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1.
Int J Cancer ; 2024 Jul 08.
Artículo en Inglés | MEDLINE | ID: mdl-38973574

RESUMEN

The objective of this study is to report the long-term timing and patterns of relapse for children enrolled in Children's Oncology Group AREN0534, a multicenter phase III clinical trial conducted from 2009 to 2015. Participants included children with bilateral Wilms tumor (BWT) or unilateral WT with genetic predisposition to develop BWT followed for up to 10 years. Smoothed hazard (risk) functions for event-free survival (EFS) were plotted so that the timing of events could be visualized, both overall and within pre-specified groups. Two hundred and twenty-two children (190 BWT and 32 unilateral WT with BWT predisposition) were followed for a median of 8.6 years. Fifty events were reported, of which 48 were relapse/progression. The overall 8-year EFS was 75% (95% confidence interval: 69%-83%). The highest risk for an EFS event was immediately after diagnosis with a declining rate over 2 years. A second peak of events was observed around 4 years after diagnosis, and a small number of events were reported until the end of the follow-up period. In subset analyses, later increases in risk were more commonly observed in patients with female sex, anaplastic histology, negative lymph nodes or margins, and favorable histology Wilms tumor patients with post-chemotherapy intermediate risk. Among relapses that occurred after 2 years, most were to the kidney. These patterns suggest that late events may be second primary tumors occurring more commonly in females, although more investigation is required. Clinicians may consider observation of patients with BWT beyond 4 years from diagnosis.

2.
AJR Am J Roentgenol ; 2024 May 22.
Artículo en Inglés | MEDLINE | ID: mdl-38775436

RESUMEN

Background: Pancreatic duct (PD) or common bile duct (CBD) dilatation can indicate ductal pathology, but limited data describe normal pediatric duct measurements on routine 2D MR sequences. Objective: To characterize the visibility and diameter of the PD and CBD on 2D MR images in children without pancreaticobiliary disease. Methods: This retrospective study included patients who underwent abdominal MRI using a rapid protocol (comprised of noncontrast axial and coronal 2D SSFSE sequences) to assess for suspected appendicitis or ovarian torsion in the emergency department setting between January 23, 2023, and September 13, 2023, excluding patients with a pancreatic or hepatobiliary abnormality on MRI or laboratory assessment. Four radiologists independently reviewed examinations. Reviewers recorded PD visibility in each of four segments (head, neck, body, and tail) and CBD visibility, and measured PD diameter in each segment and maximal CBD diameter. Duct measurements by age were characterized by linear regression analyses. Results: The study included 177 patients [112 female, 65 female; mean age, 12.3±3.4 years (range, 5.1-17.7 years)]. The observers reported PD visibility in the head in 32.5-93.5%, neck in 18.4-71.5%, body in 22.3-69.8%, and tail in 7.3-25.7%, and in all four segments in 6.2-22.4%, of patients. Maximum PD diameter in any segment, as a mean across observers, was 1.8 mm (range across observers, 0.7-3.5 mm). Expected maximal PD diameter in any segment, in terms of the 5th and 95th percentile values of observers' mean measurements, was 1.4-2.3 mm; the prediction interval's upper limit increased from age 5 to 17 from 2.1 to 2.5 mm. All observers reported CBD visibility in all patients. Mean CBD diameter across observers was 3.1 mm (range across observers, 2.9-3.4 mm). Expected CBD diameter, in terms of the 5th and 95th percentile values of observers' mean measurements, was 2.3-4.9 mm; the prediction interval's upper limit increased from age 5 to 17 from 3.9 to 5.0 mm. Conclusion: We report expected upper limits for PD and CBD measurements on 2D MR images in children without evidence of pancreaticobiliary disease. Clinical Impact: These findings may aid radiologists' identification of pancreaticobiliary duct abnormalities on routine abdominal MRI examinations.

