Effusion In Pediatric Patients Research Articles

XRAInet: AI-based decision support for pneumothorax and pleural effusion management.

This study aimed to develop and assess the performance of an artificial intelligence(AI)-driven decision support system, XRAInet, in accurately identifying pediatric patients with pleural effusion or pneumothorax and determining whether tube thoracostomy intervention is warranted. In this diagnostic accuracy study, we retrospectively analyzed a data set containing 510 X-ray images from 170 pediatric patients admitted between 2005 and 2022. Patients were categorized into two groups: Tube (requiring tube thoracostomy) and Conservative (managed conservatively). XRAInet, a deep learning-based algorithm, was trained using this data set. We evaluated its performance using various metrics, including mean Average Precision (mAP), recall, precision, and F1 score. XRAInet, achieved a mAP score of 0.918. This result underscores its ability to accurately identify and localize regions necessitating tube thoracostomy for pediatric patients with pneumothorax and pleural effusion. In an independent testing data set, the model exhibited a sensitivity of 64.00% and specificity of 96.15%. In conclusion, XRAInet presents a promising solution for improving the detection and decision-making process for cases of pneumothorax and pleural effusion in pediatric patients using X-ray images. These findings contribute to the expanding field of AI-driven medical imaging, with potential applications for enhancing patient outcomes. Future research endeavors should explore hybrid models, enhance interpretability, address data quality issues, and align with regulatory requirements to ensure the safe and effective deployment of XRAInet in healthcare settings.

DraiNet: AI-driven decision support in pneumothorax and pleural effusion management.

This study presents DraiNet, a deep learning model developed to detect pneumothorax and pleural effusion in pediatric patients and aid in assessing the necessity for tube thoracostomy. The primary goal is to utilize DraiNet as a decision support tool to enhance clinical decision-making in the management of these conditions. DraiNet was trained on a diverse dataset of pediatric CT scans, carefully annotated by experienced surgeons. The model incorporated advanced object detection techniques and underwent evaluation using standard metrics, such as mean Average Precision (mAP), to assess its performance. DraiNet achieved an impressive mAP score of 0.964, demonstrating high accuracy in detecting and precisely localizing abnormalities associated with pneumothorax and pleural effusion. The model's precision and recall further confirmed its ability to effectively predict positive cases. The integration of DraiNet as an AI-driven decision support system marks a significant advancement in pediatric healthcare. By combining deep learning algorithms with clinical expertise, DraiNet provides a valuable tool for non-surgical teams and emergency room doctors, aiding them in making informed decisions about surgical interventions. With its remarkable mAP score of 0.964, DraiNet has the potential to enhance patient outcomes and optimize the management of critical conditions, including pneumothorax and pleural effusion.

Quantitative transmastoid ultrasound for detecting middle ear effusion in pediatric patients

Background and objectiveUltrasound has emerged as a promising modality for detecting middle ear effusion (MEE) in pediatric patients. Among different ultrasound techniques, ultrasound mastoid measurement was proposed to allow noninvasive detection of MEE by estimating the Nakagami parameters of backscattered signals to describe the echo amplitude distribution. This study further developed the multiregional-weighted Nakagami parameter (MNP) of the mastoid as a new ultrasound signature for assessing effusion severity and fluid properties in pediatric patients with MEE. MethodsA total of 197 pediatric patients (n = 133 for the training group; n = 64 for the testing group) underwent multiregional backscattering measurements of the mastoid for estimating MNP values. MEE, the severity of effusion (mild to moderate vs. severe), and the fluid properties (serous and mucous) were confirmed through otoscopy, tympanometry, and grommet surgery and were compared with the ultrasound findings. The diagnostic performance was evaluated using the area under the receiver operating characteristic curve (AUROC). ResultsThe training dataset revealed significant differences in MNPs between the control and MEE groups, between mild to moderate and severe MEE, and between serous and mucous effusion were observed (p < 0.05). As with the conventional Nakagami parameter, the MNP could be used to detect MEE (AUROC: 0.87; sensitivity: 90.16%; specificity: 75.35%). The MNP could further identify effusion severity (AUROC: 0.88; sensitivity: 73.33%; specificity: 86.87%) and revealed the possibility of characterizing fluid properties (AUROC: 0.68; sensitivity: 62.50%; specificity: 70.00%). The testing results demonstrated that the MNP method enabled MEE detection (AUROC = 0.88, accuracy = 88.28%, sensitivity = 92.59%, specificity = 84.21%), was effective in assessing MEE severity (AUROC = 0.83, accuracy = 77.78%, sensitivity = 66.67%, specificity = 83.33%), and showed potential for characterizing fluid properties of effusion (AUROC = 0.70, accuracy = 72.22%, sensitivity = 62.50%, specificity = 80.00%). ConclusionsTransmastoid ultrasound combined with the MNP not only leverages the strengths of the conventional Nakagami parameter for MEE diagnosis but also provides a means to assess MEE severity and effusion properties in pediatric patients, thereby offering a comprehensive approach to noninvasive MEE evaluation.

