Karen Manias

Prediction of severe bacterial infection in children with an emergency department diagnosis of infection

Objective To determine the relationship between near-patient-test (NPT) lactate, white blood cell count (WBC) and C-reactive protein (CRP) and severe bacterial infection (SBI) in children presenting to the emergency department (ED) with infection. Methods An observational cohort study was undertaken in a paediatric emergency department of a large urban teaching hospital. Data were collected from January 2007 until December 2007. Inclusion criteria were age <16 years, blood test including NPT lactate obtained in the ED and infection-related ED diagnosis. Patients were pre-assigned to risk groups according to their NPT lactate, WBC and CRP. Results 506 children were included in the study, of which 42 (8.3%) had SBI. NPT lactate, WBC and CRP were significantly higher in the SBI cohort. High-risk NPT lactate (≥4 mmol/l) had a sensitivity of 38.1% (95% CI 23.6% to 54.4%) and a specificity of 89.7% (95% CI 86.5% to 92.3%); high-risk WBC (<5 or ≥15×109/l) had a sensitivity of 51.2% (95% CI 35.1% to 67.1%) and a specificity of 73.8% (95% CI 69.4% to 77.8%); and high-risk CRP (≥50 mg/l) had a sensitivity of 36.8% (95% CI 21.8% to 54.1%) and a specificity of 83.6% (95% CI 79.4% to 87.2%) for SBI. All three high-risk markers combined yielded a sensitivity of 5.3% (95% CI 1.5% to 17.3%) and a specificity of 99.2% (95% CI 97.6% to 99.7%) for SBI. Conclusion The data from our study suggest that NPT lactate provides early diagnostic information about the risk of SBI in children presenting to the ED with a suspected infection. Combining NPT lactate with WBC and CRP resulted in a promising rule-in-tool for SBI in children in the ED which, with prospective validation, has the potential to aid early identification of SBI in children.

Multiclass imbalance learning: Improving classification of pediatric brain tumors from magnetic resonance spectroscopy: Imbalanced learning for MRS tumor classification

Classification of pediatric brain tumors from 1H‐magnetic resonance spectroscopy (MRS) can aid diagnosis and management of brain tumors. However, varied incidence of the different tumor types leads to imbalanced class sizes and introduces difficulties in classifying rare tumor groups. This study assessed different imbalanced multiclass learning techniques and compared the use of complete spectra and quantified metabolite profiles for classification of three main childhood brain tumor types.

Multiclass imbalance learning: Improving classification of pediatric brain tumors from magnetic resonance spectroscopy.

Classification of pediatric brain tumors from 1H‐magnetic resonance spectroscopy (MRS) can aid diagnosis and management of brain tumors. However, varied incidence of the different tumor types leads to imbalanced class sizes and introduces difficulties in classifying rare tumor groups. This study assessed different imbalanced multiclass learning techniques and compared the use of complete spectra and quantified metabolite profiles for classification of three main childhood brain tumor types.

Evaluation of the added value of 1H-magnetic resonance spectroscopy for the diagnosis of pediatric brain lesions in clinical practice

Abstract Background Magnetic resonance spectroscopy (MRS) aids noninvasive diagnosis of pediatric brain tumors, but use in clinical practice is not well documented. We aimed to review clinical use of MRS, establish added value in noninvasive diagnosis, and investigate potential impact on patient care. Methods Sixty-nine children with lesions imaged using MRS and reviewed by the tumor board from 2014 to 2016 met inclusion criteria. Contemporaneous MRI diagnosis, spectroscopy analysis, histopathology, and clinical information were reviewed. Final diagnosis was agreed on by the tumor board at study end. Results Five cases were excluded for lack of documented MRI diagnosis. The principal MRI diagnosis by pediatric radiologists was correct in 59%, increasing to 73% with addition of MRS. Of the 73%, 19.1% (95% CI, 9.1%-33.3%) were incorrectly diagnosed with MRI alone. MRS led to a significant improvement in correct diagnosis over all tumor types (P = .012). Of diagnoses correctly made with MRI, confidence increased by 37% when adding MRS, with no patients incorrectly re-diagnosed. Indolent lesions were diagnosed noninvasively in 85% of cases, with MRS a major contributor to 91% of these diagnoses. Of all patients, 39% were managed without histopathological diagnosis. MRS contributed to diagnosis in 68% of this group, modifying it in 12%. MRS influenced management in 33% of cases, mainly through avoiding and guiding biopsy and aiding tumor characterization. Conclusion MRS can improve accuracy and confidence in noninvasive diagnosis of pediatric brain lesions in clinical practice. There is potential to improve outcomes through avoiding biopsy of indolent lesions, aiding tumor characterization, and facilitating earlier family discussions and treatment planning.

Diffusion-weighted MRI and intravoxel incoherent motion model for diagnosis of pediatric solid abdominal tumors: Diagnosis of Pediatric Abdominal Tumors

Pediatric retroperitoneal tumors in the renal bed are often large and heterogeneous, and their diagnosis based on conventional imaging alone is not possible. More advanced imaging methods, such as diffusion‐weighted (DW) MRI and the use of intravoxel incoherent motion (IVIM), have the potential to provide additional biomarkers that could facilitate their noninvasive diagnosis.

