Impact of a statewide computed tomography scan educational campaign on radiation dose and repeat CT scan rates for transferred injured children.

PURPOSE: Research demonstrates that children receive twice as much medical radiation from Computed Tomography (CT) scans performed at non-pediatric facilities as equivalent CTs performed at pediatric trauma centers (PTCs). In 2014, AFMC outreach staff educated Emergency Department (ED) staff on appropriate CT imaging utilization to reduce unnecessary medical radiation exposure. We set out to determine the educational campaign's impact on injured children received radiation dose. METHODS: All injured children who underwent CT imaging and were transferred to a Level I PTC during 2010 to 2013 (pre-campaign) and 2015 (post-campaign) were reviewed. Patient demographics, mode of transportation, ED length of stay, scanned body region, injury severity score, and trauma center level were analyzed. Median effective radiation dose (ERD) controlled for each variable, pre-campaign and post-campaign, was compared using Wilcoxon rank sum test. RESULTS: Three hundred eighty-five children under 17 years were transferred from 45 and 48 hospitals, pre- and post-campaign. Most (43%) transferring hospitals were urban or critical access hospitals (30%). Pre- and post-campaign patient demographics were similar. We analyzed 482 and 398 CT scans pre- and post-campaign. Overall, median ERD significantly decreased from 3.80 to 2.80. Abdominal CT scan ERD declined significantly from 7.2 to 4.13 (P-value 0.03). Head CT scan ERD declined from 3.27 to 2.45 (P-value < 0.0001). CONCLUSION: A statewide, CT scan educational campaign contributed to ERD decline (lower dose scans and fewer repeat scans) among transferred injured children seen at PTCs. State-level interventions are feasible and can be effective in changing radiology provider practices.

Ultra-Low-Dose Computed Tomography Protocol for Preoperative Evaluation in Children With Craniofacial Anomalies.

PURPOSE: Preoperative three-dimensional computed tomography is currently the gold standard imaging modality in patients with craniofacial anomalies. In these patients, bone structural evaluation is paramount for surgical planning and evaluation of brain parenchyma is often secondary. With the significant complexity of these patients, a majority of patients undergo multiple Computed Tomography (CT) studies from infancy into adulthood. This study presents an ultra-low-dose CT protocol that limits the radiation exposure per CT scan in patients with craniofacial anomalies. MATERIAL AND METHODS: A total of 200 consecutive patients who underwent head CT for preoperative evaluation of craniofacial anomalies at Tertiary Children's Hospital were included in the study. The kVp, (KiloVoltage Peak) mA (milliAnperage), CT dose index (CTDI), and dose-length product (DLP) were documented from the dose page. Patients were stratified based on age for determining age specific effective dose and for age matched comparison. The age specific effective dose was derived by using the established conversion factor as described in the paper. (1) Standard t test was performed to determine the statistical significance of radiation dose reduction. The Institutional Review Board approved the study and data was collected from 2012-2014. FINDINGS: Of the 200 patients assessed in our study, 90 patients had low-dose CT scans and 110 patients had ultra-low-dose CT scans of the head. All patients had diagnostic quality CT studies. The low-dose CT was performed at 120 kVp and 100 mA. The ultra-low-dose CT was performed at 80 kVp and fixed 80 mA. The minimum, maximum and mean effective dose before the introduction of the ultra-low-dose protocol was 0.8 mSv, 6.9 mSV and 2.82 mSv. The minimum, maximum and mean effective dose after the introduction of the ultra-low-dose protocol was 0.6 mSv, 3.8 mSV, and 1.37 mSv. The reduction in the effective radiation dose was statistically significant (standard t test; P = 0.0001). CONCLUSION: Compared to the regular low-dose protocol, the ultra-low-dose CT protocol provided appropriate diagnostic images with a significantly decreased radiation dose.

Injured Children Receive Twice the Radiation Dose at Nonpediatric Trauma Centers Compared With Pediatric Trauma Centers.

