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Inci O, Altuncı YA, Can O, Akarca FK, Ersel M. The Efficiency of Focused Assessment with Sonography for Trauma in Pediatric Patients with Blunt Torso Trauma. J Emerg Trauma Shock 2024; 17:8-13. [PMID: 38681885 PMCID: PMC11044999 DOI: 10.4103/jets.jets_137_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 07/13/2023] [Accepted: 07/31/2023] [Indexed: 05/01/2024] Open
Abstract
Introduction Focused Assessment with Sonography for Trauma (FAST) has attracted attention for its use in the detection of intra-abdominal pathology for pediatric patients. However, computed tomography (CT) remains the gold standard for the assessment of blunt torso trauma. The study examines the effectiveness of FAST both in the detection of intra-abdominal pathology in pediatric patients (<19 years) with blunt torso trauma and in the determination of the need for CT for further examination. Methods The study was designed as a retrospective observational investigation of diagnostic value. The pediatric patients who were admitted to the Emergency Department with blunt torso trauma between January 2013 and October 2016 were included in the study. The sample of the study comprised 255 patients who met the inclusion criteria. The primary outcome was the effectiveness of FAST in the detection of intra-abdominal pathology and the determination of the need for CT. The secondary outcome was to identify the agreement between CT and FAST for intra-abdominal injuries. The Chi-square test and Fisher's exact test were used for comparisons. A logistic regression model was developed to determine the variables that independently affect the agreement between FAST and CT. Results FAST was determined to have low sensitivity (20.3%) despite its high specificity (87%). However; FAST had a good negative likelihood ratio. There was a poor agreement between CT and FAST in terms of the presence of both intra-abdominal and intrathoracic injuries in pediatric patients with blunt trunk trauma. The error rate of FAST increased by five-fold, especially in the presence of concomitant thorax trauma. However, FAST had a good negative likelihood ratio. Conclusion FAST should not be regarded as an equivalent tool to CT for pediatric patients with blunt torso trauma. It is, instead, a noteworthy complementary tool that is a negative predictor.
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Affiliation(s)
- Ozlem Inci
- Department of Emergency Medicine, Batman Education and Research Hospital, Batman, Turkey
| | - Yusuf Ali Altuncı
- Department of Emergency, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Ozge Can
- Department of Emergency, Faculty of Medicine, Ege University, Izmir, Turkey
| | | | - Murat Ersel
- Department of Emergency, Faculty of Medicine, Ege University, Izmir, Turkey
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Cunha SC, DE-Oliveira Filho AG, Miranda ML, Silva MACPDA, Pegolo PTDEC, Lopes LR, Bustorff-Silva JM. Analysis of the efficacy and safety of conservative treatment of blunt abdominal trauma in children: retrospective study. Conservative treatment of blunt abdominal trauma in children. Rev Col Bras Cir 2023; 50:e20233429. [PMID: 36995834 PMCID: PMC10519698 DOI: 10.1590/0100-6991e-20233429-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 12/06/2022] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION in Brazil, trauma is responsible for 40% of deaths in the age group between 5 and 9 years old, and 18% between 1 and 4 years, and bleeding is the leading cause of preventable death in the traumatized child. Conservative management of blunt abdominal trauma with solid organs injury - started in the 60s - is the current world trend, with studies showing survival rates above 90%. The objective was to assess the efficacy and safety of conservative treatment in children with blunt abdominal trauma treated at the Clinical Hospital of the University of Campinas, in the last five years. METHODS retrospective analysis of medical records of patients classified by levels of injury severity, in 27 children. RESULTS only one child underwent surgery for initial failure of conservative treatment (persistent hemodynamic instability), resulting in a 96% overall success rate of the conservative treatment. Five other children (22%) developed late complications that required elective surgery: a bladder injury, two cases of infected perirenal collections (secondary to injury of renal collecting system), a pancreatic pseudocyst and a splenic cyst. Resolution of the complications was attained in all children, with anatomical and functional preservation of the affected organ. There were no deaths in this series. CONCLUSION the conservative initial approach in the treatment of blunt abdominal trauma was effective and safe with high resolution and low rate of complications leading to a high preservation rate of the affected organs. Level of evidence III - prognostic and therapeutic study.
