Ultrasound measurement of traumatic scar and skin thickness: a scoping review of evidence across the translational pipeline of research-to-practice

OBJECTIVES

To identify the ultrasound methods used in the literature to measure traumatic scar thickness, and map gaps in the translation of these methods using evidence across the research-to-practice pipeline.

DESIGN

Scoping review.

DATA SOURCES

Electronic database searches of Ovid MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature and Web of Science. Grey literature searches were conducted in Google. Searches were conducted from inception (date last searched 27 May 2022).

DATA EXTRACTION

Records using brightness mode (B-mode) ultrasound to measure scar and skin thickness across the research-to-practice pipeline of evidence were included. Data were extracted from included records pertaining to: methods used; reliability and measurement error; clinical, health service, implementation and feasibility outcomes; factors influencing measurement methods; strengths and limitations; and use of measurement guidelines and/or frameworks.

RESULTS

Of the 9309 records identified, 118 were analysed (n=82 articles, n=36 abstracts) encompassing 5213 participants. Reporting of methods used was poor. B-mode, including high-frequency (ie, >20 MHz) ultrasound was the most common type of ultrasound used (n=72 records; 61% of records), and measurement of the combined epidermal and dermal thickness (n=28; 24%) was more commonly measured than the epidermis or dermis alone (n=7, 6%). Reliability of ultrasound measurement was poorly reported (n=14; 12%). The scar characteristics most commonly reported to be measured were epidermal oedema, dermal fibrosis and hair follicle density. Most records analysed (n=115; 97%) pertained to the early stages of the research-to-practice pipeline, as part of research initiatives.

CONCLUSIONS

The lack of evaluation of measurement initiatives in routine clinical practice was identified as an evidence gap. Diverse methods used in the literature identified the need for greater standardisation of ultrasound thickness measurements. Findings have been used to develop nine methodological considerations for practitioners to guide methods and reporting.

Benchmarking non-attendance patterns in paediatric medical imaging: A retrospective cohort study spotlighting First Nations children

INTRODUCTION

Non-attendance at Medical Imaging (MI) appointments can result in inefficiencies in healthcare resource allocation, increased financial burdens, and lead to potential barriers to effective healthcare delivery. We evaluated factors associated with non-attendance of MI appointments for children including variables: gender; age groups; residential postcodes; Indigenous status; appointment dates; appointment reminders and socio-economic status.

METHOD

Retrospective cohort study of children with scheduled MI appointments at a Tertiary paediatric hospital in Australia, between January and December 2022. Data were extracted from the Radiology Information System and integrated with socio-economic census data through linking with postcode. Chi-squared, and logistic regression analysis were performed to identify significant predictors of non-attendance.

RESULTS

Out of 17,962 scheduled outpatient appointments, 6.2 % did not attend. Males were less likely to attend than females (7.3 % vs. 5.8 %; p < 0.001). Older children had the highest frequency of non-attendance (p < 0.001). First Nations identified children had a higher likelihood of non-attendance at 14.5 % compared to non-First Nations at 5.8 %, and the odds ratio (OR) of First Nation children not attending was 2.54 (CI 2.13-3.03; p < 0.001) higher than non-First Nations children. Children from areas of disadvantage were less likely to attend (p < 0.001). Bone mineral densitometry had the highest odds of non-attendance (19.4 % of bookings) compared to other imaging modalities (p < 0.001).

CONCLUSION

The following characteristics were associated with non-attendance: older male gender, residing in areas of socio-economic disadvantage, or identifying as First Nations Australians. By reviewing these findings with the cultural and professional experience of our Indigenous co-author, we have identified some strategies for improving attendance amongst First Nations children.

IMPLICATIONS FOR PRACTICE

Factors associated with non-attendance, or "missed opportunities for care", provide opportunities for intervention to improve attendance for vulnerable groups of children who require medical imaging.