BACKGROUND: Use of cranial CT scans in children has been increasing, in part due to increased awareness of sports-related concussions. CT is the largest contributor to medical radiation exposure, a risk factor for cancer. Long-term cancer risks of CT scans can be two to three times higher for children than for adults because children are more radiosensitive and have a longer lifetime in which to accumulate exposure from multiple scans. STUDY AIM: To compare the radiation exposure injured children receive when imaged at nonpediatric hospitals (NPHs) versus pediatric hospitals. METHODS: Injured children younger than 18 years who received a CT scan at a referring hospital during calendar years (CYs) 2010 and 2013 were included. Patient-level factors included demographics, mode of transportation, and Injury Severity Score, and hospital-level factors included region of state, radiology services, and hospital type and size. Our primary outcome of interest was the effective radiation dose. RESULTS: Four hundred eighty-seven children were transferred to the pediatric trauma center during CYs 2010 and 2013, with a median age of 7.2 years (interquartile range 5-13). The median effective radiation dose received at NPHs was twice that received at the pediatric trauma center (3.8 versus 1.6 mSv, P < .001). Results were confirmed in independent and paired analyses, after controlling for mode of transportation, emergency department disposition, level of injury severity, and at the NPH trauma center level, hospital type, size, region, and radiology services location. CONCLUSION: NPHs have the potential to substantially reduce the medical radiation received by injured children. Pediatric CT protocols should be considered.

The Clinical Impact of a Web-Based Image Repository on Radiation Exposure in Injured Children.

PURPOSE: The long-term cancer risks for children exposed to radiologic images can be two to three times higher than for adults because children are more sensitive to radiation and have a longer lifetime in which to accumulate exposure from CT scans. Injured children often undergo repeat CT imaging if they are transferred from non-pediatric hospitals to a Level I pediatric trauma center (PTC). This study determined the impact of a statewide web-based image repository (WBIR) on repeat imaging among transferred injured children. METHODS: All injured children who underwent CT imaging and were transferred to the PTC in 2010 (pre-WBIR) and 2013 (post-WBIR) were included. Patient-level factors studied included demographics, body region of scan, Injury Severity Score, and Emergency Department (ED) disposition. Change from pre to post on rate of repeat imaging was assessed. RESULTS: Two hundred fifty-four and 233 children, with a median age of 7.3 years, were transferred to the Children's Hospital in 2010 and 2013, respectively. Repeat imaging levels at the PTC were lower post-WBIR than pre-WBIR (20% versus 33%, odds ratio [OR] 0.54, P = .005). Images of the head decreased most significantly (60% versus 33%, OR 0.33). Images performed at Level II and III trauma centers were repeated less often after WBIR. CONCLUSIONS: The WBIR significantly reduced repeat imaging among injured children transferred to a PTC, especially children transferred from Level II and Level III trauma centers, children with lower-acuity injuries, and children with initial scans of the head. Radiation savings are expected to be beneficial to children.

Do prehospital criteria optimally assign injured children to the appropriate level of trauma team activation and emergency department disposition at a level I pediatric trauma center?

PURPOSE: To examine the association of prehospital criteria with the appropriate level of trauma team activation (TTA) and emergency department (ED) disposition among injured children at a level I pediatric trauma center. METHODS: Injured children younger than 15 years and transported by emergency medical services (EMS) from the scene of injury between January 1, 2008 and December 31, 2011 were identified using the institution's trauma registry. Logistic regression was used to study the main outcomes of interest, full TTA (FTTA) and ED disposition. RESULTS: Out of 3,213 children, 1,991 were eligible and analyzed. Only 279 children initiated the FTTA and 73.9% were admitted. Having a chest injury, abnormal heart rate or Glasgow Coma Scale less than 9 (GCSLT9) in the field was associated with higher odds of initiating the FTTA (odds ratio [OR] = 3.33, 95% confidence interval [CI] 1.54-7.20; OR = 2.59, CI 1.15-5.79 and OR = 2.67, CI 1.14-6.22, respectively). Children with the criteria above in addition to abdominal injury were more likely to be discharged to the ICU, OR or morgue compared to those without them. CONCLUSION: Children with GCSLT9, abnormal heart rate, chest and abdominal injury showed a strong association with FTTA and higher resource utilization.

Diagnostic radiation exposure in pediatric trauma patients.

