Pediatric Train Injuries: A 10-Year Review From the Pennsylvania Trauma Outcomes Study Database.

OBJECTIVES: Trains can cause severe injuries in pediatric patients requiring significant resource utilization. We sought to review train injuries in Pennsylvania to determine the burden of these injuries on the pediatric trauma system. METHODS: We queried the Pennsylvania Trauma Outcomes Study Database to identify patients younger than 18 years injured by trains between 2007 and 2016. Demographics, hospital course, outcomes, and resource utilization were reviewed. RESULTS: Thirty-five children from 17 Pennsylvania counties were included. Three counties accounted for 48.6% of injured children. The median age was 15.0 years, and most patients were White (60.0%) and male (77.1%). The median length of stay was 8.0 days and overall mortality 8.6%. Intensive care unit admission was required for 65.7%. The median Injury Severity and Functional Status at Discharge scores were 14.0 and 18.0, respectively. Major orthopedic injuries (fracture or amputation) were the most common (57.1%) followed by traumatic brain injury (45.7%), pneumothorax (14.3%), and solid organ injury (14.3%). Operative management was common with 65.7% undergoing surgery. CONCLUSIONS: Injuries caused by trains can be severe and are most commonly orthopedic or traumatic brain injuries. Targeted safety interventions may be possible given the common mechanisms and geographic clustering of these injuries.

Adherence to PECARN criteria in children transferred to a pediatric trauma center: An opportunity for improvement?

BACKGROUND: The Pediatric Emergency Care Applied Research Network (PECARN) criteria identify children at low risk of clinically important traumatic brain injury (ciTBI) in whom CT head (CTH) is unnecessary. We assessed compliance with PECARN at outside hospitals (OSH) among children transferred to our pediatric trauma center. METHODS: Patients <18 years transferred between May 2016 and December 2018 undergoing CTH at an OSH were reviewed. A ciTBI was defined as one requiring hospitalization ≥2 midnights, intubation >24 h, neurosurgical intervention, or causing death. RESULTS: 202 children were transferred after CTH. 53 were excluded for incomplete records (16), suspected abuse (33), or penetrating injury (4). Of the 149 included children, PECARN recommended CTH in 39 (26.2%), shared decision making in 79 (53.0%), and no imaging in 31 (20.8%). 26 children (17.4%) had a radiographic traumatic brain injury (rTBI) while only 6 (4.0%) had ciTBIs. Of those with ciTBIs, PECARN recommended CTH in 4 and shared decision making in 2. No child in whom CTH was not recommended had a ciTBI. 45 (30.2%) children had isolated extracranial injuries requiring transfer and 83 (55.7%) were transferred despite normal CTHs and no associated injuries. 2 (1.3%) children underwent non-emergent surgery for ciTBI. CONCLUSIONS: Compliance with PECARN was low among referring facilities with nearly 75% of CTHs being potentially avoidable with proper adherence and parental counseling. Deferring imaging until after transfer appears safe as no child underwent emergent intervention upon arrival. Early transfer and improved compliance with PECARN may reduce the number of CTHs performed.

Admission of Pediatric Concussion Injury Patients: Is It Necessary?

BACKGROUND: Currently there is no consensus on the management of patients with a concussion and negative computed tomography (CT) of the head. This study examined the necessity of admitting pediatric patients with concussive symptoms. The purpose of this study was to determine if pediatric patients evaluated in the emergency department (ED) for concussion with a negative head CT scan require routine hospital admission. MATERIALS AND METHODS: A retrospective chart review of pediatric trauma patients admitted to the hospital for a concussion from 2010 to 2017 was conducted after IRB approval (1709005621). Only patients with a negative head CT were included. Demographic information, ED evaluation, and hospital course were reviewed. RESULTS: A total of 90 patients (Mage = 10 y; 72.2% male) were included in the analysis. The average Glasgow coma scale was 14.6 (range 9-15). Loss of consciousness was reported by 36.7% (n = 33) of patients. Reported symptoms included nausea/emesis in 35.5% (n = 32) and altered mental status in 40% (n = 36). Following admission, 94.4% of patients were discharged within 24 h of admission. Of the four patients (4.4%) that stayed longer than 24 h, only two hospitalizations were related to the concussion (inability to tolerate diet). One patient had a fever unrelated to the concussion and one stayed because of social issues. Average length of stay for these patients was 2.75 d (range 2-4 d). There was no difference in Glasgow coma scale in comparison to patients who were discharged within 24 h. CONCLUSIONS: Although there are a large number of pediatric patients evaluated in the ED for concussion injuries, very few of these patients require any further care. Our study suggests that patients with concussion and a negative head CT who tolerate a diet can be safely discharged home.

