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Ugalde IT, Chaudhari PP, Badawy M, Ishimine P, McCarten-Gibbs KA, Yen K, Atigapramoj NS, Sage A, Nielsen D, Adelson PD, Upperman J, Tancredi D, Kuppermann N, Holmes JF. Validation of Prediction Rules for Computed Tomography Use in Children With Blunt Abdominal or Blunt Head Trauma: Protocol for a Prospective Multicenter Observational Cohort Study. JMIR Res Protoc 2022; 11:e43027. [PMID: 36422920 PMCID: PMC9732756 DOI: 10.2196/43027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/09/2022] [Accepted: 11/12/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Traumatic brain injuries (TBIs) and intra-abdominal injuries (IAIs) are 2 leading causes of traumatic death and disability in children. To avoid missed or delayed diagnoses leading to increased morbidity, computed tomography (CT) is used liberally. However, the overuse of CT leads to inefficient care and radiation-induced malignancies. Therefore, to maximize precision and minimize the overuse of CT, the Pediatric Emergency Care Applied Research Network (PECARN) previously derived clinical prediction rules for identifying children at high risk and very low risk for IAIs undergoing acute intervention and clinically important TBIs after blunt trauma in large cohorts of children who are injured. OBJECTIVE This study aimed to validate the IAI and age-based TBI clinical prediction rules for identifying children at high risk and very low risk for IAIs undergoing acute intervention and clinically important TBIs after blunt trauma. METHODS This was a prospective 6-center observational study of children aged <18 years with blunt torso or head trauma. Consistent with the original derivation studies, enrolled children underwent routine history and physical examinations, and the treating clinicians completed case report forms prior to knowledge of CT results (if performed). Medical records were reviewed to determine clinical courses and outcomes for all patients, and for those who were discharged from the emergency department, a follow-up survey via a telephone call or SMS text message was performed to identify any patients with missed IAIs or TBIs. The primary outcomes were IAI undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion, or intravenous fluid for ≥2 days for pancreatic or gastrointestinal injuries) and clinically important TBI (death from TBI, neurosurgical procedure, intubation for >24 hours for TBI, or hospital admission of ≥2 nights due to a TBI on CT). Prediction rule accuracy was assessed by measuring rule classification performance, using standard point and 95% CI estimates of the operational characteristics of each prediction rule (sensitivity, specificity, positive and negative predictive values, and diagnostic likelihood ratios). RESULTS The project was funded in 2016, and enrollment was completed on September 1, 2021. Data analyses are expected to be completed by December 2022, and the primary study results are expected to be submitted for publication in 2023. CONCLUSIONS This study will attempt to validate previously derived clinical prediction rules to accurately identify children at high and very low risk for clinically important IAIs and TBIs. Assuming successful validation, widespread implementation is then indicated, which will optimize the care of children who are injured by better aligning CT use with need. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR1-10.2196/43027.
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Affiliation(s)
- Irma T Ugalde
- Department of Emergency Medicine, Children's Memorial Hermann Hospital, McGovern Medical School at UTHealth Houston, Houston, TX, United States
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Mohamed Badawy
- Department of Pediatrics, University of Texas Southwestern, Dallas, TX, United States
| | - Paul Ishimine
- Department of Emergency Medicine and Pediatrics, University of California San Diego School of Medicine, Rady Children's Hospital, San Diego, CA, United States
| | - Kevan A McCarten-Gibbs
- Department of Emergency Medicine, University of California San Francisco Benioff Children's Hospital, Oakland, CA, United States
| | - Kenneth Yen
- Department of Pediatrics, University of Texas Southwestern, Dallas, TX, United States
| | - Nisa S Atigapramoj
- Department of Emergency Medicine, University of California San Francisco Benioff Children's Hospital, Oakland, CA, United States
| | - Allyson Sage
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, United States
| | - Donovan Nielsen
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, United States
| | - P David Adelson
- Barrow Neurological Institute of Phoenix Children's Hospital, Department of Child Health, Division of Pediatric Neurosurgery, University of Arizona College of Medicine, Phoenix, AZ, United States
| | - Jeffrey Upperman
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Daniel Tancredi
- Department of Pediatrics, University of California Davis School of Medicine, Sacramento, CA, United States
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, United States
| | - James F Holmes
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, United States
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Kornblith AE, Singh C, Devlin G, Addo N, Streck CJ, Holmes JF, Kuppermann N, Grupp-Phelan J, Fineman J, Butte AJ, Yu B. Predictability and stability testing to assess clinical decision instrument performance for children after blunt torso trauma. PLOS DIGITAL HEALTH 2022; 1:e0000076. [PMID: 36812570 PMCID: PMC9931266 DOI: 10.1371/journal.pdig.0000076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/14/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The Pediatric Emergency Care Applied Research Network (PECARN) has developed a clinical-decision instrument (CDI) to identify children at very low risk of intra-abdominal injury. However, the CDI has not been externally validated. We sought to vet the PECARN CDI with the Predictability Computability Stability (PCS) data science framework, potentially increasing its chance of a successful external validation. MATERIALS & METHODS We performed a secondary analysis of two prospectively collected datasets: PECARN (12,044 children from 20 emergency departments) and an independent external validation dataset from the Pediatric Surgical Research Collaborative (PedSRC; 2,188 children from 14 emergency departments). We used PCS to reanalyze the original PECARN CDI along with new interpretable PCS CDIs developed using the PECARN dataset. External validation was then measured on the PedSRC dataset. RESULTS Three predictor variables (abdominal wall trauma, Glasgow Coma Scale Score <14, and abdominal tenderness) were found to be stable. A CDI using only these three variables would achieve lower sensitivity than the original PECARN CDI with seven variables on internal PECARN validation but achieve the same performance on external PedSRC validation (sensitivity 96.8% and specificity 44%). Using only these variables, we developed a PCS CDI which had a lower sensitivity than the original PECARN CDI on internal PECARN validation but performed the same on external PedSRC validation (sensitivity 96.8% and specificity 44%). CONCLUSION The PCS data science framework vetted the PECARN CDI and its constituent predictor variables prior to external validation. We found that the 3 stable predictor variables represented all of the PECARN CDI's predictive performance on independent external validation. The PCS framework offers a less resource-intensive method than prospective validation to vet CDIs before external validation. We also found that the PECARN CDI will generalize well to new populations and should be prospectively externally validated. The PCS framework offers a potential strategy to increase the chance of a successful (costly) prospective validation.