3.
AJR Am J Roentgenol ; 222(1): e2329812, 2024 01.
Artículo en Inglés | MEDLINE | ID: mdl-37530398

RESUMEN

BACKGROUND. Radiologists have variable diagnostic performance and considerable interreader variability when interpreting MR enterography (MRE) examinations for suspected Crohn disease (CD). OBJECTIVE. The purposes of this study were to develop a machine learning method for predicting ileal CD by use of radiomic features of ileal wall and mesenteric fat from noncontrast T2-weighted MRI and to compare the performance of the method with that of expert radiologists. METHODS. This single-institution study included retrospectively identified patients who underwent MRE for suspected ileal CD from January 1, 2020, to January 31, 2021, and prospectively enrolled participants (patients with newly diagnosed ileal CD or healthy control participants) from December 2018 to October 2021. Using axial T2-weighted SSFSE images, a radiologist selected two slices showing greatest terminal ileal wall thickening. Four ROIs were segmented, and radiomic features were extracted from each ROI. After feature selection, support-vector machine models were trained to classify the presence of ileal CD. Three fellowship-trained pediatric abdominal radiologists independently classified the presence of ileal CD on SSFSE images. The reference standard was clinical diagnosis of ileal CD based on endoscopy and biopsy results. Radiomic-only, clinical-only, and radiomic-clinical ensemble models were trained and evaluated by nested cross-validation. RESULTS. The study included 135 participants (67 female, 68 male; mean age, 15.2 ± 3.2 years); 70 were diagnosed with ileal CD. The three radiologists had accuracies of 83.7% (113/135), 88.1% (119/135), and 86.7% (117/135) for diagnosing CD; consensus accuracy was 88.1%. Interradiologist agreement was substantial (κ = 0.78). The best-performing ROI was bowel core (AUC, 0.95; accuracy, 89.6%); other ROIs had worse performance (whole-bowel AUC, 0.86; fat-core AUC, 0.70; whole-fat AUC, 0.73). For the clinical-only model, AUC was 0.85 and accuracy was 80.0%. The ensemble model combining bowel-core radiomic and clinical models had AUC of 0.98 and accuracy of 93.5%. The bowel-core radiomic-only model had significantly greater accuracy than radiologist 1 (p = .009) and radiologist 2 (p = .02) but not radiologist 3 (p > .99) or the radiologists in consensus (p = .05). The ensemble model had greater accuracy than the radiologists in consensus (p = .02). CONCLUSION. A radiomic machine learning model predicted CD diagnosis with better performance than two of three expert radiologists. Model performance improved when radiomic data were ensembled with clinical data. CLINICAL IMPACT. Deployment of a radiomic-based model including T2-weighted MRI data could decrease interradiologist variability and increase diagnostic accuracy for pediatric CD.


Asunto(s)
Enfermedad de Crohn , Enfermedades del Íleon , Niño , Humanos , Masculino , Femenino , Adolescente , Imagen por Resonancia Magnética/métodos , Estudios Retrospectivos , Radiómica , Aprendizaje Automático
4.
Emerg Infect Dis ; 29(11): 2382-2385, 2023 11.
Artículo en Inglés | MEDLINE | ID: mdl-37877613

RESUMEN

We describe a case of New Delhi metallo-ß-lactamase 1-producing carbapenem-resistant Pseudomonas aeruginosa (CRPA) in a transplant patient with multiple hospitalizations in California, USA. Whole-genome sequencing revealed the isolate was genetically distinctive, despite ≈95% similarity to other global strains. The patient's lack of international travel suggests this CRPA was acquired domestically.


Asunto(s)
Infecciones por Pseudomonas , Pseudomonas aeruginosa , Humanos , Pseudomonas aeruginosa/genética , beta-Lactamasas/genética , Secuenciación Completa del Genoma , Pruebas de Sensibilidad Microbiana , Antibacterianos/farmacología , Antibacterianos/uso terapéutico , Infecciones por Pseudomonas/epidemiología
5.
Pediatr Blood Cancer ; 70 Suppl 4: e30004, 2023 06.
Artículo en Inglés | MEDLINE | ID: mdl-36308415

RESUMEN

Malignant renal tumors account for approximately 6% of pediatric malignancies, with Wilms tumor (WT) representing approximately 90% of pediatric renal tumors. This paper provides consensus-based imaging guidelines for the initial evaluation of a child with suspected WT and follow-up during and after therapy co-developed by the Children's Oncology Group (COG) Diagnostic Imaging and Society for Pediatric Radiology (SPR) oncology committees. The guidelines for Wilms Tumor Imaging in the Society of International Pediatric Oncology (SIOP) are briefly discussed to highlight some of the differences in imaging approach.


Asunto(s)
Neoplasias Renales , Radiología , Tumor de Wilms , Niño , Humanos , Descanso , Resonancia por Plasmón de Superficie , Neoplasias Renales/patología , Tumor de Wilms/diagnóstico por imagen , Tumor de Wilms/terapia , Tumor de Wilms/patología , Radiografía
6.
Pediatr Blood Cancer ; 70 Suppl 2: e30080, 2023 05.
Artículo en Inglés | MEDLINE | ID: mdl-36349564

RESUMEN

Malignant renal tumors are rare in children, and Wilms tumors (WTs) are the most common subtype. Imaging plays an essential role in the diagnosis, staging, and follow-up of these patients. Initial workup for staging is mainly performed by cross-sectional imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI). Imaging approach within the two core international groups, the Children's Oncology Group (COG, North America) and the International Society of Pediatric Oncology - Renal Tumor Study Group (SIOP-RTSG, Europe), differs. Whereas abdominal ultrasound (US) is used for the initial diagnosis of a suspected pediatric renal tumor globally, COG protocols support the use of CT or MRI for locoregional staging, contrary to the preference for MRI over CT for abdominopelvic evaluation within the SIOP-RTSG. The purpose of this manuscript is to summarize current imaging approaches, highlighting differences and similarities within these core international groups, while focusing on future innovative efforts and collaboration within the HARMONICA initiative.


