysiology. Limited data exist regarding the glymphatic system's involvement in pediatric patients with IIH. Therefore, the study's objective was to quantitatively evaluate alterations in parenchymal diffusivity and magnetic resonance imaging (MRI)-visible dilated perivascular spaces (PVS) as imaging indicators of glymphatic dysfunction in pediatric patients with IIH. Methods: Patients diagnosed with IIH in 2017-2022 in a single tertiary center (Sheba Medical Center, Israel) were retrospectively reviewed. Twenty-four pediatric patients were enrolled. All patients underwent clinical 3-T brain MRI. The control group included 24 age- and gender-matched healthy subjects with a normal-appearing brain on imaging. We used automatic atlas-based diffusion-weighted imaging analysis to determine regional diffusivity of the thalamus, caudate, putamen, globus pallidus, hippocampus, amygdala, and brain stem. PVS were evaluated using a semi-quantitative rating scale on T2-weighted images. Variables were compared using the Mann-Whitney test. Multivariate analysis of covariance was used to test for differences between controls and IIH patients. Results: No significant differences in regional brain diffusivity were observed between individuals with IIH and healthy controls (P=0.14-0.91 for various brain regions). The number of visible PVS was comparable between patients with IIH and the control group across all evaluated sites (P=0.12-0.74 for various brain regions). Conclusions: Pediatric IIH patients exhibited similar patterns of parenchymal diffusivity and PVS compared to age-matched controls. These findings do not support the hypothesis that the glymphatic system may play a role in the pathophysiology of pediatric IIH, although previously postulated. However, employing more sophisticated magnetic resonance (MR) techniques could enhance the sensitivity in uncovering underlying glymphatic dysfunction. Further research is warranted to validate and explore this association in larger cohorts and investigate the underlying mechanisms involved in IIH.

Large language model (ChatGPT) as a support tool for breast tumor board.

Large language models (LLM) such as ChatGPT have gained public and scientific attention. The aim of this study is to evaluate ChatGPT as a support tool for breast tumor board decisions making. We inserted into ChatGPT-3.5 clinical information of ten consecutive patients presented in a breast tumor board in our institution. We asked the chatbot to recommend management. The results generated by ChatGPT were compared to the final recommendations of the tumor board. They were also graded independently by two senior radiologists. Grading scores were between 1-5 (1 = completely disagree, 5 = completely agree), and in three different categories: summarization, recommendation, and explanation. The mean age was 49.4, 8/10 (80%) of patients had invasive ductal carcinoma, one patient (1/10, 10%) had a ductal carcinoma in-situ and one patient (1/10, 10%) had a phyllodes tumor with atypia. In seven out of ten cases (70%), ChatGPT's recommendations were similar to the tumor board's decisions. Mean scores while grading the chatbot's summarization, recommendation and explanation by the first reviewer were 3.7, 4.3, and 4.6 respectively. Mean values for the second reviewer were 4.3, 4.0, and 4.3, respectively. In this proof-of-concept study, we present initial results on the use of an LLM as a decision support tool in a breast tumor board. Given the significant advancements, it is warranted for clinicians to be familiar with the potential benefits and harms of the technology.

Effect of General Anesthesia on MR Optic Nerve Sheath Diameter in the Pediatric Population.

