Bone marrow necrosis in pediatric malignancies: 10-Year retrospective review and review of literature.

Bone marrow necrosis (BMN) is a rare pathologic finding, but when encountered is most often associated with malignancy. In adults, its presence correlates with an inferior prognosis, however in children the prognostic implication is unclear. We performed a retrospective review of 3,760 bone marrow specimens in patients ≤18 years over a 10-year period. BMN was identified in less than 1% of specimens and only in patients with leukemia, lymphoma, or neuroblastoma. BMN contributed to a delay in diagnosis; however, advanced medical imaging may serve as a tool to localize nonnecrotic areas for bone marrow sampling, facilitating an expedited diagnosis.

Implementing an ultrasound-based protocol for diagnosing appendicitis while maintaining diagnostic accuracy.

BACKGROUND: The use of ultrasound to diagnose appendicitis in children is well-documented but not universally employed outside of pediatric academic centers, especially in the United States. Various obstacles make it difficult for institutions and radiologists to abandon a successful and accurate CT-based imaging protocol in favor of a US-based protocol. OBJECTIVE: To describe how we overcame barriers to implementing a US-based appendicitis protocol among a large group of nonacademic private-practice pediatric radiologists while maintaining diagnostic accuracy and decreasing medical costs. MATERIALS AND METHODS: A multidisciplinary team of physicians (pediatric surgery, pediatric emergency medicine and pediatric radiology) approved an imaging protocol using US as the primary modality to evaluate suspected appendicitis with CT for equivocal cases. The protocol addressed potential bias against US and accommodated for institutional limitations of radiologist and sonographer experience and availability. Radiologists coded US reports according to the probability of appendicitis. Radiology reports were compared with clinical outcomes to assess diagnostic accuracy. During the study period, physicians from each group were apprised of the interim US protocol accuracy results. Problematic cases were discussed openly. RESULTS: A total of 512 children were enrolled and underwent US for evaluation of appendicitis over a 30-month period. Diagnostic accuracy was comparable to published results for combined US/CT protocols. Comparing the first 12 months to the last 12 months of the study period, the proportion of children achieving an unequivocal US result increased from 30% (51/169) to 53% (149/282) and the proportion of children undergoing surgery based solely on US findings increased from 55% (23/42) to 84% (92/109). Overall, 63% (325/512) of patients in the protocol did not require a CT. Total patient costs were reduced by $30,182 annually. CONCLUSION: We overcame several barriers to implementing a US protocol. During the study period our ability to visualize the appendix with US increased and utilization of CT decreased. Our overall diagnostic accuracy with the US-based protocol was comparable to other published results and remained unchanged throughout the study.

Pulmonary Manifestations of Inflammatory Bowel Disease in Children.

The recognition of pulmonary manifestations of inflammatory bowel disease (IBD) is important as these diseases can be confused with infectious etiologies (e.g., tuberculosis or fungal infection) and, as a result, may unnecessarily delay institution of appropriate therapy (e.g., infliximab). Furthermore, they are a source of morbidity that may be overlooked and, like other IBD-related pathologies, are often responsive to treatment with corticosteroids, immunomodulators, or biologic therapies. The purpose of this paper is to describe the cases of six children at a single institution with differing presentations, treatments, and responses to treatment of their IBD-related lung disease to improve recognition of this uncommon process.

MRI findings after successful vertebroplasty.

BACKGROUND AND PURPOSE: Recurrent or residual back pain after vertebroplasty (VP) is common, and many patients with these symptoms are evaluated by MRI. The purpose of this report is to describe post-treatment MRI findings after successful VP. METHODS: We identified all patients who underwent VP at our institution and later presented with back pain and had a spine MRI. From these patients, we identified a cohort with uncomplicated procedures, in whom back pain at the site of the VP was not the dominant pain source at follow-up. Using the pre- and postoperative MRIs and the VP conventional radiographs, we assessed such features as interval height loss and changes in marrow edema in treated vertebrae. RESULTS: Thirty patients (51 treated vertebrae) met our clinical criteria for uncomplicated VP. Nine (18%) of 51 vertebrae lost additional height after the procedure. Neither patient demographics nor variables associated with the procedure itself, including volume of cement injected, correlated with additional height loss after VP. Moderate or severe marrow edema was demonstrated in 62% of vertebrae on preoperative MRI and in 33% of vertebrae on follow-up MRI. Twenty-one percent of vertebrae had new areas of marrow edema on follow-up. Twenty-two percent of vertebrae imaged >6 months after VP had moderate or severe edema. CONCLUSION: Progressive and persistent edema and interval height loss after successful VP are common and should not be interpreted as sufficient evidence of ongoing pathology at the treated vertebral level.