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Vertebral fractures are clinically important sequelae of a wide array of pediatric diseases. In this study, we examined the accuracy of case-finding strategies for detecting incident vertebral fractures (IVF) over 2 years in glucocorticoid-treated children (n = 343) with leukemia, rheumatic disorders, or nephrotic syndrome. Two clinical situations were addressed: the prevalent vertebral fracture (PVF) scenario (when baseline PVF status was known), which assessed the utility of PVF and low lumbar spine bone mineral density (LS BMD; Z-score-1.4), and the non-PVF scenario (when PVF status was unknown), which evaluated low LS BMD and back pain. LS BMD was measured by dual-energy X-ray absorptiometry, vertebral fractures were quantified on spine radiographs using the modified Genant semiquantitative method, and back pain was assessed by patient report. Forty-four patients (12.8%) had IVF. In the PVF scenario, both low LS BMD and PVF were significant predictors of IVF. Using PVF to determine which patients should have radiographs, 11% would undergo radiography (95% confidence interval [CI] 8-15) with 46% of IVF (95% CI 30-61) detected. Sensitivity would be higher with a strategy of PVF or low LS BMD at baseline (73%; 95% CI 57-85) but would require radiographs in 37% of children (95% CI 32-42). In the non-PVF scenario, the strategy of low LS BMD and back pain produced the highest specificity of any non-PVF model at 87% (95% CI 83-91), the greatest overall accuracy at 82% (95% CI 78-86), and the lowest radiography rate at 17% (95% CI 14-22). Low LS BMD or back pain in the non-PVF scenario produced the highest sensitivity at 82% (95% CI 67-92), but required radiographs in 65% (95% CI 60-70). These results provide guidance for targeting spine radiography in children at risk for IVF. © 2021 American Society for Bone and Mineral Research (ASBMR).

Due to concerns about cumulative radiation exposure in the pediatric population, it is not standard practice to perform spine radiographs in most conditions that predispose to vertebral fracture (VF). In this study we examined the accuracy of two clinical predictors, back pain and lumbar spine bone mineral density (LS BMD), to derive four case-finding paradigms for detection of prevalent VF (PVF). Subjects were 400 children at risk for PVF (leukemia 186, rheumatic disorders 135, nephrotic syndrome 79). Back pain was assessed by patient report, LS BMD was measured by dual-energy X-ray absorptiometry, and PVF were quantified on spine radiographs using the modified Genant semiquantitative method. Forty-four patients (11.0%) had PVF. Logistic regression analysis between LS BMD and PVF produced an odds ratio (OR) of 1.9 (95% confidence interval [CI], 1.5 to 2.5) per reduction in Z-score unit, an area under the receiver operating characteristic curve of 0.70 (95% CI, 0.60 to 0.79), and an optimal BMD Z-score cutoff of -1.6. Case identification using either low BMD alone (Z-score < -1.6) or back pain alone gave similar results for sensitivity (55%, 52%, respectively), specificity (78%, 81%, respectively), positive predictive value (PPV; 24%, 25%, respectively), and negative predictive value (NPV; 93%, 93%, respectively). The paradigm using low BMD plus back pain produced lower sensitivity (32%), higher specificity (96%), higher PPV (47%), and similar NPV (92%). The approach using low BMD or back pain had the highest sensitivity (75%), lowest specificity (64%), lowest PPV (20%), and highest NPV (95%). All paradigms had increased sensitivities for higher fracture grades. Our results show that BMD and back pain history can be used to identify children with the highest risk of PVF so that radiography can be used judiciously. The specific paradigm to be applied will depend on the expected PVF rate and the clinical approach to the use of radiography. © 2019 American Society for Bone and Mineral Research.

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 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.

Objective To assess whether children with juvenile idiopathic arthritis (JIA) in clinical remission show pathologic findings on either gray-scale or power Doppler ultrasound of their joints. Methods Children with JIA were eligible if they were in clinical remission for at least 3 months, as defined by the absence of clinically active joints and serologic markers of inflammation. Gray-scale as well as power Doppler ultrasonography of the wrist, knee, and ankle were carried out on previously affected joints and unaffected contralateral joints. Images were read by 2 independent readers. Findings were categorized as 1) structural abnormalities in the case of synovial thickening or increased joint fluid on gray-scale ultrasound or 2) power Doppler positive in the case of an abnormal power Doppler signal. Results The study cohort consisted of 28 patients. Eight of 14 patients with previous wrist involvement had pathologic gray-scale findings, and 3 of these 14 patients also had pathologic Doppler findings in the wrist. None of the 20 patients with past knee involvement had pathologic gray-scale or Doppler findings in the knee. Six of 15 patients with previous ankle involvement had pathologic gray-scale findings and 1 of the 15 patients had pathologic Doppler findings in the tibiotalar joint. Conclusion This study demonstrates that some patients who meet clinical criteria for remission continue to show ongoing pathology on joint ultrasound, which may be suggestive of persistent inflammation.