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Spampinato MD, Luppi F, Cristofaro E, Benedetto M, Cianci A, Bachechi T, Ghirardi C, Perna B, Guarino M, Passaro A, De Giorgio R, Sofia S. Diagnostic accuracy of Point Of Care UltraSound (POCUS) in clinical practice: A retrospective, emergency department based study. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:255-264. [PMID: 38059395 DOI: 10.1002/jcu.23619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/02/2023] [Accepted: 11/16/2023] [Indexed: 12/08/2023]
Abstract
AIMS Point-of-care ultrasound (POCUS) is the acquisition and interpretation of ultrasound imaging at the bedside to solve specific clinical questions based on signs and symptoms of presentation. While several studies evaluated POCUS diagnostic accuracy for a variety of clinical pictures in the emergency department (ED), only a few data are available on POCUS diagnostic accuracy performed by physicians with different POCUS skills. The objective of this research was to evaluate the diagnostic accuracy of POCUS compared to standard diagnostic imaging in the ED. MATERIALS AND METHODS This was a retrospective study conducted in the ED of a third-level university hospital. Patients who underwent cardiac, thoracic, abdominal, or venous lower limb POCUS and a standard imaging examination between June 2021 and January 2022 were included. RESULTS 1047 patients were screened, and 844 patients included. A total of 933 POCUS was included (102, 12.09%, cardiac; 466, 55.21%, thoracic; 336, 39.8%, abdominal; 29, 3.44%, lower limb venous POCUS), accounting for 2029 examinations. POCUS demonstrated 96.6% (95% CI 95.72-97.34) accuracy, 47.73 (95% CI 33.64-67.72) +LR, 0.09 (95% CI 0.06-0.12) -LR. +LR was greater than 10 for all investigations but for hydronephrosis (5.8), and -LR never exceeded 0.4. CONCLUSIONS POCUS exhibited high diagnostic accuracy for virtually all conditions when performed by emergency department physicians.
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Affiliation(s)
- Michele Domenico Spampinato
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- School of Emergency Medicine, University of Ferrara, Ferrara, Italy
| | - Francesco Luppi
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Enrico Cristofaro
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- School of Emergency Medicine, University of Ferrara, Ferrara, Italy
| | - Marcello Benedetto
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- School of Emergency Medicine, University of Ferrara, Ferrara, Italy
| | - Antonella Cianci
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- School of Emergency Medicine, University of Ferrara, Ferrara, Italy
| | - Tommaso Bachechi
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- School of Emergency Medicine, University of Ferrara, Ferrara, Italy
| | - Caterina Ghirardi
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- School of Emergency Medicine, University of Ferrara, Ferrara, Italy
| | - Benedetta Perna
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Matteo Guarino
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- School of Emergency Medicine, University of Ferrara, Ferrara, Italy
| | - Angelina Passaro
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Roberto De Giorgio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- School of Emergency Medicine, University of Ferrara, Ferrara, Italy
| | - Soccorsa Sofia
- Emergency Department, Maggiore Hospital, AUSL di Bologna, Bologna, Italy
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Joyce A, Snelling PJ, Elsayed T, Keijzers G. Point-of-care ultrasound to diagnose acute cholecystitis in the emergency department: A scoping review. Australas J Ultrasound Med 2024; 27:26-41. [PMID: 38434543 PMCID: PMC10902832 DOI: 10.1002/ajum.12371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
Introduction/Purpose Ultrasound is the first-line imaging modality for suspected acute cholecystitis. This can be radiology-performed ultrasound or point-of-care ultrasound (POCUS). POCUS can potentially streamline patient assessment in the emergency department (ED). The primary objective was to evaluate the literature for the diagnostic accuracy of POCUS performed for acute cholecystitis in the ED. Secondary objectives were to assess the effect of POCUS operator training on diagnostic accuracy for acute cholecystitis, utility of POCUS measurement of the common bile duct and POCUS impact on resource utilisation. Methods A systematic scoping review of articles was conducted using Medline, Embase, CENTRAL and CINAHL. Original studies of adults with POCUS performed for the diagnosis of acute cholecystitis in the ED were included. The study was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist (PRISMA-ScR). Results A total of 1090 publications were identified. Forty-six met the eligibility criteria. Studies were thematically grouped into categories according to specified objectives. Point-of-care ultrasound was of acceptable but variable accuracy, contributed to by the absence of a consistent reference standard and uniform training requirements. It may positively impact ED resource utilisation through reduced ED length of stay and radiology-performed imaging, whilst improving patient experience. Conclusion This review highlights the heterogeneity of existing research, emphasising the need for standardisation of training and reference standards in order to precisely define the utility of POCUS for acute cholecystitis in the ED and its benefits on ED resource utilisation.
