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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Aygun E, Aygun ST, Uysal T, Aygun F, Dursun H, Irdem A. Aetiological evaluation of chest pain in childhood and adolescence. Cardiol Young. 30(5):617-623, 2020 May. Review/Other-Dx 782 patients with chest pain To determine the distribution of diseases causing chest pain in children and investigate the clinical characteristics of children with chest pain. Most prevalent causes of chest pain were musculoskeletal system (33%) and psychogenic (28.4%) causes. Chest pain due to cardiac reasons was seen in eight patients (1%). Diseases of musculoskeletal and gastrointestinal systems and psychogenic disorders were significantly more common in male and female patients, respectively (p < 0.001 for all). In winter, patients' age and the number of patients with =12 years were higher than those in other seasons (p < 0.001). Most of the parents (70.8%) and patients (90.2%) thought that chest pain in their children was caused by cardiac causes. 4
2. Huang SW, Liu YK. Pediatric Chest Pain: A Review of Diagnostic Tools in the Pediatric Emergency Department. Diagnostics (Basel). 2024 Mar 01;14(5):526. Review/Other-Dx N/A In this review, we have identified musculoskeletal pain as the most prevalent etiology of chest pain in the pediatric population, accounting for 38.7–86.3% of cases, followed by pulmonary (1.8–12.8%), gastrointestinal (0.3–9.3%), psychogenic (5.1–83.6%), and cardiac chest pain (0.3–8.0%). To avoid the overuse of these diagnostic tools, a well-designed standardized algorithm for pediatric chest pain could decrease unnecessary examination without missing severe diseases. In this review, we have identified musculoskeletal pain as the most prevalent etiology of chest pain in the pediatric population, accounting for 38.7-86.3% of cases, followed by pulmonary (1.8-12.8%), gastrointestinal (0.3-9.3%), psychogenic (5.1-83.6%), and cardiac chest pain (0.3-8.0%). Various diagnostic procedures are commonly used in the emergency department for cardiac chest pain, including electrocardiogram (ECG), chest radiography, cardiac troponin examination, and echocardiography. However, these examinations demonstrate limited sensitivity in identifying cardiac etiologies, with sensitivities ranging from 0 to 17.8% for ECG and 11.0 to 17.2% for chest radiography. 4
3. Powell AW, Pater CM, Chin C, et al. Implementation of a Pediatric Chest Pain Local Consensus Guideline Decreases the Total Tests Performed Without Negatively Affecting the Yield of Abnormal Cardiac Results. Pediatr Cardiol. 41(8):1580-1586, 2020 Dec. Experimental-Dx 1546 The aims of this study are (i) to determine the effect of the newly instituted local consensus guideline on testing ordered; (ii) to examine if the overall yield for pathology changed after local consesus guideline implementation; and (iii) to examine if adding pulmonary function testing to CPET can increase the diagnostic yield in these patients. The hypothesis of this study is that the local consensus guideline will reduce the number of unneccessary tests ordered. There were no significant differences in patient volume or demographic characteristics in the 18 months before (n = 768) and after (n = 778) guideline implementation. There were significant reductions in the number of ordered echocardiograms (n = 131; 17% vs. n = 75; 9.6%, p < 0.001) and cardiopulmonary exercise tests (n = 46; 6% vs. n = 29; 4%, p = 0.04) with no concerning pathology discovered in either group. Associated pulmonary function testing performed prior to with exercise testing discovered abnormalities in 19% of the total patients tested. The implementation of a local consensus guideline for pediatric chest pain results in fewer unnecessary tests ordered. 3
4. Majerus CR, Tredway TL, Yun NK, Gerard JM. Utility of Chest Radiographs in Children Presenting to a Pediatric Emergency Department With Acute Asthma Exacerbation and Chest Pain. Pediatr Emerg Care. 37(7):e372-e375, 2021 Jul 01. Observational-Dx 793 patients, ages 2 to 18 years, presenting for acute asthma exacerbation to the emergency department To evaluate the symptom of chest pain as a predictor for clinicians obtaining a CXR in these patients and to evaluate chest pain as a predictor of a positive CXR finding. Two hundred thirty-one (29.1%) reported chest pain. Chest radiographs were obtained in 184 patients (23.2%). Of those, 74 patients (40.2%) had chest pain and 21 (11.4%) had a positive CXR. Providers were more likely to obtain CXRs in patients who reported chest pain (odds ratio = 2.2 [95% confidence interval = 1.5-3.2]). Patients reporting chest pain were more likely to have a positive CXR although this difference was not statistically significant (odds ratio = 2.0 [95% confidence interval = 0.7-5.6]). 4