Analysis of factors that influence the occurrence of otitis media with effusion in pediatric patients with adenoid hypertrophy.

Adenoid hypertrophy (AH) and otitis media with effusion (OME) are common pediatric otolaryngological diseases and often occur concurrently. The purpose of this study was to comprehensively analyze the factors that influence the occurrence of OME pediatric patients with AH. Patients younger than 12 years with AH, who were hospitalized for treatment at Beijing Tsinghua Changgung Hospital in Beijing, China, between March 2018 and February 2022 were enrolled. The patients were divided into an AH group and an AH + OME group based on the presence of OME. The authors collected the following clinical data for univariable analysis: sex; age; body mass index (BMI); comorbid nasal congestion/rhinorrhea, recurrent tonsillitis, or allergic rhinitis (AR); adenoid and tonsil grade; tonsillar hypertrophy; food/drug allergy; history of adenoidectomy and congenital diseases; breastfeeding status; preterm birth; exposure to environmental tobacco smoke (ETS); family history of adenotonsillectomy, otitis media, and AR; main data of polysomnography and oropharyngeal conditional pathogen culture data of some patients. Univariate analysis was performed as a basis for logistic regression analysis. A total of 511 children (329 boys and 182 girls) were included, their mean age was 5.37 ± 2.10 years. Of them, 407 (79.6%) were in the AH group and 104 (20.4%) in the AH + OME group. Univariate analysis revealed statistically significant differences in age, BMI, adenoid grade, AR, breastfeeding status, and ETS exposure between the two groups. Multivariate stepwise logistic regression analysis showed that age, adenoid grade, AR, breastfeeding status, and ETS influenced the occurrence of OME in pediatric patients with AH. The risk of OME decreased with increasing age. High adenoid grade, ETS exposure, and comorbid AR were risk factors for OME in pediatric patients with AH, but breastfeeding was a protective factor. The final analytical results of the oropharyngeal conditional pathogen culture data showed that Streptococcus pneumoniae positivity was associated with OME in AH. The pathogenesis of AH with OME is complex. Young age, high adenoid grade, ETS exposure, non-breastfed status, comorbid AR, and the presence of S. pneumoniae in the oropharynx are risk factors for OME in pediatric patients with AH.

Prognosis of otitis media with effusion in pediatric patients with cleft palate during language-acquisition period treated by simultaneous tympanostomy tube placement with palatoplasty

ObjectiveCleft palate (CP) in children is frequently complicated by otitis media with effusion (OME) due to Eustachian tube dysfunction. Although tympanostomy tube (TT) placement can be beneficial in the treatment of OME to prevent short-term hearing loss, there is no consensus regarding the indications for and timing of TT insertion. The present study was performed to define the safety and effectiveness of simultaneous TT placement with palatoplasty during the language-acquisition period. MethodsWe retrospectively reviewed the medical charts of pediatric patients who underwent palatoplasty for CP in a tertiary medical center, Kyoto University Hospital, from June 2010 to October 2018. The TT retention time was estimated using the Kaplan-Meier method. The incidence of OME recurrence was compared among four Veau classification groups based on the patients' sex, type of CP, median TT retention time, and type of fluid. ResultsSeventy-six subjects (150 ears) were enrolled in the study. The median follow-up duration was 48.7 months (range, 18.2–108.0 months) after the first TT placement. A first TT retention time of <20.1 months was a significant risk factor for OME recurrence. Subjects with maxillofacial anomaly complex and subjects with cleft lip and palate and an alveolar cleft showed a significantly higher OME recurrence rate than subjects with clefts only in the hard and/or soft palate. There was no significant difference in the occurrence of sequelae between subjects with only a single TT placement and subjects with more than one TT placement. ConclusionsBased on the findings of the present study, it is reasonable to perform TT insertion at the same time as palatoplasty on patients who meet the indications. This technique may reduce the number of times the patient requires general anesthesia and maintain good middle ear condition during the period of language acquisition between 1 and 3 years of age.