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Affiliation(s)
- Alexander Joyce
- Department of Emergency MedicineGold Coast University HospitalSouthportQueenslandAustralia
| | - Peter J Snelling
- Department of Emergency MedicineGold Coast University HospitalSouthportQueenslandAustralia
- School of Medicine and DentistryGriffith UniversitySouthportQueenslandAustralia
- Sonography Innovation and Research GroupSouthportQueenslandAustralia
| | - Tarek Elsayed
- Department of Emergency MedicineGold Coast University HospitalSouthportQueenslandAustralia
- Faculty of Health Sciences and MedicineBond UniversityGold CoastQueenslandAustralia
| | - Gerben Keijzers
- Department of Emergency MedicineGold Coast University HospitalSouthportQueenslandAustralia
- School of Medicine and DentistryGriffith UniversitySouthportQueenslandAustralia
- Faculty of Health Sciences and MedicineBond UniversityGold CoastQueenslandAustralia
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Huang SS, Lin KW, Liu KL, Wu YM, Lien WC, Wang HP. Diagnostic performance of ultrasound in acute cholecystitis: a systematic review and meta-analysis. World J Emerg Surg 2023; 18:54. [PMID: 38037062 PMCID: PMC10687940 DOI: 10.1186/s13017-023-00524-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 11/25/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND An updated overview of ultrasound (US) for diagnosis of acute cholecystitis (AC) remains lacking. This systematic review was conducted to evaluate the diagnostic performance of US for AC. METHODS A systematic review was conducted following PRISMA guidelines. We meticulously screened articles from MEDLINE, Embase, and the Cochrane Library, spanning from inception to August 2023. We employed the search strategy combining the keywords "bedside US", "emergency US" or "point-of-care US" with "AC". Two reviewers independently screened the titles and abstracts of the retrieved articles to identify suitable studies. The inclusion criteria encompassed articles investigating the diagnostic performance of US for AC. Data regarding diagnostic performance, sonographers, and sonographic findings including the presence of gallstone, gallbladder (GB) wall thickness, peri-GB fluid, or sonographic Murphy sign were extracted, and a meta-analysis was executed. Case reports, editorials, and review articles were excluded, as well as studies focused on acalculous cholecystitis. The study quality was assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. RESULTS Forty studies with 8,652 patients were included. The majority of studies had a low risk of bias and applicability concerns. US had a pooled sensitivity of 71% (95% CI, 69-72%), a specificity of 85% (95% CI, 84-86%), and an accuracy of 0.83 (95% CI, 0.82-0.83) for the diagnosis of AC. The pooled sensitivity and specificity were 71% (95% CI, 67-74%) and 92% (95% CI, 90-93%) performed by emergency physicians (EPs), 79% (95% CI, 71-85%) and 76% (95% CI, 69-81%) performed by surgeons, and 68% (95% CI 66-71%) and 87% (95% CI, 86-88%) performed by radiologists, respectively. There were no statistically significant differences among the three groups. CONCLUSION US is a good imaging modality for the diagnosis of AC. EP-performed US has a similar diagnostic performance to radiologist-performed US. Further investigations would be needed to investigate the impact of US on expediting the management process and improving patient-centered outcomes.
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Affiliation(s)
- Sih-Shiang Huang
- Department of Emergency Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, No.7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Kai-Wei Lin
- Department of Emergency Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, No.7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Kao-Lang Liu
- Department of Medical Imaging, National Taiwan University Cancer Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medical Imaging, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yao-Ming Wu
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wan-Ching Lien
- Department of Emergency Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, No.7, Chung-Shan South Road, Taipei, 100, Taiwan.
