Ultrasound accurate for appendicitis in children

Ultrasound accurate for appendicitis in children

By AuntMinnie.com staff writers

February 11, 2014 -- Portable ultrasound is an excellent first-line choice for diagnosing appendicitis in children, according to an article published online February 10 in Academic Emergency Medicine.

Bedside ultrasound delivered a specificity of 94% and reduced the need for CT scans by more than a third, according to study co-author Dr. Ee Tein Tay, assistant professor of emergency medicine and pediatrics at the Icahn School of Medicine at Mount Sinai.

CT is the most accurate imaging modality for diagnosing appendicitis, but it delivers a potentially harmful radiation dose, particularly in children. As a result, efforts are underway to reduce the 4 million radiation-emitting scans given to children each year.

The prospective, observational study included 150 pediatric patients who were evaluated for suspected appendicitis between May 2011 and October 2012 in an urban pediatric emergency department.

Use of portable ultrasound reduced the CT scanning rate by more than 35% -- from a 44% rate before the study to 27% during the study.

In addition, the emergency department length of stay declined 46% (by two hours and 14 minutes) for those undergoing radiology department ultrasound. Length of stay decreased by 68% (almost six hours) for those who required CT after an initial point-of-care ultrasound was inconclusive.

No cases of appendicitis were missed with the use of first-line ultrasound, and no unnecessary surgeries were performed for a normal appendix.

Related Reading

AJR: Using ultrasound 1st for appendicitis saves money, January 14, 2014

Study: Use ultrasound 1st for appendicitis in kids, December 3, 2013

Teleradiology on mobile devices OK for appendicitis, November 4, 2013

ARRS: MRI tops US in appendicitis detection in pregnant women, April 22, 2013

MRI helps guide appendicitis assessment in pregnant women, April 2, 2013

Copyright © 2014 AuntMinnie.com

Last Updated np 2/10/2014 5:41:54 PM

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SHEAR WAVE ELASTOGRAPHY of LIVER FIBROSIS

Sonography is a noninvasive and inexpensive procedure for diagnosis of diffuse liver disease; however, the value of sonography for distinguishing a low degree of liver fibrosis from cirrhosis is limited. In a study by Colli et al, 28 of 107 patients with severe fibrosis or definite cirrhosis (26%) had negative results for liver surface nodularity and caudate lobe hypertrophy and had normal hepatic venous flow. In this regard, elastography integrated into ultrasound systems is an effective adjunctive tool for quantifying liverfibrosis.

Conclusions

In patients with chronic viral hepatitis, particularly in patients with hepatitis C virus infection, all noninvasive methods are ready to be used for detecting and staging liver fibrosis before therapy at a safe level of predictability.

As with transient elastography, elastographic techniques based on shear waves generated by the acoustic beam are more accurate in detecting cirrhosis than significant fibrosis. They have the advantage of B-mode guidance, which allows one to choose an area of liver parenchyma better suited for stiffness assessment (ie, free of large vessels and focal lesions).

These methods are all valid when information about fibrosis is needed. Liver biopsy should still be performed when biochemical tests and imaging studies are inconclusive or information other than liver fibrosis is required.

FACTORS CORRELATING with ARFI ELASTOGRAPHY in CHRONIC HEPATITIS C

Abstract

AIM: To investigate the factors other than fibrosis stage correlating with acoustic radiation force impulse (ARFI) elastograpy in chronic hepatitis C.

METHODS: ARFI elastograpy was performed in 108 consecutive patients with chronic hepatitis C who underwent a liver biopsy. The proportion of fibrosis area in the biopsy specimens was measured by computer-assisted morphometric image analysis.

