Remote and interdisciplinary research in surgical knowledge production.

BACKGROUND: Surgical knowledge production has changed dramatically in the last 30 y, moving away from investigations by individual surgeon researchers and toward remote and interdisciplinary research. We investigated how surgeons make decisions about engaging in research and identify motivators, facilitators, and barriers to conducting research in an increasingly challenging environment. MATERIALS AND METHODS: We performed a qualitative analysis of semistructured interviews with surgeons from academic medical centers across the United States. We asked participants to describe their experiences and opinions regarding remote and interdisciplinary collaborations. RESULTS: Of 64 surgeon researchers invited, 21 (33%) agreed and participated in semistructured interviews. Each interview lasted an average (standard deviation) of 29 min (12). Surgeons were motivated by both internal and external factors, including some that might be identified as barriers. The internal desire to improve care and the need for collaboration to address increasingly complex questions requiring larger samples sizes emerged as most significant to interview participants. Social networks were identified as the dominant facilitator of multisite research, with technology playing a supporting role. Barriers to remote and interdisciplinary research ranged from individual, "micro" level barriers, through structural barriers that include institutional level challenges and competing priorities, to macrolevel system and policy-level barriers. CONCLUSIONS: Surgeons clearly recognize the importance of high-quality research aligned with current paradigms of clinical care and are using remote and interdisciplinary collaboration to improve the quality of the science they produce and align their work with the demand for increasingly high levels of evidence.

Key issues for elderly patients contemplating clinical trial participation.

This pilot study explored issues important to enrollment in clinical trials by elderly patients. We surveyed and interviewed elderly patients who had been asked to participate in trials. The information covered general attitudes toward research and specific aspects of trial recruitment. Elderly patients had favorable attitudes toward research. This favorable attitude was significantly stronger in men than in women and stronger in Whites than non-Whites but not significantly so. Altruistic motives, physician recommendations, and individual assessment of inconveniences, benefits, and risks of trial participation drove decisions. Elderly patients have positive views of research; however, this will only facilitate trial participation if patients perceive the commitment of enrolling, the potential risks, and possible side effects as reasonable.

Emergency codes: a study of hospital attitudes and practices.

Many hospitals use color codes to denote internal (i.e. patient respiratory distress), or external (i.e. natural disasters) emergencies, via public announcement systems. Variations in the codes used by different hospitals can create confusion among providers who may practice in more than one hospital. This study sought to understand emergency code practices in the Delaware Valley region, assess patient and provider knowledge of codes at one hospital in that region, and patient and provider preferences for emergency code standardization and format. Anonymous electronic surveys on procedural knowledge and perspectives of emergency codes were disseminated to hospital staff and patients located at a large regional hospital. Phone interviews were conducted with hospital administration at the regional hospital and other hospitals within a 50-mile radius. The author's research indicates that standardization would be accepted by patients and providers and its lack is considered a barrier to providing high quality care.

Overall ED efficiency is associated with decreased time to percutaneous coronary intervention for ST-segment elevation myocardial infarction.

BACKGROUND: Performance of percutaneous coronary intervention (PCI) within 90 minutes of hospital arrival for ST-segment elevation myocardial infarction patients is a commonly cited clinical quality measure. The Centers for Medicare and Medicaid Services use this measure to adjust hospital reimbursement via the Value-Based Purchasing Program. This study investigated the relationship between hospital performance on this quality measure and emergency department (ED) operational efficiency. METHODS: Hospital-level data from Centers for Medicare and Medicaid Services on PCI quality measure performance was linked to information on operational performance from 272 US EDs obtained from the Emergency Department Benchmarking Alliance annual operations survey. Standard metrics of ED size, acuity, and efficiency were compared across hospitals grouped by performance on the door-to-balloon time quality measure. RESULTS: Mean hospital performance on the 90-minute arrival to PCI measure was 94.0% (range, 42-100). Among hospitals failing to achieve the door-to-balloon time performance standard, median ED length of stay was 209 minutes, compared with 173 minutes among those hospitals meeting the benchmark standard (P < .001). Similarly, median time from ED patient arrival to physician evaluation was 39 minutes for hospitals below the performance standard and 23 minutes for hospitals at the benchmark standard (P < .001). Markers of ED size and acuity, including annual patient volume, admission rate, and the percentage of patients arriving via ambulance did not vary with door-to-balloon time. CONCLUSION: Better performance on measures associated with ED efficiency is associated with more timely PCI performance.