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Hsiu-Po Wang
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
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Kambadakone AR, Santillan CS, Kim DH, Fowler KJ, Birkholz JH, Camacho MA, Cash BD, Dane B, Felker RA, Grossman EJ, Korngold EK, Liu PS, Marin D, McCrary M, Pietryga JA, Weinstein S, Zukotynski K, Carucci LR. ACR Appropriateness Criteria® Right Lower Quadrant Pain: 2022 Update. J Am Coll Radiol 2022; 19:S445-S461. [PMID: 36436969 DOI: 10.1016/j.jacr.2022.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
This document focuses on imaging in the adult and pregnant populations with right lower quadrant (RLQ) abdominal pain, including patients with fever and leukocytosis. Appendicitis remains the most common surgical pathology responsible for RLQ abdominal pain in the United States. Other causes of RLQ pain include right colonic diverticulitis, ureteral stone, and infectious enterocolitis. Appropriate imaging in the diagnosis of appendicitis has resulted in decreased negative appendectomy rate from as high as 25% to approximately 1% to 3%. Contrast-enhanced CT remains the primary and most appropriate imaging modality to evaluate this patient population. MRI is approaching CT in sensitivity and specificity as this technology becomes more widely available and utilization increases. Unenhanced MRI and ultrasound remain the diagnostic procedures of choice in the pregnant patient. MRI and ultrasound continue to perform best in the hands of the experts. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Avinash R Kambadakone
- Division Chief, Abdominal Imaging, Massachusetts General Hospital, Boston, Massachusetts; Medical Director, Martha's Vineyard Hospital Imaging.
| | - Cynthia S Santillan
- Vice Chair of Clinical Operations, University of California, San Diego, San Diego, California
| | - David H Kim
- Panel Chair; Vice Chair of Education, Department of Radiology, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Kathryn J Fowler
- Panel Vice-Chair, University of California, San Diego, San Diego, California. ACR LI-RADS; Division Chief, SAR Portfolio Director; RSNA Radiology Senior DE
| | - James H Birkholz
- Divisional Director, Quality and Safety (Abdominal Imaging), Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania. Radiology Representative to the Interdisciplinary Dysmotility (GIMIG) Conference
| | - Marc A Camacho
- The University of South Florida Morsani College of Medicine, Tampa, Florida; Committee on Emergency Radiology-GSER
| | - Brooks D Cash
- Chief of Gastroenterology, Hepatology, and Nutrition Division, University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Bari Dane
- Director of Body CT, Abdominal Imaging; Director of Quality and Safety Outpatient Imaging, NYU Grossman School of Medicine, New York, New York
| | - Robin A Felker
- Associate Clerkship Director for Internal Medicine, Georgetown University; Primary care physician, Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Eric J Grossman
- Medical Director, Multi-Specialty Clinic, Santa Barbara Cottage Hospital, Santa Barbara, California; American College of Surgeons
| | - Elena K Korngold
- Section Chief, Body Imaging, Chair, Department of Radiology Promotion and Tenure Committee, Oregon Health and Science University, Portland, Oregon
| | - Peter S Liu
- Section Head, Abdominal Imaging, Cleveland Clinic, Cleveland, Ohio
| | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | - Marion McCrary
- Associate Director of Duke GME Coaching, Duke Signature Care, Durham, North Carolina; American College of Physicians; Governor-Elect, American College of Physicians North Carolina Chapter
| | | | | | - Katherine Zukotynski
- Co-Associate Chair for Research, Department of Radiology, McMaster University, Hamilton, Ontario, Canada; Commission on Nuclear Medicine and Molecular Imaging
| | - Laura R Carucci
- Specialty Chair; Section Chief Abdominal Imaging, Director of MRI and CT, Virginia Commonwealth University Medical Center, Richmond, Virginia
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Point-of-care ultrasound for acute abdomen: 5W1H (Translated version). J Med Ultrason (2001) 2022; 49:609-618. [PMID: 35355123 DOI: 10.1007/s10396-022-01203-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 02/24/2022] [Indexed: 12/18/2022]
Abstract
In this paper, point-of-care ultrasound (POCUS) for the initial diagnosis and the management of acute abdomen is discussed. POCUS is supposed to be executed mainly by doctors other than ultrasound specialists anytime and anywhere such as in the emergency room or the intensive care unit. Although it seems rather difficult to cover the wide spectrum of organs as well as diseases causing acute abdominal pain, the author advocates a "six approach" for the diagnosis and triage of acute abdomen, which consists of scanning at eight points in less than 5 min. With this method, the attending doctor can diagnose most of the diseases frequently encountered in patients with acute abdomen, which can help patients avoid unnecessary examinations or admissions. However, users of POCUS should be aware of its limitations, especially when they are using pocket-sized ultrasound equipment. Therefore, users should be careful when ruling out a disease even when they cannot find any pathological findings, and consider the need for further examinations such as US done by specialists with high-end equipment or CT. Since there has been no standard curriculum in Japan for POCUS training that should deal with basic physics and techniques for US, normal abdominal anatomy, typical pathological US findings, and interventional US, the establishment of a learning program for doctors and training of experts as instructors of POCUS are needed.