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Affiliation(s)
- Sarah Crestian Cunha
- - Universidade Estadual de Campinas (UNICAMP), Cirurgia - Campinas - SP - Brasil
| | | | - Marcio Lopes Miranda
- - Universidade Estadual de Campinas (UNICAMP), Cirurgia - Campinas - SP - Brasil
| | | | | | - Luiz Roberto Lopes
- - Universidade Estadual de Campinas (UNICAMP), Cirurgia - Campinas - SP - Brasil
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CUNHA SARAHCRESTIAN, DE-OLIVEIRA FILHO ANTONIOGONÇALVES, MIRANDA MARCIOLOPES, SILVA MARCIAALESSANDRACAVALAROPEREIRADA, PEGOLO PATRÍCIATRABALLIDECARVALHO, LOPES LUIZROBERTO, BUSTORFF-SILVA JOAQUIMMURRAY. Análise de eficácia e segurança do tratamento conservador do trauma abdominal contuso em crianças: estudo retrospectivo. Tratamento conservador de trauma abdominal contuso em crianças. Rev Col Bras Cir 2023. [DOI: 10.1590/0100-6991e-20233429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
RESUMO Introdução: no Brasil, o trauma é responsável por 40% dos óbitos na faixa etária entre 5 e 9 anos, e 18% entre 1 e 4 anos, e o sangramento é a principal causa de prevenção morte na criança traumatizada. O manejo conservador de trauma abdominal contuso com lesão de órgãos sólidos - iniciado na década de 60 - é a tendência mundial atual, com estudos mostrando taxas de sobrevivência acima de 90%. O objetivo do presente trabalho foi avaliar a eficácia e segurança do tratamento conservador em crianças com trauma abdominal contuso tratado no Hospital das Clínicas da Universidade de Campinas, nos últimos cinco anos. Métodos: análise retrospectiva de prontuários de pacientes classificados por níveis de gravidade da lesão, em 27 crianças. Resultados: apenas uma criança foi submetida a cirurgia por falha inicial do tratamento conservador (instabilidade hemodinâmica persistente), resultando em uma taxa de sucesso global de 96% do tratamento conservador inicial. Outras cinco crianças (22%) desenvolveram complicações tardias que exigiram cirurgias eletivas: lesão na bexiga, dois casos de coleção perirenal infectada (secundária à lesão de sistema de coleta renal), um pseudocisto pancreático e um cisto esplênico. Resolução da complicação foi atingida em todas as crianças, com preservação anatômica e funcional do órgão afetado. Não houve mortes nesta série. Conclusão: a abordagem inicial conservadora no tratamento de trauma abdominal contundente foi eficaz e segura com alta resolução e baixa taxa de complicações levando a uma alta taxa de preservação dos órgãos afetados. Nível de evidência III - estudo prognóstico e terapêutico.
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Gagnon MA, Bérubé M, Mercier É, Yanchar N, Cameron P, Stelfox T, Gabbe B, Bourgeois G, Lauzier F, Turgeon A, Belcaid A, Moore L. Low-value injury admissions in an integrated Canadian trauma system: A multicentre cohort study. Int J Clin Pract 2021; 75:e14473. [PMID: 34107144 DOI: 10.1111/ijcp.14473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/29/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Injury represents 260 000 hospitalisations and $27 billion in healthcare costs each year in Canada. Evidence suggests that there is significant variation in the prevalence of hospital admissions among emergency department presentations between countries and providers, but we lack data specific to injury admissions. We aimed to estimate the prevalence of potentially low-value injury admissions following injury in a Canadian provincial trauma system, identify diagnostic groups contributing most to low-value admissions and assess inter-hospital variation. METHODS We conducted a retrospective multicentre cohort study based on all injury admissions in the Québec trauma system (2013-2018). Using literature and expert consultation, we developed criteria to identify potentially low-value injury admissions. We used a multilevel logistic regression model to evaluate inter-hospital variation in the prevalence of low-value injury admissions with intraclass correlation coefficients (ICC). We stratified our analyses by age (1-15; 16-64; 65-74; 75+ years). RESULTS The prevalence of low-value injury admissions was 16% (n = 19 163) among all patients, 26% (2136) in children, 11% (4695) in young adults and 19% (12 345) in older adults. Diagnostic groups contributing most to low-value admissions were mild traumatic brain injury in children (48% of low-value paediatric injury admissions; n = 922), superficial injuries (14%, n = 660) or minor spinal injuries (14%, n = 634) in adults aged 16-64 and superficial injuries in adults aged 65+ (22%, n = 2771). We observed strong inter-hospital variation in the prevalence of low-value injury admissions (ICC = 37%). CONCLUSION One out of six hospital admissions following injury may be of low value. Children with mild traumatic brain injury and adults with superficial injuries could be good targets for future research efforts seeking to reduce healthcare services overuse. Inter-hospital variation indicates there may be an opportunity to reduce low-value injury admissions with appropriate interventions targeting modifications in care processes.