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Affiliation(s)
- Aaron E. Kornblith
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, United States of America
- Department of Pediatrics, University of California, San Francisco, San Francisco, United States of America
| | - Chandan Singh
- Department of Electrical Engineering & Computer Science, University of California, Berkeley, Berkeley, United States of America
| | - Gabriel Devlin
- Department of Pediatrics, University of California, San Francisco, San Francisco, United States of America
| | - Newton Addo
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, United States of America
| | - Christian J. Streck
- Department of Surgery, Medical University of South Carolina, Children’s Hospital, Charleston, United States of America
| | - James F. Holmes
- Department of Emergency Medicine, University of California, Davis, Davis, United States of America
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis, Davis, United States of America
- Department of Pediatrics, University of California, Davis, Davis, United States of America
| | - Jacqueline Grupp-Phelan
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, United States of America
- Department of Pediatrics, University of California, San Francisco, San Francisco, United States of America
| | - Jeffrey Fineman
- Department of Pediatrics, University of California, San Francisco, San Francisco, United States of America
| | - Atul J. Butte
- Bakar Computational Health Sciences Institute, University of California, San Francisco, San Francisco, United States of America
| | - Bin Yu
- Department of Electrical Engineering & Computer Science, University of California, Berkeley, Berkeley, United States of America
- Departments of Statistics, University of California, Berkeley, Berkeley, United States of America
- * E-mail:
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Abstract
OBJECTIVES The aim of this study was to determine the interrater reliability (IRR) of the Pediatric Asthma Score (PAS) and to evaluate the discriminative performance of this score to predict the need for hospital admission among children with acute asthma. METHODS A secondary analysis of prospective data was performed to compare triage nurse and study personnel PAS scores among children aged 6 to 18 years presenting to the emergency department with acute asthma. The IRR was determined by calculation of weighted Cohen κ with differences evaluated by Wilcoxon ranked pairs. Receiver operating characteristic curves were created to evaluate the predictive ability of PAS to determine the need for hospital admission. RESULTS One hundred one subjects were evaluated by both study personnel and a triage nurse with PAS score recorded. The IRR of the total PAS score was determined to be moderate (κ = 0.57) and acceptable, although lower than previously reported. Individual components of the PAS score demonstrated fair to substantial agreement. Receiver operating characteristic analysis demonstrated total PAS at emergency department triage to have poor test characteristics in predicting the need for hospital admission, whether PAS was determined by study personnel, triage nurse, or an average score (area under the curve, 0.62-0.65). CONCLUSIONS In this study, total PAS score demonstrated a moderate and acceptable level of IRR with a poor discriminative ability to determine the need for hospital admission at the time of ED triage.
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Affiliation(s)
- Michael A Gardiner
- From the Department of Pediatrics, University of California, San Diego, San Diego, CA
| | - Matthew H Wilkinson
- Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, TX
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Hoyt KS, Agan DL, Jordan KS, Ramirez E, Nichols S, Topp R. Comparing nurse practitioners/physician assistants and physicians in diagnosing pediatric abdominal pain for ESI level 3 patients seen in the emergency department. J Am Assoc Nurse Pract 2021; 34:270-274. [PMID: 34014895 DOI: 10.1097/jxx.0000000000000609] [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: 12/31/2020] [Accepted: 03/31/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Accuracy of emergency department (ED) diagnosis affects care management including tests, discharges, and readmissions. PURPOSE This retrospective study compared nurse practitioners/physician assistants (NPs/PAs) with physicians (MDs/DOs) on accuracy of diagnosing Emergency Severity Index (ESI) level 3 pediatric abdominal pain (AP) in the ED. Abdominal pain unrelated to trauma is a common ED pediatric visit. METHODOLOGY Data acquired from four hospital sites of a multistate emergency group examined patients younger than 18 years who were initially admitted for AP ESI level 3. RESULTS The accuracy of AP ESI level 3 diagnoses was 94.9%, 90.9%, and 96.5% by physicians, NPs/PAs, and a collaboration of NP/PA/physician, respectively (χ2 = 13.187, p < .001). Accuracy of AP ESI level 3 diagnoses was greater with general admissions, intensive care unit admissions, transfers, or left against medical advice (100%) than with those who were discharged (χ2 = 11.058, p = .001). Abdominal pain complaints were segmented into five areas (i.e., AP, back pain, chest pain, epigastric pain, and pelvic pain). Irrespective of provider, those with a final diagnosis of AP or epigastric pain were correctly triaged and those with a final diagnosis of chest or back pain were incorrectly triaged as AP ESI level 3. CONCLUSIONS When comparing providers in this subset (n = 43), there was no significant difference in the accuracy of assigning AP ESI level 3 (χ2 = 0.467, p = .495). IMPLICATIONS Only cases with a final diagnosis of pelvic/genitourinary pain saw disparity in the accuracy (27 correct, 16 incorrect, χ2 = 1,681.80, p < .001).