Asunto(s)
Neoplasias Renales , Tumor de Wilms , Niño , Humanos , Neoplasias Renales/patología , Tumor de Wilms/patología , Tomografía Computarizada por Rayos X , Europa (Continente) , Estadificación de Neoplasias
7.
AJR Am J Roentgenol ; 220(1): 126-133, 2023 01.
Artículo en Inglés | MEDLINE | ID: mdl-35946860

RESUMEN

BACKGROUND. The simplified MR index of activity (MaRIA) score is used to assess the severity of small-bowel inflammation without use of IV contrast material. OBJECTIVE. The purposes of this study were to assess interreader agreement on the use of simplified MaRIA scores for evaluation of the inflammatory activity of terminal ileal Crohn disease in children and young adults and to assess whether simplified MaRIA scores change after biologic medical therapy. METHODS. This analysis was ancillary to a previously reported primary prospective research investigation. The study included 20 children and young adults with newly diagnosed ileal Crohn disease and 15 healthy control participants who underwent research small-bowel MRI examinations between December 2018 and October 2021. The participants with Crohn disease underwent baseline MRI and MRI 6 weeks and 6 months after beginning anti-tumor necrosis factor α-treatment as well as weighted pediatric Crohn disease activity index (wPCDAI) and C-reactive protein (CRP) assessment on the day of each examination. Control participants underwent one MRI examination. Four pediatric radiologists independently assigned simplified MaRIA scores using axial and coronal T2-weighted SSFSE images. Median simplified MaRIA score among readers was computed. Interreader agreement was assessed with Fleiss kappa coefficients and intra-class correlation coefficient (ICC). Analysis included the Mann-Whitney U test, Friedman test, and Spearman rank correlation. RESULTS. Simplified MaRIA scores (across time points and study groups) had substantial interreader agreement (κ = 0.65 [95% CI, 0.56-0.74]; ICC, 0.71 [95% CI, 0.63-0.78]). Median scores were higher in participants with Crohn disease at baseline than in healthy control participants (3.5 [IQR, 2.5-4.9] vs 0.5 [IQR, 0-2.0]; p < .001). Scores decreased after medical treatment in participants with Crohn disease (p = .005). The median score was 3.5 (IQR, 2.5-4.9) at baseline, 2.3 (IQR, 1.6-3.9) at 6 weeks, and 2.0 (IQR, 0.5-2.5) at 6 months. In participants with Crohn disease, median scores had significant correlations with wPCDAI (ρ = 0.46 [95% CI, 0.18-0.64]; p < .001) and CRP level (ρ = 0.48 [95% CI, 0.27-0.65]; p < .001). CONCLUSION. Radiologists had substantial agreement in use of simplified MaRIA scores to assess intestinal inflammation in ileal Crohn disease. Scores changed over time after medical therapy. CLINICAL IMPACT. The results support the simplified MaRIA score as an objective MRI-based clinical measure of intestinal inflammation in children and young adults with Crohn disease.


Asunto(s)
Enfermedad de Crohn , Adulto Joven , Humanos , Niño , Enfermedad de Crohn/diagnóstico por imagen , Enfermedad de Crohn/patología , Estudios Prospectivos , Intestino Delgado/diagnóstico por imagen , Intestino Delgado/patología , Imagen por Resonancia Magnética/métodos , Inflamación
8.
Pediatr Blood Cancer ; 68(5): e28920, 2021 05.
Artículo en Inglés | MEDLINE | ID: mdl-33644927

RESUMEN

INTRODUCTION: Diffuse liver lesions in an infant have a differential diagnosis including infantile hemangioma (IH), which is common in the first year of life, and neuroblastoma (NBL) which presents at a median age of 18 months. RESULTS: We describe the case of a 4-month-old girl with a known superficial/deep IH who presented with new axillary nodules and hepatosplenomegaly, initially suspected to reflect IH but later determined to be widely metastatic NBL. CONCLUSION: Hepatic IH and metastatic NBL can present similarly. Clinicians must maintain a broad differential when evaluating new findings in a patient with previously diagnosed IH.


Asunto(s)
Hemangioma/patología , Neoplasias Hepáticas/patología , Neoplasias Primarias Múltiples/diagnóstico , Neuroblastoma/patología , Neoplasias Cutáneas/patología , Diagnóstico Diferencial , Femenino , Humanos , Lactante , Neoplasias Hepáticas/diagnóstico , Neoplasias Primarias Múltiples/patología , Neuroblastoma/diagnóstico
9.
Am J Emerg Med ; 50: 160-166, 2021 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-34365066

RESUMEN

STUDY OBJECTIVE: Determine whether an expanded emergency medicine (EM) pharmacist scope of practice reduces the frequency of major delays in subsequent antibiotic administration in patients boarded in the emergency department (ED). METHODS: A pre-post, quasi-experimental study conducted from November 2019-March 2020 at a single-center tertiary academic medical center following the implementation of an expanded EM pharmacist scope of practice. Adult patients were included if they received an initial antibiotic dose in the ED and deemed to be high-risk. Subsequent antibiotic doses were reordered by EM pharmacists for up to 24-h after the initial order pending ED length of stay (LOS). The historical control group consisted of retrospective chart review of cases from the previous year. RESULTS: The study identified that of the 181 participants enrolled, major delays in subsequent antibiotic administration occurred in 13% of the intervention group and 48% of the control group (p < 0.01). When compared to the control group, the intervention group had a significant decrease in the number of delays among antibiotics dosed at 6-h (39% vs 13%) and 8-h (60% vs 8%) intervals. For antibiotics dosed at 12-h intervals, no statistically significant difference was observed between the control and intervention groups respectively (19% vs 5%). A statistically significant lower incidence of in-hospital mortality was observed in the intervention group (3% vs 11%, p = 0.02). In the intervention group, 97% of patients received subsequent antibiotic doses while boarded in the ED, compared to 65% in the control group (<0.01). CONCLUSION: Expanding EM pharmacist scope of practice was associated with a significant reduction in the frequency of major delays in subsequent antibiotic administration as well as a decreased incidence of hospital mortality.


