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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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Chen LG, Kao HW, Wu PA, Sheu MH, Huang LC. Optimal image quality and radiation doses with optimal tube voltages/currents for pediatric anthropomorphic phantom brains. PLoS One 2024; 19:e0306857. [PMID: 39037987 PMCID: PMC11262643 DOI: 10.1371/journal.pone.0306857] [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: 02/14/2024] [Accepted: 06/25/2024] [Indexed: 07/24/2024] Open
Abstract
OBJECTIVE Using pediatric anthropomorphic phantoms (APs), we aimed to determine the scanning tube voltage/current combinations that could achieve optimal image quality and avoid excessive radiation exposure in pediatric patients. MATERIALS AND METHODS A 64-slice scanner was used to scan a standard test phantom to determine the volume CT dose indices (CTDIvol), and three pediatric anthropomorphic phantoms (APs) with highly accurate anatomy and tissue-equivalent materials were studied. These specialized APs represented the average 1-year-old, 5-year-old, and 10-year-old children, respectively. The physical phantoms were constructed with brain tissue-equivalent materials having a density of ρ = 1.07 g/cm3, comprising 22 numbered 2.54-cm-thick sections for the 1-year-old, 26 sections for the 5-year-old, and 32 sections for the 10-year-old. They were scanned to acquire brain CT images and determine the standard deviations (SDs), effective doses (EDs), and contrast-to noise ratios (CNRs). The APs were scanned by 21 combinations of tube voltages/currents (80, 100, or 120 kVp/10, 40, 80, 120, 150, 200, or 250 mA) and rotation time/pitch settings of 1 s/0.984:1. RESULTS The optimal tube voltage/current combinations yielding optimal image quality were 80 kVp/80 mA for the 1-year-old AP; 80 kVp/120 mA for the 5-year-old AP; and 80 kVp/150 mA for the 10-year-old AP. Because these scanning tube voltages/currents yielded SDs, respectively, of 12.81, 13.09, and 12.26 HU, along with small EDs of 0.31, 0.34, and 0.31 mSv, these parameters and the induced values were expediently defined as optimal. CONCLUSIONS The optimal tube voltages/currents that yielded optimal brain image quality, SDs, CNRs, and EDs herein are novel and essentially important. Clinical translation of these optimal values may allow CT diagnosis with low radiation doses to children's heads.
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Affiliation(s)
- Li-Guo Chen
- Department of Medical Imaging, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Hung-Wen Kao
- Department of Medical Imaging, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Department of Radiology, School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ping-An Wu
- Department of Medical Imaging, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Ming-Huei Sheu
- Department of Medical Imaging, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Li-Chuan Huang
- Department of Medical Imaging, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Department of Medical Imaging and Radiological Sciences, Tzu Chi University of Science and Technology, Hualien, Taiwan
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Molla YD, Mekonnen DC, Beza AD, Alemu HT, Gebrehana DA. Surgical outcome of pediatric abdominal trauma at Tertiary Hospital, Northwest Ethiopia, a 3-year retrospective study. BMC Surg 2024; 24:203. [PMID: 38978029 PMCID: PMC11229280 DOI: 10.1186/s12893-024-02493-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 07/01/2024] [Indexed: 07/10/2024] Open
Abstract
INTRODUCTION Abdominal trauma in children is a significant health concern that often leads to severe complications and even death. Children experience trauma more frequently than adults, with approximately one in four pediatric patients suffering from serious abdominal injuries. Falls are the leading cause of such trauma among children, which is intriguing considering that most hospital admissions for pediatric abdominal injuries result from blunt force impacts. METHOD A retrospective cross-sectional analysis of medical records was conducted to examine all patients under the age of 16 who underwent exploratory laparotomy for abdominal trauma between January 1, 2020, and January 1, 2023. The clinical data were gathered using a data extraction sheet from each patient's medical charts. Information on socio-demographic characteristics, injury mechanisms, clinical conditions at the initial presentation, intraoperative findings and complications, and patient outcomes were collected. RESULTS The study involved a total of 90 patients, consisting of 72 males (80%) and 18 females (20%). The average age of the patients was 10, with a standard deviation of 4.7, ranging from 2 to 16 years. Half of the patients were below the age of 10, accounting for 46 individuals (51%). The causes of the injuries varied among patients below and above the age of 10. However, overall, bullet injuries were the most common cause, accounting for 28 cases (31%), followed by falls in 21 cases (23.3%), horse or donkey kicks in 10 cases (11.1%), stab injuries in 10 cases (11.1%), horn injuries in 7 cases (7.8%), and road traffic accidents in 6 cases (6.7%). Physical assault, blasts, and other types of injuries, such as hen bites and metal rod injuries, were observed in 8 cases (8.9%) of the patients. Fall accidents, horse or donkey kicks, and horn injuries were particularly more common among children below the age of 10, while bullet injuries and stab injuries were most common among those above the age of 10. CONCLUSION Following abdominal trauma in children, a range of complications may arise, including immediate issues such as infections and hemorrhaging, as well as long-term consequences like impaired organ functionality and psychological distress. In our region, young children are particularly vulnerable to accidents involving falls, kicks from horses or donkeys, and injuries caused by horns. Therefore, it is crucial to educate parents about these hazards. Additionally, providing appropriate guidance on firearm safety is essential for individuals who possess such weapons.
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Affiliation(s)
- Yohannis Derbew Molla
- Department of Surgery, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | | | - Andinet Desalegn Beza
- Department of Surgery, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | | | - Deresse Abebe Gebrehana
- Department of Internal Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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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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Gungor E, Haliloglu G, Yalnizoglu D, Oguz KK, Teksam O. Predictors of Clinically Important Neuroimaging Findings in Children Presenting Pediatric Emergency Department. Pediatr Emerg Care 2024; 40:474-479. [PMID: 38587067 DOI: 10.1097/pec.0000000000003203] [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] [Indexed: 04/09/2024]
Abstract
OBJECTIVE The aim of the study is to evaluate predictors of clinically important neuroimaging results, that is, computed tomography and magnetic resonance imaging in children in an academic pediatric emergency department (PED) from 2015 to 2019. METHODS This study was conducted in an academic PED. The patient's demographic and clinical characteristics of PED visits and neuroimaging findings requested at the PED were recorded for January 1, 2015, to December 31, 2019. In addition, descriptive statistics and logistic regression analyses were conducted. We described and determined the predictors of clinically important neuroimaging findings in children. RESULTS Clinically important neuroimaging findings were detected in patients with blurred vision ( P = 0.001), ataxia ( P = 0.003), unilateral weakness ( P = 0.004), and altered level of consciousness ( P = 0.026). Clinically important neuroimaging was found 9.4 times higher in patients with altered level of consciousness, 7.4 times higher in patients with focal weakness, 4.6 times higher in patients with blurred vision, and 3.5 times more in patients presenting with ataxia. CONCLUSIONS Advanced neuroimaging, especially for selected patients in PED, can improve the quality of health care for patients. On the other hand, irrelevant neuroimaging findings can lead physicians away from prompt diagnosis and accurate management. According to our study, advanced neuroimaging can be performed in the early period for both diagnosis and early treatment, especially in selected patients with ataxia, blurred vision, altered consciousness, and unilateral weakness. In other cases, clinicians may find more supporting evidence.
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Affiliation(s)
- Emre Gungor
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics
| | | | | | - Kader Karli Oguz
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ozlem Teksam
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics
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Lyons A, Mohammed Ali A, England A, Moore N, Young R, Leamy B, Tam W, Bezzina P, Pongnapang N, McEntee MF. Expansion of Typical Values for Paediatric Patients in Ireland and Comparison with Published DRLs - Experiences of a Single Institution. J Med Imaging Radiat Sci 2024; 55:101421. [PMID: 38735771 DOI: 10.1016/j.jmir.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 04/16/2024] [Accepted: 04/22/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION To reduce the risks involved with ionising radiation exposure, typical values (TVs) and diagnostic reference levels (DRLs) have been established to help keep radiation doses 'as low as reasonably practicable. TVs/DRLs provide standardised radiation dose metrics that can be used for comparative purposes. However, for paediatrics, such values should consider the size of the child instead of their age. This study aimed to establish and compare paediatric TVs for chest, abdomen and pelvis radiography. METHODS Study methods followed processes for establishing paediatric DRLs as outlined by the Health Information and Quality Authority (HIQA). Kerma-area product (KAP) values, excluding rejected images, were retrospectively acquired from the study institution's Picture Archiving and Communications System (PACS). Paediatric patients were categorised into the following weight-based groupings (5 to <15 kg, 15 to <30 kg, 30 to <50 kg, 50 to 80 kg) and stratified based on the examination that was performed (chest, abdomen, and pelvis), and where it was performed (the different X-ray rooms). Anonymised data were inputted into Microsoft Excel for analysis. Median and 3rd quartile KAP values were reported together with graphical illustrations. RESULTS Data from 407 X-ray examinations were analysed. For the previously identified weight categories (5 to <15 kg, 15 to <30 kg, 30 to <50 kg, 50 to 80 kg), TVs for the chest were 0.10, 0.19, 0.37 and 0.53 dGy.cm2, respectively. For the abdomen 0.39, 1.04, 3.51 and 4.05 dGy.cm2 and for the pelvis 0.43, 0.87, 3.50 and 7.58 dGy.cm2. Between X-ray rooms TVs varied against the institutional TVs by -60 to 119 % (chest), -50 to 103 % (abdomen) and -14 and 24 %% (pelvis). CONCLUSION TVs in this study follow established trends with patient weight and examination type and are comparable with published literature. Variations do exist between individual examination rooms and reasons are multifactorial. Given that age and size do not perfectly correlate further work should be undertaken around weight-based TVs/DRLs in the paediatric setting.
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Affiliation(s)
- Andrew Lyons
- Discipline of Medical Imaging & Radiation Therapy, University College Cork, Cork, Ireland
| | - Ali Mohammed Ali
- Department of Medical Physics, College of Applied Medical Sciences, University of Kerbala, Karbala, Iraq
| | - Andrew England
- Discipline of Medical Imaging & Radiation Therapy, University College Cork, Cork, Ireland.
| | - Niamh Moore
- Discipline of Medical Imaging & Radiation Therapy, University College Cork, Cork, Ireland
| | - Rena Young
- Discipline of Medical Imaging & Radiation Therapy, University College Cork, Cork, Ireland
| | - Brid Leamy
- Department of Radiology, Cork University Hospital, Cork, Ireland
| | - Winnie Tam
- Department of Radiography, City, University of London, London, UK
| | - Paul Bezzina
- Department of Radiography, University of Malta, Msida, Malta
| | - Napapong Pongnapang
- Department of Radiological Technology, Mahidol University, Bangkok, Thailand
| | - Mark F McEntee
- Discipline of Medical Imaging & Radiation Therapy, University College Cork, Cork, Ireland
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Tanaanantarak P, Suntornsawat S, Samphao S. Clinical characteristics associated with pediatric traumatic intracranial hemorrhage. Chin J Traumatol 2024:S1008-1275(24)00029-4. [PMID: 38490943 DOI: 10.1016/j.cjtee.2024.03.003] [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: 07/18/2023] [Revised: 12/26/2023] [Accepted: 01/30/2024] [Indexed: 03/17/2024] Open
Abstract
PURPOSE Traumatic brain injury (TBI) can cause significant morbidity and mortality in the pediatric population. Brain CT is the mainstay in the diagnosis of intracranial hemorrhage (ICH). The aim of this study was to explore the clinical characteristics that can predict ICH on brain CT in pediatric TBI patients, to assist physicians in deciding on the use of brain CT. METHODS A total of 475 pediatric TBI patients who underwent brain CT within 24 h after injury from January 2012 to December 2021 in the level 1 trauma center in Thailand were included in this cross-sectional study. Clinical data and brain CT findings were collected. Logistic regression analysis was applied to evaluate clinical characteristics that could predict ICH on brain CT in pediatric TBI patients. A p value was less than 0.05 being indicated that the difference is statistically significant. R software version 3.6.1 was used to statistical analysis. RESULTS The mean age of included cases was 7.7 years (interquartile range (IQR) 3.5 - 12.6 years). ICH was found in 98 (20.63%) pediatric patients based on brain CT findings. On multivariable analysis, high blunt energy injury (odds ratio (OR) = 2.79, 95% CI 1.27 - 6.11, p = 0.010), motor vehicle accidents (OR = 2.04, 95% CI: 1.14 - 3.67, p = 0.017), Glasgow coma scale score <13 (OR = 4.28, 95% CI: 1.87 - 9.78, p < 0.001), palpable skull fractures (OR = 7.30, 95% CI: 1.44 - 37.04, p = 0.016), signs of basilar skull fracture (OR = 6.10, 95% CI: 2.16 - 17.24, p < 0.001), and vomiting ≥ 3 times (OR = 2.60, 95% CI: 1.17 - 5.77, p = 0.022) were statistically significant predictive factors for ICH in pediatric TBI patients. CONCLUSION These factors might aid clinicians in making an appropriate decision regarding the use of brain CT in pediatric TBI cases.
