COVID-19 Pandemic Effects on the Epidemiology and Mortality of Pediatric Firearm Injuries; A Single Center Study.

BACKGROUND: The COVID-19 pandemic has been associated with increased firearm injuries amongst adults, though the pandemic's effect on children is less clearly understood. METHODS: This cross-sectional study was performed at a Level 1 Pediatric Trauma Center and included youths 0-19 years. The trauma registry was retrospectively queried for firearm injuries occurring pre-COVID-19 pandemic (March 2015-February 2020). Baseline data was compared to prospectively collected data occurring during the COVID-19 pandemic (March 2020-March 2022). Fischer's exact, Pearson's Chi-square and/or correlation analysis was used to compare pre and post-COVID-19 firearm injury rates and intent, victim demographics and disposition. Temporal relationships between firearm injury rates and local COVID-19 death rates were also described. RESULTS: 413 pre-COVID-19 firearm injuries were compared to 259 pandemic firearm injuries. Victims were mostly Black males with a mean age of 13.4 years. Compared to the 5 years pre-pandemic, monthly firearm injury rates increased 51.5% (6.8 vs 10.3 shootings/month), including a significant increase (p = 0.04) in firearm assaults/homicides and a relative decrease in unintentional shootings. Deaths increased 29%, and there were significantly fewer ED discharges and more admissions to OR and/or PICU (p = 0.005). There was a significant increase in Black victims (p = 0.01) and those having Medicaid or self-pay (p<0.001). Firearm injury spikes were noted during or within the 3 months following surges in local COVID-19 death rates. CONCLUSIONS: The COVID-19 pandemic was associated with an increase in the frequency and mortality of pediatric firearm injuries, particularly assaults amongst Black children following surges in COVID death rates. Increased violence-intervention services are needed, particularly amongst marginalized communities. LEVEL OF EVIDENCE: This is a prognostic study, evaluating the effects of the COVID-19 pandemic on pediatric firearm injuries, including victim demographics, injury intent and mortality. This study is retrospective and observational, making it Oxford Level III evidence.

Pediatric injury trends and relationships with social vulnerability during the COVID-19 pandemic: A multi-institutional analysis.

BACKGROUND: The impact of the COVID-19 pandemic on pediatric injury, particularly relative to a community's vulnerability, is unknown. The objective of this study was to describe the change in pediatric injury during the first 6 months of the COVID-19 pandemic compared with prior years, focusing on intentional injury relative to the social vulnerability index (SVI). METHODS: All patients younger than 18 years meeting inclusion criteria for the National Trauma Data Bank between January 1, 2016, and September 30, 2020, at nine Level I pediatric trauma centers were included. The COVID cohort (children injured in the first 6 months of the pandemic) was compared with an averaged historical cohort (corresponding dates, 2016-2019). Demographic and injury characteristics and hospital-based outcomes were compared. Multivariable logistic regression was used to estimate the adjusted odds of intentional injury associated with SVI, moderated by exposure to the pandemic. Interrupted time series analysis with autoregressive integrated moving average modeling was used to predict expected injury patterns. Volume trends and observed versus expected rates of injury were analyzed. RESULTS: There were 47,385 patients that met inclusion criteria, with 8,991 treated in 2020 and 38,394 treated in 2016 to 2019. The COVID cohort included 7,068 patients and the averaged historical cohort included 5,891 patients (SD, 472), indicating a 20% increase in pediatric injury ( p = 0.031). Penetrating injuries increased (722 [10.2%] COVID vs. 421 [8.0%] historical; p < 0.001), specifically firearm injuries (163 [2.3%] COVID vs. 105 [1.8%] historical; p = 0.043). Bicycle collisions (505 [26.3%] COVID vs. 261 [18.2%] historical; p < 0.001) and collisions on other land transportation (e.g., all-terrain vehicles) (525 [27.3%] COVID vs. 280 [19.5%] historical; p < 0.001) also increased. Overall, SVI was associated with intentional injury (odds ratio, 7.9; 95% confidence interval, 6.5-9.8), a relationship which increased during the pandemic. CONCLUSION: Pediatric injury increased during the pandemic across multiple sites and states. The relationship between increased vulnerability and intentional injury increased during the pandemic. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Slipping Rib Syndrome in Children: Natural History and Outcomes Following Costal Cartilage Excision.