Asunto(s)
Antibacterianos/uso terapéutico , Servicio de Urgencia en Hospital , Neumonía/tratamiento farmacológico , Pautas de la Práctica Farmacéutica/estadística & datos numéricos , Sepsis/tratamiento farmacológico , Anciano , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino
10.
Pediatr Radiol ; 51(7): 1231-1236, 2021 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-33544191

RESUMEN

BACKGROUND: Salter-Harris 2 fractures of the distal radius are common in pediatrics. Children with these fractures have a theoretical risk of developing a physeal bridge with subsequent growth disturbance. OBJECTIVE: The purpose of this study was to investigate the clinical utility and economic impact of obtaining routine delayed radiographs in asymptomatic patients with uncomplicated Salter-Harris 2 fractures of the distal radius. MATERIALS AND METHODS: Radiology records were searched retrospectively between Jan. 1, 2016, and Jan. 1, 2018, to identify patients with an acute Salter-Harris type 2 fracture of the distal radius and delayed wrist radiography 3 to 8 months after the injury. Exclusion criteria included distal radius surgery, clinical symptoms, secondary wrist trauma or a history of infection. The financial cost associated with follow-up imaging was determined based on standard charges associated with wrist/forearm radiography, wrist magnetic resonance imaging (MRI) and orthopedic clinical care. RESULTS: A total of 381 children with Salter-Harris 2 fractures of the distal radius and delayed radiographs were identified, 56% male (ages 1-18 years, mean: 9.8 years). Four children were excluded because of surgical intervention or clinical symptoms to the same wrist resulting in 377 subjects. There were five confirmed positive cases (1.3%) of distal radius physeal bridge formation, with four cases confirmed on MRI and one case confirmed clinically and radiographically. Based on routine institutional charges for the wrist/forearm radiographs and orthopedic clinic visits, the total billed charges for the 377 patients would equal $245,804, or $49,161 in billed charges per identified physeal bridge. Only three of the five positive cases of confirmed physeal bridge went on to surgical treatment. The billed charges per identified physeal bridge requiring surgery were $81,935. CONCLUSION: In asymptomatic children with uncomplicated Salter-Harris 2 fractures of the distal radius, detection of a physeal bridge on delayed radiographs is rare. The financial burden of routine delayed follow-up in asymptomatic patients, a common clinical practice, is an important consideration.


Asunto(s)
Fracturas del Radio , Fracturas de Salter-Harris , Adolescente , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Lactante , Masculino , Radiografía , Radio (Anatomía)/diagnóstico por imagen , Fracturas del Radio/diagnóstico por imagen , Estudios Retrospectivos
11.
Lancet Oncol ; 21(8): 1110-1122, 2020 08.
Artículo en Inglés | MEDLINE | ID: mdl-32702309

