Updates in pediatric ultrasound.

PURPOSE OF REVIEW: Point-of-care ultrasound (POCUS) has various diagnostic and therapeutic applications in the pediatric acute care setting that have an impact on clinical outcomes. RECENT FINDINGS: POCUS can improve diagnostic efficiency and expedite management in pediatric patients who present to the emergency department with common complaints such as respiratory distress, abdominal pain, shock, and pain. SUMMARY: Rapid advancements in POCUS have allowed it to become a powerful tool in pediatric care. As the clinical applications of ultrasound diversify, research is needed to evaluate impacts on healthcare outcomes, delivery, and costs.

Validation of a Clinical Decision Rule for Ultrasound Identification of MRSA Skin Abscesses in Children.

OBJECTIVE: The aim of this study was to validate an adult-derived clinical decision rule for ultrasound identification of methicillin-resistant Staphylococcus aureus (MRSA) skin abscesses in a pediatric cohort. METHODS: We conducted a retrospective study of skin and soft tissue infections in patients <21 years presenting to the emergency department who had radiology performed ultrasounds completed and wound cultures obtained. Ultrasound scans were reviewed for edge definition, volume, and shape by 2 pediatric emergency physicians with expertise in point-of-care ultrasound, with approximately 25% of scans reviewed by both experts to evaluate interrater reliability. A third, blinded expert weighed in for discrepancies before analysis. Test performance characteristics were calculated for the clinical decision rule in children. RESULTS: Two hundred nine patients were enrolled, with mean age of 9.8 (±6.7) years; 87 (42%) were male. Sixty-nine (33%) patients had a wound culture positive for MRSA. The clinical decision rule had a sensitivity of 86% (95% confidence interval [CI], 75%-93%), specificity of 32% (95% CI, 25%-41%), positive predictive value of 38% (95% CI, 35%-42%), negative predictive value of 82% (95% CI, 71%-89%), positive likelihood ratio of 1.26 (95% CI, 1.08-1.46), negative likelihood ratio of 0.45 (95% CI, 0.24-0.84), and an odds ratio of 2.8 (95% CI, 1.31-5.97). CONCLUSIONS: This clinical decision rule for ultrasound identification of MRSA abscesses had moderately high sensitivity and negative predictive value in pediatric patients, with similar sensitivity compared with the original adult validation group. Ultrasound may help identify MRSA abscesses, allowing for improved antibiotic choices and outcomes for children with MRSA abscesses.

Beyond garden design: A review of outdoor occupation in hospital and residential care settings for people with dementia.

INTRODUCTION: Access to outdoor space is widely recommended for people with dementia. However, there is limited information on the occupations of people with dementia within these spaces. We sought to review the research literature to identify the occupations of people with dementia in outdoor spaces in residential aged care and/or hospitals and report on features that support occupational participation as well as the benefits of occupational participation in these spaces. METHODS: Scoping review. We searched electronic databases involving health, design, and horticulture literature. Studies were included if they involved people with dementia and considered occupations within gardens or garden-like spaces of hospitals, subacute rehabilitation facilities, or residential aged care. RESULTS: We identified 19 articles meeting the review criteria. Outdoor spaces for people with dementia varied in design and supported a range of occupations with the most common being social occupations, gardening, and physical activities. Quantitative studies suggested that benefits of outdoor occupations for people with dementia were improvements in activity participation, social connection, mood, agitation, light exposure, and sleep. Qualitative studies supported these findings and identified additional perceived benefits such as engagement, maintaining identity, health, and reduced levels of distress. Benefits were also reported for families and staff. CONCLUSIONS: Current literature shows that many occupations can be done outside and that these are beneficial for people with dementia. Despite the wide range of benefits, multiple studies reported that outdoor spaces remain under-utilised. More work is required to design spaces for occupational engagement, support access to outdoor spaces, and promote occupational participation.

Lack of Association Between a Quantified Lung Ultrasound Score and Illness Severity in Pediatric Emergency Department Patients With Acute Lower Respiratory Infections.