Machine Learning for Accurate Intraoperative Pediatric Middle Ear Effusion Diagnosis.

Misdiagnosis of acute and chronic otitis media in children can result in significant consequences from either undertreatment or overtreatment. Our objective was to develop and train an artificial intelligence algorithm to accurately predict the presence of middle ear effusion in pediatric patients presenting to the operating room for myringotomy and tube placement. We trained a neural network to classify images as " normal" (no effusion) or "abnormal" (effusion present) using tympanic membrane images from children taken to the operating room with the intent of performing myringotomy and possible tube placement for recurrent acute otitis media or otitis media with effusion. Model performance was tested on held-out cases and fivefold cross-validation. The mean training time for the neural network model was 76.0 (SD ± 0.01) seconds. Our model approach achieved a mean image classification accuracy of 83.8% (95% confidence interval [CI]: 82.7-84.8). In support of this classification accuracy, the model produced an area under the receiver operating characteristic curve performance of 0.93 (95% CI: 0.91-0.94) and F1-score of 0.80 (95% CI: 0.77-0.82). Artificial intelligence-assisted diagnosis of acute or chronic otitis media in children may generate value for patients, families, and the health care system by improving point-of-care diagnostic accuracy. With a small training data set composed of intraoperative images obtained at time of tympanostomy tube insertion, our neural network was accurate in predicting the presence of a middle ear effusion in pediatric ear cases. This diagnostic accuracy performance is considerably higher than human-expert otoscopy-based diagnostic performance reported in previous studies.

Agreement With Pediatric Suprapatellar Bursa Effusion Assessments by Point-of-Care Ultrasound After Remote Training.

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.

Effects of Systemic Steroid Administration on Recurrence of Pericardial Effusion in Pediatric Patients After Hematopoietic Stem Cell Transplantation

Although rare in the general pediatric population, the incidence of pericardial effusion is significantly higher in pediatric patients undergoing hematopoietic stem cell transplant (HCT) with a reported incidence of up to 16.9%. The development of pericardial effusion in this setting is associated with higher mortality. Although pericardiocentesis is a relatively safe procedure for treating pericardial effusion, it is invasive, painful, and exposes an immunosuppressed patient to the risks of infection, bleeding, and injury to surrounding structures. Given the procedural risks of pericardiocentesis, systemic steroids are often administered for the treatment of pericardial effusion given their use for pericarditis in the general population. However, the effectiveness of systemic steroids for the treatment of pericardial effusion in the pediatric HCT population has not been confirmed. We studied the role of systemic steroids, administered at the time of initial pericardiocentesis performed for pericardial effusion, in preventing repeat pericardiocentesis. A total of 37 pericardiocenteses after HCT were performed during the study period with 25 patients undergoing first-time pericardiocentesis and 15 of those patients receiving systemic steroids. Eight patients required repeat pericardiocentesis; 5 of 15 (33%) received steroids and 3 of 10 (30%) did not receive steroids. Our data in this small cohort of pediatric HCT patients did not show a significant difference in the need for repeat pericardiocentesis with the use of systemic steroids, initiated within 48 hours of pericardiocentesis.

Microbiological Results From Middle Ear Effusion in Pediatric Patients Receiving Ventilation Tube Insertion: Multicenter Registry Study on the Effectiveness of Ventilation Tube Insertion in Pediatric Patients With Chronic Otitis Media With Effusion: Part I.

ObjectivesThe aim of this multicenter registry study was to investigate the effectiveness of ventilation tube insertion and the microbiology of otitis media with effusion (OME) in children. This part I study was conducted to evaluate the microbiological profile of children with OME who needed ventilation tube insertion.MethodsPatients <15 years old who were diagnosed as having OME and received ventilation tube insertion were prospectively enrolled in 16 tertiary hospitals from June 2014 to December 2016. After excluding patients with missing data, the data of 397 patients were analyzed among a total of 433 enrolled patients. The clinical symptoms, findings of the tympanic membrane, hearing level, and microbiological findings were collected.ResultsIn 103 patients (25.9%), antibiotics were used within 3 weeks before surgery. Ventilation tube insertion was performed in a total of 710 ears (626 in both ears in 313 patients, 55 in the left ear only, and 29 in the right ear only). Culture of middle ear effusion was done in at least one ear in 221 patients (55.7%), and in a total of 346 ears. Only 46 ears (13.3%) showed positive results in middle ear effusion culture. Haemophilus influenzae (17.3%, followed by coagulase-negative Staphylococcus and Staphylococcus auricularis) was the most common bacteria detected.ConclusionH. influenzae was the most commonly found bacteria in middle ear effusion. Relatively low rates of culture positivity were noted in middle ear effusion of patients with OME in Korea.

