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Take a look at a selection of our recent media coverage:
4th July 2022
The introduction of an alert system to provide clinical decision support in emergency departments on whether to perform a computed tomography (CT) scan on children with head trauma, has resulted in more appropriate use of such scans. This was the main conclusion of a study by a team from Utah, US.
Traumatic brain injury (TBI) is an important public health problem and data produced by the CDC in the US reveal how there are approximately half a million emergency department visits for TBI every year by children aged 0 to 14 years. An important concern for clinicians is to identify whether a child has a clinically important TBI and a CT scan represents an excellent imaging modality for the identification of an intracranial injury. However, not all children with a head injury require a CT scan and clinical decision rules can help standardise and improve the use of CT for children with minor head injury.
For the present study, the US wanted to explore whether the introduction of an alert system at the point when clinicians were considering the use of a CT scan, could provide enhanced support and therefore make more appropriate use of these scans. The alert system made use of the Pediatric Emergency Care Applied Research Network (PECARN) head trauma clinical decision rules, which provided risk stratification to help reduce diagnostic uncertainty and the need for unnecessary CT scans. Prior to the decision-making for the need to perform a CT scan, clinicians were presented with a pop-up’ alert, which provided a risk assessment. In trying to assess the value of introducing the alert system, the researchers considered guideline adherence, which they considered to be not performing a CT scan when the alert system identified the patient as being at low risk. For the study, all sites provided data on the level of CT scans before and after introduction of the intervention for comparative purposes.
Alert system and change in CT scanning
A total of 12, 670 paediatric minor head trauma encounters were included in the analysis. The proportion of guideline-adherent encounters increased from 94.8% in the control period to 99.4% during the time when the intervention was implemented. Furthermore, the proportion of CT scans performed reduced from 38.6% in the control period to 29.8% after implementation of the intervention.
The authors calculated that the odds of an encounter being guideline-adherent was 1.12 (95% CI 1.03 – 1.22) or approximately 10% higher during the intervention compared to the control time period. Moreover, when using a pre-post comparison, guideline adherence remained significantly higher than the control period (odds ratio = 5.33, 95% CI 3.75 – 7.59).
The authors concluded that the implementation of the alert system led to sustained improvements in adherence to guidelines on the need for a CT scan and a modest reduction in scans among low risk patients.
Knighton AJ et al. Improving Head CT Scan Decisions for Pediatric Minor Head Trauma in General Emergency Departments: A Pragmatic Implementation Study Ann Emerg Med 2022
24th May 2022
Point-of-care ultrasound (POC ultrasound) has a high sensitivity and specificity for the identification of testicular torsion in paediatric patients within an emergency care setting. This was the conclusion of a systematic review and meta-analysis of studies by Japanese researchers from Tokyo, Japan.
Testicular torsion is defined as the rotation of the longitudinal axis of the spermatic cord, resulting in the absence of testicular blood flow. The estimated annual incidence of the condition among those younger than 18 years is 3.8 per 100,000 with a mean age of 10.6 years at presentation. Common symptoms include acute scrotum pain, erythema and scrotal swelling. It has been suggested that a scoring system based on testicular swelling, a hard testicle, an absent cremasteric reflex, nausea/vomiting and high riding testis, can potentially diagnose or rule out testicular torsion in 80% of cases.
POC ultrasound use within an emergency department in children with suspected acute appendicitis has been shown to be diagnostic. Moreover, although ultrasound has been found to be an effective imaging modality for diagnosing testicular torsion in adult patients with acute scrotal pain, the diagnostic accuracy of POC ultrasound for testicular torsion in children has not been fully assessed.
In the current study, the Japanese team undertook a meta-analysis of studies in children (under 19 years of age) who presented at an emergency department with symptoms suggestive of an acute scrotum. The researchers included any studies which used POC ultrasound but excluded both case studies and case series with less than 10 patients. The primary outcome was an assessment of the diagnostic accuracy of POC ultrasound for paediatric testicular torsion based on sensitivity and specificity.
POC ultrasound and testicular torsion
A total of four studies including 784 patients were included in the analysis. The median age of children in the four studies ranged from 10 to 13 (although it was not reported in one study).
Among the 4 studies, testicular torsion was identified via POC ultrasound in 205 patients although 3 of these were found to be false positives.
The pooled sensitivity was 98.4% (95% CI 88.5 – 99.8%) and the specificity was 97.2% (95% CI 87.2 – 99.4%). The overall false positive rate was 2.8% (95% CI 0.6 – 12.8) and the positive predictive value (i.e., the probability that an individual has the condition) was 84.9%.
Based on their analysis, the researched felt that POC ultrasound had the potential to allow clinicians to diagnose testicular torsion rapidly and safely. They added that children with a positive result should undergo immediate exploratory surgery. However, an important caveat from their analysis was how the quality of the available evidence was only moderate because of a high risk of bias and heterogeneity.
The authors concluded that although POC ultrasound appeared to be able to accurately diagnose testicular torsion, prior to implementing such as recommendation, prospective studies were required to clarify the accuracy of this imaging modality.
Mori T et al. Diagnostic accuracy of point-of-care ultrasound for paediatric testicular torsion: a systematic review and meta-analysis Emerg Med J 2022