Diagnostic Tool In Children Research Articles

Tryptase levels in children presenting with anaphylaxis to the Montreal Children’s Hospital

U E S D A Y 760 Tryptase Levels in Children Presenting with Anaphylaxis to the Montreal Children's Hospital Michelle Halbrich, MD, Ann Elaine Clarke, MD, MSc, Sebastian La Vieille, MD, Harley Eisman, MD, Reza Alizadehfar, MD, Lawrence Joseph, PhD, Judy Morris, MD, Moshe Ben-Shoshan, MD, MSc; McGill University, Montreal, QC, Canada, McGill University Health Centre, Montreal, Canada, Food Directorate, Ottawa, ON, Canada, University de Montreal, Montreal, QC, Canada. RATIONALE: There are little data on the role of tryptase in the diagnosis of anaphylaxis. We aimed to determine if total tryptase levels are elevated (>11.5 ng/mL) at the time of anaphylaxis and to identify factors associated with elevated tryptase levels. METHODS: Children presenting with anaphylaxis to the Montreal Children’s Hospital Emergency Department (ED) between April 2011 and April 2012 were recruited. The treating physician documented symptoms, triggers, and management of the anaphylactic reactions. Total tryptase levels were measured 30-120 minutes following onset of symptoms. Charts of all ED patients were reviewed to identify cases that were missed in prospective recruitment. Multivariate logistic regression was used to examine the association between an elevated tryptase level and age, gender, reaction trigger, reaction severity, and history of atopy. RESULTS: Of 180 anaphylaxis cases (90 of whom were recruited prospectively), 32 children had serum tryptase levels measured. The median age of these 32 children was 6.0 years (IQR 1.2, 11.5), 62.5% [95% CI, 43.8%, 78.3%]weremale, 68.8% (49.9%, 83.3%) identified food as the potential anaphylactic trigger, and 9.4% (2.5%, 26.2%) experienced a severe reaction. Age, gender, anaphylactic trigger, and severity of reaction were comparable between cases with and without tryptase measurements. The mean tryptase level was 6.2 ng/mL (4.5, 8.0). Only 3 patients [9.4% (2.5%, 26.2%)] had elevated levels. Older age (odds ratio (OR) 1.0, 1.01, 1.03) and severe reactions [1.7, (1.3, 2.3)] were associated with higher levels. CONCLUSIONS: Our results do not support the use of total typtase as a diagnostic tool in children with anaphylaxis.

P82 Induced sputum is a feasible diagnostic tool in children with chronic cough possibly due to asthma

Background Chronic cough is a common childhood symptom, reported in 22% of preschool children. Many are misdiagnosed as asthmatic. Induced sputum (IS) using hypertonic saline (HTS) has been used as a diagnostic tool in patients with cough; its bronchoconstriction effects being used as a test for the bronchial hyper-reactivity (BHR) in asthma (ISSAC study). Conversely it is used as a bronchodilator in the treatment of bronchiolitis and pre-school wheeze. Sputum eosinophilia indicates airway inflammation in keeping with a diagnosis of asthma. This study aimed to determine if IS is a feasible diagnostic tool in children with problem cough query asthma. In addition we wished to determine the relationship between BHR to HTS and the eosinophil count in sputum. Methods A retrospective review of children with problem cough who underwent sputum induction with nebulised 3% HTS. Sputum samples were obtained for microbiology, virology and differential cell count. Spirometry was performed before and after administration of 3% HTS. Change in FEV 1 (Δ FEV 1 = FEV 1 post HTS minus FEV 1 pre HTS) was used as a measure of BHR. Correlation between Δ FEV 1 and sputum eosinophilia was calculated using Spearmen rank coefficient. Results 146 patients referred for IS between 2001 and January 2013 were included. Mean age = 8 years (range = 2 to 13), mean cough duration = 4.25 years (range 0.17 to 11.5). Sputum induction was successful in 131 patients (89%). 12 children (8%) became symptomatic; 4% required test termination. 44 children increased FEV 1 with 12 having >9% FEV 1 increase. 63 children reduced FEV 1 with 21 having > 9% reduction. Viral or bacterial pathogens were identified in 29% of samples obtained. Sputum eosinophilia (eosinophil count > 3%) was present in 66% of samples obtained. There was no correlation between FEV 1 and sputum eosinophilia (R = 0.04). Conclusions IS is a feasible and safe tool in children with problem chronic cough, aiding diagnosis with spirometry and sputum analysis. However BHR induced with HTS does not correlate with sputum eosinophilia. Several children increased FEV 1 with HTS administration, suggesting it may have a therapeutic role in the treatment of some children with chronic cough.