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Affiliation(s)
- Marc-Aurèle Gagnon
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Québec, QC, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Québec, QC, Canada
- Faculté des sciences infirmières, Université Laval, Québec, QC, Canada
| | - Éric Mercier
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Québec, QC, Canada
| | - Natalie Yanchar
- Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Peter Cameron
- The Alfred Hospital, Monash University, Melbourne, VIC, Australia
| | - Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary & Alberta Health Services, Calgary, AB, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | | | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Québec, QC, Canada
- Département de médecine interne, Université Laval, Québec, QC, Canada
| | - Alexis Turgeon
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Québec, QC, Canada
- Département d'anesthésiologie et de soins intensifs, Université Laval, Québec, QC, Canada
| | - Amina Belcaid
- Institut National d'Excellence en Santé et Services Sociaux, Montréal, QC, Canada
| | - Lynne Moore
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Québec, QC, Canada
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Predictors of False-Negative Focused Assessment With Sonography for Trauma Examination in Pediatric Blunt Abdominal Trauma. Pediatr Emerg Care 2020; 36:e274-e279. [PMID: 32304524 DOI: 10.1097/pec.0000000000002094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES This study investigated associations between patient and injury characteristics and false-negative (FN) focused assessment with sonography for trauma (FAST) in pediatric blunt abdominal trauma (BAT). We also evaluated the effects of FN FAST on in-hospital mortality and length of stay (LOS) variables. METHODS This retrospective cohort studied children younger than 18 years between January 1, 2002, and December 31, 2013, with BAT, documented FAST, and pathologic fluid on computed tomography, surgery, or autopsy. Multivariable and bivariate analyses were used to assess associations between FN FAST and patient injury characteristics, mortality, and hospital LOS. RESULTS A total of 141 pediatric BAT patients with pathologic free fluid were included. There were no patient or injury characteristics, which conferred increased odds of an FN FAST. Splenic and bladder injury were negatively associated with FN FAST odds ratio of 0.4 (95% confidence interval [CI], 0.2-0.8) and 0.1 (95% CI, 0-0.8). Abbreviated Injury Scale score of 4 or greater to the abdomen and extremity was negatively associated with FN FAST odds ratio of 0.1 (95% CI, 0-0.3) and 0.3 (95% CI, 0.1-0.9). There was no association between FN FAST and mortality. Patients with an FN FAST had increased hospital LOS after controlling for sex, age, and Injury Severity Score. CONCLUSIONS Clinicians need to be cautious applying a single initial FAST to patients with minor abdominal trauma or with suspected injuries to organs other than the spleen or bladder. Formalized studies to develop risk stratification tools could allow clinicians to integrate FAST into the pediatric patient population in the safest manner possible.
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Jing X, Gong Z, Zhang N, Chen G, Li F, Chen Q, Xu Z, Zhang R. Fracture and dislocation of lumbar vertebrae with entrapment of small bowel: A case report and literature review. J Int Med Res 2019; 47:1043-1051. [PMID: 30618309 PMCID: PMC6381458 DOI: 10.1177/0300060518816205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Traumatic incarceration of the small bowel accompanied by vertebral fractures and dislocation is rare and usually misdiagnosed until laparotomy. This report presents a rare case of jejunum entrapment between lumbar spine fractures. A 43-year-old man was clamped between two railway tracks on the upper abdomen and lower back. Following ineffective conservative treatment, he underwent a laparotomy due to the development of guarding and rebound tenderness. Loss of vitality of the jejunal loop, which was incarcerated between the L3 and L4 vertebrae, was observed. The necrotic bowel was removed and end-to-end anastomosis was performed. When his condition was stable, anterior and posterior lumbar fixation surgery was performed. The patient had no abdominal complications and lower limb nerve function deficiency during the follow-up period. A review of the literature since 1979 on incarceration of the bowel associated with lumbar fracture and dislocation identified 12 cases: five patients showed persistent neurological symptoms, but none of the patients died as a result of their injuries. It should be borne in mind that patients with hyperextension or flexion-distraction injury of the lumbar spine could show symptoms of intestinal obstruction and bowel incarceration. Enhanced computed tomography or magnetic resonance imaging will be helpful for diagnosis.