5. Chan SS, Kotecha MK, Rigsby CK, et al. ACR Appropriateness Criteria® Pneumonia in the Immunocompetent Child. J Am Coll Radiol 2020;17:S215-S25. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for pneumonia in the immunocompetent child. No results stated in abstract. 4
6. Kane DA, Friedman KG, Fulton DR, Geggel RL, Saleeb SF. Needles in Hay II: Detecting Cardiac Pathology by the Pediatric Chest Pain Standardized Clinical Assessment and Management Plan. Congenit. heart dis.. 11(5):396-402, 2016 Sep. Review/Other-Dx 34 patients with reported chest pain To determine if patients evaluated using the pediatric chest pain standardized clinical assessment and management plan (SCAMP) in cardiology clinic were later diagnosed with unrecognized cardiac pathology, and to determine if other patients with cardiac pathology not enrolled in the SCAMP would have been identified using the algorithm. Among 98 patients with cardiac pathology, 34 (35%) reported chest pain, of whom 10 were diagnosed as outpatients. None of these patients were enrolled in the SCAMP because of alternate chief complaints (n = 4) or referral to BCH for management of the new diagnosis (n = 6). Each of these patients would have had an echocardiogram recommended by retrospective application of the SCAMP algorithm. Two other patients with cardiac pathology were among the 1124 patients assessed by the SCAMP. One patient initially diagnosed with noncardiac chest pain presented 18 months later and was diagnosed with myocarditis as an inpatient. One patient seen initially in the emergency department was subsequently diagnosed with pericarditis as an outpatient. 4
7. Creary SE, Krishnamurti L. Prodromal illness before acute chest syndrome in pediatric patients with sickle cell disease. J Pediatr Hematol Oncol. 36(6):480-3, 2014 Aug. Observational-Dx 196 ACS episodes Acute chest syndrome (ACS) is associated with morbidity and mortality in children with sickle cell disease. We hypothesize that children with sickle cell disease have a distinct prodromal illness before their ACS episode. We identified 196 ACS episodes. Children received prodromal care in 29% of the ACS episodes. Painful vaso-occlusive crisis was a common reason for seeking this care (61%) and was commonly located in the chest or back (81%). We also observed that patients were hypoxic (53%), tachypneic (29%), had a history of asthma (39%) or ACS (80%), and presented during the winter months (38%). 4
8. Bhasin N, Sarode R. Acute Chest Syndrome in Sickle Cell Disease. Transfus Med Rev 2023;37:150755. Review/Other-Tx N/A In this review, we conclude that the development of clinical and laboratory risk stratification is necessary to further study an optimal management strategy for individuals with acute chest syndrom (ACS) to avoid transfusion-related complications while minimizing mortality. This manuscript reviews the pathophysiology, risk factors, and current management strategies for ACS through a review of published data on this subject between 1988 and 2022. Blood transfusion is often used as a therapeutic intervention for ACS to increase blood's oxygen-carrying capacity and reduce complications by reducing hemoglobin S (HbS) percentage, based on the very low quality of the evidence about its efficacy. The benefit of RBC transfusion for ACS has been described in case series and observational studies, but randomized studies comparing simple transfusion vs. exchange transfusions for ACS are lacking. 4
9. Assad Z, Valtuille Z, Rybak A, et al. Unique Changes in the Incidence of Acute Chest Syndrome in Children With Sickle Cell Disease Unravel the Role of Respiratory Pathogens: A Time Series Analysis. Chest 2024;165:150-60. Review/Other-Dx 55,941 hospitalizations of children What is the respective role of respiratory pathogens in ACS epidemiology? Among the 55,941 hospitalizations of children with SCD, 2,306 episodes of ACS were included (median [interquartile range] age, 9 [5-13] years). A significant decrease was observed in ACS incidence after NPI implementation in March 2020 (-29.5%; 95% CI, -46.8 to -12.2; P = .001) and a significant increase after lifting of the NPIs in April 2021 (24.4%; 95% CI, 7.2 to 41.6; P = .007). Using population-level incidence of several respiratory pathogens, Streptococcus pneumoniae accounted for 30.9% (95% CI, 4.9 to 56.9; P = .02) of ACS incidence over the study period and influenza 6.8% (95% CI, 2.3 to 11.3; P = .004); other respiratory pathogens had only a minor role. 4
10. Thacker PG, Lee EY. Advances in Multidetector CT Diagnosis of Pediatric Pulmonary Thromboembolism. [Review]. Korean J Radiol. 17(2):198-208, 2016 Mar-Apr. Review/Other-Dx N/A To review the most recent updates on multidetector computed tomography (MDCT) diagnosis of pediatric pulmonary thromboembolism. No results stated in the abstract. 4