Incidence and Outcome of Pericardial Effusion in Pediatric Patients After Hematopoietic Stem Cell Transplant: A Single-institution Experience.

Pericardial effusion (PE) is a known complication after hematopoietic stem cell transplant (HSCT). Limited data is currently available regarding the incidence and outcomes of PE in pediatric HSCT. We conducted a retrospective study on a cohort of patients who underwent HSCT between 2004 and 2015. Risk factors associated with development of PE were evaluated. In 111 HSCT, stem cell source was bone marrow in 37 (33.3%), peripheral blood-42 (37.8%) and cord blood-32 (28.8%). Incidence of PE after HSCT was 37.8%. Insignificant effusion (trivial or small) was noted in 30 (27.0%) transplants, and significant (moderate or large) PE in 12 (10.8%). There were no associations between incidence of effusion and stem cell source, graft versus host disease or CMV infection. Risk factors associated with development of PE included systemic hypertension (P<0.05), total body irradiation (P<0.05), and sinusoidal obstruction syndrome formerly known as venoocclusive disease (P=0.03). Overall mortality was 22.5% after HSCT, but 38.1% among those with effusion (P<0.05). None of these deaths were attributed to primary cardiac etiologies. The incidence of PE in this cohort of pediatric HSCT recipients is high and associated with higher morbidity and mortality.

Clinicopathologic analysis of malignant effusions in pediatric patients

The utility of cytologic evaluation of effusion fluids in adults is well established but has been less well documented in the pediatric population. We examined the clinicopathologic characteristics of children with malignant effusions to establish the value of cytologic examination of these specimens. Pleural, pericardial, peritoneal, and intraoperative washing specimens obtained between January 2000 and October 2015 were identified via surgical pathology database search. Relevant clinical and pathologic data was recorded. Statistical analysis of patient groups was performed via two-sided heteroscedastic Student t tests, and Kaplan-Meier analysis was used to compare overall survival between patient groups. 474 effusion/washing specimens obtained from 342 patients were identified: 179 pleural effusions, 220 peritoneal fluids, 28 pericardial effusions, and 47 intraoperative washing specimens. Of these, 13.7% (56 of 474) effusion specimens were positive for malignancy. Among cancer patients with effusions, malignant effusions were seen in 54.5% of patients with rhabdomyosarcoma and 28.8% of patients with hematolymphoid malignancies. Regarding patient outcomes, malignant effusions were associated with statistically significantly shorter overall survival (P = 0.019). When compared with stage IV patients with benign effusions, those with malignant effusions had a shorter 5-year overall survival (P = 0.042); multiple malignant effusions were associated with a dramatically shorter survival than a single malignant effusion. The overall rate of malignant effusions in our patient population was 13.7%. Malignant effusions in children, particularly multiple, portend a poor prognosis. Our observations emphasize the importance of accurate cytologic diagnosis of effusion fluids, and reinforce the value of their cytologic evaluation.

Real-time ultrasound-guided placement of a pigtail catheter in supine position for draining pleural effusion in pediatric patients who have undergone liver transplantation.