OBJECTIVES: Lung ultrasound (LUS) may help determine illness severity in children with acute lower respiratory tract infections (LRTI) but limited pediatric studies exist. Our objective was to determine the association between LUS findings and illness severity in children with LRTI. METHODS: We conducted a prospective study of patients <20 years with LRTI. Trained investigators performed standardized LUS examinations of 12 regions. Blinded sonologists reviewed examinations for individual pathologic features and also calculated a Quantified Lung Ultrasound Score (QLUS). We defined focal severity as QLUS of ≥2 in ≥1 region, and diffuse severity as QLUS of ≥1 in ≥3 regions. The primary outcome was the Respiratory component of the Pediatric Early Warning Score (RPEWS), a 14-item scale measuring respiratory illness severity. Secondary outcomes included hospital admission, length of stay, supplemental oxygen, and antibiotic use. RESULTS: We enrolled 85 patients with LRTIs, 46 (54%) whom were hospitalized (5.4% intensive care). Median RPEWS was 1 (interquartile range 2). Neither individual features on ultrasound nor total QLUS were associated with RPEWS, hospitalization, length of stay, or oxygen use. Mean RPEWS was similar for participants regardless of focal (1.46 versus 1.26, P = .57) or diffuse (1.47 versus 1.21, P = .47) severity findings, but those with focal or diffuse severity, or isolated consolidation, had greater antibiotic administration (P < .001). CONCLUSIONS: In children with LRTI, neither individual features nor QLUS were associated with illness severity. Antibiotics were more likely in patients with either focal or diffuse severity or presence of consolidation on ultrasound.

Amyand Hernia: As Seen on Point-of-Care Emergency Ultrasound.

ABSTRACT: Amyand hernia is a rare type of inguinal hernia defined by the presence of the appendix in the inguinal hernia sac. Clinical diagnosis of Amyand hernia can be challenging because this diagnosis is typically made intraoperatively, often as an incidental finding. Preoperative diagnosis by computed tomography and radiology ultrasound has previously been reported; however, there exists no reports of the diagnosis being made by point-of-care ultrasound. We present a case of Amyand hernia visible on point-of-care ultrasound performed by a pediatric emergency medicine physician.

COVUS: An Algorithm to Maximize the Use of Point-of-Care Ultrasound in the Emergency Management of COVID-19.

BACKGROUND: Patients with coronavirus disease 2019 (COVID-19) present with diagnostic challenges because COVID-19 can cause varied end-organ failures that mimic respiratory distress of pulmonary origin. Early identification of concurrent complications can significantly alter patient management and course. Point-of-care ultrasound (POCUS) can be particularly useful in helping to differentiate concomitant complications with COVID-19. While lung POCUS findings related to COVID-19 have been published, little guidance exists on how ultrasound can be incorporated into a more comprehensive evaluation of patients under investigation for COVID-19. OBJECTIVES: We devised a pathway called COVUS that incorporates POCUS into the initial evaluation of patients under investigation for COVID-19 to guide diagnosis and management. DISCUSSION: The pathway was derived based on a review of literature, consensus from the ultrasound faculty, as well as feedback from the entire faculty group at one academic institution with high volumes of patients with COVID-19. The scanning protocol uses a cardiac-first (rather than lung-first) approach to identify potential concomitant organ failure that may immediately alter management. CONCLUSIONS: COVUS aims to maximize identification of the most immediately life-threatening complications while minimizing time at bedside and provider risk of exposure to COVID-19.

Point-of-Care Ultrasound Findings in Multisystem Inflammatory Syndrome in Children: A Cross-Sectional Study.