Hidden morbidity of ethanol lock therapy.

AIMS: Long-term central venous catheters are essential in sustaining growth and development in patients with intestinal failure (IF). Several strategies have been developed to prevent and treat catheter-related blood stream infections (CRBSIs), including ethanol lock therapy. We sought to evaluate the efficacy of ethanol lock therapy in our IF population. METHOD: This is a retrospective review of IF patients treated with ethanol lock therapy at a single institution from 2006 to 2013. We evaluated the number of catheter days, rate of CRBSI per 1000 catheter days, rate of central venous catheter (CVC) thrombosis, rate of CVC breakage, total number of CVC replacements, total number of hospital admissions, and total number days in the hospital. RESULT: We identified 19 patients who underwent ethanol lock therapy for CRBSI. There was no difference in CRBSI rate prior to (5.6 per 1000 catheter days) and after (7 per 1000 catheter days) initiation of ethanol lock therapy. The mean rate of thrombosis increased from 0 to 3 per 1000 catheter days with ethanol lock therapy (p < 0.05). In addition, the CVC breakage rate increased from 0 to 13.7 per 1000 catheter days with ethanol lock therapy (p < 0.001). Hospital admissions and catheter-related ER visits increased following the initiation of ethanol lock therapy. CONCLUSIONS: Contrary to other studies, there was no difference in CRBSI rate prior to and after initiation of ethanol lock therapy. Factors in the methodology of ethanol lock therapy may influence the effectiveness of infection prevention associated with ethanol lock therapy, as well as the rate of line breakage, line thrombosis, and the need for line replacement.

A Standardized Protocol for Nonoperative Management of Complicated Appendicitis in Children Reduces Resource Utilization.

INTRODUCTION: To standardize care and reduce resource utilization, we implemented a standardized protocol (SP) for the nonoperative treatment of complicated appendicitis. MATERIALS AND METHODS: We conducted a prospective, historically controlled, study of patients <21 years with complicated appendicitis managed nonoperatively using an SP from January 2017 to November 2018. The primary outcomes included length of stay (LOS), antibiotic days, peripheral inserted central catheter (PICC) utilization, discharge on intravenous antibiotics, and predischarge imaging. Secondary outcomes were protocol adherence and the rates of adverse events (AE) including return to emergency department (ED), readmission, failure of nonoperative treatment, and interval appendectomy complications. RESULTS: Protocol adherence was 67.9%. In total, 741 children were treated for appendicitis of which 58 (30 pre-SP and 28 post-SP) were treated nonoperatively for complicated appendicitis at presentation. Patients were well matched for age, admission white blood cell, sex, body mass index, race, and the proportion requiring percutaneous drainage. After implementing the SP, fewer children had PICCs (100.0 vs. 57.1%, p ≤ 0.001), fewer were discharged on intravenous antibiotics (90.0 vs. 42.9%, p < 0.001), and total antibiotic days were reduced (14.0 vs. 10.0, p = 0.006). There was no difference in LOS (5.5 vs. 6.0 days, p = 0.790) or the proportion undergoing ultrasound (36.7 vs. 39.3%, p = 0.837) or computed tomography scan (16.7 vs. 3.6%, p = 0.195) prior to discharge. There were nonsignificant trends toward reduced AEs (46.7 vs. 35.7%, p = 0.397), returns to ED (40.0 vs. 28.6%, p = 0.360), and readmissions (26.7 vs. 17.9%, p = 0.421). The proportion failing nonoperative treatment (10.0 vs. 3.6%, p = 0.612) and experiencing complications of interval appendectomy (3.3 vs. 3.6%, p = 0.918) were not significantly different. CONCLUSION: Implementing an SP for treating complicated appendicitis nonoperatively reduced resource utilization without negatively affecting clinical outcomes.

