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Lyons TW, Mannix R, Monuteaux MC, Schutzman SA. Emergency Department Evaluation of Young Infants With Head Injury. Pediatrics 2024; 153:e2023065037. [PMID: 38813646 DOI: 10.1542/peds.2023-065037] [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: 11/17/2023] [Revised: 02/14/2024] [Accepted: 02/14/2024] [Indexed: 05/31/2024] Open
Abstract
OBJECTIVES We compared the emergency department (ED) evaluation and outcomes of young head-injured infants to older children. METHODS Using the Pediatric Health Information Systems database, we performed a retrospective, cross-sectional analysis of children <2 years old with isolated head injuries (International Classification of Diseases, 10th Revision, diagnoses) at one of 47 EDs from 2015 to 2019. Our primary outcome was utilization of diagnostic cranial imaging. Secondary outcomes were diagnosis of traumatic brain injury (TBI), clinically important TBI, and mortality. We compared outcomes between the youngest infants (<3 months old) and children 3 to 24 months old. RESULTS We identified 112 885 ED visits for children <2 years old with isolated head injuries. A total of 62 129 (55%) were by males, and 10 325 (9.1%) were by infants <3 months of age. Compared with older children (12-23 months old), the youngest infants were more likely to: Undergo any diagnostic cranial imaging (50.3% vs 18.3%; difference 31.9%, 95% confidence interval [CI] 35.0-28.9%), be diagnosed with a TBI (17.5% vs 2.7%; difference 14.8%, 95% CI 16.4%-13.2%) or clinically important TBI (4.6% vs 0.5%; difference 4.1%, 95% CI 3.8%-4.5%), and to die (0.3% vs 0.1%; difference 0.2%, 95% CI 0.3%-0.1%). Among those undergoing computed tomography or MRI, TBIs were significantly more common in the youngest infants (26.4% vs 8.8%, difference 17.6%, 95% CI 16.3%-19.0%). CONCLUSIONS The youngest infants with head injuries are significantly more likely to undergo cranial imaging, be diagnosed with brain injuries, and die, highlighting the need for a specialized approach for this vulnerable population.
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Affiliation(s)
- Todd W Lyons
- Departments of Pediatrics and Emergency Medicine
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Rebekah Mannix
- Departments of Pediatrics and Emergency Medicine
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Michael C Monuteaux
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Sara A Schutzman
- Departments of Pediatrics and Emergency Medicine
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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2
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Raut A, Pierce MC. Cranial Imaging in the Youngest Infants: Worth the Risk. Pediatrics 2024; 153:e2023065511. [PMID: 38813619 DOI: 10.1542/peds.2023-065511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 05/31/2024] Open
Affiliation(s)
- Audrey Raut
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Mary Clyde Pierce
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, Illinois
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3
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Mao W, Chen W, Wang Y. Effect of virtual reality-based mindfulness training model on anxiety, depression, and cancer-related fatigue in ovarian cancer patients during chemotherapy. Technol Health Care 2024; 32:1135-1148. [PMID: 37781832 PMCID: PMC11002720 DOI: 10.3233/thc-230735] [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: 06/06/2023] [Accepted: 08/05/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Although the prognosis of ovarian cancer can be significantly improved through standardized surgery and chemotherapy, 70% of epithelial ovarian cancer (EOC) patients would suffer from drug resistance and recurrence during the long chemotherapy cycle. OBJECTIVE To explore the impact of a training mode based on the integration of virtual reality technology and mindfulness on anxiety, depression, and cancer-related fatigue in ovarian cancer patients during chemotherapy. METHOD Through virtual reality technology, a mindfulness training software was designed and developed, and a mindfulness training mode based on virtual reality technology was constructed. Using a self-controlled design, 48 ovarian cancer patients undergoing chemotherapy who were hospitalized in a tertiary hospital in Beijing from August 2022 to May 2023 were conveniently selected as the research subjects. The patients were subjected to four weeks of mindfulness training based on virtual reality technology, and the acceptance of the mindfulness training mode using virtual reality technology was evaluated. The Hospital Anxiety and Depression Scale (HADS) and Cancer Related Fatigue Scale (CRF) were used to evaluate the anxiety, depression, and fatigue of patients before and after intervention. RESULTS The virtual reality based mindfulness training mode includes four functional modules: personalized curriculum, intelligent monitoring, emotion tracking, and Funny Games. 48 patients had a high acceptance score (139.21 ± 10.47), and after using mindfulness training mode based on virtual reality technology, anxiety, depression, and cancer-related fatigue in ovarian cancer patients during chemotherapy were significantly reduced, with a statistically significant difference (p< 0.001). CONCLUSION Ovarian cancer patients during chemotherapy have a high acceptance of virtual reality based mindfulness training mode. The application of this mode can reduce the psychological problems of anxiety, depression, and cancer-related fatigue in ovarian cancer patients during chemotherapy, and is worth promoting and using.
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Affiliation(s)
- Wenjuan Mao
- Department of Gynaecology, Peking University International Hospital, Beijing, China
| | - Wenduo Chen
- Department of Gynaecology, Peking University International Hospital, Beijing, China
| | - Yanbo Wang
- Obstetrics and Gynecology Clinic, Peking University International Hospital, Beijing, China
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4
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Engel J, van Ierssel JJ, Osmond MH, Tsampalieros A, Webster R, Zemek R. Return to the Emergency Department Within 3 Months Following Pediatric Acute Concussion. J Head Trauma Rehabil 2023; 38:319-328. [PMID: 36854112 DOI: 10.1097/htr.0000000000000852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
OBJECTIVE To determine the proportion of concussed children returning to the emergency department (ED) for a concussion-related reason within 3 months of initial presentation and to determine which clinical composite score (5P or Post-Concussion Symptom Inventory) best predicts a return visit. SETTING, DESIGN, AND PARTICIPANTS We combined a secondary analysis of data from the prospectively collected 5P study with a retrospective medical record review of children aged 5 to 18 years who returned to the Children's Hospital of Eastern Ontario (CHEO) ED for a concussion-related reason within 3 months of an acutely diagnosed concussion. Among 770 eligible participants, 632 children (median age: 11.8 [interquartile range (IQR), 9.0-14.5] years; 58.9% male) were included in the study. MAIN MEASURES The primary outcome was the number of patients who returned to CHEO ED for a concussion-related reason within 3 months of an acute concussion diagnosed at CHEO ED. The secondary outcome was number of patients who returned within 14 days. RESULTS Forty-seven children (7.4%; 95% confidence interval [CI]: 5.6-9.7) had a concussion-related return to the ED within 3 months, the majority of which occurred in the first 14 days (29/47; 61.7%; 95% CI: 47.4-74.2). History of migraines (21.3% vs 9.7%; P = .03) were more common in those with a return visit. Headache was the most frequently reported symptom (87.2%) on revisit. Females aged 13 to 18 years had the highest return rate (survival rate: 85.8% [95% CI: 79.8-92.3]) compared with males and younger age groups. In multivariable Cox hazards regression modeling, inclusion of risk scores improved prognostication (pseudo R2 = 8%). The difference in pseudo R2 between 5P and Post-Concussion Symptom Inventory is small. CONCLUSION Most children and adolescents do not return to the ED following an acute concussion. Female youth with medium to high 5P scores at the index concussion visit may benefit from early referral to interdisciplinary specialty concussion care to guide treatment in anticipation of prolonged symptoms. By identifying these risk factors at the initial ED visit, healthcare and patient burden may be reduced.