Colonic Manometry and Colonic Scintigraphy as a Diagnostic Tool for Children With Severe Constipation

In adults, colonic manometry and colonic scintigraphy are both valuable studies in discriminating normal and abnormal colonic motility. The objective of this study was to compare the diagnostic yield and tolerability of colonic manometry and colonic scintigraphy in children with severe constipation. Twenty-six children (mean age 11.4 years, 77% boys) who had received colonic manometry and colonic scintigraphy as part of a colonic motility evaluation were included. Manometry was performed as per department protocol. After swallowing a methacrylate-coated capsule containing indium-111, images were taken at 4, 24, and 48 hours, and geometric centers were calculated. Results of both tests were categorized in 3 groups: normal, abnormal function in the distal part of the colon, and colonic inertia. Cohen κ was used for the level of agreement. Patients and parents completed a questionnaire regarding their experience. Colonic scintigraphy showed normal transit time in 20%, delay in the distal colon in 48%, and colonic inertia in 32% of patients. Colonic manometry was normal in 40%, abnormal in the distal colon in 40%, and colonic inertia was diagnosed in 20%. The κ score was 0.34. All 5 patients with colonic inertia during manometry had a similar result by scintigraphy. Eighty-eight percent of patients preferred scintigraphy over manometry and 28% of parents preferred colonic manometry over scintigraphy. Colonic manometry and colonic scintigraphy have a fair agreement regarding the categorization of constipation. Scintigraphy is well tolerated in pediatric patients and may be a useful tool in the evaluation of children with severe constipation.

Speed-Accuracy Testing on the Apple iPad® Provides a Quantitative Test of Upper Extremity Motor Performance in Children with Dystonia

The currently available scales for quantitative measurement of the severity of childhood dystonia require human observer ratings and provide poor granularity in the scores for individual limbs. We evaluated the use of new-generation high-quality touchscreens (an iPad) according with the Fitts law, which is a mathematical model that takes into account the relation between movement time and the task accuracy. We compared the abilities of healthy subjects and children with dystonia. The linear relation described by Fitts law held for all the groups. The movement time and the information transmitted were age and severity related. Our results provide evidence for the usability and validity of using Fitts law as a quantitative diagnostic tool in children with dystonia. Furthermore, testing on touchscreen tablets may help to guide the design of user interfaces to maximize the communication rate for children who depend upon assistive communication devices.

A new diagnostic tool for children with sleep disorders

Background In addition to a parental evaluation, the diagnosis of childhood sleep disorders should include a child’s own assessment of sleep behavior. In order to address the lack of self-rating instruments for the assessment of sleep in young children, a new self-assessment tool was developed: the Children’s Sleep Comic. Here we present the first validation data.

GROWTH HORMONE ESTIMATION;

Introduction: Despite the use of growth hormone replacement therapy for decades, our ability to make a definitive diagnosisof growth hormone deficiency in children is limited. Growth hormone stimulation tests have been used to discriminate between Growthhormone deficiency and idiopathic short stature. However all these tests lack reproducibility, accuracy, cost affectivity and safety. Insulinlikegrowth factor-1 is an effector hormone and its serum level may be used as simple, easy to perform diagnostic test for growthhormone deficiency. Objective: To determine the efficacy of IGF-1 as a diagnostic tool in children with growth hormone deficiency. StudyDesign: Prospective cross sectional survey. Place of Study: Departments of Pediatrics and Pathology, Shalamar Medical & DentalCollege, Lahore. Duration of study: 1st July to 31st December, 2011. Material & Methods: We included 40 children of 3.5 – 17 year ageand detailed clinical data was collected. All these children were subjected to stimulation by standardized exercise on treadmill, after takingbasal blood samples for GH and IGF-1. Post stimulation growth hormone was recorded to identify growth hormone deficient children.Results: 17 (42.5%) children had post stimulation growth hormone level <10ng/ml while 23 (57.5%) had values >10ng/ml. Postexercise stimulation GH level showed weak correlation with IGF-1 in either of the two study groups. P value was found >0.05 in deficientas well as sufficient groups, depicting non significance of IGF-1 in relation to post stimulation GH level. Conclusions: IGF-1 is not asuitable surrogate diagnostic marker for growth hormone deficiency. Diagnosis should always be based on combination of auxologicalbiochemical, radiological and genetic considerations, Abbreviations: GHD – Growth Hormone Deficiency, GH – Growth Hormone,GHSTs – Growth Hormone Stimulation Tests, IGF-1 – Insulin-like Growth Factor-1, MPH – Mid Parental Height, BA – Bone Age.