INTRODUCTION: Slipping rib syndrome (SRS) or subluxation of the medial aspect of the lower rib costal cartilages is an underdiagnosed cause of debilitating pain in otherwise healthy children. Costal cartilage excision may provide definitive symptom relief. However, limited data exist on the natural history, difficulty in diagnosis, and patient-reported outcomes for SRS in children. METHODS: We performed a single-institution descriptive study using chart review and a patient-focused survey for patients who underwent surgery for SRS from 2012 to 2020. Data regarding demographics, symptoms, diagnostic workup, and patient-reported outcomes were collected. RESULTS: Surgical resection was performed in 13 children. The median age at symptom onset was 12.5 y [IQR 9.7, 13.9], with a preponderance of girls (10, 77%). Eight patients participated in competitive athletics at the time of symptom onset. Prior to diagnosis, patients were seen by a median 3 [IQR 2, 5] providers with a median of 4 [IQR 3, 6] non-diagnostic imaging exams performed. The children included in the study underwent surgery for left (8), bilateral (4), and right (1) SRS. Two were lost to follow-up. At median post-op follow-up of 3.5 mo [IQR 1.2, 9.6], 73% (8/11) had returned to full activity. One reported non-limiting persistent pain symptoms. CONCLUSIONS: Lack of knowledge regarding SRS may result in delayed diagnosis, excessive testing, and limitation of physical activity. Operative treatment appears to provide durable relief and should be considered for children with SRS. The challenge remains to decrease the number of non-diagnostic exams and time to diagnosis.

The COVID-19 pandemic and associated rise in pediatric firearm injuries: A multi-institutional study.

BACKGROUND: Firearm sales in the United States (U.S.) markedly increased during the COVID-19 pandemic. Our objective was to determine if firearm injuries in children were associated with stay-at-home orders (SHO) during the COVID-19 pandemic. We hypothesized there would be an increase in pediatric firearm injuries during SHO. METHODS: This was a multi institutional, retrospective study of institutional trauma registries. Patients <18 years with traumatic injuries meeting National Trauma Data Bank (NTDB) criteria were included. A "COVID" cohort, defined as time from initiation of state SHO through September 30, 2020 was compared to "Historical" controls from an averaged period of corresponding dates in 2016-2019. An interrupted time series analysis (ITSA) was utilized to evaluate the association of the U.S. declaration of a national state of emergency with pediatric firearm injuries. RESULTS: Nine Level I pediatric trauma centers were included, contributing 48,111 pediatric trauma patients, of which 1,090 patients (2.3%) suffered firearm injuries. There was a significant increase in the proportion of firearm injuries in the COVID cohort (COVID 3.04% vs. Historical 1.83%; p < 0.001). There was an increased cumulative burden of firearm injuries in 2020 compared to a historical average. ITSA showed an 87% increase in the observed rate of firearm injuries above expected after the declaration of a nationwide emergency (p < 0.001). CONCLUSION: The proportion of firearm injuries affecting children increased during the COVID-19 pandemic. The pandemic was associated with an increase in pediatric firearm injuries above expected rates based on historical patterns.

Impact of "Stay-at-Home" orders on non-accidental trauma: A multi-institutional study.

BACKGROUND: It is unclear how Stay-at-Home Orders (SHO) of the COVID-19 pandemic impacted the welfare of children and rates of non-accidental trauma (NAT). We hypothesized that NAT would initially decrease during the SHO as children did not have access to mandatory reporters, and then increase as physicians' offices and schools reopened. METHODS: A multicenter study evaluating patients <18 years with ICD-10 Diagnosis and/or External Cause of Injury codes meeting criteria for NAT. "Historical" controls from an averaged period of March-September 2016-2019 were compared to patients injured March-September 2020, after the implementation of SHO ("COVID" cohort). An interrupted time series analysis was utilized to evaluate the effects of SHO implementation. RESULTS: Nine Level I pediatric trauma centers contributed 2064 patients meeting NAT criteria. During initial SHO, NAT rates dropped below what was expected based on historical trends; however, thereafter the rate increased above the expected. The COVID cohort experienced a significant increase in the proportion of NAT patients age ≥5 years, minority children, and least resourced as determined by social vulnerability index (SVI). CONCLUSIONS: The COVID-19 pandemic affected the presentation of children with NAT to the hospital. In times of public health crisis, maintaining systems of protection for children remain essential. LEVEL OF EVIDENCE: III.

