Accuracy and Interrater Reliability of Point-of-Care Ultrasonography Image Interpretation for Intussusception.

OBJECTIVES: The aim of this study was to determine the accuracy and interrater reliability of (1) point-of-care ultrasound (POCUS) image interpretation for identification of intussusception and (2) reliability of secondary signs associated with intussusception among experts compared with novice POCUS reviewers. METHODS: We conducted a planned secondary analysis of a prospective, convenience sample of children aged 3 months to 6 years who were evaluated with POCUS for intussusception across 17 international pediatric emergency departments between October 2018 and December 2020. A random sample of 100 POCUS examinations was reviewed by novice and expert POCUS reviewers. The primary outcome was identification of the presence or absence of intussusception. Secondary outcomes included intussusception size and the presence of trapped free fluid or echogenic foci. Accuracy was summarized using sensitivity and specificity, which were estimated via generalized mixed effects logistic regression. Interrater reliability was summarized via Light's κ statistics with bootstrapped standard errors (SEs). Accuracy and reliability of expert and novice POCUS reviewers were compared. RESULTS: Eighteen expert and 16 novice POCUS reviewers completed the reviews. The average expert sensitivity was 94.5% (95% confidence interval [CI], 88.6-97.5), and the specificity was 94.3% (95% CI, 90.3-96.7), significantly higher than the average novice sensitivity of 84.7% (95% CI, 74.3-91.4) and specificity of 80.4% (95% CI, 72.4, 86.7). κ was significantly greater for expert (0.679, SE 0.039) compared with novice POCUS reviewers (0.424, SE 0.044; difference 0.256, SE 0.033). For our secondary outcome measure of intussusception size, κ was significantly greater for experts (0.661, SE 0.038) compared with novices (0.397, SE 0.041; difference 0.264, SE 0.029). Interrater reliability was weak for expert and minimal for novice reviewers regarding the detection of trapped free fluid and echogenic foci. CONCLUSIONS: Expert POCUS reviewers demonstrate high accuracy and moderate interrater reliability when identifying intussusception via image interpretation and perform better than novice reviewers.

Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception: A Multicenter, Noninferiority Study of Paired Diagnostic Tests.

STUDY OBJECTIVE: To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) performed by experienced clinician sonologists compared to radiology-performed ultrasound (RADUS) for detection of clinically important intussusception, defined as intussusception requiring radiographic or surgical reduction. METHODS: We conducted a multicenter, noninferiority, observational study among a convenience sample of children aged 3 months to 6 years treated in tertiary care emergency departments across North and Central America, Europe, and Australia. The primary outcome was diagnostic accuracy of POCUS and RADUS with respect to clinically important intussusception. Sample size was determined using a 4-percentage-point noninferiority margin for the absolute difference in accuracy. Secondary outcomes included agreement between POCUS and RADUS for identification of secondary sonographic findings. RESULTS: The analysis included 256 children across 17 sites (35 sonologists). Of the 256 children, 58 (22.7%) had clinically important intussusception. POCUS identified 60 (23.4%) children with clinically important intussusception. The diagnostic accuracy of POCUS was 97.7% (95% confidence interval [CI] 94.9% to 99.0%), compared to 99.3% (95% CI 96.8% to 99.9%) for RADUS. The absolute difference between the accuracy of RADUS and that of POCUS was 1.5 percentage points (95% CI -0.6 to 3.6). Sensitivity for POCUS was 96.6% (95% CI 87.2% to 99.1%), and specificity was 98.0% (95% CI 94.7% to 99.2%). Agreement was high between POCUS and RADUS for identification of trapped free fluid (83.3%, n=40/48) and decreased color Doppler signal (95.7%, n=22/23). CONCLUSION: Our findings suggest that the diagnostic accuracy of POCUS performed by experienced clinician sonologists may be noninferior to that of RADUS for detection of clinically important intussusception. Given the limitations of convenience sampling and spectrum bias, a larger randomized controlled trial is warranted.

Utilization of computed tomography imaging in the pediatric emergency department.

