Arun Mohanta

Predictors of Non-Diagnostic Ultrasound Scanning in Children with Suspected Appendicitis

OBJECTIVE To determine predictors of diagnostically inaccurate ultrasound scanning for suspected appendicitis. STUDY DESIGN Prospective emergency department cohort study of 263 previously healthy children 4 to 17 years of age undergoing ultrasound scanning. Ultrasound scanning results were interpreted as positive, negative, or equivocal for appendicitis and classified as diagnostically accurate and inaccurate. The main outcome measure was association between inaccurate ultrasound scanning and age, sex, body mass index percentiles, pain duration, white blood cell count, Faces Pain Score-Revised, clinical probability of appendicitis, and ultrasound scanning operator. RESULTS Of the 263 patients, 95 ultrasound scanning examinations were read as positive, 76 as negative, and 92 were equivocal. A total of 162 (61.6%) ultrasound scanning examinations were accurate (TP86, TN76), and 101 (38.4%) ultrasound scanning examinations were inaccurate (FP88, FN13). Children with body mass index percentiles ≥ 85 and clinical probability of appendicitis ≤ 50% had 58.1% probability of inaccurate ultrasound scanning examination (odds ratio, 2.48; 95% confidence interval, 1.48-2.78). In lean children, diagnostic accuracy of the screening ultrasound scanning examination with second ultrasound scanning or clinical reassessment was 93% versus 83% in the obese children (95% confidence interval of the difference, 1-19%). CONCLUSION Screening ultrasound scanning for pediatric appendicitis has suboptimal accuracy, particularly in obese children with a low likelihood of appendicitis who should not routinely undergo ultrasound scanning. However, when followed by a second ultrasound scanning or a clinical reassessment, it offers high diagnostic accuracy in lean children.

Dermatological Complications of Continuous Subcutaneous Insulin Infusion in Children and Adolescents

OBJECTIVES To describe the dermatological changes associated with continuous subcutaneous insulin infusion (CSII) therapy in youth with type 1 diabetes mellitus (T1D). To assess their association with duration of CSII, age, adiposity, HbA1(c), insulin dose, insulin brand, infusion set or site. STUDY DESIGN We conducted a cross-sectional study of 50 consecutive patients with T1D who were using CSII for >6 months (26 female; age, 13.3 +/- 3.5 years [mean +/- SD]; CSII duration, 2.8 +/- 1.7 years; HbA1(c), 7.7% +/- 1.1%). A grading scale was devised. Ultrasound scanning was performed in 8 subjects. RESULTS The mean (+/-SD) severity score was 6.3 +/- 3.5 (range, 0-14; maximum possible, 69). Most common were scars <3 mm diameter (94%), erythema not associated with nodules (66%), subcutaneous nodules (62%), and lipohypertrophy (42%). There was a significant negative correlation between severity score and body mass index z-score (r = -0.3, P = .039), but no correlation with HbA1(c), insulin brand or site. Infusion sets inserted at 90 degrees were associated with lower scores (P = .03). Less than 5% of patients and parents considered stopping CSII because of skin concerns. Ultrasound scanning results of CSII sites revealed mild increased echogenicity of the dermis and hypodermis. CONCLUSIONS Dermatological changes were frequent, with increased severity associated with lower adiposity. These complications were not associated with glycemic control, nor did they prompt most to consider stopping CSII.

Topical imiquimod 5% cream for pediatric plaque morphea: a prospective, multiple-baseline, open-label pilot study.

Background/Aims: Therapeutic options for the treatment of plaque morphea are limited. We explored the efficacy and safety of imiquimod cream in children with plaque morphea. Methods: Prospective, open-label, double-baseline study, using imiquimod 5% cream topically for 9 months. The primary outcome measure was improvement in the thickening of morphea plaques using a visual analog scale (VAS) and the DIET score (dyspigmentation/induration/erythema/telangiectasia). Secondary outcome measures were clinicoradiographic correlations and frequency of adverse events. Results: Nine patients, 89% females, with a mean age of 11.33 years (SD = 3.52) were enrolled. At 36 weeks, the mean VAS had decreased from 48.08 (SD = 18.85) to 22.7 (SD = 12.9) (p < 0.0001), and the mean DIET score from 4.38 (SD = 1.2) to 3.06 (SD = 1.39) (p = 0.23). There was very good interrater reliability between DIET score assessments (intraclass correlation coefficient, ICC = 0.75) and VAS (ICC = 0.59) and moderate agreement between parent and investigator VAS (ICC = 0.5). Ultrasonographically measured dermis thickness changed from 1.05 (SD = 0.34) to 0.95 (SD = 0.19) (p = 0.001). One patient experienced ulceration that required temporary discontinuation of intervention. Conclusions: This proof of concept study revealed that imiquimod 5% cream is effective in decreasing the thickening of plaque morphea and safe for pediatric use. Further prospective studies are warranted.

