Decreasing Radiation Exposure in Pediatric Trauma Related to Cervical Spine Clearance: A Quality Improvement Project.

STUDY DESIGN: Quality improvement project. OBJECTIVES: Reduce the amount of radiation exposure in the pediatric trauma population 5 years of age and older in relation to cervical spine clearance. BACKGROUND: The evaluation of pediatric cervical spine injuries must be accurate and timely to avoid missed injuries. The difficult clinical examination in pediatric trauma patients necessitates the use of radiologic examinations to avoid missing catastrophic injuries. However, exposure to radiation at an early age increases the pediatric patients' risk of developing cancer (R. A. ). METHODS: A retrospective chart review was conducted to assess radiation exposure in pediatric patients requiring evaluation for cervical spine clearance. Surgical staff and emergency department physicians received education on the risks related to pediatric radiation exposure and information related to the institution's diagnostic trends for cervical spine clearance. An algorithm was then developed to assist with determining the necessary imaging study for cervical spine clearance. Radiation exposure was monitored following initial education and use of the algorithm to determine its effect on radiation exposure. RESULTS: The retrospective chart review identified cervical spine computed tomography (CT) in 34%, with an average radiation exposure of 3.5 mSv. Following education and introduction of an algorithm, 18% of patients underwent CT for cervical spine clearance with an average radiation exposure of 3.2 mSv, representing a 47% decrease in the use of CT. CONCLUSION: Staff education and the use of an algorithm show promise in the reduction of radiation exposure and provide safe, effective clearance of the cervical spine in pediatric trauma.

Pre-hospital CPR after traumatic arrest: Outcomes at a level 1 pediatric trauma center.

BACKGROUND: The survival of traumatic cardiopulmonary arrest (TCA) requiring pre-hospital cardiopulmonary resuscitation (P-CPR) is abysmal across age groups. We aim to describe the mechanisms of injury and outcomes of children suffering from TCA leading to P-CPR at our institution. METHODS: A retrospective review was conducted to identify children ages 0-17 years who suffered TCA leading to P-CPR at our institution between 5/2009 and 3/2020. For analysis, patients were stratified into those still undergoing CPR at arrival and those who attained pre-hospital return of spontaneous circulation (ROSC). Primary outcome was discharge alive from the hospital. RESULTS: P-CPR was initiated for 48 patients who had TCA; 23 had pre-hospital ROSC. Of the 25 children undergoing CPR at presentation, none survived to discharge. The median duration of CPR, from initiation to time of death declaration was 34 min [29,50]. Seventeen patients died after resuscitation attempts in the ED, while 8 died after admission to the PICU. Of the 23 patients who attained pre-hospital ROSC, 6 survived to discharge. All survivors required intensive rehabilitation services at discharge and at most recent follow-up, 5 had residual deficits requiring medical attention. CONCLUSION: There are poor outcomes in children with pre-hospital traumatic cardiopulmonary arrest, particularly in those without pre-hospital ROSC. These data further support the need for standardized guidelines for resuscitation in children with traumatic cardiopulmonary arrest.

Asymptomatic non-occult pneumothorax in pediatric blunt chest trauma: Chest tube versus observation.

BACKGROUND: The treatment of asymptomatic non-occult pneumothoraces (ANOPTX) secondary to blunt chest trauma (BCT) has not been well delineated. We sought to analyze our experience with ANOPTX in pediatric trauma patients and determine if a chest tube (CT) is mandatory. METHODS: A retrospective chart review of patients < 17 years old with ANOPTX from BCT who presented to a level 1 trauma children's hospital, between January 2000 and June 2015 was performed. Demographics, vitals, trauma scores, imaging, interventions, hospital expenses and outcomes were analyzed. RESULTS: Of the 77 patients who had ANOPTX, 48 (62.3%) were managed with observation only, while 29 (37.7%) underwent CT placement. The median length of stay for patients who had CT placement was 7 days (IQR, 4, 12) and 2 days (IQR, 1, 4) in those observed (p < 0.01). All patients who were observed had complete resolution of the pneumothorax without recurrence or the need for CT placement. Patients who had CT placement had more imaging performed and more hospital expenditure compared to those who were observed. CONCLUSIONS: CT is not mandatory in all pediatric patients with ANOPTX from BCT and observation has been found to be safe and cost effective.