Ultrasound (US) guidance is currently used for placement of wire-guided thoracic drains, and its use is associated with a decreased risk of complications. However, most studies conducted to date in this field have been performed on adult patients. The aim of this study was to report the technical success and complication rates observed during real-time US-guided placement of a thoracic pigtail catheter in pediatric liver-transplant recipients with symptomatic pleural effusion. This was a single-center retrospective review of the clinical records and images from pediatric liver-transplant patients with symptomatic pleural effusion who had undergone real-time US-guided pleural-space puncture followed by placement (via the Seldinger technique) of a pigtail catheter for drainage, between May 2006 and June 2014. We identified 25 patients who had undergone 41 pigtail catheter-placement procedures during the study period. The patients' mean age (± SD) was 4.2 ± 3.9 years (range, 2 months to 16 years), and their mean weight was 14.2 ± 7.2 kg (range, 4.5-33 kg). Seventeen procedures had been performed in the intensive care unit, and 8, in patients undergoing mechanical ventilation. Twelve of the 41 procedures had been performed in patients with altered hemostasis (ie, platelet count < 50 × 10(3) /μl and/or international normalized ratio > 1.5). The size of the pigtail catheters ranged from 5 F to 8.5 F. The technical success rate was 100%, with no major complications such as pneumothorax or hemothorax. Accidental dislocation of the catheter occurred in four patients (9%) over 3-10 days after the first procedure. In our experience, real-time US-guided pleural-space puncture, performed at bedside, with the patient in the supine position, followed by placement of a pigtail catheter for drainage of effusion, is safe to use and has a high rate of technical success in pediatric patients. © 2015 Wiley Periodicals, Inc. J Clin Ultrasound 44:284-289, 2016.

Pleural effusion in pediatric patients submitted to liver transplantation: ultrasound and radiological assessment

ObjectiveTo evaluate the ability of bedside lung ultrasound todiagnose and quantify pleural effusion in pediatricpatients submitted to liver transplantation, in compari-son with supine chest radiograph.Patients and methods30 pediatric patients (mean age: 36 months, mean PIM211%) with end stage liver failure submitted to livertransplantation from living/dead donor (split). All thepatients during the first three postoperative days weresubmitted to supine chest radiograph and bedside lungultrasound, during mechanical ventilation or NIV.Three measurements were made in first, second, andthird postoperative day: chest x-ray was performed witha portable set; bedside lung ultrasound detected thepleural effusion at the PLAPS (posterolateral alveolar orpleural syndromes) point. The depth of the pleural effu-sion was evaluated according with the quad sign: thespace outlined between the pleural line and the pulmon-ary line (indicating the visceral pleura).Atelectasis, lung consolidation and pleural effusion arecommon in pediatric patients submitted to liver transplan-tation during the first postoperative days: chest radiographshowed to lack sensitivity in detecting pleural effusion andin differentiating atelectasis from pleural effusion, which iseasy instead with lung ultrasound.Ultrasound can detect the echogenicity of the effusionand help to assess the nature of it, measuring also itseffective volume.Statistically lung ultrasound has better sensitivity (80%)and specificity (90%), compared to chest radiograph,respectively 70% and 70%.ConclusionLung ultrasound is more sensitive and even more speci-fic in comparison to chest radiograph to detect andmeasure pleural effusion in children submitted to livertransplantation.

Tissue Plasminogen Activator for the Treatment of Parapneumonic Effusions in Pediatric Patients

Intrapleural fibrinolysis has been investigated for the treatment of pleural effusion for several decades. Fibrinolytics have the ability to break up fibrin and loculations that characterize complicated pleural effusions, facilitating drainage. Older fibrinolytics such as urokinase and streptokinase have been replaced by tissue plasminogen activator (tPA) for this indication due to product availability and a more favorable safety profile. The literature supports tPA as a treatment approach for this indication in adult patients, and the use of tPA has become a standard management approach in this population. Over the past decade, data on the efficacy of intrapleural fibrinolytic therapy in children have also been generated, which now support the use of fibrinolysis as a treatment alternative to more invasive therapeutic options such as surgical intervention. In this review, we discuss the pathophysiology, diagnosis, and treatment of parapneumonic effusion and empyema, with a focus on intrapleural fibrinolysis, specifically tissue plasminogen activator, in the pediatric population. Recent articles provide sufficient evidence to support the use of this drug in pediatric patients for the management of pleural effusions; however, due to study heterogeneity, questions remain that may be addressed in future studies.

Pneumococcal Serotypes Causing Pneumonia with Pleural Effusion in Pediatric Patients

To determine the prevalence of serotypes of Streptococcus pneumoniae responsible for pneumonia with pleural effusion, we determined the capsular polysaccharide (PS) type directly on 49 pleural fluid specimens collected from pediatric patients during 2007 to 2009 with laboratory-confirmed pneumococcal pneumonia by using monoclonal antibodies and a multiplex, bead array immunoassay. Because the fluids had to be heated to remove nonspecific reactivity before being tested in the immunoassay and type 19A PS is heat labile, the pleural fluid samples were also tested for serotype 19A capsule gene locus by PCR. Use of the multiplex immunoassay combined with type-specific 19A PCR allowed for serotype determination on 40 of 49 pleural fluids. Pneumococcal pneumonia with pleural effusion was associated with a limited number of serotypes, with types 1, 3, 7F/A, and 19A accounting for 75% of the typeable cases. The concentration of capsular PS in the pleural fluids was often greater than 1 μg/ml and sufficient to inhibit the opsonic capacity of sera from individuals who had received the 23-valent pneumococcal PS vaccine. Based on the serotypes observed before and after introduction of the 7-valent pneumococcal conjugate vaccine, the recently licensed 13-valent pneumococcal conjugate vaccine may reduce the incidence of pneumonia with pleural effusions.

