Evaluating the feasibility and outcomes of a resident-led school-based pediatric clinic.

Objective: A resident-led school-based clinic to serve low-income populations was established in 2019 and served as a continuity clinic for pediatric residents at a single university. Our aim was to assess the feasibility, clinic outcomes, and resident experience of a resident-led school-based clinic (RLSBC), established in an elementary school that serves an underserved population. Methods: A retrospective chart review for the first 6 months (October 2019 to March 2020) of clinic operations was conducted. Feasibility metrics included the number of patients, visits and planned follow-ups; clinic outcomes included the number and type of presenting complaint, new diagnoses and interventions. Residents were also surveyed to assess their satisfaction and perceived learning in training at the school-based clinic. Results: Over the first 19 clinic days, 48 children were seen at the school-based clinic. Of the clinic users, 60% did not have a primary care physician, 46% received a new diagnosis, 46% received an intervention in the form of medication prescription, laboratory/imaging requisitions or referrals, and 96% received a treatment plan. Residents positively rated the experience of staffing the school-based clinic in all aspects, including learning environment, clinic and team environment, teaching obtained, practice management, and overall experience. Conclusion: A RLSBC is feasible and our outcomes suggest that such clinics may address health care needs of low-income families and children, while being a positively rated educational experience for pediatric residents.

The Emergence of Child Protection Capacities in Oman: Lessons learned.

Child maltreatment (CM) is the abuse and neglect of children under the age of 18 years. Many types of CM lead to actual or potential harm to the child's health. It is a widespread phenomenon and is well reported in Western countries in contrast with the Gulf countries. Reports documenting CM in Oman are now available; therefore, this review aimed to provide an overview of the state and patterns of CM in Oman. It also addresses the current child protection services (CPS) in Oman and the sociocultural constraints. All English-language relevant medical literature about CM in Oman that were published before January 2020 were included. This review can serve as a basic reference in the field of CM in Oman and should help to identify lacunas in the current CPS as well as provide guidance in the establishment of a more effective one.

Family Members' Perceptions of Their Psychological Responses One Year Following Pediatric Intensive Care Unit (PICU) Hospitalization: Qualitative Findings From the Caring Intensively Study.

Introduction: PICU hospitalization can have a profound impact on child survivors and their families. There is limited research on children's long-term recovery within the context of the family following critical illness. This study aimed to explore children's and parents' perceptions of long-term psychological and behavioral responses within the context of the family one year following PICU hospitalization. Materials and Methods: Caring Intensively is a mixed methods multi-site prospective cohort study that aims to examine children's psychological and behavioral responses over a 3-year period following PICU hospitalization. In this study, part of the qualitative arm of Caring Intensively, an interpretive descriptive design was used to explore children's recovery one year post-discharge. Purposive sampling was used to select 17 families, including 16 mothers, 6 fathers, and 9 children. Semi-structured, audio-recorded interviews were conducted. Data were analyzed iteratively using the constant comparison method. Results: Families described efforts to readapt to routine life and find a new normal following PICU hospitalization. Finding a New Normal consisted of four major themes: (1) Processing PICU Reminders and Memories, (2) Changing Perceptions of Health and Illness, (3) We Are Not the Same, and (4) Altered Relationships. Participants described significant emotional and behavioral changes during the year following discharge. The psychological impact of individual family members' experiences led to changes in their sense of self, which affected family dynamics. PICU memories and reminders impacted participants' perceptions of childhood health and illness and resulted in increased vigilance. Parents and siblings demonstrated increased concern for the child survivor's health, and the experience of long absences and new or altered caregiving roles resulted in changes in relationships and family dynamics. Conclusion: PICU hospitalization impacted the psychological well-being of all family members as they sought to re-establish a sense of normalcy one year following discharge. Parent and child experiences and responses were closely interconnected. Findings highlight the importance of increased follow-up care aimed at supporting the family's psychological recovery.

Development of the Pediatric Social Risk Instrument Using a Structured Panel Approach.

BACKGROUND: Social determinants of health impact child illness. Currently, no instrument exists to identify social need during hospital admission. METHODS: Using the UCLA (University of California Los Angeles)-RAND appropriateness method, consensus was reached for an instrument to identify social need in hospitalized children. A panel of 11 experts reviewed candidate indicators through 3 rounds to reach consensus. The instrument then underwent usability testing. RESULTS: Three hundred and forty-seven indicators from the literature were sorted into 18 social risk themes. After 3 rounds, consensus was reached on 82 indicators. Six additional social risk themes were recommended by the panel, resulting in consensus for 18 additional indicators. Final refinement resulted in an instrument containing 86 indicators representing 11 social risk themes. Usability testing identified that the tool was well received by families. Final feedback was incorporated into a post-usability instrument. CONCLUSIONS: Using the UCLA-RAND appropriateness method, a new pediatric social risk instrument was created to identify social need for hospitalized children.

Correlates, stability and predictors of borderline personality disorder among previously suicidal youth.

