Jeffrey Traubici

Association Between Corticosteroids and Infection, Sepsis, and Infectious Death in Pediatric Acute Myeloid Leukemia (AML): Results From the Canadian Infections in AML Research Group

BACKGROUND Infection continues to be a major problem for children with acute myeloid leukemia (AML). Objectives were to identify factors associated with infection, sepsis, and infectious deaths in children with newly diagnosed AML. METHODS We conducted a retrospective, population-based cohort study that included children ≤ 18 years of age with de novo, non-M3 AML diagnosed between January 1995 and December 2004, treated at 15 Canadian centers. Patients were monitored for infection from initiation of AML treatment until recovery from the last cycle of chemotherapy, conditioning for hematopoietic stem cell transplantation, relapse, persistent disease, or death (whichever occurred first). Consistent trained research associates abstracted all information from each site. RESULTS 341 patients were included. Median age was 7.1 years (interquartile range [IQR], 2.0-13.5) and 29 (8.5%) had Down syndrome. In sum, 26 (7.6%) experienced death as a first event. There were 1277 courses of chemotherapy administered in which sterile site microbiologically documented infection occurred in 313 courses (24.5%). Sepsis and infectious death occurred in 97 (7.6%) and 16 (1.3%) courses, respectively. The median days of corticosteroid administration was 2 per course (IQR, 0-6). In multiple regression analysis, duration of corticosteroid exposure was significantly associated with more microbiologically documented sterile site infection, bacteremia, fungal infection, and sepsis. The only factor significantly associated with infectious death was days of corticosteroid exposure (odds ratio, 1.05; 95% confidence interval, 1.02-1.08; P = .001). CONCLUSIONS In pediatric AML, infection, sepsis, and infectious death were associated with duration of corticosteroid exposure. Corticosteroids should be avoided when possible for this population.

Mesenteric lymphatic malformation associated with small-bowel volvulus – two cases and a review of the literature

Abstract. Cystic mesenteric lymphatic malformations are uncommon abdominal masses, which can cause abdominal signs and symptoms for a wide variety of reasons. Symptoms owing to volvulus are uncommon and have not been illustrated previously in the radiology literature. We present two cases to illustrate volvulus as a complication of mesenteric lymphatic malformations and how imaging can aid in the diagnosis of this complication. While uncommon, volvulus should be considered in any child with sonographic findings of an abdominal lymphatic malformation and acute abdominal pain.

CT diagnosis of traumatic bronchial rupture in children.

Abstract. Bronchial rupture is a rare and serious complication of blunt chest trauma in children. The diagnosis of this injury is challenging and requires a high degree of clinical suspicion. It is frequently associated with other severe injuries that may draw the focus of attention away from this potentially catastrophic but treatable injury. The radiographic findings of bronchial rupture have been reported in very few series. We report the findings in two children with bronchial rupture diagnosed by CT, in whom CT resulted in a significant change in patient management.

Utility of Contrast Echocardiography for Pulmonary Arteriovenous Malformation Screening in Pediatric Hereditary Hemorrhagic Telangiectasia

OBJECTIVE To evaluate the utility of transthoracic contrast echocardiography (TTCE) as a screening tool for pulmonary arteriovenous malformations (PAVMs) in children with hereditary hemorrhagic telangiectasia (HHT). STUDY DESIGN This was a single-center study of children who underwent baseline screening for PAVMs using both TTCE and chest computed tomography (CT) for evaluation of HHT. The CT and TTCE results were prospectively reviewed independently by 2 radiologists and 2 cardiologists blinded to the study results. RESULTS Both intraobserver and interobserver agreement for interpreting TTCE results were excellent (κ = 0.97 and 0.92, respectively) and higher than the interobserver agreement for CT interpretation (κ = 0.75). The sensitivity and specificity of TTCE to predict PAVMs were 1 and 0.82, respectively, and the positive predictive and negative predictive values were 0.39 and 1, respectively. CONCLUSION TTCE is a sensitive test for PAVMs in children with suspected HHT and can be a useful initial screening tool in pediatric HHT.