BACKGROUND: The amount of imaging studies performed for disease diagnosis has been rapidly increasing. We examined the amount of radiation exposure that pediatric trauma patients receive because they are an at-risk population. Our hypothesis was that pediatric trauma patients are exposed to high levels of radiation during a single hospital visit. METHODS: Retrospective review of children who presented to Johns Hopkins Pediatric Trauma Center from July 1, 2004, to June 30, 2005. Radiographic studies were recorded for each patient and doses were calculated to give a total effective dose of radiation. All radiographic studies that each child received during evaluation, including any associated hospital admission, were included. RESULTS: A total of 945 children were evaluated during the study year. A total of 719 children were included in the analysis. Mean age was 7.8 (±4.6) years. Four thousand six hundred three radiographic studies were performed; 1,457 were computed tomography (CT) studies (31.7%). Average radiation dose was 12.8 (±12) mSv. We found that while CT accounted for only 31.7% of the radiologic studies performed, it accounted for 91% of the total radiation dose. Mean dose for admitted children was 17.9 (±13.8) mSv. Mean dose for discharged children was 8.4 (±7.8) mSv (p<0.0001). Burn injuries had the lowest radiation dose [1.2 (±2.6) mSv], whereas motor vehicle collision victims had the highest dose [18.8 (±14.7) mSv]. CONCLUSION: When the use of radiologic imaging is considered essential, cumulative radiation exposure can be high. In young children with relatively long life spans, the benefit of each imaging study and the cumulative radiation dose should be weighed against the long-term risks of increased exposure.

Gastrointestinal ramifications of the cloacal exstrophy complex: a 44-year experience.

PURPOSE: Cloacal exstrophy is a rare and complex congenital anomaly requiring coordination among multiple pediatric subspecialties. There is currently no consensus regarding the fate and function of the hindgut, which plays an integral role in patients' long-term gastrointestinal health and genitourinary reconstruction. METHODS: A retrospective chart review was performed evaluating 77 patients with cloacal exstrophy treated during the previous 44 years at our institution. RESULTS: Seventy-seven patients with cloacal exstrophy were treated between 1965 and 2008. Sixty-five were white, 6 were African American, 3 were Asian, and 3 were Hispanic. Genotypes included 44 XY, 32 XX, and 1 XYY. Fifty-one were reared as females and 26 as males. The hindgut length was 2 to 5 cm in 11 patients, 6 to 10 cm in 18 patients, 11 to 15 cm in 6 patients, 16 to 20 cm in 7 patients, and greater than 20 cm in 2 patients. The hindgut length was unknown in 33 patients. Forty-seven patients had tubularization of the cecal plate with an end colostomy, and 30 patients had an ileostomy placed for bowel diversion purposes. Four patients had short gut syndrome. Thirty-one patients had genitourinary reconstruction, 12 using small bowel and 19 using colon. Eight patients had hindgut pull-through procedures. CONCLUSION: Gastrointestinal ramifications of the cloacal exstrophy complex include the occurrence of short gut syndrome and significant fluid and electrolyte derangements in patients receiving an ileostomy for initial intestinal management. This has caused a paradigm shift of initial intestinal management to tubularization of the cecal plate with end colostomy placement. This shift has eliminated the occurrence of short gut syndrome and enabled patients to be candidates for intestinal pull-through procedure if these patients are able to form solid stool, have a reasonable degree of pelvic neuromuscular development, and are able to comply with a bowel management program.

Pectus bar repair of pectus excavatum in patients with connective tissue disease.

PURPOSE: Few studies address the surgical correction of pectus excavatum (PE) in patients with connective tissue disease (CTD). We have identified the preoperative characteristics, postoperative complications, and outcomes of patients with CTD undergoing bar repair of PE and compared these outcomes to a control group without CTD. METHODS: A retrospective review of patients undergoing primary repair of PE with a bar procedure from 1997 to 2006 identified 22 patients with CTD. Of those, 20 (90.9%) had their bars removed. We identified 223 patients of similar age without CTD whose bars were removed. Data collected included demographics, preoperative symptoms, operative characteristics, and postoperative outcomes. RESULTS: Among those with CTD, the median age at repair was 15.5 years, with a mean pectus index of 4.0 +/- 1.4. Three patients (13.6%) experienced bar displacement or upper sternal depression requiring surgical revision. Only 1 patient recurred after bar removal. Rates of bar displacement, upper sternal depression, and recurrence were not statistically different than those in the comparison group. CONCLUSIONS: Patients with CTD benefit from primary bar repair of PE and experience excellent operative outcomes after repair, with complication rates being no different than those found in similarly aged control patients.

Splenectomy in hereditary spherocytosis: Review of 1,657 patients and application of the pediatric quality indicators.

