Ultrasounds could replace radiography for detecting pneumonia in children

Pediatric UltrasoundUltrasounds could be an equally accurate method for detecting pneumonia in children compared with chest x-rays.

That’s according to a recent study which compared ultrasonography with chest radiography for detecting pneumonia in children.

It suggests that this could mean that more children could be diagnosed, especially in resource-limited settings.

The children would also be exposed to less radiation.

The research was carried out by Dr Lilliam Ambroggio at Cincinnati Children’s Hospital Medical Center, Cincinnati, USA.

Study 

The study enrolled patients aged 3 months to 18 years with a clinically ordered CT or admitted to the hospital with a respiratory condition.

Main exposures were chest ultrasound and x-ray findings read by four radiologists blinded to the clinical diagnosis of the patient.

The authors were able to determine the accuracy of both methods by comparing them to the CT reference standard.

The researchers found that, when compared with chest X-rays, ultrasound may be more sensitive (identifying more true positive results) and less specific (less true negative results) than chest x-rays in detecting consolidations and pleural effusions, both common indicators of pneumonia.

However overall the two techniques were statistically equivalent.

Dr Ambroggio said:

Ultrasound and chest radiography in our study were statistically equivalent, suggesting the potential for chest ultrasonography to replace chest x-rays in detecting pneumonia in children, particularly in outpatient and resource-limited settings.

“The advent of ultrasound technology in the diagnosis of pneumonia in developing countries is potentially easier to establish as the infrastructure needed to perform and interpret a chest ultrasound is much less than what is needed to perform a chest radiograph.”

The research was presented at the annual meeting of the European Society for Pediatric Infectious Diseases in Dublin.

Want to learn more about U/S evaluation of the lung & bowel?  Attend the Pediatric Emergency or Pediatric Ultrasound courses coming up June 25-26.

Reference: MSN News; http://news.ie.msn.com/ireland/ultrasounds-could-replace-radiography-for-detecting-pneumonia-in-children

Mesenteric Adenitis

A valued follower of our prolific blog has requested for “a rundown on the mesenteric adenitis in children.” So here it is.

Thank You to all our followers!
- Ultrasound Connection

Stephanie Doniger, MD, RDMS, FAAP, FACEPMesenteric Adenitis

by Stephanie J. Doniger MD RDMS FAAP FACEP

Background

Abdominal pain is one of the most frequent presenting complaints of children to the emergency department. Mesenteric adenitis, or lymphadenitis is commonly encountered when evaluating a child presenting with acute abdominal pain.  Mesenteric adenitis, represents the inflammation of abdominal lymph nodes, and may be present in the ileo-cecal and/or para-aortic regions. The most common location is in the right lower quadrant (Vayner, 2003). The peak incidence is 10 years of age. There are varying etiologies, but most commonly due to Yersinia, Staphylococcus, Salmonella, Streptococcus, and various mycobacteria and viruses. Enlarged abdominal lymph nodes have also been found in children with recurrent abdominal pain and acute gastroenteritis.

There is some disagreement in the radiology literature regarding the sonographic criteria for the diagnosis of mesenteric adenitis. While asymptomatic children may have the presence of enlarged abdominal lymph nodes, they are generally 5mm or less. Those with acute abdominal pain due to mesenteric adenitis, have the presence of lymph nodes greater than 10 mm (Simanovsky, 2007).

US Technique

The high-frequency (5-10 MHz), linear transducer is utilized. The technique is the same as for the evaluation for appendicitis. Start at the point of maximal tenderness, or at McBurney’s point, in the right lower quadrant. Look for the landmarks of the psoas muscle and the adjacent iliac vessels. The appendix generally should lie on top of the psoas muscle, but may be located medially, laterally, or retro-cecally. Use the graded compression technique for better visualization. It may be helpful to utilize color Doppler to distinguish lymph nodes from blood vessels. Suspected lymph nodes should be measured in two dimensions: the short-axis and the long-axis.

Ultrasound Findings

Look for evidence of appendicitis:  a tubular, non-compressible structure measuring greater than 6 mm. Lymph nodes are also non-compressible, but elliptical or circular in shape. The often appear hypoechoic but have consistent and symmetric echotexture throughout the structure (in contrast to an abscess). In the radiology literature, lymph nodes measured in their short-axis of greater than 5 mm is the criteria for the sonographic diagnosis of mesenteric adenitis. Once study (Simanovsky, 2007) suggested that lymph nodes with measurements greater than 10 mm should be diagnostic for mesenteric adenitis, since they found many asymptomatic children with lymph nodes measuring 5 mm.

Hypoecoic Circle
Figure 1. Right lower quadrant ultrasound performed in the evaluation of a child with acute abdominal pain. This hypoechoic circular structure was visualized, in addition to a normal appendix.

Importance

Children often present with acute abdominal pain. Mesenteric adenitis can mimic acute appendicitis, ovarian torsion, intussusception, and other causes of an acute abdomen. Often ultrasound examinations are performed in order to assess for the presence of these etiologies, especially for appendicitis. Mesenteric lymphadenitis is often found, and may be an alternative cause of right lower quadrant pain. When a normal appendix is visualized in addition to enlarged lymph nodes, one can confidently diagnose mesenteric adenitis as the etiology of a child’s acute abdominal pain. Children may briefly need pain control or fluid hydration during the acute process. But ultimately, this is a benign, self-limiting condition that does not require medical or surgical intervention.

