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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement. Ann Emerg Med 2024; 84:e13-e23. [PMID: 39032991 DOI: 10.1016/j.annemergmed.2024.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 03/21/2024] [Indexed: 07/23/2024]
Abstract
Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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2
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Annam A, Alexander ES, Cahill AM, Foley D, Green J, Himes EA, Johnson DT, Josephs S, Kulungowski AM, Leonard JC, Nance ML, Patel S, Pezeshkmehr A, Riggle K. Society of Interventional Radiology Position Statement on Endovascular Trauma Intervention in the Pediatric Population. J Vasc Interv Radiol 2024; 35:1104-1116.e19. [PMID: 38631607 DOI: 10.1016/j.jvir.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 04/19/2024] Open
Affiliation(s)
- Aparna Annam
- Division of Pediatric Radiology, Department of Radiology, University of Colorado, School of Medicine, Children's Hospital Colorado, Aurora, Colorado.
| | - Erica S Alexander
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne Marie Cahill
- Department of Interventional Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David Foley
- Department of Surgery, University of Louisville, School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Jared Green
- Joe DiMaggio Children's Hospital, Envision Radiology Associates of Hollywood, Pembroke Pines, Florida
| | | | | | - Shellie Josephs
- Department of Radiology, Texas Children's Hospital North Austin/Baylor College of Medicine, Austin, Texas
| | - Ann M Kulungowski
- Division of Pediatric Surgery, Department of Surgery, University of Colorado, School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Julie C Leonard
- Division of Emergency Medicine, Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Michael L Nance
- Department of Surgery, Division of Pediatric General and Thoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Amir Pezeshkmehr
- Department of Radiology, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Kevin Riggle
- Department of Surgery, University of Louisville, School of Medicine, Norton Children's Hospital, Louisville, Kentucky
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3
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement. J Am Coll Radiol 2024; 21:1108-1118. [PMID: 38944444 DOI: 10.1016/j.jacr.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement. Pediatrics 2024; 154:e2024066854. [PMID: 38932710 DOI: 10.1542/peds.2024-066854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging, is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Lyttle BD, Williams RF, Stylianos S. Management of Pediatric Solid Organ Injuries. CHILDREN (BASEL, SWITZERLAND) 2024; 11:667. [PMID: 38929246 PMCID: PMC11202015 DOI: 10.3390/children11060667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 05/24/2024] [Accepted: 05/26/2024] [Indexed: 06/28/2024]
Abstract
Solid organ injury (SOI) is common in children who experience abdominal trauma, and the management of such injuries has evolved significantly over the past several decades. In 2000, the American Pediatric Surgical Association (APSA) published the first societal guidelines for the management of blunt spleen and/or liver injury (BLSI), advocating for optimized resource utilization while maintaining patient safety. Nonoperative management (NOM) has become the mainstay of treatment for SOI, and since the publication of the APSA guidelines, numerous groups have evaluated how invasive procedures, hospitalization, and activity restrictions may be safely minimized in children with SOI. Here, we review the current evidence-based management guidelines in place for the treatment of injuries to the spleen, liver, kidney, and pancreas in children, including initial evaluation, inpatient management, and long-term care, as well as gaps that exist in the current literature that may be targeted for further optimization of protocols for pediatric SOI.
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Affiliation(s)
- Bailey D. Lyttle
- Department of Surgery, University of Colorado School of Medicine and Children’s Hospital Colorado, 12631 East 17th Avenue, Room 6111, Aurora, CO 80045, USA;
| | - Regan F. Williams
- Department of Surgery, Le Bonheur Children’s Hospital, 49 North Dunlap Avenue, Second Floor, Memphis, TN 38105, USA;
| | - Steven Stylianos
- Division of Pediatric Surgery, Columbia University Vagelos College of Physicians & Surgeons, Morgan Stanley Children’s Hospital, 3959 Broadway—Rm 204 N, New York, NY 10032, USA
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Holmes JF, Yen K, Ugalde IT, Ishimine P, Chaudhari PP, Atigapramoj N, Badawy M, McCarten-Gibbs KA, Nielsen D, Sage AC, Tatro G, Upperman JS, Adelson PD, Tancredi DJ, Kuppermann N. PECARN prediction rules for CT imaging of children presenting to the emergency department with blunt abdominal or minor head trauma: a multicentre prospective validation study. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:339-347. [PMID: 38609287 DOI: 10.1016/s2352-4642(24)00029-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND The intra-abdominal injury and traumatic brain injury prediction rules derived by the Pediatric Emergency Care Applied Research Network (PECARN) were designed to reduce inappropriate use of CT in children with abdominal and head trauma, respectively. We aimed to validate these prediction rules for children presenting to emergency departments with blunt abdominal or minor head trauma. METHODS For this prospective validation study, we enrolled children and adolescents younger than 18 years presenting to six emergency departments in Sacramento (CA), Dallas (TX), Houston (TX), San Diego (CA), Los Angeles (CA), and Oakland (CA), USA between Dec 27, 2016, and Sept 1, 2021. We excluded patients who were pregnant or had pre-existing neurological disorders preventing examination, penetrating trauma, injuries more than 24 h before arrival, CT or MRI before transfer, or high suspicion of non-accidental trauma. Children presenting with blunt abdominal trauma were enrolled into an abdominal trauma cohort, and children with minor head trauma were enrolled into one of two age-segregated minor head trauma cohorts (younger than 2 years vs aged 2 years and older). Enrolled children were clinically examined in the emergency department, and CT scans were obtained at the attending clinician's discretion. All enrolled children were evaluated against the variables of the pertinent PECARN prediction rule before CT results were seen. The primary outcome of interest in the abdominal trauma cohort was intra-abdominal injury undergoing acute intervention (therapeutic laparotomy, angiographic embolisation, blood transfusion, intravenous fluid for ≥2 days for pancreatic or gastrointestinal injuries, or death from intra-abdominal injury). In the age-segregated minor head trauma cohorts, the primary outcome of interest was clinically important traumatic brain injury (neurosurgery, intubation for >24 h for traumatic brain injury, or hospital admission ≥2 nights for ongoing symptoms and CT-confirmed traumatic brain injury; or death from traumatic brain injury). FINDINGS 7542 children with blunt abdominal trauma and 19 999 children with minor head trauma were enrolled. The intra-abdominal injury rule had a sensitivity of 100·0% (95% CI 98·0-100·0; correct test for 145 of 145 patients with intra-abdominal injury undergoing acute intervention) and a negative predictive value (NPV) of 100·0% (95% CI 99·9-100·0; correct test for 3488 of 3488 patients without intra-abdominal injuries undergoing acute intervention). The traumatic brain injury rule for children younger than 2 years had a sensitivity of 100·0% (93·1-100·0; 42 of 42) for clinically important traumatic brain injuries and an NPV of 100·0%; 99·9-100·0; 2940 of 2940), whereas the traumatic brain injury rule for children aged 2 years and older had a sensitivity of 98·8% (95·8-99·9; 168 of 170) and an NPV of 100·0% (99·9-100·0; 6015 of 6017). The two children who were misclassified by the traumatic brain injury rule were admitted to hospital for observation but did not need neurosurgery. INTERPRETATION The PECARN intra-abdominal injury and traumatic brain injury rules were validated with a high degree of accuracy. Their implementation in paediatric emergency departments can therefore be considered a safe strategy to minimise inappropriate CT use in children needing high-quality care for abdominal or head trauma. FUNDING The Eunice Kennedy Shriver National Institute of Child Health and Human Development.