The application of artificial intelligence in the sonography profession: Professional and educational considerations

The integration of artificial intelligence (AI) technology within the health industry is increasing. This educational piece discusses the implementation of AI and its impact on sonography. The authors investigate how AI may influence the profession and provide examples of how ultrasound imaging may be enhanced and innovated by integrating AI technology. This article highlights challenges related to the application of AI and provides insight into how they could be addressed. The critical distinction between the role of a sonographer and the reporting specialist in the context of AI is highlighted as a key issue for those developing, researching, and evaluating AI systems. A key recommendation is for the sonography community to address ultrasound education, particularly how AI knowledge could be incorporated into university education. This is an important consideration that should be extended to practising professionals as they may be involved in evaluating the efficiency and methodologies used in new research that may incorporate AI technologies.

Vocal cord dysfunction after pediatric cardiac surgery: A prospective implementation study

Objective

To determine the incidence, outcomes, and evaluate diagnostic modalities for postoperative vocal cord dysfunction (VCD) following cardiothoracic surgery in children.

Methods

A prospective mixed-methods study using principles of implementation science was completed. All patients undergoing surgery involving the aortic arch, ductus, or ligamentum arteriosum and vascular rings from September 2019 to December 2020 were enrolled. Patients underwent speech pathology assessment, laryngeal ultrasound, and flexible direct laryngoscopy.

Results

Ninety-five patients were eligible for inclusion. The incidence of VCD ranged from 18% to 56% and varied according to procedure group. VCD occurred in 42% of neonates. Repair of hypoplastic aortic arch was associated with increased risk of VCD (57%; P = .002). There was no significant difference in duration of intubation, pediatric intensive care unit stay, or hospital stay. Forty percent children were able to achieve full oral feeding. Children with VCD were more likely to require nasogastric supplementary feeding at discharge (60% vs 36%; P = .044). Sixty-eight percent of patients demonstrated complete resolution of VCD at a median of 97 days postoperatively. Laryngeal ultrasound and speech pathology assessment combined had a sensitivity of 91% in comparison to flexible direct laryngoscopy.

Conclusions

VCD occurred in one-third and resolved in two-thirds of patients at a median of 3 months following cardiac surgery. Aortic arch repair carried the highest risk of VCD. VCD adversely influenced feeding. Forty percent of patients achieved full oral feeding before discharge. VCD did not delay intensive care unit or hospital discharge. Speech pathology assessment and laryngeal ultrasound combined was reliable for diagnosis in most patients and was more patient friendly than flexible direct laryngoscopy.

Single versus double hamstring tendon graft in anterior cruciate ligament reconstruction in the paediatric patient: a single-blind randomised controlled trial study protocol

INTRODUCTION

There is currently no clear indication in the literature regarding a single or double hamstring tendon (single bundle) autograft for anterior cruciate ligament (ACL) reconstruction in the paediatric patient. The primary aim of this single blind randomised controlled trial is to determine whether a single or double hamstring tendon graft ACLR leads to superior clinical outcomes postsurgery in paediatric patients with ACL injury.

METHODS AND ANALYSIS

Single site, prospective, single blind, randomised controlled trial with two parallel treatment arms. 100 patients aged 10-18 years who present with an isolated ACL tear±meniscal injury, verified on MRI, will be randomly allocated to one of the two surgical groups. The primary outcomes will be side-to-side difference in anterior tibial translation and graft failure incidence 12 months postsurgery. Primary and secondary outcomes will also be assessed at 2-year and 5-year postsurgery.

ETHICS AND DISSEMINATION

Results will be presented in peer-reviewed journals and at international conferences and disseminated to participants and healthcare professionals via newsletters and hospital presentations. This study is approved by the Children's Health Queensland Hospital and Health Service Human Research Ethics committee.

TRIAL REGISTRATION NUMBER

ACTRN12620001170910p; Australian New Zealand Clinical Trials Registry.