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Affiliation(s)
- Pattama Tanaanantarak
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
| | - Soraya Suntornsawat
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Srila Samphao
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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Lee S, Kim HY, Lee KH, Cho J, Lee C, Kim KP, Hwang J, Park JH. Risk of hematologic malignant neoplasms from head CT radiation in children and adolescents presenting with minor head trauma: a nationwide population-based cohort study. Eur Radiol 2024:10.1007/s00330-024-10646-2. [PMID: 38358528 DOI: 10.1007/s00330-024-10646-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/06/2023] [Accepted: 01/16/2024] [Indexed: 02/16/2024]
Abstract
OBJECTIVES The carcinogenic risks of CT radiation in children and adolescents remain debated. We aimed to assess the carcinogenic risk of CTs performed in children and adolescents with minor head trauma. METHODS In this nationwide population-based cohort study, we included 2,411,715 patients of age 0-19 with minor head trauma from 2009 to 2017. We excluded patients with elevated cancer risks or substantial past medical radiation exposure. Patients were categorized into CT-exposed or CT-unexposed group according to claim codes for head CT. The primary outcome was development of hematologic malignant neoplasms. Secondary outcomes included development of malignant solid neoplasms and benign neoplasms in the brain. We measured the incidence rate ratio (IRR) and incidence rate difference (IRD) using G-computation with Poisson regression adjusting for age, sex, hospital setting, and the type of head trauma. RESULTS Hematologic malignant neoplasms developed in 100 of 216,826 patients during 1,303,680 person-years in the CT-exposed group and in 808 of 2,194,889 patients during 13,501,227 person-years in the CT-unexposed group. For hematologic malignant neoplasms, the IRR was 1.29 (95% CI, 1.03-1.60) and the IRD was 1.71 (95% CI, 0.04-3.37) per 100,000 person-years at risk. The majority of excess hematologic malignant neoplasms were leukemia (IRR, 1.40 [98.3% CI, 1.05-1.87]; IRD, 1.59 [98.3% CI, 0.02-3.16] per 100,000 person-years at risk). There were no between-group differences for secondary outcomes. CONCLUSIONS Radiation exposure from head CTs in children and adolescents with minor head trauma was associated with an increased incidence of hematologic malignant neoplasms. CLINICAL RELEVANCE STATEMENT Our study provides a quantitative grasp of the risk conferred by CT examinations in children and adolescents, thereby providing the basis for cost-benefit analyses and evidence-driven guidelines for patient triaging in head trauma. KEY POINTS • This nationwide population-based cohort study showed that radiation exposure from head CTs in children and adolescents was associated with a higher incidence of hematologic malignant neoplasms. • The incidence rate of hematologic malignant neoplasms in the CT-exposed group was 29% higher than that in the CT-unexposed group (IRR, 1.29 [95% CI, 1.03-1.60]), and there were approximately 1.7 excess neoplasms per 100,000 person-years at risk in the CT-exposed group (IRD, 1.71 [0.04-3.37]). • Our study provides a quantified grasp of the risk conferred by CT examinations in children and adolescents, while controlling for biases observed in previous studies via specifying CT indication and excluding patients with predisposing conditions for cancer development.
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Affiliation(s)
- Seungjae Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-Do, South Korea
- Institute of Health and Environment, Seoul National University, Seoul, South Korea
| | - Hae Young Kim
- Department of Radiology, Asan Medical Center, Seoul, South Korea
| | - Kyung Hee Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-Do, South Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, 13620, Gyeonggi-Do, South Korea
| | - Jungheum Cho
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-Do, South Korea
| | - Choonsik Lee
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kwang Pyo Kim
- Department of Nuclear Engineering, Kyung Hee University, Seoul, Gyeonggi-Do, South Korea
| | - Jinhee Hwang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-Do, South Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, South Korea
| | - Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-Do, South Korea.
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, 13620, Gyeonggi-Do, South Korea.
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, South Korea.
- Department of Medical Device Development, Seoul National University College of Medicine, Seoul, South Korea.
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12
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Cappellari AM, Bruschi G, Beretta GB, Molisso MT, Bertolozzi G. How Can Specialist Advice Influence the Neuroimaging Practice for Childhood Headache in Emergency Department? CHILDREN (BASEL, SWITZERLAND) 2023; 10:1837. [PMID: 38136039 PMCID: PMC10742139 DOI: 10.3390/children10121837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023]
Abstract
Differentiating between primary and secondary headaches can be challenging, especially in the emergency department (ED). Since symptoms alone are inadequate criteria for distinguishing between primary and secondary headaches, many children with headaches undergo neuroimaging investigations, such as brain CT and MRI. In various studies, the frequency of neuroimaging utilization is influenced by several factors, including teaching status, ownership, metropolitan area, insurance status, and ethnicity of patients. However, only a few studies have considered the role of specialist consultations in ordering neuroimaging studies on childhood headaches. We report the contributions of different specialists to the evaluation of children with headaches admitted to the ED and their influence on neuroimaging decisions. We retrospectively reviewed the medical reports of paediatric patients who presented with headaches to the paediatric ED of the Ospedale Maggiore Policlinico of Milano between January 2017 and January 2022. Overall, 890 children with headaches were evaluated (mean age: 10.0 years; range: 1 to 17 years). All patients were examined by the ED paediatricians, while specialist consultations were required for 261 patients, including 240 neurological (92.0%), 46 ophthalmological (17.6%), and 20 otorhinolaryngological (7.7%) consultations. Overall, 173 neuroimaging examinations were required, of which 51.4 and 48.6% were ordered by paediatricians and neurologists, respectively. In particular, paediatricians required 61.4% of brain CT scans, and neurologists required 92.0% of brain MRI scans. In conclusion, paediatricians were responsible for the management of most children with headaches admitted to the ED, while specialist consultations were required only in about a third of the cases. Although there was no significant difference in the number of neuroimaging studies ordered by specialists, brain CT scans were most often used by paediatricians, and MRI scans by neurologists.
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Affiliation(s)
- Alberto M. Cappellari
- Department of Neuroscience and Mental Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Gaia Bruschi
- Postgraduate School of Paediatrics, Università degli Studi di Milano, 20122 Milan, Italy; (G.B.); (G.B.B.)
| | - Gisella B. Beretta
- Postgraduate School of Paediatrics, Università degli Studi di Milano, 20122 Milan, Italy; (G.B.); (G.B.B.)
| | - Maria T. Molisso
- Department of Neuroscience and Mental Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Giuseppe Bertolozzi
- Pediatric Emergency Department, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
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13
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Simoni P, Kozlowski L, Boitsios G, De Angelis R, De Leucio A. American College of Radiology (ACR) Appropriateness Criteria and EURO-2000 Guidelines Offer Limited Guidance for MRI Imaging of Pediatric Patients. Acad Radiol 2023; 30:1991-1999. [PMID: 36572626 DOI: 10.1016/j.acra.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 12/26/2022]
Abstract
PURPOSE This study aims to evaluate the clinical scenarios addressed by the EURO-2000 guidelines and the ACR appropriateness criteria for referring children to MRI and assessing the referring physician compliance with both guidelines. METHODS In January 2022, clinical scenarios reported in the last 1000 consecutive MRI requests for children (0-16 years) in one university children's hospital and two general university hospitals in Belgium, Europe, were retrospectively matched to the EURO-2000 guidelines and ACR appropriateness criteria. The number of clinical scenarios addressed and the justification for MRI referral were independently assessed for both guidelines. Pooled data from the three centers were evaluated and then analyzed by center, body area and prescriber using McNemar's test for paired proportions and χ2-tests unpaired proportions. RESULTS After excluding incomplete or missing MRI requests, 2932 of 3000 requests were included in the analysis. Overall, out of 2932 clinical scenarios, 1229 (37.99%) were addressed by EURO-2000 and 1081 (36.37%) were addressed by the ACR appropriateness criteria (McNemar test, p = 0.12). The proportions of clinical scenarios covered by the two guidelines were statistically similar when comparing centers, but varied across body regions (p < 0.001) and referring physician specialty (p between 0.75 and 0.001). EURO-2000 guidelines provided better coverage for head and spine (p < 0.05), while the ACR appropriateness criteria provided broader coverage for abdomen, pelvis, and musculoskeletal system (p < 0.0001). For addressed clinical scenarios, prescriber compliance for both guidelines was excellent with > 94% of justified MRI examinations in all the centers. CONCLUSIONS Both the EURO-2000 guidelines and the ACR appropriateness criteria did not address two-thirds of clinical scenarios in children. Head and neck, chest and abdominal-pelvic examinations are the anatomic regions which should receive a specific attention for the future implementation of evidence-based clinical decision support tools for all referring specialists.
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Affiliation(s)
- Paolo Simoni
- Department of Pediatric Imaging, "Reine Fabiola" Children's University Hospital, Université Libre de Bruxelles, 15, Jean-Joseph Crocq, 1020, Brussels, Belgium.
| | - Lysandre Kozlowski
- Department of Pediatric Imaging, "Reine Fabiola" Children's University Hospital, Université Libre de Bruxelles, 15, Jean-Joseph Crocq, 1020, Brussels, Belgium
| | - Grammatina Boitsios
- Department of Pediatric Imaging, "Reine Fabiola" Children's University Hospital, Université Libre de Bruxelles, 15, Jean-Joseph Crocq, 1020, Brussels, Belgium
| | - Riccardo De Angelis
- Department of Pediatric Imaging, "Reine Fabiola" Children's University Hospital, Université Libre de Bruxelles, 15, Jean-Joseph Crocq, 1020, Brussels, Belgium
| | - Alessandro De Leucio
- Department of Pediatric Imaging, "Reine Fabiola" Children's University Hospital, Université Libre de Bruxelles, 15, Jean-Joseph Crocq, 1020, Brussels, Belgium
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14
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Schunn MC, Schäfer J, Neunhoeffer F, Lieber J, Fuchs J. [Blunt abdominal trauma in children and adolescents: treatment concepts in the acute phase]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:651-663. [PMID: 37338573 DOI: 10.1007/s00104-022-01798-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 06/21/2023]
Abstract
Fatal accidents due to blunt force trauma are the leading cause of death in children and adolescents [1]. Abdominal trauma is the third most common cause of death after traumatic brain injury and thoracic injuries [2]. Abdominal injury is seen in approximately 2-5% of children involved in accidents [3]. Blunt abdominal injuries are common sequelae of traffic accidents (for example as seat belt injury), falls, and sports accidents. Penetrating abdominal injuries are rare in central Europe. Spleen, liver, and kidney lacerations are the most common injuries after blunt abdominal trauma [4]. In most situations, nonoperative management (NOM) has become the gold standard with the surgeon leading the multidisciplinary treatment [5].