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Affiliation(s)
- Jake Engel
- University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada (Mr Engel and Drs Osmond and Zemek); Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada (Drs van Ierssel, Osmond, Tsampalieros, Webster, and Zemek); and Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada (Drs Osmond and Zemek)
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McNickle AG, Jones SA, Yacoub M, Streit SM, Bailey D, Ari JB, Fraser DR. BIG Kids: Application of a modified brain injury guideline in a pediatric trauma center. J Pediatr Surg 2023; 58:552-557. [PMID: 35953341 DOI: 10.1016/j.jpedsurg.2022.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/18/2022] [Accepted: 07/25/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Brain Injury Guidelines (BIG) were developed to stratify traumatic brain injuries (TBIs) by severity to decrease unnecessary CT imaging and neurosurgical consultation in low-risk cases. This study evaluated the potential effect of a modified pediatric BIG (pBIG) algorithm would have on resource utilization. METHODS Isolated TBIs (<18 years) were queried from our Pediatric Trauma Registry from 2017 to 2020. Injuries were classified as mild (pBIG 1), moderate (pBIG 2), or severe (pBIG 3) based on neurologic status, skull fractures, size, and the number of bleeds. Modifications from the institutional adult algorithm were upgrading <4 mm epidural hematomas to pBIG 2 and eliminating interfacility transfer as a pBIG 2 criteria. The proposed pBIG 1 and 2 care plans do not include routine repeat CTs or neurosurgical consultation. RESULTS A total of 314 children with a mean age of 4.9 years were included. Skull fractures (213, 68%) and subdural hematomas (162, 52%) were the most common injuries. 89 (28%) children had repeat head CTs (2 (7%) pBIG 1, 26 (25%) pBIG 2, 61 (34%) pBIG 3). Neurosurgical consultation was obtained in 306 (98%), with 50 (16%) requiring intervention (1 (1%) pBIG 2 and 49 (27%) pBIG 3). Following the proposed pBIG would decrease neurosurgical consults to 181 (58%) and repeat CTs to 63 (20%). Following the algorithm, 91 (29%) kids would have been admitted to a higher level of care and 45 (14.3%) to a lower level. CONCLUSIONS Implementation of our pBIG algorithm would decrease neurosurgery consults (40% reduction) and repeat head CTs (29% reduction).
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Affiliation(s)
- Allison G McNickle
- Department of Surgery, Kirk Kerkorian School of Medicine at UNLV, 1701 West Charleston Blvd, Suite 490, Las Vegas, NV 89102, USA.
| | - Stephanie A Jones
- Department of Surgery, Kirk Kerkorian School of Medicine at UNLV, 1701 West Charleston Blvd, Suite 490, Las Vegas, NV 89102, USA
| | - Mais Yacoub
- Pediatric Critical Care Medicine, University Medical Center of Southern Nevada, 1800 West Charleston Blvd, 4th Floor Trauma Building, Las Vegas, NV 89102, USA
| | - Stephanie M Streit
- Department of Surgery, Kirk Kerkorian School of Medicine at UNLV, 1701 West Charleston Blvd, Suite 490, Las Vegas, NV 89102, USA
| | - Dina Bailey
- Trauma Administration, University Medical Center of Southern Nevada, 1800 West Charleston Blvd, 5th Floor Trauma Building, Las Vegas, NV 89102, USA
| | - Judith Ben Ari
- Pediatric Critical Care Medicine, University Medical Center of Southern Nevada, 1800 West Charleston Blvd, 4th Floor Trauma Building, Las Vegas, NV 89102, USA
| | - Douglas R Fraser
- Department of Surgery, Kirk Kerkorian School of Medicine at UNLV, 1701 West Charleston Blvd, Suite 490, Las Vegas, NV 89102, USA
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Vajna de Pava M, Milani GP, Zuccotti GV, Tommasi P, Calvi M, Amoroso A, Montesano P, Boselli G, Castellazzi ML, Agosti M. Multi-centre study found no increased risk of clinically important brain injuries when children presented more than 24 hours after a minor head trauma. Acta Paediatr 2022; 111:2125-2130. [PMID: 35917207 DOI: 10.1111/apa.16507] [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: 02/01/2022] [Revised: 07/07/2022] [Accepted: 08/01/2022] [Indexed: 11/30/2022]
Abstract
AIM Validated clinical decision rules on neuroimaging are not available for children who are evaluated more than 24 hours after a minor head trauma. We compared clinically important traumatic brain injuries in children who presented with a minor head trauma within, or after, 24 hours. METHODS This was a retrospective analysis of patients aged 0-17 years, who were evaluated for minor head traumas by 5 paediatric emergency departments in Northern Italy between January 2019 and June 2020. Children with clinically important traumatic brain injuries were divided into those who had presented within, and after, 24 hours. RESULTS The study comprised 5,981 children (59.9% boys), with a median age of 2 years, including 243 (4.1%) who had presented more than 24 hours after their minor head trauma. Neuroimaging was performed on 448 (7.5%) patients and the time of presentation had no impact on the rates of clinically important traumatic brain injuries. Multiple logistic regression did not show any association between clinically important traumatic brain injuries and late presentation. CONCLUSION Delayed presentation to a paediatric emergency department after a minor head trauma did not alter the risk of clinically important traumatic brain injuries and the same neuroimaging rules could apply.