Do additional views improve the diagnostic performance of cervical spine radiography in pediatric trauma

OBJECTIVE The aims of this study were to measure the diagnostic performances of lateral views alone and multiple radiographic views of the cervical spine in comparison with MDCT scans in pediatric trauma and to determine whether evaluation of additional views, in relation to lateral views alone, improves the performance of radiography. MATERIALS AND METHODS Retrospective analysis of cervical spine radiographs of 234 pediatric patients (age range, 3 months-17 years 11 months) who had been seen in our pediatric emergency department during the period of 2000-2005 for evaluation after acute trauma was performed. All patients underwent cervical spine MDCT examination at the same presentation. Radiographs were evaluated for the presence of fractures, subluxations, and dislocations. Radiographic abnormalities were correlated to findings on MDCT, which was used as the reference standard. RESULTS Twenty-two patients had positive findings on CT: Atlantooccipital subluxation/dislocation was seen in one patient; C1 ring fracture, in three patients; C1-C2 rotatory subluxation, in one; C1-C2 subluxation/dislocation, in one; odontoid fracture, in two; vertebral body wedge fracture, in six; posterior arch fracture dislocation, in 10; and spinous process fracture, in none. The lateral view radiograph alone had 73% sensitivity (95% CI, 50-89%) and 92% specificity (95% CI, 87-95%) for cervical spine abnormalities compared with MDCT. The addition of other views did not change the sensitivity of radiography but rather marginally decreased its specificity to 91% (95% CI, 86-94%). CONCLUSION Lateral view radiographs had a borderline acceptable sensitivity to cervical spine abnormalities in pediatric patients compared with MDCT. The addition of other radiographic views did not seem to improve the diagnostic performance of radiography.

Reliability of contrast enhanced sonography with harmonic imaging for detecting early renal scarring in experimental pyelonephritis in a porcine model: preliminary results.

PURPOSE Contrast medium enhanced harmonic ultrasound is a recently developed ultrasound technique that improves the assessment of renal parenchymal vascularity. We performed a preliminary study to define the ability of contrast enhanced ultrasound with harmonic imaging to detect and localize renal scars in a porcine model of experimentally induced pyelonephritis. MATERIALS AND METHODS Vesicoureteral reflux was surgically induced in 10 pigs weighing 10 kg. with the contralateral kidney serving as a control. Approximately 4 weeks after the creation of vesicoureteral reflux cystography confirmed reflux. Infection was induced by placing a suspension of paraffin broth impregnated with Escherichia coli in the bladder of each pig. At 4 to 8 weeks (mean 6.5) after the induction of infection a radiologist blinded to the side of the previous procedure performed conventional gray scale ultrasound, color Doppler ultrasound and contrast enhanced ultrasound with harmonic power imaging. The animals were sacrificed; the kidneys were inspected and tissues from the upper, mid and lower poles were sent for culture and histological examination. Histology results were compared with the findings of the 3 ultrasound modalities. RESULTS All 10 pigs survived the surgical procedures with no complications. Post-contrast harmonic ultrasound images were available in 9 pigs (18 renal units). Harmonic ultrasound revealed decreased blood flow in 11 renal units, including the upper pole in 7, lower pole in 3, and upper and lower poles in 2. Renal tissue cultures were positive in 11 renal units (6 refluxing units). Histological findings revealed fibrosis in 10 renal units (8 refluxing units). Harmonic ultrasound findings in these 10 renal units showed 9 with changes consistent with inflammation or scars. Using histological results as the gold standard for renal injury harmonic ultrasound was more sensitive than gray scale ultrasound for detecting renal injury with 90% sensitivity, 75% specificity, 81% positive predictive value and 85% negative predictive value. CONCLUSIONS Preliminary results indicate that contrast enhanced ultrasound with harmonic imaging is a sensitive method for determining renal scarring without the need for radiation exposure. It may be prove to be a useful adjunct for evaluating children who present with urinary tract infection.

Gastrointestinal complications in children with acute myeloid leukemia

Gastrointestinal complications in pediatric acute myeloid leukemia (AML) have not been systematically described in the literature. Our objective was to describe complications related to the small and large bowel in children with AML. Literature searches were conducted of Ovid Medline™ from 1950 to November 2009 and EMBASE™ from 1980 to November 2009. We included any study design that described gastrointestinal complications in children and/or adults with AML. Common gastrointestinal complications were typhlitis and enterocolitis. Less common complications included appendicitis, pneumatosis intestinalis, and perianal infections. Both leukemia infiltration and intensive chemotherapy likely play a role in the etiology of these conditions. There is a paucity of carefully conducted studies that describe the natural history of typhlitis and enterocolitis and evidence is needed to help guide the management of gastrointestinal complications. Gastrointestinal complications are relatively common in children with AML. Conduction of carefully performed cohort studies is needed to better understand the spectrum of symptoms and expected consequences of gastrointestinal complications. Randomized trials are required to develop evidence-based guidelines for the management of gastrointestinal complications in pediatric AML.