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Affiliation(s)
- James F Holmes
- Department of Emergency Medicine, School of Medicine, University of California Davis, Sacramento, CA, USA.
| | - Kenneth Yen
- Division of Pediatric Emergency Medicine, Department of Pediatrics, School of Medicine, University of Texas Southwestern, Dallas, TX, USA; Children's Health, University of Texas Southwestern, Dallas, TX, USA
| | - Irma T Ugalde
- Department of Emergency Medicine, McGovern Medical School, Houston, TX, USA
| | - Paul Ishimine
- Department of Emergency Medicine and Department of Pediatrics, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Nisa Atigapramoj
- Department of Emergency Medicine, UCSF Benioff Children's Hospital, Oakland, CA, USA
| | - Mohamed Badawy
- Division of Pediatric Emergency Medicine, Department of Pediatrics, School of Medicine, University of Texas Southwestern, Dallas, TX, USA; Children's Health, University of Texas Southwestern, Dallas, TX, USA
| | | | - Donovan Nielsen
- Department of Emergency Medicine, School of Medicine, University of California Davis, Sacramento, CA, USA
| | - Allyson C Sage
- Department of Emergency Medicine, School of Medicine, University of California Davis, Sacramento, CA, USA
| | - Grant Tatro
- Virginia Commonwealth School of Medicine, Richmond, VA, USA
| | - Jeffrey S Upperman
- Department of Pediatric Surgery, Vanderbilt University, Nashville, TN, USA
| | - P David Adelson
- Department of Neurosurgery, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA
| | - Daniel J Tancredi
- Department of Pediatrics, School of Medicine, University of California Davis, Sacramento, CA, USA
| | - Nathan Kuppermann
- Department of Emergency Medicine, School of Medicine, University of California Davis, Sacramento, CA, USA; Department of Pediatrics, School of Medicine, University of California Davis, Sacramento, CA, USA
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Lamoshi A, Lay R, Wakeman D, Edwards M, Wallenstein K, Fabiano T, Singh Z, Zipkin J, Park S, Yu J, Chess M, Vali K. Validation of the predictive model for operative intervention after blunt abdominal trauma in children with equivocal computed tomography findings: a multi-institutional study. Pediatr Surg Int 2024; 40:39. [PMID: 38270628 DOI: 10.1007/s00383-023-05616-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND We recently developed a preliminary predictive model identifying clinical and radiologic factors associated with the need for surgery following blunt abdominal trauma (BAT) in children. Our aim in this study was to further validate the factors in this predictive model in a multi-institutional study. METHODS A retrospective chart review of pediatric patients from five pediatric trauma centers who experienced BAT between 2011 and 2020 was performed. Patients under 18 years of age who had BAT and computed tomography (CT) abdomen imaging were included. Children with evidence of pneumoperitoneum, and hemodynamic instability were excluded. Fisher's exact test was used for statistical analysis of the association between the following risk factors and need for laparotomy: abdominal wall bruising (AWB), abdominal pain/tenderness (APT), thoracolumbar fracture (TLF), presence of free fluid (FF), presence of solid organ injury (SOI). A predictive logistic regression model was then estimated employing these factors. FINDINGS Seven hundred thirty-four patients were identified in this multi-institutional dataset with BAT and abdominal CT imaging, and 726 were included. Of those, 59 underwent surgical intervention (8.8%). Univariate analysis of association between the studied factors and need for surgical management showed that the presence of TLF (p < 0.01), APT (p < 0.01), FF (p < 0.01), and SOI (p < 0.01) were significantly associated. A predictive model was created using the 5 factors resulting in an area under the curve (AUC) of 0.80. For the motor vehicle collisions (MVC) group, only FF, SOI, and TLF are significantly associated with the need for surgical intervention. The AUC for the MVC group was 0.87. CONCLUSIONS A clinical and radiologic prediction rule was validated using a large multi-institutional dataset of pediatric BAT patients, demonstrating a high degree of accuracy in identifying children who underwent surgery. FF, SOI, and TLF are the most important factors associated with the need for surgical intervention. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - Raymond Lay
- University of Rochester Medical Center, Rochester, NY, USA
| | - Derek Wakeman
- University of Rochester Medical Center, Rochester, NY, USA
| | - Mary Edwards
- Albany Medical College and Center, Albany, NY, USA
| | | | | | | | - Jacob Zipkin
- Albany Medical College and Center, Albany, NY, USA
| | | | | | - Mitchell Chess
- University of Rochester Medical Center, Rochester, NY, USA
| | - Kaveh Vali
- John R. Oishei Children's Hospital, Buffalo, NY, USA
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Lavigne JM, Thompson RJ, Short M. Cirrhotic ascites masquerading as haemoperitoneum in paediatric trauma: The diagnostic dilemma. Emerg Med Australas 2023; 35:1047-1048. [PMID: 37666653 DOI: 10.1111/1742-6723.14314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 11/18/2022] [Accepted: 08/24/2023] [Indexed: 09/06/2023]
Affiliation(s)
- Jordan M Lavigne
- Department of Paediatric Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Richard J Thompson
- Department of Paediatric Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Melissa Short
- Department of Paediatric Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