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Affiliation(s)
| | - Gregorio Paolo Milani
- Paediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Science and Community Health, University of Milan, Italy
| | - Gian Vincenzo Zuccotti
- Department of Paediatrics, Ospedale dei Bambini Vittore Buzzi, Milan, Italy.,Department of Biomedical and Clinical Sciences, University of Milan, Italy
| | - Paola Tommasi
- Department of Paediatrics, Ospedale dei Bambini Vittore Buzzi, Milan, Italy
| | - Matteo Calvi
- Paediatric Emergency Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Angela Amoroso
- Paediatric Emergency Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Paola Montesano
- Department of Emergency Medicine, University Children's Hospital, Spedali Civili, Brescia, Italy
| | - Giulia Boselli
- Department of Emergency Medicine, University Children's Hospital, Spedali Civili, Brescia, Italy
| | - Massimo Luca Castellazzi
- Paediatric Emergency Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Agosti
- Woman and Child Department, ASST dei Sette Laghi, Varese, Italy.,Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Ellethy, ME H, Chandra SS, Nasrallah FA. Deep Neural Networks Predict the Need for CT in Pediatric Mild Traumatic Brain Injury: A Corroboration of the PECARN Rule. J Am Coll Radiol 2022; 19:769-778. [DOI: 10.1016/j.jacr.2022.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 11/28/2022]
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Abid Z, Kuppermann N, Tancredi DJ, Dayan PS. Risk of Traumatic Brain Injuries in Infants Younger than 3 Months With Minor Blunt Head Trauma. Ann Emerg Med 2021; 78:321-330.e1. [PMID: 34148662 DOI: 10.1016/j.annemergmed.2021.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Indexed: 01/21/2023]
Abstract
STUDY OBJECTIVE Infants with head trauma often have subtle findings suggestive of traumatic brain injury. Prediction rules for traumatic brain injury among children with minor head trauma have not been specifically evaluated in infants younger than 3 months old. We aimed to determine the risk of clinically important traumatic brain injuries, traumatic brain injuries on computed tomography (CT) images, and skull fractures in infants younger than 3 months of age who did and did not meet the age-specific Pediatric Emergency Care Applied Research Network (PECARN) low-risk criteria for children with minor blunt head trauma. METHODS We conducted a secondary analysis of infants <3 months old in the public use data set from PECARN's prospective observational study of children with minor blunt head trauma. Main outcomes included (1) clinically important traumatic brain injury, (2) traumatic brain injury on CT, and (3) skull fracture on CT. RESULTS Of 10,904 patients <2 years old, 1,081 (9.9%) with complete data were <3 months old; most (750/1081, 69.6%) sustained falls, and 633/1081 (58.6%) underwent CT scans. Of the 514/1081 (47.5%) infants who met the PECARN low-risk criteria, 1/514 (0.2%, 95% confidence interval [CI] 0.005% to 1.1%), 10/197 (5.1%, 2.5% to 9.1%), and 9/197 (4.6%, 2.1% to 8.5%) had clinically important traumatic brain injuries, traumatic brain injuries on CT, and skull fractures, respectively. Of 567 infants who did not meet the low-risk PECARN criteria, 24/567 (4.2%, 95% CI 2.7% to 6.2%), 94/436 (21.3%, 95% CI 17.6% to 25.5%), and 122/436 (28.0%, 95% CI 23.8% to 32.5%) had clinically important traumatic brain injuries, traumatic brain injuries, and skull fractures, respectively. CONCLUSION The PECARN traumatic brain injury low-risk criteria accurately identified infants <3 months old at low risk of clinically important traumatic brain injuries. However, infants at low risk for clinically important traumatic brain injuries remained at risk for traumatic brain injuries on CT, suggesting the need for a cautious approach in these infants.
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Affiliation(s)
- Zaynah Abid
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY.
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, Davis School of Medicine, University of California, Sacramento, CA
| | - Daniel J Tancredi
- Departments of Emergency Medicine and Pediatrics, Davis School of Medicine, University of California, Sacramento, CA
| | - Peter S Dayan
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY
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Arora R, White EN, Niedbala D, Ravichandran Y, Sethuraman U, Radovic N, Watson K, Nypaver M. Reducing Computed Tomography Scan Utilization for Pediatric Minor Head Injury in the Emergency Department: A Quality Improvement Initiative. Acad Emerg Med 2021; 28:655-665. [PMID: 33368815 DOI: 10.1111/acem.14177] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 11/12/2020] [Accepted: 11/18/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The validated Pediatric Emergency Care Applied Research Network (PECARN) prediction rules are meant to aid clinicians in safely reducing unwarranted imaging in children with minor head injuries (MHI). Even so, computed tomography (CT) scan utilization remains high, especially in intermediate-risk (per PECARN) MHI patients. The primary objective of this quality improvement initiative was to reduce CT utilization rates in the intermediate-risk MHI patients. METHODS This project was conducted in a Level I trauma pediatric emergency department (ED). Children < 18 years evaluated for intermediate-risk MHI from June 2016 through July 2019 were included. Our key drivers were provider education, decision support, and performance feedback. Our primary outcome was change in head CT utilization rate (%). Balancing measures included return visit within 72 hours of the index visit, ED length of stay (LOS), and clinically important traumatic brain injury (ciTBI) on the revisit. We used statistical process control methodology to assess head CT rates over time. RESULTS A total of 1,535 eligible intermediate-risk MHI patients were analyzed. Our intervention bundle was associated with a decrease in CT use from 18.5% (95% confidence interval [CI] = 14.5% to 22.5%) in the preintervention period to 13.9% (95% CI = 13.8% to 14.1%) in the postintervention period, an absolute reduction of 4.6% (p = 0.015). Over time, no difference was noted in either ED LOS or return visit rate. There was only one revisit with a ciTBI to our institution during the study period. CONCLUSIONS Our multifaceted quality improvement initiative was both safe and effective in reducing our CT utilization rates in children with intermediate-risk MHI.
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Affiliation(s)
- Rajan Arora
- From the Department of Pediatrics Division of Pediatric Emergency Medicine Central Michigan UniversityChildren’s Hospital of Michigan Detroit MIUSA
| | - Emily N. White
- the Department of Biostatistics University of Michigan Ann Arbor MIUSA
| | - Deborah Niedbala
- and the Department of Quality Children’s Hospital of Michigan Detroit MIUSA
| | - Yagnaram Ravichandran
- From the Department of Pediatrics Division of Pediatric Emergency Medicine Central Michigan UniversityChildren’s Hospital of Michigan Detroit MIUSA
- and the Department of Pediatrics Wright State UniversityDayton Children’s Hospital Dayton OHUSA
| | - Usha Sethuraman
- From the Department of Pediatrics Division of Pediatric Emergency Medicine Central Michigan UniversityChildren’s Hospital of Michigan Detroit MIUSA
| | - Nancy Radovic
- and the Department of Quality Children’s Hospital of Michigan Detroit MIUSA
| | - Kristin Watson
- and the Department of Quality Children’s Hospital of Michigan Detroit MIUSA
| | - Michele Nypaver
- the Department of Emergency Medicine University of Michigan Ann ArborMIUSA
- and the Department of Pediatrics University of Michigan Ann Arbor MIUSA
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10
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Shimony N, Dailey T, Barrow D, Bui A, Noureldine MHA, Martínez-Sosa M, Rodriguez LF, Carey CM, Tuite GF, Jallo GI. Pediatric mild head trauma: is outpatient follow-up imaging necessary or beneficial? J Neurosurg Pediatr 2021; 28:62-68. [PMID: 33962382 DOI: 10.3171/2020.11.peds20588] [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: 07/12/2020] [Accepted: 11/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric traumatic brain injury (TBI) is the leading cause of death among children and is a significant cause of morbidity. However, the majority of injuries are mild (Glasgow Coma Scale score 13-15) without any need for neurosurgical intervention, and clinically significant neurological decline rarely occurs. Although the question of repeat imaging within the first 24 hours has been discussed in the past, the yield of short-term follow-up imaging has never been thoroughly described. In this paper, the authors focus on the yield of routine repeat imaging for pediatric mild TBI (mTBI) at the first clinic visit following hospital discharge. METHODS The authors conducted a retrospective review of patients with pediatric brain trauma who had been admitted to Johns Hopkins All Children's Hospital (JHACH). Patients with mTBI were identified, and their presentation, hospital course, and imaging results were reviewed. Those pediatric patients with mTBI who had undergone no procedure during their initial admission (only conservative treatment) were eligible for inclusion in the study. Two distinct groups were identified: patients who underwent repeated imaging at their follow-up clinic visit and those who underwent only clinical evaluation. Each case was assessed on whether the follow-up imaging had changed the follow-up course. RESULTS Between 2010 and 2015, 725 patients with TBI were admitted to JHACH. Of those, 548 patients qualified for analysis (i.e., those with mTBI who received conservative treatment without any procedure and were seen in the clinic for follow-up evaluation within 8 weeks after the trauma). A total of 392 patients had only clinic follow-up, without any diagnostic imaging study conducted as part of their clinic visit, whereas the other 156 patients underwent repeat MRI. Only 1 patient had a symptomatic change and was admitted after undergoing imaging. For 30 patients (19.2%), it was decided after imaging to continue the neurosurgical follow-up, which is a change from the institutional paradigm after mTBI. None of these patients had a change in neurological status, and all had a good functional status. All of these patients had one more follow-up in the clinic with new MRI, and none of them required further follow-up. CONCLUSIONS Children with mTBI are commonly followed up in the ambulatory clinic setting. The authors believe that for children with mTBI, normal clinical examination, and no new symptoms, there is no need for routine ambulatory imaging since the clinical yield of such is relatively low.