11. Goo HW. Dual-energy lung perfusion and ventilation CT in children. Pediatr Radiol 2013;43:298-307. Review/Other-Dx N/A In this review, imaging protocols, analysis methods, clinical applications and diagnostic pitfalls of dual-energy thoracic computed tomography (CT) for evaluating lung perfusion and ventilation in children are described. Dual-energy thoracic CT provides two key insights into lung physiology, i.e. regional perfusion and ventilation, and has been actively investigated to find clinically relevant applications since the introduction of dual-source CT. This functional information provided by dual-energy thoracic CT is supplementary because high-resolution thoracic anatomy is entirely preserved on dual-energy thoracic CT. In addition, virtual non-contrast imaging can omit pre-contrast scanning. In this respect, dual-energy CT imaging technique is at least dose-neutral, which is a critical requirement for paediatric imaging. 4
12. Rapp JB, Ho-Fung VM, Ramirez KI, White AM, Otero HJ, Biko DM. Dual-source computed tomography protocols for the pediatric chest - scan optimization techniques. Pediatr Radiol 2023;53:1248-59. Review/Other-Dx N/A In this article we discuss the benefits and tradeoffs of dual-source CT scan modes and tips on image optimization. Dual-source CT offers a variety of scan types to be selected based on the appropriate indication, be it for the need to decrease sedation or radiation, or to gather specific functional or diagnostic information. As long as CT remains the mainstay in diagnostic imaging, dual-source CT will continue to play a significant role in the imaging of the pediatric chest. 4
13. Schleifer J, Liteplo AS, Kharasch S. Point-of-Care Ultrasound in a Child with Chest Wall Pain and Rib Osteomyelitis. J Emerg Med 2019;57:550-53. Review/Other-Dx 1 We present thecase of a 26-month-old child with fever and chest wallpain and point-of-care ultrasound (POCUS) demonstrating findings suggestive of acute rib osteomyelitis guiding early diagnosis and treatment. In our patient, POCUS in the ED identified deep soft tissue swelling, periostial elevation, and increased vascular flow with color Doppler, heightening the suspicion for acute osteomyelitis in a rare location and guidingearly diagnosis and treatment 4
14. Ayloo A, Cvengros T, Marella S. Evaluation and treatment of musculoskeletal chest pain. [Review]. Prim Care. 40(4):863-87, viii, 2013 Dec. Review/Other-Dx N/A To summarize the evaluation and treatment of musculoskeletal causes of chest pain. Conditions such as costochondritis, rib pain caused by stress fractures, slipping rib syndrome, chest wall muscle injuries, fibromyalgia, and herpes zoster are discussed, with emphasis on evaluation and treatment of these and other disorders No results stated in the abstract. 4
15. Ngo AV, Kim HHR, Maloney E, et al. Palpable pediatric chest wall masses. [Review]. Pediatr Radiol. 52(10):1963-1973, 2022 09. Review/Other-Dx N/A Here we review the most relevant palpable pediatric chest entities, their expected appearance and the specifc clinical issues to aid in diagnosis and appropriate treatment Palpable pediatric chest wall lesions can cause parental anxiety and clinical concern; however, the majority of these entities are benign. Imaging workup of these lesions usually Fig. 14 Ewing sarcoma arisingfrom the left second rib in an 11-year-old boy. a Posteroanterior chest radiograph obtained for dyspnea demonstrates a large left upper thoracic opacity that partially obscures the left superior mediastinal margin.b Axial contrast-enhanced CT shows a hypodense mass occupying the left upper thorax. Note the irregular osteolysis of the left anterior second rib (arrow) and the subpectoral extrathoracic component of thetumor anteriorly (arrowhead). Coronal positron emission tomography image reveals mild difuse hypermetabolism throughout the mass (arrow) begins with targeted US or radiography, with CT and MRIutilized for problem-solving or to evaluate the extent of disease. Here we reviewed the most relevant palpable pediatric chest entities, their expected appearance and the specifc clinical issues to aid in diagnosis and appropriate treatment. 4
16. Aboughalia HA, Ngo AV, Menashe SJ, Kim HHR, Iyer RS. Pediatric rib pathologies: clinicoimaging scenarios and approach to diagnosis. [Review]. Pediatr Radiol. 51(10):1783-1797, 2021 Sep. Review/Other-Dx N/A To increase pediatric and musculoskeletal radiologists' awareness of the spectrum of disease and how to leverage a pattern-based approach. No results stated in abstract. 4