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Affiliation(s)
- M C Schunn
- Klinik für Kinder- und Jugendmedizin, Abteilung für Kinderchirurgie und Kinderurologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland.
| | - J Schäfer
- Diagnostische und Interventionelle Radiologie, Abteilung für Kinderradiologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - F Neunhoeffer
- Klinik für Kinderheilkunde, Abteilung für Kinderkardiologie, Intensivmedizin und Pulmonologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - J Lieber
- Klinik für Kinder- und Jugendmedizin, Abteilung für Kinderchirurgie und Kinderurologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - J Fuchs
- Klinik für Kinder- und Jugendmedizin, Abteilung für Kinderchirurgie und Kinderurologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
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15
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Yoneyama T, Sato I, Nakashima M, Takeuchi M, Kawakami K. Recent Trend of Using Computed Tomography to Diagnose Pediatric Appendicitis at the First Hospital Visit: A Descriptive Study Using a Medical Claims Database. Pediatr Emerg Care 2023; 39:236-241. [PMID: 36944031 DOI: 10.1097/pec.0000000000002930] [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] [Indexed: 03/23/2023]
Abstract
OBJECTIVE We recognize that computed tomography (CT) should not be used to diagnosis pediatric appendicitis due to radiation exposure. However, few studies have recently shown a trend in its use. This study aimed to investigate the annual use of CT for the diagnosis of pediatric appendicitis at the first hospital visit. METHODS This was a descriptive study using nationwide claims data. We extracted the data of children younger than 15 years who underwent imaging tests to diagnose acute and suspected appendicitis at the first visit between January 2008 and September 2018. We summarized the patient characteristics and the percentage of CT, ultrasonography (US), or CT/US utilization by year, age, and department. RESULTS We identified 6658 children who underwent CT (2349 [35.8%]), US (53,57 [54.5%]), and CT/US (634 [9.7%]). The annual CT use dropped from 43.1% in 2012 to 29.4% in 2018. According to age group, the highest percentage of CT use in 2018 was 84.6% in preschool children, followed by adolescents (40.3%), upper-grade (26.0%), and lower-grade (15.0%) children. Data of annual CT use by department revealed that CT usage was much higher in internal and emergency medicine than in pediatrics. Furthermore, adolescents accounted for approximately 50% of CT use in internal medicine. CONCLUSIONS The percentage of CT use for pediatric appendicitis at the first visit declined annually. However, CT use still tended to be higher in preschool- and adolescent-aged children, or in departments other than pediatrics. Further studies are required to clarify the clinical benefits of CT use to diagnose pediatric appendicitis.
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Affiliation(s)
- Tetsuji Yoneyama
- From the Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoecho, Sakyoku, Kyoto
| | - Izumi Sato
- Department of Clinical Epidemiology, Graduate School of Biomed Science and School of Medicine, Nagasaki University, Sakamoto, Nagasaki, Japan
| | - Masayuki Nakashima
- From the Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoecho, Sakyoku, Kyoto
| | - Masato Takeuchi
- From the Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoecho, Sakyoku, Kyoto
| | - Koji Kawakami
- From the Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoecho, Sakyoku, Kyoto
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Tintor G, Jukić M, Šupe-Domić D, Jerončić A, Pogorelić Z. Diagnostic Accuracy of Leucine-Rich α-2-Glycoprotein 1 as a Non-Invasive Salivary Biomarker in Pediatric Appendicitis. Int J Mol Sci 2023; 24:ijms24076043. [PMID: 37047015 PMCID: PMC10094467 DOI: 10.3390/ijms24076043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/19/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
The aim of this study is to evaluate the diagnostic accuracy of leucine-rich α-2-glycoprotein 1 (LRG1) in saliva as a novel biomarker for acute appendicitis in the pediatric population. From October 2021 to June 2022, 92 children aged 5 to 17 years who presented with acute abdomen and suspected acute appendicitis were enrolled in this prospective study. The parameters documented included demographic and clinical information, as well as operative and postoperative data. Patients were divided into two groups: those with acute appendicitis who underwent laparoscopic appendectomy (n = 46) and those without appendicitis (n = 46). The total white blood cell (WBC) count, percent of neutrophils, C-reactive protein (CRP) level, and salivary LRG1 were compared between groups. A commercially available enzyme-linked immunosorbent assay (ELISA) LRG kit was used to measure the LRG levels. The median salivary LRG1 level was significantly higher in the group of children with pathohistologically confirmed acute appendicitis compared to the control group: 233.45 ng/mL (IQR 114.9, 531.2) vs. 55.95 ng/mL (IQR 51.5, 117.9), p < 0.001. LRG1 had an overall good receiver-operator characteristic area under the curve of 0.85 (95% CI 0.76-0.92; p < 0.001). The optimal LRG1 cutoff with best separation between acute appendicitis and the controls was >352.6 ng/mL (95% CI from >270.7 to >352.6). Although the specificity was 100% at this cutoff, the sensitivity for identifying appendicitis was 36%. In addition, a significant difference was found between groups in the laboratory values of all inflammatory markers tested: WBC, absolute neutrophil count, and CRP (p < 0.001 for all). Although LRG1 in saliva showed a good AUC parameter and significantly higher values in patients with acute appendicitis compared to the controls, its usefulness in the patient population who present at emergency departments with abdominal pain is debatable. Future studies should focus on investigating its diagnostic potential.
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Affiliation(s)
- Goran Tintor
- Department of Plastic Reconstructive and Aesthetic Surgery, University Hospital of Split, 21 000 Split, Croatia
- Department of Surgery, School of Medicine, University of Split, 21 000 Split, Croatia
| | - Miro Jukić
- Department of Surgery, School of Medicine, University of Split, 21 000 Split, Croatia
- Department of Pediatric Surgery, University Hospital of Split, 21 000 Split, Croatia
| | - Daniela Šupe-Domić
- Department of Medical Laboratory Diagnostics, University Hospital of Split, 21 000 Split, Croatia
| | - Ana Jerončić
- Department of Research in Biomedicine and Health, School of Medicine, University of Split, 21 000 Split, Croatia
| | - Zenon Pogorelić
- Department of Surgery, School of Medicine, University of Split, 21 000 Split, Croatia
- Department of Pediatric Surgery, University Hospital of Split, 21 000 Split, Croatia
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17
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Tintor G, Jukić M, Šupe-Domić D, Jerončić A, Pogorelić Z. Diagnostic Utility of Serum Leucine-Rich α-2-Glycoprotein 1 for Acute Appendicitis in Children. J Clin Med 2023; 12:jcm12072455. [PMID: 37048540 PMCID: PMC10094962 DOI: 10.3390/jcm12072455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/15/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
PURPOSE The aim of this study is to assess the diagnostic utility of serum leucine-rich α-2-glycoprotein 1 (LRG1) in pediatric patients with acute abdominal pain, admitted to the emergency surgical unit, in order to make a prompt and accurate diagnosis of acute appendicitis. PATIENTS AND METHODS Pediatric patients older than 5 years of age who presented to the emergency department from 15 October 2021 to 30 June 2022 with acute abdominal pain and suspected acute appendicitis were prospectively recruited in the study. Demographic and clinical data, as well as operative and postoperative data, were recorded. A total of 92 patients were equally distributed into two groups: children with acute appendicitis who underwent laparoscopic appendectomy and non-appendicitis patients, presenting with non-specific abdominal pain. LRG1 levels were determined using a commercially available LRG1 enzyme-linked immunosorbent assay (ELISA) kit. Serum LRG1 levels, as well as other inflammatory markers (white blood cell count (WBC), C-reactive protein (CRP) and absolute neutrophil count) were compared between groups. RESULTS The median level of LRG1 in serum was significantly higher in the group of children with pathohistologically confirmed acute appendicitis than in the control group, at 350.3 µg/mL (interquartile range (IQR) 165.2-560.3) and 25.7 µg/mL (IQR 14.7-36.8) (p < 0.001), respectively. Receiver operating characteristic area under the curve for LRG1 from serum was 1.0 (95% CI 0.96-1.00; p < 0.001) and the value of >69.1 µg/mL was found to perfectly separate acute appendicitis cases from controls. Additionally, as expected, each of the examined laboratory inflammatory markers provided a significantly higher values in the acute appendicitis group compared to the control group: WBC 14.6 × 109/L (IQR 12.7, 18.7) vs. 7.0 × 109/L (IQR 5.4, 9.0) (p < 0.001), CRP 16.3 mg/dL (IQR 6.9, 50.4) vs. 2.2 mg/dL (IQR 2, 2) (p < 0.001) and absolute neutrophil count 84.6% (IQR 79.5, 89.0) vs. 59.5% (IQR 51.5, 68.6) (p < 0.001). CONCLUSIONS LRG1 in the serum was found to be a promising novel biomarker, with excellent differentiation of acute appendicitis from non-appendicitis cases in children presenting with non-specific abdominal pain.
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Affiliation(s)
- Goran Tintor
- Department of Plastic Reconstructive and Aesthetic Surgery, University Hospital of Split, 21000 Split, Croatia
- Department of Surgery, School of Medicine, University of Split, 21000 Split, Croatia
| | - Miro Jukić
- Department of Surgery, School of Medicine, University of Split, 21000 Split, Croatia
- Department of Pediatric Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Daniela Šupe-Domić
- Department of Medical Laboratory Diagnostics, University Hospital of Split, 21000 Split, Croatia
- Department of Health Studies, University of Split, 21000 Split, Croatia
| | - Ana Jerončić
- Department of Research in Biomedicine and Health, School of Medicine, University of Split, 21000 Split, Croatia
| | - Zenon Pogorelić
- Department of Surgery, School of Medicine, University of Split, 21000 Split, Croatia
- Department of Pediatric Surgery, University Hospital of Split, 21000 Split, Croatia
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18
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Gerber N, Munnangi S, Vengalasetti Y, Gupta S. Trauma center variation of head computed tomography utilization in children presenting with mild traumatic brain injury. Clin Imaging 2023; 94:125-131. [PMID: 36529077 DOI: 10.1016/j.clinimag.2022.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 10/16/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although published clinical decision rules have identified indications for the use of head CT in children with mild traumatic brain injury, practices vary. OBJECTIVE This study seeks to evaluate whether the utilization of head CT in pediatric trauma patients presenting with mTBI varies between American College of Surgeons verified pediatric trauma centers (ACS-PTC) and adult-only trauma centers (ACS-AOTC). MATERIAL AND METHODS A retrospective cohort study of 24,104 trauma patients, ≤17, who presented to the emergency department at 337 ACS verified level I/II trauma centers with isolated mTBI was conducted using National Trauma Data Bank records (2011-2015). Multivariable logistic regression was used to compare the odds of a patient receiving a head CT when treated at an ACS-PTC vs. an ACS-AOTC, controlling for demographic, injury, and hospital-level confounders. Effect modification by loss of consciousness was assessed and adjusted head CT odds were recalculated in patients stratified by LOC status. RESULTS There was no significant difference in the adjusted odds of receiving a head CT at an ACS-PTC vs. an ACS-AOTC (odds ratio: 0.98, 95% confidence interval: 0.92-1.04). However, in patients who had a LOC, the adjusted OR of receiving a head CT at an ACS-PTC vs ACS-AOTC was 0.71 (95% confidence interval: 0.65-0.78). CONCLUSION Children presenting to the emergency department of an ACS-verified level I or II trauma center with mTBI who had a loss of consciousness are less likely to receive a head CT at an ACS verified pediatric trauma center than at an ACS verified adult-only trauma center.
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Affiliation(s)
- Noam Gerber
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, United States of America.
| | - Swapna Munnangi
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, United States of America
| | - Yasaswi Vengalasetti
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Sameer Gupta
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, United States of America
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Miyagawa T, Saga M, Sasaki M, Shimizu M, Yamaura A. Statistical and machine learning approaches to predict the necessity for computed tomography in children with mild traumatic brain injury. PLoS One 2023; 18:e0278562. [PMID: 36595496 PMCID: PMC9810188 DOI: 10.1371/journal.pone.0278562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/18/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Minor head trauma in children is a common reason for emergency department visits, but the risk of traumatic brain injury (TBI) in those children is very low. Therefore, physicians should consider the indication for computed tomography (CT) to avoid unnecessary radiation exposure to children. The purpose of this study was to statistically assess the differences between control and mild TBI (mTBI). In addition, we also investigate the feasibility of machine learning (ML) to predict the necessity of CT scans in children with mTBI. METHODS AND FINDINGS The study enrolled 1100 children under the age of 2 years to assess pre-verbal children. Other inclusion and exclusion criteria were per the PECARN study. Data such as demographics, injury details, medical history, and neurological assessment were used for statistical evaluation and creation of the ML algorithm. The number of children with clinically important TBI (ciTBI), mTBI on CT, and controls was 28, 30, and 1042, respectively. Statistical significance between the control group and clinically significant TBI requiring hospitalization (csTBI: ciTBI+mTBI on CT) was demonstrated for all nonparametric predictors except severity of the injury mechanism. The comparison between the three groups also showed significance for all predictors (p<0.05). This study showed that supervised ML for predicting the need for CT scan can be generated with 95% accuracy. It also revealed the significance of each predictor in the decision tree, especially the "days of life." CONCLUSIONS These results confirm the role and importance of each of the predictors mentioned in the PECARN study and show that ML could discriminate between children with csTBI and the control group.