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Mahdi E, Toscano N, Pierson L, Ndikumana E, Ayers B, Chacon A, Brayer A, Chess M, Davis C, Dorman R, Livingston M, Arca M, Wakeman D. Sustaining the gains: Reducing unnecessary computed tomography scans in pediatric trauma patients. J Pediatr Surg 2023; 58:111-117. [PMID: 36272813 DOI: 10.1016/j.jpedsurg.2022.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 09/16/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND/PURPOSE "Pan-scanning" pediatric blunt trauma patients leads to exposure to harmful radiation and increased healthcare costs without improving outcomes. We aimed to reduce computed tomography (CT) scans that are not indicated (NI) by imaging guidelines for injured children. METHODS In July 2017, our Pediatric Trauma Center prospectively implemented validated imaging guidelines to direct CT imaging for trauma activations and consultations for children younger than 16 years old with blunt traumatic injuries. Patients with suspected physical abuse, CT imaging prior to arrival, penetrating mechanism, and instability precluding CT imaging were excluded. We compared CT scanning rates for pre-implementation (01/2016-06/2017) and post-implementation (07/2017-08/2021) time periods. Guideline compliance was evaluated by chart review and sustained through iterative process improvement cycles. RESULTS During the pre-implementation era, 61 patients underwent 171 CT scans of which 87 (51%) scans were not indicated by guidelines. Post-implementation, 363 patients had 531 scans and only 134 (25%) CTs were not indicated. Total CTs performed declined after initiation of guidelines (2.80 vs 1.46 scans/patient, p<0.0001). Total NI CTs declined (1.41 vs 0.37 NI scans/patient, p<0.0001) reflected in significant reductions in all anatomic regions: head, cervical spine, chest, and abdomen/pelvis. Charges related to NI scans decreased from $1,490.31/patient to $408.21/patient, saving $218,000 in charges. Based on prior utilization, 146 children were spared excessive radiation with no clinically significant missed injuries since guideline implementation. CONCLUSIONS Quality improvement and implementation science methodologies to enhance compliance with imaging guidelines for children with blunt injuries can significantly reduce unnecessary CT scanning without compromising care. This practice reduces harmful radiation exposure in a sensitive patient population and may save healthcare systems money and resources.
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Affiliation(s)
- Elaa Mahdi
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Nicole Toscano
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Lauren Pierson
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Eric Ndikumana
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Brian Ayers
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Alexander Chacon
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Anne Brayer
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Mitchell Chess
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Colleen Davis
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Robert Dorman
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Michael Livingston
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Marjorie Arca
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Derek Wakeman
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States.
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Kolousek A, Sharma B, Lian B, Koganti D, Smith RN, Sola R. Understanding abdominal pelvic computerized tomography scan usage amongst adolescent blunt trauma patients treated at adult trauma centers. Injury 2023; 54:100-104. [PMID: 35999064 DOI: 10.1016/j.injury.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/25/2022] [Accepted: 08/03/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The algorithm for evaluating adolescent patients with blunt trauma includes abdominal pelvic CT (APCT). The aim of this study is to evaluate the utility of APCT in this context. METHODS We performed a retrospective review of adolescent (11 to 18 years of age) blunt trauma patients at an urban adult level 1 trauma center from January 2015 to December 2019. The primary outcome was the prevalence of positive findings on APCT scan. Additionally, clinical risk factors concerning for intra-abdominal injury were analyzed. RESULTS There were 546 patients evaluated for blunt trauma and the prevalence of APCT within the population was 59.3% (95% CI 54.2%-64.9%). Of the patients who received APCT, 123 (37.9%) had positive findings on APCT. Only 25 patients (7.7% of those who underwent APCT) required abdominal surgery while 40 patients (12.3%) had intraabdominal injury that did not require surgery. Risk factors were present in 100% of patients with intraabdominal injury and absent in 28.7% of patients without intraabdominal injury. Abnormal abdominal exam, abnormal FAST, positive chest x-ray and elevated transaminases were independently associated with intraabdominal injury. CONCLUSIONS Our study found that adolescent blunt trauma patients treated at our trauma center had a higher rate of APCT usage, but a comparable rate of positive findings when compared with the most recent literature. Future studies should focus on reducing the number of patients who undergo APCT despite an absence of clinical risk factors.
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Affiliation(s)
- Anastasia Kolousek
- Morehouse School of Medicine, Department of Surgery, 720 Westview Drive, Atlanta, GA 30310, United States.
| | - Bharath Sharma
- Morehouse School of Medicine, Department of Surgery, 720 Westview Drive, Atlanta, GA 30310, United States.
| | - Brad Lian
- Mercer University School of Medicine, Department of Community Medicine, 1501 Mercer University Drive, Macon, GA 30341, United States.
| | - Deepika Koganti
- Emory University School of Medicine, Department of Surgery, 69 Jesse Hill Jr. Dr. SE, Atlanta, GA 30303, United States.
| | - Randi N Smith
- Emory University School of Medicine, Department of Surgery, 69 Jesse Hill Jr. Dr. SE, Atlanta, GA 30303, United States.
| | - Richard Sola
- Morehouse School of Medicine, Department of Surgery, 720 Westview Drive, Atlanta, GA 30310, United States.