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Wehrle CJ, Talukder A, Tien L, Parikh S, Devarakonda A, Holsten SB, Fox ED, Lawson A. The Accuracy of Point-of-Care Ultrasound in the Diagnosis of Acute Cholecystitis. Am Surg 2021; 88:267-272. [PMID: 33517707 DOI: 10.1177/0003134821989057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
PURPOSE Acute cholecystitis (AC) affects 50-200 000 patients per year. Early surgery is the treatment of choice for AC. Therefore, timely diagnosis is important to begin proper management. Recently, emergency departments have adopted point-of-care ultrasound (POCUS) for the initial evaluation of AC. The accuracy of POCUS for AC has not been well studied. METHODS Patients receiving POCUS for evaluation of AC in the emergency department at our tertiary care institution for 2 years were considered. Patients with previous biliary diagnoses were excluded. Patients were deemed to have AC from a recorded POCUS result or 2/3 of the following POCUS findings: pericholecystic fluid, gallbladder wall hyperemia, and sonographic Murphy's sign. Formal ultrasound and final diagnosis from surgical and pathology reports were used as gold standards for comparison. RESULTS In total, 147 patients met inclusion criteria. POCUS had a sensitivity and specificity of .4 (95% CI: .1216-.7376) and .99 (.9483-.9982), respectively, when compared to a final diagnosis and .33 (.0749-.7007) and .94 (.8134-.9932) when compared to formal US. The modified Tokyo guidelines for suspicion of AC had a sensitivity of .2 (.0252-.5561) and specificity of .88 (.8173-.931) compared to the final diagnosis. CONCLUSION Point-of-care ultrasound was not a better screening test than the modified Tokyo guidelines. We recommend a simplified screening approach for AC using clinical findings and laboratory data, followed by confirmatory formal imaging. This strategy could prevent unnecessary delays in surgical management and use of physician resources.
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Affiliation(s)
- Chase J Wehrle
- Department of Surgery, 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Asif Talukder
- Department of Surgery, 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Lillie Tien
- Department of Surgery, 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Soham Parikh
- Department of Surgery, 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Aditya Devarakonda
- Department of Surgery, 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Steven B Holsten
- Department of Surgery, 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Elizabeth D Fox
- Department of Surgery, 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Andrew Lawson
- Department of Surgery, 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
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Nestler T. Bildgebung. Urolithiasis 2021. [DOI: 10.1007/978-3-662-62454-8_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Sorensen B, Hunskaar S. Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations. Ultrasound J 2019; 11:31. [PMID: 31749019 PMCID: PMC6868077 DOI: 10.1186/s13089-019-0145-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/21/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Both the interest and actual extent of use of point-of-care ultrasound, PoCUS, among general practitioners or family physicians are increasing and training is also increasingly implemented in residency programs. However, the amount of research within the field is still rather limited compared to what is seen within other specialties in which it has become more established, such as in the specialty of emergency medicine. An assumption is made that what is relevant for emergency medicine physicians and their populations is also relevant to the general practitioner, as both groups are generalists working in unselected populations. This systematic review aims to examine the extent of use and to identify clinical studies on the use of PoCUS by either general practitioners or emergency physicians on indications that are relevant for the former, both in their daily practice and in out-of-hours services. METHODS Systematic searches were done in PubMed/MEDLINE using terms related to general practice, emergency medicine, and ultrasound. RESULTS On the extent of use, we identified 19 articles, as well as 26 meta-analyses and 168 primary studies on the clinical use of PoCUS. We found variable, but generally low, use among general practitioners, while it seems to be thoroughly established in emergency medicine in North America, and increasingly also in the rest of the world. In terms of clinical studies, most were on diagnostic accuracy, and most organ systems were studied; the heart, lungs/thorax, vessels, abdominal and pelvic organs, obstetric ultrasound, the eye, soft tissue, and the musculoskeletal system. The studies found in general either high sensitivity or high specificity for the particular test studied, and in some cases high total accuracy and superiority to other established diagnostic imaging modalities. PoCUS also showed faster time to diagnosis and change in management in some studies. CONCLUSION Our review shows that generalists can, given a certain level of pre-test probability, safely use PoCUS in a wide range of clinical settings to aid diagnosis and better the care of their patients.
