Delayed Gadolinium Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC) was first introduced in 1996 by Bashir et al. as a method of indirectly evaluating glycosaminoglycan (GAG) changes in cartilage microstructure. Following publications originating from the Boston Children’s research group describing the association of early joint failure following periacetabular osteotomy (PAO) in patients with diminished preoperative cartilage T1 relaxation values, the interest in this imaging technique spread. dGEMRIC imaging was introduced into our clinical practice in 2013 with enrollment of both pediatric and adult patients. However, since the program’s apex in 2015, a marked decline in referral of adolescent patients for preoperative dGEMRIC imaging has occurred. Using data acquired during a quality analysis of the dGEMRIC program, this project was designed to investigate the utility of the dGEMRIC exam in our adolescent imaging cohort from 2013-2015 and to identify potential factors leading to decreased utilization from 2015-2018.
Objective Our aim was to implement a standardized US report that included secondary signs of appendicitis (SS) to facilitate accurate diagnosis of appendicitis and decrease the use of computed tomography (CT) and admissions for observation. Methods A multidisciplinary team implemented a quality improvement (QI) intervention in the form of a standardized US report and provided stakeholders with monthly feedback. Outcomes including report compliance, CT use, and observation admissions were compared pretemplate and posttemplate. Results We identified 387 patients in the pretemplate period and 483 patients in the posttemplate period. In the posttemplate period, the reporting of SS increased from 5.4% to 79.5% (p < 0.001). Despite lower rates of appendix visualization (43.9% to 32.7%, p < 0.001) with US, overall CT use (8.5% vs 7.0%, p = 0.41) and the negative appendectomy rate remained stable (1.0% vs 1.0%, p = 1.0). CT utilization for patients with an equivocal ultrasound and SS present decreased (36.4% vs 8.9%, p = 0.002) and admissions for observations decreased (21.5% vs 15.3%, p = 0.02). Test characteristics of RLQ US for appendicitis also improved in the posttemplate period. Conclusion A focused QI initiative led to high compliance rates of utilizing the standardized US report and resulted in lower CT use and fewer admissions for observation. Study of a Diagnostic Test Level of Evidence: 1.
Introduction: Ultrasound (US) is the preferred imaging modality for evaluating appendicitis. Our purpose was to determine if including secondary signs (SS) improve diagnostic accuracy in equivocal US studies.
Methods: Retrospective review identified 825 children presenting with concern for appendicitis and with a right lower quadrant (RLQ) US. Regression models identified which SS were associated with appendicitis. Test characteristics were demonstrated.
Results: 530 patients (64%) had equivocal US reports. Of 114 (22%) patients with equivocal US undergoing CT, those with SS were more likely to have appendicitis (48.6% vs 14.6%, p <  0.001). Of 172 (32%) patients with equivocal US admitted for observation, those with SS were more likely to have appendicitis (61.0% vs 33.6%, p <  0.001). SS associated with appendicitis included fluid collection (adjusted odds ratio (OR) 13.3, 95% confidence interval (CI) 2.1–82.8), hyperemia (OR = 2.0, 95%CI 1.5–95.5), free fluid (OR = 9.8, 95%CI 3.8–25.4), and appendicolith (OR = 7.9, 95%CI 1.7–37.2). Wall thickness, bowel peristalsis, and echogenic fat were not associated with appendicitis. Equivocal US that included hyperemia, a fluid collection, or an appendicolith had 96% specificity and 88% accuracy.
Conclusion: Use of SS in RLQ US assists in the diagnostic accuracy of appendicitis. SS may guide cl inicians and reduce unnecessary CT and admissions.