BACKGROUND: Papilledema is thought to be the hallmark sign of increased intracranial pressure (ICP). Distension of the subarachnoid space within the optic nerve sheath is also commonly reported in MR studies as an indirect sign of increased ICP. HYPOTHESIS: General anesthesia and positive pressure ventilation might result in changes in optic sheath diameter (OSD) observed on clinical brain MRI. STUDY TYPE: Retrospective. POPULATION: One hundred forty-five  patients (154 MRI scans, 7.3 years ± 5.1); 97 studies in the anesthesia group (4.4 years ± 3.4) of which 22 had papilledema, and 57 in the non-anesthesia group (12.3 years ± 3.2), of which 28 had papilledema. FIELD STRENGTH/SEQUENCE: 1.5T or 3.0T volumetric T2 images. T2 images were obtained from different vendors. ASSESSMENT: OSD, optic nerve diameter (OND), and peri-optic cerebrospinal fluid (CSF) were measured manually on T2-weighted MR images for various population subgroups (with and without anesthesia; with or without papilledema). The correlation between these measurements and the clinical diagnosis of papilledema was evaluated via receiver operating characteristic (ROC) analysis. STATISTICAL TESTS: Chi-square test; Mann-Whitney Test; Spearman's test and ROCs; Interclass correlation coefficient, P = 0.05. RESULTS: General anesthesia resulted in significantly larger mean OSD in patients with or without papilledema (7.3 ± 1.0 mm vs. 6.1 ± 1.1 mm and 6.7 ± 1.0 mm vs. 5.4 ± 0.9 mm, respectively). In the non-anesthesia group, the average OSD values (6.1 ± 1.1 mm) were significantly higher in papilledema patients compared to non-papilledema patients (5.4 ± 0.9 mm), with larger peri-optic CSF rim (1.6 ± 0.4 mm vs. 1.3 ± 0.3 mm). In the anesthesia group, OND was significantly larger in papilledema patients (3.4 ± 0.4 mm vs. 3.1 ± 0.5 mm), though the average peri-optic CSF rim did not reach a significance in papilledema compared with non-papilledema patients (2.0 ± 0.3 mm vs. 1.8 ± 0.4 mm, P = 0.06). In patients with general anesthesia, peri-optic CSF rim had a limited correlation with increased ICP. DATA CONCLUSION: In the pediatric population, imaging findings of increased OSD on brain MRI might be related to general anesthesia rather than increased ICP. The interpretation of optic nerve sheath distention should be reported cautiously in conjunction with anesthesia status, especially in the pediatric population. EVIDENCE LEVEL: 4 Technical Efficacy: 5.

[THE SURGERY EPIDEMIC AND TIBIAL SHAFT FRACTURES: CONSERVATIVE FUNCTIONAL TREATMENT ALGORITHM FOR TIBIAL SHAFT FRACTURE].

INTRODUCTION: With the emergence in recent years of advanced surgical methods for treatment of diaphyseal fractures of the tibia bone, there appears to be a decline in the familiarity and use of the conservative treatment based on weight bearing casts and early weight bearing. This phenomenon, dubbed "the surgery epidemic" by Dr. Sarmiento, one of the forefathers of tibial fractures treatment, refers to orthopedics surgeons' tendency to treat surgically, even in patients viable for conservative treatment. OBJECTIVES: In this study, we examined all the patients with diaphyseal tibial fracture who were treated at the Orthopedic ward at "Rambam" Hospital in the study period (2012-2016), in order to evaluate the results of the conservative functional treatment, to identify the different stages of said treatment, and to create a clear and accessible protocol for treating physicians. In addition, we sought to examine whether there is a preference for surgical treatment among physicians, even in cases where fracture characteristics, according to accepted criteria, would have allowed for conservative treatment. METHODS: Clinical and radiological evaluation of all patients who arrived with tibia bone fractures to "Rambam" hospital in the study period (2012-2106); identifying patients who fit the criteria for conservative functional treatment and were treated either conservatively or surgically. In those who were treated conservatively we documented the course of their treatment until full recovery. RESULTS: A total of 153 patients with tibial bone fracture were admitted in the study period. Of those patients, 15 were treated according to the conservative functional treatment, 33 were treated surgically despite their adherence to the conservative treatment guidelines. Of all the patients adhering to the conservative treatment criteria (48 patients), only 31.2% were treated conservatively, while 68.8% were treated surgically, unnecessarily, some would say. In other words, 25% of all the patients treated surgically for tibial bone fracture, could have been treated conservatively but instead were treated surgically with internal fixation in accordance to their surgeon's preference. DISCUSSION: In this study we observed a clear preference for surgical treatment in tibial bone fractures, even in cases where the fracture position met the accepted criteria for conservative treatment. We found that the conservative functional treatment, as practiced in our hospital, adheres to the highest standard of care. Taking into account surgery and anesthesia complications, and its added cost to the health care system, we believe it is appropriate to increase awareness among physicians to the possibility and benefits of conservative functional treatment that allows for early weight bearing and patient activity.

Data-Driven Tree Transforms and Metrics.

We consider the analysis of high dimensional data given in the form of a matrix with columns consisting of observations and rows consisting of features. Often the data is such that the observations do not reside on a regular grid, and the given order of the features is arbitrary and does not convey a notion of locality. Therefore, traditional transforms and metrics cannot be used for data organization and analysis. In this paper, our goal is to organize the data by defining an appropriate representation and metric such that they respect the smoothness and structure underlying the data. We also aim to generalize the joint clustering of observations and features in the case the data does not fall into clear disjoint groups. For this purpose, we propose multiscale data-driven transforms and metrics based on trees. Their construction is implemented in an iterative refinement procedure that exploits the co-dependencies between features and observations. Beyond the organization of a single dataset, our approach enables us to transfer the organization learned from one dataset to another and to integrate several datasets together. We present an application to breast cancer gene expression analysis: learning metrics on the genes to cluster the tumor samples into cancer sub-types and validating the joint organization of both the genes and the samples. We demonstrate that using our approach to combine information from multiple gene expression cohorts, acquired by different profiling technologies, improves the clustering of tumor samples.