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Affiliation(s)
- Xiaowei Jing
- 1 Department of Orthopaedic Surgery, Fourth Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, Zhejiang Province, China
| | - Zhiyuan Gong
- 1 Department of Orthopaedic Surgery, Fourth Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, Zhejiang Province, China
| | - Ning Zhang
- 2 Department of Orthopaedic Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Gang Chen
- 2 Department of Orthopaedic Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Fangcai Li
- 2 Department of Orthopaedic Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Qixin Chen
- 2 Department of Orthopaedic Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Zhengkuan Xu
- 2 Department of Orthopaedic Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Rui Zhang
- 1 Department of Orthopaedic Surgery, Fourth Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, Zhejiang Province, China
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Bonasso PC, Dassinger MS, Wyrick DL, Gurien LA, Burford JM, Smith SD. Review of bedside surgeon-performed ultrasound in pediatric patients. J Pediatr Surg 2018; 53:2279-2289. [PMID: 29807830 DOI: 10.1016/j.jpedsurg.2018.04.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 03/21/2018] [Accepted: 04/28/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE Pediatric surgeon performed bedside ultrasound (PSPBUS) is a targeted examination that is diagnostic or therapeutic. The aim of this paper is to review literature involving PSPBUS. METHODS PSPBUS practices reviewed in this paper include central venous catheter placement, physiologic assessment (volume status and echocardiography), hypertrophic pyloric stenosis diagnosis, appendicitis diagnosis, the Focused Assessment with Sonography for Trauma (FAST), thoracic evaluation, and soft tissue infection evaluation. RESULTS There are no standards for the practice of PSPBUS. CONCLUSIONS As the role of the pediatric surgeon continues to evolve, PSPBUS will influence practice patterns, disease diagnosis, and patient management. TYPE OF STUDY Review Article. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Patrick C Bonasso
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202.
| | - Melvin S Dassinger
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Deidre L Wyrick
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Lori A Gurien
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Jeffrey M Burford
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Samuel D Smith
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
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A Case of Child Physical Abuse With a Rolling Pin Insertion, Resulting in Bladder and Rectal Perforation. Pediatr Emerg Care 2018; 34:e44-e46. [PMID: 27749800 DOI: 10.1097/pec.0000000000000883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Visceral injuries are not uncommon in nonaccidental trauma and often require emergent operative intervention. However, sometimes it can be difficult to assess the extent of injury. In this report, we present a case of child physical abuse resulting in bladder and rectal perforations, which was initially referred to our hospital as acute abdomen with intraperitoneal free fluid on ultrasonography. An exploratory laparotomy revealed the perforations and surgical repair was performed. The patient was evaluated by the Hospital Child Protective team and it was revealed that bladder and rectum perforations were due to insertion of rolling pin into the rectum by the stepmother. The child was discharged home uneventfully with a temporary colostomy. We believe that this is the first reported case in the English literature of inflicted perforation of the rectum and bladder through insertion of a rolling pin.
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Yang K, Li Y, Wang C, Xiang B, Chen S, Ji Y. Clinical features and outcomes of blunt splenic injury in children: A retrospective study in a single institution in China. Medicine (Baltimore) 2017; 96:e9419. [PMID: 29390566 PMCID: PMC5758268 DOI: 10.1097/md.0000000000009419] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Although the spleen is the most commonly injured intra-abdominal organ after blunt trauma, there are limited data available in China. The objectives of this study were to investigate the clinical features and determine the risk factors for operative management (OM) in children with blunt splenic injury (BSI).A review of the medical records of children diagnosed with BSI between January 2010 and September 2016 at West China Hospital of Sichuan University was performed.A total of 101 patients diagnosed with BSI were recruited, including 76 patients transferred from other hospitals. The male-to-female ratio was 2.06:1, with a mean age of 7.8 years old. The most common injury season was summer and the most common injury mechanism was road traffic accidents. Sixty-eight patients suffered multiple injuries. Thirty-four patients received blood transfusions. Two patients died from multiple organ failure or hemorrhagic shock. Significant differences were observed in the injury season, injury mechanism, injury date, and hemoglobin levels between the isolated injury group and the multiple injuries group. The overall operative rate was 29.7%. Multivariate regression analysis revealed that age, blood transfusion, and grade of injury were independent risk factors for OM.Our study provided evidence that the management of pediatric BSI was variable. The operative rate in pediatric BSI may be higher in certain patient groups. Although nonoperative management is one of the standard treatment options, our data suggest that OM is an appropriate way to treat patients who are hemodynamically unstable.