Renal pyramid echogenicity in ureteropelvic junction obstruction: correlation between altered echogenicity and differential renal function

BackgroundImprovement in resolution and use of high-frequency transducers in US has enabled visualization of previously unreported changes in medullary pyramid echogenicity in children with obstructive hydronephrosis.ObjectiveTo determine whether these unreported changes in echogenicity and morphology of the renal pyramids in ureteropelvic junction (UPJ) obstruction correlate with differential renal function (DRF) of the kidney as determined by technetium-99m mercaptoacetyltriglycine (99mTc-MAG3) scan.Materials and methodsRenal sonograms in 60 children with UPJ obstruction were retrospectively reviewed. Children were divided into three groups based on the echogenicity of the pyramids: (1) normal echogenicity of the pyramids, (2) increased echogenicity of the pyramids with maintained corticomedullary differentiation (CMD), and (3) loss of CMD. DRF, as determined by 99mTc-MAG3 scan, of the obstructed kidney of ≥45% was considered normal and of ≤44% was considered abnormal based on a published study correlating histological changes with DRF. Fisher′s exact test was performed for assessing the association between DRF and altered echogenicity of the pyramids.ResultsIn group 1, which consisted of 13 patients with normal pyramids on US, DRF was normal in 11 and abnormal in two. In group 2, which consisted of 33 patients with echogenic pyramids and preserved CMD, DRF was normal in 15 and abnormal in 18. In group 3, which consisted of 14 patients with complete loss of CMD, DRF was normal in 2 and abnormal in 12. There was a strong correlation between abnormal pyramids and DRF (P=0.0009). The risk ratio (RR) of DRF becoming abnormal for those kidneys with abnormal echogenicity of the pyramids with preserved CMD (group 2) compared to normal pyramid echogenicity (group 1) was 1.56 (95% CI 1.088–2.236). The RR of DRF becoming abnormal for those kidneys with loss of CMD (group 3) compared to normal pyramid echogenicity (group 1) was 5.571 (95% CI 1.530–20.294).ConclusionWe observed that in obstructed kidneys the echogenicity of the pyramids may be abnormal. Increased echogenicity of the pyramids correlated weakly with abnormal DRF and does not necessarily indicate poor renal function. However, loss of CMD strongly correlated with poor renal function.

Evolution of Renal Cysts to Anaplastic Sarcoma of Kidney in a Child With DICER1 Syndrome

Anaplastic sarcoma of kidney (ASK) is a rare neoplasm recently associated with DICER1 mutations. We report a child with germline DICER1 mutation who developed ASK in preexisting septated renal cysts, which were likely cystic nephroma. From age 2.5 to 6 years, sonographic imaging illustrated changes in the size and number of renal cysts, followed at age 8.8 years by a mass, pathologically an ASK. Lung cysts resected in infancy were diagnosed retrospectively as pleuropulmonary blastoma. Both tumors had acquired somatic DICER1 mutations. Ultrasonographic evolution of renal cysts to ASK has not previously been documented. Children with both pulmonary and renal cysts are candidates for DICER1 mutation testing.

Intravascular linear thrombus after catheter removal: sonographic appearance mimicking retained catheter fragment

BackgroundA common complication of central catheters is vascular thrombosis. We have observed that the remaining thrombus can sonographically simulate the appearance of the catheter itself, suggesting that the catheter may have broken.ObjectiveTo describe the difference in the sonographic appearance of an intravascular linear thrombus and a retained catheter.Patients and methodsThe study comprised 11 infants who were born between 1 January 2000 and 31 December 2001 and had at least one sonographic examination after removal of a central venous or arterial catheter, in whom a residual thrombus had a sonographic appearance simulating the appearance of the catheter itself.ResultsIn all of our cases the thrombus appeared as two parallel hyperechoic lines. In comparison to the sonographic appearance of a true catheter, these lines were less sharply demarcated, not quite geometrically parallel, less echogenic, and did not shadow or have reverberation artifacts.ConclusionsAlthough the sonographic appearance of a residual linear thrombus may closely resemble the sonographic appearance of a retained catheter fragment, appreciation of the subtle differences between the two is important, and could obviate the necessity for more invasive procedures.