OBJECTIVE: The objective of the present study is to profile the outcome and safety of pediatric patients undergoing splenectomy with hereditary spherocytosis (HS) using a nationwide sample and the Agency for Healthcare Research and Quality (AHRQ) Pediatric Quality Indicators (PDIs). PATIENTS AND METHODS: A retrospective cross-sectional descriptive analysis of a non-overlapping combination of the National Inpatient Sample (NIS), and Kids' Inpatient Database (KID) databases (1988-2004) were performed. These combined databases contain information from nearly 93 million discharges in the United States. Children with an age at admission of <18 years of age and HS (ICD-9 diagnosis code of 282.0) who underwent total splenectomy (ICD-9 procedure code of 41.5) were identified. Variables of gender, race, co-existing diagnoses, hospital type, and charges adjusted to 2006 dollars, length of stay, inpatient mortality, and complications were collected. PDIs were identified for each patient by linking the data obtained from the NIS and KID databases with the PDIs using the AHRQ Quality Indicators Wizard. RESULTS: Splenectomy for HS was associated with low morbidity and mortality. Accompanying cholecystectomy and/or appendectomy appeared to be safely performed at the same operation. Of the 13 PDIs identified by AHRQ as potentially avoidable adverse events, none were observed to occur in more than 1% of the patients. CONCLUSIONS: Based on the results of this study, splenectomy in patients with HS appears safe and to result in a minimal number of potentially preventable complications as identified by the AHRQ PDIs. We have successfully demonstrated use of the indicators to aid in the analysis of a specific surgical procedure within a subset of the pediatric population.

Prehospital predictors of risk for pelvic fractures in pediatric trauma patients.

Pelvic fractures are uncommon in children, but can occur as a result of high-energy impact injuries to the lower torso in association with blunt trauma. Pelvic fractures can be associated with significant morbidity while the work-up and treatment for these injuries is costly. The aim was to identify risk factors that help determine which pediatric trauma patients are at highest risk of sustaining a pelvic fracture to aid in the development of criteria for the targeted use of pelvic radiographic imaging. A retrospective analysis was conducted using the only pediatric trauma registry in the state of Maryland, located at The Johns Hopkins Children's Center. All blunt trauma patients who were younger than 15 years of age from 1990 to 2005 were included in the analysis (n = 13,360) with a final diagnosis of pelvic fracture as the primary outcome of interest. Comparisons were made using Pearson's chi-square for categorical and the Mann-Whitney rank sum test for non-normally distributed variables. Pelvic fractures following blunt trauma in children are associated with age, race, place and mechanism of injury. Compared to children 4 years and younger, pelvic fractures were more likely to occur in children aged 5-9 years (OR = 3; P = 0.000), as well as 10-14 years (OR = 5; P = 0.000). Compared to blunt trauma injuries from falls, children who were struck by vehicles or who were occupants in motor vehicle crashes (MVC) were six times (P = 0.000) and twice (P = 0.02) as likely to sustain a pelvic fracture, respectively. Four factors were demonstrated by this study to be significantly associated with pediatric pelvic fractures: being Caucasian, age between 5 and 14 years, being struck as a pedestrian or a motor vehicle crash occupant. Identification of these factors may aid clinicians in selecting patients who are at highest risk for pelvic fracture and may benefit most from pelvic radiography.

Lorenz bar repair of pectus excavatum in the adult population: should it be done?

BACKGROUND: Although extensive literature exists on the Lorenz bar repair of pectus excavatum (PE) in pediatric patients, few data examine this repair in adults or compare long-term outcomes in adults with the pediatric population. We identified the preoperative characteristics, postoperative complications, and outcomes of adult patients undergoing Lorenz bar repair of PE who had bar removal and compared these outcomes with a pediatric population undergoing the same procedure. METHODS: A retrospective review (1997 to 2006) of patients undergoing primary repair of PE with a Lorenz bar identified 107 individuals aged older than 18 and 137 patients aged 6 to 14, of whom 52 and 80 had their bar(s) removed, respectively. These latter patients were the focus of analysis. Data collected included demographics, preoperative symptoms, operative characteristics, and postoperative outcomes. RESULTS: The median (interquartile range, IQR) age and pectus index of adult patients (81% men) at the time of repair was 23 (18 to 30) years and 3.8 (3.5 to 4.3), respectively. In 2 adults (3.9%), PE recurred after bar removal, and 6 (11.6%) required surgical revision for bar displacement or upper sternal depression. These rates of complications were similar to those found in children undergoing Lorenz bar repair of PE at our institution. CONCLUSIONS: Lorenz bar placement to correct PE in adults can be performed safely and effectively, with rates of bar displacement, sternal depression, recurrence, and reoperation that are not statistically different than those found in a younger pediatric population.

Upper sternal depression following Lorenz bar repair of pectus excavatum.