18F-FDG PET/CT in the diagnosis of occult bacterial infections in children

The role of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) in the diagnosis and follow-up of infectious diseases has expanded recently. The aim of this report is to communicate our experience regarding its role in the diagnosis and management of occult bacterial infections in children. We present three pediatric patients with occult bacterial infections and negative conventional studies in whom (18)F-FDG PET/CT had a significant effect on clinical management. One patient had streptococcal endocarditis and prolonged fever. (18)F-FDG PET/CT identified pneumonia and osteomyelitis, and was also used to monitor therapeutic response. Other patient had a cerebrospinal shunt fluid infection. (18)F-FDG PET/CT was used to determine the exact localization of infection and establish the best surgical approach. The last patient had fever of unknown origin. (18)F-FDG PET/CT identified splenic abscesses, which were surgically treated. (18)F-FDG PET/CT should be considered as a useful diagnostic tool in children with suspected bacterial infections, if conventional diagnostic imaging techniques have failed to yield positive results.

Anaphylaxis in Children Treated At the Montreal Children's Hospital: Rate, Clinical Characteristics, Triggers and Management

U E S D A Y 760 Tryptase Levels in Children Presenting with Anaphylaxis to the Montreal Children's Hospital Michelle Halbrich, MD, Ann Elaine Clarke, MD, MSc, Sebastian La Vieille, MD, Harley Eisman, MD, Reza Alizadehfar, MD, Lawrence Joseph, PhD, Judy Morris, MD, Moshe Ben-Shoshan, MD, MSc; McGill University, Montreal, QC, Canada, McGill University Health Centre, Montreal, Canada, Food Directorate, Ottawa, ON, Canada, University de Montreal, Montreal, QC, Canada. RATIONALE: There are little data on the role of tryptase in the diagnosis of anaphylaxis. We aimed to determine if total tryptase levels are elevated (>11.5 ng/mL) at the time of anaphylaxis and to identify factors associated with elevated tryptase levels. METHODS: Children presenting with anaphylaxis to the Montreal Children’s Hospital Emergency Department (ED) between April 2011 and April 2012 were recruited. The treating physician documented symptoms, triggers, and management of the anaphylactic reactions. Total tryptase levels were measured 30-120 minutes following onset of symptoms. Charts of all ED patients were reviewed to identify cases that were missed in prospective recruitment. Multivariate logistic regression was used to examine the association between an elevated tryptase level and age, gender, reaction trigger, reaction severity, and history of atopy. RESULTS: Of 180 anaphylaxis cases (90 of whom were recruited prospectively), 32 children had serum tryptase levels measured. The median age of these 32 children was 6.0 years (IQR 1.2, 11.5), 62.5% [95% CI, 43.8%, 78.3%]weremale, 68.8% (49.9%, 83.3%) identified food as the potential anaphylactic trigger, and 9.4% (2.5%, 26.2%) experienced a severe reaction. Age, gender, anaphylactic trigger, and severity of reaction were comparable between cases with and without tryptase measurements. The mean tryptase level was 6.2 ng/mL (4.5, 8.0). Only 3 patients [9.4% (2.5%, 26.2%)] had elevated levels. Older age (odds ratio (OR) 1.0, 1.01, 1.03) and severe reactions [1.7, (1.3, 2.3)] were associated with higher levels. CONCLUSIONS: Our results do not support the use of total typtase as a diagnostic tool in children with anaphylaxis.

Home urine C-peptide creatinine ratio testing can identify type 2 and MODY in pediatric diabetes