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Affiliation(s)
- Bjarte Sorensen
- Hjelmeland General Practice Surgery, Prestagarden 13, 4130, Hjelmeland, Norway.
| | - Steinar Hunskaar
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Bergen, Norway
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Shen G, Wang J, Fei F, Mao M, Mei Z. Bedside ultrasonography for acute appendicitis: An updated diagnostic meta-analysis. Int J Surg 2019; 70:1-9. [PMID: 31404675 DOI: 10.1016/j.ijsu.2019.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/28/2019] [Accepted: 08/06/2019] [Indexed: 12/12/2022]
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Seitz C, Bach T, Bader M, Berg W, Knoll T, Neisius A, Netsch C, Nothacker M, Schmidt S, Schönthaler M, Siener R, Stein R, Straub M, Strohmaier W, Türk C, Volkmer B. Aktualisierung der S2k-Leitlinie zur Diagnostik, Therapie und Metaphylaxe der Urolithiasis (AWMF Registernummer 043-025). Urologe A 2019; 58:1304-1312. [DOI: 10.1007/s00120-019-01033-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Zusammenfassung
Die Zunahme des medizinischen Wissens, technische Neuerungen gemeinsam mit demographischem Wandel stellen eine Herausforderung an die Neukonzeption von Leitlinien und klinischen Studien dar. Die vorliegende S2k-Leitlinie, die sich ausschließlich mit Nieren- und Harnleitersteinen beschäftigt, soll die Behandlung von Harnsteinpatienten in Klinik und Praxis unterstützen, aber auch Patienteninformationen zur Urolithiasis geben. Die zunehmende interdisziplinäre Zusammenarbeit in der Steintherapie zeigt sich auch an der Anzahl beteiligter Fachgruppen und Arbeitsgemeinschaften in der Erstellung des neuen Leitlinienupdates. Die vorliegende, aus einem interdisziplinären Konsensusprozess hervorgegangene S2k-Leitlinie stellt die aktuellen Empfehlungen praxisnah dar und gibt Entscheidungshilfen für Diagnostik‑, Therapie- und Metaphylaxemaßnahmen auf Basis von Expertenmeinungen und verfügbaren Evidenzgrundlagen aus der Literatur.
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11
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Garcia EM, Camacho MA, Karolyi DR, Kim DH, Cash BD, Chang KJ, Feig BW, Fowler KJ, Kambadakone AR, Lambert DL, Levy AD, Marin D, Moreno C, Peterson CM, Scheirey CD, Siegel A, Smith MP, Weinstein S, Carucci LR. ACR Appropriateness Criteria ® Right Lower Quadrant Pain-Suspected Appendicitis. J Am Coll Radiol 2019; 15:S373-S387. [PMID: 30392606 DOI: 10.1016/j.jacr.2018.09.033] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 09/07/2018] [Indexed: 02/07/2023]
Abstract
Appendicitis remains the most common surgical pathology responsible for right lower quadrant (RLQ) abdominal pain presenting to emergency departments in the United States, where the incidence continues to increase. Appropriate imaging in the diagnosis of appendicitis has resulted in decreased negative appendectomy rate from as high as 25% to approximately 1% to 3%. Contrast-enhanced CT remains the primary and most appropriate imaging modality to evaluate this patient population. MRI is approaching CT in sensitivity and specificity as this technology becomes more widely available and utilization increases. Unenhanced MRI and ultrasound remain the diagnostic procedures of choice in the pregnant patient. MRI and ultrasound continue to perform best in the hands of experts. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Evelyn M Garcia
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia.
