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

Updates on the clinical integration of point-of-care ultrasound in pediatric emergency medicine

PURPOSE OF REVIEW

There is expanding evidence for point-of-care ultrasound (POCUS) use in pediatric emergency medicine - this review highlights the benefits and challenges in the clinical integration of high-yield POCUS applications. Specifically, it will delve into POCUS applications during resuscitations, controversies of Focused Assessment with Sonography for Trauma (FAST) in pediatric trauma, POCUS-guided procedures, and examples of clinical pathways where POCUS can expedite definitive care.

RECENT FINDINGS

POCUS can enhance diagnostic accuracy and aid in management of pediatric patients in shock and help identify reversible causes during cardiac arrest. The use of the FAST in pediatric blunt abdominal trauma remains nuanced - its proper use requires an integration with clinical findings and an appreciation of its limitations. POCUS has been shown to enhance safety and efficacy of procedures such as nerve blocks, incision & drainage, and intravenous access. Integrating POCUS into pathways for conditions such as intussusception and testicular torsion expedites downstream care.

SUMMARY

POCUS enhances diagnostic efficiency and management in pediatric patients arriving at the ED with undifferentiated shock, cardiac arrest, or trauma. Additionally, POCUS improves procedural success and safety, and is integral to clinical pathways for expediting definitive care for various pediatric emergencies. Future research should continue to focus on the impact of POCUS on patient outcomes, ensuring user competency, and the expansion of POCUS into diverse settings.

A POCUS-first pathway to streamline care for children with suspected ileocolic intussusception

OBJECTIVES

As point-of-care ultrasound (POCUS) has emerged as a valuable tool for intussusception screening, this quality improvement study aimed to implement a "POCUS-first" pathway in a Pediatric Emergency Department (ED) to streamline workflow and expedite care for children with suspected intussusception.

METHODS

This was a prospective analysis of children diagnosed with ileocolic intussusception in a Pediatric ED between June 2022 and June 2023. The study compared the "POCUS-first" cohort with the group receiving only radiology-performed ultrasound. Key outcomes included physician initial assessment to radiology-performed US time and physician initial assessment to reduction time. Continuous improvement efforts incorporated pediatric emergency medicine physician training, education, and pathway dissemination through plan-do-study-act cycles.

RESULTS

The study included 29 patients in the "POCUS-first" pathway group and 70 patients in the non-POCUS group. The "POCUS-first" pathway demonstrated a significantly shorter physician initial assessment to reduction time compared to the non-POCUS group (170.7 min vs. 240.6 min, p = 0.02). Among non-transferred patients, the "POCUS-first" group also had a significantly shorter emergency department length of stay (386 min vs. 544 min, p = 0.047).

CONCLUSIONS

Implementation of a "POCUS-first" pathway for managing ileocolic intussusception led to notable improvements in process efficiency. The shorter physician initial assessment to reduction time highlights the potential for expedited decision-making and intervention. These study findings support the potential of this pathway to optimize the management and outcomes of children with ileocolic intussusception.

Feasibility of a deep learning artificial intelligence model for the diagnosis of pediatric ileocolic intussusception with grayscale ultrasonography

PURPOSE

This study explored the feasibility of utilizing a deep learning artificial intelligence (AI) model to detect ileocolic intussusception on grayscale ultrasound images.

METHODS

This retrospective observational study incorporated ultrasound images of children who underwent emergency ultrasonography for suspected ileocolic intussusception. After excluding video clips, Doppler images, and annotated images, 40,765 images from two tertiary hospitals were included (positive-to-negative ratio: hospital A, 2,775:35,373; hospital B, 140:2,477). Images from hospital A were split into a training set, a tuning set, and an internal test set (ITS) at a ratio of 7:1.5:1.5. Images from hospital B comprised an external test set (ETS). For each image indicating intussusception, two radiologists provided a bounding box as the ground-truth label. If intussusception was suspected in the input image, the model generated a bounding box with a confidence score (0-1) at the estimated lesion location. Average precision (AP) was used to evaluate overall model performance. The performance of practical thresholds for the modelgenerated confidence score, as determined from the ITS, was verified using the ETS.

RESULTS

The AP values for the ITS and ETS were 0.952 and 0.936, respectively. Two confidence thresholds, CTopt and CTprecision, were set at 0.557 and 0.790, respectively. For the ETS, the perimage precision and recall were 95.7% and 80.0% with CTopt, and 98.4% and 44.3% with CTprecision. For per-patient diagnosis, the sensitivity and specificity were 100.0% and 97.1% with CTopt, and 100.0% and 99.0% with CTprecision. The average number of false positives per patient was 0.04 with CTopt and 0.01 for CTprecision.

CONCLUSION

The feasibility of using an AI model to diagnose ileocolic intussusception on ultrasonography was demonstrated. However, further study involving bias-free data is warranted for robust clinical validation.

