Lung Ultrasonography: A Viable Alternative to Chest Radiography in Children with Suspected Pneumonia?

OBJECTIVE: To determine the interrater reliability (IRR) of lung ultrasonography (LUS) and chest radiography (CXR) and evaluate the accuracy of LUS compared with CXR for detecting pediatric pneumonia compared with chest computed tomography (CT) scan. STUDY DESIGN: This was a prospective cohort study of children aged 3 months to 18 years with a CXR and LUS performed between May 1, 2012, and January 31, 2014 with or without a clinical diagnosis of pneumonia. Four pediatric radiologists blinded to clinical information reported findings for the CXR and LUS images. IRR was estimated for 50 LUS and CXR images. The main outcome was the finding from CT ordered clinically or the probability of the CT finding for patients clinically requiring CT. Two radiologists reviewed CT scans to determine an overall finding. Latent class analysis was used to evaluate the sensitivity and specificity for findings (eg, consolidation) for LUS and CXR compared with CT. RESULTS: Of the 132 patients in the cohort, 36 (27%) had CT performed for a clinical reason. Pneumonia was clinically documented in 47 patients (36%). The IRR for lung consolidation was 0.55 (95% CI, 0.40-0.70) for LUS and 0.36 (95% CI, 0.21-0.51) for CXR. The sensitivity for detecting consolidation, interstitial disease, and pleural effusion was statistically similar for LUS and CXR compared with CT; however, specificity was higher for CXR. The negative predictive value was similar for CXR and LUS. CONCLUSIONS: LUS has a sufficiently high IRR for detection of consolidation. Compared with CT, LUS and CXR have similar sensitivity, but CXR is more specific for findings indicating pneumonia.

Emergency Department Use of Computed Tomography for Children with Ventricular Shunts.

OBJECTIVES: To quantify rates and variation in emergency department (ED) cranial computed tomography (CT) utilization in children with ventricular shunts, estimate radiation exposure, and evaluate the association between CT utilization and shunt revision. STUDY DESIGN: Retrospective longitudinal cohort study of ED visits from 2003-2013 in children 0-18 years old with initial shunt placement in 2003. Data were examined from 31 hospitals in the Pediatric Health Information System. Main outcomes were cranial CT performed during an ED visit, estimated cumulative effective radiation dose, and shunt revision within 7 days. Multivariable regression modeled the relationship between patient- and hospital-level covariates and CT utilization. RESULTS: The 1319 children with initial shunt placed in 2003 experienced 6636 ED visits during the subsequent decade. A cranial CT was obtained in 49.4% of all ED visits; 19.9% of ED visits with CT were associated with a shunt revision. Approximately 6% of patients received ≥10 CTs, accounting for 37.2% of all ED visits with a CT. The mean number of CTs per patient varied nearly 20-fold across hospitals; the individual hospital accounted for the most variation in CT utilization. The median (IQR) cumulative effective radiation dose was 7.2 millisieverts (3.6-14.0) overall, and 33.4 millisieverts (27.2-43.8) among patients receiving ≥10 CTs. CONCLUSIONS: A CT scan was obtained in half of ED visits for children with a ventricular shunt, with wide variability in utilization by hospitals. Strategies are needed to identify children at risk of shunt malfunction to reduce variability in CT utilization and radiation exposure in the ED.