Facial Paralysis From Post-transplant Lymphoproliferative Disorder.

OBJECTIVE: We report a case of facial paresis and profound hearing loss from post-transplant lymphoproliferative disorder (PTLD) in a pediatric patient with neuroblastoma. PATIENT: Three-year-old boy with rapidly progressive right facial paresis and sensorineural hearing loss. High-risk neuroblastoma had been diagnosed 1 year earlier, treated with chemotherapy and resection of the adrenal primary tumor. Two months after two autologous hematopoietic stem cell transplantations (HSCT), the patient developed facial paralysis. Magnetic resonance imaging (MRI) showed bilateral progressive internal auditory canal (IAC) enhancing lesions with a mass lesion on the right and wispy enhancement on the left and enhancement within the right cochlea. Lumbar puncture (LP) was positive for Epstein-Barr virus (EBV) making the diagnosis of PTLD most probable. Biopsy of the right IAC lesion was deferred because of potential procedural risks including intradural spread of tumor or fungus. The patient was treated with anti-fungal therapy and systemic rituximab without improvement. Subsequent intrathecal rituximab resulted in improvement of lesions on MRI and clearance of EBV from the cerebrospinal fluid (CSF). INTERVENTIONS: Mastoidectomy for biopsies from the mastoid and middle ear. Intrathecal treatment with rituximab. MAIN OUTCOME MEASURES: Imaging assessment of IAC lesion, CSF EBV titers, facial nerve function. RESULTS: Gradual resolution of IAC mass lesions, remission of PTLD, and facial improvement from House-Brackmann score of 4 to 3. CONCLUSIONS: PTLD causing facial paresis after autologous HSCT has not been previously reported and may be considered in the differential diagnosis of lesions causing facial paresis in patients who have received a stem cell or solid organ transplant.

Educational Initiative to Standardize Concussion Management in Pediatric Primary Care.

Pediatric primary care providers report limited training and tools to manage concussion. We developed a learning community intervention for a large independent pediatric practice association affiliated with a university hospital to standardize concussion management and improve the use of consensus-based guidelines. The learning community included in-person and online didactics, followed by a web-based reinforcement platform to educate and train clinicians on our treatment algorithm and decision support tools. Chart reviews before and after the intervention demonstrated significant increases in the use of standardized symptom rating scales (19.6% to 69.3%; P < .001), balance assessment (2.3% to 37.6%; P < .001), and scheduled follow-up (41.8% to 61.2%; P < .001), with an increase in delivery of our entire best practice bundle from 3.5% to 28.1% ( P < .001). A multimodal educational intervention can effect change among pediatric primary care providers and help align their management practices with consensus-based guidelines.

Trends in Ambulatory Care for Children with Concussion and Minor Head Injury from Eastern Massachusetts between 2007 and 2013.

OBJECTIVE: To characterize trends in health care utilization and costs for children diagnosed with concussion or minor head injury within a large pediatric primary-care association. STUDY DESIGN: We conducted a retrospective cohort analysis from 2007 through 2013 examining all outpatient medical claims related to concussion and minor head injury from 4 commercial insurance companies for children 6-21 years of age who were patients within a large pediatric independent practice association located throughout eastern Massachusetts. RESULTS: Health care visits for concussion and minor head injury increased more than 4-fold during the study period, with primary-care and specialty clinics experiencing the greatest increases in the rate of visits while emergency department visits increased comparatively less. These increases were accounted for by both the proportion of children diagnosed with concussion or minor head injury (1.3% of all children in 2007 vs 3.3% in 2013) and the number of encounters per diagnosed patient (1.0 encounters per patient in 2007 vs 1.7 in 2013). Although the overall population costs devoted to care for concussion or minor head injury increased 34%, the cost per individual diagnosed child decreased 31%. CONCLUSIONS: Over the past 7 years, health care encounters for children diagnosed with concussion or minor head injury increased substantially in eastern Massachusetts. Care for these injuries increasingly shifted from the emergency department to primary-care and specialty providers.