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Affiliation(s)
- Kaiying Yang
- Division of Oncology, Department of Pediatric Surgery
| | - Yanan Li
- Division of Oncology, Department of Pediatric Surgery
| | - Chuan Wang
- Division of Oncology, Department of Pediatric Surgery
| | - Bo Xiang
- Division of Oncology, Department of Pediatric Surgery
| | - Siyuan Chen
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Yi Ji
- Division of Oncology, Department of Pediatric Surgery
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Drucker NA, McDuffie L, Groh E, Hackworth J, Bell TM, Markel TA. Physical Examination is the Best Predictor of the Need for Abdominal Surgery in Children Following Motor Vehicle Collision. J Emerg Med 2017; 54:1-7. [PMID: 29107481 DOI: 10.1016/j.jemermed.2017.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/28/2017] [Accepted: 08/08/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Exploratory laparotomy in children after motor vehicle collision (MVC) is rare. In the absence of definitive hemorrhage or free abdominal air on radiographic imaging, predictors for operative exploration are conflicting. OBJECTIVE The purpose of this study was to explore objective findings that may aid in determining which children require operative abdominal exploration after MVC. METHODS Data from 2010-2014 at an American College of Surgeons-certified level 1 pediatric trauma center were retrospectively reviewed. Demographics, vital signs, laboratory data, radiologic studies, operative records, associated injuries, and outcomes were analyzed and p < 0.05 was considered statistically significant. RESULTS Eight hundred sixty-two patients 0-18 years of age presented to the hospital after an MVC during the study period. Seventeen patients (2.0%) required abdominal exploration and all were found to have intraabdominal injuries. Respiratory rate was the only vital sign that was significantly altered (p = 0.04) in those who required abdominal surgery compared with those who did not. Physical examination findings, such as the seat belt sign, abdominal bruising, abdominal wound, and abdominal tenderness, were present significantly more frequently in those requiring abdominal surgery (p < 0.0001). Each finding had a negative predictive value for the need for operative exploration of at least 0.98. There were no significant differences in trauma laboratory values or radiographic findings between the 2 groups. CONCLUSION Data from this study solidify the relationship between specific physical examination findings and the need for abdominal exploration after MVC in children. In addition, these data suggest that a lack of the seat belt sign, abdominal bruising, abdominal wounds, or abdominal tenderness are individually predictive of patients who will not require surgical intervention.
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Affiliation(s)
- Natalie A Drucker
- Indiana University School of Medicine, Section of Pediatric Surgery, Indianapolis, Indiana
| | - Lucas McDuffie
- Indiana University School of Medicine, Section of Pediatric Surgery, Indianapolis, Indiana
| | - Eric Groh
- Indiana University School of Medicine, Section of Pediatric Surgery, Indianapolis, Indiana
| | - Jodi Hackworth
- Riley Hospital for Children, Indiana University Health, Section of Pediatric Surgery, Indianapolis, Indiana
| | - Teresa M Bell
- Indiana University School of Medicine, Section of Pediatric Surgery, Indianapolis, Indiana
| | - Troy A Markel
- Indiana University School of Medicine, Section of Pediatric Surgery, Indianapolis, Indiana; Riley Hospital for Children, Indiana University Health, Section of Pediatric Surgery, Indianapolis, Indiana; Department of Surgery, Section of Pediatric Surgery, Indianapolis, Indiana
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Abstract
In the last decade, higher rates of nonoperative management of liver, spleen, and kidney injuries have been achieved. An algorithmic approach may improve success on a national level. Factors for success include management strategy based on physiologic status of the child, early attempt at resuscitation using blood products, and appropriate use of adjuncts. Shorter hospitalizations are appropriate for children who have not bled significantly, and discharge instructions facilitate the safety of early discharge. Although routine imaging is not required for liver or spleen injury, symptoms should prompt reevaluation. Reimaging of renal injuries remains in common use.
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Cullison K, Milne WK, Crocco AG. Hot Off the Press: Comparison of Clinical Suspicion Versus a Clinical Prediction Rule When Evaluating Children Following Blunt Torso Trauma. Acad Emerg Med 2016; 23:110-2. [PMID: 26720745 DOI: 10.1111/acem.12851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kevin Cullison
- Department of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - William K. Milne
- Department of Emergency Medicine; University of Western Ontario School of Medicine; London Ontario Canada
| | - Anthony G. Crocco
- Division of Pediatric Emergency Medicine; McMaster University; Montreal Quebec Canada
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Hojreh A, Weber M, Homolka P. Effect of staff training on radiation dose in pediatric CT. Eur J Radiol 2015; 84:1574-1578. [PMID: 26001436 DOI: 10.1016/j.ejrad.2015.04.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 03/22/2015] [Accepted: 04/23/2015] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To evaluate the efficacy of staff training on radiation doses applied in pediatric CT scans. METHODS Pediatric patient doses from five CT scanners before (1426 scans) and after staff training (2566 scans) were compared statistically. Examinations included cranial CT (CCT), thoracic, abdomen-pelvis, and trunk scans. Dose length products (DLPs) per series were extracted from CT dose reports archived in the PACS. RESULTS A pooled analysis of non-traumatic scans revealed a statistically significant reduction in the dose for cranial, thoracic, and abdomen/pelvis scans (p<0.01). This trend could be demonstrated also for trunk scans, however, significance could not be established due to low patient frequencies (p>0.05). The percentage of scans performed with DLPs exceeding the German DRLs was reduced from 41% to 7% (CCT), 19% to 5% (thorax-CT), from 9% to zero (abdominal-pelvis CT), and 26% to zero (trunk; DRL taken as summed DRLs for thorax plus abdomen-pelvis, reduced by 20% accounting for overlap). Comparison with Austrian DRLs - available only for CCT and thorax CT - showed a reduction from 21% to 3% (CCT), and 15 to 2% (thorax CT). CONCLUSIONS Staff training together with application of DRLs provide an efficient approach for optimizing radiation dose in pediatric CT practice.