A Standardized Protocol for the Management of Appendicitis in Children Reduces Resource Utilization.

Appendicitis is the most common condition requiring emergency surgery in children. We implemented a standardized protocol (SP) for treating children with appendicitis to provide more uniform care and reduce resource utilization. METHODS: All patients younger than 21 years were managed with the SP beginning in January 2017. We compared data from 22 months before and after implementation. The primary outcomes included the length of stay (LOS), antibiotic days, discharge on intravenous antibiotics, utilization of peripherally inserted central catheters lines, and postoperative imaging. Secondary outcomes were protocol adherence and the rates adverse events, including postoperative abscess, return to emergency department or operating room, surgical site infection, and readmission. RESULTS: Protocol adherence was 92.3%. For uncomplicated cases (n = 412), LOS (P = 0.010) and postoperative antibiotic days (P < 0.001) were significantly reduced. There was no difference in the rates of any adverse event (6.7% versus 2.7%; P = 0.058), postoperative abscess (0.4% versus 0.0%; P = 0.544), return to emergency department (6.3% versus 2.7%; P = 0.084), readmission (1.8% versus 0.5%; P = 0.245), or postoperative ultrasound (0.4% versus 0.5%; P = 0.705) and computed tomography (0.0% versus 0.5%; P = 0.456). For complicated cases (n = 229), the post-SP cohort had a shorter LOS (P = 0.015), fewer peripherally inserted central catheters lines (26.9% versus 2.7%; P < 0.001), fewer postoperative ultrasounds (8.4% versus 1.8%; P = 0.027), and fewer discharges on intravenous antibiotics (17.6% versus 0.9%; P < 0.001). There were no differences in adverse events before and after the SP (16.0% versus 18.3%; P = 0.633). CONCLUSION: Implementing an SP for appendicitis in children reduced resource utilization, and by inference healthcare costs, for both uncomplicated and complicated cases without adversely affecting clinical outcomes.

Case report of severe psychiatric sequelae in a 16-year-old female following resection of a purely dopamine-secreting ganglioneuroma.

BACKGROUND: Ganglioneuromas (GN) are rare, benign tumors derived from neural crest cells. They are in the same family of neuroblastic tumors that includes the intermediate ganglioneuroblastoma (GNB) and the malignant neuroblastoma (NB), each of which carries a different prognosis based on tumor histopathology. GNs are generally asymptomatic and usually found incidentally when the tumor becomes palpable or has grown large enough to exert mass effect on adjacent structures. Unlike their malignant counterparts, GNs are rarely hormonally active and usually do not exhibit systemic metabolic activity. We present a case of an adolescent female with a pelvic tumor that was found to be a purely dopamine-secreting GN. Resection resulted in sudden dopamine withdrawal and unexpected severe emotional lability post-operatively. CASE: A 16-year-old female presented with a history of increasingly irregular menses over the past year and was found to have an 8-centimeter pelvic tumor. Subsequent work up revealed the mass to be solely dopamine secreting. The tumor was excised without preoperative hormonal blockade. Post-operatively, the patient developed severe emotional lability and symptoms of depression, likely related to the acute withdrawal of circulating dopamine. CONCLUSION: Ganglioneuromas are rarely metabolically active. However, a preoperative endocrine workup should be done to rule out other more commonly hormonally active tumors such as neuroblastomas, pheochromocytomas, and paragangliomas. If isolated dopamine secretion is found, hormonal blockade is not required preoperatively and operative manipulation and removal should be considered safe. However, one should anticipate potential emotional and psychiatric issues post-operatively due to the acute withdrawal of circulating dopamine.

