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      Radiology Imaging Adds Time and Diagnostic Uncertainty when Point of Care Ultrasound Demonstrates Cholecystitis

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          Abstract

          Background: Point of care ultrasound (POCUS) is specific for acute cholecystitis (AC), but surgeons request radiology imaging (RI) prior to admitting patients with POCUS-diagnosed AC. Objectives: We sought to determine the test characteristics of POCUS for AC when performed and billed by credentialed emergency physicians (EPs), the accuracy rate of RI when performed after POCUS, and the time added when RI is requested after POCUS demonstrates AC. Methods: We performed a dual-site retrospective cohort study of admitted adult ED patients who had received biliary POCUS from November 1, 2020 to April 30, 2022. Patients with previously diagnosed AC, liver failure, ascites, hepatobiliary cancer, or cholecystectomy were excluded. Descriptive statistics and 95% confidence intervals for point estimates were calculated. Medians were compared using a Wilcoxon signed-rank test. Test characteristics of POCUS for AC were calculated using inpatient intervention for AC as the reference standard. Results: Of 473 screened patients, 143 were included for analysis: 80 (56%) had AC according to our reference standard. POCUS was positive for AC in 46 patients: 44 true positives and two false positives, yielding a positive likelihood ratio of 17.3 (95%CI 4.4-69.0) for AC. The accuracy rate of RI after positive POCUS for AC was 39.0%. Median time from ED arrival to POCUS and ED arrival to RI were 115 (IQR 64, 207) and 313.5 (IQR 224, 541) minutes, respectively; p < 0.01. Conclusion: RI after positive POCUS performed by credentialed EPs takes additional time and may increase diagnostic uncertainty.

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          Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos).

          The Tokyo Guidelines 2013 (TG13) for acute cholangitis and cholecystitis were globally disseminated and various clinical studies about the management of acute cholecystitis were reported by many researchers and clinicians from all over the world. The 1st edition of the Tokyo Guidelines 2007 (TG07) was revised in 2013. According to that revision, the TG13 diagnostic criteria of acute cholecystitis provided better specificity and higher diagnostic accuracy. Thorough our literature search about diagnostic criteria for acute cholecystitis, new and strong evidence that had been released from 2013 to 2017 was not found with serious and important issues about using TG13 diagnostic criteria of acute cholecystitis. On the other hand, the TG13 severity grading for acute cholecystitis has been validated in numerous studies. As a result of these reviews, the TG13 severity grading for acute cholecystitis was significantly associated with parameters including 30-day overall mortality, length of hospital stay, conversion rates to open surgery, and medical costs. In terms of severity assessment, breakthrough and intensive literature for revising severity grading was not reported. Consequently, TG13 diagnostic criteria and severity grading were judged from numerous validation studies as useful indicators in clinical practice and adopted as TG18/TG13 diagnostic criteria and severity grading of acute cholecystitis without any modification. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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            Point-of-Care Ultrasonography

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              Optimal time for early laparoscopic cholecystectomy for acute cholecystitis.

              There is growing evidence in support of performing early laparoscopic cholecystectomy (LC) for acute cholecystitis. However, the definition of early LC varies from 0 through 10 days depending on the research protocol. The optimum time to perform early LC is still unclear.
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                Author and article information

                Contributors
                Journal
                POCUS J
                POCUS J
                CINQUILL Medical Publishers Inc.
                POCUS Journal
                CINQUILL Medical Publishers Inc
                2369-8543
                2369-8543
                2024
                22 April 2024
                : 9
                : 1
                : 87-94
                Affiliations
                [1 ] University of Connecticut School of Medicine Farmington, CT USA
                [2 ] Department of Emergency Medicine, Hartford Hospital Hartford, CT USA
                [3 ] Department of Emergency Medicine, University of Connecticut School of Medicine Farmington, CT USA
                Article
                10.24908/pocus.v9i1.16596
                11044937
                cc6bb426-2a8f-4162-87b8-1c51b76b9e5a
                Copyright (c) 2024 David Cannata, Callista Love, Pascale Carrel, Trent She, Seth Lotterman, Felix Pacheco, Meghan Herbst

                This work is licensed under a Creative Commons Attribution 4.0 International License.

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                Categories
                Medicine

                length-of-stay,diagnostic imaging,point of care ultrasound,acute cholecystitis

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