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Affiliation(s)
- Karen Sue Hoyt
- Hahn School of Nursing and Health Science, Beyster Institute of Nursing Research, University of San Diego, San Diego, California
| | - Donna L Agan
- University of San Diego, San Diego, California
- California State University San Marcos, San Marcos, California
| | - Kathleen Sanders Jordan
- Mid-Atlantic Emergency Medicine Associates, Charlotte, North Carolina
- The University of North Carolina School of Nursing, Charlotte, North Carolina
| | - Elda Ramirez
- University of Texas Health Science Center Houston, Houston, Texas
| | | | - Robert Topp
- Hahn School of Nursing and Health Science, University of San Diego, San Diego, California
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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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Tsze DS, Cruz AT, Mistry RD, Gonzalez AE, Ochs JB, Richer L, Kuppermann N, Dayan PS. Interobserver Agreement in the Assessment of Clinical Findings in Children with Headaches. J Pediatr 2020; 221:207-214. [PMID: 32446483 PMCID: PMC7251971 DOI: 10.1016/j.jpeds.2020.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/10/2020] [Accepted: 02/11/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine the interobserver agreement of history and physical examination findings in children undergoing evaluation in the emergency department (ED) for headaches. STUDY DESIGN We conducted a prospective, cross-sectional study of children aged 2-17 years evaluated at 3 tertiary-care pediatric EDs for non-traumatic headaches. Two clinicians independently completed a standardized assessment of each child and documented the presence or absence of history and physical examination variables. Unweighted κ statistics were determined for 68 history and 24 physical examination variables. RESULTS We analyzed 191 paired observations; median age was 12 years, with 19 (9.9%) children younger than 7 years. Interrater reliability was at least moderate (κ ≥ 0.41) for 41 (60.3%) patient history variables. Eleven (61.1%) of 18 physical examination variables for which κ statistics could be calculated had a κ that was at least moderate. CONCLUSIONS A substantial number of history and physical examination findings demonstrated at least moderate κ statistic values when assessed in children with headaches in the ED. These variables may be generalizable across different types of clinicians for evaluation of children with headaches. If also found to predict the presence or absence of emergent intracranial abnormalities, the more reliable clinical findings may be helpful in the development of clinical prediction rules or risk stratification models that could be used across settings for children with headaches.
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Affiliation(s)
- Daniel S. Tsze
- Department of Emergency Medicine. Division of Pediatric Emergency Medicine. Columbia University College of Physicians and Surgeons. New York, NY
| | - Andrea T. Cruz
- Department of Pediatrics, Baylor College of Medicine. Houston, TX
| | - Rakesh D. Mistry
- Department of Pediatrics, University of Colorado School of Medicine. Aurora, CO
| | - Ariana E. Gonzalez
- Department of Emergency Medicine. Division of Pediatric Emergency Medicine. Columbia University College of Physicians and Surgeons. New York, NY
| | - Julie B. Ochs
- Department of Emergency Medicine. Division of Pediatric Emergency Medicine. Columbia University College of Physicians and Surgeons. New York, NY
| | - Lawrence Richer
- Department of Pediatrics, University of Alberta. Edmonton, Alberta, Canada
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine. Sacramento, CA
| | - Peter S. Dayan
- Department of Emergency Medicine. Division of Pediatric Emergency Medicine. Columbia University College of Physicians and Surgeons. New York, NY
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Prieur J, Le Du G, Stomp M, Barbu S, Blois-Heulin C. Human laterality for manipulation and gestural communication: A study of beach-volleyball players during the Olympic Games. Laterality 2020; 25:229-254. [PMID: 31366285 DOI: 10.1080/1357650x.2019.1648485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Comparative studies can help understand better brain functional lateralization for manipulation and language. This study investigated and compared, for the first time, human adults' laterality for manipulation and gestures in a non-experimental social context. We analysed the manual laterality of 48 beach volleyball athletes for four frequently expressed behaviours: a complex throwing action (jump serve) and three gestures (CLAP HAND, PUMP FIST and SLAP HAND-TO-HAND). We evaluated population-level laterality bias for each of the four behaviours separately, compared manual laterality between behaviours and investigated factors influencing gestural laterality. We furthered our between-gestures comparison by taking into account three categories of factors simultaneously: gesture characteristics (sensory modality), interactional context components (positions of interactants and emotional valence), and individual demographic characteristics (age, sex and country). Our study showed that (1) each behaviour considered presented a population-level right-hand bias, (2) differences of laterality between behaviours were probably related to gesture sensory modality and (3) signaller's laterality was modulated differently in relation to positions of interactants, emotional valence, age and sex. Our results support the literature suggesting that left-hemisphere specialization for manipulation and language (speech and gestures) may have evolved from complex manual activities such as throwing and from gestural communication.
