Pediatric Mild Traumatic Brain Injury: Who Can Be Managed at a Non-pediatric Trauma Center Hospital? A Systematic Review of the Literature.

BACKGROUND: Pediatric traumatic brain injury (TBI) affects about 475,000 children in the United States annually. Studies from the 1990s showed worse mortality in pediatric TBI patients not transferred to a pediatric trauma center (PTC), but did not examine mild pediatric TBI. Evidence-based guidelines used to identify children with clinically insignificant TBI who do not require head CT were developed by the Pediatric Emergency Care Applied Research Network (PECARN). However, which patients can be safely observed at a non-PTC is not directly addressed. METHODS: A systematic review of the literature was conducted, focusing on management of pediatric TBI and transfer decisions from 1990 to 2020. RESULTS: Pediatric TBI patients make up a great majority of preventable transfers and admissions, and comprise a significant portion of avoidable costs to the health care system. Majority of mild TBI patients admitted to a PTC following transfer do not require ICU care, surgical intervention, or additional imaging. Studies have shown that as high as 83% of mild pediatric TBI patients are discharged within 24 hrs. CONCLUSIONS: An evidence-based clinical practice algorithm was derived through synthesis of the data reviewed to guide transfer decision. The papers discussed in our systematic review largely concluded that transfer and admission was unnecessary and costly in pediatric patients with mild TBI who met the following criteria: blunt, no concern for NAT, low risk on PECARN assessment, or intermediate risk on PECARN with negative imaging or imaging with either isolated, nondisplaced skull fractures without ICH and/or EDH, or SDH <0.3 cm with no midline shift.

Burden of Respiratory Syncytial Virus Hospitalizations in Canada.

Objective: To examine the socioeconomic burden of respiratory syncytial virus (RSV) disease for Canadian infants hospitalized for the condition. Data and Methods: The descriptive study used data collected in Alberta, Canada, during 2 consecutive RSV seasons. Infants (<1 year of age) were included if they had not received palivizumab and were hospitalized with a confirmed diagnosis of RSV. Hospitalization resource use and parental time burden, out-of-pocket costs, lost work productivity, and stress and anxiety were assessed. Results: 13.4% of all infants (n = 67) had intensive care unit (ICU) admission, and average ICU stay for these infants was 6.5 days. Families had average out-of-pocket expenses of 736.69 Canadian dollars (CAD $), and the average time both parents spent in hospital was nearly 7 days (164.0 hours). For working parents (n = 43), average absenteeism was 49% and overall work impairment was 77.8%. Parents also exhibited significant parental stress (3.6 on the Parental Stressor Scale: 43.9 state anxiety and 36.9 trait anxiety scores). Conclusions: Results indicate a high burden associated with the hospitalization of an infant due to RSV disease in terms of resource use, time, productivity, costs, and stress, even among a population of infants not considered to be at risk for the condition.

Feasibility of the Enhancing Participation In the Community by improving Wheelchair Skills (EPIC Wheels) program: study protocol for a randomized controlled trial.

BACKGROUND: Many older adults rely on a manual wheelchair for mobility but typically receive little, if any, training on how to use their wheelchair effectively and independently. Standardized skill training is an effective intervention, but limited access to clinician trainers is a substantive barrier. Enhancing Participation in the Community by Improving Wheelchair Skills (EPIC Wheels) is a 1-month monitored home training program for improving mobility skills in older novice manual wheelchair users, integrating principles from andragogy and social cognitive theory. The purpose of this study is to determine whether feasibility indicators and primary clinical outcome measures of the EPIC Wheels program are sufficiently robust to justify conducting a subsequent multi-site randomized controlled trial. METHODS: A 2 × 2 factorial randomized controlled trial at two sites will compare improvement in wheelchair mobility skills between an EPIC Wheels treatment group and a computer-game control group, with additional wheelchair use introduced as a second factor. A total of 40 community-dwelling manual wheelchair users at least 55 years old and living in two Canadian metropolitan cities (n = 20 × 2) will be recruited. Feasibility indicators related to study process, resources, management, and treatment issues will be collected during data collection and at the end of the study period, and evaluated against proposed criteria. Clinical outcome measures will be collected at baseline (pre-randomization) and post-intervention. The primary clinical outcome measure is wheelchair skill capacity, as determined by the Wheelchair Skills Test, version 4.1. Secondary clinical outcome measures include wheelchair skill safety, satisfaction with performance, wheelchair confidence, life-space mobility, divided-attention, and health-related quality of life. DISCUSSION: The EPIC Wheels training program offers several innovative features. The convenient, portable, economical, and adaptable tablet-based, home program model for wheelchair skills training has great potential for clinical uptake and opportunity for future enhancements. Theory-driven design can foster learning and adherence for older adults. Establishing the feasibility of the study protocol and estimating effect size for the primary clinical outcome measure will be used to develop a multi-site randomized controlled trial to test the guiding hypotheses. TRIAL REGISTRATION: Clinical Trials NCT01740635.