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Affiliation(s)
- Tadashi Miyagawa
- Department of Pediatric Neurosurgery, Matsudo City General Hospital, Matsudo, Japan
- * E-mail:
| | - Marina Saga
- Department of Neurosurgery, Matsudo City General Hospital, Matsudo, Japan
| | - Minami Sasaki
- Department of Neurosurgery, Matsudo City General Hospital, Matsudo, Japan
| | - Miyuki Shimizu
- Department of Neurosurgery, Matsudo City General Hospital, Matsudo, Japan
| | - Akira Yamaura
- Department of Neurosurgery, Matsudo City General Hospital, Matsudo, Japan
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Hiraoka T, Kawamura M, Takada K, Moriwake T. A pediatric case of ureterolithiasis due to cystinuria accompanied by acute appendicitis; a case report. Int J Surg Case Rep 2022; 99:107596. [PMID: 36115118 PMCID: PMC9568739 DOI: 10.1016/j.ijscr.2022.107596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 08/31/2022] [Accepted: 08/31/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Acute abdominal pain, a chief complaint frequently seen in the emergency department, can be triggered by a vast range of conditions. Although ureterolithiasis is a less common cause in children, renal colic can be caused by calculi due to hereditary metabolic diseases among patients in those age groups. Presentation of case We report a 12-year-old girl with abdominal pain who was diagnosed with concurrent acute appendicitis and ureterolithiasis due to cystinuria. Acute appendicitis was successfully treated with cefmetazole, and the calculus was eliminated after adequate fluid loading. Discussion Synchronous acute appendicitis and ureterolithiasis is reported to be rare. Cystinuria is a hereditary metabolic stone-forming disease, and the first calculi can be detected in childhood. Increasing the solubility of cystine in the urine is required to prevent recurrent stone formation and accompanying complications. Urinalysis, ultrasound, and computed tomography coincidentally demonstrated two different acute pathological processes of ureterolithiasis and appendicitis. Conclusion Careful physical and laboratory examination can help clinicians find coexisting etiologies of acute abdominal pain. Ureterolithiasis can be seen in children with hereditary disorders such as cystinuria. Early diagnosis of cystinuria and close monitoring may lead to a better long-term outcome. Abdominal pain can be caused by coexisting different disease processes. Patients with cystinuria usually experience the first stone formation in childhood. Diagnostic clues: cystine stone, hexagonal crystals, and urinary cystine excretion Treatments include adequate fluid intake, urinary alkalinization, and nutritional therapy. A proper selection of imaging modalities is needed for the assessment and follow-up.
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21
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Graffeo CS, Yagnik KJ, Carlstrom LP, Lakomkin N, Bancos I, Davidge-Pitts C, Erickson D, Choby G, Pollock BE, Chamberlain AM, Van Gompel JJ. Pituitary Adenoma Incidence, Management Trends, and Long-term Outcomes: A 30-Year Population-Based Analysis. Mayo Clin Proc 2022; 97:1861-1871. [PMID: 35753823 PMCID: PMC9981281 DOI: 10.1016/j.mayocp.2022.03.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 02/05/2022] [Accepted: 03/11/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To perform a population-based study of pituitary adenoma epidemiology, including longitudinal trends in disease incidence, treatment patterns, and outcomes. PATIENTS AND METHODS In this study of incident pituitary adenomas in Olmsted County, Minnesota, from January 1, 1989, through December 31, 2019, we identified 785 patients who underwent primary screening, 435 of whom were confirmed as harboring incident pituitary adenomas and were included. Primary outcomes of interest included demographic characteristics, presenting features, and disease outcomes (tumor control, biochemical control, and complications). RESULTS Among our 435 study patients, 438 unique pituitary adenomas were diagnosed at a median patient age of 39 years (interquartile range [IQR], 27 to 58 years). Adenomas were incidentally identified in 164 of the 438 tumors (37%). Common symptomatic presentations included hyperprolactinemia (188 of 438 [43%]) and visual field deficit (47 of 438 [11%]). Laboratory tests confirmed pituitary hormone hypersecretion in 238 of the 435 patients (55%), which was symptomatic in 222. The median tumor diameter was 8 mm (IQR, 5 to 17 mm). Primary management strategies were observation (156 of 438 tumors [36%]), medication (162 of 438 tumors [37%]), and transsphenoidal resection (120 of 438 tumors [27%]). Tumor and biochemical control were achieved in 398 (95%) and 216 (91%) secreting tumors, respectively. New posttreatment pituitary or visual deficits were noted in 43 (11%) and 8 (2%); apoplexy occurred in 28 (6%). Median clinical follow-up was 98 months (IQR, 47 to 189 months). Standardized incidence rates were 3.77 to 16.87 per 100,000 population, demonstrating linear expansion over time (R2=0.67). The mean overall standardized incidence rate was 10.1 per 100,000 population; final point prevalence was 175.1 per 100,000 population. CONCLUSION Pituitary adenoma is a highly incident disease, with prolactin-secreting and incidental lesions representing the majority of tumors. Incidence rates and asymptomatic detection appear to be increasing over time. Presenting symptoms and treatment pathways are variable; however, most patients achieve favorable outcomes with observation or a single treatment modality.
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Affiliation(s)
| | - Karan J Yagnik
- Department of Neurologic Surgery, Mayo Clinic, Rochester MN
| | | | | | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester MN
| | - Caroline Davidge-Pitts
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester MN
| | - Dana Erickson
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester MN
| | - Garret Choby
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester MN
| | - Bruce E Pollock
- Department of Neurologic Surgery, Mayo Clinic, Rochester MN; Department of Radiation Oncology, Mayo Clinic, Rochester MN
| | | | - Jamie J Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester MN; Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester MN.
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22
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Akın B, Coşkun A, Demirci B, Karaçam H, Çam B. Clinical and Imaging Consequences in Pediatric Head Trauma. BAGCILAR MEDICAL BULLETIN 2022. [DOI: 10.4274/bmb.galenos.2022.2022-03-030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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23
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Regmi PR, Amatya I, Paudel S, Kayastha P. Modern Paediatric Radiology: Meeting the Challenges in CT and MRI. JNMA J Nepal Med Assoc 2022; 60:661-663. [PMID: 36705198 PMCID: PMC9297347 DOI: 10.31729/jnma.7539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/25/2022] [Indexed: 01/31/2023] Open
Abstract
Radiology plays a very important part in the diagnosis, treatment, and follow-up of children. Computed tomography and magnetic resonance imaging are the two most crucial developments in the modern era. However, the two modalities have their challenges to overcome. Radiation dose is the most unwanted side effect of computed tomography scans while longer scan time along with sedation is a major disadvantage in children during magnetic resonance imaging. Paediatric-specific protocol selection and limiting the exposure to the area of interest aid in reducing the dose during computed tomography scans. Faster scan protocols and sequences can result in imaging without sedation in magnetic resonance imaging. Considering the radiation exposure, "as low as reasonably achievable" principle should be followed strictly in the paediatric population. In this article, possible ways for minimising the radiation dose in computed tomography, as well as effective, short, and sedation-free magnetic resonance imaging, are discussed. Keywords computed X-ray tomography; magnetic resonance imaging; pediatrics; radiation exposure; X-ray.
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Affiliation(s)
- Pradeep Raj Regmi
- Department of Radiology and Imaging, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Isha Amatya
- Health Research Section, Nepal Health Research Council, Ramshahpath, Kathmandu, Nepal
| | - Sharma Paudel
- Department of Radiology and Imaging, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal,Correspondence: Dr Sharma Paudel, Department of Radiology and Imaging, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal. , Phone: +977-9841393486
| | - Prakash Kayastha
- Department of Radiology and Imaging, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
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24
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Emergency department diagnosis and management of constipation in the United States, 2006–2017. Am J Emerg Med 2022; 54:91-96. [DOI: 10.1016/j.ajem.2022.01.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/22/2022] [Accepted: 01/27/2022] [Indexed: 11/30/2022] Open
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25
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Variability in advanced imaging of pediatric neck infections in US emergency departments. Am J Emerg Med 2022; 53:140-143. [PMID: 35051700 DOI: 10.1016/j.ajem.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 01/01/2022] [Accepted: 01/04/2022] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES To describe the use of computed tomography (CT) and ultrasound (US) imaging for the evaluation of neck infections in pediatric patients in United States emergency departments (EDs). METHODS This is a cross-sectional analysis, using the National Emergency Department Sample database, of pediatric patients evaluated for common neck infections between 2012 and 2018. We used bivariable analysis to assess for differences in US and CT use by ED type. We performed multivariable logistic regression to adjust for potential confounding factors including patient characteristics (sex, age, insurance status, discharge diagnosis) and ED characteristics (metropolitan statistical area, pediatric center). Results are reported as odds ratios and adjusted odds ratios with 95% confidence intervals. RESULTS There were 19,363 ED visits for pediatric neck infections in the database over the study period, representing 84,439 national visits. Of those imaged, 80.8% were imaged with CT and 19.2% were imaged with US. Pediatric patients evaluated in general EDs as compared to pediatric EDs (aOR 5.32, 95% CI 3.06, 9.24) and patients with a diagnosis of peritonsillar abscess (aOR 2.11, 95% CI 1.34, 3.33) and retropharyngeal abscess (aOR 6.12, 95% CI 2.14, 17.53) were more likely to be imaged with CT scan. CONCLUSIONS Children with neck infections evaluated in general EDs are significantly more likely to undergo CT scans when compared to those evaluated in pediatric EDs. To reduce exposure to radiation in children, we propose the dissemination of US-first protocols in general EDs for the evaluation of pediatric neck infections.
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26
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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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27
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Wiitala EL, Parker JL, Jones JS, Benner CA. Comparison of Computed Tomography Use and Mortality in Severe Pediatric Blunt Trauma at Pediatric Level I Trauma Centers Versus Adult Level 1 and 2 or Pediatric Level 2 Trauma Centers. Pediatr Emerg Care 2022; 38:e138-e142. [PMID: 32658115 DOI: 10.1097/pec.0000000000002183] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Computed tomography (CT) is the criterion standard for identifying blunt trauma injuries in pediatric patients, but there are long-term risks of CT exposure. In pediatric blunt trauma, multiple studies have shown that increased CT usage does not necessarily equate to improvements in mortality. The aim of this study was to compare CT usage between level 1 pediatric trauma centers versus level 2 pediatric centers and adult level 1 and 2 centers. METHODS We performed a retrospective, multicenter analysis of National Trauma Data Bank patient records from the single admission year of 2015. Eligible subjects were defined as younger than 18 years with abdominal or thoracic blunt trauma, had an Injury Severity Scale score of greater than 15, and were treated at a level 1 or 2 trauma center. Data were then compared between children treated at level 1 pediatric trauma centers (PTC group) versus level 2 PTCs or adult level 1/2 trauma centers (ATC group). The primary outcomes measured were rates of head, thoracic, abdominal CT, and mortality. Data from ATC and PTC groups were propensity matched for age, sex, race, and Glasgow Coma Scale. RESULTS There were 6242 patients after exclusion criteria. Because of differences in patient demographics, we propensity matched 2 groups of 1395 patients. Of these patients, 39.6% of PTC patients received abdominal CT versus 45.5% of ATC patients (P = 0.0017). Similarly, 21.9% of PTC patients received thoracic CT versus 34.7% of ATC patients (P < 0.0001). There was no difference in head CT usage between PTC and ATC groups (P = 1.0000). There was no significant difference in mortality between patients treated in the PTC versus ATC groups (P = 0.1198). CONCLUSIONS Among children with severe blunt trauma, patients treated at level 1 PTCs were less likely to receive thoracic and abdominal CTs than those treated at level 2 pediatric or adult trauma level 1/2 centers, with no significant differences in mortality. These findings support the use of selective imaging in severe blunt pediatric trauma.