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Affiliation(s)
- Jacques Prieur
- CNRS, EthoS (Ethologie animale et humaine), Univ Rennes, Normandie Univ, Paimpont, France
| | - Gwendoline Le Du
- CNRS, EthoS (Ethologie animale et humaine), Univ Rennes, Normandie Univ, Paimpont, France
| | - Mathilde Stomp
- CNRS, EthoS (Ethologie animale et humaine), Univ Rennes, Normandie Univ, Paimpont, France
| | - Stéphanie Barbu
- CNRS, EthoS (Ethologie animale et humaine), Univ Rennes, Normandie Univ, Paimpont, France
| | - Catherine Blois-Heulin
- CNRS, EthoS (Ethologie animale et humaine), Univ Rennes, Normandie Univ, Paimpont, France
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Leonard JC, Browne LR, Ahmad FA, Schwartz H, Wallendorf M, Leonard JR, Lerner EB, Kuppermann N. Cervical Spine Injury Risk Factors in Children With Blunt Trauma. Pediatrics 2019; 144:peds.2018-3221. [PMID: 31221898 PMCID: PMC6615532 DOI: 10.1542/peds.2018-3221] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Adult prediction rules for cervical spine injury (CSI) exist; however, pediatric rules do not. Our objectives were to determine test accuracies of retrospectively identified CSI risk factors in a prospective pediatric cohort and compare them to a de novo risk model. METHODS We conducted a 4-center, prospective observational study of children 0 to 17 years old who experienced blunt trauma and underwent emergency medical services scene response, trauma evaluation, and/or cervical imaging. Emergency department providers recorded CSI risk factors. CSIs were classified by reviewing imaging, consultations, and/or telephone follow-up. We calculated bivariable relative risks, multivariable odds ratios, and test characteristics for the retrospective risk model and a de novo model. RESULTS Of 4091 enrolled children, 74 (1.8%) had CSIs. Fourteen factors had bivariable associations with CSIs: diving, axial load, clotheslining, loss of consciousness, neck pain, inability to move neck, altered mental status, signs of basilar skull fracture, torso injury, thoracic injury, intubation, respiratory distress, decreased oxygen saturation, and neurologic deficits. The retrospective model (high-risk motor vehicle crash, diving, predisposing condition, neck pain, decreased neck mobility (report or exam), altered mental status, neurologic deficits, or torso injury) was 90.5% (95% confidence interval: 83.9%-97.2%) sensitive and 45.6% (44.0%-47.1%) specific for CSIs. The de novo model (diving, axial load, neck pain, inability to move neck, altered mental status, intubation, or respiratory distress) was 92.0% (85.7%-98.1%) sensitive and 50.3% (48.7%-51.8%) specific. CONCLUSIONS Our findings support previously identified pediatric CSI risk factors and prospective pediatric CSI prediction rule development.
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Affiliation(s)
| | - Lorin R. Browne
- Department of Pediatrics and Emergency Medicine,
Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Hamilton Schwartz
- Department of Pediatrics, Cincinnati
Children’s Hospital Medical Center and College of Medicine, University of
Cincinnati, Cincinnati, Ohio; and
| | - Michael Wallendorf
- Biostatistics, School of Medicine, Washington
University, St Louis, Missouri
| | - Jeffrey R. Leonard
- Neurosurgery, Nationwide Children’s Hospital
and College of Medicine, The Ohio State University, Columbus, Ohio
| | - E. Brooke Lerner
- Department of Pediatrics and Emergency Medicine,
Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics,
School of Medicine, University of California, Davis, Sacramento,
California
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External validation of a five-variable clinical prediction rule for identifying children at very low risk for intra-abdominal injury after blunt abdominal trauma. J Trauma Acute Care Surg 2019; 85:71-77. [PMID: 29659473 DOI: 10.1097/ta.0000000000001933] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A clinical prediction rule was previously developed by the Pediatric Surgery Research Collaborative (PedSRC) to identify patients at very low risk for intra-abdominal injury (IAI) and intra-abdominal injury receiving an acute intervention (IAI-I) who could safely avoid abdominal computed tomography (CT) scans after blunt abdominal trauma (BAT). Our objective was to externally validate the rule. METHODS The public-use dataset was obtained from the Pediatric Emergency Care Applied Research Network (PECARN) Intra-abdominal Injury Study. Patients 16 years of age and younger with chest x-ray, completed abdominal history and physical examination, aspartate aminotransferase (AST), and amylase or lipase collected within 6 hours of arrival were included. We excluded patients who presented greater than 6 hours after injury or missing any of the five clinical prediction variables from the PedSRC prediction rule. RESULTS We included 2,435 patients from the PECARN dataset, with a mean age of 9.4 years. There were 235 patients with IAI (9.7%) and 60 patients with IAI-I (2.5%). The clinical prediction rule had a sensitivity of 97.5% for IAI and 100% for IAI-I. In patients with no abnormality in any of the five prediction rule variables, the rule had a negative predictive value of 99.3% for IAI and 100.0% for IAI-I. Of the "very low-risk" patients identified by the rule, 46.8% underwent abdominal CT imaging. CONCLUSIONS A highly sensitive clinical prediction rule using history and abdominal physical examination, laboratory values, and chest x-ray was successfully validated using a large public-access dataset of pediatric BAT patients. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III; therapeutic care/management study, level IV.
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Matsumoto S, Hayashida K, Furugori S, Shimizu M, Sekine K, Kitano M. Impact of self-inflicted injury on nontherapeutic laparotomy in patients with abdominal stab wounds. Injury 2018; 49:1706-1711. [PMID: 29887502 DOI: 10.1016/j.injury.2018.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/10/2018] [Accepted: 06/01/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Because Japan has high suicide rates and low violent crime rates, it is likely that most abdominal stab wounds (ASWs) in Japan are self-inflicted. Although physical examination is one of the most important factors in surgical decision making, such evaluations can be difficult in patients with self-inflicted ASWs due to patient agitation and uncooperative behavior. Therefore, the self-inflicted nature of an injury may strongly affect clinical practice, particularly in Japan, but its influence remains uncertain. We hypothesized that the rates of exploratory laparotomy and nontherapeutic laparotomy (NTL) would be higher in self-inflicted patients. METHODS We reviewed ASW patients from 2004 to 2014 in the Japan Trauma Data Bank. The rates of exploratory laparotomy and NTL were compared between self-inflicted and non-self-inflicted ASWs. RESULTS Of the 1705 eligible patients, 1302 patients (76.4%) had self-inflicted ASWs, and 403 patients (23.6%) had non-self-inflicted ASWs. Self-inflicted patients had a significantly higher rate of psychiatric history, but lower injury severity. The in-hospital mortality rate was similar between the two groups (4.5% vs. 5.2%, p = 0.576). Self-inflicted patients had significantly higher rates of exploratory laparotomy and NTL (69.1% vs. 56.7%, p < 0.001, 22.5% vs. 13.6%, p = 0.03, respectively). Self-inflicted patients were also associated with significantly longer hospital stays (10.0 [5.0-21.0] vs. 9.0 [4.0-18.0] days, P = 0.045). In a multivariable analysis, self-inflicted patients were independently associated with exploratory laparotomy (odds ratio [OR], 2.05; 95% confidence interval [CI]: 1.55-2.72) and NTL (OR, 1.61; 95% CI: 1.01-2.56). CONCLUSION ASWs in Japan were predominantly self-inflicted. The clinical patterns of self-inflicted ASWs had some unique features. Patients with self-inflicted ASWs had higher rates of laparotomy and NTL. Further studies are needed to develop a useful protocol specific to self-inflicted ASWs.