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Affiliation(s)
- Nir Shimony
- 1Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
- 3Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
- 4Department of Neurosurgery, Geisinger Commonwealth School of Medicine, Danville, Pennsylvania
| | - Travis Dailey
- 2Morsani College of Medicine, Department of Neurosurgery, Tampa, Florida
| | - David Barrow
- 2Morsani College of Medicine, Department of Neurosurgery, Tampa, Florida
| | - Anh Bui
- 2Morsani College of Medicine, Department of Neurosurgery, Tampa, Florida
| | | | | | - Luis F Rodriguez
- 1Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Carolyn M Carey
- 1Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Gerald F Tuite
- 1Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - George I Jallo
- 3Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
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11
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Arora R, Shukla M, McQuillen E, Sethuraman U. Pediatric minor head injury related return visits to the emergency department and their outcome. Am J Emerg Med 2021; 45:71-74. [PMID: 33676078 DOI: 10.1016/j.ajem.2021.01.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 01/11/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Minor head injury (MHI) in children is a common emergency department (ED) presentation. It is well established that majority of these patients don't require imaging and can be safely discharged. What is less known is how often these children come back to the ED and the outcome of their revisits? The objective of this study was to describe the frequency and outcome of unscheduled return visits (RVs) for MHI in a pediatric ED. METHODS A retrospective chart review of emergency department RV's database was conducted from August 2016 to July 2019. MHI patients <18 years of age who came back to the ED within 72 h of their index visit - for head injury related complaints - were eligible for inclusion. RESULTS Return visit rate for MHI was around 1% (61/6225). Of these, 55.7% (34/61) were female and 85.5% (53/61) were in the age group 2-17 years. Three-fourths of the revisits were for concussion-related symptoms. Nearly two-thirds of the patients required one or more interventions upon revisit. Missed clinically important traumatic brain injury was rare. Only one patient required operative intervention upon revisit. Though largely unpreventable, 5% (3/61) of the revisits were deemed potentially avoidable. CONCLUSION(S) RVs secondary to MHI in children remain low and are associated with good outcomes.
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Affiliation(s)
- Rajan Arora
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Central Michigan University, Children's Hospital of Michigan, Detroit, MI, United States of America.
| | - Meghna Shukla
- Division of Pediatric Emergency Medicine, Wayne State University, Children's Hospital of Michigan, Detroit, MI, United States of America.
| | - Elizabeth McQuillen
- Office of Faculty Affairs, College of Nursing, Wayne State University, Detroit, MI, United States of America.
| | - Usha Sethuraman
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Central Michigan University, Children's Hospital of Michigan, Detroit, MI, United States of America.
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Abstract
Concussion is a common pediatric problem, and the best point of intervention would be to prevent a concussion from occurring. Unfortunately, information in this area has inconsistent support for the various methods that have been attempted. In infants, concussions are typically related to safety hazards in the environment and attempts to make the environment safer have resulted in decreased injuries over time. Toddlers also face environmental hazards that are slightly different in light of their increased mobility. School-aged children and adolescents primarily sustain concussions in the course of participation in organized contact sports. Although much research has been devoted to protective equipment, there is not a clearly effective piece of equipment that prevents concussions. Some effect has been demonstrated with changes in rules and policy that limit or eliminate certain kinds of dangerous contact. Research is still being performed to adequately evaluate methods that are already being used, as well as to find new methods in the future that may help protect today's children from concussions.
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13
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Hanson HR, Gittelman MA, Pomerantz WJ. Trends of ED visits, admissions, and deaths for pediatric traumatic brain injury comparing sport and non-sport mechanisms. Inj Epidemiol 2019; 6:23. [PMID: 31333989 PMCID: PMC6617460 DOI: 10.1186/s40621-019-0207-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Traumatic brain injuries (TBI) in children result in significant morbidity and mortality. There are many mechanisms, both sport and non-sport related, which cause these injuries. Studies have reported that Emergency Department (ED) visits for pediatric TBI caused by sports are increasing; however, no subsequent study has evaluated the trend in non-sport TBI. The objective of this study was to evaluate ED visits, admissions, and deaths for non-sport TBI compared to those caused by sports. Methods A retrospective study of children 5-19 years of age was performed at a pediatric, level 1 trauma center from 2002 to 2012. Subjects with a primary or secondary diagnosis of TBI were identified from the hospital's trauma registry, and mechanism of injury, disposition, injury severity score, and length of stay were recorded. Frequencies were used to characterize the population, Chi-square analysis was performed to determine differences between groups, and linear trend lines were calculated for sport-related and non-sport TBI by year. Results Thirteen thousand two hundred ninty one subjects were seen in the ED between 2002 and 2012 for a TBI; 9527 (72%) were from a non-sport mechanism, and 3764 (28%) were from a sport mechanism. Subjects with a non-sport TBI were more likely to be younger (p < 0.001), African American (p < 0.001), and have Medicare/Medicaid (p < 0.001). Subjects with a non-sport TBI were admitted to the hospital 15% of the time, and subjects with a sport-related TBI were admitted 10% of the time (p < 0.001). When evaluating all TBI by mechanism of injury, sport had the lowest injury severity score (mean 4.4) and the shortest length of stay (mean 1.6 days) of any mechanism. There were six deaths reported from non-sport TBI and none from sport-related TBI. ED visits for sport-related TBI increased 92%, and non-sport TBI increased 22% over 10 years. There was a peak in TBI, in both groups, seen in 2009. Conclusions ED visits for both sport and non-sport TBI have increased over the past 10 years. TBI from a non-sport mechanism was more likely to result in hospitalization or death. Prevention efforts should be expanded to include all high-risk TBI mechanisms, not just sports.