Making the correct diabetes diagnosis in children is crucial for lifelong management. Type 2 diabetes and maturity onset diabetes of the young (MODY) are seen in the pediatric setting, and can be difficult to discriminate from type 1 diabetes. Postprandial urinary C-peptide creatinine ratio (UCPCR) is a non-invasive measure of endogenous insulin secretion that has not been tested as a diagnostic tool in children or in patients with diabetes duration <5 yr. We aimed to assess whether UCPCR can discriminate type 1 diabetes from MODY and type 2 in pediatric diabetes. Two-hour postprandial UCPCR was measured in 264 patients aged <21 yr (type 1, n = 160; type 2, n = 41; and MODY, n = 63). Receiver operating characteristic curves were used to identify the optimal UCPCR cutoff for discriminating diabetes subtypes. UCPCR was lower in type 1 diabetes [0.05 (<0.03-0.39) nmol/mmol median (interquartile range)] than in type 2 diabetes [4.01 (2.84-5.74) nmol/mmol, p < 0.0001] and MODY [3.51 (2.37-5.32) nmol/mmol, p < 0.0001]. UCPCR was similar in type 2 diabetes and MODY (p = 0.25), so patients were combined for subsequent analyses. After 2-yr duration, UCPCR ≥ 0.7 nmol/mmol has 100% sensitivity [95% confidence interval (CI): 92-100] and 97% specificity (95% CI: 91-99) for identifying non-type 1 (MODY + type 2 diabetes) from type 1 diabetes [area under the curve (AUC) 0.997]. UCPCR was poor at discriminating MODY from type 2 diabetes (AUC 0.57). UCPCR testing can be used in diabetes duration greater than 2 yr to identify pediatric patients with non-type 1 diabetes. UCPCR testing is a practical non-invasive method for use in the pediatric outpatient setting.

Children&amp;rsquo;s Sleep Comic: development of a new diagnostic tool for children with sleep disorders

BackgroundA solid diagnosis of sleep disorders in children should include both self-ratings and parent ratings. However, there are few standardized self-assessment instruments to meet this need. The Children’s Sleep Comic is an adapted version of the unpublished German questionnaire “Freiburger Kinderschlafcomic” and provides pictures for items and responses. Because the drawings were outdated and allowed only for qualitative analysis, we revised the comic, tested its applicability in a target sample, and suggest a procedure for quantitative analysis.MethodsAll items were updated and pictures were newly drawn. We used a sample of 201 children aged 5–10 years to test the applicability of the Children’s Sleep Comic in young children and to run a preliminary analysis.ResultsThe Children’s Sleep Comic comprises 37 items covering relevant aspects of sleep disorders in children. Application took on average 30 minutes. The procedure was well accepted by the children, as reflected by the absence of any dropouts. First comparisons with established questionnaires indicated moderate correlations.ConclusionThe Children’s Sleep Comic is appropriate for screening sleep behavior and sleep problems in children. The interactive procedure can foster a good relationship between the investigator and the child, and thus establish the basis for successful intervention if necessary.

Molecular Karyotyping as a Relevant Diagnostic Tool in Children with Growth Retardation with Silver-Russell Features

To determine the contribution of submicroscopic chromosomal imbalances to the etiology of Silver-Russell syndrome (SRS) and SRS-like phenotypes. We performed molecular karyotyping in 41 patients with SRS or SRS-like features without known chromosome 7 and 11 defects using the Affymetrix SNP Array 6.0 system (Affymetrix, High Wycombe, United Kingdom). In 8 patients, pathogenic copy number variations with sizes ranging from 672 kb to 9.158 Mb were identified. The deletions in 1q21, 15q26, 17p13, and 22q11 were associated with known microdeletion syndromes with overlapping features with SRS. The duplications in 22q13 and Xq25q27 represent unique novel copy number variations but have an obvious influence on the phenotype. In 5 additional patients, the pathogenetic relevance of the detected variants remained unclear. Pathogenic submicroscopic imbalances were detectable in a significant proportion of patients with short stature and features reminiscent of SRS. Therefore, molecular karyotyping should be implemented in routine diagnostics for growth-retarded patients with even slight dysmorphisms suggestive for SRS.

First preoperative functional mapping via navigated transcranial magnetic stimulation in a 3-year-old boy

Preoperative functional mapping in children younger than 5 years old remains a challenge. Awake functional MRI (fMRI) is usually not an option for these patients. Except for a description of passive fMRI in sedated patients and magnetoencephalography, no other noninvasive mapping method has been reported as a preoperative diagnostic tool in children. Therefore, invasive intraoperative direct cortical stimulation remains the method of choice. To the authors' knowledge, this is the first case of a young child undergoing preoperative functional motor cortex mapping with the aid of navigated transcranial magnetic stimulation (nTMS). In this 3-year-old boy with a rolandic ganglioglioma, awake preoperative mapping was performed using nTMS. A precise location of Broca area 4 could be established. The surgical approach was planned according to the preoperative findings. Intraoperative direct cortical stimulation verified the location of the nTMS hotspots, and complete resection of the precentral tumor was achieved. Navigated TMS is a precise tool for preoperative motor cortex mapping and is feasible even in very young pediatric patients. In children for whom performing the fMRI motor paradigm is challenging, nTMS is the only available option for functional mapping.