BACKGROUND: In recent years, there has been a movement toward more judicious use of computed tomography (CT) imaging in an attempt to limit exposure of pediatric patients to ionizing radiation. The Image Gently Alliance and like-minded movements began advocating for safe and high-quality pediatric imaging worldwide in the late 2000s. OBJECTIVE: In the context of these efforts, we evaluate CT utilization rates in the pediatric emergency department at a major academic medical center. MATERIALS AND METHODS: We tracked utilization in several categories of CT, magnetic resonance imaging (MRI) and ultrasonography (US) between July 2008 and June 2017 and compared them with utilization rates from 2000 to 2006. RESULTS: A total of 4,955 pediatric patients underwent a total of 5,973 CT scans, 2,775 US studies and 293 MRI scans while in the pediatric emergency department during the 2008-2017 study period. We observed decreases in CT scans across all categories, ranging from a 19% decrease in abdominal CT to a 66% decrease in chest CT. Relatively greater decreases in CT scans were observed in patients younger than 3 years of age as compared to older children and adolescents. Abdominal and pelvic US increased. Brain MRI also increased over the final two years of the study. CONCLUSION: CT utilization decreased throughout the 2008-2017 study period.

The Role of Limited Head Computed Tomography in the Evaluation of Pediatric Ventriculoperitoneal Shunt Malfunction.

BACKGROUND: The evaluation of children with suspected ventriculoperitoneal shunt (VPS) malfunction has evolved into a diagnostic dilemma. This patient population is vulnerable not only to the medical risks of hydrocephalus and surgical complications but also to silent but harmful effects of ionizing radiation secondary to imaging used to evaluate shunt efficacy and patency. The combination of increased medical awareness regarding ionizing radiation and public concern has generated desire to reduce the reliance on head computed tomography (CT) for the evaluation of VPS malfunction. Many centers have started to investigate the utility of low-dose CT scans and alternatives, such as fast magnetic resonance imaging for the investigation of VP shunt malfunction in order to keep radiation exposure as low as reasonably achievable. This pilot study hopes to add to the armamentarium available to the clinician charged with evaluating this challenging patient population by testing the feasibility of a limited CT protocol as an alternative to a full head CT examination. OBJECTIVE: To evaluate the efficacy of a limited head CT protocol compared with a complete head CT for the evaluation of children presenting to the pediatric emergency department with suspected shunt malfunction. METHODS: We retrospectively reviewed all pediatric patients who received a head CT for suspected VPS malfunction evaluation at a tertiary care children's hospital from January 2001 through January 2013. Children were included in the pilot study if they had at least 2 CT scans in this study period interpreted by a specific senior attending neuroradiologist. For each patient enrolled, a limited series was generated from the most recent CT scan by selecting four representative axial slices based on the sagittal scout image. These 4 slices where selected at the level of the fourth ventricle, third ventricle, basal ganglia level, and lateral ventricles, respectively. A blinded, senior attending neuroradiologist first reviewed the limited 4-slice CT data set and was asked to determine if the ventricular system had increased, decreased, or remained stable. Subsequently, the neuroradiologist compared their interpretation of the limited examination with the official report from the full CT data set as the standard of reference as well as the interpretation of the most recent prior scan. RESULTS: Forty-six patients (age range, 2 months to 18 years; average age, 6.4 years (SD, 4.2), 54% male) were included in the study. Forty-four of 46 (95.7%) limited CT scans matched the official report of the full CT scan. No cases of increased ventricular size were missed (100% positive predictive value for increased ventricular size). The use of a limited head CT (4 axial images) instead of a complete head CT (average of 31 axial images in our studied patients) confers a radiation dose reduction of approximately 87%. CONCLUSIONS: Our pilot study demonstrates that utilization of limited head CT scan in the evaluation of children with suspected VP shunt malfunction is a feasible strategy for the evaluation of the ventricular size. Further prospective and multidisciplinary studies are needed to evaluate the reliability of limited head CT for the clinical evaluation of VP shunt malfunction.

A Porcine Anterior Segment Perfusion and Transduction Model With Direct Visualization of the Trabecular Meshwork.