Development and Implementation of a Semi-Automated Workflow for Point-of-Care Ultrasound Billing and Documentation Within an Electronic Health Record

Point-of-care ultrasound (POCUS) is widely used for both diagnostic and therapeutic purposes. With its many advantages, including ease of use, real-time multisystem assessment, affordability, availability, and accuracy, it has been adopted by all medical specialties. Despite its advantages, the lack of standard workflow and automated billing solutions makes it difficult to launch a comprehensive POCUS program. In this work, we describe how we created and implemented an efficient standardized EHR-based workflow for POCUS that has been used across multiple division and settings within our organization.

Establishing the international research priorities for pediatric emergency medicine point-of-care ultrasound: A modified Delphi study

BACKGROUND

The Pediatric Emergency Medicine (PEM) Point-of-care Ultrasound (POCUS) Network (P2Network) was established in 2014 to provide a platform for international collaboration among experts, including multicenter research. The objective of this study was to use expert consensus to identify and prioritize PEM POCUS topics, to inform future collaborative multicenter research.

METHODS

Online surveys were administered in a two-stage, modified Delphi study. A steering committee of 16 PEM POCUS experts was identified within the P2Network, with representation from the United States, Canada, Italy, and Australia. We solicited the participation of international PEM POCUS experts through professional society mailing lists, research networks, social media, and "word of mouth." After each round, responses were refined by the steering committee before being reissued to participants to determine the ranking of all the research questions based on means and to identify the high-level consensus topics. The final stage was a modified Hanlon process of prioritization round (HPP), which emphasized relevance, impact, and feasibility.

RESULTS

Fifty-four eligible participants (16.6%) provided 191 items to Survey 1 (Round 1). These were refined and consolidated into 52 research questions by the steering committee. These were issued for rating in Survey 2 (Round 2), which had 45 participants. At the completion of Round 2, all questions were ranked with six research questions reaching high-level consensus. Thirty-one research questions with mean ratings above neutral were selected for the HPP round. Highly ranked topics included clinical applications of POCUS to evaluate and manage children with shock, cardiac arrest, thoracoabdominal trauma, suspected cardiac failure, atraumatic limp, and intussusception.

CONCLUSIONS

This consensus study has established a research agenda to inform future international multicenter PEM POCUS trials. This study has highlighted the ongoing need for high-quality evidence for PEM POCUS applications to guide clinical practice.

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 ultrasonography for intussusception in children: A systematic review and meta-analysis

OBJECTIVES

Ileocolic intussusception can be challenging to diagnose due to vague complaints, but rapid diagnosis and treatment can help prevent morbidity and mortality. Prior research has focused on radiologic ultrasound, with more recent studies focusing on point-of-care ultrasonography (POCUS). This systematic review and meta-analysis assesses the diagnostic accuracy of POCUS for children with suspected ileocolic intussusception.

METHODS

PubMed, Embase, CINAHL, LILACS, the Cochrane databases, Google Scholar, conference abstracts, and bibliographies of selected articles were searched for studies evaluating the accuracy of POCUS for the diagnosis of intussusception in children. Data were dual extracted into a predefined worksheet, and quality analysis was performed with the QUADAS-2 tool. Data were summarized, and a meta-analysis was performed.

RESULTS

Eleven studies (n = 2400 children) met our inclusion criteria. Overall, 14.4% of children had intussusception. POCUS was 95.1% (95% CI: 90.3% to 97.2%) sensitive and 98.1% (95% CI: 95.8% to 99.2%) specific with a positive likelihood ratio of 50 (95% CI: 23 to 113) and a negative likelihood ratio of 0.05 (95% CI: 0.03 to 0.09).

CONCLUSIONS

POCUS has excellent diagnostic accuracy for intussusception in children presenting to the emergency department.

Integrating Point of Care Ultrasound Education into Clinical Practice at the Emergency Department

Point of care ultrasound (POCUS) competency is now required learning for emergency medicine trainees. However, there is a wide range of areas that need to be assessed when determining competence. Therefore, this study aims to evaluate competence levels of POCUS skill acquisition including the areas of image acquisition, image interpretation and clinical integration of the emergency medicine residents while on shift in real clinical practice situations. This was a retrospective descriptive study. This study was conducted at Srinagarind Hospital, Thailand from January 2021 through December 2021. The data were collected and reviewed from electronic medical records, ultrasound images and video clips. All POCUS competency skills were assessed by researcher staff. Our results demonstrated that our learners had overall satisfactory competence of image acquisition, satisfactory image interpretation skills, and good clinical integration skills. However, obstetrics and gynecology (OB-GYN) ultrasound scores were poor and cardiac ultrasound had the most varied score of image quality. This study clearly showed the measurable benefits of a POCUS course being integrated into real clinical practice.

Eldow Ahmed A, Abdelmutalib Mohamed RE, Osman Hamza SG, Mohammed Elagib E, H. Awadalla H, Hassan A, Ahmed AA, Adam Essa ME. Systemic lupus erythematous as an unusual cause of intussusception in Sudanese woman: A case report

Abdominal pain does have a wide differential diagnosis, however, gastrointestinal involvement is not unusual in SLE, and this report is to describe an unusual case of intussusception due to SLE in a Sudanese woman.