Accuracy of Point-of-care Ultrasonography for Diagnosing Acute Appendicitis: A Systematic Review and Meta-analysis.

BACKGROUND: The use of ultrasonography (US) to diagnose appendicitis is well established. More recently, point-of-care ultrasonography (POCUS) has also been studied for the diagnosis of appendicitis, which may also prove a valuable diagnostic tool. The purpose of this study was through systematic review and meta-analysis to identify the test characteristics of POCUS, specifically US performed by a nonradiologist physician, in accurately diagnosing acute appendicitis in patients of any age. METHODS: We conducted a thorough and systematic literature search of English language articles published on point-of-care, physician-performed transabdominal US used for the diagnosis of acute appendicitis from 1980 to May, 2015 using OVID MEDLINE In-Process & Other Non-indexed Citations and Scopus. Studies were selected and subsequently independently abstracted by two trained reviewers. A random-effects pooled analysis was used to construct a hierarchical summary receiver operator characteristic curve, and a meta-regression was performed. Quality of studies was assessed using the QUADAS-2 tool. RESULTS: Our search yielded 5,792 unique studies and we included 21 of these in our final review. Prevalence of disease in this study was 29.8%, (range = 6.4%-75.4%). The sensitivity and specificity for POCUS in diagnosing appendicitis were 91% (95% confidence interval [CI] = 83%-96%) and 97% (95% CI = 91%-99%), respectively. The positive and negative predictive values were 91 and 94%, respectively. Studies performed by emergency physicians had slightly lower test characteristics (sensitivity = 80%, specificity = 92%). There was significant heterogeneity between studies (I2 = 99%, 95% CI = 99%-100%) and the quality of the reported studies was moderate, mostly due to unclear reporting of blinding of physicians and timing of scanning and patient enrollment. Several of the studies were performed by a single operator, and the education and training of the operators were variably reported. CONCLUSION: Point-of-care US has relatively high sensitivity and specificity for diagnosing acute appendicitis, although the data presented are limited by the quality of the original studies and large CIs. In the hands of an experienced operator, POCUS is an appropriate initial imaging modality for diagnosing appendicitis. Based on our results, it is premature to utilize POCUS as a stand-alone test or to rule out appendicitis.

Diagnostic Accuracy of Ultrasonography in Retained Soft Tissue Foreign Bodies: A Systematic Review and Meta-analysis.

OBJECTIVES: Open wounds with the potential for retained foreign bodies are frequently seen in the emergency department (ED). Common foreign bodies, such as wood or glass, are often missed on physical examination and conventional radiography. The increased use of ultrasonography (US) in the ED presents an opportunity to better identify retained soft tissue foreign bodies, and understanding of its test characteristics is desirable. The authors set out to determine the test characteristics of US for detection of soft tissue foreign bodies by performing a systematic review and meta-analysis of the existing literature. METHODS: This was a thorough, systematic review of OVID Medline, SCOPUS, and Cochrane databases and a limited review of Directory of Open Access Journals, Google Scholar, and ClinicalTrials.gov to identify clinical studies examining the diagnostic accuracy of US in the identification of retained soft tissue foreign bodies. Studies were selected for full-text review by two independent reviewers to determine if they met inclusion criteria. Results were pooled for test characteristics using STATA and assessed for risk of bias and applicability using the QUADAS-2 tool. RESULTS: This systematic search strategy identified 5,059 unique articles, and 17 articles met inclusion criteria. Pooled sensitivity and specificity were, respectively, 72% (95% confidence interval [CI] = 57% to 83%) and 92% (95% CI = 88% to 95%). Overall quality of the studies was low and interstudy heterogeneity was high (I(2)  = 90%, 95% CI = 80% to 100%). CONCLUSIONS: Ultrasonography is highly specific and moderately sensitive in the identification of retained soft tissue foreign bodies; however, studies to date have a high degree of heterogeneity and a high risk of bias.

Risk factors associated with difficult venous access in adult ED patients.

OBJECTIVE: The objective was to determine risk factors associated with difficult venous access (DVA) in the emergency department (ED). METHODS: This was a prospective, observational study conducted in the ED of an urban tertiary care hospital. Adult patients undergoing intravenous (IV) placement were consecutively enrolled during periods of block enrollment. The primary outcome was DVA, defined as 3 or more IV attempts or use of a method of rescue vascular access to establish IV access. Univariate and multivariate analyses for factors predicting DVA were performed using logistic regression. RESULTS: A total of 743 patients were enrolled, of which 88 (11.8%) met the criteria for DVA. In the adjusted analysis, only 3 medical conditions were significantly associated with DVA: diabetes (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.1-2.8), sickle cell disease (OR 3.8, 95% CI 1.5-9.5), and history of IV drug abuse (OR 2.5, 95% CI 1.1-5.7). Notably, age, body mass index, and dialysis were not. Of patients who reported a history of requiring multiple IV attempts in the past for IV access, 14% met criteria for DVA on this visit (OR 7.7 95% CI 3-18). Of the patients who reported a history of IV insertion into the external jugular, ultrasound-guided IV placement, or a central venous catheter for IV access, 26% had DVA on this visit (OR 16.7, 95% CI 6.8-41). CONCLUSIONS: Nearly 1 of every 9 to 10 adults in an urban ED had DVA. Diabetes, IV drug abuse, and sickle cell disease were found to be significantly associated with DVA.