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13
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Perin I, Guetter CR, Klüppel LE, Fachin CG, Pimentel SK. CT scan in the evaluation of pediatric abdominal trauma. Rev Col Bras Cir 2022; 49:e20223246. [PMID: 36515330 PMCID: PMC10578840 DOI: 10.1590/0100-6991e-20223246-en] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 08/06/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE to assess the need of computed tomography (CT) for the definition of management in pediatric abdominal trauma. METHODS observational retrospective study with patients under 18 years old victims of blunt or penetrating abdominal trauma that underwent CT of the abdomen and pelvis at admission. We evaluated CT scan findings, indications and management. We calculated the sensitivity, specificity, positive predictive value and negative predictive value of clinical variables and energy of trauma for findings on CT. RESULTS among the 236 patients included in our study, 72% (n=170) did not present abnormal findings on CT. It was performed surgical treatment in 15% (n=10), conservative treatment in 54,5% (n=36) and 27% (n=18) did not receive treatment for abdominal injuries. In the assessment of CT indications, 28,8% (n=68) presented no justifications. In this group, 91% (n=62) did not show any abnormal findings. Among the six patients with positive findings, half were selected for conservative treatment, while the rest did not need any treatment for abdominal injuries. The presence of abdominal pain, hemodynamic alterations and high energy blunt trauma had low positive predictive values when isolated, whereas the negative predictive values were higher. CONCLUSION although CT is necessary in some instances, there is a possible high number of exams that did not make any difference in the management of the pediatric population.
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Affiliation(s)
- Isabella Perin
- - Universidade Federal do Paraná - Curitiba - PR - Brasil
| | - Camila Roginski Guetter
- - Universidade Federal do Paraná - Curitiba - PR - Brasil
- - Johns Hopkins Bloomberg School of Public Health - Baltimore - Maryland - Estados Unidos
| | | | | | - Silvania Klug Pimentel
- - Universidade Federal do Paraná - Curitiba - PR - Brasil
- - Hospital do Trabalhador, Cirurgia Geral - Curitiba - PR - Brasil
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14
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Notrica D. Evidence-based management of pediatric solid organ injury. Semin Pediatr Surg 2022; 31:151216. [PMID: 36395651 DOI: 10.1016/j.sempedsurg.2022.151216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- David Notrica
- Phoenix Children's - Division of Pediatric Surgery, 1919 E Thomas Rd, Phoenix, AZ 85016-7710.
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15
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Can we reduce CT scan and hospital costs in children with blunt trauma using four parameters? ANNALS OF PEDIATRIC SURGERY 2022. [DOI: 10.1186/s43159-021-00142-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Blunt trauma is one of the most common causes of admission to the emergency service in childhood. Children with trauma are generally evaluated in emergency services where pediatric and adult patients are together, and difficulties are experienced in managing children exposed to trauma. CT is preferred for quick detection and grading of toracoabdominal, skeleton, and neurological injury in high energy trauma. The present study aims to determine the severity of trauma and whether CT exposure can be reduced and patient cost using four parameters.
This study was conducted with 586 pediatric patients exposed to blunt abdominal trauma. The clinical prediction rule consisted of four parameters, including abdominal pain, physical examination findings, aspartate aminotransferase (AST), and chest x-ray (CXR, which was used to predict intraabdominal injury in patients with blunt trauma. Patients with no parameters of the clinical decision rule were considered very low risk, and those with one or more parameters were considered at risk. The hospital cost of the patients with and without clinical decision rule was calculated and compared.
Results
In our study, according to the four-variable clinical prediction rule, 88.1% of the patients had a very low risk of intraabdominal injury and 11.9% of them were at risk. The sensitivity was 97.3%, specificity 98.2%, and accuracy was 97.4% in very low-risk patients with four variables clinical prediction rule. In the very low-risk patients, the abnormal CT rate was 0.3% and conservative treatment was performed. With the use of four variables, 0.17% of solid organ injuries may be overlooked. In the risk of patients, 2.9% of these patients were abnormal CT findings, while tube thoracostomy was performed in four patients with pneumothorax, conservative treatment was performed in other patients.
It was determined that routine computed tomography scan increased the patient cost by 5.5 times.
Conclusion
Patients exposed to blunt trauma with a very low risk of intra-abdominal injury can be identified with a four-variable clinical prediction rule. According to the four-variable clinical prediction rule, very low-risk patients do not require immediate CT. The hospital costs can be reduced by reducing the CT scan. However, it should be kept in mind that a small proportion of intra-abdominal injuries may be overlooked.
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Sigal AP, Deaner T, Woods S, Mannarelli E, Muller AL, Martin A, Schoener A, Brower M, Ong A, Geng T, Guillen F, Lahmann B, Wasser T, Valente C. External validation of a pediatric decision rule for blunt abdominal trauma. J Am Coll Emerg Physicians Open 2022; 3:e12623. [PMID: 35072160 PMCID: PMC8760953 DOI: 10.1002/emp2.12623] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 11/04/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Blunt traumatic injuries are a leading cause of morbidity and mortality in the pediatric population. Contrast-enhanced multidetector computed tomography is the best imaging tool for screening patients at risk of blunt abdominal injury. The Pediatric Emergency Care Applied Research Network (PECARN) abdominal rule was derived to identify patients at low risk for significant abdominal injury who do not require imaging. METHODS We conducted a retrospective review of pediatric patients with blunt trauma to validate the PECARN rule in a non-pediatric specialized hospital from February 3, 2013, through December 31, 2019. We excluded those with penetrating or mild isolated head injury. The PECARN decision rule was retrospectively applied for the presence of a therapeutic intervention, defined as a laparotomy, angiographic embolization, blood transfusion, or administration of intravenous fluids for pancreatic or gastrointestinal injury. Sensitivity and specificity analysis were conducted along with the negative and positive predictive values. RESULTS A total of 794 patients were included in the final analysis; 23 patients met the primary outcome for an acute intervention. The PECARN clinical decision rule (CDR) had a sensitivity of 91.3%, a negative predictive value of 99.5, and a negative likelihood ration of 0.16. CONCLUSION In a non-pediatric specialty hospital, the PECARN blunt abdominal CDR performed with comparable sensitivity and negative predictive value to the derivation and external validation study performed at specialized children's hospitals.