Melatonin does not influence sleep deprivation electroencephalogram recordings in children

The electroencephalogram (EEG) is an essential diagnostic tool in children with epilepsy. The recording of a sleep EEG can increase the yield of EEG recordings in certain epileptic syndromes. The primary aim of this study was to assess the influence of melatonin on EEG recording (quality, EEG characteristics) and to assess its efficacy to induce sleep. Children with epilepsy or non-epileptic neurological patients requiring sleep deprivation EEG studies were enrolled into this prospective study at a tertiary University Hospital study. Sequential recording of sleep deprivation EEGs both with and without prior administration of melatonin was performed. A total of 50 patients (27 with epilepsy, 23 non-epileptic neurological patients) were included in this study (median age 9.5 years; range 1-18 years; male 28). The quality and EEG characteristics (abnormal findings, depth of sleep) were not affected by the use of melatonin. In total, 92 of 100 EEGs were successfully performed without significant differences between the two groups (six failures with melatonin, two failures without melatonin; p = 0.289). We conclude that melatonin does not alter the quality of sleep EEG studies in children with epilepsy or suspected epilepsy. Melatonin does not increase the rate of successfully performed EEG studies in sleep-deprived children.

Interleukin-8 Values in Pediatric Oncology Patients with Febrile Neutropenia and Bloodstream Infections

Background and aims: Upon bacterial stimulation, leukocytic cells and non-leukocytic somatic cells produce variety of cytokines which regulate immune response, inflammatory and hematopoiesis processes. One of these cytokines - interleukin-8 (IL-8) - takes part in leukocytic cells homing and chemotaxis, wound healing, angiogenesis, tumor development.The aim of this study was to evaluate and compare of values of IL-8 in oncohematologic children with febrile neutropenia (FN) and bloodstream infections.Methods: A total of 16 febrile neutropenic episodes in 16 children were studied. Serum samples were collected on day 1 and day 2. Microbiological evaluation and IL-8 determination of the samples were performed. Comparison of IL-8 values was performed using Mann-Whitney non-parametric statistical test.Results: Gram-negative infection was detected in 11 children, whereas Gram-positive infection - in 5 children. Patients with Gram-negative infection have IL-8 values of 3,9 - 4,3 times higher than patients with Gram-positive infection (see Table 1).Conclusions: These data showed a distinct innate immune response to different types of bacteria in oncohematologic children with FN. IL-8 could be used as a additional diagnostic tool in children with FN and malignancies for sepsis or bacteremia determination on the first days of fever. In the meantime, validation of IL-8 in various diagnostic settings is required.

Use of radioisotope bone scans in children with obscure foot pain

Foot pain in pediatric patients often presents as a diagnostic challenge. Studies in adults with foot pain have shown that bone scans are valuable diagnostic tools, especially in instances in which clinical evaluation and conventional radiography have failed to provide a clear answer. To our knowledge, no similar investigation has ever been conducted in the pediatric population. The objective of this study was to determine the utility of bone scans as a diagnostic tool for children with foot pain of unclear etiology. Our secondary objective was to determine whether obtaining a bone scan, in fact, alters the treatment plan of such patients. Chart review was done, documenting the prebone scan versus post bone scan diagnosis and treatment plans. We found that bone scans were diagnostically useful in 38 of 49 [77.6%, 66-87, 90% confidence interval (CI)] cases, helping to establish new diagnoses in 31 of 49 (63%, 51-75, 90% CI) cases, and directing the treatment of children with clinically unclear foot pain in 31 of 49 (63%, 51-75, 90% CI) cases. We conclude that children between the age of 2 and 11 years who present with unilateral or bilateral foot pain of unclear clinical etiology, with a normal or inconclusive radiograph and physical examination, and who had no previous magnetic resonance imaging and/or computed tomography scan, may benefit from the use of a bone scan to guide diagnosis and treatment.

