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.

Point-of-Care Ultrasound Identification of Right-Sided Cardiac Chamber Collapse Associated With Pericardial Effusions Without Hypotension: A Case Series.

ABSTRACT: We present a case series of 6 children in whom point-of-care ultrasound revealed a pericardial effusion with right atrial or ventricular collapse, and show how this may heighten concern for development of pericardial tamponade and expedite care.

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.

Ventricular tachycardia in an adolescent with severe diabetic ketoacidosis.

Diabetic ketoacidosis (DKA) occurs frequently among children and adolescents with type 1 diabetes. Although a number of complications may occur during episodes of DKA, significant cardiac arrhythmias are uncommon. We present the case of an adolescent who presented with severe DKA and wide complex tachycardia that was unresponsive to multiple doses of adenosine and ultimately required synchronized cardioversion. This case reminds the clinician of the importance of cardiac monitoring in children with DKA, particularly in the setting of hyperkalemia.

Trends in Medical Claims and Utilization of Limited Ultrasonography Among Emergency Physicians and Radiologists Within a Large Health Plan Provider.

OBJECTIVES: The goal of this study was to evaluate trends in medical claim submissions for limited ultrasound studies performed (1) during emergency department (ED) encounters and (2) by ED providers compared to radiologists. METHODS: We conducted a retrospective, descriptive study using medical claims data from Medica Health Plans from January 1, 2011 to December 31, 2015. Current procedural terminology codes were abstracted for limited ultrasound applications performed during an ED visit and further stratified by studies performed by ED providers compared with radiologists. We excluded claims for which we could not determine provider specialty. RESULTS: We identified 42,576 encounters with limited US claims, of which, 32,666 were submitted by ED providers (N = 9649) or radiologists (N = 23,017). Among ED providers, there was a significant linear increase in the annual number of claims for retroperitoneal (P < .001) and nonlinear increases for thoracic, soft tissue, cardiac, transvaginal genitourinary (GU) and transabdominal GU claims (all P < .001). Compared with radiologists, there was a linear increase in the annual proportion of claims submitted for retroperitoneal (P = .023), transabdominal GU (P = .003), and transvaginal GU (P < .001) studies by ED providers. There was a nonlinear decrease in the annual proportion of limited abdomen claims (P < .001) submitted by ED providers compared with radiologists. CONCLUSIONS: Using data from a large health plan provider, we show that medical claims for many limited ultrasound studies are increasing among ED providers. Compared with radiologists, ED providers are increasingly submitting claims for retroperitoneal, soft tissue, and transabdominal GU studies.

Point-of-Care Ultrasound Identification of Internal Jugular Vein Thrombosis in Newly Diagnosed Lymphoma.

We present a case of a child who presented with neck swelling and was ultimately diagnosed with lymphoma after an internal jugular vein thrombosis was discovered by point-of-care ultrasound. The use of point-of-care ultrasound enabled thrombus detection, which prompted further evaluation and treatment.

An Unexpected Guest: A Case of Cutaneous Furuncular Myiasis: The 2013 PEMpix Photo Competition Winner.

Dermatobia hominis, also known as the botfly, is a parasitic infestation commonly found in Central and South America. In humans, this usually presents as cutaneous furuncular myiasis, after the larvae become embedded in the skin. This produces a local inflammatory reaction, which may mimic cellulitis; however, definitive treatment requires removal of the botfly larvae. This infestation is uncommon in the United States but should remain high on the differential diagnosis of returning travelers presenting with cutaneous lesions, as seen in the reported case of a teenager after return from Central America.

Rapunzel syndrome: diagnosis via radiograph and history.

Rapunzel syndrome is defined as a gastric trichobezoar with a tail that extends distally into the small intestine. It is extremely rare and found more often in premenarchal girls with psychiatric comorbidities. Symptoms can be vague and linger for years. However, prolonged intake of indigestible material can lead to gastric outlet obstruction, which may present similarly to a small bowel obstruction. The standard imaging modality of choice to make a presurgical diagnosis is via computed tomography (CT) scan of the abdomen. However, the risk of radiation-induced malignancy associated with a CT scan is an important consideration when managing children. We report a case of Rapunzel syndrome in a 6-year-old girl who was diagnosed presurgically without the use of a CT scan.