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Affiliation(s)
- Ellen L Wiitala
- From the Michigan State University College of Human Medicine
| | | | - Jeffrey S Jones
- From the Michigan State University College of Human Medicine
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28
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Khan HH, Subedi S, Kumar S, Lyons H. The Pattern of CT Scan Use in the Diagnosis of Abdominal Pain in Children Presenting to the Emergency Department of a Tertiary Community Hospital. Cureus 2021; 13:e19162. [PMID: 34873505 PMCID: PMC8631058 DOI: 10.7759/cureus.19162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2021] [Indexed: 11/17/2022] Open
Abstract
Background and objective Pediatric populations are highly sensitive to ionizing radiations and, therefore, are more at risk of their harmful outcomes. Our study aimed to determine the percentage of children who underwent a CT scan after presenting to the ED with abdominal pain. The secondary aim was to determine the change in management related to the CT results. In addition, we also wanted to determine the predictors associated with the use of abdominal CT scans in the evaluation of children presenting to ED with abdominal pain as well as the predictors associated with positive CT scan results in children with abdominal pain. Materials and methods We retrospectively reviewed the medical records of children with abdominal pain seen in our ED from 01/01/2011 through 12/30/2012. Patients aged 4-18 years presenting with abdominal pain were identified from the medical records. Data on demographics, clinical characteristics, associated factors, CT use, CT findings, and change in management were collected. Data were analyzed using Chi-square (χ2) analysis and Student’s t-test. Results A total of 1,780 charts were reviewed and 1,272 children were included in the study. The mean age of the cohort was 12.6 ± 4.6 years; 62.6% were female and 68.7% were African American. Of note, 14% (181/1,272) of the study group had received a CT scan; change in medical management was noted in 34.8% (63/181) of the scanned patients. Predictors of CT use included older age (p<0.0001), male gender (p<0.0001), white race (p<0.0001), an attending without advanced training in pediatric emergencies (p=0.001), acute onset of symptoms (p<0.0001), higher pain score (p<0.0001), right lower quadrant pain (p<0.0001), abdominal wall rebound tenderness (p<0.0001), abdominal tenderness (p<0.0001), fever (p<0.0001), and absence of constipation (p=0.04). Positive CT scan results were predicted by the presence of fever (p=0.013), lack of constipation (p=0.025), and white race (p=0.022). A multivariate analysis could not be done because not all data were available for each patient. Conclusion The use of the CT scan in children with abdominal pain affected the management in one out of three patients (34.8%). Fever, constipation, and white race were the factors associated with an increased likelihood of performing a CT scan and were also linked to positive results.
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Affiliation(s)
- Hamza H Khan
- Medicine, Shifa International Hospital, Islamabad, PAK.,Pediatrics, Ascension St. John Hospital, Detroit, USA.,Pediatric Gastroenterology, Medical University of South Carolina, Charleston, USA
| | - Shova Subedi
- Pediatric Gastroenterology, Brown University, Providence, USA
| | - Sanjay Kumar
- Pediatric Gastroenterology, Ascension St. John Hospital, Detroit, USA
| | - Hernando Lyons
- Pediatric Gastroenterology, Ascension St. John Hospital, Detroit, USA
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29
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Engineer RS, Podolsky SR, Fertel BS, Grover P, Jimenez H, Simon EL, Smalley CM. A Pilot Study to Reduce Computed Tomography Utilization for Pediatric Mild Head Injury in the Emergency Department Using a Clinical Decision Support Tool and a Structured Parent Discussion Tool. Pediatr Emerg Care 2021; 37:e1670-e1674. [PMID: 29768294 DOI: 10.1097/pec.0000000000001501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The American College of Emergency Physicians embarked on the "Choosing Wisely" campaign to avoid computed tomographic (CT) scans in patients with minor head injury who are at low risk based on validated decision rules. We hypothesized that a Pediatric Mild Head Injury Care Path could be developed and implemented to reduce inappropriate CT utilization with support of a clinical decision support tool (CDST) and a structured parent discussion tool. METHODS A quality improvement project was initiated for 9 weeks to reduce inappropriate CT utilization through 5 interventions: (1) engagement of leadership, (2) provider education, (3) incorporation of a parent discussion tool to guide discussion during the emergency department (ED) visit between the parent and the provider, (4) CDST embedded in the electronic medical record, and (5) importation of data into the note to drive compliance. Patients prospectively were enrolled when providers at a pediatric and a freestanding ED entered data into the CDST for decision making. Rate of care path utilization and head CT reduction was determined for all patients with minor head injury based on International Classification of Diseases, Ninth Revision codes. Targets for care path utilization and head CT reduction were established a priori. Results were compared with baseline data collected from 2013. RESULTS The CDST was used in 176 (77.5%) of 227 eligible patients. Twelve patients were excluded based on a priori criteria. Adherence to recommendations occurred in 162 (99%) of 164 patients. Head CT utilization was reduced from 62.7% to 22% (odds ratio, 0.17; 95% confidence interval, 0.12-0.24) where CDST was used by the provider. There were no missed traumatic brain injuries in our study group. CONCLUSION A Pediatric Mild Head Injury Care Path can be implemented in a pediatric and freestanding ED, resulting in reduced head CT utilization and high levels of adherence to CDST recommendations.
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Affiliation(s)
- Rakesh S Engineer
- From the Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH
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30
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Klim S, Kelly AM, Krieser D. Epidemiology of Headache in Children in a Community Emergency Department: A Scoping Study. Pediatr Emerg Care 2021; 37:e1270-e1273. [PMID: 31977770 DOI: 10.1097/pec.0000000000002000] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to describe the epidemiology of headache in children attending a community mixed adult-pediatric emergency department (ED) in Australia with a view to providing scoping data for future headache-related projects for the pediatric ED research networks. METHODS This is a retrospective cohort study by medical record review. Participants were children aged 2 to 16 years who presented to the ED between January 1, 2016, and December 31, 2016, with a major symptom of headache. Exclusion criteria were a history of recent head trauma, a ventriculoperitoneal shunt in situ, or known intracranial conditions associated with headache. Data collected included demographics, clinical features, investigations, diagnosis, disposition, and outcome. The primary outcomes of interest were the proportion of children with a serious ED diagnosis, the distribution of ED diagnoses, investigation ordering patterns, treatments provided, and clinical outcome. RESULTS A total of 225 children were studied, with a median age of 9 years (interquartile range, 6-13 years). The most common associated symptoms were fever (47%) and vomiting (42%). The most common examination feature was fever (21%). Abnormal neurological findings were very uncommon. Few children underwent advanced neuroimaging (7 patients; 3%), and no intracranial abnormalities were detected. Seven children had a serious diagnosis (7/225 [3%]; 95% confidence interval, 2%-6%). Six of these 7 were viral meningitis, and there was 1 case of bacterial meningitis. CONCLUSIONS In a community teaching hospital cohort of children with headache, intercurrent viral illness is the most common cause. Serious causes were very uncommon. The rate of bacterial meningitis, tumor, or abscess was <1%. This has implications for the planning of research projects.
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Affiliation(s)
- Sharon Klim
- From the Joseph Epstein Centre for Emergency Medicine Research at Western Health, Sunshine Hospital
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31
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Yang K, Zhao M, Sun J, Nie X. Accuracy of PECARN decision rule in minor blunt head trauma in pediatric emergency department: A meta-analysis. Int J Clin Pract 2021; 75:e14586. [PMID: 34191372 DOI: 10.1111/ijcp.14586] [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: 05/11/2021] [Accepted: 06/21/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Paediatric Emergency Care Applied Research Network (PECARN) is a useful Clinical Decision Support Tool (CDST) to identify traumatic brain injuries and reduce the use of head computed tomography (CT) scans among paediatric patients. The present Meta-analysis aims to evaluate the diagnostic accuracy of the PECARN rule from 2009 to 2020 in children with a very low risk of blunt head trauma. METHODS A detailed search was conducted from the databases of Medline (via PubMed), Cinahl (via Ebsco), Scopus, Web of Sciences, from 2009 till the end of December 2020 using the keywords like decreased use of CT scan, blunt head trauma (BHT) combined with accuracy, PECARN OR CDST. Studies showing the diagnostic accuracy of the PECARN rule in children younger than 18 years of age with minor BHT were included. RESULTS Thirteen studies were included in the present analysis. Pooled sensitivity of 0.08, (95% confidence interval of 0.074-0.087), pooled specificity of 0.20 (95% CI of 0.196-0.213) and diagnostic odds ratio of 0.004 (95% CI of 0.000-0.1666) was in <2 years of age. The overall sensitivity of 0.07, specificity of 0.66, and the diagnostic odds ratio of 0.54 (95% CI of 0.10-2.78) were seen in ≥2 years of age. Overall sensitivity of 0.13 (95% CI 0.12-0.14), specificity of 0.81 (95% CI 0.80-0.82) and diagnostic odds ratio of 0.79 (95% CI of 0.08-7.71) was in 0-18 years of age. CONCLUSION The present analysis indicates the PECARN decision tool as an accurate CDST in low-risk minor BHT cases in children below two years of age and can become a valuable tool in reducing Head CT scan overuse in paediatric emergency departments.
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Affiliation(s)
- Ke Yang
- Department of CT and MRI, The First People's Hospital of Tianmen City, Tianmen, China
| | - Meng Zhao
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Sun
- Department of Radiology, Jinan Central Hospital Affiliated to Shandong University, Jinan, China
| | - Xiuli Nie
- Department of Radiology, Jinan Central Hospital Affiliated to Shandong University, Jinan, China
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32
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Bressan S, Eapen N, Phillips N, Gilhotra Y, Kochar A, Dalton S, Cheek JA, Furyk J, Neutze J, Williams A, Hearps S, Donath S, Oakley E, Singh S, Dalziel SR, Borland ML, Babl FE. PECARN algorithms for minor head trauma: Risk stratification estimates from a prospective PREDICT cohort study. Acad Emerg Med 2021; 28:1124-1133. [PMID: 34236116 DOI: 10.1111/acem.14308] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/11/2021] [Accepted: 05/25/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND The Pediatric Emergency Care Applied Research Network (PECARN) head trauma clinical decision rules informed the development of algorithms that risk stratify the management of children based on their risk of clinically important traumatic brain injury (ciTBI). We aimed to determine the rate of ciTBI for each PECARN algorithm risk group in an external cohort of patients and that of ciTBI associated with different combinations of high- or intermediate-risk predictors. METHODS This study was a secondary analysis of a large multicenter prospective data set, including patients with Glasgow Coma Scale scores of 14 or 15 conducted in Australia and New Zealand. We calculated ciTBI rates with 95% confidence intervals (CIs) for each PECARN risk category and combinations of related predictor variables. RESULTS Of the 15,163 included children, 4,011 (25.5%) were aged <2 years. The frequency of ciTBI was 8.5% (95% CI = 6.0%-11.6%), 0.2% (95% CI = 0.0%-0.6%), and 0.0% (95% CI = 0.0%-0.2%) in the high-, intermediate-, and very-low-risk groups, respectively, for children <2 years and 5.7% (95% CI = 4.4%-7.2%), 0.7% (95% CI = 0.5%-1.0%), and 0.0% (95% CI = 0.0%-0.1%) in older children. The isolated high-risk predictor with the highest risk of ciTBI was "signs of palpable skull fracture" for younger children (11.4%, 95% CI = 5.3%-20.5%) and "signs of basilar skull fracture" in children ≥2 years (11.1%, 95% CI = 3.7%-24.1%). For older children in the intermediate-risk category, the presence of all four predictors had the highest risk of ciTBI (25.0%, 95% CI = 0.6%-80.6%) followed by the combination of "severe mechanism of injury" and "severe headache" (7.7%, 95% CI = 0.2%-36.0%). The very few children <2 years at intermediate risk with ciTBI precluded further analysis. CONCLUSIONS The risk estimates of ciTBI for each of the PECARN algorithms risk group were consistent with the original PECARN study. The risk estimates of ciTBI within the high- and intermediate-risk predictors will help further refine clinical judgment and decision making on neuroimaging.