Index Admission Cholecystectomy and Recurrence of Pediatric Gallstone Pancreatitis: Multicenter Cohort Analysis.

BACKGROUND: We aim to evaluate recurrence rates of gallstone pancreatitis in children undergoing early vs interval cholecystectomy. STUDY DESIGN: A multicenter, retrospective review of pediatric patients admitted with gallstone pancreatitis from 2010 through 2017 was performed. Children were evaluated based on timing of cholecystectomy. Early cholecystectomy was defined as surgery during the index admission, whereas the delayed group was defined as no surgery or surgery after discharge. Outcomes, recurrence rates, and complications were evaluated. RESULTS: Of 246 patients from 6 centers with gallstone pancreatitis, 178 (72%) were female, with mean age 13.5 ± 3.2 years and a mean body mass index of 28.9 ± 15.2. Most (90%) patients were admitted with mild pancreatitis (Atlanta Classification). Early cholecystectomy was performed in 167 (68%) patients with no difference in early cholecystectomy rates across institutions. Delayed group patients weighed less (61 kg vs. 72 kg, p = 0.003) and were younger (12 vs. 14 years, p = 0.001) than those who underwent early cholecystectomy. However, there were no differences in clinical, radiological, or laboratory characteristics between groups. There were 4 (2%) episodes of postoperative recurrent pancreatitis in the early group compared with 22% in the delayed group. More importantly, when cholecystectomy was delayed more than 6 weeks from index discharge, recurrence approached 60%. There were no biliary complications in any group. CONCLUSIONS: Cholecystectomy during the index admission for children with gallstone pancreatitis reduces recurrent pancreatitis. Recurrence proportionally increases with time when patients are treated with a delayed approach.

Racial disparities in triage of adolescent patients after bullet injury.

BACKGROUND: While pediatric trauma centers (PTCs) and adult trauma centers (ATCs) exhibit equivalent trauma mortality, the optimal care environment for traumatically injured adolescents remains controversial. Race has been shown to effect triage within emergency departments (EDs) with people of color receiving lower acuity triage scores. We hypothesized that African-American adolescents were more likely triaged to an ATC than a PTC compared with their White peers. METHODS: Institutional trauma databases from a neighboring, urban Level I PTC and ATC were queried for gunshot wounds in adolescents (15-18 years) presenting to the ED from 2015 to 2017. The PTC and ATC were compared in terms of demographics, services, and outcomes. Results were analyzed using univariate analysis and logistic regression. RESULTS: Among 316 included adolescents, 184 were treated in an ATC versus 132 in a PTC. Patients at the PTC were significantly more likely to be younger (16.1 vs. 17.5 years; p < 0.001), White (16% vs. 5%; p = 0.001), and privately insured (41% vs. 30%; p = 0.002). At each age, the proportion of Whites treated at the PTC exceeded the proportion of African-Americans. At the PTC, patients were more likely to receive inpatient and outpatient social work follow-up (89% vs. 1%, p < 0.001). Adolescents treated at the PTC were less likely to receive opioids (75% vs. 56%, p = 0.001) at discharge and to return to ED within 6 months (25% vs. 11%, p = 0.005). On multivariate logistic regression, African-American adolescents were less likely to be treated at a PTC (odds ratio, 0.30; 95% confidence interval, 0.10-0.85; p = 0.02) after controlling for age and Injury Severity Score. CONCLUSION: Disparities in triage of African-American and White adolescents after bullet injury lead to unequal care. African-Americans were more likely to be treated at the ATC, which was associated with increased opioid prescription, decreased social work support, and increased return to ED. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.

Implementation of a clinical guideline for nonoperative management of isolated blunt renal injury in children.

BACKGROUND: The aim was to evaluate the impact of a standardized nonoperative management protocol by comparing patients with isolated blunt renal injury before and after implementation. METHODS: We retrospectively reviewed the trauma registry at our Level 1 pediatric trauma center. We compared consecutive patients (≤ 18 years) managed nonoperatively for blunt renal injury Pre (1/2010-9/2014) and Post (10/2014-3/2020) implementation of a clinical guideline. Outcomes included length of stay, intensive care unit admission, urinary catheter use, and imaging studies. RESULTS: We included 48 patients with isolated blunt renal injuries (29 Pre, 19 Post). There were no differences in age, sex, injury grade, or mechanism (P > .05). Postprotocol had decreased length of stay (P = .040), intensive care unit admissions (P = .015), urinary catheter use (P = .031), and ionizing radiation imaging (P < .001). CONCLUSION: These data suggest improved outcomes and resource utilization following implementation of a nonoperative management protocol of pediatric isolated blunt renal injuries.