RESUMEN

BACKGROUND: Outcomes for children and adults with advanced soft tissue sarcoma are poor with traditional therapy. We investigated whether the addition of pazopanib to preoperative chemoradiotherapy would improve pathological near complete response rate compared with chemoradiotherapy alone. METHODS: In this joint Children's Oncology Group and NRG Oncology multicentre, randomised, open-label, phase 2 trial, we enrolled eligible adults (aged ≥18 years) and children (aged between 2 and <18 years) from 57 hospitals in the USA and Canada with unresected, newly diagnosed trunk or extremity chemotherapy-sensitive soft tissue sarcoma, which were larger than 5 cm in diameter and of intermediate or high grade. Eligible patients had Lansky (if aged ≤16 years) or Karnofsky (if aged >16 years) performance status score of at least 70. Patients received ifosfamide (2·5 g/m2 per dose intravenously on days 1-3 with mesna) and doxorubicin (37·5 mg/m2 per dose intravenously on days 1-2) with 45 Gy preoperative radiotherapy, followed by surgical resection at week 13. Patients were randomly assigned (1:1) using a web-based system, in an unmasked manner, to receive oral pazopanib (if patients <18 years 350 mg/m2 once daily; if patients ≥18 years 600 mg once daily) or not (control group), with pazopanib not given immediately before or after surgery at week 13. The study projected 100 randomly assigned patients were needed to show an improvement in the number of participants with a 90% or higher pathological response at week 13 from 40% to 60%. Analysis was done per protocol. This study has completed accrual and is registered with ClinicalTrials.gov, NCT02180867. FINDINGS: Between July 7, 2014, and Oct 1, 2018, 81 eligible patients were enrolled and randomly assigned to the pazopanib group (n=42) or the control group (n=39). At the planned second interim analysis with 42 evaluable patients and a median follow-up of 0·8 years (IQR 0·3-1·6) in the pazopanib group and 1 year (0·3-1·6) in the control group, the number of patients with a 90% pathological response or higher was 14 (58%) of 24 patients in the pazopanib group and four (22%) of 18 patients in the control group, with a between-group difference in the number of 90% or higher pathological response of 36·1% (83·8% CI 16·5-55·8). On the basis of an interim analysis significance level of 0·081 (overall one-sided significance level of 0·20, power of 0·80, and O'Brien-Fleming-type cumulative error spending function), the 83·8% CI for response difference was between 16·5% and 55·8% and thus excluded 0. The improvement in pathological response rate with the addition of pazopanib crossed the predetermined boundary and enrolment was stopped. The most common grade 3-4 adverse events were leukopenia (16 [43%] of 37 patients), neutropenia (15 [41%]), and febrile neutropenia (15 [41%]) in the pazopanib group, and neutropenia (three [9%] of 35 patients) and febrile neutropenia (three [9%]) in the control group. 22 (59%) of 37 patients in the pazopanib group had a pazopanib-related serious adverse event. Paediatric and adult patients had a similar number of grade 3 and 4 toxicity. There were seven deaths (three in the pazopanib group and four in the control group), none of which were treatment related. INTERPRETATION: In this presumed first prospective trial of soft tissue sarcoma spanning nearly the entire age spectrum, adding pazopanib to neoadjuvant chemoradiotherapy improved the rate of pathological near complete response, suggesting that this is a highly active and feasible combination in children and adults with advanced soft tissue sarcoma. The comparison of survival outcomes requires longer follow-up. FUNDING: National Institutes of Health, St Baldrick's Foundation, Seattle Children's Foundation.


Asunto(s)
Antineoplásicos/administración & dosificación , Quimioradioterapia/métodos , Terapia Neoadyuvante/métodos , Pirimidinas/administración & dosificación , Sarcoma/tratamiento farmacológico , Neoplasias de los Tejidos Blandos/tratamiento farmacológico , Sulfonamidas/administración & dosificación , Adolescente , Adulto , Antineoplásicos/efectos adversos , Quimioradioterapia/efectos adversos , Quimioterapia Adyuvante/efectos adversos , Quimioterapia Adyuvante/métodos , Niño , Preescolar , Femenino , Humanos , Indazoles , Masculino , Persona de Mediana Edad , Terapia Neoadyuvante/efectos adversos , Pirimidinas/efectos adversos , Radioterapia Adyuvante , Sarcoma/radioterapia , Neoplasias de los Tejidos Blandos/radioterapia , Sulfonamidas/efectos adversos , Adulto Joven
12.
Clin Infect Dis ; 71(12): 3168-3173, 2020 12 15.
Artículo en Inglés | MEDLINE | ID: mdl-32575124

RESUMEN

BACKGROUND: Preliminary data from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia patients indicate that a cytokine storm may increase morbidity and mortality. Tocilizumab (anti-IL-6R) is approved by the Food and Drug Administration for treatment of cytokine storm associated with chimeric antigen receptor T-cell therapy. Here we examined compassionate use of tocilizumab in patients with SARS-CoV-2 pneumonia. METHODS: We report on a single-center study of tocilizumab in hospitalized patients with SARS-CoV-2 pneumonia. All patients had confirmed SARS-CoV-2 pneumonia and oxygen saturations <90% on oxygen support with most intubated. We examined clinical and laboratory parameters including oxygen and vasopressor requirements, cytokine profiles, and C-reactive protein (CRP) levels pre- and post-tocilizumab treatment. RESULTS: Twenty-seven SARS-CoV-2 pneumonia patients received one 400 mg dose of tocilizumab. Interleukin (IL)-6 was the predominant cytokine detected at tocilizumab treatment. Significant reductions in temperature and CRP were seen post-tocilizumab. However, 4 patients did not show rapid CRP declines, of whom 3 had poorer outcomes. Oxygen and vasopressor requirements diminished over the first week post-tocilizumab. Twenty-two patients required mechanical ventilation; at last follow-up, 16 were extubated. Adverse events and serious adverse events were minimal, but 2 deaths (7.4%) occurred that were felt unrelated to tocilizumab. CONCLUSIONS: Compared to published reports on the morbidity and mortality associated with SARS-CoV-2, tocilizumab appears to offer benefits in reducing inflammation, oxygen requirements, vasopressor support, and mortality. The rationale for tocilizumab treatment is supported by detection of IL-6 in pathogenic levels in all patients. Additional doses of tocilizumab may be needed for those showing slow declines in CRP. Proof of efficacy awaits randomized, placebo-controlled clinical trials.