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Affiliation(s)
- Azadeh Hojreh
- Medical University of Vienna, Department of Biological Imaging and Image-guided Therapy, Division of General and Paediatric Radiology, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
| | - Michael Weber
- Medical University of Vienna, Department of Biomedical Imaging and Image-guided Therapy, Division of General and Paediatric Radiology, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
| | - Peter Homolka
- Medical University of Vienna, Centre for Medical Physics and Biomedical Engineering, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
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Sheybani EF, Gonzalez-Araiza G, Kousari YM, Hulett RL, Menias CO. Pediatric nonaccidental abdominal trauma: what the radiologist should know. Radiographics 2015; 34:139-53. [PMID: 24428287 DOI: 10.1148/rg.341135013] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Abdominal injury in nonaccidental trauma (NAT) is an increasingly recognized cause of hospitalization in abused children. Abdominal injuries in NAT are often severe and have high rates of surgical intervention. Certain imaging findings in the pediatric abdomen, notably bowel perforation and pancreatic injury, should alert the radiologist to possible abuse and incite close interrogation concerning the reported mechanism of injury. Close inspection of the imaging study is warranted to detect additional injury sites because these injuries rarely occur in isolation. When abdominal injury is suspected in known or speculated NAT, computed tomography (CT) of the abdomen and pelvis with intravenous contrast material is recommended for diagnostic and forensic evaluation. Although the rate of bowel injury is disproportionately high in NAT, solid organs, including the liver, pancreas, and spleen, are most often injured. Adrenal and renal trauma is less frequent in NAT and is generally seen with multiple other injuries. Hypoperfusion complex is a constellation of abdominal CT findings that indicates current or impending decompensated shock and is most often due to severe neurologic impairment in NAT. Although abdominal injuries in NAT are relatively uncommon, knowledge of injury patterns and their imaging appearances is important for patient care and protection.
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Affiliation(s)
- Elizabeth F Sheybani
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo
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15
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Iaselli F, Mazzei MA, Firetto C, D'Elia D, Squitieri NC, Biondetti PR, Danza FM, Scaglione M. Bowel and mesenteric injuries from blunt abdominal trauma: a review. Radiol Med 2015; 120:21-32. [PMID: 25572542 DOI: 10.1007/s11547-014-0487-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 12/12/2014] [Indexed: 12/01/2022]
Abstract
The bowel and the mesentery represent the third most frequently involved structures in blunt abdominal trauma after the liver and the spleen. Clinical assessment alone in patients with suspected intestinal and/or mesenteric injury from blunt abdominal trauma is associated with unacceptable diagnostic delays. Multi-detector computed tomography, thanks to its high spatial, time and contrast resolutions, allows a prompt identification and proper classification of such conditions. The radiologist, in fact, is asked not only to identify the signs of trauma but also to provide an indication of their clinical significance, suggesting the chance of conservative treatment in the cases of mild and moderate, non-complicated or self-limiting injuries and focusing on life-threatening conditions which may benefit from immediate surgical or interventional procedures. Specific and non-specific CT signs of bowel and mesenteric injuries from blunt abdominal trauma are reviewed in this paper.
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Affiliation(s)
- Francesco Iaselli
- Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domitiana, Km 30, 81100, Castel Volturno, Italy,
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Ann Sens M, Meyers SE, Koponen MA, Graff AH, Reynolds RD, Storm WG. Cervical Ganglia and Nerve Root Injury: Evidence for Respiratory Arrest as Initiating Injury in Pediatric Head Trauma. Acad Forensic Pathol 2014. [DOI: 10.23907/2014.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Cervical ganglia and nerve root injury with resultant paralysis of the phrenic nerve is proposed as a mechanism of injury in “shaken baby syndrome” or nonaccidental head injury of children. We report autopsy findings of a 22-month-old girl in which cervical ganglia and nerve hemorrhage was present along with the triad of encephalopathy, bilateral retinal hemorrhage, and bilateral subdural, intradural, and subarachnoid hemorrhages. Clear evidence of near immediate respiratory arrest was documented from first responder medical reports, juvenile witness statements, and perpetrator confession. The narrowing of time of injury from the anatomic findings at autopsy allowed investigative efforts to focus on a single individual and cleared several other adults with access to the child. Additional technical notes based on our experience are provided for users of cervical neck dissection. Hemorrhage in the tissues surrounding the vertebral artery raises a potential additional injury site in cases of neck injury.