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Affiliation(s)
- Holly R Hanson
- 1Division of Pediatric Emergency Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232 USA
| | - Michael A Gittelman
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 2008, Cincinnati, OH 45255 USA
| | - Wendy J Pomerantz
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 2008, Cincinnati, OH 45255 USA
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14
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Ballard DW, Kuppermann N, Vinson DR, Tham E, Hoffman JM, Swietlik M, Deakyne Davies SJ, Alessandrini EA, Tzimenatos L, Bajaj L, Mark DG, Offerman SR, Chettipally UK, Paterno MD, Schaeffer MH, Richards R, Casper TC, Goldberg HS, Grundmeier RW, Dayan PS. Implementation of a Clinical Decision Support System for Children With Minor Blunt Head Trauma Who Are at Nonnegligible Risk for Traumatic Brain Injuries. Ann Emerg Med 2019; 73:440-451. [DOI: 10.1016/j.annemergmed.2018.11.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/31/2018] [Accepted: 11/08/2018] [Indexed: 11/26/2022]
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15
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The Epidemiology of Pediatric Head Injury Treated Outside of Hospital Emergency Departments. Epidemiology 2019; 29:269-279. [PMID: 29240568 DOI: 10.1097/ede.0000000000000791] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although head trauma-related deaths, hospitalizations, and emergency department visits are well characterized, few studies describe pediatric patients presenting outside of emergency departments. We compared the epidemiology and extent of healthcare-seeking pediatric (0-17 years) patients presenting in outpatient settings with those of patients seeking nonhospitalized emergency department care. METHODS We used MarketScan Medicaid and commercial claims, 2004-2013, to identify patients managed in two outpatient settings (physician's offices/clinics, urgent care) and the emergency department. We then examined differences in demographic and injury-specific factors, Centers for Disease Control and Prevention-defined head trauma diagnoses, the extent of and reasons for post-index visit ambulatory care use within 30/90/180 days, and annual and monthly variations in head trauma trends. Outpatient incidence rates in 2013 provided estimates of the nationwide US outpatient burden. RESULTS A total of 1,683,097 index visits were included, representing a nationwide burden in 2013 of 844,660 outpatient cases, a number that encompassed 51% of healthcare-seeking head trauma that year and that substantially increased in magnitude from 2004 to 2013. Two-thirds (68%) were managed in outpatient settings. While demographic distributions varied with index-visit location, injury-specific factors were comparable. Seasonal spikes appeared to coincide with school sports. CONCLUSIONS There is an urgent need to better understand the natural history of head trauma in the >800,000 pediatric patients presenting each year for outpatient care. These outpatient injuries, which are more than double the number of head trauma cases recorded in the hospital-affiliated settings, illustrate the potential importance of expanding inclusion criteria in surveillance and prevention efforts designed to address this critical issue.
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16
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Gise R, Truong T, Poulsen DM, Soliman Y, Parsikia A, Mbekeani JN. Pediatric traumatic brain injury and ocular injury. J AAPOS 2018; 22:421-425.e3. [PMID: 30342183 DOI: 10.1016/j.jaapos.2018.07.351] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/16/2018] [Accepted: 07/19/2018] [Indexed: 11/17/2022]
Abstract
PURPOSE Traumatic brain injury (TBI) is a leading cause of pediatric disability and mortality. Together with sight-threatening ocular injuries, TBIs may lead to devastating consequences in developing children and complicate rehabilitation. We sought to investigate this relationship in pediatric patients admitted with major trauma. METHODS The records of pediatric patients admitted with ocular injury and concomitant TBI were reviewed retrospectively using the National Trauma Data Bank (2008-2014). RESULTS Of 58,765 pediatric patients admitted for trauma and also had ocular injuries, 32,173 were diagnosed with TBI. Mean patient age was 12.3 ± 7 years. Most were male (69.8%) and White (61.2%). The most frequent injuries were contusion of the eye/adnexa (39.1%) and orbital fractures (35.8%). The youngest age groups had greatest odds of falls in home locations, whereas older groups were more likely to suffer motor vehicle trauma as occupants (MVTO), struck by or against (SBA) injuries, and firearms injuries in street locations (P < 0.001). Blacks and Hispanics were most likely to suffer assault (P < 0.001) and Whites, unintentional (P < 0.001) and self-inflicted (P < 0.012) injury. Blacks were at a higher risk of firearms injury, Whites of MVTO, and Hispanics of motor vehicles as pedestrians (P < 0.001). CONCLUSIONS TBI frequently is experienced by trauma patients with concomitant ocular injury and should be considered in children admitted with major trauma. Resultant demographic patterns may help identify patients that have a higher risk of TBI leading to earlier diagnosis and treatment.
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Affiliation(s)
- Ryan Gise
- Ophthalmology & Visual Sciences, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York.
| | - Timothy Truong
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - David M Poulsen
- Ophthalmology & Visual Sciences, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Yssra Soliman
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Afshin Parsikia
- Department of Surgery (Trauma), Jacobi Medical Center, Bronx, New York
| | - Joyce N Mbekeani
- Ophthalmology & Visual Sciences, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; Department of Surgery (Ophthalmology), Jacobi Medical Center, Bronx, New York
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17
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Parameswaran A, Heitner S, Thosar D, Fowler A, Marks S, O'Leary F. Trial of life: Well infants presenting more than 24 h after head injury with a scalp haematoma: A 10-year review. J Paediatr Child Health 2018; 54:1193-1198. [PMID: 29748981 DOI: 10.1111/jpc.13932] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 03/26/2018] [Indexed: 11/28/2022]
Abstract
AIM To review the investigation, patterns of injury and short-term outcomes of infants younger than 12 months of age who presented more than 24 h after head injury with an isolated scalp haematoma. METHODS A retrospective chart review of infants who presented with a head injury to the emergency department of a major paediatric hospital between 2006 and 2016. Patients were included if they presented more than 24 h after the injury, were clinically well and had a documented scalp haematoma. Charts were abstracted using a standardised instrument to yield patient characteristics, mechanism of injury, imaging performed, identified injuries and patient outcome. RESULTS A total of 2433 records were reviewed, with 157 included in the study. The mean age was 7.5 months (standard deviation 2.6). Of the patients, 14 had a documented palpable skull fracture; 43 patients had a skull X-ray reported as a fracture; 13 patients had cranial ultrasounds with 3 reported as having a fracture; 124 patients had computed tomography head imaging, with 112 demonstrating a fracture; and 52 patients had acute intracranial abnormalities. There were nine unplanned representations (5.7%). No patients required any neurosurgical intervention. CONCLUSIONS Infants presenting after 24 h with isolated scalp haematomas had good short-term outcomes despite a high prevalence of underlying injury on imaging. Expectant management, rather than imaging, may be a valid approach in this patient population. However, some of these injuries may have been the result of inflicted injury, and all of these patients require a robust assessment regardless of the decision to use a computed tomography scan.
