Incidental Findings on Pediatric Abdominal Computed Tomography At A Pediatric Trauma Center

A systematic review and meta-analysis of incidental findings in computed tomography scans for pediatric trauma patients

PURPOSE

To quantitatively synthesize and report the frequency and category of incidental findings on Computed Tomography (CT) scans in pediatric trauma patients.

METHODS

A thorough literature search was carried out in PubMed, Scopus, and Web of Science databases until March 6, 2023, in adherence to the preferred reporting items for systematic review and meta-analyses (PRISMA) guidelines. Studies describing incidental findings on CT scans in trauma patients ≤21 years were included. Incidental findings were grouped into three categories: Category 1 (requiring immediate or urgent evaluation or treatment), Category 2 (likely benign but which may require outpatient follow-up), and Category 3 (benign anatomic variants or pathologic findings that do not require follow-up or intervention).

RESULTS

Seven studies were included in this study, which revealed a combined rate of 27.10 % of incidental findings with notable heterogeneity among the studies. Aggregated frequencies were 10.15 % for Category 1, 32.18 % for Category 2 and 51.44 % for Category 3. Subgroup meta-analysis on abdominal CT scans showed a higher pooled incidence of incidental findings at 47.17 %, but with lower heterogeneity than the general meta-analysis.

CONCLUSION

The study underscores the prevalence of incidental findings in pediatric trauma patients undergoing CT scans. The categorization of these findings provides useful information for clinicians in determining appropriate follow-up and management strategies.

Assessment of the Response to Abdominal and Pelvic Computed Tomography Report Recommendations: A Single-Center, Retrospective, Chart Review Study

Objectives

The radiology report is the primary form of communication between the radiologists and referring clinicians. It is a structured document containing several key components pertaining to the interpretation of radiological examinations and may require the addition of follow-up imaging recommendations to optimize patient outcomes. This study aims to determine whether follow-up imaging recommendations are being acknowledged and acted upon by referrers.

Methods

This retrospective study was conducted at a single tertiary hospital. Prerecorded BESTCare data of patients who underwent abdominal and pelvic computed tomography (CT) scans between October 1, 2017, and December 31, 2017, and received recommendations for further evaluation were collected after obtaining ethical approval from the local authority. Data of patients younger than 14 years old, patients who did not receive a recommendation, and patients who had CT scans that were uploaded to the BESTCare system but were performed outside the institution were excluded. The collected data were recorded in a password-protected Microsoft Excel file for further analysis.

Results

A total of 523 report recommendations from 422 abdominal and pelvic CT reports were analyzed. The most common organs indicated for CT scan evaluation were the breast (N = 54, 10.33%), kidney (N = 46, 8.80%), lymph node (N = 36, 6.88%), and colon (N = 33, 6.31%). The most common type of further evaluation recommended was further imaging (N = 410, 78.39%). A total of 278 (53.15%) recommendations were not performed, with 199 (71.58%) not having a documented rationale for noncompliance.

Conclusion

The majority of the follow-up imaging recommendations to ordering physicians were not carried out. This study highlights the need for notification and audit systems to monitor compliance with follow-up recommendations. Improving the communication between radiologists and referring physicians is key to optimizing patient healthcare.

Computed Tomography Scan Utilization in Pediatric Trauma: Impact on Length of Stay and Incidence of False Positive Findings

INTRODUCTION

Computerized tomography (CT) scans are the mainstay of diagnostic imaging in blunt trauma. Particularly in pediatric trauma, utilization of CT scans has increased exponentially in recent years. Concerns regarding radiation exposure to this vulnerable population have resulted in increased scrutiny of practice. What is not known is if liberal imaging practices decrease length of stay by eliminating the need for clinical observation, and the impact of false-positive rates from liberal use of CT scanning on clinical outcomes.

METHODS

Medical records from a nonaccredited pediatric trauma center with a practice of liberal imaging were reviewed over a 2-year period. Total CT scans obtained were recorded, in addition to length of stay, age, and Injury Severity Score (ISS). Rates of clinically significant imaging findings were recorded, as were false positive findings and complications of imaging.