Diffuse esophageal leiomyomatosis: A case report with surgical correlation.

A 15 year old female with a history only significant for long standing dysphagia and intermittent chest pain underwent a screening chest radiograph. Findings of a large mass prompted cross sectional imaging where extensive and marked diffuse esophageal thickening was demonstrated. The patient ultimately underwent biopsy and surgical resection for diffuse esophageal leiomyomatosis. Diffuse leiomyomatosis of the esophagus has been described in the literature for about 100 years with increasing recognition in more recent times. There is a known association with inherited syndromes such as Alport and Esophageal-Vulvar syndrome, though some cases are sporadic. This case report will demonstrate the imaging features of diffuse esophageal leiomyomatosis utilizing multiple modalities including radiography, fluoroscopy, CT, and MRI, with surgical and pathologic correlation.

Standardization of common bile duct size using ultrasound in pediatric patients.

BACKGROUND/PURPOSE: The incidence of choledocholithiasis is increasing. The diagnosis of common bile duct (CBD) obstruction is based on abnormal CBD size. Establishing norms for CBD size in children would improve diagnostic accuracy. We analyzed ultrasounds (US) to determine normal pediatric CBD size based on age and then validated this against patients with choledocholithiasis. METHODS: A retrospective review was conducted for children less than 21 years of age with US defined CBD size. Patients were stratified into age groups by ANOVA statistical analysis. Secondary analysis included patients with confirmed choledocholithiasis in comparison to the normal cohort. RESULTS: A total of 778 patients had US without pathology. Group 1 (<1 year) had a mean CBD of 1.24±0.54 mm, group 2 (1-10 years) 1.97±0.71 mm, and group 3 (>10 years) 2.98±1.17 mm, p<0.05. Fourteen additional patients were found to have choledocholithiasis with a mean CBD size of 8.1 mm. All patients with choledocholithiasis had CBD sizes outside of our normal range, but only 50% of patients had enlarged CBD size based on adult normal range of values. CONCLUSION: Normal CBD size in children is less than a normal adult patient. More accurate normal values will aid in determining if a child needs further evaluation for possible obstruction of the CBD. TYPE OF STUDY: diagnostic Level of evidence: III.

Single-lateral cervical radiograph in pediatric trauma is equivalent to multiple views.

BACKGROUND: Cervical spine injuries (CSI) are rare within the pediatric population. Due to the significant consequences of missed CSI, children are often imaged excessively. In an attempt to decrease imaging of the cervical spine in children, we reviewed abnormal cervical radiographs (XR) to determine if the diagnosis of CSI could be made using a single-lateral cervical radiograph (LAT). Furthermore, we reviewed cervical computed tomography (CT) and magnetic resonance imaging (MRI) to ensure there were no missed CSI. METHODS: Electronic medical records of trauma patients treated at a Level I Pediatric Trauma Center with abnormal XR findings followed by confirmatory CT or MRI between 2012 and 2017 were reviewed. All abnormal imaging on XR was compared with the LAT. In addition, all abnormal CTs and MRIs were reviewed to ensure there were no false negative XR. RESULTS: A total of 3,735 XR were performed with 26 abnormal interpretations. All bony CSI were visualized on LAT. Confirmatory imaging found 13 (50%) were false positive and 13 (50%) were true positive. Secondary analysis of CT identified 12 injuries with prior XR; 8 of 12 LAT identifying the injury and 4 of 12 false positive on CT. Secondary analysis of MRI identified nine injuries with prior XR; 5 of 9 LAT identifying the injury. The four false-negative reads on MRI were ligamentous injuries. CONCLUSION: Radiographs are commonly performed when evaluating CSI. In our population, initial assessment with a single LAT was equivalent to a multiple view XR. On secondary review, the only false-negative LAT reports were due to ligamentous injuries. This data suggests limiting exposure to LAT would accomplish the goal of reducing imaging without missing bony CSI and when ligamentous injury is suspected MRI should be the confirmatory study rather than CT. LEVEL OF EVIDENCE: Diagnostic Test, level III.