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Affiliation(s)
- Silvia Bressan
- Department of Women's and Children's Health University of Padova Padova Italy
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
| | - Nitaa Eapen
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics and Centre for Integrated Critical Care Faculty of Medicine, Dentistry and Health Sciences University of Melbourne Melbourne Victoria Australia
| | - Natalie Phillips
- Queensland Children's Hospital Brisbane Queensland Australia
- Child Health Research Centre University of Queensland Brisbane Queensland Australia
| | - Yuri Gilhotra
- Queensland Children's Hospital Brisbane Queensland Australia
| | - Amit Kochar
- Emergency Department Women's & Children's Hospital Adelaide South Australia Australia
| | - Sarah Dalton
- Emergency Department The Children's Hospital at Westmead Sydney New South Wales Australia
| | - John A. Cheek
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics and Centre for Integrated Critical Care Faculty of Medicine, Dentistry and Health Sciences University of Melbourne Melbourne Victoria Australia
- Emergency Department Royal Children's Hospital Melbourne Victoria Australia
- Emergency Department Monash Medical Centre Melbourne Victoria Australia
| | - Jeremy Furyk
- Emergency Department The Townsville Hospital Townsville Queensland Australia
- Emergency Department University Hospital Geelong Geelong Victoria Australia
- School of Medicine Faculty of Health Deakin University Geelong Victoria Australia
| | - Jocelyn Neutze
- Emergency Department Kidzfirst Middlemore Hospital Auckland New Zealand
| | - Amanda Williams
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
| | - Stephen Hearps
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
| | - Susan Donath
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics and Centre for Integrated Critical Care Faculty of Medicine, Dentistry and Health Sciences University of Melbourne Melbourne Victoria Australia
| | - Ed Oakley
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics and Centre for Integrated Critical Care Faculty of Medicine, Dentistry and Health Sciences University of Melbourne Melbourne Victoria Australia
- Emergency Department Royal Children's Hospital Melbourne Victoria Australia
| | - Sonia Singh
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics and Centre for Integrated Critical Care Faculty of Medicine, Dentistry and Health Sciences University of Melbourne Melbourne Victoria Australia
- Emergency Department Royal Children's Hospital Melbourne Victoria Australia
- University of California Davis Medical Center Sacramento California USA
| | - Stuart R. Dalziel
- Emergency Department Starship Children's Health Auckland New Zealand
- Departments of Surgery and Paediatrics: Child and Youth Health University of Auckland Auckland New Zealand
| | - Meredith L. Borland
- Emergency Department Perth Children's Hospital Perth Western Australia Australia
- Divisions of Emergency Medicine and Paediatrics School of Medicine University of Western Australia Perth Western Australia Australia
| | - Franz E. Babl
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics and Centre for Integrated Critical Care Faculty of Medicine, Dentistry and Health Sciences University of Melbourne Melbourne Victoria Australia
- Emergency Department Royal Children's Hospital Melbourne Victoria Australia
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33
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The Evaluation of Patients Admitted due to Minor Head Trauma with Clinical Decision Rules. JOURNAL OF CONTEMPORARY MEDICINE 2021. [DOI: 10.16899/jcm.958770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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34
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El-Gohary Y, Molina M, Chang J, Dodd A, Miller E, Harrell C, Wang F, Zhang H, Davidoff AM, Fernandez-Pineda I, Murphy AJ, Huang EY. The use of computed tomography versus clinical acumen in diagnosing appendicitis in children: A two-institution international study. J Pediatr Surg 2021; 56:1356-1361. [PMID: 33339568 DOI: 10.1016/j.jpedsurg.2020.09.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/15/2020] [Accepted: 09/21/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Appendicitis in children can be diagnosed utilizing clinical and laboratory findings, with the assistance of ultrasound (US) and/or computed tomography (CT). However, repeated exposure to ionizing radiation increases the lifetime risk of cancer. We compared the work-up of suspected appendicitis between a children's hospital in the United States (USA) and one in Spain to identify differences in imaging use and associated outcomes. METHODS A two-institution retrospective review was performed for surgical consultations of suspected appendicitis from 2015-2017. We compared imaging use, the utilization of overnight observation, and diagnostic accuracy rates between the two centers. RESULTS A total of 1,952 children were evaluated. Among the 1,288 in the USA center, 754(58.5%) underwent CT during their evaluation. The most common imaging modality was US only (39.9%), then CT only (39.3%), CT+US (19.3%), and no imaging (i.e. only clinical acumen) (1.6%). In Spain, only 19 (2.9%) of 664 children underwent CT compared to the USA (p < 0.0001). Only clinical acumen was the most common modality employed (48.6%), followed by US only (48.5%), US+CT (2.4%), and CT only (0.5%). In the USA, 16.8% were observed overnight, 2.3% of whom received no imaging. In Spain, 33.4% were observed overnight, 32.4% of whom had no imaging (p < 0.0001). The accuracy rates for diagnosing appendicitis in the USA and Spain centers were 94.7% and 95.1%, respectively. CONCLUSION Use of clinical acumen and/or US have similar clinical outcomes and similar accuracy rates compared to heavy reliance on CT imaging for diagnosing appendicitis, with associated decrease in radiation exposure. The disparate diagnostic approach of the two centers may reflect that physical examination is a dying art in North America. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Yousef El-Gohary
- Department of Surgery, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN 38105, USA.
| | - Maria Molina
- Department of Pediatric Surgery, Hospital Universitario Virgen Del Rocio, Sevilla, Spain
| | - Jeremy Chang
- College of Medicine, University of Tennessee Health Sciences Center, Memphis, TN 38105, USA
| | - Ashley Dodd
- College of Medicine, University of Tennessee Health Sciences Center, Memphis, TN 38105, USA
| | - Emily Miller
- College of Medicine, University of Tennessee Health Sciences Center, Memphis, TN 38105, USA
| | - Camden Harrell
- Department of Biostatistics, University of Tennessee Health Sciences Center, Memphis, TN 38105, USA
| | - Fang Wang
- Department of Biostatistics, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN 38105, USA
| | - Hui Zhang
- Department of Biostatistics, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN 38105, USA; Division of Biostatistics, Department of Biostatistics, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Chicago, IL 60611, USA
| | - Andrew M Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN 38105, USA; Division of Pediatric Surgery, Department of Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN 38105, USA
| | | | - Andrew J Murphy
- Department of Surgery, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN 38105, USA; Division of Pediatric Surgery, Department of Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN 38105, USA
| | - Eunice Y Huang
- Division of Pediatric Surgery, Department of Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN 38105, USA..
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Ukwuoma OI, Allareddy V, Allareddy V, Rampa S, Rose JA, Shein SL, Rotta AT. Trends in Head Computed Tomography Utilization in Children Presenting to Emergency Departments After Traumatic Head Injury. Pediatr Emerg Care 2021; 37:e384-e390. [PMID: 30256318 DOI: 10.1097/pec.0000000000001618] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Although closed head injuries occur commonly in children, most do not have a clinically important traumatic brain injury (ciTBI) and do not require neuroimaging. We sought to determine whether the utilization of computed tomography of the head (CT-H) in children presenting to an emergency department (ED) with a closed head injury changed after publication of validated clinical prediction rules to identify children at risk of ciTBI by the Pediatric Emergency Care Applied Research Network (PECARN). METHODS We used the nationwide ED sample (2008-2013) to examine children visiting an ED after a mild closed head injury. Multiple patient and hospital characteristics were assessed. RESULTS Of the 4,552,071 children presenting to an ED with a mild closed head injury, 1,181,659 (26.0%) underwent CT-H. Care was most commonly received at metropolitan teaching hospitals (43.5%) and varied markedly by geographic region. Overall, there were no significant changes in the nationwide rates of CT-H utilization in the period immediately after publication of the PECARN prediction rules. However, compared with metropolitan teaching hospitals, CT-H utilization increased significantly for patients treated at nonteaching hospitals and at nonmetropolitan hospitals. CONCLUSIONS There was no overall reduction in CT-H utilization after publication of the 2009 PECARN prediction rules. However, patients treated at metropolitan teaching hospitals were significantly less likely to undergo CT-H after 2009, suggesting some penetration of the PECARN tool in that setting. Further research should study patterns of CT-H utilization in nonteaching hospitals and nonmetropolitan hospitals to assess challenges for adoption of validated pediatric ciTBI prediction rules.
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Affiliation(s)
- Onyinyechi I Ukwuoma
- From the UH Rainbow Babies & Children's Hospital, Case Western Reserve School of Medicine, Cleveland, OH
| | | | | | - Sankeerth Rampa
- Management & Marketing Department, School of Business, Rhode Island College, Providence, RI
| | - Jerri A Rose
- From the UH Rainbow Babies & Children's Hospital, Case Western Reserve School of Medicine, Cleveland, OH
| | - Steven L Shein
- From the UH Rainbow Babies & Children's Hospital, Case Western Reserve School of Medicine, Cleveland, OH
| | - Alexandre T Rotta
- From the UH Rainbow Babies & Children's Hospital, Case Western Reserve School of Medicine, Cleveland, OH
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Ramgopal S, Zhou AZ, Hickey RW, Marin JR. Rates of Presentation, Treatments and Serious Neurologic Disorders Among Children and Young Adults Presenting to US Emergency Departments With Headache. J Child Neurol 2021; 36:475-481. [PMID: 33356803 DOI: 10.1177/0883073820979137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate rates of presentation, neuroimaging, therapies, and serious neurologic disorders (SNDs) among children and young adults presenting to the emergency department with headache. METHODS We performed a cross-sectional study of a nationally representative sample survey of visits to US emergency departments between 2002 and 2017. We identified encounters of patients ≤25 years old with chief complaint of headache. We report the rates of presentation, imaging, and treatments and report proportions having concomitant diagnoses of serious neurologic disorders. RESULTS Among encounters ≤25 years, 2.0% had a chief complaint of headache, with no change in the yearly rates of encounters (P = .98). Overall, 20.8% had a head computed tomography (CT), with a reduction in performance between 2007 and 2016 (P < .01). One-quarter (25.2%, 95% confidence interval [CI] 22.2%-28.3%) were given narcotics and 2.5% (95% CI 1.7%-3.2%) had serious neurologic disorders. CONCLUSION Overall, 2.0% of emergency department encounters among patients ≤25 years were for headache, with low rates of serious neurologic disorders. CT use appeared to be declining.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, 2429Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Amy Z Zhou
- Division of Emergency Medicine, 2429Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert W Hickey
- Division of Pediatric Emergency Medicine, Department of Pediatrics, 6619UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jennifer R Marin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, 6619UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Joyce S, Carey BW, Moore N, Mullane D, Moore M, McEntee MF, Plant BJ, Maher MM, O'Connor OJ. Computed tomography in cystic fibrosis lung disease: a focus on radiation exposure. Pediatr Radiol 2021; 51:544-553. [PMID: 33743038 DOI: 10.1007/s00247-020-04706-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 03/03/2020] [Accepted: 05/05/2020] [Indexed: 11/27/2022]
Abstract
Thoracic computed tomography (CT) is the imaging reference method in the diagnosis, assessment and management of lung disease. In the setting of cystic fibrosis (CF), CT demonstrates increased sensitivity compared with pulmonary function tests and chest radiography, and findings correlate with clinical outcomes. Better understanding of the aetiology of CF lung disease indicates that even asymptomatic infants with CF can have irreversible pulmonary pathology. Surveillance and early diagnosis of lung disease in CF are important to preserve lung parenchyma and to optimise long-term outcomes. CF is associated with increased cumulative radiation exposure due to the requirement for repeated imaging from a young age. Radiation dose optimisation, important for the safe use of CT in children with CF, is best achieved in a team environment where paediatric radiologists work closely with paediatric respiratory physicians, physicists and radiography technicians to achieve the best patient outcomes. Despite the radiation doses incurred, CT remains a vital imaging tool in children with CF. Radiologists with special interests in CT dose optimisation and respiratory disease are key to the appropriate use of CT in paediatric imaging. Paediatric radiologists strive to minimise radiation dose to children whilst providing the best possible assessment of lung disease.
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Affiliation(s)
- Stella Joyce
- Department of Radiology, School of Medicine, University College Cork, Cork, Ireland
| | - Brian W Carey
- Department of Radiology, School of Medicine, University College Cork, Cork, Ireland.,Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland
| | - Niamh Moore
- Department of Radiography, University College Cork, Cork, Ireland
| | - David Mullane
- Department of Radiology, School of Medicine, University College Cork, Cork, Ireland.,Department of Paediatrics, Cork University Hospital, Cork, Ireland
| | - Michael Moore
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland
| | - Mark F McEntee
- Department of Radiography, University College Cork, Cork, Ireland
| | - Barry J Plant
- Department of Radiology, School of Medicine, University College Cork, Cork, Ireland.,Department of Medicine, Cork University Hospital, Cork, Ireland.,APC Microbiome Institute, University College Cork, Cork, Ireland
| | - Michael M Maher
- Department of Radiology, School of Medicine, University College Cork, Cork, Ireland.,Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,APC Microbiome Institute, University College Cork, Cork, Ireland
| | - Owen J O'Connor
- Department of Radiology, School of Medicine, University College Cork, Cork, Ireland. .,Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland. .,APC Microbiome Institute, University College Cork, Cork, Ireland.