OBJECTIVES: Multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 is a novel pediatric condition with significant morbidity and mortality. The primary objective of this investigation was to describe the point-of-care ultrasound (POCUS) findings in patients evaluated in the emergency department (ED) who were diagnosed with MIS-C. METHODS: A retrospective cross-sectional study was conducted including patients <21-years-old who had POCUS performed for clinical care in a pediatric ED and were diagnosed with MIS-C. Point-of-care ultrasound studies were performed by pediatric emergency medicine attending physicians or fellows. Data abstracted by chart review included patient demographics, clinical history, physical examination findings, diagnostic test results, the time POCUS studies and echocardiograms were performed, therapies administered, and clinical course after admission. RESULTS: For the 24 patients included, 17 focused cardiac ultrasound, 9 lung POCUS, 7 pediatric modified rapid ultrasound for shock and hypotension, 1 focused assessment with sonography for trauma, 1 POCUS for suspected appendicitis, and 1 ocular POCUS were performed by 13 physicians. Point-of-care ultrasound identified impaired cardiac contractility in 5 patients, large intraperitoneal free fluid with inflamed bowel in 1 patient, and increased optic nerve sheath diameters with elevation of the optic discs in 1 patient. Trace or small pericardial effusions, pleural effusions, and intraperitoneal free fluid were seen in 3 patients, 6 patients, and 4 patients, respectively. CONCLUSIONS: This study demonstrates the spectrum of POCUS findings in MIS-C. Prospective studies are needed to help delineate the utility of incorporating POCUS into an ED management pathway for patients with suspected MIS-C.

Lung Point-of-Care Ultrasound in Pediatric COVID-19: A Case Series.

Lung point-of-care ultrasound (POCUS) has been shown to be useful for identifying pulmonary pathology in adult patients with coronavirus disease 2019 (COVID-19). However, pediatric literature for POCUS in COVID-19 is limited. The objective of this case series was to describe lung POCUS findings in pediatric patients with COVID-19. Three patients with COVID-19 who had lung POCUS performed in a pediatric emergency department were included. Point-of-care ultrasound revealed bilateral abnormalities in all patients, including pleural line irregularities, scattered and coalescing B-lines, consolidations, and pleural effusions. Additional pediatric studies are necessary to gain a broader understanding of COVID-19's sonographic appearance in this age group and to determine whether POCUS may be helpful to facilitate diagnosis and expedite management decisions.

An Easy-to-Make, Low-Cost Ultrasound Phantom for Simulation Training in Abscess Identification and Aspiration.

We have created a low-cost and easy to make phantom for abscess identification using point-of-care ultrasound. The phantom also allows needle tracking and abscess aspiration using ultrasound guidance.

Precision Medicine With Point-of-Care Ultrasound: The Future of Personalized Pediatric Emergency Care.

The Precision Medicine Initiative spearheaded by the National Institute of Health has pioneered a new model of health care focused on health care delivery that is tailored to an individual. Medical advances have already provided clinicians with the tools to better predict treatment outcomes based on the individual needs of each patient's disease process. Three-dimensional printing allows medical devices and implants to be custom made-to-order. Technological advances in preoperative imaging have augmented the ability for surgeons to plan a specific surgical approach for each patient. In a similar vein, point-of-care ultrasound offers the emergency care provider an opportunity to move beyond protocols and provide precise medical care tailored to the acute needs of each ill or injured emergent patient. In this article, we explore several cutting-edge applications of point-of-care ultrasound that can help providers develop a personalized approach to resuscitation and emergent procedures in pediatrics.

Attitudes towards three ultrasound-guided vascular access techniques in a paediatric emergency department.

BACKGROUND: although nurses often place peripheral intravenous (IV) catheters, little is known about their perceptions regarding use of ultrasound guidance. AIM: the authors aimed to determine paediatric emergency department nurses' attitudes toward ultrasound-guided IV access techniques and assessed practice change after training. METHOD: In a cross-sectional study of nurses, they had didactic and hands-on practice sessions, using three short-axis ultrasound-guided IV access techniques on gel models. Outcomes included likability and ease of learning and performing the techniques. A 3-month follow-up questionnaire assessed attitudes and behavioural changes. RESULTS: 18 nurses were enrolled and 17 analysed. Participants liked all three techniques and thought they were easy to learn and perform. Eighty-two percent of the nurses used at least one technique clinically. The two-person self-guided technique was most preferred (65%) and used 3 months later (65%). CONCLUSIONS: nurses reported generally positive attitudes toward all three ultrasound-guided IV access techniques, but preferred the two-person self-guided technique. Owing to the small sample size, these results cannot be generalised and further research is needed.