Patient-centered outcomes research in appendicitis in children: Bridging the knowledge gap.

PURPOSE: Patient-centered outcomes research (PCOR) aims to give patients a better understanding of the treatment options to enable optimal decision-making. As nonoperative alternatives are now being evaluated in children for acute appendicitis, we surveyed patients and their families regarding their knowledge of appendicitis and evaluated whether providing basic medical information would affect their perception of the disease and allow them to more rationally consider the treatment alternatives. METHODS: Families of children aged 5-18 presenting to the Emergency Department with suspected appendicitis were recruited for a tablet-based interactive educational survey. One hundred subjects (caregivers and patients ≥ 15 years) were questioned before and after an education session about their understanding of appendicitis, including questions on three hypothetical treatment options: urgent appendectomy, antibiotics alone, or initial antibiotics followed by elective appendectomy. Subjects were clearly informed that urgent appendectomy is currently the standard of care. RESULTS: Only 14% of respondents correctly identified the mortality rate of appendicitis (17 deaths/year according to the 2010 US census) when compared with other extremely rare causes of death. Fifty-four and 31% thought it was more common than death from lightning (40/year) and hunting-associated deaths (44/year), respectively. Eighty-two percent of respondents believed it "likely" or "very likely" that the appendix would rupture if operation was at all delayed, and 81% believed that rupture of the appendix would rapidly lead to severe complications and death. In univariate analysis, this perception was significantly more prevalent for mothers (odds ratio, (OR) 5.19, confidence interval (CI) 1.33-21.15), and subjects who knew at least one friend or relative who had a negative experience with appendicitis (OR 5.53, CI 1.40-25.47). Following education, these perceptions changed significantly (53% still believed that immediate operation was necessary, and 47% believed perforation led to great morbidity and potential mortality, P<0.001). In a survey of potential appendicitis treatment options, urgent appendectomy was considered a "good" or "very good" option by 74% of subjects, compared with 68% for antibiotics only without appendectomy and 49% for initial antibiotic therapy followed by elective outpatient appendectomy. CONCLUSION: There was a striking knowledge gap in the participant perception of appendicitis. Appropriate education can correct anecdotally supported misconceptions. Adequate education may empower patients to make better-informed decisions about their medical care and may be important for future studies in alternative treatments for appendicitis in children.

Interactive Instrument-Driven Image Display in Laparoscopic Surgery.

BACKGROUND: A significant limitation of minimally invasive surgery is dependence of the entire surgical team on a single endoscopic viewpoint. An individualized, instrument-driven image display system that allows all operators to simultaneously define their viewing frame of the surgical field may be the solution. We tested the efficacy of such a system using a modified Fundamentals of Laparoscopic Surgery™ (Society of American Gastrointestinal and Endoscopic Surgeons, Los Angeles, CA) bead transfer task. MATERIALS AND METHODS: A program was custom-written to allow zooming and centering of the image window on specific color signals, each attached near the tip of a different laparoscopic instrument. Two controls were used for the bead transfer task: (1) a static, wide-angle view and (2) a single moving camera allowing close-up and tracking of the bead as it was transferred. Time to task completion and number of bead drops were recorded. RESULTS: Thirty-six sessions were performed by surgical residents. Average time for bead transfer was 127.3±21.3 seconds in the Experimental group, 139.1±27.8 seconds in the Control 1 group, and 186.2±18.5 seconds in the Control 2 group (P=.034, by analysis of variance). Paired analysis (the Wilcoxon Signed-Rank Test) showed that the Experimental group was significantly faster than the Control 1 group (P=.035) and the Control 2 group (P=.028). CONCLUSIONS: We have developed an image navigation system that allows intuitive and efficient laparoscopic performance compared with two controls. It offers high-resolution images and ability for multitasking. The tracking system centers close-up images on the laparoscopic target. Further development of robust prototypes will help transition this in vitro system into clinical application.