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Affiliation(s)
- Adam P. Sigal
- Department of Emergency MedicineReading HospitalWest ReadingPennsylvaniaUSA
| | - Traci Deaner
- Department of Emergency MedicineReading HospitalWest ReadingPennsylvaniaUSA
| | - Sam Woods
- Department of Emergency MedicineReading HospitalWest ReadingPennsylvaniaUSA
| | | | - Alison L. Muller
- Department of SurgerySection of Trauma and Critical CareReading HospitalWest ReadingPennsylvaniaUSA
| | - Anthony Martin
- Department of SurgerySection of Trauma and Critical CareReading HospitalWest ReadingPennsylvaniaUSA
| | | | | | - Adrian Ong
- Department of SurgerySection of Trauma and Critical CareReading HospitalWest ReadingPennsylvaniaUSA
| | - Thomas Geng
- Department of SurgerySection of Trauma and Critical CareReading HospitalWest ReadingPennsylvaniaUSA
| | - Felipe Guillen
- Drexel University College of MedicinePhiladelphiaPennsylvaniaUSA
| | - Brian Lahmann
- Department of Emergency MedicineReading HospitalWest ReadingPennsylvaniaUSA
| | - Tom Wasser
- Department of Emergency MedicineReading HospitalWest ReadingPennsylvaniaUSA
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Ozcan A, Ahn T, Akay B, Menoch M. Imaging for Pediatric Blunt Abdominal Trauma With Different Prediction Rules: Is the Outcome the Same? Pediatr Emerg Care 2022; 38:e654-e658. [PMID: 33616315 DOI: 10.1097/pec.0000000000002346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Computerized tomography (CT) of the abdomen and pelvis is the standard imaging modality to diagnose intra-abdominal injury (IAI). Clinicians must weigh the risk-benefit of CT compared with the degree of clinical suspicion for an IAI. Pediatric Emergency Care Applied Research Network (PECARN), Streck, and blunt abdominal trauma in children (BATiC) prediction rules have been published to help guide evaluation of these patients. Pediatric Emergency Care Applied Research Network uses history and physical examination findings, whereas Streck and BATiC use examination plus laboratory and imaging findings. At the time of the study, there was not a protocol that was more routinely sited. Our goal was to compare these different prediction rules. METHODS This was a retrospective electronic chart review of all children younger than 18 years presenting for either level 1 or 2 trauma activations at our pediatric emergency department (ED) between June 1, 2015, to June 30, 2017. Charts were manually reviewed for a mechanism concerning for abdominal trauma, and demographic data, history and physical examination findings, laboratory and imaging results per prediction rules, and revisits in 7 days were collected.The prediction rules were applied to all charts that had all data necessary. For study purposes, a score of zero for PECARN and Streck, and score of ≤5 for modified BATiC (mBATiC) were defined as "low risk." Patients with no CT, negative CT, and no new injury found on revisit were classified as "no IAI identified," and patients with positive CT or revisit with injury found as "IAI identified." The results were compared via Fisher exact test. RESULTS A total of 249 patients met the inclusion criteria with a median age of 12 years. Of the low-risk patients, 119 (98.7%) of 121 in PECARN group, 21 (100%) of 21 in Streck, and 48 (85.7%) of 56 in mBATiC group had no IAI identified. None of the low-risk patients required any intra-abdominal intervention. No missed IAI was identified during revisit review. Negative predictive values of all 3 rules were significant for PECARN, Streck, and mBATiC (98.35%, 100%, and 85.71%, respectively). Overall, 27 patients had positive CT results for IAI. CONCLUSIONS The PECARN and Streck rules have high negative predictive values to predict low-risk patients who do not require CT. When laboratory studies are not obtained, PECARN is an effective means of excluding IAI for low-risk patients. When laboratory tests were obtained, the Streck rule performed well. Overall, the results are similar to the past individual studies done on each individual rule. History and physical examination findings are of high importance in pediatric trauma. This study supports limited imaging when no abnormal findings are present in children with blunt torso trauma. This is the only study found in the literature that has compared 3 different prediction rules.
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Affiliation(s)
- Ali Ozcan
- From the Pediatric Emergency Department, Loma Linda University Medical Center, Loma Linda, CA
| | - Terrie Ahn
- Pediatric Allergy and Immunology Department, UCLA Mattel Children's Hospital, Los Angeles, CA
| | | | - Margaret Menoch
- Pediatric Emergency Department,William Beaumont Hospital, Royal Oak, MI
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18
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Prospective evaluation of an evidence-based decision tool to assess pediatric blunt abdominal trauma (BAT). Pediatr Surg Int 2022; 38:183-191. [PMID: 34586483 DOI: 10.1007/s00383-021-05013-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Computed tomography (CT) is currently the standard for evaluation of intra-abdominal injury (IAI) after BAT. Pediatric patients receiving CT scans based on adult clinical protocols are potentially exposed to unnecessary radiation. The purpose of this study is to determine the rate of CT scans before and after implementation of a pediatric BAT decision tool. METHODS We adapted and implemented an evidence-based decision tool for pediatric BAT based on five clinical variables. We reviewed patient charts 18 months pre- and post-implementation. Demographics and outcomes were compared using Chi-square and Fisher's exact test, accordingly. RESULTS The pre and post-implementation groups were uniform when comparing age, sex, mechanism, and Injury Severity Score. The decision tool was utilized in 85% of patients post-implementation. Fewer CT scans were obtained in the post-implementation group (28 vs. 21%, p = 0.215) with no missed injuries or late diagnoses. CONCLUSION Implementation of a pediatric BAT decision tool decreased CT usage and radiation exposure without an obvious compromise to patient care. This experience supports the utilization of these tools for the assessment of IAI after BAT and have resulted in more selective use of CT during pediatric BAT in our program.