Asunto(s)
COVID-19 , SARS-CoV-2 , Adulto , Anciano , Anciano de 80 o más Años , Anticuerpos Monoclonales Humanizados , Ensayos de Uso Compasivo , Humanos , Masculino , Persona de Mediana Edad , Resultado del Tratamiento
13.
AJR Am J Roentgenol ; 214(4): 917-922, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32023119

RESUMEN

OBJECTIVE. The objective of our study was to assess whether secretin improves visualization of a nondilated pancreatic duct and whether it increases identification of variant duct anatomy on MRCP in pediatric patients. MATERIALS AND METHODS. This study is a delayed retrospective review of MRCP images that were prospectively obtained of 50 volunteers without a history of pancreatic disease who ranged in age from 6 to 15 years old. MRCP images (coronal 3D fast recovery fast spin-echo [FSE] and coronal single-shot FSE fat-saturated sequences) obtained before and after secretin administration were separated for review by three radiologists (reviewers 1-3). The reviewers were blinded to the purpose of the study and to secretin administration. Reviewers ranked subjective image quality (Likert scale, 1-5 points) and reported pancreaticobiliary duct anatomy and duct visibility (yes or no). Paired t tests were used for comparison of means, and the chi-square test or Fisher exact test was used for comparison of frequencies. Sensitivity and specificity of MRCP images obtained before secretin administration were judged against MRCP images obtained after secretin administration as the reference standard. RESULTS. The frequency of image quality scores of 4 or greater assigned to 3D MRCP images was statistically significantly greater after secretin administration for reviewer 2 (p < 0.0001) and reviewer 3 (p = 0.005) and approached statistical significance for reviewer 1 (p = 0.052). Mean number of visible pancreatic duct segments (head and uncinate, body, tail) was significantly greater on the MRCP images obtained after secretin administration than on those obtained before secretin administration for all reviewers (reviewer 1, 1.9 vs 1.3; reviewer 2, 1.9 vs 1.2; reviewer 3, 1.4 vs 0.8; all, p < 0.01). For all three reviewers, the sensitivity of MRCP images obtained before secretin administration was poor for variant pancreatic ductal anatomy (reviewer 1, 37.5%; reviewer 2, 50.0%; reviewer 3, 40.0%). CONCLUSION. Secretin administration improved subjective MRCP image quality, improved subjective visualization of the pancreatic duct, and provided greater sensitivity for anatomic variants such as pancreas divisum in a cohort of children with nondilated pancreatic ducts.


Asunto(s)
Pancreatocolangiografía por Resonancia Magnética , Aumento de la Imagen/métodos , Enfermedades Pancreáticas/diagnóstico por imagen , Conductos Pancreáticos/diagnóstico por imagen , Secretina/administración & dosificación , Adolescente , Niño , Femenino , Humanos , Masculino , Estudios Retrospectivos
14.
AJR Am J Roentgenol ; 214(5): 987-994, 2020 05.
Artículo en Inglés | MEDLINE | ID: mdl-32160052

RESUMEN

OBJECTIVE. Distinguishing nephrogenic rests from small Wilms tumors can be challenging. This retrospective study was performed to determine if imaging characteristics can be used to distinguish nephrogenic rests from Wilms tumors. MATERIALS AND METHODS. All cases of pathologically confirmed nephrogenic rests and Wilms tumors smaller than 5 cm in maximum dimension on imaging in patients younger than 5 years old were identified from the Children's Oncology Group AREN03B2 study (July 2006-August 2016). Exclusion criteria were chemotherapy before pathologic evaluation or more than 30 days between imaging and surgery; in addition, patients with nephrogenic rests occurring within or juxtaposed to a Wilms tumor and patients with diffuse hyperplastic perilobar nephroblastomatosis were excluded. Two radiologists who were blinded to pathology results assessed all lesions. The two-sample t test was used for continuous variables, and the Fisher exact test was used for categoric variables. ROC analysis was performed to determine the optimal size cutoff for distinguishing between nephrogenic rests and Wilms tumors. RESULTS. Thirty-one pathologically confirmed rests (20 perilobar, 11 intralobar) and 26 Wilms tumors smaller than 5 cm met the eligibility criteria for study inclusion. The median diameter of the nephrogenic rests was 1.3 cm (range, 0.7-3.4 cm) and the median diameter of the Wilms tumor was 3.2 cm (range, 1.8-4.9 cm) (p < 0.001). Imaging findings supportive of Wilms tumors were spherical (p < 0.001) and exophytic (p < 0.001) lesions. Perilobar rests (17/20) were more likely to be homogeneous than intralobar rests (3/11) or Wilms tumor (3/26) (p < 0.001). ROC analysis showed that the optimal size cutoff for distinguishing between nephrogenic rests and Wilms tumors was 1.75 cm. CONCLUSION. In children younger than 5 years old, the diagnosis of a Wilms tumor should be favored over a nephrogenic rest when a renal mass is spherical, exophytic, or larger than 1.75 cm. Homogeneity favors the diagnosis of perilobar nephrogenic rests, whereas intralobar rests and Wilms tumors are more likely to be inhomogeneous.