Extended sternotomy with lateral neck incision: An alternative approach for children with large apical chest masses with thoracic inlet involvement.

Pediatric tumors in the apex of the thoracic cavity are often diagnosed late due to the absence of symptoms. These tumors can be quite large at presentation with involvement of the chest wall, sympathetic chain, spine, and aortic arch. The tumors can also extend into the thoracic inlet and encircle the brachial plexus. Depending on the diagnosis, treatment may involve chemotherapy with subsequent surgery or require primary resection. Optimal exposure to resect large apical tumors with thoracic inlet extension is a surgical challenge. To date, several surgical techniques have been described to resect these tumors - including both anterior and posterior thoracic approaches. Each of these techniques can be limited by inadequate exposure of the mass. We describe an alternative approach to surgical resection of these masses that employs an extended sternotomy with a lateral neck incision. This report details two successful resections of large left apical masses with thoracic inlet involvement in children using this technique (Level of evidence 4).

North American survey on the post-neuroimaging management of children with mild head injuries.

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.

Traumatic colorectal injuries in children: The National Trauma Database experience.

PURPOSE: We sought to utilize a nationwide database to characterize colorectal injuries in pediatric trauma. METHODS: The National Trauma Database (NTDB) was queried for all patients (age≤14years) with colorectal injuries from 2013 to 2014. We stratified patients by demographics and measured outcomes. We analyzed groups based on mechanism, colon vs rectal injury, as well as colostomy creation. Statistical analysis was conducted using t-test and ANOVA for continuous variables as well as chi-square for continuous variables. RESULTS: There were 534 pediatric patients who sustained colorectal trauma. The mean ISS was 15.6±0.6 with an average LOS of 8.5±0.5days. 435 (81.5%) were injured by blunt mechanism while 99 (18.5%) were injured by penetrating mechanism. There were no differences between age, ISS, complications, mortality, LOS, ICU LOS, and ventilator days between blunt and penetrating groups. Significantly more patients in the penetrating group had associated small intestine and hepatic injuries as well as underwent colostomies. Patients with rectal injuries (25.7%) were more likely to undergo colonic diversion (p<0.0001), but also had decreased mortality (p=0.001) and decreased LOS (p=0.01). Patients with colostomies (9.9%) had no differences in age, ISS, GCS, transfusion of blood products, and complications compared to patients who did not receive a colostomy. Despite this, colostomy patients had significantly increased hospital LOS (12.1±1.8 vs 8.2±0.5days, p=0.02) and ICU LOS (9.0±1.7 vs 5.4±0.3days, p=0.02). CONCLUSION: Although infrequent, colorectal injuries in children are associated with considerable morbidity regardless of mechanism and may be managed without fecal diversion. LEVEL OF EVIDENCE: III. STUDY TYPE: Epidemiology.

Missed injuries and unplanned readmissions in pediatric trauma patients.

BACKGROUND: We sought to determine the incidence and characteristics of missed injuries and unplanned readmissions at a Level-1 pediatric trauma center. METHODS: We conducted a retrospective review of all trauma patients who presented to our ACS-verified Level-1 pediatric trauma center from 2009 to 2014. RESULTS: Overall, there were 27 readmissions and 27 missed injuries (0.38%). Patients who were unplanned readmissions had a greater Injury Severity Score (ISS) (8.6 vs 5.2, p=0.03), had longer hospitalizations (4.9 vs 2.5days, p=0.02), and were more likely to have required operative intervention (51.9% vs 32.3%, p=0.04). Similarly, patients identified with missed injuries had a higher ISS (15.2 vs 5.2, p<0.0001), greater length of stay (12.7 vs 2.5days, p<0.0001), and were also more likely to be intubated (25.9% vs 3.6%, p<0.0001) or require critical care (48.1% vs 10.3%, p<0.0001). Seven missed injuries were in patients who were deemed nonaccidental trauma (25.9%) and significantly altered their hospital course while 10 patients (37%) required operative intervention. On multivariate analysis, only ISS was found to be an independent risk factor for readmissions and missed injuries. CONCLUSIONS: Missed injuries and unplanned readmissions were rare occurrences among our pediatric patient population. These events, however, did result in longer hospitalizations and additional procedures. Patients with multisystem injuries and compromised physical exam are at higher risk. LEVEL OF EVIDENCE: IV.