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Affiliation(s)
- Mary Ann Sens
- Professor and Chair of Pathology at University of North Dakota School of Medicine and Health Sciences, Coroner, Grand Forks County, ND, Forensic Examiner for 19 counties in ND, and Chief Medical Examiner for Kittson, Lake of the Woods, Mahnomen, Marshall, Norman, Polk, Red Lake and Roseau Counties in MN
| | - Sarah E. Meyers
- Professor and Chair of Pathology at University of North Dakota School of Medicine and Health Sciences, Coroner, Grand Forks County, ND, Forensic Examiner for 19 counties in ND, and Chief Medical Examiner for Kittson, Lake of the Woods, Mahnomen, Marshall, Norman, Polk, Red Lake and Roseau Counties in MN
| | - Mark A. Koponen
- Professor and Chair of Pathology at University of North Dakota School of Medicine and Health Sciences, Coroner, Grand Forks County, ND, Forensic Examiner for 19 counties in ND, and Chief Medical Examiner for Kittson, Lake of the Woods, Mahnomen, Marshall, Norman, Polk, Red Lake and Roseau Counties in MN
| | - Arne H. Graff
- Professor and Chair of Pathology at University of North Dakota School of Medicine and Health Sciences, Coroner, Grand Forks County, ND, Forensic Examiner for 19 counties in ND, and Chief Medical Examiner for Kittson, Lake of the Woods, Mahnomen, Marshall, Norman, Polk, Red Lake and Roseau Counties in MN
| | - Ryan D. Reynolds
- Professor and Chair of Pathology at University of North Dakota School of Medicine and Health Sciences, Coroner, Grand Forks County, ND, Forensic Examiner for 19 counties in ND, and Chief Medical Examiner for Kittson, Lake of the Woods, Mahnomen, Marshall, Norman, Polk, Red Lake and Roseau Counties in MN
| | - Waldemar G. Storm
- Professor and Chair of Pathology at University of North Dakota School of Medicine and Health Sciences, Coroner, Grand Forks County, ND, Forensic Examiner for 19 counties in ND, and Chief Medical Examiner for Kittson, Lake of the Woods, Mahnomen, Marshall, Norman, Polk, Red Lake and Roseau Counties in MN
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17
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Hynick NH, Brennan M, Schmit P, Noseworthy S, Yanchar NL. Identification of blunt abdominal injuries in children. J Trauma Acute Care Surg 2014; 76:95-100. [PMID: 24368362 DOI: 10.1097/ta.0b013e3182ab0dfa] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The use of computed tomography (CT) to screen for injuries in pediatric blunt abdominal trauma (BAT) is increasing, concurrent with increasing concern over long-term risk of radiation-associated malignancies. We proposed to determine features that could be identified in the early assessment of these patients, which can predict the likelihood of clinically important intra-abdominal injuries warranting imaging by CT. We further queried if these were discrepant from factors associated with the decision to obtain an abdominal CT. METHODS Data of patients admitted with BAT to one of two Level I pediatric trauma centers were reviewed retrospectively. Clinical, laboratory, radiographic, and epidemiologic data were collected. Logistic regression was used to determine associations between pre-CT findings and ultimate diagnoses of "notable" or "clinically important" intra-abdominal injuries. Similar analyses were performed to determine which findings were associated with actually receiving an abdominal CT scan. RESULTS Of 571 patients, 37% had a notable intra-abdominal injury and 18% a clinically important intra-abdominal injury. After adjusting for all covariates, hematuria (gross or microscopic), elevated serum alanine aminotransferase, and documentation of clinically concerning abdominal findings upon examination remained significant predictors (odds ratio (OR), 3.5; 95% confidence interval [CI], 1.8-6.8; OR, 10.9; 95% CI, 2.5-47, respectively) of a clinically important injury. Undergoing a CT head and the presence of hematuria were significantly associated with obtaining a CT of the abdomen (OR, 3.4; 95% CI, 1.5-7.7; OR, 2.9; 95% CI, 1.1-7.3, respectively), while concerning abdominal findings and decreased Glasgow Coma Scale (GCS) score were not. CONCLUSION Clinical variables may be used to predict intra-abdominal injuries after pediatric BAT that may warrant imaging with CT scanning. Combined with findings from similar studies, it may be possible to derive and validate a decision-making rule both sensitive and specific in predicting the need for abdominal CT scanning in these patients. LEVEL OF EVIDENCE Prognostic study, level III.