RESULTS: ARFI correlated significantly with fibrosis stage (β  = 0.1865, P  < 0.0001) and hyaluronic acid levels ( β = 0.0008, P = 0.0039) in all patients by multiple regression analysis. Fibrosis area correlated significantly with ARFI by Spearman’s rank correlation testbut not by multiple regression analysis. ARFI correlatedsignificantly with body mass index (BMI) ( β = -0.0334, P = 0.0001) in F0 or F1, with γ-glutamyltranspeptidase levels ( β = 0.0048, P = 0.0012) in F2, and with fibrosis stage (β  = 0.2921, P  = 0.0044) and hyaluronic acid levels ( β = 0.0012, P = 0.0025) in F3 or F4. The ARFIcutoff value was 1.28 m/s for  F ≥ 2, 1.44 m/s for  F ≥ 3, and 1.73 m/s for  F4.

CONCLUSION:

ARFI correlated with fibrosis stage and hyaluronic acid but not with inflammation. ARFI was affected by BMI, γ-glutamyltranspeptidase, and hyaluronic acid in each fibrosis stage. 

© 2014 Baishideng Publishing Group Co., Limited. All rights reserved

Core tip: The assessment of liver fibrosis stage is important to estimate prognosis and to identify the patients requiring antiviral treatment in chronic hepatitis C. Liver biopsy is a gold standard for assessing fibrosis, but is invasive. Thus methods for noninvasively assessing fibrosis have been developed. Liver stiffness measurement (LSM) by Fibroscan and acoustic radiation force impulse correlate with fibrosis stage. However, LSM may be affected by factors other than fibrosis, such as edema, steatosis, and inflammation.

DISCUSSION

The assessment of fibrosis stage is important to estimate prognosis and to identify the patients requiring antiviral treatment in chronic hepatitis C. A lot of noninvasive methods to assess liver fibrosis stage other than liver biopsy are available, for example, ARFI, TE, real-timeelastography [23], and algorithm of serum fibrosis markers such as FibroTest [24] and APRI [25]. They provide good performances in estimation of fibrosis stage, while there are problems such as influence of inflammation. In the present study, factors other than fibrosis stage that affect ARFI were investigated in patients with chronic hepatitis C.

The present study confirmed findings reported previously that ARFI correlates with fibrosis stage [10-13,26,27].

The ARFI cutoff values for different fibrosis stages were 1.28 m/s for F ≥ 1, 1.28 m/s for F ≥ 2, 1.44 m/s for F ≥ 3 and 1.73 m/s for F4. This result suggests that distinguishing between F0 and F1 is impossible, as the cutoff value for F ≥ 1 and that for F ≥ 2 are the same. However, Sporea et al [26] reported that the cutoff value is 1.19 m/s for F ≥ 1, 1.33 m/s for F ≥ 2, 1.43 m/s for F ≥ 3, and 1.55 m/s for F4 [26]. Rizzo et al [13] reported that the cutoff value is 1.3 m/s for F ≥ 2, 1.7 m/s for F ≥ 3 and 2.0 m/s for F4 [13]. Thus, discrepancies are apparent among the cutoff values reported in different studies. The discrepancies are probably attributed to the difference in the population studied. Further studies should be conducted to establish standard ARFI cutoff values for staging fibrosis.

In the present study, AST, ALT and inflammatory grade were correlated with ARFI in the univariate analysis that included all patients, but were not selected as factors independently correlating with ARFI in the multiple regression analysis. In addition, inflammatory factors did not correlate with ARFI when patients with different fibrosis stages were analyzed separately. These results suggest that inflammatory activity does not affect ARFI in patients with chronic hepatitis C. Rizzo  et al [13] also reported that ARFI is not associated with ALT, BMI, Metavir grade, or liver steatosis, whereas TE is significantly correlated with ALT[13]. Bota et al [10] reported that discordance of at least two fibrosis stages between ARFI and histologic assessment were associated with female sex, interquartile range interval (IQR) ≥ 30%, high AST and high ALT in univariate analysis,while, in multivariate analysis, the female gender and IQR ≥ 30% (P = 0.004) were associated with the discordances. In contrast, Yoon et al [12] reported that the optimum ARFI cutoff values are 1.13 m/s for F ≥ 2 and 1.98 m/s for F4, whereas these values decreased to 1.09 m/s for F ≥ 2 and 1.81 m/s for F4 when patients with normal ALT levelswere selected. Chen et al [11] reported that ALT, ActiTest A score, Metavir activity (A) grade, Metavir F stage, BMI, and platelet count are independently associated with ARFI and suggested that a 100 IU/L increase in serum ALT levels augmented ARFI by approximately 0.155 m/s. In the present study, only 25 patients had ALT levels of 100 IU/L or higher. The low ALT levels among the patients studied may be a reason why ALT was not correlated with ARFI.