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PERIN ISABELLA, GUETTER CAMILAROGINSKI, KLÜPPEL LÚCIOEDUARDO, FACHIN CAMILAGIRARDI, PIMENTEL SILVANIAKLUG. Tomografia computadorizada na avaliação do trauma abdominal pediátrico. Rev Col Bras Cir 2022. [DOI: 10.1590/0100-6991e-20223246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
RESUMO Introdução: avaliar a necessidade da tomografia computadorizada (TC) para definição de condutas em trauma abdominal pediátrico. Métodos: estudo observacional retrospectivo com pacientes menores de 18 anos vítimas de trauma abdominal contuso ou penetrante e que realizaram TC de abdome e pelve na admissão. Avaliou-se achados das tomografias, condutas e justificativas para indicação da TC. Foram calculados sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo de fatores clínicos e energia do trauma para alterações na TC. Resultados: dentre os 236 pacientes incluídos, 72% (n=170) não apresentaram alterações na TC. Foi realizado tratamento cirúrgico em 15% (n=10), tratamento conservador em 54,5% (n=36) e 27% (n=18) não receberam tratamento por lesões abdominais. Na avaliação das indicações de TC, 28,8% (n=68) não apresentavam nenhuma justificativa, sendo que nesse grupo 91% (n=62) resultaram em ausência de achados. Dentre os seis pacientes com achados positivos, metade recebeu tratamento conservador, enquanto o restante não necessitou de tratamento por lesões abdominais. A presença de dor abdominal, alteração hemodinâmica e trauma contuso de alta energia apresentaram baixos valores preditivos positivos de forma isolada, enquanto os valores preditivos negativos foram mais altos. Conclusão: apesar de a TC ser necessária e justificável em alguns casos, há um possível excesso de tomografias dispensáveis para definição de condutas em população pediátrica.
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Affiliation(s)
| | - CAMILA ROGINSKI GUETTER
- Universidade Federal do Paraná, Brazil; Johns Hopkins Bloomberg School of Public Health, Estados Unidos
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20
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Ohana-Sarna-Cahan L, Levin Y, Gross I, Hassidim A, Yuval JB, Hess A, Bala M, Hashavya S. Microhematuria as an Indicator of Significant Abdominal Injury. Pediatr Emerg Care 2021; 37:e1020-e1025. [PMID: 31283723 DOI: 10.1097/pec.0000000000001878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Trauma is one of the leading causes of morbidity and mortality in the pediatric population. In many centers, microhematuria is used as a screening tool for the presence of significant abdominal injury and as an indication for further imaging. Our objective was to evaluate the role of microhematuria by dipstick as an indicator of significant abdominal injury in children. METHODS A retrospective review of children aged 0 to 16 years admitted for a motor vehicle accident or a fall from 2007 to 2017 who had urinalyses performed. RESULTS The charts of 655 children were reviewed. Microhematuria was found in 100 children, of whom 49 (49%), 28 (28%), and 23 (23%) had small, moderate, and large amounts of hematuria, respectively. Of the children who had microhematuria, 41 underwent a computed tomography scan. Positive findings were recorded in 16 (39%) of these patients. There was a clear association between microhematuria as detected by the urine dipstick and a significant finding on the computed tomography scan (P = 0.002). The sensitivity of microhematuria for significant abdominal pathology on imaging was 66.6% and the specificity was 68.3% (positive predictive value, 39%; negative predictive value, 87.1%). Microhematuria was associated with increased length of stay in the hospital (P < 0.001), surgical interventions (P = 0.036), and admission to the pediatric intensive care unit (P < 0.001). CONCLUSIONS The diagnostic role of dipstick urine analysis in the assessment of intra-abdominal injury has low sensitivity and specificity. Nevertheless, it is still a valuable screening tool for the evaluation of the severity of injury.
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Affiliation(s)
| | | | - Itai Gross
- Department of Pediatric Emergency Medicine
| | | | | | - Amit Hess
- Department of Pediatric Emergency Medicine
| | - Miklosh Bala
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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21
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Wu A, Edwards MJ, Le R, Ata A, Adderly J, Savage C, Rosati C, Edwards K, Duncan L. Pediatric evidence-based imaging guidelines for adult trauma providers significantly reduces radiation exposure to children. TRAUMA-ENGLAND 2021. [DOI: 10.1177/14604086211028452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction Evidence suggests that stand-alone pediatric trauma centers outperform adult and combined adult/pediatric trauma centers in limiting radiation exposure to injured children. We sought to determine the impact of implementing evidence-based guidelines for pediatric imaging at a combined adult (level 1) and pediatric (level 2) center. The initiative focused on trauma/critical care surgeons as the pediatric surgeons did not participate in the resuscitation and initial evaluation of injured children. Methods Imaging guidelines were developed from existing clinical studies. After 3 months of education, guidelines were implemented, and regular feedback was given to providers regarding compliance. Data were collected from the trauma registry for all pediatric patients (aged less than 15 years), in calendar years 2017 (pre-guideline) and 2019 (post-guideline). All admissions were analyzed, with subgroup analysis of children with multisystem trauma admitted to the trauma surgery service. Results Following guideline implementation, mean computed tomography (CT) scans per injured child fell by over 50% (.93 vs .45). For patients admitted to the trauma service, the mean fell by 58% (1.82 vs 0.76). The number of patients receiving more than 1 CT significantly decreased for all children (26% vs 10%), and particularly those admitted to the trauma service (52% vs 17%). During this time, there was only one injury missed at the initial admission, which was clinically insignificant (non-displaced skull fracture). Conclusions Implementation of evidence-based guidelines for imaging eliminates disparity in practices between a combined adult/pediatric trauma center and stand-alone pediatric trauma centers.