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Affiliation(s)
- Nina H Hynick
- From the Division of Pediatric General Surgery (N.H.H., N.L.Y.) and Department of Diagnostic Imaging (P.S.), Dalhousie University, Halifax, Nova Scotia; and Department of Emergency Medicine (M.B., S.N.), Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Abstract
Radiologic studies are a vital component in the workup and diagnosis of disease. An appropriate radiographic study will accurately rule in or rule out disease with the least possible harm. Special considerations are necessary for the imaging of children. Current trends in pediatric imaging support the increased use of ultrasound and magnetic resonance imaging to decrease radiation exposure. In this review, we highlight some of the emerging concepts in the radiographic workup of pediatric disease, with a focus on decreasing ionizing radiation, increasing ultrasound use, and using clinical decision rules to identify children who do not need imaging.
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The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. J Pediatr Surg 2013; 48:1377-83. [PMID: 23845633 DOI: 10.1016/j.jpedsurg.2013.03.038] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 03/08/2013] [Indexed: 01/08/2023]
Abstract
PURPOSE With increasing concerns about radiation exposure, we questioned whether a structured program of FAST might decrease CT use. METHODS All pediatric trauma surgeons in our level 1 pediatric trauma center underwent formal FAST training. Children with potential abdominal trauma and no prior imaging were prospectively evaluated from 10/2/09 to 7/31/11. After physical exam and FAST, the surgeon declared whether the CT could be eliminated. RESULTS Of 536 children who arrived without imaging, 183 had potential abdominal trauma. FAST was performed in 128 cases and recorded completely in 88. In 48% (42/88) the surgeon would have elected to cancel the CT based on the FAST and physical exam. One of the 42 cases had a positive FAST and required emergent laparotomy; the others were negative. The sensitivity of FAST for injuries requiring operation or blood transfusion was 87.5%. The sensitivity, specificity, PPV, and NPV in detecting pathologic free fluid were 50%, 85%, 53.8%, and 87.9%. CONCLUSIONS True positive FAST exams are uncommon and would rarely direct management. While the negative FAST would have potentially reduced CT use due to practitioner reassurance, this reassurance may be unwarranted given the test's sensitivity.
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Khasawneh R, Ramakrishnaiah RH, Singh S, Hegde SV. CT findings in pediatric blunt intestinal injury. Emerg Radiol 2013; 20:545-52. [PMID: 23584795 DOI: 10.1007/s10140-013-1122-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 03/19/2013] [Indexed: 10/27/2022]
Abstract
Trauma is the leading cause of morbidity and mortality in children. Computed tomography examinations play an important role in the management of patients with major trauma. Though abdominal trauma is less common compared to head injuries, the associated morbidity and mortality are substantial. It is easier to diagnose solid abdominal injuries than intestinal or mesenteric injuries on CT examinations. However, recognition of bowel injury is very important as a delay in diagnosis increases the morbidity and mortality. Hence, with every CT of the abdomen and pelvis, the radiologist must look for signs of bowel and mesenteric injury. This pictorial review presents various CT findings of blunt intestinal injury in children.
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Affiliation(s)
- Ruba Khasawneh
- Section of Pediatric Radiology, Department of Radiology, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's way, Little Rock, AR, 72202, USA
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Lindberg DM, Shapiro RA, Blood EA, Steiner RD, Berger RP. Utility of hepatic transaminases in children with concern for abuse. Pediatrics 2013; 131:268-75. [PMID: 23319537 DOI: 10.1542/peds.2012-1952] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Routine testing of hepatic transaminases, amylase, and lipase has been recommended for all children evaluated for physical abuse, but rates of screening are widely variable, even among abuse specialists, and data for amylase and lipase testing are lacking. A previous study of screening in centers that endorsed routine transaminase screening suggested that using a transaminase threshold of 80 IU/L could improve injury detection. Our objectives were to prospectively validate the test characteristics of the 80-IU/L threshold and to determine the utility of amylase and lipase to detect occult abdominal injury. METHODS This was a retrospective secondary analysis of the Examining Siblings To Recognize Abuse research network, a multicenter study in children younger than 10 years old who underwent subspecialty evaluation for physical abuse. We determined rates of identified abdominal injuries and results of transaminase, amylase, and lipase testing. Screening studies were compared by using basic test characteristics (sensitivity, specificity) and the area under the receiver operating characteristic curve. RESULTS Abdominal injuries were identified in 82 of 2890 subjects (2.8%; 95% confidence interval: 2.3%-3.5%). Hepatic transaminases were obtained in 1538 (53%) subjects. Hepatic transaminases had an area under the receiver operating characteristic curve of 0.87. A threshold of 80 IU/L yielded sensitivity of 83.8% and specificity of 83.1%. The areas under the curve for amylase and lipase were 0.67 and 0.72, respectively. CONCLUSIONS Children evaluated for physical abuse with transaminase levels >80 IU/L should undergo definitive testing for abdominal injury.
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Affiliation(s)
- Daniel M Lindberg
- Department of Emergency Medicine, Brigham & Women's Hospital, 75 Francis St, Neville House, Boston, MA 02132, USA.
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