A multiple linear regression analysis in our previous study on TE selected fibrosis area, ALT levels, γ-GTP levels, prothrombin time, and hyaluronic acid levels as factors correlating with TE[21]. Many studies on TE have reported that LSM is affected by ALT levels. Franquelli et al [28]  reported that TE fibrosis staging is overestimated by necroinflammatory activity and steatosis. Coco et al [7] found that LSM is higher in patients with an elevated ALT than in those with either spontaneous biochemical remission or after antiviral therapy. Thus, it is probable that ALT or inflammatory activity affects TE. However, it is still unclear whether they also affect ARFI. Further studies are needed to clarify factors that affect ARFI other than fibrosis stage. ARFI was significantly correlated with BMI in the 31 patients with stage F0 or F1; the higher the BMI, the lower the ARFI. However, ARFI was not associated with steatosis grade. Motosugi et al [29] reported that fat deposition in the liver does not affect ARFI. Thus, the negativecorrelation between BMI and ARFI could not be attributed to steatosis, which accompanies higher BMI [30].

Actually, BMI and steatosis grade were not correlated in patients with stage F0 or F1 in the present study (data not shown). The mechanism of the association between higher BMI and lower ARFI is unclear. Because a higher BMI is associated with lower ARFI, and may cause anunderestimation of fibrosis staging, careful attention should be paid to BMI during ARFI staging of fibrosis in patients with stage F0 or F1 disease.

ARFI significantly correlated with γ-GTP levels in patients with F2 and with fibrosis stage and hyaluronic acid levels in patients with stage F3 or F4. γ-GTP[24,31] and hyaluronic acid [32,33]  levels have been regarded as the most informative fibrosis markers. Thus, it is reasonable that γ-GTP and hyaluronic acid levels independently correlated with ARFI. Isgro  et al [20]  showed that the collagen proportional area has a better relationship with TE and with hepaticvenous pressure gradient compared with Ishak stage. In the present study, fibrosis area was correlated significantly with fibrosis stage, but only fibrosis stage and hyaluronic acid levels were selected as factors independently correlating with ARFI. Our previous study demonstrated a better correlation of TE with fibrosis stage than with fibrosis area in patients with chronic hepatitis C[21]. The Metavir stages represent categories of increasing fibrosis severity based on a combination of location and quantity of scarring as well as whether the fibrous tissue forms septa, bridges, or nodules. Fibrosis area represents only the quantity of fibrosis in liver tissues. Our results indicate that not only the quantity of fibrosis but also other histological factors such as patterns of fibrosis also affect ARFI.

The present study demonstrated that ARFI correlated with fibrosis stage but was not associated with inflammation. BMI negatively correlated with ARFI in the patients with stage F0 or F1. γ-GTP and hyaluronic acid levels were positively correlated in those with stage F2 and in those with F3 or F4, respectively. Thus, careful attention should be paid to BMI, γ-GTP levels, and hyaluronic acid levels when estimating fibrosis stage by ARFI. Fibrosis stage showed a better correlation with ARFI than fibrosis area, indicating that not only the quantity of fibrosis but also other factors such as patterns of fibrosis also affect ARFI. Since the number of the patients studied is small,further studies are needed to confirm the conclusion of the present study.