| | - Marc A Camacho
- The University of South Florida Morsani College of Medicine, Tampa, Florida
| | | | - David H Kim
- Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Brooks D Cash
- University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | | | - Barry W Feig
- The University of Texas MD Anderson Cancer Center, Houston, Texas; American College of Surgeons
| | | | | | - Drew L Lambert
- University of Virginia Health System, Charlottesville, Virginia
| | - Angela D Levy
- Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | | | | | | | - Alan Siegel
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Martin P Smith
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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12
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Yard J, Richman PB, Leeson B, Leeson K, Youngblood G, Guardiola J, Miller M. The Influence of Cervical Collar Immobilization on Optic Nerve Sheath Diameter. J Emerg Trauma Shock 2019; 12:141-144. [PMID: 31198282 PMCID: PMC6557047 DOI: 10.4103/jets.jets_80_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 12/22/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Prior research has revealed that cervical collars elevate intracranial pressure (ICP) in patients with traumatic brain injury. Two recent small studies evaluated the change in optic sheath nerve diameter (ONSD) measured by ultrasound as a proxy for ICP following cervical collar placement in healthy volunteers. OBJECTIVE We sought to validate the finding that ONSD measured by ultrasound increases after cervical collar placement within an independent data set. METHODS This was a prospective, crossover study involving volunteers. Participants were randomized to either have the ONSD measured first without a cervical collar or initially with a cervical collar. Two sonographers performed independent ONSD diameter measurements. Continuous data were analyzed by matched-paired t-tests. Alpha was set at 0.05. The primary outcome parameter was the overall mean difference between ONSD measurements with the cervical collar on and off. Multiple linear regression was performed to examine the relationship between variables and the primary outcome parameter. RESULTS There were 30 participants enrolled in the study. Overall mean ONSD for participants without the collar was 0.365 ± 0.071 cm and with the collar was 0.392 ± 0.081 cm. The mean change in ONSD for participants with and without the collar was 0.026 ± 0.064 cm (95% confidence interval of difference: 0.015-0.038; P < 0.001). Multiple regression analysis did not identify any variables associated with the variation in ONSD observed for collar versus noncollar. CONCLUSIONS We confirmed that ONSD does vary by a measurable amount with placement of a rigid cervical collar on healthy volunteers when assessed by ultrasound.
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Affiliation(s)
- Joseph Yard
- CHRISTUS Health/Texas A&M Residency in Emergency Medicine, Corpus Christi, TX, USA
| | - Peter B. Richman
- CHRISTUS Health/Texas A&M Residency in Emergency Medicine, Corpus Christi, TX, USA
| | - Ben Leeson
- CHRISTUS Health/Texas A&M Residency in Emergency Medicine, Corpus Christi, TX, USA
| | - Kimberly Leeson
- CHRISTUS Health/Texas A&M Residency in Emergency Medicine, Corpus Christi, TX, USA
| | - Guy Youngblood
- CHRISTUS Health/Texas A&M Residency in Emergency Medicine, Corpus Christi, TX, USA
| | - Jose Guardiola
- Texas A&M University-Corpus Christi, Corpus Christi, TX, USA
| | - Michael Miller
- CHRISTUS Health/Texas A&M Residency in Emergency Medicine, Corpus Christi, TX, USA
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13
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Chari G, Yadav K, Nishijima D, Omurtag A, Zehtabchi S. Improving the ability of ED physicians to identify subclinical/electrographic seizures on EEG after a brief training module. Int J Emerg Med 2019; 12:11. [PMID: 31179946 PMCID: PMC6437897 DOI: 10.1186/s12245-019-0228-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/12/2019] [Indexed: 11/30/2022] Open