PURPOSE: To establish a consistent and affordable, high quality porcine anterior segment perfusion and transduction model that allows direct visualization of the trabecular meshwork. METHODS: Porcine anterior segments were cultured within 2 hours of death by removing lens and uvea and securing in a specially designed petri dish with a thin bottom to allow direct visualization of the trabecular meshwork with minimal distortion. Twenty-two control eyes (CO) with a constant flow rate were compared to eight gravity perfused eyes (COgr, 15 mm Hg). We established gene delivery to the TM using eGFP expressing feline immunodeficiency virus (FIV) vector GINSIN at 108 transducing units (TU) per eye (GINSIN_8, n = 8) and 107 TU (GINSIN_7, n = 8). Expression was assessed for 14 days before histology was obtained. RESULTS: Pig eyes were a reliable source for consistent and high quality anterior segment cultures with a low failure rate of 12%. Control eyes had an intraocular pressure (IOP) of 15.8 ± 1.9 mm Hg at fixed pump perfusion with 3 µL/min compared to gravity perfused COgr with imputed 3.7 ± 1.6 µL/min. Vector GINSIN_8 eyes experienced a transient posttransduction IOP increase of 44% that resolved at 48 hours; this was not observed in GINSIN_7 eyes. Expression was higher in GINSIN_8 than in GINSIN_7 eyes. Trabecular meshwork architecture was well preserved. CONCLUSIONS: Compared with previously used human donor eyes, this inexpensive porcine anterior segment perfusion model is of sufficient, repeatable high quality to develop strategies of TM bioengineering. Trabecular meshwork could be observed directly. Despite significant anatomic differences, effects of transduction replicate the main aspects of previously explored human, feline and rodent models.

On Shaky Ground: Learner Response and Confidence After Tabletop Earthquake Simulation.

OBJECTIVE: The aim of this study was to evaluate residents' confidence and attitudes related to management of earthquake victims during a tabletop simulation and 6 months after the intervention. METHODS: Pediatric residents from 4 training programs were recruited via e-mail. The tabletop simulation involved 3 pediatric patients (crush injury, head injury, and a nonverbal patient with minor injuries). A facilitated debriefing took place after the simulation. The same simulation was repeated 6 months later. A survey was administered before the simulation, immediately after, and after the 6-month repeat simulation to determine participants' self-rated confidence and willingness to respond in the event of a disaster. A 5-point Likert scale that ranged through novice, advanced beginner, competent, proficient, and expert was used. RESULTS: Ninety-nine participants completed the survey before the initial simulation session. Fifty-one residents completed the immediate postsurvey, and 75 completed the 6-month postsurvey. There was a statistically significant improvement in self-rated confidence identifying and managing victims of earthquake disasters after participating in the simulation, with 3% rating themselves as competent on the presurvey and 33% rating themselves as competent on the postsurvey (P < 0.05). There was a nonstatistically significant improvement in confidence treating suspected traumatic head injury as well as willingness to deploy to both domestic and international disasters. CONCLUSIONS: Tabletop simulation can improve resident comfort level with rare events, such as caring for children in the aftermath of an earthquake. Tabletop can also be easily integrated into resident curriculum and may be an effective way to provide disaster medical response training for trainees.

Ultrasound-Guided Diagnosis of Femoral Osteomyelitis and Abscess.

Skin and soft tissue infections are common disease presentations to the pediatric emergency department, and rapid and accurate identification of potentially serious skin and soft tissue infections is critical. In cases of atraumatic musculoskeletal pain with systemic complaints, a bacterial etiology must be ruled out. Point-of-care ultrasonography is increasingly common in the pediatric emergency department and assists in rapid and accurate identification of a variety of disease processes. We present a case of a 14-year-old adolescent boy with atraumatic right knee pain to illustrate the benefits of point-of-care ultrasonography in the timely diagnosis of musculoskeletal and soft tissue pathology. Moreover, we describe the use of ultrasound in procedural guidance of deep-space fluid aspiration, with an eventual diagnosis of femoral osteomyelitis. Ultrasonographic techniques and the emergent work-up and management of osteomyelitis are reviewed.

Point-of-Care Ultrasound for Pediatric Shock.

The evaluation of critically ill children in the emergency department is oftentimes challenging. Point-of-care ultrasound is an essential tool in the rapid identification of reversible pathology and provides unique insight into the appropriate treatment approach. In this article, we discuss a straightforward sonographic approach to pediatric patients who present in shock.

Ketamine Saves the Day: Priapism in a Pediatric Psychiatric Patient.

Priapism is an adverse effect of medications used to treat psychiatric disorders. Often, this condition is self-limiting but may require urologic intervention involving aspiration and injection to induce detumescence. A case of a 15-year-old patient with priapism secondary to a long-acting stimulant is presented to describe the effectiveness of ketamine treatment for priapism.

Extraocular cranial nerve palsies in children.