Do patients accurately perceive their fall risk?

BACKGROUND: In U.S. hospitals, from 700,000 to 1 million inpatients fall each year. About a third of these falls could have been prevented. OBJECTIVES: This project's purpose was to document patient perceptions of their inpatient fall risk and determine how these perceptions were associated with clinical indicators of fall risk. METHODS: From six medical-surgical units, 193 patients were randomly selected and surveyed about their perceived fall risk during their hospital stay. For 101 of them, the Schmid fall risk assessment score, age, and gender were recorded. A retrospective review of the Schmid scores of all patients who fell during a 6-month historical sample period was reviewed for comparison. RESULTS: Most patients (88%) reported that they didn't feel at risk for falling during their hospital stay. No correlation between their Schmid score and their perceived fall risk was found. Historical review of all inpatients who'd fallen in a prior period showed that the 358 patients with known Schmid scores had a full range of scores. These are normally distributed from 0 to 6, with over 40% of patients experiencing falls having Schmid scores of less than 3. CONCLUSIONS: Patient perceptions of falls match neither their clinical risk nor their actual likelihood of falling. When designing fall prevention strategies, it may be important to remind providers of this gap in patient knowledge, which includes overconfidence in the role of the care team in preventing falls

Altered thyroid function in severely injured patients.

BACKGROUND: Hemorrhagic shock profoundly affects the neuroendocrine profile of trauma patients, and we hypothesized that massive resuscitation would negatively impact thyroid function. METHODS: A prospective, observational study investigating thyroid function in hypotensive trauma patients (systolic blood pressure <90 mm Hg × 2) who survived >48 h was conducted at a Level I center over a 6-mo period. Blood samples for thyroid function were collected at time of presentation to the trauma bay and serially for 48 h. Collected data included demographics, injury data, vital signs, transfusion needs, crystalloid use, and vasopressor requirements. Patients receiving >5 units packed red blood cells (PRBC) within 12 h were compared with those receiving ≤5 units. RESULTS: Patients who required >5 units of PRBC/12 h had significantly lower total and free T4 levels on initial presentation, and levels remained significantly depressed over the next 48 h when compared with patients who required a less aggressive resuscitative effort. T3 values were markedly suppressed during the initial 48 h post trauma in all patients, but were significantly lower in patients requiring >5 units PRBC. TSH levels remained within the normal range for all time points. Lower trauma admission T4 levels were associated with the need for greater crystalloid resuscitation within the first 24 h. CONCLUSION: Measurements of thyroid function are significantly altered in severely injured patients on initial presentation, and low T4 levels predict the need for large resuscitation. Further research investigating the profile and impact of thyroid function in trauma patients during resuscitation and recovery is warranted.

Mineralocorticoid deficiency in hemorrhagic shock.

BACKGROUND: In the critically ill, mineralocorticoid deficiency (MD) is associated with greater disease severity, the development of acute renal insufficiency, and increased mortality. We hypothesized that severely injured trauma patients presenting with hemorrhagic shock would demonstrate a high degree of MD. We also hypothesized that MD in these patients would be associated with increased length of stay, hypotension, fluid requirements, and acute kidney injury (AKI). MATERIALS AND METHODS: Thirty-two trauma patients in hemorrhagic shock on admission to the trauma bay (SBP <90 mm Hg × 2) were enrolled. Blood samples were obtained on ICU admission and 8, 16, 24, and 48 hours later. Plasma aldosterone (PA) and renin (PR) were assayed by radioimmunoassay. MD was defined as a ratio of PA/PR ≤2. Demographic data, injury severity score, ICU and hospital length of stay, fluid requirements, mean arterial pressure, serum sodium, hypotension, and risk for AKI were compared for patients with and without MD. RESULTS: At ICU admission, 48% of patients met criteria for MD. Patients with MD were significantly more likely to experience hypotension (MAP ≤60 mm Hg) during the study period. MD patients required significantly more units of blood in 48 h than non-MD patients (13 [7-22] versus 5 [2-7], P = 0.015) and had increased crystalloid requirements (18L [14-23] versus 9L [6-10], P < 0.001). MD patients were at higher risk for AKI according to RIFLE and AKIN criteria. CONCLUSIONS: MD is a common entity in trauma patients presenting in hemorrhagic shock. Patients with MD required a more aggressive resuscitative effort, were more likely to experience hypotension, and had a higher risk of AKI than non-MD patients. Future studies are needed to fully understand the impact of MD following trauma and the potential role for hormonal replacement therapy.