Abstract
Background Approximately 5% of emergency department (ED) patients with altered mental status (AMS) have non-convulsive seizures (NCS). Patients with NCS should be diagnosed with EEG as soon as possible to initiate antiepileptic treatment. Since ED physicians encounter such patients first in the ED, they should be familiar with general EEG principles as well as the EEG patterns of NCS/NCSE. We evaluated the utility of a brief training module in enhancing the ED physicians’ ability to identify seizures on EEG. Methods This was a randomized controlled trial conducted in three academic institutions. A slide presentation was developed describing the basic principles of EEG including EEG recording techniques, followed by characteristics of normal and abnormal patterns, the goal of which was to familiarize the participants with EEG seizure patterns. We enrolled board-certified emergency medicine physicians into the trial. Subjects were randomized to control or intervention groups. Participants allocated to the intervention group received a self-learning training module and were asked to take a quiz of EEG snapshots after reviewing the presentation, while the control group took the quiz without the training. Results A total of 30 emergency physicians were enrolled (10 per site, with 15 controls and 15 interventions). Participants were 52% male with median years of practice of 9.5 years (3, 14). The percentage of correct answers in the intervention group (65%, 63% and 75%) was significantly different (p = 0.002) from that of control group (50%, 45% and 60%). Conclusions A brief self-learning training module improved the ability of emergency physicians in identifying EEG seizure patterns.
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Affiliation(s)
- Geetha Chari
- Department of Neurology, SUNY Downstate Medical Center, Brooklyn, NY, USA.
| | - Kabir Yadav
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Daniel Nishijima
- Department of Emergency Medicine, University of California at Davis Health System, Sacramento, CA, USA
| | | | - Shahriar Zehtabchi
- Department of Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
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14
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Kozaci N, Avci M, Tulubas G, Ararat E, Karakoyun OF, Karaman C, Erol B. Role of emergency physician–performed ultrasound in the differential diagnosis of abdominal pain. HONG KONG J EMERG ME 2018. [DOI: 10.1177/1024907918808115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objectives: This prospective study was performed to evaluate the diagnostic accuracy of bedside point-of-care abdominal ultrasonography performed by emergency physician in patients with non-traumatic acute abdominal pain. Methods: The patients, who were admitted to emergency department due to abdominal pain, were included in this study. The emergency physician obtained a routine history, physical examination, blood draws, and ordered diagnostic imaging. After the initial clinical examinations, all the patients underwent ultrasonography for abdominal pathologies by emergency physician and radiologist, respectively. Point-of-care abdominal ultrasonography compared with abdominal ultrasonography performed by radiologist as the gold standard. Results: The study included 122 patients. Gallbladder and appendix pathologies were the most commonly detected in the abdominal ultrasonography. Compared with abdominal ultrasonography, point-of-care abdominal ultrasonography was found to have 89% sensitivity and 94% specificity in gallbladder pathologies; 91% sensitivity and 91% specificity in acute appendicitis; 79% sensitivity and 97% specificity in abdominal free fluid; 83% sensitivity and 96% specificity in ovarian pathologies. Compared to final diagnosis, preliminary diagnoses of emergency physicians were correct in 92 (75.4%) patients. Conclusion: This study showed that emergency physicians were successful in identifying abdominal organ pathologies with point-of-care abdominal ultrasonography after training.