17. Van Tassel D, McMahon LE, Riemann M, Wong K, Barnes CE. Dynamic ultrasound in the evaluation of patients with suspected slipping rib syndrome. Skeletal Radiol. 48(5):741-751, 2019 May. Observational-Dx 46 patients To describe the development of a reproducible protocol for imaging in patients with Slipping rib syndrome Slipping rib syndrome (SRS). Thirty-six of the 46 patients had a diagnosis of SRS, and had an average age of 17 years. Thirty-one patients were female, 15 were male. Thirty-one out of 46 (67%) were athletes. Average BMI was 22.6. Dynamic ultrasound correctly detected SRS in 89% of patients (32 out of 36) and correctly detected the absence in 100% (10 out of 10). Push maneuver had the highest sensitivity (87%; 0.70, 0.96) followed by morphology (68%; 0.51, 0.81) and crunch maneuver (54%; 0.37, 0.71). Valsalva was the least sensitive (13%; 0.04, 0.29). 2
18. Gasser CR, Pellaton R, Rochat CP. Pediatric Spontaneous Pneumomediastinum: Narrative Literature Review. [Review]. Pediatr Emerg Care. 33(5):370-374, 2017 May. Review/Other-Dx 216 patients To identify the circumstances leading to a spontaneous pneumomediastinum, the most relevant signs and symptoms, investigations, as well as treatment recommendations. Of 216 patients, 66.2% are boys, and mean ages range from 6.9 to 14 years. The most frequent comorbidity in children is asthma (22.2%), and the most common trigger factors are bronchospasm (49%), cough (45.6%), various respiratory tract infections, vomiting (10.3%), and foreign body aspiration (8.3%). It remains idiopathic in 33.3%. Relevant signs are chest pain (54.6%), neck pain and/or sore throat (53.3%), and dyspnea (41.2%). The most relevant sign is palpation of subcutaneous emphysema (66.4%). The classically described Hamman crunch is only present in 11.6%. Chest x-ray provides the right diagnosis in 99.5% of the patients. Pneumothorax is associated in 11.6%. Most patients are hospitalized (88.3%); treatment is based on oxygen therapy, painkillers, and rest. In some series, there can be up to 25.8% of patients requiring intensive care and 5.5% requiring drainage of associated pneumothorax. Survival rate is 92.5%, and long-term follow-up shows normal x-rays after 4 days and no recurrence. 4
19. Ozkale Yavuz O, Ayaz E, Ozcan HN, Oguz B, Haliloglu M. Spontaneous pneumothorax in children: a radiological perspective. Pediatr Radiol 2024;54:1864-72. Review/Other-Dx 39 children To describe the etiologic factors of spontaneous pneumothorax in children from a radiological perspective. Twenty-one patients without underlying lung disease were assessed as primary spontaneous pneumothorax; eight of these 21 patients (38.9%) had subpleural air cysts in the apices/upper lobes of the lung on chest computed tomography (CT). In the remaining 18 patients with secondary spontaneous pneumothorax, the most common causes were respiratory diseases (33.3%), infectious lung diseases (33.3%), interstitial lung diseases (27.7%), and connective tissue diseases (5.5%). The mean age of children with secondary spontaneous pneumothorax was lower than that of children with primary spontaneous pneumothorax (P = 0.002). Recurrences occurred in 11 patients (52.3%) with primary spontaneous pneumothorax and three patients (16.6%) with secondary spontaneous pneumothorax. Bilateral pneumothorax was observed in three of the 18 patients with secondary spontaneous pneumothorax. 4
20. Bakhos CT, Pupovac SS, Ata A, Fantauzzi JP, Fabian T. Spontaneous pneumomediastinum: an extensive workup is not required. J Am Coll Surg 2014;219:713-7. Review/Other-Dx 49 patients To review our experience with this condition and examine the optimal management strategy. Forty-nine patients with spontaneous pneumomediastinum were identified, including 26 male patients (53%). Mean age was 19 ± 9 years. Chest pain was the most common presenting symptom (65%), followed by dyspnea (51%). Forceful coughing (29%) or vomiting (16%) were the most common eliciting factors, and no precipitating event was identified in 41% of patients. Computed tomography was performed in 38 patients (78%) and showed a pneumomediastinum that was not seen on chest x-ray in 9 patients. Esophagography was performed in 17 patients (35%) and was invariably negative for a leak. Thirty-eight patients (78%) were hospitalized for a mean of 1.8 ± 2.6 days. No mortality was recorded. Compared with patients who presented with pneumomediastinum secondary to esophageal perforation, spontaneous pneumomediastinum patients were younger, had a lower white cell count, and were less likely to have a pleural effusion. 4
21. Richer EJ, Sanchez R. Are esophagrams indicated in pediatric patients with spontaneous pneumomediastinum? J Pediatr Surg 2016;51:1778-81. Review/Other-Dx 27 patients To identify whether esophagrams performed on pediatric patients for spontaneous pneumomediastinum are warranted. All esophagrams in patients with both spontaneous and post traumatic pneumomediastinum were negative. Patients were exposed to radiation doses between 61 and 92 µGy m2 during esophagrams. Contrast aspiration occurred in one patient. 4