Feasibility, acceptability and preliminary effectiveness of patient advocates for improving asthma outcomes in adults.

BACKGROUND: Asthmatic adults from low-income urban neighborhoods have inferior health outcomes which in part may be due to barriers accessing care and with patient-provider communication. We adapted a patient advocate (PA) intervention to overcome these barriers. OBJECTIVE: To conduct a pilot study to assess feasibility, acceptability and preliminary evidence of effectiveness. METHODS: A prospective randomized design was employed with mixed methods evaluation. Adults with moderate or severe asthma were randomized to 16 weeks of PA or a minimal intervention (MI) comparison condition. The PA, a non-professional, modeled preparations for a medical visit, attended the visit and confirmed understanding. The PA facilitated scheduling, obtaining insurance coverage and overcoming barriers to implementing medical advice. Outcomes included electronically-monitored inhaled corticosteroid (ICS) adherence, asthma control, quality of life, FEV1, emergency department (ED) visits and hospitalizations. Mixed-effects models guided an intention-to-treat analysis. RESULTS: 100 adults participated: age 47 ± 14 years, 75% female, 71% African-American, 16% white, baseline FEV1 69% ± 18%, 36% experiencing hospitalizations and 56% ED visits for asthma in the prior year. Ninety-three subjects completed all visits; 36 of 53 PA-assigned had a PA visit. Adherence declined significantly in the control (p = 0.001) but not significantly in the PA group (p = 0.30). Both PA and MI groups demonstrated improved asthma control (p = 0.01 in both) and quality of life (p = 0.001, p = 0.004). Hospitalizations and ED visits for asthma did not differ between groups. The observed changes over time tended to favor the PA group, but this study was underpowered to detect differences between groups. CONCLUSION: The PA intervention was feasible and acceptable and demonstrated potential for improving asthma control and quality of life.

Management of the ptotic or hypertrophic breast in immediate autologous breast reconstruction: a comparison between the wise and vertical reduction patterns for mastectomy.

BACKGROUND: The Wise pattern can be used in mastectomies to address the excess skin in the ptotic or hypertrophic breast; however, limitations include mastectomy flap necrosis (MFN) and poor shape. The vertical pattern can potentially reduce the amount of MFN with improved aesthetic results. This study compares the Wise and vertical mastectomy patterns in immediate, autologous breast reconstruction. METHODS: Thirty-three patients with grade 2 or 3 ptosis who elected to undergo immediate, autologous breast reconstruction were prospectively recruited into 2 nonrandomized cohorts. Of total, 17 patients (26 reconstructions) had Wise pattern and 16 (28 reconstructions) had vertical pattern. All patients were followed for MFN, time for wound healing, and postoperative complications. Patient and surgeon surveys rated the aesthetics of the reconstructions. RESULTS: The 2 groups did not differ in age, body mass index, smoking, or breast measurements. The Wise group had significantly larger areas of MFN, higher number of postoperative visits, and longer wound-healing periods, compared with the vertical group (P < 0.05). There was no difference in time to adjuvant therapy or additional procedures. Patient surveys rated both incisions with equal satisfaction, except for symmetry that rated better in the Wise group. Surgeon surveys showed better scores for the vertical incision. CONCLUSIONS: The Wise pattern is associated with significantly more MFN and prolonged wound care. Despite this complication, patients rate their breast reconstructions favorably, regardless of the type of incision. Both the Wise and vertical patterns can be safely used in skin-sparing mastectomies with immediate, autologous breast reconstruction with good aesthetic outcomes. The authors recommend the vertical pattern because of less MFN and surgeon-preferred aesthetics.

Breast cancer surgery trend changes since the introduction of BRCA1/2 mutation screening: a retrospective cohort analysis of 158 mutation carriers treated at a single institution.

