Improving the value of ultrasound in children with suspected appendicitis: a prospective study integrating secondary sonographic signs

Purpose The purpose of this study was to determine whether the awareness and inclusion of secondary sonographic signs of appendicitis, in combination with a structured evaluation as part of engagement and training for sonographers, improved appendix visualization rates and reduced equivocal findings in children with suspected acute appendicitis. Methods This was a prospective study of 230 children at a tertiary children’s hospital in Australia referred for an ultrasound examination of suspected appendicitis. The ultrasound findings, radiology reports, histology, clinical results, and follow-up were collated. Secondary signs were used as an additional assessment of the likelihood of disease where possible, even in the absence of an identified appendix. Results The implementation of a structured evaluation as part of sonographer engagement and training resulted in a 28% improvement in appendix visualization (68.7%) compared with a prior retrospective study in a similar population (40.7%). The diagnostic accuracy was 91.7%, with likelihood ratios suggesting a meaningful influence of the pre-test probability of appendicitis in children studied (positive likelihood ratio, 11.22; negative likelihood ratio, 0.09.). Only 7.8% of the findings were equivocal. A binary 6-mm diameter cut-off did not account for equivocal cases, particularly lymphoid hyperplasia. Conclusion Engagement of sonographers performing pediatric appendiceal ultrasound through training in the scanning technique and awareness of secondary signs significantly improved the visualization rate and provided more meaningful findings to referrers

Stumped? It Could be Stump Appendicitis (ePoster)

Purpose or Case Report: The purpose of this educational exhibit poster is to increase the awareness of stump appendicitis using two case examples. Stump appendicitis is rare, with sixty-one cases identified in the literature between 1945 and 2005. Of the two common techniques of appendicectomy, ligation and invagination, the former can leave a residual stump with a potential lumen for the pathophysiological process of appendicitis to recur. Remnant stump lengths of greater than 5 mm are considered to have a higher risk of leading to stump appendicitis, acting as a potential reservoir for a faecolith. Whilst ultrasound has been commonly used to diagnose acute appendicitis for over 30 years, its utility in preoperative identification of stump appendicitis in patients postappendicectomy has only been documented more recently. Traditional sonographic criteria for diagnosing acute appendicitis have been applied to the appendiceal stump, with a transverse diameter greater than 6 mm, non-compressibility and wall hyperaemia all being concerning for stump appendicitis. Secondary sonographic signs of acute appendicitis, such as echogenic peri-appendiceal mesentery, can also indicate stump inflammation. Two case examples are presented, both in patients who are nine years old. One patient had surgically confirmed stump appendicitis. The second had sonographic features of stump appendicitis which settled with antibiotics without requiring surgery. Inflammation of the base or stump of a surgically removed appendix is an uncommon, and likely under-recognised condition in both children and adults. The majority of cases have had previous open appendicectomy, which is in contrast to a theory that laparascopic surgery is a potential factor in incomplete removal of the appendix due to poor visualisation of the appendiceal base. Both methods of appendicectomy, ligation or invagination, have been associated with stump appendicitis. Suspicion of the condition and prompt diagnosis can potentially reduce the risk of serious complications due to delayed treatment (perforation, abscess formation), or misdiagnosis (constipation, gastroenteritis). Whilst the possibility of appendicitis is usually dismissed in patients with a history of appendicectomy, sonographers should be aware of stump inflammation in such patients that present with RIF pain from weeks to decades after surgery

Large expert-curated database for benchmarking document similarity detection in biomedical literature search

Document recommendation systems for locating relevant literature have mostly relied on methods developed a decade ago. This is largely due to the lack of a large offline gold-standard benchmark of relevant documents that cover a variety of research fields such that newly developed literature search techniques can be compared, improved and translated into practice. To overcome this bottleneck, we have established the RElevant LIterature SearcH consortium consisting of more than 1500 scientists from 84 countries, who have collectively annotated the relevance of over 180 000 PubMed-listed articles with regard to their respective seed (input) article/s. The majority of annotations were contributed by highly experienced, original authors of the seed articles. The collected data cover 76% of all unique PubMed Medical Subject Headings descriptors. No systematic biases were observed across different experience levels, research fields or time spent on annotations. More importantly, annotations of the same document pairs contributed by different scientists were highly concordant. We further show that the three representative baseline methods used to generate recommended articles for evaluation (Okapi Best Matching 25, Term Frequency-Inverse Document Frequency and PubMed Related Articles) had similar overall performances. Additionally, we found that these methods each tend to produce distinct collections of recommended articles, suggesting that a hybrid method may be required to completely capture all relevant articles. The established database server located at https://relishdb.ict.griffith.edu.au is freely available for the downloading of annotation data and the blind testing of new methods. We expect that this benchmark will be useful for stimulating the development of new powerful techniques for title and title/abstract-based search engines for relevant articles in biomedical research.Peer reviewe

A 2-year-old girl with intermittent vomiting [Imaging for residents - Quiz]

This is the case of a 2-year-old female that presented with a 2-week history of intermittent nonbilious vomiting and diffuse abdominal pain. She had a history of gastroschisis repair as a neonate which involved an initial surgical reduction shortly after birth, returning as much bowel as possible. The remaining eviscerated bowel was placed in a silo for 5 days, after which the wound site and wall defect were surgically closed..