22. Roby K, Barkach C, Studzinski D, Novotny N, Akay B, Brahmamdam P. Spontaneous Pneumomediastinum is Not Associated With Esophageal Perforation: Results From a Retrospective, Case-Control Study in a Pediatric Population. Clin Pediatr (Phila) 2023;62:1568-74. Review/Other-Dx N/A What is the optimal management of spontaneous pneumomediastinum (SPM) and is there a risk of esophageal perforation in patients with SPM No results stated in abstract. 4
23. Yamada A, Taiji R, Nishimoto Y, et al. Pictorial Review of Pleural Disease: Multimodality Imaging and Differential Diagnosis. Radiographics 2024;44:e230079. Review/Other-Dx N/A To provide a comprehensive review of the clinical and multimodality imaging findings of pleural diseases and their differential diagnoses. No results stated in abstract. 4
24. Trinavarat P, Riccabona M. Potential of ultrasound in the pediatric chest. [Review]. Eur J Radiol. 83(9):1507-18, 2014 Sep. Review/Other-Dx N/A Cover techniques, indications, and applications of chest US in neonates, infants and children No results stated in abstract. 4
25. Volpicelli G, Boero E, Sverzellati N, et al. Semi-quantification of pneumothorax volume by lung ultrasound. Intensive Care Med. 40(10):1460-7, 2014 Oct. Observational-Dx 124 patients with pneumothorax To determine the ability of LUS in the semi-quantification of pneumothorax volume, we compared the projection of the lung point (LP) with the pneumothorax volume measured by computerized tomography (CT) and the interpleural distance on chest radiography (CXR). A total of 124 patients with pneumothorax were enrolled (76 spontaneous, 20 traumatic and 28 post-procedural). Ninety-four CXR and 58 CT were available for the analysis. An LP posterior to the mid axillary line corresponded to three different CXR criteria for large pneumothorax with sensitivity from 81.4 to 88.2 % and specificity from 64.7 to 72.6 %. The mid axillary line also represented the limit for predicting greater than 15 % of lung collapse when volume is measured at CT, with sensitivity 83.3 % and specificity 82.4 %. 1
26. Basaran AE, Basaran A, Durmus SY, Kazli T, Keven A, Bingol A. Analysis of predictive factors in children with high suspicion of pulmonary embolism. Pediatr Pulmonol. 59(2):274-280, 2024 Feb. Observational-Dx 110 patients To identify the predictive factors for PE and assess the effectiveness of the PERC, Wells, and pediatric-specific PE (PPE) criteria. Of the 110 patients included in the study, 27 (24.5%) had PE. Saturation, albumin, cough, calf swelling, central catheter, and malignancy were found to significantly contribute to the model. The total weighted risk score, which represents the sum of all predictive scores, ranged from 0 to 16 with a mean of 5.41 ± 4.02. When the cut-off >6.5, the model had good discrimination power for positive PE (AUC 0.79, 77% sensitivity, and 70% specificity). In our study, the Wells criteria showed a sensitivity of 96% and a specificity of 24%. The PERC exhibited a sensitivity of 96% and a specificity of 21%, while the PPE demonstrated a sensitivity of 74% and a specificity of 30%. 4
27. Sharaf N, Sharaf VB, Mace SE, Nowacki AS, Stoller JK, Carl JC. D-dimer in Adolescent Pulmonary Embolism. Acad Emerg Med. 25(11):1235-1241, 2018 11. Observational-Dx 88 patients PE-positive, 88 patients with both CT negative for PE To evaluate D-dimer in PE-positive and PE-negative adolescents. Ages of PE-positive patients ranged from 13 to 21 years, 64 (73%) were female, and 52 (60%) were Caucasian. Mean D-dimer was significantly higher (3,256 ng/mL, 95% confidence interval [CI] = 2,505-4,006 ng/mL) in PE-positive versus PE-negative patients (1,244 ng/mL, 95% CI = 493-1,995 ng/mL; p < 0.001). Mean D-dimer was higher in patients with massive or submassive PE (8,742 ng/mL, 95% CI = 5,994-11,491 ng/mL), followed by PE in central (4,795 ng/mL [95% CI = 3,465-6,125 ng/mL), lobar (3,758 ng/mL [95% CI = 1,841-5,676), and distal (2,327 ng/mL [95% CI = 1,273-3,381 ng/mL]) arteries. When comparing thresholds of positive D-dimer (=500, =750, and =1,000 ng/mL), D-dimer had sensitivities of 90, 82, and 67% and specificities of 16, 53, and 67%, respectively. Negative predictive values were 61, 75, and 71% while positive likelihood ratios were 1.1, 1.8, and 2.2, respectively. 4