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Affiliation(s)
- Shokei Matsumoto
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Japan.
| | - Kei Hayashida
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital/Harvard Medical School, United States.
| | - Shintaro Furugori
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Japan.
| | - Masayuki Shimizu
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Japan.
| | - Kazuhiko Sekine
- Department of Emergency Medicine, Saiseikai Central Hospital, Japan.
| | - Mitsuhide Kitano
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Japan.
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Do Mechanical Effectiveness and Recipient Species Influence Intentional Signal Laterality in Captive Chimpanzees (Pan troglodytes)? INT J PRIMATOL 2018. [DOI: 10.1007/s10764-018-0054-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Flynn‐O'Brien KT, Kuppermann N, Holmes JF. Costal Margin Tenderness and the Risk for Intraabdominal Injuries in Children With Blunt Abdominal Trauma. Acad Emerg Med 2018; 25:776-784. [PMID: 29654622 DOI: 10.1111/acem.13426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 03/25/2018] [Accepted: 03/28/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The risk of radiation exposure from computed tomography (CT) imaging in children is well recognized. Patient history and physical examination findings, including costal margin tenderness (CMT), influence a physician's decision to image a child with blunt torso trauma. The objective of this study was to determine the importance of CMT for identifying children with intraabdominal injuries (IAI) found on CT and IAI undergoing acute intervention. METHODS We conducted an analysis of the Pediatric Emergency Care Applied Research Network (PECARN) IAI public use data set, representing a large prospective multicenter cohort study from May 2007 to January 2010. Isolated CMT was defined as CMT without other identified PECARN risk factors for IAI (i.e., abdominal or thoracic wall trauma, abdominal tenderness or pain, decreased breath sounds, or vomiting). Logistic regression was used to calculate adjusted odds of IAI in children presenting with isolated and nonisolated CMT. Risk differences were calculated to estimate the risk of IAI independently attributable to CMT in the setting of isolated PECARN risk factors. Finally, CT use among exposure groups was estimated to quantify potentially avoidable imaging. RESULTS Among 9,174 children with Glasgow Coma Scale scores of 14 or 15 who sustained blunt torso trauma, 1,267 (13.8%) had CMT. Among those with CMT, 177 (14.0%) had isolated CMT and 1,090 (86.0%) had nonisolated CMT. No children (0/177; 0%, 95% confidence interval [CI] = 0.0%-2.1%) with isolated CMT had IAI, compared to 17.2% (187/1,090; 95% CI = 15.0%-19.5%) of those with nonisolated CMT. The risk differences were not statistically significant. 36/177 (20.3%; 95% CI = 14.7%-27.0%) children with isolated CMT underwent abdominal CT scans. CONCLUSIONS The risk of IAI associated with isolated CMT is minimal. For children with blunt abdominal trauma and isolated CMT, abdominal CT scan is of low yield.
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Affiliation(s)
| | - Nathan Kuppermann
- Department of Emergency Medicine UC Davis School of Medicine Sacramento CA
- Department of Pediatrics UC Davis School of Medicine Sacramento CA
| | - James F. Holmes
- Department of Emergency Medicine UC Davis School of Medicine Sacramento CA
- Department of Pediatrics UC Davis School of Medicine Sacramento CA
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13
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Browne LR, Schwartz H, Ahmad FA, Wallendorf M, Kuppermann N, Lerner EB, Leonard JC. Interobserver Agreement in Pediatric Cervical Spine Injury Assessment Between Prehospital and Emergency Department Providers. Acad Emerg Med 2017; 24:1501-1510. [PMID: 28921731 DOI: 10.1111/acem.13312] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 08/25/2017] [Accepted: 09/11/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Investigators have derived cervical spine injury (CSI) decision support tools from physician observations. There is a need to demonstrate that prehospital emergency medical services (EMS) providers can use these tools to appropriately determine the need for spinal motion restrictions and make field disposition decisions. OBJECTIVES The objective was to determine the interobserver agreement between EMS and emergency department (ED) providers for CSI risk assessment variables and overall gestalt for CSI in children after blunt trauma. METHODS This was a planned, substudy of a four-site, prospective cohort of children < 18 years transported by EMS to pediatric EDs for evaluation of CSI after blunt trauma. Inclusion criteria were trauma team activation and/or EMS-initiated spinal motion restriction. Exclusion criteria were penetrating trauma, transfer to another facility for definitive care, state custody, or substantial language barrier. For each eligible child, the transporting EMS provider and treating ED provider independently recorded their clinical assessment for CSI. This included mechanism of injury and patient history and physical examination findings. We assessed each paired variable for interobserver agreement between EMS and ED provider using kappa (κ) analysis. We considered variables with κ lower confidence interval values ≥0.4 to have moderate or better agreement. RESULTS We obtained 1,372 paired observations for 29 variables. After finding prevalence and observer bias were adjusted for, all variables achieved moderate to better agreement including eight variables previously shown to be independently associated with CSI in children: diving mechanism, high-risk motor vehicle collision, altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, and predisposing medical condition. EMS and ED providers, however, showed less than moderate agreement for their overall gestalt for CSI in children. Of note, both EMS and ED providers did not assess for neck pain, inability to move the neck, and/or cervical spine tenderness in more than 10% of study patients. CONCLUSIONS Emergency medical services and ED providers achieved at least moderate agreement in the assessment of CSI risk factors in children after blunt trauma. However, EMS and ED providers did not achieve moderate agreement on gestalt for CSI and some risk factors went unassessed by providers. These findings support the development of a pediatric CSI risk assessment tool for EMS and ED providers to reduce interventions for those children at very low risk for CSIs while still identifying all children with injury.