Sonographic evaluation of pediatric localized scleroderma: preliminary disease assessment measures

BackgroundOur earlier work in the ultrasonograpy of localized scleroderma (LS) suggests that altered levels of echogenicity and vascularity can be associated with disease activity. Utrasound is clinically benign and readily available, but can be limited by operator dependence. We present our efforts to standardize image acquisition and interpretation of pediatric LS to better evaluate the correlation between specific sonographic findings and disease activity.MethodsSeveral meetings have been held among our multi-center group (LOCUS) to work towards standardizing sonographic technique and image interpretation. Demonstration and experience in image acquisition were conducted at workshop meetings. Following meetings in 2007, an ultrasound measure was developed to standardize evaluation of differences in echogenicity and vascularity. Based upon our initial observations, we have labeled this an ultrasound disease activity measure. This preliminary measure was subsequently evaluated on over 180 scans of pediatric LS lesions. This review suggested that scoring levels should be expanded to better capture the range of observed differences. The revised levels and their definitions were formulated at a February 2009 workshop meeting. We have also developed assessments for scoring changes in tissue thickness and lesion size to better determine if these parameters aid evaluation of disease state.ResultsWe have standardized our protocol for acquiring ultrasound images of pediatric LS lesions. A wide range of sonographic differences has been seen in the dermis, hypodermis, and deep tissue layers of active lesions. Preliminary ultrasound assessments have been generated. The disease activity measure scores for altered levels of echogenicity and vascularity in the lesion, and other assessments score for differences in lesion tissue layer thickness and changes in lesion size.ConclusionsWe describe the range of sonographic differences found in pediatric LS, and present our efforts to standardize ultrasound acquisition and image interpretation for this disease. We present ultrasound measures that may aid evaluation of disease state. These assessments should be considered a work in progress, whose purpose is to facilitate further study in this area. More studies are needed to assess their validity and reliability.

Properties of Serial Ultrasound Clinical Diagnostic Pathway in Suspected Appendicitis and Related Computed Tomography Use

OBJECTIVES The primary objective was to determine the diagnostic accuracy of a serial ultrasound (US) clinical diagnostic pathway to detect appendicitis in children presenting to the emergency department (ED). The secondary objective was to examine the diagnostic performance of the initial and interval US and to compare the accuracy of the pathway to that of the initial US. METHODS This was a prospective cohort study of 294 previously healthy children 4 to 17 years old with suspected appendicitis and baseline pediatric appendicitis scores of ≥2, who were managed with the serial US clinical diagnostic pathway. This pathway consisted of an initial US followed by a clinical reassessment in each patient and an interval US and surgical consultation in patients with equivocal initial US and persistent concern about appendicitis. The USs were interpreted by published criteria as positive, negative, or equivocal for appendicitis. Children in whom this pathway did not rule in or rule out appendicitis underwent computed tomography (CT). Cases with missed appendicitis, negative operations, and CTs after the pathway were considered inaccurate. The primary outcome was the diagnostic accuracy of the serial US clinical diagnostic pathway. The secondary outcomes included the test performance of the initial and interval US imaging studies. RESULTS Of the 294 study children, 111 (38%) had appendicitis. Using the serial US clinical diagnostic pathway, 274 of 294 children (93%, 95% confidence interval [CI] = 90% to 96%) had diagnostically accurate results: 108 of the 111 (97%) appendicitis cases were successfully identified by the pathway without CT scans (two missed and one CT), and 166 of the 183 (91%) negative cases were ruled out without CT scans (14 negative operations and three CTs). The sensitivity of this pathway was 108 of 111 (97%, 95% CI = 94% to 100%), specificity 166 of 183 (91%, 95% CI = 87% to 95%), positive predictive value 108 of 125 (86%; 95% CI = 79% to 92%), and negative predictive value 166 of 169 (98%, 95% CI = 96% to 100%). The diagnostic accuracy of the pathway was higher than that of the initial US alone (274 of 294 vs. 160 of 294; p < 0.0001). Of 123 patients with equivocal initial US, concern about appendicitis subsided on clinical reassessment in 73 (no surgery and no missed appendicitis). Of 50 children with persistent symptoms, 40 underwent interval US and 10 had surgical consultation alone. The interval US confirmed or ruled out appendicitis in 22 of 40 children (55.0%) with equivocal initial US, with one false-positive interval US. CONCLUSIONS The serial US clinical diagnostic pathway in suspected appendicitis has an acceptable diagnostic accuracy that is significantly higher than that of the initial US and results in few CT scans. This approach appears most useful in children with equivocal initial US, in whom the majority of negative cases were identified at clinical reassessment and appendicitis was diagnosed by interval US or surgical consultation in most study patients.

Sonography for Assessment of Elbows in Hemophilic Children: A Systematic Protocol

Evaluation of joints using sensitive non-invasive tools is important for diagnosis and follow-up of hemophilic patients who are continuously at risk of development and/or progression of arthropathy. Because conventional radiography is inadequate for assessing early arthropathic changes in hemophilic patients, there has been an increasing interest in the development of systematic protocols and scoring systems using magnetic resonance imaging (MRI) and ultrasound for evaluating hemophilic arthropathy in recent years. Given some advantages of ultrasound over MRI for this purpose, namely easier access, lower costs and no need for sedation in younger patients, detailed sonographic protocols have recently been proposed for assessment of large joints, most notably knees and ankles, which are most frequently affected by hemophilic arthropathy. Due to the challenges that the elbow joint offers to the reproducibility of positioning of the extremity on ultrasound which is an operator dependent imaging modality, the elbow joint requires dedicated attention. In this paper, we present a systematic protocol for sonographic data acquisition of the elbow in hemophilic children along with examples of findings of joint effusion, synovial hypertrophy, hemosiderin deposition, surface erosions, subchondral cysts and cartilage loss. We also correlate the ultrasound findings with corresponding MR images demonstrating the anatomic planes used for imaging acquisition. The development of a systematic protocol for ultrasound imaging acquisition of elbows in hemophilic children opens avenues for the development/refinement of ultrasound scales for assessment of hemophilic arthropathy which should reduce the opportunity for inter-and intraoperator variability during acquisition of images. Further validation of the proposed systematic protocol for assessment of arthropathic changes in hemophilic elbows is required for its future use in cross-sectional and longitudinal clinical trials. Standardization and validation of such protocols is essential for comparison of results of clinical trials conducted in different hemophilia centres across the world.