The utility of abdominal ultrasonography in the diagnosis of fungal infections in children: a narrative review

In paediatric patients, ultrasonography is one of the preferred medical imaging modalities due to the lack of ionising radiation. Abdominal ultrasonography can be a useful tool in diagnosing cases of fungal infections but may introduce some risks for further infection in vulnerable patients or cause anxiety and discomfort. The aim of this narrative review is to analyse the utility of abdominal ultrasonography in diagnosing fungal infections in children in terms of its positive hit rates and utility in typical use. Text words and indexed terms related to ‘fungal infection and ultrasonography’ and ‘children’ were searched on MEDLINE, EMBASE, Cochrane Library and Scopus. Paediatric oncology patients, neonates and generally immunocompromised children were found to be at‐risk groups with increasing susceptibility to risk factors for contracting fungal infections. Abdominal ultrasonography was found to aid in the diagnosis of fungal infection in many cases, but not all patients with the identified risk factors were diagnosed with fungal infections and not all patients diagnosed with fungal infections had identified risk factors. Ultrasonography was found to be overutilised and the current decision process in requesting abdominal ultrasonography in diagnosing fungal infection should be revised. Further study into an effective criterion in requesting abdominal ultrasonography is suggested to reduce the overutilisation of ultrasonography, thus reducing risk of infection and discomfort while also saving time and money.

Ultrasonographic assessment of aortic flow characteristics in a paediatric patient with sepsis treated with extracorporeal life support: defining the mixing zone

We describe a case of severe sepsis in a 14-year-old boy who was treated with veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) support. The haemodynamic challenges inherent to femoro-femoral VA ECMO are discussed, and the use of ultrasonography to define the location of the mixing zone in the abdominal aorta is demonstrated. We propose that the use of ultrasound is able to assist clinicians in understanding perfusion of abdominal organs in the presence of suspected differential oxygenation.

A review of sonographic thyroid volume and iodine sufficiency in children: An Australian perspective

Sonographic measurement of the thyroid gland volume is a safe and reliable method for epidemiologic studies in iodine deficiency disorders. Several factors such as age, sex and anthropometric characteristics are known to be the determinants of thyroid gland size but the most widely studied is the effect of insufficient iodine intake. Low iodine intake induces enlargement of the thyroid gland known as goitre. The assessment of urinary iodine concentration alone is not reliable as it can vary daily within individuals. Urinary iodine concentration in conjunction with sonographic thyroid gland measurements is a widely used method of thyroid gland assessment. Establishment of normative thyroid volume is essential for the assessment of iodine deficiency disorders, and studies have been conducted in several countries. These studies have shown that thyroid gland volumes are likely population-specific even in iodine-sufficient countries limiting the effectiveness of international reference ranges. Based on currently available data of sonographic thyroid gland volume measurements and how they vary across populations of school children, this review argues for the establishment of population-specific reference ranges in regions such as Australia, which are now considered iodine-sufficient.

Bayesian Approach to Predicting Acute Appendicitis Using Ultrasonographic and Clinical Variables in Children

Objectives

Ultrasound has an established role in the diagnostic pathway for children with suspected appendicitis. Relevant clinical information can influence the diagnostic probability and reporting of ultrasound findings. A Bayesian network (BN) is a directed acyclic graph (DAG) representing variables as nodes connected by directional arrows permitting visualisation of their relationships. This research developed a BN model with ultrasonographic and clinical variables to predict acute appendicitis in children.

Methods

A DAG was designed through a hybrid method based on expert opinion and a review of literature to define the model structure; and the discretisation and weighting of identified variables were calculated using principal components analysis, which also informed the conditional probability table of nodes.

Results

The acute appendicitis target node was designated as an outcome of interest influenced by four sub-models, including Ultrasound Index, Clinical History, Physical Assessment, and Diagnostic Tests. These sub-models included four sonographic, three blood-test, and six clinical variables. The BN was scenario tested and evaluated for face, predictive, and content validity. A lack of similar networks complicated concurrent and convergent validity evaluation.

Conclusions

To our knowledge, this is the first BN model developed for the identification of acute appendicitis incorporating imaging variables. It has particular benefit for cases in which variables are missing because prior probabilities are built into corresponding nodes. It will be of use to clinicians involved in ultrasound examination of children with suspected appendicitis, as well as their treating clinicians. Prospective evaluation and development of an online tool will permit validation and refinement of the BN.

Paediatric appendiceal ultrasound: a survey of Australasian sonographers' opinions on examination performance and sonographic criteria

INTRODUCTION

The objectives of this study were to identify knowledge gaps and/or perceived limitations in the performance of paediatric appendiceal ultrasound by Australasian sonographers. We hypothesised that: sonographers' confidence in visualising the appendix in children was poor, particularly outside predominantly paediatric practice; workplace support for prolonging examinations to improve visualisation was limited; and the sonographic criteria applied in diagnosis did not reflect contemporary literature.

