超音波、CT在侦测孩童阑尾炎的效果相当


  【24drs.com】根据发表于12月美国放射学期刊的回溯研究,使用超音波作为侦测孩童阑尾炎之第一种诊断影像工具的效果和计算机断层(CT)扫描相当,而且放射线较少、也不会增加住院天数。
  
  第二作者、Montefiore儿童医师小儿放射科主治医师、纽约市Yeshiva大学Albert Einstein医学院助理教授Jessica Kurian在新闻稿中表示,随著越来越多人知道医疗用放射线的风险,越来越多人致力于使用非放射性成像技术作为第一种诊断方式;我们的研究显示,先使用超音波评估阑尾炎时,一般可获得临床可用的结果,可考虑增加其临床运用,以减少孩童的放射线曝露。
  
  阑尾炎是美国孩童常见的状况,发生率持续增加;虽然CT是最常用来评估疑似阑尾炎患者之症状的影像技术,但它与显著增加放射线曝露有关,而超音波不会有放射线曝露。
  
  研究目标是,孩童急性阑尾炎时,使用超音波作为第一种影像检查方式时,确认是否会增加复杂性阑尾炎比率与住院天数(LOS)。
  
  为了确认2005-2011年间手术证实阑尾炎的小儿科病患,研究者查找了医院帐务资料库中,出院诊断码为单纯性阑尾炎(International Classification of Diseases, 9th Revision [ICD-9], code 540.9)与复杂性阑尾炎(ICD-9 codes 540.0 and 540.1)的病患。
  
  他们评估并绘制这些病患在研究期间内进行超音波和CT的百分比与年度趋势,使用Spearman(ρ)等级相关检测检视复杂性阑尾炎与住院天数中位数之关联。
  
  符合纳入规范的804名病患中,每年进行CT的病患百分比适度降低(ρ, -0.32;P < .01),首先使用超音波的病患百分比则是适度上升(ρ, 0.44;P < .01)。
  
  在7年的研究期间,阑尾切除术前只有进行超音波影像检查的病患百分比适度增加(ρ, 0.33;P < .01)。
  
  不过,因为放射科医师和临床医师在小儿外科和急诊医学之间的合作增加,使用超音波作为第一种影像检查的比率也增加,从研究开始时的33%增加到研究结束时的近90%;相反的,先使用CT扫描且只有用这一项的比率从43%降低到小于10%。
  
  研究期间,复杂性阑尾炎患者的比率(ρ, -0.01;P = .74)或住院天数中位数(ρ, -0.04;P = .25)并未显著增加。
  
  研究限制包括,回溯研究设计、特定病患为何进行或不进行特定检查的资料有限、只纳入证实有阑尾炎的患者而非所有疑似阑尾炎的病患、可能有干扰因素。
  
  Kurian医师表示,我们的研究发生在Montefiore医院优先使用超音波的立场之下,病患优先接受超音波的百分比显著增加且不会影响住院天数中位数,这些研究结果支持使用超音波来帮助减少孩童的放射线曝露,且认为可运用到其它疾病之诊断,以使孩童的终生放射线曝露累积剂量更少。
  
  在作者的机构中,改变检查选项如超音波和磁振造影方面的教育之下,使小儿科病患进行CT的数量大幅减少。策略包括有关适当放射线剂量的教育讲座、强调「ALARA」(最小有效剂量原则)、鼓励技术员使用适当剂量、发布各种成像方式之可能风险与效益的文宣资料。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=7034&x_classno=0&x_chkdelpoint=Y
  

Ultrasound, CT Comparable to Detect Appendicitis in Children

By Laurie Barclay, MD
Medscape Medical News

Using ultrasound as the first diagnostic imaging technique to detect appendicitis in children produces comparable outcomes to computed tomography (CT) scanning with less radiation and without increasing hospital length of stay, according to a retrospective study published in the December issue of the American Journal of Roentgenology.

"As more people become aware of the risks of medical radiation, there are increasing efforts to utilize non-radiation emitting imaging techniques as a first approach to diagnosis," second author Jessica Kurian, MD, attending radiologist, Division of Pediatric Radiology, the Children's Hospital at Montefiore and assistant professor, Albert Einstein College of Medicine of Yeshiva University in New York City, said in a news release. "Our research shows that using ultrasound first in the evaluation of appendicitis commonly produces actionable results and should be considered more frequently as clinicians try to limit medical radiation exposure in children."

Appendicitis is one of the prevalent conditions among US children, and the incidence is increasing. Although CT is the most frequently used imaging technique to assess patients with symptoms suggesting appendicitis, it is associated with significant radiation exposure. In contrast, ultrasound causes no radiation exposure.

The study goal was to determine whether the rate of complicated appendicitis and the hospital length of stay (LOS) increased during the transition to a protocol of using ultrasound first for the imaging workup of acute appendicitis in children.

To identify pediatric patients with surgically proven appendicitis from 2005 to 2011, the investigators searched the hospital billing database for discharge diagnosis codes for simple appendicitis (International Classification of Diseases, 9th Revision [ICD-9], code 540.9) and complicated appendicitis (ICD-9 codes 540.0 and 540.1).

They evaluated and plotted annual trends for the study period of the percentages of these patients who underwent ultrasound and CT. Using the Spearman (ρ) rank correlation test, they examined correlation of complicated appendicitis and median hospital LOS with calendar year.

Ultrasound Use Increased During the Study

Among 804 patients who met inclusion criteria, there was a moderate downward association of percentage of patients undergoing CT with year (ρ, ?0.32; P < .01) and a moderate upward trend in the percentage of patients who first had ultrasound (ρ, 0.44; P < .01).

During the 7-year study period, the percentage of patients who had only ultrasound imaging before appendectomy increased moderately (ρ, 0.33; P < .01).

As collaboration between radiologists and clinicians in pediatric surgery and emergency medicine increased, however, use of ultrasound as the first imaging test also increased, going from 33% at the beginning of the study to nearly 90% at study end. In contrast, use of CT scan as the first and only diagnostic test decreased from 43% to less than 10%.

During the study, there was no significant increase in the proportion of patients with complicated appendicitis (ρ, ?0.01; P = .74) or in the median hospital LOS (ρ, ?0.04; P = .25).

Limitations of this study include a retrospective design, few data about why specific tests were or were not performed in specific patients, inclusion of only the patients who had proven appendicitis rather than all the patients who presented with suspected appendicitis, and possible confounding.

Ultrasound First Safely Limits Radiation Exposure

"Our study, which took place during Montefiore's transition to an 'ultrasound-first' model, shows that the percentage of patients who received ultrasound first significantly increased without impacting the median hospital [LOS], which remained consistent," Dr. Kurian said. "These findings support the use of ultrasound in helping to reduce radiation exposure in kids and suggest this approach could be applied in the diagnosis of other conditions to minimize the cumulative radiation dose a child is exposed to over the course of a lifetime."

At the authors' institution, education about alternate testing options, such as ultrasound and magnetic resonance imaging, has recently led to a dramatic decrease in the number of CTs done on pediatric patients. Strategies include educational seminars regarding the appropriate radiation dose, reinforcement of "ALARA" ("as low as reasonably achievable"), encouraging technologists to use appropriate dosage, and distributing awareness materials regarding the potential risks and benefits of various imaging modalities.

The National Center for Research Resources, a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research supported this study in part. The authors have disclosed no relevant financial relationships.

Am J Roentgenol. 2013;201:1348-1352.

    
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