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Affiliation(s)
- Anna Wu
- Department of Surgery, Albany Medical College and Center, Albany, NY, USA
| | - Mary J Edwards
- Department of Surgery, Albany Medical College and Center, Albany, NY, USA
| | - Rachel Le
- Department of Emergency Medicine, Albany Medical College and Center, Albany, NY, USA
| | - Ashar Ata
- Department of Surgery, Albany Medical College and Center, Albany, NY, USA
| | - Jasmine Adderly
- Department of Surgery, Albany Medical College and Center, Albany, NY, USA
| | - Colleen Savage
- Department of Surgery, Albany Medical College and Center, Albany, NY, USA
| | - Carl Rosati
- Department of Surgery, Albany Medical College and Center, Albany, NY, USA
| | - Kurt Edwards
- Department of Surgery, Albany Medical College and Center, Albany, NY, USA
| | - Luke Duncan
- Department of Emergency Medicine, Albany Medical College and Center, Albany, NY, USA
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22
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Isolated low-grade solid organ injuries in children following blunt abdominal trauma: Is it time to consider discharge from the emergency department? J Trauma Acute Care Surg 2021; 89:887-893. [PMID: 32769952 DOI: 10.1097/ta.0000000000002899] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Acute intervention (AI) for solid organ injury (SOI) is rare in hemodynamically stable children. Pediatric guidelines recommend admission with follow-up laboratories, even for low-grade injuries. METHODS Data sets from two large multicenter prospective observational studies were used to analyze a cohort of children (age, <17 years) with grade I to III SOI following blunt abdominal trauma. Children with hollow viscus injuries were excluded. Patients were divided into (a) those with or without other major injuries (OMIs) (traumatic brain injury, hemothorax or pneumothorax, pelvic fracture, urgent orthopedic or neurosurgical operations) and (b) with grade I or II versus grade III injuries. Outcomes included AIs (transfusion, angiography, abdominal operation) and disposition (admission unit and length of stay). RESULTS There were 14,232 children enrolled in the two studies, and 791 patients had a SOI (5.6%). After excluding patients with hollow viscus injuries and higher-grade SOIs, 517 patients with a grade I to III SOI were included, and 262 of these had no OMI. Among patients with no OMI, none of 148 patients with grade I or II SOI underwent AI, while only 3 of 114 patients with grade III injuries underwent AI (3 transfusions/1 angioembolization). All three had hemoperitoneum; two of three had an additional organ with a grade II injury. Among grade I and II SOIs with no OMI, 28 (18.9%) of 148 were admitted to an intensive care unit, 110 (74.3%) of 148 to floor, and 7 (4.7%) of 148 discharged home from emergency department; median length of stay 2 days. Among grade III SOIs with no OMI, 38 (33.3%) of 114 were admitted to an intensive care unit and 61.4% to the floor; median length of stay was 4 days. Among 255 patients with a grade I to III SOI and other major organ system injuries, 31 (12.2%) underwent AI. CONCLUSION No patient with a grade I and II SOI and no OMI following blunt abdominal trauma received intervention, suggesting that patients with low-grade SOI without OMIs could be safely observed and discharged from the emergency department. LEVEL OF EVIDENCE Therapeutic study, level IV.
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23
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Gaffley M, Neff LP, Sieren LM, Zeller KA, Pranikoff T, Rush T, Petty JK. Evaluation of an evidence-based guideline to reduce CT use in the assessment of blunt pediatric abdominal trauma. J Pediatr Surg 2021; 56:297-301. [PMID: 32788046 DOI: 10.1016/j.jpedsurg.2020.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/17/2020] [Accepted: 07/05/2020] [Indexed: 02/03/2023]
Abstract
PURPOSE About half of pediatric blunt trauma patients undergo an abdominopelvic computed tomographic (CT) scan, while few of these require intervention for an intraabdominal injury. We evaluated the effectiveness of an evidence-based guideline for blunt abdominal trauma at a Level I pediatric trauma center. METHODS Pediatric blunt trauma patients (n = 998) age 0-15 years who presented from the injury scene were evaluated over a 10 year period. After five years, we implemented our guideline in which the decision for CT was standardized based on mental status, abdominal examination, and laboratory results (alanine aminotransferase, aspartate aminotransferase, hemoglobin, urinalysis). RESULTS There were no differences in age, GCS, SIPA or ISS scores between the patients before or after guideline implementation. Nearly half of the patients (48.3%) underwent CT scan before guideline implementation compared to 36.7% after (p < 0.0002). There was no difference in ISS (p = 0.44) between CT scanned patients in either group. No statistical differences were found in rate of intervention (p = 0.20), length of stay (p = 0.65), or readmission rate (0.2%) before versus after guideline implementation. There were no missed injuries. CONCLUSION Implementation of an evidence-based clinical guideline for pediatric patients with blunt abdominal trauma decreases the rate of CT utilization while accurately identifying significant injuries. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Michaela Gaffley
- Wake Forest School of Medicine, General Surgery, Winston-Salem, North Carolina.
| | - Lucas P Neff
- Wake Forest School of Medicine, General Surgery, Section of Pediatric Surgery, Winston-Salem, North Carolina
| | - Leah M Sieren
- Wake Forest School of Medicine, General Surgery, Section of Pediatric Surgery, Winston-Salem, North Carolina
| | - Kristen A Zeller
- Wake Forest School of Medicine, General Surgery, Section of Pediatric Surgery, Winston-Salem, North Carolina
| | - Thomas Pranikoff
- Wake Forest School of Medicine, General Surgery, Section of Pediatric Surgery, Winston-Salem, North Carolina
| | - Tammy Rush
- Wake Forest School of Medicine, General Surgery, Section of Pediatric Surgery, Winston-Salem, North Carolina
| | - John K Petty
- Wake Forest School of Medicine, General Surgery, Section of Pediatric Surgery, Winston-Salem, North Carolina
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Utilization of CT imaging in minor pediatric head, thoracic, and abdominal trauma in the United States. J Pediatr Surg 2020; 55:1766-1772. [PMID: 32029235 DOI: 10.1016/j.jpedsurg.2020.01.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/20/2019] [Accepted: 01/02/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Liberal use of CT scanning in children with blunt trauma risks unnecessary radiation exposure and cost. Recent literature questions the utility of whole-body CT in stable children without clinical evidence of significant injury, but this is often done based on injury mechanism. The purpose of this study is to quantify the utilization of CT scans of the head, chest, abdomen, and pelvis based on injury severity in these body regions and to assess the impact of American College of Surgeons (ACS) pediatric trauma center designation on CT utilization in children with minor or no injuries. METHODS We queried the National Trauma Databank for 2014, 2015, and 2016 to identify all patients 14 years and younger. Using Abbreviated Injury Scale (AIS) score as a proxy for injury severity, we analyzed the number of head, thoracic, and abdominal CT scans done for patients at low levels of injury severity (AIS 0-2) in each of these body regions and according to trauma center level designation (ACS I, II, III, standalone pediatric I or II, and non ACS accredited). RESULTS Of 257,661 children who were entered into the database for any reason, overall CT utilization was 20% for head, 5% for the chest and 9% for the abdomen and pelvis. Children with no injuries or minimal injury to the head were scanned 7% and 46% of the time, respectively, for the chest 3% and 13% and for the abdomen 6% and 30%. For all body regions and all levels of injury severity, level 1 stand-alone pediatric centers displayed significantly lower CT utilization rates than others. CONCLUSION CT scan rates for children with minimal or no injuries to the head, chest, abdomen and pelvis are significant. Level 1 stand-alone pediatric trauma centers are least likely to perform these studies. Widespread education and acceptance of clinical guidelines for imaging in stable patients throughout trauma systems could alleviate this disparity. LEVEL OF EVIDENCE Level III retrospective comparative study.