P07.8 MRI of the brain as a diagnostic tool in children with disorders due to disturbed mitochondrial energy metabolism

P07.8 MRI of the brain as a diagnostic tool in children with disorders due to disturbed mitochondrial energy metabolism

Colonic Manometry Versus Colonic Scintigraphy as a Diagnostic Tool for Children With Severe Constipation

Colonic Manometry Versus Colonic Scintigraphy as a Diagnostic Tool for Children With Severe Constipation

Utility of Simplified Criteria for the Diagnosis of Autoimmune Hepatitis in Children

Although the diagnostic scoring system of autoimmune hepatitis (AIH) has been used, these criteria are intended mainly as research tools and are complicated to apply. To resolve these difficulties and allow quick diagnosis, a simplified scoring system was proposed in 2007. We retrospectively compared the simplified AIH scoring system with the 1999 revised original AIH scoring system in children. Twenty children (boys/girls 10/10, age 1-15 years, mean age ± SD 8.4 ± 4.4 years) who were diagnosed with AIH based on clinical, biochemical, immunological, and histological data were enrolled in this study. In addition, 36 children with non-AIH liver diseases (boys/girls 22/14, age 1-16 years, mean age ± SD 7.8 ± 4.4 years) were available for evaluation of both the simplified and the 1999 revised scoring system. The sensitivity and specificity of the 1999 revised scoring system were 100% and 81%, respectively. In contrast, the sensitivity and specificity of the simplified scoring system were 55% and 86%, respectively. Of the 20 children with AIH, 9 (45%) were classified as not having AIH using the simplified scoring system. Of the 9 children, 2 and 7 were classified as having definite AIH and probable AIH using the 1999 revised scoring system, respectively. All 5 children with primary sclerosing cholangitis were graded as having AIH using the simplified AIH criteria and the 1999 revised criteria. Although the simplified AIH scoring system has low sensitivity for the diagnosis of AIH in children, the specificity of the simplified AIH scoring system is high. However, the simplified AIH scoring system could not differentiate between AIH and primary sclerosing cholangitis. Therefore, the simplified AIH scoring system does not seem to be a reliable diagnostic tool in children.

M1571: Capsule Endoscopy in Pediatric Patients: Technique and Results in Our First 94 Consecutive Children (8 Months to 16 Years of Age)

We have made 94 Capsule Endoscopies in pediatric patients. Our youngest patient was only 8 months old and 26 of our patients were less than 8 years old. The average age of our patients was 10.5 years (range 0,7-16 years). The indications for Capsule Endoscopy were the following: Obscure or overt gastrointestinal bleeding (n= 17), suspicion or evaluation of Crohn's disease (n=31), evaluation of earlier diagnosed ulcerative colitis (indeterminate colitis; n=24) and 22 others (4 polyposis-syndromes, 7 protein losing enteropathies, 4 blood vessel anomalies and 7 others (intestinal pseudo-obstruction, abdominal pain etc.). The youngest patients to swallow the capsule were 7 years old, although usually patients more than 10 years old were able to swallow the capsule without any problems. In younger patients the capsule was taken in to the duodenum with gastroscopic quidance. In our first 3 patients we used a self made plastic tube to deliver the capsule into the stomach, in 12 patients we used Roth Net® and in 79 patients we used the newer Capsule Delivery Devise®. After the capsule had been released in the duodenum, the normal capsule endoscopy recording was made. 8 patients had nausea and vomiting during CE, but this was most probably caused by the anesthetic drugs. Otherwise the CE was done without any special problems. In 1 (0,5%) patient of those who could swallow the capsule, the capsule stayed in the stomach during the whole 8 hours of recording, although it was later on expelled naturally. In 21% of examinations the capsule didn't reach the caecum during the 8 hours of recording. We got a significant finding (multiple ulcers, bleeding, tumors, strictures, Crohn's disease) altogether in 50 % of patients. Of course in some patients we could also rule out significant small intestinal disease.As a conclusion capsule endoscopy is a safe procedure also in very young patients and it seems to be a very effective diagnostic tool in children with difficult GI symptoms and negative results in conventional endoscopic and radiologic examinations.

Isolated extramedullary relapse of acute lymphoblastic leukemia in the breast of an adolescent girl: radiologic findings and discussion

We report a case of isolated extramedullary leukemia relapse in the breast of an adolescent girl. A 13-year-old girl with acute lymphoblastic leukemia in remission, post-chemotherapy and unrelated cord blood transplant, presented with a breast lump. US and mammography demonstrated a large hypervascular heterogeneous mass. Examination of tissue provided by US-guided core biopsy confirmed focal leukemic relapse. US is a commonly used diagnostic tool in children and adolescents with a breast mass, for both characterization and guided biopsy.