Exaggerated intergroup bias in economical decision making games: differential effects of primary and secondary psychopathic traits.

Psychopathic personality traits are linked with selfish and non-cooperative responses during economical decision making games. However, the possibility that these responses may vary when responding to members of the in-group and the out-group has not yet been explored. We aimed to examine the effects of primary (selfish, uncaring) and secondary (impulsive, irresponsible) psychopathic personality traits on the responses of non-offending participants to the in-group and the out-group (defined in terms of affiliation to a UK University) across a series of economical decision making games. We asked a total of 60 participants to act as the proposer in both the dictator game and the ultimatum game. We found that across both tasks, those who scored highly for secondary psychopathic traits showed an elevated intergroup bias, making more generous offers toward members of the in-group relative to the out-group. An exaggerated intergroup bias may therefore represent a motivational factor for the antisocial behavior of those with elevated secondary psychopathic traits.

Advanced care nurse practitioners can safely provide sole resident cover for level three patients: impact on outcomes, cost and work patterns in a cardiac surgery programme.

OBJECTIVES: There are significant pressures on resident medical rotas on intensive care. We have evaluated the safety and feasibility of nurse practitioners (NPs) delivering first-line care on an intensive care unit with all doctors becoming non-resident. Previously, resident doctors on a 1:8 full-shift rota supported by NPs delivered first-line care to patients after cardiac surgery. Subsequently, junior doctors changed to a 1:5 non-resident rota and NPs onto a 1:7 full-shift rota provided first-line care. METHODS: A single centre before-and-after service evaluation on cardiac intensive care. KEY MEASURES FOR IMPROVEMENT: mortality rates, surgical trainee attendance in theatre and cost before and after the change. After-hour calls by NPs to doctors and subsequent actions were also audited after the change. RESULTS: The overall mortality rates in the 12 months before the change were 2.8 and 2.2% in the 12 months after (P = 0.43). The median [range] logistic EuroSCORE was 5.3 [0.9-84] before and 5.0 [0.9-85] after the change (P = 0.16). After accounting for the risk profile, the odds ratio for death after the change relative to before was 0.83, 95% confidence interval 0.41-1.69. Before the change, a surgical trainee attended theatre 467 of 702 (68%) cases. This increased to 539 of 677 (80%) cases after the change (P < 0.001). The annual cost of staffing the junior doctor and NP programme before the change was £933 344 and £764 691 after. In the year after the change, 192 after-hour calls were made to doctors. In 57% of cases telephone advice sufficed and doctors attended in 43%. CONCLUSIONS: With adequate training and appropriate support, resident NPs can provide a safe, sustainable alternative to traditional staffing models of cardiac intensive care. Training opportunities for junior surgeons increased and costs were reduced.

A model of the costs of community and nosocomial pediatric respiratory syncytial virus infections in Canadian hospitals.

BACKGROUND: Approximately one in 10 hospitalized patients will acquire a nosocomial infection (NI) after admission to hospital, of which 71% are due to respiratory viruses, including the respiratory syncytial virus (RSV). NIs are concerning and lead to prolonged hospitalizations. The economics of NIs are typically described in generalized terms and specific cost data are lacking. OBJECTIVE: To develop an evidence-based model for predicting the risk and cost of nosocomial RSV infection in pediatric settings. METHODS: A model was developed, from a Canadian perspective, to capture all costs related to an RSV infection hospitalization, including the risk and cost of an NI, diagnostic testing and infection control. All data inputs were derived from published literature. Deterministic sensitivity analyses were performed to evaluate the uncertainty associated with the estimates and to explore the impact of changes to key variables. A probabilistic sensitivity analysis was performed to estimate a confidence interval for the overall cost estimate. RESULTS: The estimated cost of nosocomial RSV infection adds approximately 30.5% to the hospitalization costs for the treatment of community-acquired severe RSV infection. The net benefits of the prevention activities were estimated to be equivalent to 9% of the total RSV-related costs. Changes in the estimated hospital infection transmission rates did not have a significant impact on the base-case estimate. CONCLUSIONS: The risk and cost of nosocomial RSV infection contributes to the overall burden of RSV. The present model, which was developed to estimate this burden, can be adapted to other countries with different disease epidemiology, costs and hospital infection transmission rates.

