Rapid, free-breathing non-contrast MRI for first-line imaging evaluation of ovarian torsion in the emergency department

BACKGROUND

Transabdominal ultrasound (US) is first-line imaging to evaluate ovaries in girls presenting to the emergency department (ED) with suspected ovarian torsion. Ovaries may be difficult to visualize sonographically; therefore, prompt diagnosis using US alone can be challenging. Rapid MRI as first-line imaging may help streamline patient throughput, especially with increasing MRI availability in the ED.

OBJECTIVE

To assess feasibility of rapid MRI for diagnosis of ovarian torsion.

MATERIALS AND METHODS

A retrospective, single-center IRB approved study of MRI performed in female pediatric patients presenting with abdominopelvic pain from August 2022 to January 2023. Imaging occurred according to one of three clinical pathways (US-first approach vs MRI-first approach vs US + MRI-second-line approach). A rapid three-sequence free-breathing MRI protocol was utilized. Frequency of ovarian torsion and secondary diagnoses was recorded. Length of MR scan time, time from ED arrival to time of diagnosis, and whether patient had US prior to MR exam were obtained. A historical cohort of patients with US only performed for assessment of ovarian torsion were evaluated for length of the US examination and time from ED arrival to time of diagnosis. Intervals were compared using the uncorrected Fisher's least significant difference and Turkey's multiple comparison tests.

RESULTS

A total of 140 MRI exams (mean age 14.6 years) and 248 historical US exams (mean age 13.5 years) were included. Of the patients with MRI, 41 (29%) patients were imaged with US + MRI and 99 (71%) imaged with MRI only; 4% (6/140) MR exams were suspicious for ovarian torsion, with one true positive case (1/6 TP) and 5 false positive cases (5/6 FP); 26.4% (37/140) of exams had secondary diagnoses. Median MRI scan time was 11.4 min (4.4) vs median historical US scan time was 24.1 min (19.7) (P<0.001). Median time from arrival in ED to MRI read was 242 (140). Median time from arrival in ED to US only read was 268 min (148). This was not a statistically significant difference when compared to the MRI only cohort.

CONCLUSION

First-line MRI imaging for evaluation of ovarian torsion is a rapid and feasible imaging modality for female patients in the emergent setting.

Characterizing the Adolescent Premature Ovarian Insufficiency Phenotype: A Case Control Study

STUDY OBJECTIVES

To characterize the skeletal, cardiometabolic, cognitive, and mental health phenotype of adolescents with idiopathic premature ovarian insufficiency (POI) DESIGN: Case control SETTING: Pediatric tertiary referral center in Cincinnati, Ohio PARTICIPANTS: Nine adolescents (ages 11-18.99 years) with newly diagnosed POI and 9 normally menstruating controls, matched by age and body mass index MAIN OUTCOME MEASURES: Between-group comparisons of bone characteristics assessed by dual energy x-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT), psychosocial health (anxiety, depression, and quality of life), and cognition and memory by questionnaire RESULTS: Adolescents with POI had lower bone density Z-scores by DXA (lumbar spine -1.93 vs 0.80; whole body less head -2.05 vs 0.00; total hip -1.03 vs 0.83; and femoral neck -1.23 vs 0.91; all P < .001), as well as lower trabecular volumetric bone mineral density (tibia 3% site 226 vs 288 mg/mm³, P < .001; radius 3% site 200 vs 251, P = .001), smaller cortical area (tibia 66% site 251 vs 292 mm², P = .028), and thickness (tibia 66% site 3.56 vs 4.30 mm, P = .001) than controls. No abnormalities in cardiometabolic biomarkers were detected in POI cases. Adolescents with POI were also more likely to report low energy (78% vs 22%, P = .02).

CONCLUSION

Estrogen deficiency adversely affects bone health in adolescents with POI. However, we did not find associations with cardiometabolic, mental health, or cognitive outcomes in this small sample.