Patient perceptions regarding effect of gynecological surgery on sexuality.

INTRODUCTION: Women undergoing surgery for benign gynecological conditions often voice concerns about how surgery will affect their sexuality. It is unclear what percentage of women shares these concerns, and how well they are addressed. AIMS: To identify what concerns women have about sexuality when they have gynecological surgery, and what factors affect these concerns. METHODS: Survey of women scheduled to undergo hysterectomy, oophorectomy, or any sterilization procedure at an academic medical center. Chi-square and Fisher's exact tests were used to analyze the data. MAIN OUTCOME MEASURE: A questionnaire was devised containing 10 statements regarding how surgery can affect sexuality and how concerns are addressed. Patients were asked to rate their agreement with each on a 5-point Likert scale. RESULTS: Patients undergoing oophorectomies were significantly more likely to agree that they would have less sexual desire (P = 0.01) and that they would be less able to enjoy sex (P = 0.002) than women undergoing hysterectomy or sterilization alone. Patients with a private physician were more likely to agree that their physician counseled them about sexual effects than patients of the resident clinic (P = 0.004). CONCLUSIONS: Women undergoing oophorectomy are more likely to have concerns regarding sexuality that need to be addressed by gynecological surgeons. These concerns are less frequently addressed by resident physicians, who need to be instructed to counsel their patients about sexuality.

Non-accidental trauma: A national survey on management.

INTRODUCTION: Non-accidental trauma (NAT) has significant societal and health care implications. Standardized care has been shown to improve outcomes. The purpose of our study was to survey trauma centers and elucidate the continued variable management of NAT. METHODS: After institutional review board approval, an email survey was sent to Level 1 and 2 ACS verified trauma centers along with general and pediatric surgery training programs. Trauma hospital characteristics and NAT management were analyzed. RESULTS: A total of 493 emails were sent and 91 responses (18%) were received. There were 74 (81%) pediatric surgeons who responded and 15(17%) adult general surgeons. The most common location of respondents were children's hospitals within academic/community hospitals (58%) followed by stand-alone children hospitals (42%), and adult only hospitals (9%). 51 (57%) providers reported using a screening tool; most commonly used by the emergency department (52%). 75% of providers reported utilizing management protocols in which 71% were initiated by trauma surgery. The most common consulting and admitting service for NAT was trauma surgery (86% and 84%). When comparing stand-alone and affiliated children hospitals, there was no difference in the use of a screening tool (54% vs. 59%; p = 0.84), and management protocol (70% vs. 85%; p = 0.19). However, those providers from pediatric trauma centers used a management protocol more often than providers from adult trauma centers (78% vs. 38%; p = 0.04). No providers from adult trauma centers had intentions to initiate a management protocol in the future. CONCLUSION: Screening and management of non-accidental trauma continues to vary across the country. Future studies focusing on standardization and outreach/education to adult trauma centers is warranted.

National survey on psychosocial obstetrics and gynecology curriculum in US medical schools.

INTRODUCTION: This study sought to identify how psychosocial topics related to women's health are taught and assessed in the obstetrics/gynecology program of American medical schools, and what issues may prevent or promote their instruction. METHODS: A questionnaire was distributed to the ob/gyn clerkship director of every US medical school. Directors were asked whether each of four recommended topics were covered in their curricula. They were also asked about barriers to instructing topics not taught, and the importance of these topics. RESULTS: Out of 136 US medical schools, 57 questionnaires were returned (response rate = 40.4%). In all, 27 schools (48%) include formal training in pregnancy-related mood disorders, 33 (58%) include pre-menstrual syndrome/pre-menstrual dysphoric disorder, 29 (51%) include female sexual dysfunction and 45 (79%) include violence against women. Six schools (12%) listed none of these topics as taught. All but three of the clerkship directors agreed that psychosocial topics are important. The most common reason given for lack of instruction was insufficient time allotted. CONCLUSIONS: Despite agreement on their importance, many US medical schools do not teach psychosocial aspects of women's health. Addressing the barriers to teaching these topics would help provide medical students with more opportunities to learn about these issues.