The baseline diameter of the inferior vena cava measured by sonography increases with age in normovolemic children.

OBJECTIVES: To evaluate normative sonographic measurements of the inferior vena cava (IVC) diameter in healthy pediatric patients. METHODS: We performed a prospective observational study of a convenience sample of healthy patients between the ages of 0 and 22 years presenting to a pediatric emergency department. Exclusion criteria included abnormal vital signs, pregnancy, or illnesses thought to influence volume status. During quiet respiration, the maximum and minimum IVC diameters were measured in the sagittal plane distal to the hepatic vein-IVC junction. As second measurements, the maximum diameters of the IVC and aorta were measured in the transverse plane distal to the insertion of the left renal vein into the IVC. RESULTS: From February 2013 through April 2014, 63 children (51% female; mean age, 11 years) were enrolled. There were 20 children in each age group of 2 to 7, 7 to 12, and 12 to 22 years. The correlations between IVC and aortic diameters as a function of age were calculated using the Spearman rank correlation coefficient. The correlation coefficients were all statistically significant (P < .001): sagittal maximum IVC diameter (0.81), sagittal minimum IVC diameter (0.79), transverse maximum IVC diameter (0.79), and transverse maximum aortic diameter (0.81). CONCLUSIONS: This pilot study of sonographic measurements of the IVC diameter in normovolemic children suggests a statistically significant positive correlation between age and IVC diameter. Future studies should focus on multicenter enrollment, children in the youngest age group, and the development of normative growth curves for the IVC by age, sex, and body mass index.

Sonographic baseline physeal plate width measurements in healthy, uninjured children.

BACKGROUND: There are limited data on the sonographic evaluation of normative physeal plate measurements in healthy, uninjured children. OBJECTIVES: This study aimed to determine baseline measurements in physeal plate widths and to assess variation in the measured widths among contralateral sides, age group, and sex in healthy, uninjured children. METHODS: This was a prospective observational study of a convenience sample of healthy patients between 0 and 12 years of age presenting to the pediatric emergency department. A point-of-care ultrasound examination of the distal radius, ulna, fibula, and tibia was performed bilaterally (8 total). Measurements were taken at the physeal plates in the longitudinal plane at the widest distance. The degree of variance of physeal plate widths within an individual and the mean values of physeal plate widths for each bone were calculated. RESULTS: A total of 95 patients were enrolled in this study. The mean age of the enrolled patients was 6 years 3 months; 40% were female. Mean (SD) physeal plate widths for the averaged measurement of each bone were as follows: radius, 0.32cm (0.09); ulna, 0.31cm (0.09); fibula, 0.31cm (0.08); and tibia, 0.39cm (0.09). Mean (SD) values for the absolute difference in physeal plate widths were as follows: radius, 0.08cm (0.06); ulna, 0.07cm (0.10); fibula, 0.06cm (0.06); and tibia, 0.06cm (0.05). When measurements were stratified by age and sex, the mean physeal plate widths and mean difference in physeal plate widths did not demonstrate any significant differences. CONCLUSIONS: This pilot study demonstrated that there was no statistically significant difference in physeal plate widths between contralateral extremities and the degree of variation between contralateral extremities was minimal. Results of this study elucidate normative physeal plate variance in healthy children and demonstrate that mean physeal plate measurements and absolute differences are narrow. This study suggests that sonographic detection of significant disparities in physeal plate widths of injured children may have the potential for earlier detection of Salter-Harris injuries with subsequent appropriate referral and management.

Focused cardiac ultrasound diagnosis of right-sided endocarditis.