Asunto(s)
Neoplasias Renales/diagnóstico por imagen , Riñón/patología , Lesiones Precancerosas/diagnóstico por imagen , Tumor de Wilms/diagnóstico por imagen , Preescolar , Diagnóstico Diferencial , Femenino , Humanos , Lactante , Neoplasias Renales/patología , Masculino , Estudios Retrospectivos
15.
Radiographics ; 40(7): 2068-2079, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33136480

RESUMEN

Ineffective communication is commonly listed as a root cause of sentinel events and other adverse events in the health care setting. The psychological safety of all employees is considered to be a factor that promotes effective communication. Recently, leaders of a radiology department learned that many of the frontline staff did not feel they were being treated respectfully by radiologists during routine interactions. On a baseline survey, only 48% of technologists, reading room assistants, and child life specialists rated their interactions with radiologists as very good or excellent. An improvement team was formed, representing radiologists, technologists, reading room assistants, and child life specialists throughout the department. The improvement team launched a series of interventions with a goal of increasing the percentage of interactions rated as very good or excellent from 48% to 90%. The improvement team focused interventions on three topics: in-person interactions, telephone interactions, and trainee interactions. By the time of this publication, the median percentage of interactions rated as very good or excellent improved to 75%, with a maximum surveyed value of 90%.Online supplemental material is available for this article.©RSNA, 2020.


Asunto(s)
Comunicación Interdisciplinaria , Mejoramiento de la Calidad , Radiólogos , Servicio de Radiología en Hospital , Adulto , Femenino , Hospitales Pediátricos , Humanos , Masculino , Encuestas y Cuestionarios
16.
Pediatr Surg Int ; 36(9): 1055-1060, 2020 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-32666296

RESUMEN

PURPOSE: The key landmark for tip position of a central venous catheter (CVC) is the SVC-RA junction. In adults, localization of the SVC-RA junction may be assessed as a function of vertebral body units (VBU) below the carina during CVC placement. We investigated the relationship between the SVC-RA junction and the carina in children. MATERIALS AND METHODS: 584 CT scans of 0-18 years were analyzed. The carina was marked automatically by software while the SVC-RA junction and vertebrae were marked manually. The SVC-RA junction to carina (JC) distance was the primary study measurement reported in both VBU and mm. RESULTS: The data show an average JC distance of 1.25 VBU for 0-1 year, 1.27 VBU for 1-4 years, 1.34 VBU for 4-9 years, 1.53 VBU for 9-15 years, and 1.64 VBU for 15-18 years. A positive relationship between weight and JC distance was also demonstrated. CONCLUSION: JC distance is a useful predictor of SVC-RA junction location in children. Significant relationships were shown between JC distance and both age and weight. Due to small differences between age groups, however, average JC distance for all comers (1.48 VBU, 95% CI 0.7 - 2.3) can be used for SVC-RA junction identification in CVC placement.


Asunto(s)
Cateterismo Venoso Central/métodos , Catéteres Venosos Centrales , Imagenología Tridimensional/métodos , Tomografía Computarizada por Rayos X/métodos , Tráquea/diagnóstico por imagen , Vena Cava Superior/diagnóstico por imagen , Cuerpo Vertebral/diagnóstico por imagen , Adolescente , Niño , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Reproducibilidad de los Resultados , Esternón/diagnóstico por imagen
17.
Pediatr Radiol ; 49(11): 1441-1452, 2019 10.
Artículo en Inglés | MEDLINE | ID: mdl-31620845

RESUMEN

Wilms tumor is the most common pediatric renal tumor, accounting for approximately 7% of all childhood cancers. Imaging plays an important role in the detection, staging, post-therapy evaluation and surveillance of Wilms tumor. Wilms tumor can be detected during surveillance of a known cancer predisposition or after a child presents with symptoms. In this manuscript we describe an evidence-based approach to the initial evaluation of Wilms tumor using current guidelines from the Children's Oncology Group (COG). We illustrate the COG staging system for pediatric renal tumors and highlight key imaging findings that are critical for surgical management. We also discuss the controversies regarding detection and significance of <5-mm pulmonary nodules at initial staging. And finally, we present some thoughts regarding surveillance of Wilms tumor, where overall survival has now approached 90%.


Asunto(s)
Neoplasias Renales/diagnóstico por imagen , Tumor de Wilms/diagnóstico por imagen , Niño , Diagnóstico Diferencial , Humanos , Neoplasias Renales/patología , Nódulos Pulmonares Múltiples/diagnóstico por imagen , Nódulos Pulmonares Múltiples/patología , Guías de Práctica Clínica como Asunto , Tumor de Wilms/patología
18.
Pediatr Radiol ; 49(2): 196-202, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30382321