BACKGROUND: Bilateral mastectomy in women diagnosed with unilateral breast cancer is on the rise in the USA. One contributing factor is increased awareness of contralateral breast cancer risk. Positive testing for deleterious mutation in BRCA1/2 is a concrete measure of this contributing factor. We hypothesize that breast cancer surgery trend change is temporally associated with the introduction of BRCA1/2 genetic testing around 1996. METHODS: Our study cohort included 158 BRCA1 or BRCA2 mutation carriers diagnosed with unilateral breast cancer between 1963 and 2009. Mutation carriers with ovarian cancer or bilateral breast cancer were excluded. Breast surgery and breast reconstruction surgery trends were analyzed according to year of breast cancer diagnosis or when bilateral mastectomy was performed, respectively. RESULTS: Surgery trends changed significantly over time. We observed a significant drop in the rate of unilateral mastectomy (P < 0.001) after the period 1996-2000, and the rate of bilateral mastectomy appears to be on the rise, up to 30.3% between 2006 and 2009. Breast reconstruction trends also changed significantly over time, with a significant rise in the rate of free flap reconstruction to 58.8% between 2006 and 2009. CONCLUSIONS: Our results demonstrated a significant decrease in unilateral mastectomy with a rise in bilateral mastectomy after the period 1996-2000, a period which encompassed the year when genetic testing of the two BRCA1/2 genes became commercially available, hence supporting our hypothesis.

Robotic vs. conventional laparoscopic gastric banding: a comparison of 407 cases.

BACKGROUND: The current indications for using a robotic technique in bariatric surgery remain unclear. The objective of this study was to quantify the safety and potential benefits of this novel technology as compared to the conventional laparoscopic approach. METHODS: A retrospective database of patients who underwent laparoscopic adjustable gastric banding (LAGB) between December 2006 and June 2009 was examined. During this period 407 consecutive patients underwent LAGB: 287 robotically and 120 conventionally. Patient demographics, operative complications, operating times, and clinical outcomes were examined. RESULTS: The patients in the robotic and conventional cohorts did not vary significantly in demographics. The prevalence of preoperative comorbidities was similar between the two groups. The rates of intraoperative and postoperative complications did not differ significantly between the two approaches. The length of postoperative hospital stay (1.3±0.6 days for both approaches) and the operating time (91.5±21.1 vs. 92.1±30.9 min for robotic and conventional, respectively) did not differ significantly between the two approaches. However, for patients with a preoperative BMI≥50 kg/m2 (n=89, 64 robotic and 25 conventional), the operating time was significantly shorter using the robotic approach (91.3±19.7 min for robotic vs. 101.3±23.7 min for conventional, p=0.04). CONCLUSIONS: In this series, robotic and conventional approaches were similar in complication rates, operating time, and length of postoperative hospital stay. However, for patients with a preoperative BMI≥50 kg/m2, the operating time is significantly shorter using the robotic approach despite the adoption of this new technique. These data suggest that the robotic approach is at least as safe as the conventional laparoscopic approach in LAGB, and that the robotic approach should be considered for gastric banding candidates with BMI≥50 kg/m2.

A writing group for female assistant professors.

INTRODUCTION: The number of female medical school faculty being promoted and the speed at which they are promoted have not kept pace with their male counterparts at many institutions. One of the reasons is that these women are not publishing peer reviewed manuscripts at an equivalent rate. This study evaluates the impact of a women's writing group on faculty publication rates. MATERIALS AND METHODS: The writing group was conducted by 2 senior faculty members at the University of Pennsylvania School of Medicine and targeted female junior faculty. The writing group consisted of a didactic skills curriculum, question sessions, and both faculty and peer support to improve publishing rates. Curriculum vitae were collected, and PubMed and Ovid searches were used to establish the publishing productivity of the writing group participants both before and after participation in the writing group. RESULTS: On average, women who completed the writing group showed a nearly 3-fold increase in average publishing rate from 1.5 papers per year preceding the course to 4.5 per year following completion of the writing group (p<.001). CONCLUSIONS: The results from our program suggest that a women's writing group is an effective intervention for increasing publishing rates of female junior faculty. In addition to the documented improvement in publication rates, we watched participants develop clearer writing styles, lose many of their inhibitions about writing, respond to group affiliation and collaboration, and gain tremendous self-confidence.

Evaluating the use of a barbed suture for skin closure during autologous breast reconstruction.