NHÂN CA HYDROCELE of CANAL of NUCK @ MEDIC CENTER

Bệnh nhân đã được mổ cấp cứu vào mùng 25 Tết tại bệnh viện Chợ Rẫy, chẩn đoán sau mổ là nang ống Nuck xuất huyết và tái tạo thành bẹn theo phương pháp Shouldice.
Ca tràn dịch ống Nuck khác, với chẩn đoán lâm sàng là thoát vị bẹn P, bệnh nhân không mổ vì không đau và vì đã biết từ khi còn bé.
 Cả 2 ca đều có cấu trúc dạng ống ngay trên gai mu và đầu trên có hình dấu phẩy đặc trưng, là nơi nối tiếp với phúc mạc, đoạn đầu của processus vaginalis.

Sơ đồ cho thấy cơ chế thành lập hydrocele ở nam (T) và nữ (P) là phần processus vaginalis của phúc mạc không xẹp dính lại sau năm tuổi đầu tiên. 

ULTRASOUND EXAMINATIONS of the HEAD and NECK: AIUM GUIDELINE

STRATEGY for BREAST CANCER SCREENING in TAIWAN

Breast cancer (BC) has become a global disease among women. Cost-effective strategies in reducing mortality caused by BC are highly desirable. Here, we suggest a working program based on an overall evaluation of the shortcomings and advantages of the current strategy for BC screening in Taiwan. From 1995 to 2002, cervical cancer was the most frequent cancer in women in Taiwan. However, invasive BC has moved from the second-most to the most frequent cancer since 2003. The incidence of BC increased by 14.69% between 2003 and 2008. In the same time interval, the incidence of cervical cancer decreased by 4.59%. Age analysis for BC incidence showed that 11% were at a relatively young age (30e39 years) and the peak incidence was in the group aged 40e49 years. Furthermore, only 31% of patients were at stage I according to data for newly diagnosed patients at National Taiwan University Hospital for 2004-2009. With the increase in pregnancy at an advanced maternal age, obstetrician egynecologists should be alert to the possibility of coexisting BC and pregnancy. To facilitate early detection of BC, a campaign for “Three points examined together” {uterine cervix and 2 breasts} should be implemented. Obstetrician-gynecologists should perform breast examination including palpation and ultrasound examination at the same time as the annual Pap smear. Mammography should be performed every 2-3 years or when indicated. If suspicious lesions are found, patients should be referred to a breast imaging laboratory, where a definitive diagnosis can be established. For confirmed cases of BC, appropriate surgery, chemotherapy and radiotherapy should be mammography or ultrasound provided. In short, active participation of obstetrician-gynecologists is a must in the campaign against BC in Taiwan.

Mammography or ultrasound

Although far from being a perfect tool, mammography has been the mainstay of BC screening. Mammography can detect microcalcification in breast lesions for stage 0 BC patients. However, it involves ionizing radiation. It is not applicable in women under 40 years of age in general. It has to be performed in rooms shielded with lead. Many studies have documented that the morphological view of breast tissue in Asian women is denser than that in Caucasian women. The pain and discomfort caused by compression during the mammography have deterred many women from BC screening programs. In fact, the acceptance rate for mammography in Taiwan has been as low as 17%. In addition, microcalcification in breast lesion is difficult to be detected by mammography for Asian compared to Caucasian women.

By contrast, ultrasound is not ionizing in nature. It is widely acceptable and available in Taiwan and it is performed in an OB/GYN clinic setting where Pap smears are performed. Thus, it is possible for “Three points examined together” to become more than a slogan. When a suspicious breast lesion is found, an experienced physician can undertake fine needle aspiration or core biopsy to make a definitive diagnosis right on site.

Taken together, these considerations indicate that the best strategy for BC detection might be to perform both mammography and ultrasound examinations without an additional charge at each visit. For women not at high risk of BC, mammography can be performed every 2-3 years, while breast ultrasound is performed annually together with Pap smears.