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Affiliation(s)
- Ahilan Parameswaran
- Emergency Department, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Shmuel Heitner
- Emergency Department, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Deepali Thosar
- Emergency Department, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Adam Fowler
- Department of Neurosurgery, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Susan Marks
- Child Protection Unit, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Fenton O'Leary
- Emergency Department, Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Disciplines of Emergency Medicine and Paediatrics and Child Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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18
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Al Daoud F, Drolet A, Carto C, Debessai H, Daswani GS. Absence of cognitive symptoms in a 6-year-old male with post-traumatic increased intracranial pressure - A case report. Ann Med Surg (Lond) 2018; 35:86-89. [PMID: 30294436 PMCID: PMC6170209 DOI: 10.1016/j.amsu.2018.09.021] [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: 08/13/2018] [Revised: 09/12/2018] [Accepted: 09/18/2018] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Traumatic Brain Injuries (TBIs) can range from mild to severe, and may result in increased intracranial pressure (ICP). Increased ICP causes hallmark physical signs, such as diaphoresis, emesis, fixed pupils, and altered mental status. Monitoring the patient's score on the Glasgow Coma Scale (GCS) and cranial CT scans are routine measures used in clinical practice to monitor the development of a TBI. PRESENTATION OF THE CASE A 6-year-old male fell off his father's shoulders and subsequently presented to ED for suspected head trauma. He was transferred to our Level 1 Trauma Center after a head CT scan demonstrated a subdural hematoma. His GCS score remained 15. The next day he began to have episodes of apnea and desaturation. Further imaging indicated expansion of the hematoma with a 5mm midline shift. He remained consistently alert and a neurological exam revealed cranial nerves to be grossly intact. Increased ICP was reduced with several days of hypertonic saline treatment without surgical intervention. DISCUSSION TBIs can have long-lasting effects in pediatric patients and are typically assessed using both diagnostic imaging and clinical judgment. CT scans are used to assess for hematoma development, while loss of consciousness (LOC) and altered mental status are standard clinical diagnostic indicators of increased ICP. This patient remained alert with a GCS score of 15, although he had clinical signs of increased ICP including apnea and bradycardia with a midline shift confirmed on imaging. CONCLUSION While GCS is an important prognostic indicator in TBI, patients should still be monitored to assure resolution of all symptoms.
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Affiliation(s)
- Fadi Al Daoud
- 1 Hurley Plaza, 7 B Trauma Services, Flint, MI, 48503, USA
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19
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Greenberg JK, Jeffe D, Carpenter CR, Yan Y, Pineda JA, Lumba-Brown A, Keller MS, Berger D, Bollo RJ, Ravindra V, Naftel RP, Dewan M, Shah MN, Burns EC, O’Neill BR, Hankinson TC, Whitehead WE, Adelson PD, Tamber MS, McDonald PJ, Ahn ES, Titsworth W, West AN, Brownson RC, Limbrick DD. North American survey on the post-neuroimaging management of children with mild head injuries. J Neurosurg Pediatr 2018; 23:227-235. [PMID: 30485194 PMCID: PMC6717430 DOI: 10.3171/2018.7.peds18263] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 07/26/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThere remains uncertainty regarding the appropriate level of care and need for repeating neuroimaging among children with mild traumatic brain injury (mTBI) complicated by intracranial injury (ICI). This study's objective was to investigate physician practice patterns and decision-making processes for these patients in order to identify knowledge gaps and highlight avenues for future investigation.METHODSThe authors surveyed residents, fellows, and attending physicians from the following pediatric specialties: emergency medicine; general surgery; neurosurgery; and critical care. Participants came from 10 institutions in the United States and an email list maintained by the Canadian Neurosurgical Society. The survey asked respondents to indicate management preferences for and experiences with children with mTBI complicated by ICI, focusing on an exemplar clinical vignette of a 7-year-old girl with a Glasgow Coma Scale score of 15 and a 5-mm subdural hematoma without midline shift after a fall down stairs.RESULTSThe response rate was 52% (n = 536). Overall, 326 (61%) respondents indicated they would recommend ICU admission for the child in the vignette. However, only 62 (12%) agreed/strongly agreed that this child was at high risk of neurological decline. Half of respondents (45%; n = 243) indicated they would order a planned follow-up CT (29%; n = 155) or MRI scan (19%; n = 102), though only 64 (12%) agreed/strongly agreed that repeat neuroimaging would influence their management. Common factors that increased the likelihood of ICU admission included presence of a focal neurological deficit (95%; n = 508 endorsed), midline shift (90%; n = 480) or an epidural hematoma (88%; n = 471). However, 42% (n = 225) indicated they would admit all children with mTBI and ICI to the ICU. Notably, 27% (n = 143) of respondents indicated they had seen one or more children with mTBI and intracranial hemorrhage demonstrate a rapid neurological decline when admitted to a general ward in the last year, and 13% (n = 71) had witnessed this outcome at least twice in the past year.CONCLUSIONSMany physicians endorse ICU admission and repeat neuroimaging for pediatric mTBI with ICI, despite uncertainty regarding the clinical utility of those decisions. These results, combined with evidence that existing practice may provide insufficient monitoring to some high-risk children, emphasize the need for validated decision tools to aid the management of these patients.
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Affiliation(s)
- Jacob K Greenberg
- Departments of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Donna Jeffe
- Departments of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Christopher R Carpenter
- Division of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Yan Yan
- Departments of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Jose A Pineda
- Departments of Pediatrics Washington University School of Medicine in St. Louis, St. Louis, MO.,Departments of Neurology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - Martin S Keller
- Departments of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Daniel Berger
- Departments of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Robert J. Bollo
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Vijay Ravindra
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Robert P Naftel
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Michael Dewan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Manish N. Shah
- Department of Neurosurgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, TX
| | - Erin C Burns
- Department of Pediatrics, Oregon Health & Science University, Portland, OR
| | - Brent R. O’Neill
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO
| | - Todd C Hankinson
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO
| | | | - P David Adelson
- Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, AZ
| | - Mandeep S Tamber
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Edward S Ahn
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William Titsworth
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alina N West
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Ross C Brownson
- Departments of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO.,Alvin J. Siteman Cancer Center, Washington University School of Medicine in St. Louis, St. Louis, MO.,Prevention Research Center, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - David D Limbrick
- Departments of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO
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20
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Using Community Detection Analysis to Elucidate Caregivers’ Mental Models of Pediatric Concussion Symptoms. SAFETY 2018. [DOI: 10.3390/safety4030035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Due to a culture of resistance around concussion reporting, novel methods are needed to reveal implicit beliefs that could affect symptom reporting. The goal of this study was to elucidate caregivers’ mental models of pediatric concussion symptoms using an exploratory community detection analysis (CDA). Caregivers (n = 76) of adolescents 10–15 years old participated in a survey that assessed their intentions of seeking medical treatment for 12 injury symptoms following their child’s involvement in three hypothetical injury scenarios. We used a series of analyses of variance (ANOVAs) to compare injury symptoms across these scenarios and CDA to determine if caregivers implicitly group symptoms together. We then used logistic regressions to further explore associations between the CDA-identified symptom indices and known factors of injury risk. There were no differences in the likelihood to seek treatment for symptoms across injury scenarios; however, the CDA revealed distinct symptom clusters that were characterized by the degree of risk for non-treatment and symptom type. We observed associations between injury risk factors and intentions of seeking medical treatment for the higher-risk indices. Results indicate that caregivers’ mental models of concussion symptoms are nuanced, not monolithic. Therefore, it is inaccurate to measure intentions to seek treatment for concussion without taking these nuances into consideration.