This study compared the use of barbed suture to a traditional skin closure method for incision closure in free flap breast reconstruction. A retrospective study compared the two closure methods in consecutive series of patients undergoing autologous breast reconstruction between January 2007 and January 2009. Outcomes included total duration of operation and wound complications. We also performed a cost analysis. Use of the barbed suture significantly decreased operative time for unilateral cases by an average of 45 minutes (405 versus 360 minutes, P = 0.02). For bilateral cases, the mean operative time was decreased by an average of 10 minutes (510 versus 500 minutes, P = 0.44). There were more episodes of delayed wound healing in the bilateral barbed suture group (33/46 [72%] versus 15/31 [48%], P = 0.04). No statistical difference was noted between the two groups with regard to dehiscence, infection, or suture extrusion. Use of the barbed suture was, however, more cost-effective. The use of a barbed suture in the closure of abdominal and breast incisions in free flap breast reconstruction may expedite wound closure and reduce the cost of the procedure but may increase wound complications.

From the Patient Perspective, Consent Forms Fall Short of Providing Information to Guide Decision Making.

OBJECTIVE: This study aimed to gather qualitative feedback on patient perceptions of informed consent forms and elicit recommendations to improve readability and utility for enhanced patient safety and engagement in shared decision making. METHODS: Sixty interviews in personal interviews were conducted consisting of a literacy and numeracy assessment, a comprehension quiz to assess retention of key information, and open-ended questions to determine reactions, clarity of information, and suggestions for improvement. RESULTS: Although 68% of the participants had education beyond high school, many still missed comprehension questions and found the forms difficult to read. Recurrent suggestions included specific formatting changes to enhance readability, a need for additional sources of information, mixed attitudes toward inclusion of risk information, and the recognized importance of physician-patient conversations. CONCLUSIONS: This study provides evidence from the patient perspective that consent forms are too complex and fail to achieve comprehension. Future studies should be conducted using patients' suggestions for form redesign and inclusion of supplemental educational tools to optimize communication and safety to achieve more informed health care decision making.

Examining faculty awards for gender equity and evolving values.

BACKGROUND: Awards given to medical school faculty are one important mechanism for recognizing what is valued in academic medicine. There have been concerns expressed about the gender distribution of awards, and there is also a growing appreciation for the evolving accomplishments and talents that define academic excellence in the 21st century and that should be considered worthy of award recognition. OBJECTIVE: Examine faculty awards at our institution for gender equity and evolving values. METHODS: Recipient data were collected on awards from 1996 to 2007 inclusively at the University of Pennsylvania School of Medicine (SOM). Descriptions of each award also were collected. The female-to-male ratio of award recipients over the time span was reviewed for changes and trends. The title and text of each award announcement were reviewed to determine if the award represented a traditional or a newer concept of excellence in academic medicine. MAIN RESULTS: There were 21 annual awards given to a total of 59 clinical award recipients, 60 research award recipients, and 154 teaching award recipients. Women received 28% of research awards, 29% of teaching awards and 10% of clinical awards. Gender distribution of total awards was similar to that of SOM full-time faculty except in the clinical awards category. Only one award reflected a shift in the culture of individual achievement to one of collaboration and team performance. CONCLUSION: Examining both the recipients and content of awards is important to assure they reflect the current composition of diverse faculty and the evolving ideals of leadership and excellence in academic medicine.

Defining pathological variables to predict biochemical failure in patients with positive surgical margins at radical prostatectomy: implications for adjuvant radiotherapy.

OBJECTIVE: To evaluate the utility of estimated tumour volume, number of positive surgical margins (PSMs), and margin location for predicting biochemical failure in patients with PSM, in an attempt to better risk-stratify the heterogeneous group of patients at high risk of biochemical failure after radical prostatectomy (RP) for prostate cancer. PATIENTS AND METHODS: We reviewed our database of 2410 patients who had RP, and isolated 423 with PSMs who had a prostate-specific antigen (PSA) nadir at undetectable levels. Kaplan-Meier curves were used for univariate survival analysis, with the log-rank test used to examine differences between survival curves. Multivariate Cox regression analysis was used to assess the independent main effect of estimated tumour volume, number of PSMs and margin location on biochemical-free survival. RESULTS: Increasing estimated tumour volume was directly associated with increasing risk of biochemical failure in patients with PSMs (P = 0.041). Patients with more than one PSM were at greater risk of biochemical failure than those with one PSM (P = 0.001). Margin location had no effect on biochemical-free survival in patients with PSMs. When incorporated into a multivariate Cox regression model including age, preoperative PSA level and pathological Gleason score, estimated tumour volume and number of PSMs remained independent predictors of biochemical recurrence. CONCLUSIONS: Coupled with other variables before and after RP, both estimated tumour volume and number of PSMs might serve to further discriminate those patients most likely to benefit from immediate adjuvant radiotherapy after RP.