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Longitudinal Analysis of Neurodiagnostic Testing Utilization in Emergency Department Patients Presenting With Seizures or Epilepsy. J Am Coll Radiol 2021; 18:344-353. [DOI: 10.1016/j.jacr.2020.03.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 11/19/2022]
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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: 4] [Impact Index Per Article: 1.3] [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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Ali MA, Salim B, Siddiqui KM, Khan MF. Attitudes and knowledge of anesthesiology trainees to radiation exposure in a Tertiary care hospital. Saudi J Anaesth 2021; 14:459-463. [PMID: 33447187 PMCID: PMC7796730 DOI: 10.4103/sja.sja_659_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 11/26/2019] [Accepted: 10/29/2019] [Indexed: 11/17/2022] Open
Abstract
Background and Aims: Ionizing radiation procedures are indispensable in medical clinical practice. Exposure to radiation at any dose could have serious adverse effects. Anesthesiologists working in interventional radiology suites are at a higher risk of radiation exposure than other personnel. The aim of this study was to assess the knowledge and attitude of anesthesiology trainees towards the radiation hazards and current safety practices. Methods: This prospective cross-sectional survey was conducted at the department of anesthesiology at Aga Khan University. All anesthesiology trainees working in the department were given a 12-question paper-based survey after getting ethical review committee approval and informed consent. The questionnaire contained requests for personal demographic data and specific questions regarding radiation protection. Results: A total of 54 participants were included in this survey. Thirty-two (59.3%) were male, and 22 (40.7%) were female. The average year of experience working in anesthesia of the participants was 2.8 ± 1.65 years (range, one to eight years). Frequency of radiation exposure of 32 (59.3%) participants was 1-5 times per week. Approximately 68.5% (37/54) of participants believed they took adequate precautions for protection against radiation. Only 20.4% (11/54) used both a lead apron and a thyroid shield for prevention of radiation exposure. Most participants using the radiation shield or clothing (70.4%; 38/54) cited concerns about cancer. Conclusions: A lack of knowledge persists among anesthesiology trainees in our institute regarding the risks associated with ionizing radiation. This study also serves to highlight the need for anesthesiology trainees to protect themselves properly. Radiation dose, hazards, and protection strategies must be included in the basic curriculum of medical colleges.
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Affiliation(s)
| | - Bushra Salim
- Department of Anesthesiology, Aga Khan University, Karachi, Pakistan
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Halliday K. Considering paediatric radiology. Pediatr Radiol 2021; 51:521-522. [PMID: 33743035 PMCID: PMC7980103 DOI: 10.1007/s00247-020-04838-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 08/21/2020] [Accepted: 09/02/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Katharine Halliday
- Department of Radiology, Nottingham University Hospitals, Queens Medical Centre, Nottingham, NG7 2UH, UK.
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Zhu Y, Pi Z, Zhou H, Li Z, Lei F, Hui J, Zhang X, Xie J, Liang Y. Imaging pediatric acute head trauma using 100-kVp low dose CT with adaptive statistical iterative reconstruction (ASIR-V) in single rotation on a 16 cm wide-detector CT. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2021; 29:517-527. [PMID: 33814483 DOI: 10.3233/xst-210856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To demonstrate the ability of achieving low dose and high-quality head CT images for children with acute head trauma using 100 kVp and adaptive statistical iterative reconstruction (ASIR-V) algorithm in single rotation on a 16 cm wide-detector system. MATERIALS AND METHODS We retrospectively analyzed the CT dose index (CTDI) and image quality of 104 children aged 0-6 years with acute head trauma (1 hour -3 days) in two groups: Group 1(n = 50) on a 256-row CT with single rotation at a reduced-dose of 100 kVp/240 mA and reconstructed using ASIR-V at 70%level; Group 2(n = 54) on a 64-row CT with multiple rotations at a standard dose of 120 kVp/ 180mA and reconstructed using a conventional filtered back-projection (FBP). Both groups used the 0.5 s/r axial scan mode. CT dose index (CTDI) and quantitative image quality measurements were compared using the Student t test; qualitative image quality comparison was carried out using Mann-Whitney rank test and the inter-reviewer agreement was evaluated using Kappa test. RESULTS The exposure time was 0.5 s for Group 1 and 3.27±0.29 s for Group 2. The CTDI in Group 1 was 9.74±0.86mGy, 36.38%lower than the 15.31mGy in Group 2 (p < 0.001). Group 1 and Group 2 had similar artifact index (2.06±1.06 vs. 2.37±1.18) in the cerebellar hemispheres, and similar contrast-to-noise ratio (2.32±0.83 vs. 1.69±0.68), (1.47±0.72 vs. 1.10±0.43) respectively for cerebellum and thalamus (p > 0.05). Image quality was acceptable for diagnosis, and motion artifacts were reduced in Group 1 (p < 0.001). CONCLUSION Single rotation CT with 100 kVp and 70%ASIR-V on 16 cm wide-detector CT reduces radiation dose and motion artifacts for children with acute head trauma without compromising diagnostic quality as compared with standard dose protocol. Thus, it provides a novel imaging method in management of pediatric acute head trauma.
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Affiliation(s)
- Yanan Zhu
- Medical Imaging Centre, Affiliated Hospital of Ankang University (Ankang Central Hospital), Ankang, China
| | - Zhian Pi
- Medical Imaging Centre, Affiliated Hospital of Ankang University (Ankang Central Hospital), Ankang, China
| | - Heping Zhou
- Medical Imaging Centre, Affiliated Hospital of Ankang University (Ankang Central Hospital), Ankang, China
| | - Zhengjun Li
- Medical Imaging Centre, Affiliated Hospital of Ankang University (Ankang Central Hospital), Ankang, China
| | - Faqing Lei
- Medical Imaging Centre, Affiliated Hospital of Ankang University (Ankang Central Hospital), Ankang, China
| | - Jianjun Hui
- Emergency Department, Affiliated Hospital of Ankang University (Ankang Central Hospital), Ankang, China
| | - Ximeng Zhang
- Medical Imaging Centre, Affiliated Hospital of Ankang University (Ankang Central Hospital), Ankang, China
| | - Juanping Xie
- School of Medicine, Ankang University, Ankang, China
| | - Yukun Liang
- Medical Imaging Centre, Affiliated Hospital of Ankang University (Ankang Central Hospital), Ankang, China
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Leventer-Roberts M, Lev Bar-Or R, Gofer I, Rosenbaum Z, Hoshen M, Feldman B, Balicer R. Choosing Wisely: Determining performance of unjustified imaging in a large healthcare system. Int J Clin Pract 2021; 75:e13644. [PMID: 32748452 DOI: 10.1111/ijcp.13644] [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] [Received: 12/01/2019] [Accepted: 07/24/2020] [Indexed: 11/29/2022] Open
Abstract
AIMS The Choosing Wisely Campaign identifies procedures and treatments that lack clinical justification for routine use according to expert opinion and evidence-based medicine. This study describes the rates and features of two such examples over a 10-year period. METHODS This is a cross-sectional rolling cohort study between 2008 and 2017 in Clalit Health Services, the largest healthcare delivery system in Israel, with seven main hospitals and over 4.5 million members nationwide. All adult members who visited a Clalit Emergency Department (ED), and all children members who visited a Clalit ED for abdominal pain or appendicitis were eligible to be included in this study. Our measures were routine chest radiograph (CXR) in the context of pre-admission assessment for adults and abdominal computed tomography (CT) to rule out appendicitis for children. RESULTS Of the 3 689 869 adult visits without a clinical indication for a CXR, 9.1% or 337 058 of them received a chest radiograph. Of the 35 973 children visits for presumed appendicitis, 7.2% of them had no imaging performed, 82.3% had an ultrasound (US), 6.9% had an US followed by a CT, and 3.6% or 1293 of them received a CT. There were several independent risk factors such as BMI, hospital, sex, year and diagnosis that are associated with having imaging that is not clinically indicated. CONCLUSIONS Overall, this study found that diagnostic imaging practices are applied inconsistently by hospital and by population. Intervention efforts should be focused on subpopulations at greatest risk to further reduce exposure to such imaging.
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Affiliation(s)
- Maya Leventer-Roberts
- Clalit Research Institute, Tel Aviv, Israel
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Ilan Gofer
- Clalit Research Institute, Tel Aviv, Israel
| | | | | | | | - Ran Balicer
- Clalit Research Institute, Tel Aviv, Israel
- Clalit Health Services, Tel Aviv, Israel
- Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Trofimova AV, Duszak R, Kadom N, Sadigh G. Increasing and disparate use of neuroimaging for adults and children with non-traumatic headaches in the US emergency departments: Opportunities for improvement. Headache 2020; 61:179-189. [PMID: 33316103 DOI: 10.1111/head.14020] [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: 06/19/2020] [Revised: 09/01/2020] [Accepted: 09/06/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Optimization of neuroimaging practices for headache is considered a national priority; however, nationwide patterns and predictors of neuroimaging use for headache in the US emergency departments (EDs) are unknown. OBJECTIVE To analyze temporal neuroimaging utilization trends for adults and children with non-traumatic headache in the US EDs and identify factors predictive of neuroimaging use in this patient population. METHODS Retrospective cross-sectional study using the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database for administrative encounter-level data analysis of a nationwide group of adult and pediatric patients with primary diagnosis of headache (ICD-9CM codes 784.0x, 339.xx, 346.xx) visited the US EDs between January 1, 2006 and December 31, 2014. Temporal trends and independent predictors of neuroimaging use (e.g., patient and hospital characteristics, primary payment sources) were determined. RESULTS In 2006-2014, a weighted group of 18,146,302 patients with a primary diagnosis of non-traumatic headache visited US EDs. Advanced neuroimaging utilization increased from 18.6% (n = 350,777) to 34.8% (n = 756,895) in the total group, from 18.8% (n = 314,646) to 36.5% (n = 698,080) in the adult subgroup (+94.1%), and from 16.9% (n = 36,131) to 22.0% (n = 58,815) (+30.2%) in the pediatric subgroup (+87.0%) between 2006 and 2014. The strongest predictors of higher neuroimaging utilization were hospital location in the Northeast (OR 3.17, 95% CI 2.67-3.76) or South (OR 2.42, 95% CI 2.03-2.88) regions. Lower utilization of imaging was associated with weekend ED visits (OR 0.92, 95% CI 0.92-0.93), female gender (OR 0.82, 95% CI 0.81-0.83), and Medicare, Medicaid, or self-pay (vs. private insurance) encounters. CONCLUSION Neuroimaging utilization in patients with headache in US EDs nearly doubled in 2006-2014, and was used in 34.8% of all ED encounters in 2014. Utilization was higher and increased at faster rates for adults than children. In US EDs, imaging for headache is preferentially performed on commercially insured and male patients, at urban hospitals, in certain geographic regions, and on weekdays, raising concerns regarding disparate imaging use.
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Affiliation(s)
- Anna V Trofimova
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Nadja Kadom
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Gelareh Sadigh
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
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Ploussi A, Syrgiamiotis V, Makri T, Hatzigiorgi C, Efstathopoulos EP. Local diagnostic reference levels in pediatric CT examinations: a survey at the largest children's hospital in Greece. Br J Radiol 2020; 93:20190358. [PMID: 32976036 PMCID: PMC7716000 DOI: 10.1259/bjr.20190358] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES The increased frequency of pediatric CT examinations and the high radiosensitivity of children entail the need to determine DRLs and optimize CT protocols. The aim of the study was twofold. Firstly, to establish pediatric LDRLs according to age and weight for the most common types of CT examinations at the largest children's hospital in Greece. Secondly, to compare LDRLs with European DRLs. METHODS A total of 756 pediatric patients who underwent head, chest, and abdomen-pelvis CT examinations were included. Patients were categorized into age groups according to the hospital's protocols. All CT examinations were performed using iterative reconstruction algorithm and AEC. LDRLs were determined in terms of 75th percentile of CTDIvol and DLP. Values of LDRLs were subsequently regrouped into weight categories and compared with European DRLs. RESULTS Gathering all age groups for head CT examinations and all weight groups for body CT examinations, LDRLs were ranged from (22-68, 2-5, 2-10) mGy in terms of CTDIvol; (317-786, 22-168, 58-425) mGy.cm in terms of DLP per acquisition and (324-838, 42-265, 85-498) mGy.cm in terms of total DLP for head, chest and abdomen-pelvis CT examinations, respectively. CONCLUSION CTDI LDRLs were comparable to European DRLs for head and either comparable or lower than European DRLs for body CT examinations. DLP LDRLs were higher than European DRLs for head and lower for body CT examinations. ADVANCES IN KNOWLEDGE Age- and weight-based LDRLs for pediatric CT examinations were established for the largest children's hospital in Greece. Further investigations across the country are required for the establishment of national pediatric DRLs in Greece.