An upper sternal depression following Lorenz bar repair of pectus excavatum (PE) represents a partial recurrence and poses a difficult problem for the surgeon. There is no published experience detailing the management options or best course of therapy for this complication. This study presents our institutional experience in treating eight patients with this specific subtype of recurrence and we discuss intraoperative considerations which aid in the identification and better management of this deformity. A retrospective review (1997-2006) of patients undergoing primary repair of PE with a Lorenz bar procedure identified eight patients who experienced upper sternal depression with the bar still in place following initial repair of PE. All patients were revised with the insertion of a second bar to elevate the upper sternal depression. Data collected for each patient included demographics, preoperative symptoms, operative characteristics, and postoperative outcomes. The mean age at the time of Lorenz bar repair and surgical revision was 20.8 +/- 9.5 and 21.5 +/- 10.1 years, respectively. A majority of patients (87.5%) were male. The mean time to reoperation was 23.8 +/- 11.8 months. Following this second procedure, no patient has experienced bar displacement, recurrence of the upper sternal depression, or has required a third procedure. Our limited experience supports the use of a second Lorenz bar in the treatment of upper sternal depression after bar correction of a PE deformity. Appropriate recognition and treatment of this entity will advance patient outcomes and satisfaction after surgery for PE deformities.

Risk stratification of 4344 patients with gastroschisis into simple and complex categories.

BACKGROUND: Gastroschisis is a congenital full-thickness abdominal wall defect characterized by the protrusion of intraabdominal organs outside the abdominal domain that requires surgical management in the early neonatal period. The goal of this study was to validate a previous risk stratification classification of infants born with this defect. METHODS: A retrospective analysis of a nonoverlapping combination of the databases National Inpatient Sample and Kids' Inpatient Database (1988-2003) was performed. These combined databases contain information from nearly 93 million discharges in the United States. Infants with gastroschisis were identified by an International Classification of Diseases, Ninth Revision procedure code of 54.71 (repair of gastroschisis) and an age at admission of less than 8 days. Infants were divided into simple and complex categories based on the absence or presence of intestinal atresia, stenosis, perforation, necrosis, or volvulus. Variables of sex, race, geographic region, coexisting diagnoses, hospital type and charges adjusted to 2005 dollars, length of stay, inpatient mortality, and complications were collected. Comparison between the 2 groups was performed using Pearson chi2 for categorical outcomes and the Kruskal-Wallis test for non-normally distributed continuous variables. RESULTS: A total of 4344 infants with gastroschisis were identified and divided into simple and complex categories. Simple gastroschisis represented 89.1% (n = 3870) of the group, whereas 10.9% (n = 474) had complex disease. Simple and complex patients differed in coexisting cardiac disease (8.3% vs 11.8%, P = .01), hospital type (78.7% vs 84.1% treated at urban teaching centers, P < .01), median length of stay (28 vs 67 days, P < .01), median inflation-adjusted hospital charges ($90,788 vs $197,871; P < .01), and inpatient mortality (2.9% vs 8.7%, P < .01). Gastrointestinal (14.4% vs 83.5%, P < .01), respiratory (2.6% vs 4.6%, P = .01), and infectious disease complications (24.3% vs 45.4%, P < .01) also differed between the groups. CONCLUSIONS: These data use the largest data set to date to validate the risk stratification of infants with gastroschisis. This analysis improves the characterization and understanding of clinical subsets of infants in whom this congenital condition is diagnosed.

Development and validation of a risk stratification index to predict death in gastroschisis.

BACKGROUND: Gastroschisis is a rare congenital anomaly, the improved surgical management of which has contributed to a survival rate greater than 90%. Development of an accurate risk stratification system to help identify the subset of patients at greatest risk for death may lead to further improvements in outcome. METHODS: Infants with gastroschisis were identified from 16 years of the National Inpatient Sample database and the Kids' Inpatient Database using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure code 54.71 (repair of gastroschisis) and an age of less than 8 days. Logistic regression analysis determined which coexisting diagnoses were significantly associated with death. Odds ratios from the logistic regression model were simplified and used as weighting factors to create an additive index. The index was validated using the 2003 Kids' Inpatient Database data set. RESULTS: Intestinal atresia, necrotizing enterocolitis, rare cardiac anomalies, and lung hypoplasia were strongly associated with death and used to create a scoring system with a potential range of 0 to 10. Every point increase on the scale of gastroschisis risk stratification index is associated with a 95% relative increase in the likelihood of death. CONCLUSION: We have developed a novel index, which is superior to previous classification systems in identifying patients with gastroschisis who are at highest risk for death.