If we can convince 2000 obstetricianegynecologists in Taiwan to actively participate in BC detection, we believe that the BC mortality rate in Taiwan could be markedly reduced within a few years via early detection and management of disease. A good example is the maternal serum screening campaign for Down syndrome (Fig. 4) [19]. With the right strategy and a collaborative team consisting of patients, obstetrician-gynecologists and other medical care providers, the Down syndrome live birth rate decreased by 70% in 3 years. It was estimated that at least 200 families in Taiwan each year would benefit from this campaign.

Framework for a BC screening campaign in Taiwan

We suggest that the following framework should be established without delay in the fight against BC, the most frequent female cancer in Taiwan:

(1) First line. Physical breast examination should be performed followed by breast ultrasound examination at the time of annual Pap smears. Mammography can be performed every 2-3 years in the radiology department. Whether cases have family history of BC or not should be carefully scrutinized. If a patient has a family history of BC, extra caution should be exercised.

(2) Second line. Breast imaging laboratories should be established in regional hospitals and medical centers and operated by experienced radiologists or breast physicians. When a suspicious breast lesion is found during first-line screening, the patient should be referred to this breast imaging laboratory, where an expert can  use breast ultrasound, mammography, or MRI coupled with aspiration cytology or core biopsy to establish a definite diagnosis.

(3) Third line. Breast surgeons should be available to perform adequate surgery for confirmed BC cases.

(4) Fourth line. High-quality pathological diagnosis, radiotherapy, chemotherapy, and genetic counseling should be provided.

Experience in NTUH

A breast imaging laboratory was established in NTUH in 2003 and has been functioning effectively since then. The laboratory has actively engaged in training for breast ultrasound imaging. Physicians from surgery, obstetrics and gynecology, and family medicine can receive 3-month fellowship training in the laboratory. A 1-week introductory course on breast ultrasound is also available for members in Taiwan Society of Obstetricians and Gynecologists. The breast imaging laboratory at NTUH is a successful model that other hospitals in Taiwan can duplicate. We hope that this type of breast imaging laboratory will become available in an increasing number of hospitals all over Taiwan.

Conclusion

The incidence of female BC in Taiwan increased by 14.69% from 2003 to 2008 and some 8136 women were newly diagnosed with BC in 2008. The incidence of female BC at NTUH increased by 62.02% in 2009 compared with 2004 (Fig. 5). The peak incidence was in the group aged 40-49 years and 11% of cases occurred in the group aged 30-39 years. The percentage of early BC detected annually is pproximately 30%, a figure much lower than that in Western countries.

The following steps are suggested to boost early detection of BC in Taiwan:

(1) The health authority should implement a policy of “Three points examined together” by establishing a workable scheme. Thus, Pap smears and BC detection can be performed at the same site during the same visit.

(2) Active participation of obstetricianegynecologists is absolutely necessary for a successful BC detection campaign.

(3) The Taiwan Society of Obstetricians and Gynecologists and all teaching hospitals should gear up in establishing an educational program in breast medicine for residents and attending physicians to provide adequate care for breast disorders.

(4) Facilities to provide Pap smears and breast examinations simultaneously should be available at as many OB/GYN clinics and hospitals as possible.

(5) Easily accessible breast imaging laboratories should be set up at regional hospitals and medical centers to provide a definite diagnosis for patients with suspicious lesions found in first-line clinics.

(6) The health authority and relevant medical societies should work together to run quality assurance programs to familiarize doctors with various breast examinations.

(7) Active public campaigns should be implemented to raise public awareness of BC detection strategies.

Over the years, obstetricians and gynecologists in Taiwan have used Pap smear screening and screening of maternal serum for Down syndrome to great effect. This has resulted in marked reductions in cervical cancer cases and live births affected by Down syndrome. If a widespread screening program is set up involving first-line clinics and a good breast imaging laboratory, we may soon witness another miracle in BC screening in terms of early detection of (pre) cancerous lesions.