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Point-of-care Ultrasound Offers Total Accuracy in Children with Suspected Appendicitis

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Based on a recent study conducted by a team of Mount Sinai researchers, utilizing portable ultrasound as a first-line imaging exam in kids with suspected appendicitis significantly helps deduct emergency room length of stay and decreases the need for CT scans.

Other than ultrasound, often referred to as point-of-care ultrasonography, has a specificity of about 94%, meaning that it misses few cases, the Mt. Sinai researchers add.

Results from the study have since been published online in the peer-reviewed journal Academic Emergency Medicine.

"From an institutional perspective, this is the most common surgical problem that we encounter with children in the emergency department," said the study's senior author and associate professor of emergency medicine and pediatrics at the Icahn School of Medicine at Mount Sinai, James W. Tsung, MD, MPH.

"CT scans have been the best imaging test for diagnosing appendicitis, but they expose children to radiation, which cumulatively can prove harmful, as increasing numbers of studies have shown."

Numerous studies have reported lifetime risks of cancer from abdominal and pelvis CT in children between 1 fatal cancer cause for every 500 to 3,000 CT scans performed, varyingon age and sex. Efforts to try to diminish the 4 million radiation-emitting CT scans obtained in children every year are presently underway, led by front-line physicians, radiologists, and radiological professional societies.

"CT scanning rate was reduced by over 35%, from a 44% CT scan rate prior to the study to a 27% rate during the study," commented assistant professor of emergency medicine and pediatrics, Icahn School of Medicine at Mount Sinai, and the study's second author, Ee Tay, MD.ct or ultra

During the course of the study, researchers used a prospective observational convenience sample of 150 children seen uninterruptedly between May 1, 2011 and October 1, 2012 in an urban pediatric emergency department. All children were under observation for suspected appendicitis. Results were determined by surgical or pathology report in those discovered to have appendicitis and three weeks later in patients who were seen as not to have appendicitis.

Operator accuracy reading the ultrasounds was reviewed in a blinded fashion by trained pediatric emergency medicine sonologists. The time to perform the point-of-care ultrasound and CT scan use was also measured.

The study revealed that emergency department length of stay decreased by 2 hrs and 14 minutes (46% decrease) for those needing radiology department ultrasound and nearly 6 hours (68% decrease) for those needing CT scan when point-of-care ultrasound was uncertain as a first-line imaging study.

Perhaps more significant, no cases of appendicitis were missed with the point-of-care ultrasound procedurel and no unnecessary surgeries were conducted for a normal appendix. With focused ultrasound training, pediatric emergency clinicians were able to assess ultrasound exams with the similar accuracy as radiologists (about 94% accuracy).

“Surgeons are becoming more comfortable using ultrasound for decision-making and that is a big change from reliance on CT scans,” said Tsung.

The Mt. Sinai Division of Emergency Ultrasound is involved with an effort to educate providers at Mount Sinai Hospital to use safer ultrasound as a faster first-line study in children. 

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