Making sense of cancer risk calculators on the web.

OBJECTIVE: Cancer risk calculators on the internet have the potential to provide users with valuable information about their individual cancer risk. However, the lack of oversight of these sites raises concerns about low quality and inconsistent information. These concerns led us to evaluate internet cancer risk calculators. DESIGN: After a systematic search to find all cancer risk calculators on the internet, we reviewed the content of each site for information that users should seek to evaluate the quality of a website. We then examined the consistency of the breast cancer risk calculators by having 27 women complete 10 of the breast cancer risk calculators for themselves. We also completed the breast cancer risk calculators for a hypothetical high- and low-risk woman, and compared the output to Surveillance Epidemiology and End Results estimates for the average same-age and same-race woman. RESULTS: Nineteen sites were found, 13 of which calculate breast cancer risk. Most sites do not provide the information users need to evaluate the legitimacy of a website. The breast cancer calculator sites vary in the risk factors they assess to calculate breast cancer risk, how they operationalize each risk factor and in the risk estimate they provide for the same individual. CONCLUSIONS: Internet cancer risk calculators have the potential to provide a public health benefit by educating individuals about their risks and potentially encouraging preventive health behaviors. However, our evaluation of internet calculators revealed several problems that call into question the accuracy of the information that they provide. This may lead the users of these sites to make inappropriate medical decisions on the basis of misinformation.

Method of primary tumor detection as a risk factor for local and distant recurrence after breast-conservation treatment for early-stage breast cancer.

BACKGROUND: Recent studies have shown that breast cancer detected by screening has a more favorable prognosis than interval breast cancer. To further understand the biologic significance of this finding, we investigated the association of disease recurrence, local and distant, with the method of detection of the primary breast cancer in a cohort of 1686 women treated with breast conservation. PATIENTS AND METHODS: The charts of 1686 women with primarily stage I or II invasive breast cancer treated by breast conservation between 1977 and 2002 were reviewed. The median length of follow-up was 6 years. Univariate and multivariate analyses using binary logistic regression were performed for 2 subgroups: (1) those with local recurrence versus those without; and (2) those with distant metastasis versus those without distant metastasis. RESULTS: Our data confirmed several of the well-known risk factors for local and distant recurrence. In addition, we found that individuals with breast cancer detected on physical examination alone have a significantly higher risk for local recurrence compared with patients with cancer detected on mammogram alone, independent of tumor size (odds ratio [OR], 2.369; 95% CI, 1.235-4.547; P = .01). We also found a similar correlation for risk of distant metastasis in these 2 groups of women (OR, 2.201; 95% CI, 1.211-3.998; P = .01). CONCLUSION: Breast cancers that are palpable might represent an aggressive biologic subtype with an increased risk of local and distant recurrence. Risk stratification might need to include this clinical feature in addition to conventional prognostic factors.

Meta-analysis of cranial CT scans in children. A mathematical model to predict radiation-induced tumors.

OBJECTIVE: We aimed to estimate the risks of radiation exposure from a single head CT scan to children of different ages. MATERIALS AND METHODS: We constructed a multistate time-dependent Markov model to simulate the course of children exposed to a head CT. The relevant literature was reviewed for probabilities, which were used to calculate tumor types, latencies after exposure and outcomes in the model. Where multiple approximations of the same probability had been reported, meta-analytic techniques were employed to compute pooled estimates. The model was then used to calculate the effect of the radiation exposure on life expectancy and quality of life for children following head CT at different ages. RESULTS: The tumors likely to be induced by low-level cranial irradiation include thyroid carcinoma (47%), meningioma (34%) and glioma (19%). According to the model, a single head CT is likely to cause one of these tumors in 0.22% of 1-year-olds, 30% of whom will consequently die. The exposure will shorten the life expectancy of all exposed 1-year-olds by an average of 0.04 years and their expected quality of life by 0.02 quality-adjusted life years. The risks of radiation exposure diminish for older children. CONCLUSIONS: The model predicts that the effective radiation dose from a single head CT is capable of inducing a thyroid or brain tumor in an infant or child. These tumors can severely impact both quality of life and life expectancy. Care should be taken before ordering CT scans in children, particularly in infants and toddlers.