Endocarditis is a serious infection of the innermost muscle layer of the heart and can lead to significant mortality and morbidity. Echocardiography is instrumental to the timely diagnosis of this disease entity. We discuss the case of a patient presenting to the emergency department (ED) with fever of unclear etiology. The diagnosis of right-sided endocarditis was made using focused cardiac ultrasound. A 46-year-old man with a history of intravenous drug abuse presented to the ED complaining of fevers and headaches. Focused cardiac ultrasound demonstrated a tricuspid vegetation. The patient was promptly treated for right-sided endocarditis. This case illustrates the use of focused cardiac ultrasound to facilitate the early diagnosis and management of endocarditis in the ED.

Does bedside sonographic measurement of the inferior vena cava diameter correlate with central venous pressure in the assessment of intravascular volume in children?

OBJECTIVES: Previous studies demonstrated that the collapsibility index (percent decrease in inferior vena cava [IVC] diameter with inspiration) of 50% or greater and an IVC/aorta ratio of 0.8 or less correlated with a low intravascular volume. Our study sought to determine if bedside ultrasound (BUS) measurements of the IVC diameter correlate with central venous pressure (CVP) measurements as an indicator of intravascular volume status in acutely ill children. METHODS: A convenience sample of children younger than 21 years who were admitted to the pediatric critical care unit and required CVP monitoring had BUS measurements of both IVC and aortic diameters with simultaneous CVP measurement. The collapsibility index (sagittal view) and IVC/aorta ratio (transverse view) were calculated from these measurements. A CVP of 8 mm Hg or less was considered as a marker for decreased intravascular volume. RESULTS: Of the 51 participants, 21 (43%) had a CVP of 8 mm Hg or less. Eight (16%) of 51 children had a collapsibility index 50% or greater, and 8 (18%) of 43 had an IVC/aorta ratio of 0.8 or less. The sensitivity of a collapsibility index 0.5 or greater to predict a CVP of 8 mm Hg or less was 14%, the specificity was 83%, the positive predictive value was 38%, and the negative predictive value was 57%. Neither collapsibility index (r = -0.23, P = 0.11) nor IVC/aorta (r = -0.19, P = 0.22) correlated with CVP in assessing intravascular volume in our study population. CONCLUSIONS: Based on these data, the IVC and aortic measurements by BUS are not reliable indicators of intravascular volume (as determined by CVP) in acutely ill children.

Development of a novel pediatric point-of-care ultrasound question bank using a modified Delphi process.

BACKGROUND AND OBJECTIVES: Measuring pediatric emergency medicine (PEM) fellow competency in point-of-care ultrasound (POCUS) is important for ensuring adequate training and performance. Assessment may include direct observation, image review, quality assessment, and written examination. The purpose of this study was to develop a pediatric POCUS question bank that could subsequently be used as a POCUS assessment for graduating PEM fellows. METHODS: We organized a 10-person question writing group (QWG). Eight hold expertise in POCUS and two hold expertise in medical education. Members of the QWG created questions within four domains: interpretation/diagnosis (50% of questions), anatomy (30%), physics (10%), and pitfalls (10%). POCUS faculty ascertained content validity and the medical education faculty revised questions for syntax and readability. In 2016, we recruited 31 pediatric POCUS experts. The majority were members of the P2 Network, an international group of experts and leaders in PEM POCUS, to participate in three iterative rounds of a modified Delphi process to review, revise, and establish consensus on the question bank. RESULTS: Thirty-one pediatric POCUS experts participated in the three rounds of the modified Delphi process and evaluated 437 questions developed by the expert panel. Forty-nine percent (n = 216) of the questions were accepted in round 1, 30% (n = 130) in round 2, and 11% (n = 47) in the final round. The final question bank included 393 questions covering 17 pediatric POCUS applications. CONCLUSION: We developed a 393-question bank to aid in the assessment of PEM POCUS competency. Future work includes piloting the questions with PEM fellows to evaluate the response process and implementing the assessment tool to establish a minimum passing score.