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Affiliation(s)
- Nalan Kozaci
- Department of Emergency Medicine, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Mustafa Avci
- Department of Emergency Medicine, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Gul Tulubas
- Department of Emergency Medicine, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Ertan Ararat
- Department of Emergency Medicine, Uşak University Education and Research Hospital, Uşak, Turkey
| | - Omer Faruk Karakoyun
- Department of Emergency Medicine, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Cagri Karaman
- Department of Emergency Medicine, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Bekir Erol
- Department of Radiology, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
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15
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Pescatori LC, Brambati M, Messina C, Mauri G, Di Leo G, Silvestri E, Sardanelli F, Sconfienza LM. Clinical impact of computed tomography in the emergency department in nontraumatic chest and abdominal conditions. Emerg Radiol 2018. [PMID: 29536277 DOI: 10.1007/s10140-018-1592-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To evaluate the clinical impact of CT scan in modifying the clinical management in patients referred to the emergency department. METHODS We prospectively evaluated 300 patients (177 males, 63 ± 18 years old) admitted in the emergency department (ED) of a single institution, who underwent a CT examination for thoracic and/or abdominal complains. Demographic and clinical data were collected. Hypothesized outcome prior to CT scan and final management (i.e., discharge, short observation in the ED, hospitalization, and department of admission) were compared. RESULTS After CT examination, a major variation in diagnosis occurred in 37% of cases and clinical management changed in 43%, occurring in 51% of patients who underwent abdominal CT, in 40% of chest CT, and in 29% of chest/abdominal CT (P = 0.015). Department of hospitalization changed in 26% of cases (P < 0.001). Clinical impact of CT scan was significantly associated (P = 0.001) with the color code at admission. In particular, the more severe was the clinical condition, the lower was the variation of management after CT examination. CONCLUSIONS This work confirms the crucial role of CT examination in the management of nontraumatic patients admitted to the ED, both in terms of better clarifying the diagnosis and in influencing the clinical management.
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Affiliation(s)
- Lorenzo Carlo Pescatori
- Scuola di Specializzazione in Radiodiagnostica, Università degli Studi di Milano, Italia Piazza Edmondo Malan, 1, San Donato Milanese, 20097, Milan, Italy.
| | - Matteo Brambati
- Dipartimento di Biotecnologie e Scienze della Vita, Università degli Studi dell'Insubria, Varese, Italy
| | - Carmelo Messina
- Unità Operativa di Radiologia / Diagnostica per Immagini con Servizio di Radiologia Interventistica, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Giovanni Mauri
- Dipartimento di Radiologia Interventistica, Istituto Europeo di Oncologia, Milan, Italy
| | - Giovanni Di Leo
- Unità di Radiologia, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Enzo Silvestri
- Servizio di Radiologia, Ospedale Evangelico Internazionale, Genova, Italy
| | - Francesco Sardanelli
- Unità di Radiologia, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, San Donato Milanese, Milan, Italy
| | - Luca Maria Sconfienza
- Unità Operativa di Radiologia / Diagnostica per Immagini con Servizio di Radiologia Interventistica, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, San Donato Milanese, Milan, Italy
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Abstract
PURPOSE OF REVIEW Various aspects of the management of acute calculous cholecystitis, including type and timing of surgery, role of antibiotics, and nonoperative management, remain controversial. This review focuses on recently published studies addressing the timing of cholecystectomy, use of cholecystostomy tubes, and role of antibiotics in this condition. RECENT FINDINGS In most cases, the diagnosis of acute cholecystitis can be initially confirmed with an abdominal ultrasound. Early laparoscopic cholecystectomy (within 24-72 h of symptom onset) is better than delayed surgery (>7 days) for most patients with grade I and II diseases. Percutaneous cholecystostomy and novel endoscopic gallbladder drainage interventions may be used as a temporizing measure or as definitive therapy in those who are too sick to undergo surgery. Studies are conflicting as to whether antibiotics are required for the treatment of uncomplicated cases. SUMMARY Cholecystectomy remains the only definitive therapy for acute cholecystitis. Current guidelines recommend treatment on the basis of disease severity at presentation. Antibiotics and a variety of minimally invasive nonsurgical interventions, although not definitive, play an adjunctive role in the management of the disease.
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Matthew Fields J, Davis J, Alsup C, Bates A, Au A, Adhikari S, Farrell I. Accuracy of Point-of-care Ultrasonography for Diagnosing Acute Appendicitis: A Systematic Review and Meta-analysis. Acad Emerg Med 2017; 24:1124-1136. [PMID: 28464459 DOI: 10.1111/acem.13212] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 03/31/2017] [Accepted: 04/07/2017] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- J. Matthew Fields
- Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
| | - Joshua Davis
- Department of Emergency Medicine; Penn State Milton S. Hershey Medical Center; Hershey PA
| | - Carl Alsup
- Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
| | | | - Arthur Au
- Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
| | | | - Isaac Farrell
- The University of Arizona College of Medicine; Tucson AZ
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