Bedside Ultrasonography to Identify Hip Effusions in Pediatric Patients

We determine whether pediatric emergency physicians can use bedside ultrasonography to accurately identify hip effusions in pediatric patients. This was a prospective study conducted in the emergency department (ED) of an urban tertiary care freestanding pediatric hospital. A convenience sample of children younger than 18 years and who required hip ultrasonography as part of their ED evaluation was enrolled. Pediatric emergency physicians with focused ultrasonographic training performed bedside ultrasonography on patients' symptomatic and contralateral hips and categorized the findings as "effusion" or "no effusion," according to a priori definitions. Physicians rated their confidence for each bedside ultrasonographic result on a scale of 1 (not confident) to 5 (very confident). Bedside ultrasonographic results were compared with the radiology department's ultrasonographic results, which were considered the criterion standard. Standard performance metrics (sensitivity, specificity, and positive and negative predictive values) were calculated. Three physicians enrolled patients. Twenty-eight patients were enrolled, and 55 hips were studied. In all hips (both symptomatic and contralateral), bedside ultrasonography had a sensitivity of 80% (95% confidence interval [CI] 51% to 95%), a specificity of 98% (95% CI 85% to 99%), a positive predictive value of 92% (95% CI 62% to 99%), and a negative predictive value of 93% (95% CI 79% to 98%). In the 28 symptomatic hips, bedside ultrasonography had a sensitivity of 85% (95% CI 54% to 97%), a specificity of 93% (95% CI 66% to 99%), a positive predictive value of 92% (95% CI 60% to 99%), and negative predictive value of 88% (95% CI 60% to 98%). When physician self-rated confidence was high, the sensitivity of bedside ultrasonography in symptomatic hips was 90% (95% CI 54% to 99%), the specificity was 100% (95% CI 70% to 100%), the positive predictive value was 100% (95% CI 63% to 100%), and the negative predictive value was 92% (95% CI 62% to 99%). With focused training, pediatric emergency physicians were able to use bedside ultrasonography to identify hip effusions in pediatric ED patients.

Association Between Parapneumonic Effusion and Pericardial Effusion in a Pediatric Cohort

Associations between pleural and pericardial effusions have been described in malignancy and autoimmune disorders. Bacterial pneumonia is the most frequent cause of parapneumonic effusion; however, knowledge of the relationship between parapneumonic effusion and the presence of pericardial fluid in children is limited. We examined this relationship. We performed a retrospective chart review of pediatric patients who were admitted to our institution during a 6-year period with a diagnosis of either parapneumonic effusion or empyema and who had undergone an echocardiogram, a computed tomography scan of the thorax, or both. All demographic, clinical, radiographic, and laboratory data of these patients were collected, and statistical analysis was done with Student's t tests and chi2 analyses. We reviewed the charts of 59 children with parapneumonic effusions. Forty-eight underwent 2-dimensional echocardiography, chest computed tomography scan, or both. Of these 48 patients, 54.2% (n=26) were found to have a concomitant pericardial effusion. The majority of patients with pericardial effusions had left-sided pleural disease. Patients with pericardial effusions had more symptomatic days before hospitalization, lower pleural fluid albumin levels, elevated serum white blood cell counts, elevated pleural fluid white blood cell and absolute neutrophil counts, and an increased incidence of surgical intervention. One patient had evidence of hemodynamic compromise that required pericardiocentesis. We found a high incidence of pericardial effusions in pediatric patients with parapneumonic effusions. Leukocytosis, higher pleural fluid leukocyte and neutrophil counts, and a propensity for surgical intervention suggest a prognostic relationship between pericardial effusions and more severe parapneumonic disease. The majority of these pericardial collections resolve with treatment of the underlying pleural disease.