Scintigraphic characteristics of non-ossifying fibroma in military recruits undergoing bone scintigraphy for suspected stress fractures and lower limb pains.

INTRODUCTION: Non-ossifying fibroma (NOF) is the most common fibrous bone lesion in children and young adults. This benign lesion is not a true neoplasm but is considered a developmental defect. Clinically, the lesion is asymptomatic and has a predilection for the long bones, particularly the femur and the tibia. NOF that ossify can show increased uptake on bone scintigraphy. Although the radiographic and histopathological findings of NOF have been well described, the scintigraphic findings of the abnormality have only been incidentally mentioned in the literature. AIM: To document the scintigraphic features of NOF in a group of military recruits undergoing bone scintigraphy for suspected stress fractures. Features to differentiate co-existent NOF and stress fractures lesions are discussed. MATERIALS AND METHODS: Eighty-three military recruits, 67 male and 16 female, aged 18 to 22 years (mean, 19.4 years), who underwent Tc-methylene diphosphonate bone scans for suspected stress fractures or because of pain of the lower limbs had 91 focal lesions on bone scan which on further evaluation demonstrated characteristic radiographic findings of NOF. We evaluated the anatomical site of the lesions, documented the intensity of uptake on bone scan and compared the findings with the radiographic description of the lesions. Comparison with the characteristic scintigraphic pattern of co-existent stress fracture lesions and with previously reported data was performed. RESULTS: A total of 91 NOF lesions were detected. Overall, 89% of NOF were located about the knee. Anatomic distribution of NOF lesions was as follows: 43 (47.3%, R=25, L=18) were located in the postero-medial aspect of the distal femur, 18 (19.8%, R=12, L=6) in the postero-medial aspect of the proximal tibia, 11 (12%, R=5, L=6) in the postero-lateral aspect of the distal femur, 10 (11%, R=4, L=6) in the postero-lateral aspect of the distal tibia, 4 (4.4%, R=2, L=2) in the postero-lateral aspect of the proximal tibia, 3 (3.3%, L=3) in the antero-central aspect of proximal tibia, 1 (1.1%, L=1) in the antero-lateral aspect of distal femur, 1 (1.1%, L=1) in the medial-central aspect of the proximal tibia. In this series NOF lesions were not found in the fibula. Eighty five of 91 (93.4%) of all NOF were located at the metaphysis of the long bones, 2/91 (2.2%) were located at the meta-diaphyseal region of the long bones and only 4/91 (4.4%) of the lesions were located at the diaphysis. All the NOF showed variable degrees of focal increased tracer uptake on bone scan. The bone scan appearance of the focal lesions was: faint uptake in 29 (31.9%), mild uptake in 27 (29.7%), moderate uptake in 28 (30.7%) and intensely increased uptake in seven (7.7%). The radiographic description of the NOF was: lucent NOF three (3.3%), mixed sclerotic and lucent 68 (74.7%) and sclerotic in 20 (22%). Most of the NOF which demonstrated moderate or intensely increased tracer uptake had mixed lucent and sclerotic radiographic appearance (healing). Most of the sclerotic lesions (healed) showed faint uptake. Co-existent stress fractures were predominantly located in the diaphysis of the long bones, characteristically in the postero-medial aspect of the mid-third of the tibia or femur. CONCLUSIONS: Military recruits undergoing bone scan for suspected stress fracture might have incidental findings which require further evaluation. Focal lesions on bone scan located about the knee in the lateral aspect of the distal femur or lateral aspect of the proximal tibia in the metaphyseal region of these bones are not compatible with the characteristic scintigraphic features of stress fracture. Such a finding should raise the suspicion for other bony lesions such as NOF, which is commonly located in this region. During the healing phase of the NOF which commonly occur in the age range of this group, the lesion shows mild-to-moderate increased tracer uptake on bone scan. Plain film radiography is usually diagnostic and patients are followed up conservatively. Some NOF lesions are still indistinguishable from stress fracture or splints on bone scan.