HISTORIQUE: Environ un patient hospitalisé sur dix contractera une infection d'origine nosocomiale (ION) après son hospitalisation, dont 71 % sont imputables à des virus respiratoires, y compris le virus respiratoire syncytial (VRS). Les ION sont inquiétantes et provoquent des hospitalisations prolongées. En général, les aspects économiques des ION sont décrits en termes généraux, et on ne possède pas de données précises sur leurs coûts. OBJECTIF: Élaborer un modèle fondé sur des données probantes pour prédire le risque et le coût des infections à VRS d'origine nosocomiale en milieu pédiatrique. MÉTHODOLOGIE: Les chercheurs ont élaboré un modèle, d'après une perspective canadienne, afin de saisir tous les coûts liés à une hospitalisation découlant d'une infection à VRS, y compris le risque et le coût d'une ION, les tests diagnostiques et le contrôle de l'infection. Toutes les données saisies étaient dérivées des publications. Les chercheurs ont effectué des analyses de sensibilité déterministe pour évaluer l'incertitude associée aux évaluations et pour explorer les répercussions de changements aux variables clés. Ils ont effectué une analyse de sensibilité probabiliste pour évaluer l'intervalle de confiance de l'évaluation globale des coûts. RÉSULTATS: Les coûts estimatifs de l'infection à VRS d'origine nosocomiale ajoutent environ 30,5 % aux frais d'hospitalisation pour traiter l'infection à VRS grave d'origine non nosocomiale. Les chercheurs ont évalué que les bénéfices nets des activités de prévention équivalaient à 9 % des coûts totaux liés au VRS. Les modifications aux taux estimatifs de transmission de l'infection en milieu hospitalier n'avaient pas de répercussions significatives sur l'évaluation des cas de base. CONCLUSIONS: Le risque et le coût de l'infection à VRS d'origine nosocomiale contribuent au fardeau global du VRS. Le présent modèle, qui a été élaboré pour évaluer ce fardeau, peut être adapté à d'autres pays selon d'autres épidémiologies de maladies, coûts et taux de transmission de l'infection en milieu hospitalier.

Trends in thyroid cancer demographics and surgical therapy in the United States.

BACKGROUND: The incidence of thyroid cancer is increasing. Our objective was to characterize the demographic pattern of this increase and to examine trends in surgical therapy for thyroid cancer. METHODS: Analysis of the SEER and NHDS databases was performed from 1974 to 2000 and from 1979 to 2004, respectively. Thyroid-related diagnoses were extracted, and thyroid cancer (ICD 193.X) were analyzed using the SAS statistical package. We compared the population-adjusted incidence of thyroid cancer and examined regional variations in the operative therapy for thyroid cancer. RESULTS: The incidence of thyroid cancer has increased during the past 26 years. This increase occurred predominantly in women and in the Northeastern and Southern United States, whereas there has been a decrease in thyroid cancers in the Midwest. Papillary cancer accounts for most of this increase. Total thyroidectomy (TT) is now the most common operation for thyroid cancer. No differences in the use of TT were observed based on hospital size or insurance status. CONCLUSION: The increasing incidence of thyroid cancer in the United States is predominantly in women. These results suggest that women are a high-risk group for developing thyroid cancer although men have higher stage disease.

Can histopathologic assessment of circumferential margin after preoperative pelvic chemoradiotherapy for T3-T4 rectal cancer predict for 3-year disease-free survival?

PURPOSE: This study set out to determine the impact of a positive circumferential resection margin (CRM) (R1-R2) and pathologic downstaging on local recurrence and survival in patients with borderline resectable or unresectable rectal adenocarcinoma treated with neoadjuvant chemoradiotherapy (CRT). METHODS AND MATERIALS: A total of 150 patients with locally advanced rectal cancer were treated with long-course neoadjuvant CRT using low-dose folinic acid and 5-fluorouracil. CRT was followed 6-12 weeks later by surgical excision. The CRM rate and incidence, site, and pattern of local and systemic recurrences were recorded. The median follow-up was 25 months. RESULTS: The overall median survival was 37 months, with a 5-year overall survival rate of 34%. Of the 150 patients, 122 underwent curative resection; 12% had a complete pathologic response, and downstaging to pT1-T2 occurred in an additional 16%. A negative CRM (R0) was achieved in 65% overall (98 of 150). Local recurrence occurred in 10% of those with R0 resection and 62% of those with R1-R2 resections. Distant metastases occurred in 29% of those with R0 resections and 75% of those with R1-R2 resections. The 3-year disease-free and 3-year overall survival rate was 9% and 25% and 52% and 64%, respectively, for patients with and without a histologically positive CRM. CONCLUSION: After 5-fluorouracil-based CRT, a positive CRM predicted for a high risk of subsequent local recurrence and a 3-year disease-free survival rate of only 9%. For this reason, the CRM should be considered a major prognostic factor and should be validated in future trials as an early alternative clinical endpoint.