Core Content for Pediatric Emergency Medicine Ultrasound Fellowship Training: A Modified Delphi Consensus Study.

BACKGROUND: Pediatric emergency medicine (PEM) point-of-care ultrasound (POCUS) fellowships exist to provide learners with expertise in ultrasound (US) education, administration, and research oversight. Currently, there are no standardized goals or objectives for these programs, resulting in considerable variability in PEM POCUS fellowship training. METHODS: A modified Delphi survey of PEM and general emergency medicine (EM) POCUS experts in Canada and the United States was conducted to obtain consensus regarding the most important curricular components of a PEM POCUS fellowship training program. Participants were solicited from the P2 Network mailing list and from PEM and EM POCUS fellowship directors listed on the Society of Clinical Ultrasound Fellowships and the Canadian Society of POCUS-EM Fellowships websites. Curricular components considered as part of the survey included US skills, educational skills, administrative skills, and research requirements. Consensus was considered to have been reached when ≥80% of respondents agreed to either include or exclude the component in fellowship training. RESULTS: Round 1 of the survey was sent to 311 participants. A total of 118 (37.9%) completed eligibility for the survey, and 92 (78.0%) met eligibility criteria. Of those, 80 (67.8% of eligible participants) completed the first round of the survey. Round 2 of the survey was sent to those who completed part 1, and 64 (80.0%) completed that round. During Round 1, consensus was achieved for 15 of 75 US applications, seven of seven educational skills, nine of 11 administrative skills, and four of six research requirements. In Round 2 of the survey, consensus was reached on two additional US skills, but no additional administrative skills or research requirements. CONCLUSIONS: With a consensus-building process, the core content for PEM POCUS fellowship training was defined. This can help POCUS educators formulate standardized curricula to create consistent training in POCUS fellowship graduates.

Dexamethasone-mediated up-regulation of human CYP2A6 involves the glucocorticoid receptor and increased binding of hepatic nuclear factor 4 alpha to the proximal promoter.

Human cytochrome P450 2A6 (CYP2A6) metabolizes various clinically relevant compounds, including nicotine- and tobacco-specific procarcinogens; however, transcriptional regulation of this gene is poorly understood. We investigated the role of the glucocorticoid receptor (GR) in transcriptional regulation of CYP2A6. Dexamethasone (DEX) increased CYP2A6 mRNA and protein levels in human hepatocytes in primary culture. This effect was attenuated by the GR receptor antagonist mifepristone (RU486; 17beta-hydroxy-11beta-[4-dimethylamino phenyl]-17alpha-[1-propynyl]estra-4,9-dien-3-one), suggesting that induction of CYP2A6 by DEX was mediated by the GR. In gene reporter assays, DEX caused dose-dependent increases in luciferase activity that was also prevented by RU486 and progressive truncations of the CYP2A6 promoter delineated DEX-responsiveness to a -95 to +12 region containing an hepatic nuclear factor 4 (HNF4) alpha response element (HNF4-RE). Mutation of the HNF4-RE abrogated HNF4alpha- and DEX-mediated transactivation of CYP2A6. In addition, overexpression of HNF4alpha increased CYP2A6 transcriptional activity by 3-fold. DEX increased HNF4alpha mRNA levels by 4-fold; however, the amount of HNF4alpha nuclear protein was unaltered. Electrophoretic mobility shift, chromatin immunoprecipitation (ChIP), and streptavidin DNA binding assays revealed that DEX increased binding of HNF4alpha to the HNF4-RE and that an interaction of GR and HNF4alpha occurred at this site. Moreover, ChIP assays indicated that histone H4 acetylation of the CYP2A6 proximal promoter chromatin was increased by DEX that may allow for increased binding of HNF4alpha to the HNF4-RE in human hepatocytes. These findings indicate that increased expression of CYP2A6 by DEX is mediated by the GR via a nonconventional transcriptional mechanism involving interaction of HNF4alpha with an HNF4-RE rather than a glucocorticoid response element.