From the Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, CT.
Pediatr Emerg Care. 2022 Feb 1;38(2):e746-e751. doi: 10.1097/PEC.0000000000002341.
The ease of instruction for point-of-care ultrasound (POCUS) to detect suprapatellar bursa (SPB) effusions in pediatric patients is unknown. Considering in person limitations because of the coronavirus pandemic, strategies for POCUS education by remote learning are necessary.
We crafted a 90-minute didactic training that was presented via a remote learning format. The main outcome of interest was the interobserver reliability of SPB effusion assessment by novice sonologists compared with POCUS faculty. Novice sonologists were pediatric emergency medicine (PEM) fellows. Pediatric emergency medicine fellows interpreted longitudinal SPB examinations obtained in our pediatric emergency department from July 2013 to June 2020. Assessments were performed 2 months after the remote training. Pediatric emergency medicine fellows had a limited experience performing these musculoskeletal scans and were blinded to POCUS faculty and each other's assessments. Interobserver reliability was assessed with Cohen κ coefficient. Second, we calculated test characteristics of knee radiography compared with PEM POCUS faculty determination of SPB effusion by ultrasound. We further explored how effusion size measured by POCUS impacted the diagnosis by knee radiography. A receiver operator characteristic curve of knee radiography diagnosis of SPB effusion was created using the maximal height of SPB effusion by POCUS as the predictor variable.
A total of 116 SPB scans in 71 patients were assessed. From this group, 70 scans were of affected knees and 46 scans were of contralateral, asymptomatic knees. The mean age of patients was 10 years and 46% were girl. The prevalence of SPB effusions was 42%. The κ coefficients between the 3 novice sonologists and POCUS faculty were 0.75 (0.62-0.87), 0.77 (0.65-0.89), and 0.83 (0.72-0.93) with 88%, 89%, and 91% agreement. Knee radiography exhibited an overall sensitivity of 65% (95% confidence interval [CI], 46-79%), specificity of 84% (95% CI, 60-97%), negative predictive value of 55% (95% CI, 43-66%), and positive predictive value of 88% (95% CI, 73-96%) to diagnose SPB effusions. The area under the receiver operator characteristic curve was 0.850. With an SPB height cutoff of 4 mm as true positives, radiography had a sensitivity of 81% and a specificity of 83%.
After a remote teleconference didactic session, PEM fellows were able to successfully diagnose SPB effusions using a longitudinal view with substantial interobserver reliability. Knee radiography exhibited limited sensitivity to rule out SPB effusions.
在儿科患者中，即时超声（POCUS）检测髌上囊（SPB）积液的教学简便程度尚不清楚。鉴于冠状病毒大流行期间的个人限制，需要通过远程学习来制定 POCUS 教育策略。
我们制作了一个 90 分钟的教学培训课程，通过远程学习格式呈现。主要观察指标是与 POCUS 教员相比，新手超声医师评估 SPB 积液的观察者间可靠性。新手超声医师是儿科急诊医学（PEM）研究员。儿科急诊医学研究员解读了 2013 年 7 月至 2020 年 6 月在我院儿科急诊室获得的纵向 SPB 检查。评估在远程培训后 2 个月进行。儿科急诊医学研究员在进行这些肌肉骨骼扫描方面经验有限，并且对 POCUS 教员和彼此的评估均不知情。观察者间可靠性通过 Cohen κ 系数评估。其次，我们计算了膝关节放射照相术与 PEM POCUS 教员通过超声确定 SPB 积液之间的测试特征。我们进一步探讨了 POCUS 测量的积液大小如何影响膝关节放射照相术的诊断。使用 POCUS 测量的 SPB 积液最大高度作为预测变量，创建了膝关节放射照相术诊断 SPB 积液的受试者工作特征曲线。
共评估了 71 名患者的 116 个 SPB 扫描。在这组中，70 个扫描是受影响的膝关节，46 个扫描是无症状的对侧膝关节。患者的平均年龄为 10 岁，其中 46%为女性。SPB 积液的患病率为 42%。3 名新手超声医师与 POCUS 教员之间的κ系数分别为 0.75（0.62-0.87）、0.77（0.65-0.89）和 0.83（0.72-0.93），一致性为 88%、89%和 91%。膝关节放射照相术的总体敏感性为 65%（95%置信区间[CI]，46-79%），特异性为 84%（95%CI，60-97%），阴性预测值为 55%（95%CI，43-66%），阳性预测值为 88%（95%CI，73-96%），用于诊断 SPB 积液。受试者工作特征曲线下面积为 0.850。当以 4 毫米的 SPB 高度作为真阳性时，放射照相术的敏感性为 81%，特异性为 83%。
在远程电话会议教学会议后，PEM 研究员能够成功使用具有良好观察者间可靠性的纵向视图诊断 SPB 积液。膝关节放射照相术对排除 SPB 积液的敏感性有限。