Statistical modelling of paediatric appendix ultrasonography and the predictive value of secondary sonographic signs

This thesis evaluated the role of ultrasonography in children with suspected appendicitis. Diagnostic criteria and important secondary sonographic signs of appendicitis were identified through statistical analysis of data collected at two children's hospitals. Findings were used to create predictive models, including a Bayesian network incorporating ultrasound and clinical variables. This thesis raised awareness of the utility of secondary sonographic signs of appendicitis, which have predictive value even when the appendix isn't seen on ultrasound. This has improved performance of appendix ultrasound at the Queensland Children's Hospital through provision of more definitive ultrasound results, potentially reducing unnecessary surgery

A 2-Year-Old girl with intermittent vomiting

This is the case of a 2-year-old female that presented with a 2-week history of intermittent nonbilious vomiting and diffuse abdominal pain. She had a history of gastroschisis repair as a neonate which involved an initial surgical reduction shortly after birth, returning as much bowel as possible. The remaining eviscerated bowel was placed in a silo for 5 days, after which the wound site and wall defect were surgically closed..

Around the twist, the sonographic whirlpool sign in a patient with a history of gastroschisis

Introduction This is the report of a two-year-old girl who presented with non-bilious vomiting, abdominal pain and a history of gastroschisis, for investigation of potential intussusception.Method An abdominal ultrasound was conducted identifying the whirlpool sign suggesting mid-gut volvulus. The patient then underwent an upper GI contrast study and follow through. Written consent was obtained inclusion in this report.Results Ultrasound identified dilated proximal small bowel and the whirlpool sign, with the superior mesenteric vein and tributaries making one-and-a-half twists around the axis of the superior mesenteric artery. Fluoroscopy demonstrated jejunal beaking with passage of some contrast. Ladd's procedure was performed, repositioning the intestines in a non-rotated position, a grossly dilated segment of jejunum was resected.Conclusion Patients with a history of gastroschisis will also have intestinal non-rotation as the normal embryological process of gut rotation is interrupted. Because of the prolonged exposure of the eviscerated gut in utero to amniotic fluid, the affected bowel is usually inflamed, and thought to be susceptible to adhesions once reduced neonatally. These adhesions are considered to be protective by reducing bowel mobility and likelihood of future volvulus.Take home message The sonographic whirlpool sign is an important indicator of possible mid-gut volvulus. Sonographers should be aware of this sign and its clinical significance, even in patients considered less likely to have the condition

ECLS and sonography in the paediatric ICU

Extracorporeal life support (ECLS) or sometimes referred to as extracorporeal membrane oxygenation is a method of supporting a patient's lungs, or heart and lungs together, called veno-venous and veno-arterial respectively. In the paediatric intensive care unit (PICU), ECLS is employed in critically ill children whose lungs and/or heart are unable to perform adequately owing to illness, injury or planned surgery. ECLS can be utilised in neonates to adults and requires careful planning and monitoring while in use. Ultrasound plays an important role in ECLS, traditionally with echocardiography, and increasingly so with general/vascular sonography. This presentation will describe the various applications of general ultrasound in the paediatric intensive care unit ECLS patient and detail a current pilot study that aims to examine the efficacy of ultrasound as a measure of neurological and renal health in these very sick children

Sonographer health and well‐being, it starts with you

This Editorial prefaces a special issue with a focus on you, specifically your health and well‐being as a sonographer or sonologist. Sonography was built on the foundation of the Soundeffects news magazine, which continues to update members with regular submissions from the Australasian Sonographers Association's (ASA) dedicated Sonographer Health and Well‐being Special Interest Group (SIG); several members of which have made significant contributions to resources and awareness of the topic. The substance of this special issue affects sonographers of all levels of experience, encompassing the spectrum of health and well‐being from physical injury to mental health considerations, topics that have been the subject of international sonography literature over recent decades.1, 2 Articles in this issue address contemporary considerations on the topic and have been contributed by a range of Australasian authors, a mix of emerging sonographer researchers, experienced clinical sonographers, and established academics from across our profession..

Not just a bump on the head: ultrasound as first-line imaging in a boy with Pott's puffy tumour

While computed tomography (CT) and magnetic resonance imaging (MRI) have established roles in evaluating Pott's puffy tumour, ultrasound can play a valuable role in identifying the condition, particularly in children. We present the case of a boy with a fluctuant forehead lump and headaches, where ultrasound was the first‐line imaging modality and expedited further investigations