Clinical impact and cost-effectiveness of noncontrast MRI in the evaluation of suspected appendiceal abscesses in children.

BACKGROUND: Noncontrast MRI has been shown to be feasible in children with postappendectomy abscesses and helps guide clinical management, but its role in preoperative appendiceal abscesses is unclear. PURPOSE: To determine the cost-effectiveness and impact on clinical management of noncontrast MRI in pediatric patients with suspected appendiceal abscess, both pre- and postappendectomy. STUDY TYPE: Retrospective cohort study. POPULATION: In all, 82 children under the age of 18 years with suspected appendiceal abscess on ultrasound. FIELD STRENGTH/SEQUENCE: Diffusion-weighted imaging and T2 -weighted single-shot fast spin-echo imaging of the abdomen and pelvis at 1.5T and 3T. ASSESSMENT: The presence, location, size, and apparent diffusion coefficient (ADC) of fluid collections and the presence of a drainage path was noted by three pediatric radiologists. Imaging time, completeness of the exam, and impact on clinical management was recorded. The incremental cost-effectiveness ratio was calculated for MRI relative to CT, taking into account hospital charges, radiation exposure, and risk of adverse reaction to iodinated contrast. STATISTICAL TESTS: Descriptive statistics were used. Intraclass correlation coefficient and Fleiss' kappa were used to assess interobserver variation. Proportions were compared using Fisher's exact test (statistical significance at P < 0.05). RESULTS: MRI confirmed the presence of collections in most cases, with alternative diagnosis established in 10 patients (Tubo-ovarian abscess n = 7, Crohn's disease, ileal anastomotic leak, and Birkitts lymphoma each n = 1). MRI showed the presence of a safe drainage pathway in 92-97% of pelvic abscesses and 86-98% of abdominal abscesses compared with 7-10% and 75-81%, respectively, for ultrasound. MR was cost-effective compared with CT, taking into account the direct charges, risk of radiation induced cancer, and adverse reaction to iodinated contrast. DATA CONCLUSION: Noncontrast MR is cost-effective and affects clinical management in a significant proportion of children with suspected appendiceal abscesses. LEVEL OF EVIDENCE: 5 Technical Efficacy: Stage 6 J. Magn. Reson. Imaging 2019.

Lymphedema after upper limb transplantation: scintigraphic study in 3 patients.

Lymphatic vasculature is known to spontaneously reconnect after hand replantation. Nonetheless, lymphatic outflow has not been specifically studied in hand transplantation.Lymphedema was studied clinically and scintigraphically in 3 bilateral upper limb transplants performed in Valencia, Spain, since 2006. Case 1 was a radiocarpal level, case 2 midforearm and proximal forearm, and case 3 was a transhumeral transplantation. Follow-up was 5, 4, and 3 years, respectively. Clinically, in case 1, there was a left-sided moderate lymphedema, case 2 was normal, and a right-sided moderate lymphedema was present in case 3. Lymphoscintigraphy results were consistent with the clinical findings. It was normal in the 4 nonedematous limbs. In the 2 affected limbs, there were scintigraphic findings of lymphatic block and lymphangiectasia.The study demonstrates objectively that lymphatic circulation can reconnect spontaneously in hand transplantations, although not in a homogeneously efficient way.