RESULTS

Out of 735 children, 58% underwent CT scanning, and if scanned, received an average of 2.4 studies. Clinically significant findings were documented in 20% of head CTs, 2% of cervical spine CTs, 3.5% of chest CTs, 24% of facial CTs, and 14.7% of abdominal CTs. False-positive findings were found in 1.5% of head CTs, 1.2% of cervical spine CTs, 2.4% of chest CTs, and 2.5% of abdominal CTs. Liberal CT scanning was not associated with decreased length of stay. In contrast, obtaining CT scans on more than 4 body regions was independently predictive of longer length of stay, independent of ISS.

CONCLUSIONS

False-positive rates of CT scans for trauma were low in this cohort. However, when scanning the cervical spine or the chest, for every 2 clinically significant findings obtained, there was at least one false positive result, calling into question the practice of liberal imaging of these regions. Liberal utilization of CT scan did not allow for more rapid discharge home, and for more than 4 CTs was independently associated with longer hospital stay.

Low-Value Diagnostic Imaging in Children with Medicaid

OBJECTIVES

To estimate rates and settings of low-value imaging among pediatric Medicaid beneficiaries and estimate the associated expenditures.

STUDY DESIGN

Retrospective longitudinal cohort study from 2014 to 2016 of children <18 years enrolled in Pennsylvania Medicaid. Outcomes were rates of low-value imaging for 5 conditions identified by diagnosis codes, healthcare settings of imaging performance, and cost based on paid amounts.

RESULTS

Of the 645 767 encounters for the 5 conditions, there were 37 525 (5.8%) low-value imaging services. Per 1000 encounters, there were 246.0 radiographs for bronchiolitis, 174.0 head computed tomography (CT) studies for minor head trauma, 155.0 and 33.3 neuroimaging studies for headache and simple febrile seizure, respectively, and 19.5 abdominal CT scans (without prior ultrasound examination) for abdominal pain. Rates of low-value imaging were highest in non-Hispanic White children and those in rural areas. In adjusted analysis, non-Hispanic White children were more likely to receive a CT scan for abdominal pain, and Black children were more likely to have imaging for bronchiolitis and minor head trauma. For individual conditions, up to 87.9% of low-value imaging (CT scan for minor head trauma) was in the emergency department (ED), with most imaging across all conditions occurring in nonpediatric EDs, up to 42.2% was in the outpatient setting (neuroimaging for headache), and up to 20.7% was during inpatient encounters (neuroimaging for febrile seizure). Outpatient and ED low-value imaging resulted in more than $7 million in Medicaid expenditures.

CONCLUSIONS

Among the studied conditions, more than 1 in 20 encounters included low-value imaging, mostly in nonpediatric EDs and for bronchiolitis, head trauma, and headache. Interventions are needed to decrease the future performance of these low-value services.

Incidental Cancer Diagnoses in Trauma Patients: A Case-Control Study Evaluating Long-term Outcomes

BACKGROUND

This study evaluates whether trauma patients who incidentally learned about a malignancy have similar long-term outcomes as patients who organically learned about their malignancy.

MATERIALS AND METHODS

Incidental findings (IF) patients were matched to noninjured cancer controls on age group, sex, cancer site, stage, and year of diagnosis. Unadjusted covariates included race, insurance type, rural residence, and time from diagnosis to first cancer intervention. Cox proportional hazard regression models were used to measure adjusted all-cause and cancer-specific mortality risk.

RESULTS

Adjusted long-term mortality risk among IF cases was 1.42 (95% confidence interval [1.11-1.81]) compared with noninjured cancer controls. There was no statistically significant difference in all-cause mortality among IF cases who survived at least 30 d (1.24 [0.88-1.74]). IF cases had no increased risk of cancer-related mortality compared with controls (1.26 [0.96-1.64]).

CONCLUSIONS

Long-term mortality risks among trauma patients with incidental cancer diagnoses are no different than the cancer population as a whole among patients who survive at least 30 d after injury. IF trauma patients are not more susceptible to cancer-related causes of death as a result of a physiological stress response due to injury.