Hormonal contraceptive choices in a clinic-based series of transgender adolescents and young adults

Aims: To describe the use of hormonal contraceptives for menstrual management and/or pregnancy prevention in a clinic-based series of transgender adolescents and young adults who were assigned female at birth (transmasculine identity). Methods: We performed a chart review of post-menarchal transgender assigned-female-at-birth (AFAB) patients, age 10-25 years, seen at CCHMC Transgender Health Clinic for at least 2 visits between July 1, 2013 and September 17, 2016, and who were not on a puberty suppression method. We collected data including choice of hormonal contraceptive and indication (menstrual suppression, pregnancy prevention, or both), duration of use, initiation of sexual activity, reported sexual partners, and use of gender-affirming hormone therapy (i.e., testosterone). We present simple descriptive statistics. Results: A total of 231 patients met inclusion criteria, with ages from 11 to 25 years. Of those, 135 (59%) were using a hormonal contraceptive method. Most patients (67%) used hormonal contraception for the indication of menstrual suppression. Most commonly used method was depot medroxyprogesterone (DMPA) (49 patients), followed by combined oral contraceptives (COC) and norethindrone (progestin-only pill, POP) (34 patients each). Thirteen patients used 52 mg levonorgestrel IUD (LNG-IUD). Of the total sample (n = 231), 82 (36%) reported sexual activity, 35 of whom (43% of sexually active patients) reported sexual intercourse with assigned-male-at-birth (AMAB) partners and/or penile-vaginal intercourse. Among 35 patients at risk for pregnancy, only 21 (60%) were using hormonal contraception. Over half (54%) of sexually active patients taking testosterone discontinued their hormonal contraceptive method once they stopped having menses. Discussion: Within a sample of transgender AFAB adolescents, half of whom were taking testosterone, a variety of contraceptives were used, including depot medroxyprogesterone, combined oral contraceptives, and levonorgestrel IUD. Among those taking testosterone, many patients discontinued contraception once they stopped having menses.

Evaluation and Management of Primary Ovarian Insufficiency in Adolescents and Young Adults

STUDY OBJECTIVE

To identify clinical features associated with primary ovarian insufficiency (POI) and collect data on the evaluation and treatment received.

DESIGN

Retrospective chart review. Data were abstracted on etiology of POI, history, laboratory evaluation, imaging results, return for clinical care, and treatment plans.

SETTING

Urban children's hospital in Cincinnati, Ohio.

PARTICIPANTS

Fifty female patients, age 11-26 years, with initial presentation of POI between January 1, 2006 and December 31, 2015.

MAIN OUTCOME MEASURES

Etiology of POI, bone mineral density (BMD), laboratory evaluation, and services utilized at presentation.

RESULTS

Three hundred thirty-one charts were reviewed, 71 with confirmed diagnosis of POI, and 50 with sufficient data for inclusion. Among the 50, 21 (42%) had Turner syndrome, 18 (36%) remained idiopathic, and 11 (22%) had another condition (eg, autoimmune polyglandular syndrome, galactosemia, etc). Thirty-six (72%) were karyotyped; in 14 (28%), 21-hydroxylase antibodies were measured; 32 (64%) underwent dual-energy x-ray absorptiometry BMD measures of lumbar spine. Eight of 50 patients (16%) reported fracture. Of these, at presentation, 4 (50%) had low BMD, and 2 (25%) had slightly low BMD. On initial spinal dual-energy x-ray absorptiometry, 9 of 32 (28%) had low BMD (Z-score ≤ -2.0) and 7 of 32 (22%) were slightly low (-1.0 to -1.9). All started estrogen therapy within 2 years of presentation. In follow-up, only 2 patients (4%) saw a mental health consultant for emotional support.

CONCLUSION

POI is a model of estrogen deficiency with most cases due to Turner syndrome or idiopathic causes. At presentation, many had low BMD and few were seen for psychological support as part of multidisciplinary care.

Anaplastic Large Cell Lymphoma in Pregnancy. A Case Report

BACKGROUND

Anaplastic large cell lymphoma is rarely diagnosed during pregnancy, and patients may be erroneously diagnosed with a dermatosis.

CASE

A 34-year-old female was diagnosed with pruritic urticarial papules and plaques of pregnancy in the third trimester. She underwent elective repeat cesarean section with a postoperative course complicated by skin and gingival ulcers and persistent fever. Imaging revealed lung and brain nodules. Video-assisted thoracic surgery lung biopsy demonstrated anaplastic large cell lymphoma.

CONCLUSION

It is important to consider the diagnosis of anaplastic large cell lymphoma in a pregnant patient who presents with cutaneous symptoms.