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Affiliation(s)
- Lorin R. Browne
- Department of Pediatrics and Emergency Medicine; Medical College of Wisconsin (LRB, EBL); Madison WI
| | - Hamilton Schwartz
- Department of Pediatrics; University of Cincinnati College of Medicine (HS); Cincinnati OH
| | - Fahd A. Ahmad
- Department Pediatrics; Washington University School of Medicine in St. Louis; St. Louis MO
| | - Michael Wallendorf
- Department of Biostatistics; Washington University School of Medicine in St. Louis; St. Louis MO
| | - Nathan Kuppermann
- Department of Emergency Medicine and Pediatrics; University of California Davis School of Medicine; Sacramento CA
| | - E. Brooke Lerner
- Department of Pediatrics and Emergency Medicine; Medical College of Wisconsin (LRB, EBL); Madison WI
| | - Julie C. Leonard
- Nationwide Children's Hospital and The Ohio State University College of Medicine; Columbus OH
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14
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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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15
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Florin TA, Ambroggio L, Brokamp C, Rattan MS, Crotty EJ, Kachelmeyer A, Ruddy RM, Shah SS. Reliability of Examination Findings in Suspected Community-Acquired Pneumonia. Pediatrics 2017; 140:peds.2017-0310. [PMID: 28835381 PMCID: PMC5574720 DOI: 10.1542/peds.2017-0310] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The authors of national guidelines emphasize the use of history and examination findings to diagnose community-acquired pneumonia (CAP) in outpatient children. Little is known about the interrater reliability of the physical examination in children with suspected CAP. METHODS This was a prospective cohort study of children with suspected CAP presenting to a pediatric emergency department from July 2013 to May 2016. Children aged 3 months to 18 years with lower respiratory signs or symptoms who received a chest radiograph were included. We excluded children hospitalized ≤14 days before the study visit and those with a chronic medical condition or aspiration. Two clinicians performed independent examinations and completed identical forms reporting examination findings. Interrater reliability for each finding was reported by using Fleiss' kappa (κ) for categorical variables and intraclass correlation coefficient (ICC) for continuous variables. RESULTS No examination finding had substantial agreement (κ/ICC > 0.8). Two findings (retractions, wheezing) had moderate to substantial agreement (κ/ICC = 0.6-0.8). Nine findings (abdominal pain, pleuritic pain, nasal flaring, skin color, overall impression, cool extremities, tachypnea, respiratory rate, and crackles/rales) had fair to moderate agreement (κ/ICC = 0.4-0.6). Eight findings (capillary refill time, cough, rhonchi, head bobbing, behavior, grunting, general appearance, and decreased breath sounds) had poor to fair reliability (κ/ICC = 0-0.4). Only 3 examination findings had acceptable agreement, with the lower 95% confidence limit >0.4: wheezing, retractions, and respiratory rate. CONCLUSIONS In this study, we found fair to moderate reliability of many findings used to diagnose CAP. Only 3 findings had acceptable levels of reliability. These findings must be considered in the clinical management and research of pediatric CAP.
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Affiliation(s)
- Todd A. Florin
- Divisions of Emergency Medicine,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Lilliam Ambroggio
- Biostatistics and Epidemiology,,Hospital Medicine, and,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Mantosh S. Rattan
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Eric J. Crotty
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Richard M. Ruddy
- Divisions of Emergency Medicine,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Samir S. Shah
- Divisions of Emergency Medicine,,Hospital Medicine, and,Infectious Diseases, and,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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16
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Depinet H, von Allmen D, Towbin A, Hornung R, Ho M, Alessandrini E. Risk Stratification to Decrease Unnecessary Diagnostic Imaging for Acute Appendicitis. Pediatrics 2016; 138:peds.2015-4031. [PMID: 27553220 DOI: 10.1542/peds.2015-4031] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND There has been an increase in the use of imaging modalities to diagnose appendicitis despite evidence that can help identify children at especially high or low risk of appendicitis who may not benefit. We hypothesized that the passive diffusion of a standardized care pathway (including diagnostic imaging recommendations) would improve the diagnostic workup of appendicitis by safely decreasing the use of unnecessary imaging when compared with historical controls and that an electronic, real-time decision support tool would decrease unnecessary imaging. METHODS We used an interrupted time series trial to compare proportions of patients who underwent diagnostic imaging (computed tomography [CT] and ultrasound) between 3 time periods: baseline historical controls, after passive diffusion of a diagnostic workup clinical pathway, and after introduction of an electronic medical record-embedded clinical decision support tool that provides point-of-care imaging recommendations (active intervention). RESULTS The moderate- and high-risk groups showed lower proportions of CT in the passive and active intervention time periods compared with the historical control group. Proportions of patients undergoing ultrasound in all 3 risk groups showed an increase from the historical baseline. Time series analysis confirmed that time trends within any individual time period were not significant; thus, incidental secular trends over time did not appear to explain the decreased use of CT. CONCLUSIONS Passive and active decision support tools minimized unnecessary CT imaging; long-term effects remain an important area of study.