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21
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Visual Pathway Injuries in Pediatric Ocular Trauma-A Survey of the National Trauma Data Bank From 2008 to 2014. Pediatr Neurol 2018; 85:43-50. [PMID: 29859721 DOI: 10.1016/j.pediatrneurol.2018.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 04/05/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Traumatic visual pathway injuries are often associated with severe head trauma and can have profound deleterious effects in developing children and their rehabilitation. We sought to elucidate the epidemiology of pediatric visual pathway injuries in the United States. MATERIALS AND METHODS This study is a retrospective evaluation of pediatric patients (less than 21 years of age) with visual pathway injuries that were submitted to the National Trauma Data Bank between 2008 to 2014. Patients were identified using the International Classification of Diseases, Ninth Revision Clinical Modification codes. Statistical analysis was performed with SPSS software. Variables were correlated using Student t test, chi-squared test, and logistic regression analyses. RESULTS Of the 58,765 pediatric patients (1.7%) who were admitted with ocular injuries, 970 had visual pathway injuries. The majority of these patients were male (69.2%), and the mean age was 11.6 years (±7.2). Traumatic optic neuropathy was the most common (86.1%) visual pathway injury. It had the greatest odds of occurring with oculomotor nerve injury (odds ratio = 3.84; P < 0.001). Associated ocular injuries were open adnexal wounds (87.4%) and orbital fractures (23%). Common mechanisms were motor vehicle occupant (21.5%) and firearms (15.6%). Motor vehicle occupants were most likely white and firearms injury, black. In the zero to three years age group, most injuries were due to falls; injuries in the 19 to 21 years age group had the greatest association with firearms. Overall mortality was 17.6%. CONCLUSIONS Visual pathway injuries may have devastatating sequelae and should be considered in pediatric ocular injuries. The clear majority were traumatic optic neuropathies. The common mechanisms, motor vehicle occupant and firearms, revealed age and race disparities.
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22
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Robinson S, Winer JL, Chan LAS, Oppong AY, Yellowhair TR, Maxwell JR, Andrews N, Yang Y, Sillerud LO, Meehan WP, Mannix R, Brigman JL, Jantzie LL. Extended Erythropoietin Treatment Prevents Chronic Executive Functional and Microstructural Deficits Following Early Severe Traumatic Brain Injury in Rats. Front Neurol 2018; 9:451. [PMID: 29971038 PMCID: PMC6018393 DOI: 10.3389/fneur.2018.00451] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 05/29/2018] [Indexed: 01/30/2023] Open
Abstract
Survivors of infant traumatic brain injury (TBI) are prone to chronic neurological deficits that impose lifelong individual and societal burdens. Translation of novel interventions to clinical trials is hampered in part by the lack of truly representative preclinical tests of cognition and corresponding biomarkers of functional outcomes. To address this gap, the ability of a high-dose, extended, post-injury regimen of erythropoietin (EPO, 3000U/kg/dose × 6d) to prevent chronic cognitive and imaging deficits was tested in a postnatal day 12 (P12) controlled-cortical impact (CCI) model in rats, using touchscreen operant chambers and regional analysis of diffusion tensor imaging (DTI). Results indicate that EPO prevents functional injury and MRI injury after infant TBI. Specifically, subacute DTI at P30 revealed widespread microstructural damage that is prevented by EPO. Assessment of visual discrimination on a touchscreen operant chamber platform demonstrated that all groups can perform visual discrimination. However, CCI rats treated with vehicle failed to pass reversal learning, and perseverated, in contrast to sham and CCI-EPO rats. Chronic DTI at P90 showed EPO treatment prevented contralateral white matter and ipsilateral lateral prefrontal cortex damage. This DTI improvement correlated with cognitive performance. Taken together, extended EPO treatment restores executive function and prevents microstructural brain abnormalities in adult rats with cognitive deficits in a translational preclinical model of infant TBI. Sophisticated testing with touchscreen operant chambers and regional DTI analyses may expedite translation and effective yield of interventions from preclinical studies to clinical trials. Collectively, these data support the use of EPO in clinical trials for human infants with TBI.
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Affiliation(s)
- Shenandoah Robinson
- Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.,Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.,F.M. Kirby Center for Neurobiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jesse L Winer
- Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Lindsay A S Chan
- Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Akosua Y Oppong
- Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | | | - Jessie R Maxwell
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, United States
| | - Nicholas Andrews
- F.M. Kirby Center for Neurobiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Yirong Yang
- Department of Pharmaceutical Sciences, University of New Mexico, Albuquerque, NM, United States
| | - Laurel O Sillerud
- Department of Neurology, University of New Mexico, Albuquerque, NM, United States
| | - William P Meehan
- Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Rebekah Mannix
- Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jonathan L Brigman
- Department of Neurosciences, University of New Mexico, Albuquerque, NM, United States
| | - Lauren L Jantzie
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, United States.,Department of Neurosciences, University of New Mexico, Albuquerque, NM, United States
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23
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Chen C, Peng J, Sribnick EA, Zhu M, Xiang H. Trend of Age-Adjusted Rates of Pediatric Traumatic Brain Injury in U.S. Emergency Departments from 2006 to 2013. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E1171. [PMID: 29874782 PMCID: PMC6024977 DOI: 10.3390/ijerph15061171] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 06/04/2018] [Accepted: 06/04/2018] [Indexed: 11/16/2022]
Abstract
Objective: To use the 2006⁻2013 Nationwide Emergency Department Sample (NEDS) database to describe trends of age-adjusted rates of pediatric traumatic brain injuries (TBI) treated in U.S. emergency departments. Methods: Time trend analysis was conducted on age-adjusted rates among children ≤17 years in the U.S. The annual percent change (APC) was calculated by fitting a least squares regression to the logarithm of the rates, using the calendar year as an independent variable. Results: In males, motor-vehicle-related trauma (APC -2.5%) and severe TBI (APC -3.6%) decreased over the study time period. Conversely, concussion (APC 5.1%), unspecified head injury (APC 6.6%), fall-related TBI (APC 7.1%), and mild TBI (APC 5.9%) increased. In females, severe TBI (APC -3.3%) decreased over the study time period and concussion (APC 6.5%), unspecified head injury (APC 7.2%), fall-related TBI (APC 7.6%), and mild TBI (APC 6.8%) increased. Conclusion: The overall age-adjusted rates of pediatric TBI-related emergency department (ED) visits increased from 2006 to 2013, which is largely caused by pediatric mild TBIs, especially unspecified injury to the head (ICD-9-CM code 959.01) and concussion. In comparison, age-adjusted rates of pediatric severe TBIs decreased. A major contributing factor might be a reduced number of traffic-related head trauma.