Early impact of American College of Surgeons-verification at a level-1 pediatric trauma center.

PURPOSE: The purpose of this study was to determine the early impact of American College of Surgeons (ACS)-level-1 verification at an established pediatric trauma center. METHODS: Following IRB approval, we conducted a retrospective review of all trauma patients treated at a level-1 state-designated pediatric trauma center, comparing 2years before (2009-2010) and 2years after ACS-verification (mid-2012-mid-2014). Statistical significance was defined as p<0.05. RESULTS: Before verification, 2105 trauma patients were admitted to our institution compared to 2248 patients admitted after ACS-verification. Overall, there were no differences in mean age or injury severity score (ISS). Hospital and pediatric intensive care unit (PICU) length of stay (LOS), ventilator days, and mortality were also unchanged. Through incorporation of clinical pathways, the number of PICU admissions decreased significantly from 17.2% to 13.7%. Morbidity in the form of hospital-acquired conditions (HACS) also decreased following verification, most notably through reduction in pneumonias. Decubitus ulcers and nosocomial infections reached their nadir by 2014. Hospital readmission rates also decreased. CONCLUSIONS: ACS-verification at a level-1 pediatric trauma center is associated with an immediate benefit to patient outcomes. Enhanced tracking and institutional policy changes resulted in fewer HACS. Further cost-saving and improved outcomes because of ACS-verification may be amplified over time.

Firearm injuries in the pediatric population: A tale of one city.

BACKGROUND: Firearm-related injuries are a significant cause of morbidity and mortality in children. To determine current trends and assess avenues for future interventions, we examined the epidemiology and outcome of pediatric firearm injuries managed at our region's two major pediatric trauma centers. METHODS: Following institutional review board approval, we conducted a 5-year retrospective review of all pediatric firearm victims, 16 years or younger, treated at either of the region's two Level 1 pediatric trauma centers, St. Louis Children's Hospital and Cardinal Glennon Children's Medical Center. RESULTS: There were 398 children treated during a 5-year period (2008-2013) for firearm-related injuries. Of these children, 314 (78.9%) were black. Overall, there were 20 mortalities (5%). Although most (67.6%) patients were between 14 years and 16 years of age, younger victims had a greater morbidity and mortality. The majority of injuries were categorized as assault/intentional (65%) and occurred between 6:00 pm and midnight, outside the curfew hours enforced by the city. Despite a regional decrease in the overall incidence of firearm injuries during the study period, the rate of accidental victims per year remained stable. Most accidental shootings occurred in the home (74.2%) and were self-inflicted (37.9%) or caused by a person known to the victim (40.4%). CONCLUSION: Despite a relative decrease in intentional firearm-related injuries, a constant rate of accidental shootings suggest an area for further intervention. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level IV.

Enteral nutrition in neonatal and pediatric extracorporeal life support: a survey of current practice.

PURPOSE: The purpose of this study was to characterize enteral (EN) nutrition practices in neonatal and pediatric patients receiving extracorporeal life support (ECLS). METHODS: A Web-based survey was administered to program directors and coordinators of Extracorporeal Life Support Organization centers providing neonatal and pediatric ECLS. The survey assessed patient and clinical factors relating to the administration of EN. RESULTS: A total of 122 responses (122/521, 23.4%) from 96 institutions (96/187; 51.3%) were received. One hundred fifteen provided neonatal or pediatric ECLS, and 84.2% reported utilizing EN during ECLS. 55% and 71% of respondents provide EN 'often' or 'always' for venoarterial and venovenous ECLS, respectively. EN was reported as given 'often' or 'always' by 24% with increased vasopressor support, 53% with "stable" vasopressor support, and 60% with weaning of vasopressor support. Favorable diagnosis for providing EN includes respiratory distress syndrome, pneumonia, asthma, trauma/post-operative, pulmonary hemorrhage, and infectious cardiomyopathy. Vasopressor requirement and underlying diagnosis were the primary or secondary determinant of whether to provide EN 81% and 72% of the time. 38% reported an established protocol for providing EN. CONCLUSION: EN support is common but not uniform among neonatal and pediatric patients receiving ECLS. ECLS mode, vasopressor status, and underlying diagnosis play an important role in the decision to provide EN.