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Affiliation(s)
- Holly Depinet
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Alex Towbin
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Richard Hornung
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mona Ho
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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17
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Natale JE, Joseph JG, Rogers AJ, Tunik M, Monroe D, Kerrey B, Bonsu BK, Cook LJ, Page K, Adelgais K, Quayle K, Kuppermann N, Holmes JF. Relationship of Physician-identified Patient Race and Ethnicity to Use of Computed Tomography in Pediatric Blunt Torso Trauma. Acad Emerg Med 2016; 23:584-90. [PMID: 26914184 DOI: 10.1111/acem.12943] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 12/02/2015] [Accepted: 12/14/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective was to determine whether a child's race or ethnicity as determined by the treating physician is independently associated with receiving abdominal computed tomography (CT) after blunt torso trauma. METHODS We performed a planned secondary analysis of a prospective observational cohort of children < 18 years old presenting within 24 hours of blunt torso trauma to 20 North American emergency departments (EDs) participating in a pediatric research network, 2007-2010. Treating physicians documented race/ethnicity as white non-Hispanic, black non-Hispanic, or Hispanic. Using a previously derived clinical prediction rule, we classified each child's risk for having an intra-abdominal injury undergoing acute intervention to define injury severity. We performed multivariable analyses using generalized estimating equations to control for confounding and for clustering of children within hospitals. RESULTS Among 12,044 enrolled patients, treating physicians documented race/ethnicity as white non-Hispanic (n = 5,847, 54.0%), black non-Hispanic (n = 3,687, 34.1%), or Hispanic of any race (n = 1,291, 11.9%). Overall, 51.8% of white non-Hispanic, 32.7% of black non-Hispanic, and 44.2% of Hispanic children underwent abdominal CT imaging. After age, sex, abdominal ultrasound use, risk for intra-abdominal injury undergoing acute intervention, and hospital clustering were adjusted for, the likelihood of receiving an abdominal CT was lower (odds ratio [OR] = 0.8, 95% confidence interval [CI] = 0.7 to 0.9) for black non-Hispanic than for white non-Hispanic children. For Hispanic children, the likelihood of receiving an abdominal CT did not differ from that observed in white non-Hispanic children (OR = 0.9, 95% CI = 0.8 to 1.1). CONCLUSIONS After blunt torso trauma, pediatric patients identified by the treating physicians as black non-Hispanic were less likely to receive abdominal CT imaging than those identified as white non-Hispanic. This suggests that nonclinical factors influence clinician decision-making regarding use of abdominal CT in children. Further studies should focus on explaining how patient race can affect provider choices regarding ED radiographic imaging.
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Affiliation(s)
- JoAnne E. Natale
- Department of Pediatrics; University of California at Davis; Sacramento CA
| | - Jill G. Joseph
- Betty Irene Moore School of Nursing; University of California at Davis; Sacramento CA
| | - Alexander J. Rogers
- Departments of Emergency Medicine and Pediatrics; University of Michigan Medical Center and University of Michigan School of Medicine; Ann Arbor MI
| | - Michael Tunik
- Departments of Pediatrics and Emergency Medicine; New York University School of Medicine; New York City NY
| | | | - Benjamin Kerrey
- Department of Pediatrics; Cincinnati Children's Hospital; Cincinnati OH
| | - Bema K. Bonsu
- Department of Pediatrics; Nationwide Children's Hospital; Columbus OH
- Department of Pediatrics; University of California at San Diego; San Diego CA
| | | | - Kent Page
- University of Utah; Salt Lake City UT
| | - Kathleen Adelgais
- Department of Pediatrics and Emergency Medicine; University of Colorado; Denver CO
| | - Kimberly Quayle
- St. Louis Children's Hospital; Washington University; St. Louis MO
| | - Nathan Kuppermann
- Department of Pediatrics; University of California at Davis; Sacramento CA
- Department of Emergency Medicine; University of California at Davis; Sacramento CA
| | - James F. Holmes
- Department of Emergency Medicine; University of California at Davis; Sacramento CA
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18
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Olsen CS, Kuppermann N, Jaffe DM, Brown K, Babcock L, Mahajan PV, Leonard JC. Interobserver agreement in retrospective chart reviews for factors associated with cervical spine injuries in children. Acad Emerg Med 2015; 22:487-91. [PMID: 25779540 DOI: 10.1111/acem.12630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 11/04/2014] [Accepted: 11/11/2014] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The objective was to describe the interobserver agreement between trained chart reviewers and physician reviewers in a multicenter retrospective chart review study of children with cervical spine injuries (CSIs). METHODS Medical records of children younger than 16 years old with cervical spine radiography from 17 Pediatric Emergency Care Applied Research Network (PECARN) hospitals from years 2000 through 2004 were abstracted by trained reviewers for a study aimed to identify predictors of CSIs in children. Independent physician-reviewers abstracted patient history and clinical findings from a random sample of study patient medical records at each hospital. Interobserver agreement was assessed using percent agreement and the weighted kappa (κ) statistic, with lower 95% confidence intervals. RESULTS Moderate or better agreement (κ > 0.4) was achieved for most candidate CSI predictors, including altered mental status (κ = 0.87); focal neurologic findings (κ = 0.74); posterior midline neck tenderness (κ = 0.74); any neck tenderness (κ = 0.89); torticollis (κ = 0.79); complaint of neck pain (κ = 0.83); history of loss of consciousness (κ = 0.89); nonambulatory status (κ = 0.74); and substantial injuries to the head (κ = 0.50), torso/trunk (κ = 0.48), and extremities (κ = 0.59). High-risk mechanisms showed near-perfect agreement (diving, κ = 1.0; struck by car, κ = 0.93; other motorized vehicle crash, κ = 0.93; fall, κ = 0.92; high-risk motor vehicle collision, κ = 0.89; hanging, κ = 0.80). Fair agreement was found for clotheslining mechanisms (κ = 0.36) and substantial face injuries (κ = 0.40). CONCLUSIONS Most retrospectively assessed variables thought to be predictive of CSIs in blunt trauma-injured children had at least moderate interobserver agreement, suggesting that these data are sufficiently valid for use in identifying potential predictors of CSI.