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Affiliation(s)
- Cheng Chen
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH 43215, USA.
- Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, OH 43215, USA.
| | - Jin Peng
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH 43215, USA.
- Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, OH 43215, USA.
- College of Public Health, The Ohio State University, Columbus, OH 43210, USA.
| | - Eric A Sribnick
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH 43215, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH 43205, USA.
- Department of Neurosurgery, Nationwide Children's Hospital, Columbus, OH 43205, USA.
| | - Motao Zhu
- Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, OH 43215, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH 43205, USA.
| | - Henry Xiang
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH 43215, USA.
- Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, OH 43215, USA.
- College of Public Health, The Ohio State University, Columbus, OH 43210, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH 43205, USA.
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Keret A, Shweiki M, Bennett-Back O, Abed-Fteiha F, Matoth I, Shoshan Y, Benifla M. The clinical characteristics of posttraumatic epilepsy following moderate-to-severe traumatic brain injury in children. Seizure 2018; 58:29-34. [DOI: 10.1016/j.seizure.2018.03.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 03/01/2018] [Accepted: 03/18/2018] [Indexed: 10/17/2022] Open
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Dewan S, Schimmel S, Borlongan CV. Treating childhood traumatic brain injury with autologous stem cell therapy. Expert Opin Biol Ther 2018; 18:515-524. [PMID: 29421958 PMCID: PMC6086119 DOI: 10.1080/14712598.2018.1439473] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Neonatal traumatic brain injury (TBI) is a significant cause of developmental disorders. Autologous stem cell therapy may enhance neonatal brain plasticity towards repair of the injured neonatal brain. AREAS COVERED The endogenous neonatal anti-inflammatory response can be enhanced through the delivery of anti-inflammatory agents. Stem cell therapy stands as a robust approach for sequestering the inflammation-induced cell death in the injured brain. Here, we discuss the use of umbilical cord blood cells and bone marrow stromal cells for acute and chronic treatment of experimental neonatal TBI. Autologous stem cell transplantation may dampen neuroinflammation. Clinical translation of this stem cell therapy will require identifying the therapeutic window post-injury and harvesting ample supply of transplantable autologous stem cells. Stem cell banking of cryopreserved cells may allow readily available transplantable cells and circumvent the unpredictable nature of neonatal TBI. Harnessing the anti-inflammatory properties of stem cells is key in combating the progressive neurodegeneration after the initial injury. EXPERT OPINION Combination treatments, such as with hypothermia, may enhance the therapeutic effects of stem cells. Stem cell therapy has immense potential as a stand-alone or adjunctive therapy for treating neuroinflammation associated with neonatal TBI acutely and for preventing further progression of the injury.
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Affiliation(s)
- Shyam Dewan
- Center of Excellence for Aging and Brain Repair, Department of Neurosugery and Brain Repair, University of South Florida Morsani College of Medicine. 3515 E. Fletcher Avenue, Tampa, FL 33613, USA
| | - Samantha Schimmel
- Center of Excellence for Aging and Brain Repair, Department of Neurosugery and Brain Repair, University of South Florida Morsani College of Medicine. 3515 E. Fletcher Avenue, Tampa, FL 33613, USA
| | - Cesar V. Borlongan
- Center of Excellence for Aging and Brain Repair, Department of Neurosugery and Brain Repair, University of South Florida Morsani College of Medicine. 3515 E. Fletcher Avenue, Tampa, FL 33613, USA
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Avraham JB, Bhandari M, Frangos SG, Levine DA, Tunik MG, DiMaggio CJ. Epidemiology of paediatric trauma presenting to US emergency departments: 2006-2012. Inj Prev 2017; 25:136-143. [PMID: 29056586 DOI: 10.1136/injuryprev-2017-042435] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 10/06/2017] [Accepted: 10/10/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Traumatic injury is the leading cause of paediatric morbidity and mortality in the USA. We present updated national data on emergency department (ED) discharges for traumatic injury for a recent 7-year period. METHODS We conducted a descriptive epidemiological analysis of the Nationwide Emergency Department Sample Survey, the largest and most comprehensive database in the USA, for 2006-2012. Among children and adolescents, we tracked changes in injury mechanism and severity, cost of care, injury intent and the role of trauma centres. RESULTS There was an 8.3% (95% CI 7.7 to 8.9) decrease in the annual number of ED visits for traumatic injury in children and adolescents over the study period, from 8 557 904 (SE=5861) in 2006 to 7 846 912 (SE=5191) in 2012. The case-fatality rate was 0.04% for all injuries and 3.2% for severely injured children. Children and adolescents with high-mortality injury mechanisms were more than three times more likely to be treated at a level 1 trauma centre (OR=3.5, 95% CI 3.3 to 3.7), but were more no more likely to die (OR=0.96, 95% CI 0.93 to 1.00). Traumatic brain injury diagnoses increased 22.2% (95% CI 20.6 to 23.9) during the study period. Intentional assault accounted for 3% (SE=0.1) of all child and adolescent ED injury discharges and 7.2% (SE=0.3) of discharges among 15-19 year-olds. There was an 11.3% (95% CI 10.0 to 12.6) decline in motor vehicle injuries from 2009 to 2012. The total cost of care was $23 billion (SE=0.01), a 78% increase from 2006 to 2012. CONCLUSIONS This analysis presents a recent portrait of paediatric trauma across the USA. These analyses indicate the important role and value of trauma centre care for injured children and adolescents, and that the most common causes and mechanisms of injury are preventable.
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Affiliation(s)
- Jacob B Avraham
- Department of Surgery, New York University School of Medicine, New York, NY, USA
| | - Misha Bhandari
- Department of Surgery, New York University School of Medicine, New York City, New York, USA.,Department of Emergency Medicine, New York Presbyterian, The University Hospital of Columbia and Cornell, New York, NY
| | - Spiros G Frangos
- Department of Surgery, Division of Acute Care and Trauma Surgery, New York University School of Medicine/Bellevue Hospital Center, New York City, New York, USA
| | - Deborah A Levine
- Department of Pediatrics, New York University School of Medicine/Bellevue Hospital Center, New York City, New York, USA.,Ronald O Perelman Department of Emergency Medicine, New York University School of Medicine/Bellevue Hospital Center, New York City, New York, USA
| | - Michael G Tunik
- Department of Pediatrics, New York University School of Medicine/Bellevue Hospital Center, New York City, New York, USA.,Ronald O Perelman Department of Emergency Medicine, New York University School of Medicine/Bellevue Hospital Center, New York City, New York, USA
| | - Charles J DiMaggio
- Department of Surgery, Division of Acute Care and Trauma Surgery, New York University School of Medicine/Bellevue Hospital Center, New York City, New York, USA.,Population Health, New York University School of Medicine, New York, NY, USA
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