28. Degerstedt SG, Winant AJ, Lee EY. Pediatric Pulmonary Embolism: Imaging Guidelines and Recommendations. [Review]. Radiol Clin North Am. 60(1):69-82, 2022 Jan. Review/Other-Dx N/A To present an up-to-date review of imaging techniques, characteristic radiologic findings, and an evidence-based algorithm for the detection of pediatric pulmonary embolism to improve the care of pediatric patients with suspected pulmonary embolism. PE is more common than previously thought in children and young adults, associated with signif-icant morbidity and mortality, and remains a clini-cally challenging diagnosis owing to nonspecific symptoms and variable clinical presentation of PE in children. There is a relative paucity of diag-nostic algorithms for pediatric PE; however, the use of a pediatric-specific risk factor analysis can help to streamline the diagnostic approach and avoid unnecessary exposure to ionizing radiation in the vulnerable pediatric population. Although CTPA is the preferred imaging modality in diag-nosing PE, MRA may be a suitable alternative cross-sectional modality in certain clinical circum-stances. Both of these modalities may provide an alternative diagnosis if PE is clinically suspected, but excluded. Advancements in imaging, such as dual-energy CT scans, also provide functional in-formation and increase diagnostic yield, without substantial increase in radiation exposure. 4
29. Lee EY, Tse SK, Zurakowski D, et al. Children suspected of having pulmonary embolism: multidetector CT pulmonary angiography--thromboembolic risk factors and implications for appropriate use. Radiology. 262(1):242-51, 2012 Jan. Observational-Dx 227 pediatric patients who underwent CT pulmonary angiography for clinically suspected PE To evaluate thromboembolic risk factors for pulmonary embolism (PE) detected by using computed tomographic (CT) pulmonary angiography in children and to determine whether such information could be used for more appropriate use of CT pulmonary angiography in this patient population. Thirty-six (16%) of 227 CT pulmonary angiography studies were positive for PE. Five risk factors, including immobilization (P < .001), hypercoagulable state (P = .003), excess estrogen state (P = .002), indwelling central venous line (P < .001), and prior PE and/or deep venous thrombosis (P < .001), were found to be significant independent risk factors for PE. With use of two or more risk factors as the clinical threshold, the sensitivity of a positive PE result was 89% (32 of 36 patients), and the specificity was 94% (180 of 191 patients). 3
30. Rajpurkar M, Biss T, Amankwah EK, et al. Pulmonary embolism and in situ pulmonary artery thrombosis in paediatrics. A systematic review. Thromb Haemost 2017;117:1199-207. Review/Other-Dx 192 articles To systematically review the current literature on childhood PE and conducted a search on paediatric PE via PubMed (1946-2013) and Embase (1980-2013). There was significant heterogeneity in reported data. Two patterns were noted: classic thromboembolic PE (TE-PE) and in situ pulmonary artery thrombosis (ISPAT). Mean age of presentation for TE-PE was 14.86 years, and 51 % of cases were males. The commonest method for diagnosis of TE-PE was contrast CT with angiography (74 % of patients). The diagnosis of TE-PE was often delayed. Although 85 % of children with TE-PE had an elevated D-dimer at presentation, it was non-discriminatory for the diagnosis. In paediatric TE-PE, the prevalence of central venous catheters was 23 %, immobilisation 38 %, systemic infection 31 % and obesity 13 %, elevated Factor VIII or von Willebrand factor levels 27 %, Protein C deficiency 17 %, Factor V Leiden 14 % and Protein S deficiency 7 %. In patients with TE-PE, pharmacologic thrombolysis was used in 29 %; unfractionated heparin was the most common initial anticoagulant treatment in 64 % and low-molecular-weight heparins the most common follow-up treatment in 83 %. Duration of anticoagulant therapy was variable and death was reported in 26 % of TE-PE patients. In contrast to TE-PE, patients with ISPAT were not investigated systematically for presence of thrombophilia, had more surgical interventions as the initial management and were often treated with anti-platelet medications. 4
31. Woodard PK, Ho VB, Akers SR, et al. ACR Appropriateness Criteria® Known or Suspected Congenital Heart Disease in the Adult. J Am Coll Radiol 2017;14:S166-S76. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for known or suspected congenital heart disease. No results stated in abstract. 4
32. Li X, Chen GZ, Zhao YE, et al. Radiation Optimized Dual-source Dual-energy Computed Tomography Pulmonary Angiography: Intra-individual and Inter-individual Comparison. Acad Radiol. 24(1):13-21, 2017 01. Observational-Dx 33 This study aimed to intra-individually and inter-individually compare image quality, radiation dose, and diagnostic accuracy of dual-source dual-energy computed tomography pulmonary angiography (CTPA) protocols in patients with suspected pulmonary embolism (PE). Mean computed tomography (CT) values of pulmonary arteries were higher in group A than group B (P = .006). There was no difference in signal-to-noise ratio and contrast-to-noise ratio between the two groups (both P > .05). Interobserver agreement for evaluating subjective image quality of CTPA and color-coded perfusion images was either good (? = 0.784) or excellent (? = 0.887). Perfusion defect scores and diagnostic accuracy of CTPA showed no difference between both groups (both P > .05). Effective dose of group A was reduced by 45.8% compared to group B (P < .001) 1