Etiology, Management, and Outcome of Pediatric Pericardial Effusions

The objective of this study was to determine the contemporary etiologies, treatment, and outcomes of moderate and large pericardial effusions in pediatric patients. We reviewed pediatric patients with moderate or large effusions diagnosed at Children's Hospital Boston. Effusion size was determined in offline review of echocardiograms. One hundred sixteen patients with moderate or large pericardial effusions were identified. The age range was 1 day to 17.8 years (median 8.6). The size of the pericardial effusions ranged from 0.5 to 4.7 cm (median 2.1). Neoplastic disease was present in 39% of patients, collagen vascular disease in 9%, renal disease in 8%, bacterial infection in 3%, and human immunodeficiency virus (HIV) in 2%; 37% were idiopathic. Pericardial drainage procedures were performed in 47 patients (41%). Of these, 29 (63%) had recurrent effusions leading to repeat drainage in 12 (41%). Pericardial effusions resolved within 3 months in 83% of patients who underwent drainage and in 91% of patients who did not. In summary, pediatric pericardial effusions were rarely caused by bacterial infections in this study population and were more frequently idiopathic or associated with neoplastic disease. Pericardial effusions often reaccumulated after drainage. The majority of both drained and undrained effusions resolved within 3 months.

Dosage and Effectiveness of Intrapleural Doxycycline for Pediatric Postcardiotomy Pleural Effusions

To determine the effectiveness of intrapleural doxycycline for the treatment of postcardiotomy pleural effusions in pediatric patients. Retrospective case series. Intensive care unit in a pediatric tertiary care center. Sequential sample of 12 pediatric patients who underwent cardiotomy for congenital heart disease and received doxycycline pleurodesis for persistent pleural effusion that lasted more than 7 days between December 21, 2001, and May 23, 2005. Mean age of the patients was 1 year (range 2 wks-2.5 yrs). Eighteen courses of doxycycline were administered among the 12 patients. An average dose of 19.1 mg/kg/dose of parenteral doxycycline was diluted in normal saline to a final syringe concentration of 2-8 mg/ml and injected through a chest tube. The patient was rotated according to a protocol. The doxycycline dose remained in the pleural space for approximately 6 hours before being drained under suction. Treatment success was defined as achievement of 0-ml/hour chest tube output after a doxycycline dose. The overall treatment success rate was 94% (17 of 18 courses). The mean times from dosing to treatment success and chest tube removal were 76 hours (range < 1 to 140 hrs) and 130 hours (range 8-453 hrs), respectively. Seventy-two percent of the courses (13 of 18) achieved treatment success within 96 hours and chest tube removal within 168 hours after dosing. Doxycycline concentration did not appear to be related to treatment success. Chest pain was the most common adverse effect. Intrapleural doxycycline infusion is effective for postcardiotomy pleural effusion in pediatric patients with persistent chest tube drainage lasting more than 7 days.

Detection of pulsus paradoxus associated with large pericardial effusions in pediatric patients by analysis of the pulse-oximetry waveform.

To determine whether analysis of the pulse-oximetry waveform can be useful in detecting the pulsus paradoxus associated with large pericardial effusions in pediatric patients. A retrospective review of charts of 8 pediatric patients (age range: 5-19 years) who had echocardiographic evidence of large pericardial effusion, subsequently underwent pericardiocentesis, and had pulse-oximetry waveform tracings obtained before and after pericardiocentesis within an 18-month period was conducted in 2 tertiary-care pediatric intensive care units. We analyzed the pulse-oximetry waveform tracings for the presence of a pulsus paradoxus. Other abstracted data included clinical evidence of tamponade, echocardiographic findings, and the volume of pericardial fluid aspirated. Before pericardiocentesis, a decrease in the highest value of the upper plethysmographic peak of the pulse-oximetry waveform was observed during inspiration in each patient. Echocardiographic evidence of large pericardial effusion with compromised cardiac filling was also present in each patient. Only 6 of these patients had clinical evidence of cardiac tamponade at that time, 4 with a documented pulsus paradoxus using standard methods of blood pressure analysis. After pericardiocentesis, the inspiratory fall in the highest value of the upper plethysmographic peak of the pulse-oximetry waveform lessened in every patient. Echocardiography documented a decrease in the size of the effusion and resolution of the compromised cardiac filling in every patient. Analysis of pulse-oximetry waveforms may be a widely available, easily interpretable, and reliable method of detecting the pulsus paradoxus associated with large pericardial effusions in pediatric patients.