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Odia OA, Yorkgitis B, Gurien L, Hendry P, Crandall M, Skarupa D, Fishe JN. An evidence-based algorithm decreases computed tomography use in hemodynamically stable pediatric blunt abdominal trauma patients. Am J Surg 2020; 220:482-488. [DOI: 10.1016/j.amjsurg.2020.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 01/02/2020] [Accepted: 01/03/2020] [Indexed: 11/25/2022]
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Lamoshi A, Wagner N, Chen Z, Fabiano T, Wilding GE, Rothstein DH, Bass K. Predictive Model for Operative Intervention after Blunt Abdominal Trauma in Children with Equivocal CT Findings: A Pilot Study. J Surg Res 2020; 255:449-455. [PMID: 32619860 DOI: 10.1016/j.jss.2020.05.088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 05/18/2020] [Accepted: 05/25/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND To study the clinical and radiologic factors predicting the need for surgical intervention after blunt abdominal trauma (BAT) in children with equivocal computed tomography (CT) scan findings. METHODS We performed a retrospective review of the trauma database at our level I pediatric trauma center between 2011 and 2019. We selected patients with BAT and equivocal findings for surgical intervention on CT scan. We studied five factors: abdominal wall bruising (AWB), abdominal pain/tenderness (APT), thoracolumbar fracture, the presence of free fluid (FF), and the presence of solid organ injury, all previously reported in the literature to predict the need for operative intervention. We used t-test, the Kruskal-Wallis test and logistic regression to study the association of these factors with the need for operation in our pediatric cohort. RESULTS Of 3044 blunt trauma patients, 288 had abdominal CT scans with 61 patients demonstrating equivocal findings. Operation was performed for 12 patients (19.7%) confirming surgically correctable traumatic injuries. The need for surgical intervention was significantly associated with the age of the patients (P = 0.03), the presence of APT (P = 0.001), AWB (P = 0.01), and FF (P = 0.04). The presence of thoracolumbar fracture and solid organ injury were not significantly associated with the need for operation. For the subset of 37 patients who were injured in a motor vehicle crash, five (13.5%) required surgical intervention, which was significantly associated with the presence of AWB (P = 0.04), APT (P = 0.01), and FF (P = 0.03). A predictive model that used these factors produced a receiver operating characteristic curve of 0.86. CONCLUSIONS In cases of equivocal abdominal CT scan findings to evaluate BAT in children, the presence of abdominal wall tenderness, AWB, or FF may be significant factors predicting more accurately the need for operative intervention. A predictive model using the combination of clinical and image findings might determine with more certainty, the need for surgical intervention in children with BAT and equivocal CT findings. Validation on a larger multi-institutional data set should be done.
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Affiliation(s)
- Abdulraouf Lamoshi
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, New York.
| | - Nicole Wagner
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, New York
| | - Ziqiang Chen
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York
| | - Tiffany Fabiano
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, New York
| | - Gregory E Wilding
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York
| | - David H Rothstein
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, New York; Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Kathyrn Bass
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, New York; Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
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Gurien LA, Smith SD, Dassinger MS, Burford JM, Tepas JJ, Crandall M. Suspected appendicitis pathway continues to lower CT rates in children two years after implementation. Am J Surg 2019; 218:716-721. [PMID: 31350004 DOI: 10.1016/j.amjsurg.2019.07.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/13/2019] [Accepted: 07/17/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND We implemented a protocol to evaluate pediatric patients with suspected appendicitis using ultrasound as the initial imaging modality. CT utilization rates and diagnostic accuracy were evaluated two years after pathway implementation. METHODS This was a retrospective observational study of patients <18 years evaluated for suspected appendicitis. CT rates were compared before and after implementation of the protocol, and monthly CT rates were calculated to assess trends in CT utilization. RESULTS CT use decreased significantly following pathway implementation from 94.2% (130/138) to 27.5% (78/284; p < 0.001). Linear regression of monthly CT utilization demonstrated that CT rates continued to trend down two years after pathway implementation. Adherence to the pathway was 89.8% (255/284). Negative appendectomy rate was 2.4% (2/85) in the post-pathway period. CONCLUSIONS Adherence to a pathway designed to evaluate pediatric patients with suspected appendicitis using ultrasound as the primary imaging modality has led to a sustained decrease in CT use without compromising diagnostic accuracy.
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Affiliation(s)
- Lori A Gurien
- University of Arkansas, Department of Pediatric Surgery, Arkansas Children's Hospital, 1 Children's Way, Slot 837, Little Rock, AR, 72202, USA; Department of Surgery, University of Florida College of Medicine - Jacksonville, 655 W 8th Street, Jacksonville, FL, 32209, USA.
| | - Samuel D Smith
- University of Arkansas, Department of Pediatric Surgery, Arkansas Children's Hospital, 1 Children's Way, Slot 837, Little Rock, AR, 72202, USA
| | - Melvin S Dassinger
- University of Arkansas, Department of Pediatric Surgery, Arkansas Children's Hospital, 1 Children's Way, Slot 837, Little Rock, AR, 72202, USA
| | - Jeffrey M Burford
- University of Arkansas, Department of Pediatric Surgery, Arkansas Children's Hospital, 1 Children's Way, Slot 837, Little Rock, AR, 72202, USA
| | - Joseph J Tepas
- Department of Surgery, University of Florida College of Medicine - Jacksonville, 655 W 8th Street, Jacksonville, FL, 32209, USA
| | - Marie Crandall
- Department of Surgery, University of Florida College of Medicine - Jacksonville, 655 W 8th Street, Jacksonville, FL, 32209, USA
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