METHODS

A cross-sectional survey of Australasian sonographers regarding paediatric appendicitis was conducted using a mixed methods approach (quantitative and qualitative data). Text responses were analysed for key themes, and quantitative data analysed using chi-square, Mann-Whitney U and Wilcoxon signed-rank tests.

RESULTS

Of the 124 respondents, 27 (21.8%) reported a visualisation rate of less than 10%. Workplace support for extending examination time was significantly related to a higher appendix visualisation rate (χ2 (2) = 16.839, P < 0.001). Text responses reported frustration locating the appendix and a desire for more time and practice to improve visualisation. Sonographers suggested a significantly lower maximum diameter cut-off in a 5-year-old compared to a 13-year-old (Z = -6.07, P < 0.001), and considered the presence of inflamed peri-appendiceal mesentery as the most useful sonographic criterion in diagnosing acute appendicitis.

CONCLUSIONS

Respondents had a low opinion of their ability to confidently identify the appendix. Confidence was greater in those centres where extending scanning time was encouraged. Application of echogenic mesentery as the most significant secondary sonographic criterion is supported by recent studies. Opinions of diameter cut-offs varied, indicating potential for improved awareness of recent research.

Improving the value of ultrasound in children with suspected appendicitis: a prospective study integrating secondary sonographic signs

PURPOSE

The purpose of this study was to determine whether the awareness and inclusion of secondary sonographic signs of appendicitis, in combination with a structured evaluation as part of engagement and training for sonographers, improved appendix visualization rates and reduced equivocal findings in children with suspected acute appendicitis.

METHODS

This was a prospective study of 230 children at a tertiary children's hospital in Australia referred for an ultrasound examination of suspected appendicitis. The ultrasound findings, radiology reports, histology, clinical results, and follow-up were collated. Secondary signs were used as an additional assessment of the likelihood of disease where possible, even in the absence of an identified appendix.

RESULTS

The implementation of a structured evaluation as part of sonographer engagement and training resulted in a 28% improvement in appendix visualization (68.7%) compared with a prior retrospective study in a similar population (40.7%). The diagnostic accuracy was 91.7%, with likelihood ratios suggesting a meaningful influence of the pre-test probability of appendicitis in children studied (positive likelihood ratio, 11.22; negative likelihood ratio, 0.09.). Only 7.8% of the findings were equivocal. A binary 6-mm diameter cut-off did not account for equivocal cases, particularly lymphoid hyperplasia.

CONCLUSION

Engagement of sonographers performing pediatric appendiceal ultrasound through training in the scanning technique and awareness of secondary signs significantly improved the visualization rate and provided more meaningful findings to referrers.

Not just a bump on the head: ultrasound as first-line imaging in a boy with Pott's puffy tumour

While computed tomography (CT) and magnetic resonance imaging (MRI) have established roles in evaluating Pott's puffy tumour, ultrasound can play a valuable role in identifying the condition, particularly in children. We present the case of a boy with a fluctuant forehead lump and headaches, where ultrasound was the first-line imaging modality and expedited further investigations.

Ultrasound of paediatric appendicitis and its secondary sonographic signs: providing a more meaningful finding

Sonography is an important clinical tool in diagnosing appendicitis in children as it can obviate both exposure to potentially harmful ionising radiation from computed tomography scans and the need for unnecessary appendicectomies. This review examines the diagnostic accuracy of ultrasound in the identification of acute appendicitis, with a particular focus on the the utility of secondary sonographic signs as an adjunct or corollary to traditionally examined criteria. These secondary signs can be important in cases where the appendix cannot be identified with ultrasound and a more meaningful finding may be made by incorporating the presence or absence of secondary sonographic signs. There is evidence that integrating these secondary signs into the final ultrasound diagnosis can improve the utility of ultrasound in cases where appendicitis is expected, though there remains some conjecture about whether they play a more important role in negative or positive prediction in the absence of an identifiable appendix.