References

Macari, M., Hines, J., Balthazar, E., et al. Mesenteric adenitis: CT diagnosis of primary versus secondary causes, incidence, and clinical significance in pediatric and adult patients. Am J Roentgenol  2002; 178(4): 853-858.

Mason, JD. The evaluation of acute abdominal pain in children. Emerg Med Clin North Am 1996; 14(3): 629-643.

Schupp, C.J., Klingmuller, V., Strauch, K., et al. Typical signs of acute appendicitis in ultrasonography mimicked by other diseases? Pediatr Surg Int 2010; 26: 697-702.

Simanovsky, N., Hiller, N.  Importance of sonographic detection of enlarged abdominal lymph nodes in children. J Ultrasound Med 2007; 26: 581-584.

Vayner, N., Coret, A., Polliack, G., et al. Mesenteric lymphadenopathy in children examined by US for chronic and/or recurrent abdominal pain. Pediatr Radiol 2003; 33: 864-867.

Watanabe, M., Ishii, E., Hayashida, Y., et al. Evaluation of abdominal lymphadenopathy in children by ultrasonography. Pediatr Radiol 1997; 27(11): 860-864.

 

Point-of-Care Ultrasound is More Accurate than the Stethoscope in Diagnosing Pneumonia in Children

Point-of-Care Ultrasound is More Accurate than the Stethoscope in Diagnosing Pneumonia in Children

The new study from Mount Sinai was published in the online edition of Archives of Pediatrics & Adolescent Medicine.

by Jim Tsung
December 10, 2012 /Press Release/  

Point-of-care ultrasound is more accurate than the traditional method of auscultation by stethoscope in diagnosing pneumonia in children and young adults, and can even detect small pneumonias that a chest x-ray may miss, a Mount Sinai researcher reports in an article titled, “Prospective Evaluation of Point-of-Care Ultrasonography for the Diagnosis of Pneumonia in Children and Young Adults” in the online edition of Archives of Pediatrics & Adolescent Medicine published December 10, 2012.

These findings have important public health implications, especially in the developing world, as pneumonia is the leading cause of death in children worldwide. Pneumonia kills an estimated 1.2 million children under the age of five years every year – more than AIDS, malaria and tuberculosis combined.

“The World Health Organization has estimated as many as three-quarters of the world’s population, especially in the developing world, does not have access to any diagnostic imaging, such as chest x-ray, to detect pneumonia,” said senior author James Tsung, MD, MPH, Associate Professor of Emergency Medicine and Pediatrics at Mount Sinai School of Medicine. “Many children treated with antibiotics may only have a viral infection– not pneumonia. Portable ultrasound machines can provide a more accurate diagnosis of pneumonia than a stethoscope.”

Dr. Tsung of Mount Sinai, along with collaborators Vaishali Shah, MD of the Children’s Hospital at Montefiore and Michael G. Tunik, MD of Bellevue Hospital Center/NYU School of Medicine, studied 200 patients from birth to 21 years of age who were presented to the emergency department with suspected community acquired pneumonia at Bellevue Hospital Center from 2008-2010. The criteria for inclusion were patients requiring a chest x-ray for evaluation. Sonologists, clinicians who perform and interpret ultrasonography, were given one hour of focused training prior to the start of the study on the use the ultrasonography to diagnose pneumonia.

Researchers found point-of-care ultrasound to be highly specific (97 percent) for diagnosing pneumonia, with sensitivity as high as 92 percent that can be achieved with training and experience.  The accuracy for diagnosing pneumonia with the stethoscope was lower: specificity ranged from 77-83 percent, and sensitivity at 24 percent.

Further analysis of the data at Mount Sinai Medical Center revealed that ultrasound was able to identify pneumonia too small (less than 1 centimeter) for a chest x-ray to detect in 12 out of 48 patients with confirmed pneumonia.

Dr. Tsung and colleagues noted that diagnosing pneumonia with a stethoscope can be more difficult when a patient is wheezing or has co-existing diseases like asthma or bronchiolitis.  This is not a problem for ultrasound.

Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs are made up of small sacs called alveoli. The alveoli fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing painful and limits oxygen intake.

References:

About The Mount Sinai Medical Center

Mount Sinai HospitalThe Mount Sinai Medical Center encompasses both The Mount Sinai Hospital and Mount Sinai School of Medicine. Established in 1968, Mount Sinai School of Medicine is one of the leading medical schools in the United States. The Medical School is noted for innovation in education, biomedical research, clinical care delivery, and local and global community service. It has more than 3,400 faculty in 32 departments and 14 research institutes, and ranks among the top 20 medical schools both in National Institutes of Health (NIH) funding and by U.S. News & World Report.

The Mount Sinai Hospital, founded in 1852, is a 1,171-bed tertiary- and quaternary-care teaching facility and one of the nation’s oldest, largest and most-respected voluntary hospitals. In 2012, U.S. News & World Report ranked The Mount Sinai Hospital 14th on its elite Honor Roll of the nation’s top hospitals based on reputation, safety, and other patient-care factors. Of the top 20 hospitals in the United States, Mount Sinai is one of 12 integrated academic medical centers whose medical school ranks among the top 20 in NIH funding and by  U.S. News & World Report and whose hospital is on the U.S. News & World Report Honor Roll.  Nearly 60,000 people were treated at Mount Sinai as inpatients last year, and approximately 560,000 outpatient visits took place.

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