Pectus carinatum.

PURPOSE OF REVIEW: Pectus carinatum has been termed the undertreated chest wall deformity. Recent advances in patient evaluation and management, including the development of nonoperative bracing protocols, have improved the care of children with this condition. RECENT FINDINGS: Recent evidence confirms that children with pectus carinatum have a disturbed body image and a reduced quality of life. Treatment has been shown to improve the psychosocial outcome of these patients. SUMMARY: Patients with pectus carinatum are at risk for a disturbed body image and reduced quality of life. Until recently, treatment required surgical reconstruction. A growing body of literature, however, now supports the use of orthotic bracing as a nonoperative alternative in select patients. This article reviews the current literature and describes the evaluation and management of children with pectus carinatum deformity.

Chromosome 2p15p16.1 microdeletion syndrome: 2.5 Mb deletion in a patient with renal anomalies, intractable seizures and a choledochal cyst.

Chromosome 2p15p16.1 microdeletion is an emerging syndrome recently described in patients with dysmorphic facial features, congenital microcephaly, mild to moderate developmental delay and neurodevelopmental abnormalities. Using clinical ultra-high resolution Affymetrix SNP 6.0 array we identified a de novo interstitial deletion on the short arm of chromosome 2, spanning approximately 2.5 Mb in the cytogenetic band position 2p15p16.1, in a female infant with characteristic features of 2p15p16.1 deletion syndrome including severe developmental delay, congenital microcephaly, intractable epilepsy, and renal anomalies, as well as a congenital choledochal cyst which has not been previously reported in other patients with this cytogenetic defect. We further redefined the previously reported critical region, supporting the presence of a newly recognized microdeletion syndrome involving haploinsufficiency of one or more genes deleted within at least a 1.1 Mb segment of the 2p15p16.1 region.

Intussusception in children: cost-effectiveness of ultrasound vs diagnostic contrast enema.

PURPOSE: The aim of the study was to compare the cost-effectiveness of different imaging strategies for the diagnosis of pediatric intussusception using a decision analytic model. METHODS: A Markov decision model was constructed to model effects of radiation exposure at the time of intussusception in a hypothetical cohort of 2-year-old children. The 2 strategies compared were ultrasound followed conditionally by contrast enema (US/CE) vs contrast enema (CE) alone. The model simulated short-term and long-term outcomes of the patients, calculating the average quality-adjusted life years (QALYs) and health care costs associated with each arm. RESULTS: The use of ultrasound as a first-line diagnostic modality would result in a decrease of 79.3 and 59.7 cases of radiation-induced malignancy per 100,000 male and female children evaluated, respectively. For male and female children with intussusception, US/CE was both the most costly initial imaging strategy and the most effective compared with CE. The incremental cost-effectiveness ratios of US/CE to CE was $70,100 (boy) and $92,227 (girl) per quality-adjusted life years gained. CONCLUSIONS: In a Markov decision model of pediatric acute intussusception, initial US/CE was both the most costly and the most effective strategy.

The significance of first rib fractures in children.

PURPOSE: The purpose of the study was to determine if first rib fractures are associated with an increased incidence of thoracic vascular injury in pediatric patients. METHODS: The medical records of all children diagnosed with a first rib fracture or a central vascular injury after blunt trauma treated at a state-designated level 1 pediatric trauma center from 2000 to 2009 were reviewed. RESULTS: Thirty-three children (0.27% of patients; mean age, 10.9 ± 0.9 years) were identified with either a first rib fracture or thoracic vascular injury owing to blunt trauma. Thirty-two children had a first rib fracture, and only 1 child (3%) had significant thoracic vascular injury. Mediastinal abnormalities (indistinct aortic knob) were identified in 3 children, 2 with first rib fracture on initial chest radiograph. Despite a normal cardiovascular examination result, 25 (74%) children with a normal mediastinum on screening chest radiograph underwent computed tomography. No child with a normal mediastinum on initial chest radiograph was found to have associated intrathoracic injuries requiring further intervention. In children with first rib fractures and a normal mediastinum by screening chest x-ray, the negative predictive value for thoracic vascular injury was 100%. CONCLUSIONS: Children with first rib fractures without mediastinal abnormality on chest radiograph require no further workup for thoracic vascular injury.