33. Weidman EK, Plodkowski AJ, Halpenny DF, et al. Dual-Energy CT Angiography for Detection of Pulmonary Emboli: Incremental Benefit of Iodine Maps. Radiology. 289(2):546-553, 2018 11. Observational-Dx 1035 To determine if there is added benefit of using iodine maps from dual-energy (DE) CT in addition to conventional CT angiography images to diagnose pulmonary embolism On 147 of 1144 (12.8%) CT angiograms, a total of 372 PEs were detected at initial review. After review of the DE CT iodine map, 27 additional PEs were found on 26 of 1144 CT angiograms (2.3%; 95% confidence interval [CI]: 1.5%, 3.3%). Of the 27 additional PEs, six (22.2%) were segmental, 21 (77.8%) were subsegmental, 24 (88.9%) were occlusive, and three (11.1%) were nonocclusive. Eleven of 1144 (1.0%; 95% CI: 0.5%, 1.7%) CT angiograms had a new diagnosis of PE after review of the DE CT iodine maps. 2
34. Kirsch J, Brown RKJ, Henry TS, et al. ACR Appropriateness Criteria® Acute Chest Pain-Suspected Pulmonary Embolism. J Am Coll Radiol 2017;14:S2-S12. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for acute chest pain-suspected pulmonary embolism. No results stated in abstract. 4
35. Angoff GH, Kane DA, Giddins N, et al. Regional implementation of a pediatric cardiology chest pain guideline using SCAMPs methodology. Pediatrics. 132(4):e1010-7, 2013 Oct. Observational-Dx 1016 ambulatory patients ages 7 to 21 years initially seen for chest pain To describe validation throughout New England of a clinical guideline for cost-effective evaluation of pediatric patients first seen by a cardiologist for chest pain using a unique methodology termed the Standardized Clinical Assessment and Management Plans (SCAMPs). Two patients had chest pain due to a cardiac etiology, 1 with pericarditis and 1 with an anomalous coronary artery origin. Testing performed outside of guideline recommendations demonstrated only incidental findings. Patients returning for persistent symptoms did not have cardiac disease. The pattern of care for the NECCA practices and BCH differed minimally. 3
36. Harahsheh AS, O'Byrne ML, Pastor B, Graham DA, Fulton DR. Pediatric Chest Pain-Low-Probability Referral: A Multi-Institutional Analysis From Standardized Clinical Assessment and Management Plans (SCAMPs R), the Pediatric Health Information Systems Database, and the National Ambulatory Medical Care Survey. Clin Pediatr (Phila). 56(13):1201-1208, 2017 Nov. Review/Other-Dx N/A We conducted a study to assess test characteristics of red-flag criteria for identifying cardiac disease causing chest pain and technical charges of low-probability referrals We compared incidence of cardiac disease causing chest pain between these 2 groups. Technical charges of Group 2 were analyzed using the Pediatric Health Information System database. Potential savings for the US population was estimated using National Ambulatory Medical Care Survey data. Fifty-two percent of subjects formed Group 1. Cardiac disease causing chest pain was identified in 8/1656 (0.48%). No heart disease was identified in patients in Group 2 ( P = .03). Applying red-flags in determining need for referral identified patients with cardiac disease causing chest pain with 100% sensitivity. Median technical charges for Group 2, over a 4-year period, were US2014$775 559. Eliminating cardiac testing of low-probability referrals would save US2014$3 775 182 in technical charges annually. Red-flag criteria were an effective screen for children with chest pain. Eliminating cardiac testing in children without red-flags for referral has significant technical charge savings. 4
37. Nguyen T, Fundora MP, Welch E, et al. Application of the Pediatric Appropriate Use Criteria for Chest Pain. Journal of Pediatrics. 185:124-128, 2017 06.J Pediatr. 185:124-128, 2017 06. Review/Other-Dx 772 outpatient TTE studies To characterize the subgroup of outpatient pediatric patients presenting with chest pain and to determine the effectiveness of published pediatric appropriate use criteria (PAUC) to detect pathology. Chest pain was the primary indication in 772 of 4562 outpatient TTE studies (17%) (median age 14 years, IQR 10-16) ordered during the study period: 458 of 772 before (59%) and 314 of 772 after (41 %) the release of PAUC with no change in appropriateness. In A indications (n?=?654), 642 (98%) were normal, 5 (1%) had incidental findings, and 7 (1%) were abnormal. A and M detected 100% of all abnormal findings (A: n?=?7; M: n?=?6; R: n?=?0), with an association between ratings and findings (P?<.001). There was no association between R rating and any pathology. 4