Prospective multicentre evaluation and refinement of an analysis tool for magnetic resonance spectroscopy of childhood cerebellar tumours

BackgroundA tool for diagnosing childhood cerebellar tumours using magnetic resonance (MR) spectroscopy peak height measurement has been developed based on retrospective analysis of single-centre data.ObjectiveTo determine the diagnostic accuracy of the peak height measurement tool in a multicentre prospective study, and optimise it by adding new prospective data to the original dataset.Materials and methodsMagnetic resonance imaging (MRI) and single-voxel MR spectroscopy were performed on children with cerebellar tumours at three centres. Spectra were processed using standard scanner software and peak heights for N-acetyl aspartate, creatine, total choline and myo-inositol were measured. The original diagnostic tool was used to classify 26 new tumours as pilocytic astrocytoma, medulloblastoma or ependymoma. These spectra were subsequently combined with the original dataset to develop an optimised scheme from 53 tumours in total.ResultsOf the pilocytic astrocytomas, medulloblastomas and ependymomas, 65.4% were correctly assigned using the original tool. An optimized scheme was produced from the combined dataset correctly assigning 90.6%. Rare tumour types showed distinctive MR spectroscopy features.ConclusionThe original diagnostic tool gave modest accuracy when tested prospectively on multicentre data. Increasing the dataset provided a diagnostic tool based on MR spectroscopy peak height measurement with high levels of accuracy for multicentre data.

What is MR spectroscopy

1H-Magnetic Resonance Spectroscopy (MRS) is a novel advanced imaging technique used as an adjunct to MRI to reveal complementary non-invasive information about the biochemical composition of imaged tissue. Clinical uses in paediatrics include aiding diagnosis of brain tumours, neonatal disorders such as hypoxic-ischaemic encephalopathy, inherited metabolic diseases, traumatic brain injury, demyelinating conditions and infectious brain lesions. MRS has potential to improve diagnosis and treatment monitoring of childhood brain tumours and other CNS diseases, facilitate biopsy and surgical planning, and provide prognostic biomarkers. MRS is employed as a research tool outside the brain in liver disease and disorders of muscle metabolism. The range of clinical uses is likely to increase with growing evidence for added value. Multicentre trials are needed to definitively establish the benefits of MRS in specific clinical scenarios and integrate this promising new technique into routine practice to improve patient care. This article gives a brief overview of MRS and its potential clinical applications, and addresses challenges surrounding translation into practice.

Magnetic resonance imaging based functional imaging in paediatric oncology

Imaging is central to management of solid tumours in children. Conventional magnetic resonance imaging (MRI) is the standard imaging modality for tumours of the central nervous system (CNS) and limbs and is increasingly used in the abdomen. It provides excellent structural detail, but imparts limited information about tumour type, aggressiveness, metastatic potential or early treatment response. MRI based functional imaging techniques, such as magnetic resonance spectroscopy, diffusion and perfusion weighted imaging, probe tissue properties to provide clinically important information about metabolites, structure and blood flow. This review describes the role of and evidence behind these functional imaging techniques in paediatric oncology and implications for integrating them into routine clinical practice.

Multiclass imbalance learning

Classification of pediatric brain tumors from 1H‐magnetic resonance spectroscopy (MRS) can aid diagnosis and management of brain tumors. However, varied incidence of the different tumor types leads to imbalanced class sizes and introduces difficulties in classifying rare tumor groups. This study assessed different imbalanced multiclass learning techniques and compared the use of complete spectra and quantified metabolite profiles for classification of three main childhood brain tumor types.

Survey of neonatal resuscitation equipment in emergency departments in the UK

Objective All emergency departments (EDs) should be adequately equipped and prepared to deal with unexpected neonatal deliveries and resuscitation. A study was undertaken to determine what neonatal resuscitation equipment is available in EDs in the UK and to formulate recommendations for improvement. Methods A prospective telephone survey of all UK EDs was conducted between November 2008 and February 2009 to determine the type of neonatal resuscitation equipment available as recommended in the fourth edition of the APLS guidelines. Results 169 EDs were identified, 137 (81%) of which successfully completed the survey. The majority of EDs followed APLS recommendations for provision of neonatal resuscitation equipment. There was a particularly good availability of basic airway equipment (99%), but 11% did not have a source of warmth, 5% lacked advanced airway equipment and 31% had no equipment for obtaining umbilical access. A Resuscitaire was present in 47% of EDs surveyed. Conclusion There is a good level of provision of neonatal resuscitation equipment in UK EDs, although certain areas need to be addressed. There is a particular need for improving the provision of warming and advanced airway equipment. The authors consider that it is not necessary to have a neonatal Resuscitaire in the ED provided other equipment is readily available. The findings of this survey prompt the recommendation that all EDs should review their neonatal resuscitation equipment in accordance with APLS guidance, and ensure that staff have immediate access to this equipment and are comfortable with its use.