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Affiliation(s)
- Agapi Ploussi
- 2nd Department of Radiology, University General Hospital ‘Attikon’, School of Medicine, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | | | | | | | - Efstathios P. Efstathopoulos
- 2nd Department of Radiology, University General Hospital ‘Attikon’, School of Medicine, National and Kapodistrian University of Athens, 12462, Athens, Greece
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Zimmermann P, Schmidt T, Nelson J, Gosemann JH, Bassler S, Stahmeyer JT, Hirsch FW, Lacher M, Zeidler J. Pediatric solid organ injury - frequency of abdominal imaging is determined by the treating department. Medicine (Baltimore) 2020; 99:e23057. [PMID: 33157961 PMCID: PMC7647522 DOI: 10.1097/md.0000000000023057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To investigate the use of abdominal CT scanning in the management of pediatric blunt abdominal trauma in pediatric and non-pediatric departments.In this observational cohort study, anonymized data were extracted from 2 large German statutory health insurances (∼5.9 million clients) in a 7-year period (2010-2016). All patients with inpatient International Classification of Diseases (ICD) codes S36.- and S37.- (injury of intra-abdominal organs; injury of urinary and pelvic organs) aged ≤18 years were included. Demographic and clinical data were analyzed by logistic regression analysis for associations with the use of abdominal CT.A total of 524 children with blunt abdominal trauma (mean age 11.0 ± 5.2 years; 62.6% males) were included; 164 patients (31.3%) received abdominal CT-imaging. There were no significant differences in traumatic non-intraabdominal comorbidity patterns (injuries of external causes; injuries to the head or thorax). There was substantial variability in the rate of abdominal CT imaging among different medical disciplines ranging from 11.6% to 44.5%. Patients admitted to pediatric departments (Pediatrics and Pediatric Surgery) underwent abdominal CT imaging significantly less frequently (19.7%; N = 55) compared to patients treated in non-pediatric departments (General/Trauma Surgery: 44.5%; N = 109) irrespective of concomitant injuries. The estimated OR for the use of abdominal CT by General/Trauma Surgery was 6.2-fold higher (OR: 6.15 [95-%-CI:3.07-13.21]; P < .001) compared to Pediatric Surgery. Other risk factors associated with the use of abdominal CT were traumatic extra-abdominal comorbidities, increasing age, male gender, and admission to a university hospital.Abdominal CT imaging was significantly less frequently used in pediatric departments. The substantial variability of the abdominal CT rate among different medical disciplines and centers indicates a potential for reduction of CT imaging by implementation of evidence-based guidelines. Furthermore, our study underlines the need for centralization of pediatric trauma care in Germany not only to improve patient outcome but to avoid radiation-induced cancer mortality.
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Affiliation(s)
| | - Torben Schmidt
- Center for Health Economics Research Hannover (CHERH), Leibniz University Hannover, Hannover
| | - Jana Nelson
- Department of Pediatric Surgery, University of Leipzig, Leipzig
| | | | - Stefan Bassler
- AOK PLUS - Die Gesundheitskasse für Sachsen und Thüringen, Dresden
| | | | | | - Martin Lacher
- Department of Pediatric Surgery, University of Leipzig, Leipzig
| | - Jan Zeidler
- Center for Health Economics Research Hannover (CHERH), Leibniz University Hannover, Hannover
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Zhou AZ, Marin JR, Hickey RW, Ramgopal S. Serious Diagnoses for Headaches After ED Discharge. Pediatrics 2020; 146:peds.2020-1647. [PMID: 33008843 DOI: 10.1542/peds.2020-1647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Headache is a common complaint among children presenting to the emergency department (ED) and can be due to serious neurologic and nonneurologic diagnoses (SNNDs). We sought to characterize the children discharged from the ED with headache found to have SNNDs at revisits. METHODS We performed a multicenter retrospective cohort study using data from 45 pediatric hospitals from October 1, 2015, to March 31, 2019. We included pediatric patients (≤18 years) discharged from the ED with a principal diagnosis of headache, excluding patients with concurrent or previous SNNDs or neurosurgeries. We identified rates and types of SNNDs diagnosed within 30 days of initial visit and compared these rates with those of control groups defined as patients with discharge diagnoses of cough, chest pain, abdominal pain, and soft tissue complaints. RESULTS Of 121 621 included patients (57% female, median age 12.4 years, interquartile range: 8.8-15.4), 608 (0.5%, 95% confidence interval: 0.5%-0.5%) were diagnosed with SNNDs within 30 days. Most were diagnosed at the first revisit (80.8%); 37.5% were diagnosed within 7 days. The most common SNNDs were benign intracranial hypertension, cerebral edema and compression, and seizures. A greater proportion of patients with SNNDs underwent neuroimaging, blood, and cerebrospinal fluid testing compared with those without SNNDs (P < .001 for each). The proportion of SNNDs among patients diagnosed with headache (0.5%) was higher than for control cohorts (0.0%-0.1%) (P < .001 for each). CONCLUSIONS A total 0.5% of pediatric patients discharged from the ED with headache were diagnosed with an SNND within 30 days. Further efforts to identify at-risk patients remain a challenge.
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Affiliation(s)
- Amy Z Zhou
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois;
| | - Jennifer R Marin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and.,Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert W Hickey
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Clinical Factors Associated With Pediatric Brain Neoplasms Versus Primary Headache: A Case-Control Analysis. Pediatr Emerg Care 2020; 36:459-463. [PMID: 29135901 DOI: 10.1097/pec.0000000000001347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Pediatric headaches are a common presentation to emergency departments accounting for almost half a million annual visits. Providers are left with the difficult task of deciding who has a secondary headache etiology that warrants neuroimaging. METHODS We conducted a retrospective case-control study. Patients from a pediatric neuro-oncology clinic database with brain cancer and a headache at presentation were identified as cases. Controls were patients from 2 local pediatric tertiary care emergency departments with a final diagnosis of headache after negative neuroimaging. Clinical factors were decided a priori, and logistic regression was used to determine which clinical factors were related to case/control status. RESULTS A total of 334 patients (203 controls and 131 cases) were included. Patients with a history of headaches had 0.5 (95% confidence interval [CI]: 0.3-0.9; P = 0.03) times the odds of being a case. Patients with vomiting had increased odds of being a case compared with controls regardless of the time of day (early morning 1.8 [95% CI: 1.0-3.2; P = 0.04] and non-early morning 6.6 [95% CI: 2.0-21.7; P < 0.01]). Patients with neurological signs had 10.3 (95% CI: 5.4-19.4; P < 0.01) times the odds of being a case, and patients with an associated seizure had 10.9 (95% CI: 3.8-30.7; P < 0.01) times the odds of being a case. CONCLUSIONS This study identified clinical factors associated with pediatric brain neoplasms that may guide acute neuroimaging decisions. This study also provides insight into potential clinical factors to be studied prospectively to derive a clinical decision rule.
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Azari S, Hoover T, Dunstan M, Harrison TJ, Browne M. Review, monitor, educate: A quality improvement initiative for sustained chest radiation reduction in pediatric trauma patients. Am J Surg 2020; 220:1327-1332. [PMID: 32928539 DOI: 10.1016/j.amjsurg.2020.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/14/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND We hypothesize that in pediatric trauma patients, CT scans after normal chest x-rays do not add information that alters clinical decision making. METHODS A retrospective review of trauma patients < 15 years with chest imaging evaluated at a pediatric trauma center between 1/2013 and 6/2019 was performed. Imaging was reviewed for significant findings that could affect care. A guideline was established in January 2017 which emphasized x-rays prior to CTs and no CTs after normal x-rays. A prospective review was performed from 1/2017-6/2019. Pre and post guideline groups were compared. RESULTS From 2013 to 2016, 246 patients met inclusion. 29.5% had a chest CT after a normal x-ray, only 1.8% (1/57) had a significant result. From 2017 to 2019, 188 patients were reviewed post guideline; only 9.4% received a CT after normal x-ray, of which 6.3% (1/16) were significant. Neither changed clinical management. CONCLUSIONS Chest CT following normal chest x-ray does not change clinical management in pediatric trauma patients. Monitoring and education following guideline implementation improves long term outcomes.
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Affiliation(s)
- Sarah Azari
- Department of Education, Lehigh Valley Health Network, 1247 S Cedar Crest Blvd, Allentown, PA, 18103, USA.
| | - Travis Hoover
- Department of Education, Lehigh Valley Health Network, 1247 S Cedar Crest Blvd, Allentown, PA, 18103, USA.
| | - Michele Dunstan
- Division of Bariatric and Trauma Surgery, Department of Surgery, Lehigh Valley Health Network, 1240 S Cedar Crest Blvd, Suite 308, Allentown, PA, 18103, USA.
| | - Timothy J Harrison
- Division of Bariatric and Trauma Surgery, Department of Surgery, Lehigh Valley Health Network, 1240 S Cedar Crest Blvd, Suite 308, Allentown, PA, 18103, USA.
| | - Marybeth Browne
- Division of Pediatric Surgical Specialties, Lehigh Valley Reilly Children's Hospital, Department of Surgery, Lehigh Valley Health Network, Allentown, PA, 18103, USA.
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50
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Marin JR, Rodean J, Hall M, Alpern ER, Aronson PL, Chaudhari PP, Cohen E, Freedman SB, Morse RB, Peltz A, Samuels-Kalow M, Shah SS, Simon HK, Neuman MI. Trends in Use of Advanced Imaging in Pediatric Emergency Departments, 2009-2018. JAMA Pediatr 2020; 174:e202209. [PMID: 32761186 PMCID: PMC7400208 DOI: 10.1001/jamapediatrics.2020.2209] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance There is increased awareness of radiation risks from computed tomography (CT) in pediatric patients. In emergency departments (EDs), evidence-based guidelines, improvements in imaging technology, and availability of nonradiating modalities have potentially reduced CT use. Objective To evaluate changes over time and hospital variation in advanced imaging use. Design, Setting, and Participants This cross-sectional study assessed 26 082 062 ED visits by children younger than 18 years from the Pediatric Health Information System administrative database from January 1, 2009, through December 31, 2018. Exposures Imaging. Main Outcomes and Measures The primary outcome was the change in CT, ultrasonography, and magnetic resonance imaging (MRI) rates from January 1, 2009, to December 31, 2018. Imaging for specific diagnoses was examined using all patient-refined diagnosis related groups. Secondary outcomes were hospital admission and 3-day ED revisit rates and ED length of stay. Results There were a total of 26 082 062 visits by 9 868 406 children (mean [SD] age, 5.59 [5.15] years; 13 842 567 [53.1%] male; 9 273 181 [35.6%] non-Hispanic white) to 32 US pediatric EDs during the 10-year study period, with 1 or more advanced imaging studies used in 1 919 283 encounters (7.4%). The proportion of ED encounters with any advanced imaging increased from 6.4% (95% CI, 6.2%-6.2%) in 2009 to 8.7% (95% CI, 8.7%-8.8%) in 2018. The proportion of ED encounters with CT decreased from 3.9% (95% CI, 3.9%-3.9%) to 2.9% (95% CI, 2.9%-3.0%) (P < .001 for trend), with ultrasonography increased from 2.5% (95% CI, 2.5%-2.6%) to 5.8% (95% CI, 5.8%-5.9%) (P < .001 for trend), and with MRI increased from 0.3% (95% CI, 0.3%-0.4%) to 0.6% (95% CI, 0.6%-0.6%) (P < .001 for trend). The largest decreases in CT rates were for concussion (-23.0%), appendectomy (-14.9%), ventricular shunt procedures (-13.3%), and headaches (-12.4%). Factors associated with increased use of nonradiating imaging modalities included ultrasonography for abdominal pain (20.3%) and appendectomy (42.5%) and MRI for ventricular shunt procedures (17.9%) (P < .001 for trend). Across the study period, EDs varied widely in the use of ultrasonography for appendectomy (median, 57.5%; interquartile range [IQR], 40.4%-69.8%) and MRI (median, 15.8%; IQR, 8.3%-35.1%) and CT (median, 69.5%; IQR, 54.5%-76.4%) for ventricular shunt procedures. Overall, ED length of stay did not change, and hospitalization and 3-day ED revisit rates decreased during the study period. Conclusions and Relevance This study found that use of advanced imaging increased from 2009 to 2018. Although CT use decreased, this decrease was accompanied by a greater increase in the use of ultrasonography and MRI. There appears to be substantial variation in practice and a need to standardize imaging practices.
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Affiliation(s)
- Jennifer R. Marin
- Division of Pediatric Emergency Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul L. Aronson
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut,Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles
| | - Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Stephen B. Freedman
- Alberta Children’s Hospital Research Institute, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada ,Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Rustin B. Morse
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Alon Peltz
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Samir S. Shah
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Harold K. Simon
- Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia,Department of Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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