38. Chamberlain RC, Pelletier JH, Blanchard S, Hornik CP, Hill KD, Campbell MJ. Evaluating Appropriate Use of Pediatric Echocardiograms for Chest Pain in Outpatient Clinics. J Am Soc Echocardiogr. 30(7):708-713, 2017 Jul. Observational-Dx 539 patients 18 years or younger undergoing an initial evaluation for chest pain To evaluate the frequency and diagnostic yield of echocardiograms performed for each AUC indication and cost associated with echocardiograms performed for indications meeting the "rarely appropriate" criteria. The cohort included 539 patients, median age 13 years (range, 3-18) and 51.0% female. With retrospective application of the AUC, echocardiogram indications were classified as "appropriate" (304/539, 56.4%), "maybe appropriate" (68/539, 12.6%), and "rarely appropriate" (167/539, 31.0%). Echocardiograms were performed in 70.5% (380/539) of patients overall and in 35.9% (60/167) of patients with "rarely appropriate" indications. Of those undergoing echocardiography, abnormal findings were present in 5.0% (19/380) and incidental findings in 2.6% (10/380); however, only one echocardiogram (0.3%) led to a diagnosis considered to be contributory to the patient's chest pain. There were no abnormal findings in the "rarely appropriate" subgroup. Provider use of echocardiography for "rarely appropriate" indications varied widely from 0 to 75% across 15 providers (P = .004). In multivariable analysis, provider clinical experience of =20 years was associated with a lower rate of echocardiograms for "rarely appropriate" indications (odds ratio, 0.21 [95% CI, 0.09-0.47] vs. providers with <10 years' experience, P < .001). There was no significant association between race, ethnicity, age, sex, payer status, or total number of patients seen and performance of an echocardiogram meeting the "rarely appropriate" indications. Echocardiograms with "rarely appropriate" indications resulted in $47,578 in excess costs over the 1-year study. 3
39. Kamra K, Russell I, Miller-Hance WC. Role of transesophageal echocardiography in the management of pediatric patients with congenital heart disease. Paediatr Anaesth 2011;21:479-93. Review/Other-Dx N/A The role of TEE in routine management of pediatric cardiac patient population with focus on indications, views, applications and technological advances. No results stated in abstract. 4
40. Tessitore A, Caiffa T, Bobbo M, D'Agata Mottolese B, Barbi E, Chicco D. Anomalous aortic origin of coronary artery: For a challenging diagnosis, a transthoracic echocardiogram is recommended. [Review]. Acta Paediatr. 111(2):265-268, 2022 Feb. Review/Other-Dx N/A To provide advice on clinical red flags and diagnostic approaches for general paediatricians since identifying an anomalous aortic origin of coronary artery (AAOCA) is challenging. Anomalous aortic origin of a coronary artery (AAOCA), especially the interarterial course of the right or left coronary artery, predisposes paediatric patients to myocardial ischaemia. This rare condition is a leading cause of sudden cardiac death. General paediatricians face challenges when diagnosing this anomaly, and they should pay particular attention to the recurrence of exercise-related syncope without prodromal symptoms, chest pain and dyspnoea. An accurate transthoracic echocardiogram with Doppler colour flow mapping is the best method to use to identify AAOCA. 4
41. Eisenbrown K, Nimmer M, Ellison AM, Simpson P, Brousseau DC. Which Febrile Children With Sickle Cell Disease Need a Chest X-Ray? Acad Emerg Med 2016;23:1248-56. Review/Other-Dx 185 To provide data informing the decision of which febrile children with SCD presenting to the emergency department (ED) require a CXR to evaluate for acute chest syndrome (ACS). A total of 185 (10%) of 1,837 febrile ED visits met ACS criteria. The current National Heart, Lung, and Blood Institute (NHLBI) consensus criteria for obtaining a CXR (shortness of breath, tachypnea, cough, or rales) identified 158 (85%) of ACS cases, while avoiding 825 CXRs. Obtaining a CXR in children with NHLBI criteria or chest pain and in children without those symptoms but with a white blood cell (WBC) count =18.75 × 109 /L or a history of ACS identified 181 (98%), while avoiding 430 CXRs. 4
42. Measuring Sex, Gender Identity, and Sexual Orientation. Review/Other-Dx N/A Sex and gender are often conflated under the assumptions that they are mutually determined and do not differ from each other; however, the growing visibility of transgender and intersex populations, as well as efforts to improve the measurement of sex and gender across many scientific fields, has demonstrated the need to reconsider how sex, gender, and the relationship between them are conceptualized. No abstract available. 4
43. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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