RESUMEN

BACKGROUND: Contrast-enhanced magnetic resonance imaging (MRI) has become the gold standard when assessing the temporomandibular joint (TMJ) in children. To our knowledge, no previous pediatric study has compared findings of TMJ MRI with direct visualization of the joint using arthroscopy. OBJECTIVE: To determine if subjective findings on contrast-enhanced MRI of the temporomandibular joint correlate with arthroscopic findings of acute and chronic inflammation of the TMJ in children. MATERIALS AND METHODS: Patients who had temporally related TMJ arthroscopy and contrast-enhanced TMJ MRI between March 2014 and March 2016 were identified. Imaging was retrospectively reviewed by two radiologists for erosions, condyle shape, bone marrow edema, effusion, severity of synovitis, joint space width measured in the coronal plane and enhancement ratio of the synovium relative to ipsilateral temporal lobe white matter. Joint space width was included because synovial thickening could widen the joint space. TMJ arthroscopy findings assessed included indicators of acute inflammation (active synovitis, number of joint sites affected, presence of retrodiscitis) and markers of chronic inflammation (hyperplastic synovitis, adhesions, disc perforation, chondromalacia). A Total Synovitis Score was given to all patients on arthroscopy, which multiplied the severity of active synovitis (0-4) with the number of joint recesses affected. Data were compared using the Fisher exact test and a P-value <0.05 was considered significant. RESULTS: There was no significant correlation between subjective synovitis on MRI and active synovitis on arthroscopy; however, there was a significant correlation between joint space width and hyperplastic synovitis (P=0.04, 3.7 mm±0.8 vs. 2.9 mm±0.6) and a trend toward significance between subjective synovitis (P=0.08) and enhancement ratio of synovium (P=0.06) on MRI and hyperplastic synovitis on arthroscopy. CONCLUSION: Joint space width and subjective synovitis on TMJ MRI correlate with arthroscopic findings of chronic synovitis. Increased joint space width may be useful when evaluating the TMJ with less time-intensive modalities, such as ultrasound. However, MRI findings did not correlate well with findings of acute inflammation on arthroscopy.


Asunto(s)
Artroscopía/métodos , Imagen por Resonancia Magnética/métodos , Sinovitis/diagnóstico por imagen , Trastornos de la Articulación Temporomandibular/diagnóstico por imagen , Adolescente , Niño , Medios de Contraste , Femenino , Humanos , Masculino , Meglumina/análogos & derivados , Compuestos Organometálicos , Estudios Retrospectivos , Adulto Joven
19.
J Surg Res ; 232: 614-620, 2018 12.
Artículo en Inglés | MEDLINE | ID: mdl-30463781

RESUMEN

BACKGROUND: Chemotherapy is used preoperatively for children with bilateral Wilms tumor (BWT) or unilateral high-risk Wilms tumor (UHRWT) to promote tumor regression to facilitate renal preservation with nephron-sparing surgery (NSS). In adults, various surgical techniques have been described to preserve renal tissue. Few studies have examined the use of surgical adjuncts in NSS in children with renal tumors. METHODS: We performed a multi-institutional retrospective review of patients with BWT or UHRWT. Patient demographics, tumor size at diagnosis, following neoadjuvant chemotherapy, utilization of surgical adjuncts including intraoperative ultrasound (IOUS), margin status, complications, renal function, and follow-up were recorded. RESULTS: The cohort comprised 23 patients: 18 BWT, 3 UHRWT, and 2 patients with solitary kidney. Twenty-two of the 23 patients had successful NSS. IOUS was used 19 times, and seven had positive margins after surgery. Cooling/vascular isolation was used six times. At a median follow-up of 18 mo, median estimated glomerular filtration rate Schwartz was 126 mL/min/1.73 m2 and median serum creatinine 0.39 mg/dL in the 22 patients who had successful NSS. There have been no tumor recurrences. CONCLUSIONS: In patients with BWT and UHRWT, surgical adjuncts such as cooling/vascular isolation are uncommonly performed. IOUS may be helpful but does not guarantee negative microscopic margins. LEVEL OF EVIDENCE: Level 4, Case series with no comparison group.


Asunto(s)
Neoplasias Renales/cirugía , Nefronas/cirugía , Tumor de Wilms/cirugía , Niño , Preescolar , Femenino , Tasa de Filtración Glomerular , Humanos , Lactante , Neoplasias Renales/diagnóstico por imagen , Masculino , Estudios Retrospectivos , Tumor de Wilms/diagnóstico por imagen
20.
Pediatr Radiol ; 48(9): 1245-1255, 2018 08.
Artículo en Inglés | MEDLINE | ID: mdl-30078050

RESUMEN

Hepatocyte-specific contrast media are gadolinium chelates that are taken up by hepatocytes and partially cleared via the biliary tree. The absence of lesional uptake of the contrast media in the hepatobiliary phase is a marker of either the absence of hepatocytes or of poorly functioning, neoplastic hepatocytes. Uptake of the contrast media in the hepatobiliary phase, whether equal to or greater than background liver, reflects the presence of hepatocytes but does not equate to absence of neoplasia. Accurate diagnosis of liver lesions utilizing hepatocyte-specific contrast media requires an understanding of the mechanisms of uptake and clearance of the contrast media to avoid misdiagnosis. In this review we discuss the mechanisms of hepatocellular transport of hepatocyte-specific contrast media and utilize an understanding of those mechanisms to discuss the imaging appearance of a subset of hepatocellular lesions that can be seen in the pediatric and young adult liver. We pay particular attention to lesions that appear iso- to hyperintense in the hepatobiliary phase but have the potential for adverse clinical outcomes. We also discuss strategies for identifying these lesions.


Asunto(s)
Medios de Contraste/farmacocinética , Hepatocitos/patología , Hepatopatías/diagnóstico por imagen , Imagen por Resonancia Magnética/métodos , Adolescente , Niño , Humanos , Hepatopatías/patología , Adulto Joven
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