Visual disturbances resulting from acute nerve paralysis of the muscles controlling eye movements can be challenging to evaluate in the pediatric population. Children may not be capable of describing symptoms or providing an adequate history. Therefore, it is important to have an understanding of the anatomical course of the extraocular cranial nerves and clinical manifestations of their dysfunction. We report 2 cases of extraocular cranial nerve palsies and, in addition to an anatomical review, discuss the common etiologies of paralysis and the importance of ophthalmological and neurological follow-up to ensure optimal long-term visual function.

Checklist use in evaluating pediatric disaster training.

OBJECTIVE: Disaster preparedness training has a small but growing part in medical education. Various strategies have been used to simulate disaster scenarios to safely provide such training. However, a modality to compare their effectiveness is lacking. The authors propose the use of checklists, which have been a standard in aviation safety for decades. DESIGN: Residents at four different academic pediatric residency programs volunteered to participate in tabletop simulation of a timed, pediatric disaster scenario. Resident teams were required to properly triage and manage simulated patients. Care intervention requests corresponding to each of the patients were recorded on a premade checklist. RESULTS: Thirty-six teams provided a total of 1,476 possible care intervention requests for three pediatric patients: one with crush injury, one with increased intracranial pressure, and a nonverbal child. Some interventions were more likely to be omitted than others, and some teams performed extra interventions. Twenty-five entries from the checklist intervention responses were missing, affecting three of the teams. On average, teams requested 65 percent, were prompted to request 11 percent, and missed 22 percent of all checklist interventions with only 2 percent of all items not being recorded. Chi-square tests were performed for each patient scenario using R software. Categories compared included total counts of "requested," "prompted," and "missed" responses. Chi-square values were all statistically significant (p value < 0.05). CONCLUSIONS: In the checklist use during a tabletop disaster simulation, the authors have demonstrated that the checklist allows trainees to receive near immediate feedback. This training exercise provided them an opportunity to explore their own preparedness for a disaster scenario in a low-stress environment and allows for evaluation of such preparedness in a safe environment.

Pulmonary embolism in the pediatric emergency department: a case demonstrating the application of point-of-care cardiac ultrasound in a pediatric patient with pulmonary embolism.

Although pulmonary embolism in children is rare, it is important for the pediatric emergency medicine provider to be aware of its presentation and emergent management. We present a case of bilateral pulmonary embolisms in an adolescent patient to illustrate the benefits from the timely diagnosis of right ventricular dysfunction by point-of-care echocardiography performed by emergency medicine physicians. Ultrasonographic techniques and the emergent management of pulmonary embolism are reviewed.

Effectiveness of a medicolegal lecture on risk-reduction medical record documentation by pediatric residents.

OBJECTIVE: To determine the effectiveness of a medicolegal lecture on risk-reduction documentation by residents in a pediatric emergency department. DESIGN/METHODS: Pediatric residents at an academic children's hospital were offered a 1-hour lecture on reducing medicolegal risks. Residents in attendance made up the intervention group (IG) and nonattendants were the control group (CG). The primary outcome was risk-reduction documentation (RRD) using patients with chief complaints of abdominal pain, extremity fractures, and lacerations with potential foreign body. RESULTS: For abdominal pain patients, RRD by IG improved 6.1% compared with 15.1% for the CG. For fracture patients, RRD by IG improved 20% compared with 26.5% decrease by CG. For laceration patients, RRD by IG decreased 20.8% compared with 30.6% decrease by CG. Although none reached statistical significance, the postintervention IG rates were greater. CONCLUSIONS: We showed a trend toward improvement in the rate of risk-reduction medical record documentation.

All that wheezes is not asthma: cognitive bias in pediatric emergency medical decision making.

OBJECTIVE: The objectives of this study were to highlight the intimate role that cognitive biases play in clinical decision making in the pediatric emergency department and to recommend strategies to limit their negative impact on patient care outcomes. METHODS: This was a descriptive study of 3 cases of presumed asthma exacerbation evolving into alternate diagnoses. RESULTS: The role cognitive biases played in either delay to diagnosis or missed diagnosis contributing to patient morbidity are illustrated in each case. CONCLUSIONS: Common cognitive biases play a role in the unique milieu of the pediatric emergency department. A case series of presumed patients with asthma illustrates how mental shortcuts (heuristics) taken in times of high decision density and uncertainty may lead to diagnostic errors and patient harm. Suggestions to address and prevent cognitive biases are presented.