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Affiliation(s)
- Cody S. Olsen
- The Division of Critical Care; Department of Pediatrics; University of Utah School of Medicine; Salt Lake City UT
| | | | - David M. Jaffe
- The Department of Pediatrics; Washington University and St. Louis Children's Hospital; St. Louis MO
| | - Kathleen Brown
- The Division of Emergency Medicine; Department of Pediatrics; George Washington University School of Medicine; Washington DC
| | - Lynn Babcock
- The Division of Emergency Medicine; Department of Pediatrics; University of Cincinnati and Cincinnati Children's Hospital Medical Center; Cincinnati OH
| | - Prashant V. Mahajan
- Children's Hospital of Michigan and Division of Emergency Medicine; Department of Pediatrics; Wayne State University School of Medicine; Detroit MI
| | - Julie C. Leonard
- The Department of Pediatrics; Washington University and St. Louis Children's Hospital; St. Louis MO
- Nationwide Children's Hospital and the Ohio State University; Columbus OH
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19
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Kwok MY, Yen K, Atabaki S, Adelgais K, Garcia M, Quayle K, Kooistra J, Bonsu BK, Page K, Borgialli D, Kuppermann N, Holmes JF. Sensitivity of Plain Pelvis Radiography in Children With Blunt Torso Trauma. Ann Emerg Med 2015; 65:63-71.e1. [DOI: 10.1016/j.annemergmed.2014.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 06/10/2014] [Accepted: 06/16/2014] [Indexed: 11/15/2022]
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20
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Adelgais KM, Kuppermann N, Kooistra J, Garcia M, Monroe DJ, Mahajan P, Menaker J, Ehrlich P, Atabaki S, Page K, Kwok M, Holmes JF. Accuracy of the abdominal examination for identifying children with blunt intra-abdominal injuries. J Pediatr 2014; 165:1230-1235.e5. [PMID: 25266346 DOI: 10.1016/j.jpeds.2014.08.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 07/02/2014] [Accepted: 08/08/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the accuracy of complaints of abdominal pain and findings of abdominal tenderness for identifying children with intra-abdominal injury (IAI) stratified by Glasgow Coma Scale (GCS) score. STUDY DESIGN This was a prospective, multicenter observational study of children with blunt torso trauma and a GCS score ≥13. We calculated the sensitivity of abdominal findings for IAI with 95% CI stratified by GCS score. We examined the association of isolated abdominal pain or tenderness with IAI and that undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion, or ≥2 nights of intravenous fluid therapy). RESULTS Among the 12 044 patients evaluated, 11 277 (94%) had a GCS score of ≥13 and were included in this analysis. Sensitivity of abdominal pain for IAI was 79% (95% CI, 76%-83%) for patients with a GCS score of 15, 51% (95% CI, 37%-65%) for patients with a GCS score of 14, and 32% (95% CI, 14%-55%) for patients with a GCS score of 13. Sensitivity of abdominal tenderness for IAI also decreased with decreasing GCS score: 79% (95% CI, 75%-82%) for a GCS score of 15, 57% (95% CI, 42%-70%) for a GCS score of 14, and 37% (95% CI, 19%-58%) for a GCS score of 13. Among patients with isolated abdominal pain and/or tenderness, the rate of IAI was 8% (95% CI, 6%-9%) and the rate of IAI undergoing acute intervention was 1% (95% CI, 1%-2%). CONCLUSION The sensitivity of abdominal findings for IAI decreases as GCS score decreases. Although abdominal computed tomography is not mandatory, the risk of IAI is sufficiently high that diagnostic evaluation is warranted in children with isolated abdominal pain or tenderness.
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Affiliation(s)
- Kathleen M Adelgais
- Department of Pediatrics, University of Colorado Denver, Aurora, CO; Department of Pediatrics, University of Utah, Salt Lake City, UT.
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis School of Medicine, Davis, CA; Department of Pediatrics, University of California Davis School of Medicine, Sacramento, CA
| | - Joshua Kooistra
- Department of Emergency Medicine, Helen DeVos Children's Hospital, Grand Rapids, MI
| | - Madelyn Garcia
- Department of Emergency Medicine, University of Rochester, Rochester, NY
| | - David J Monroe
- Department of Pediatrics, Howard County Hospital, Columbia, MD
| | - Prashant Mahajan
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI
| | - Jay Menaker
- Department of Surgery, University of Maryland, Baltimore, MD
| | - Peter Ehrlich
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Shireen Atabaki
- Department of Emergency Medicine, Children's National Medical Center, Washington, DC
| | - Kent Page
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Maria Kwok
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - James F Holmes
- Department of Emergency Medicine, University of California Davis School of Medicine, Davis, CA
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21
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Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries. Ann Emerg Med 2013; 62:107-116.e2. [PMID: 23375510 DOI: 10.1016/j.annemergmed.2012.11.009] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 11/05/2012] [Accepted: 11/13/2012] [Indexed: 11/22/2022]
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