This article examines a large cohort of previously suicidal adolescents, identifying those that surpassed threshold criteria for borderline personality disorder (BPD), according to the Abbreviated Diagnostic Interview of Borderlines (Ab-DIB), and determining the stability, correlates and predictors of BPD from early-to-late adolescence. Two hundred and eighty-six youth (mean baseline age 14.6 years; SD 1.5), presenting consecutively to a metropolitan pediatric hospital emergency department for evaluation of suicidality, were assessed at initial consultation for Axis I and II disorders and demographic and clinical variables. Two hundred and twenty-nine (80%) were re-assessed for those variables 4 years later and 204 (70.3%) had complete data sets at recruitment and follow-up. Previously suicidal youths who met BPD threshold on the Ab-DIB at recruitment were distinguishable at baseline from those who did not in conduct disorder symptoms (p < 0.003), lower levels of functioning (p < 0.001), drug use (p < 0.001), stressful life events (p < 0.003) and family relations (p < 0.001). The BPD diagnosis was consistent, according to this measure, at baseline and follow-up for 76% of participants. Four groups with respect to borderline pathology (persisting, remitting, emerging and never) were identified (ICC = 0.603, 95% CI = 0.40-0.78). Persistent BPD status was predictable by older age at presentation (p < 0.01) and level of functioning (p < 0.05). Eight percent were also suicidal at the 4-year follow-up. Using a self-report measure of BPD, we suggest that suicidal youth can indeed be diagnosed with the disorder at 14 years old, supporting the shift from DSM-IV to DSM-5, given what appears to be its temporal stability, differentiation of those suffering with considerable symptomatology or not, and predictors of its status in late adolescence. The low suicidality rate at follow-up indicates a good short-term prognosis.

Children's psychological and behavioral responses following pediatric intensive care unit hospitalization: the caring intensively study.

BACKGROUND: Pediatric intensive care unit (PICU) hospitalization places children at increased risk of persistent psychological and behavioral difficulties following discharge. Despite tremendous advances in medical technology and treatment regimes, approximately 25% of children demonstrate negative psychological and behavioral outcomes within the first year post-discharge. It is imperative that a broader array of risk factors and outcome indicators be explored in examining long-term psychological morbidity to identify areas for future health promotion and clinical intervention. This study aims to examine psychological and behavioral responses in children aged 3 to 12 years over a three year period following PICU hospitalization, and compare them to children who have undergone ear, nose and/or throat (ENT) day surgery. METHODS/DESIGN: This mixed-methods prospective cohort study will enrol 220 children aged 3 to 12 years during PICU hospitalization (study group, n = 110) and ENT day surgery hospitalization (comparison group, n = 110). Participants will be recruited from 3 Canadian pediatric hospitals, and followed for 3 years with data collection points at 6 weeks, 6 months, 1 year, 2 years and 3 years post-discharge. Psychological and behavioral characteristics of the child, and parent anxiety and parenting stress, will be assessed prior to hospital discharge, and again at each of the 5 subsequent time points, using standardized measures. Psychological and behavioral response scores for both groups will be compared at each follow-up time point. Multivariate regression analysis will be used to adjust for demographic and clinical variables at baseline. To explore baseline factors predictive of poor psychological and behavioral scores at 3 years among PICU patients, correlation analysis and multivariate linear regression will be used. A subgroup of 40 parents of study group children will be interviewed at years 1 and 3 post-discharge to explore their perceptions of the impact of PICU hospitalization on their children and enhance our understanding of findings generated from standardized measures in the larger cohort study. An interpretive descriptive approach will guide qualitative data collection and analysis. DISCUSSION: This study aims to generate new information regarding the magnitude and duration of psychological and behavioral disturbances among children admitted to PICUs, potentially leading to remedial or preventive interventions.

International migration to Canada: the post-birth health of mothers and infants by immigration class.

There are over 214 million international migrants worldwide, half of whom are women, and all of them assigned by the receiving country to an immigration class. Immigration classes are associated with certain health risks and regulatory restrictions related to eligibility for health care. Prior to this study, reports of international migrant post-birth health had not been compared between immigration classes, with the exception of our earlier, smaller study in which we found asylum-seekers to be at greatest risk for health concerns. In order to determine whether refugee or asylum-seeking women or their infants experience a greater number or a different distribution of professionally-identified health concerns after birth than immigrant or Canadian-born women, we recruited 1127 migrant (and in Canada <5 years) women-infant pairs, defined by immigration class (refugee, asylum-seeker, immigrant, or Canadian-born). Between February 2006 and May 2009, we followed them from childbirth (in one of eleven birthing centres in Montreal or Toronto) to four months and found that at one week postpartum, asylum-seeking and immigrant women had greater rates of professionally-identified health concerns than Canadian-born women; and at four months, all three migrant groups had greater rates of professionally-identified concerns. Further, international migrants were at greater risk of not having these concerns addressed by the Canadian health care system. The current study supports our earlier findings and highlights the need for case-finding and services for international migrant women, particularly for psychosocial difficulties. Policy and program mechanisms to address migrants' needs would best be developed within the various immigration classes.

Prospective validation of the pediatric appendicitis score in a Canadian pediatric emergency department.

OBJECTIVES: Clinical scoring systems attempt to improve the diagnostic accuracy of pediatric appendicitis. The Pediatric Appendicitis Score (PAS) was the first score created specifically for children and showed excellent performance in the derivation study when administered by pediatric surgeons. The objective was to validate the score in a nonreferred population by emergency physicians (EPs). METHODS: A convenience sample of children, 4-18 years old presenting to a pediatric emergency department (ED) with abdominal pain of less than 3 days' duration and in whom the treating physician suspected appendicitis, was prospectively evaluated. Children who were nonverbal, had a previous appendectomy, or had chronic abdominal pathology were excluded. Score components (right lower quadrant and hop tenderness, anorexia, pyrexia, emesis, pain migration, leukocytosis, and neutrophilia) were collected on standardized forms by EPs who were blinded to the scoring system. Interobserver assessments were completed when possible. Appendicitis was defined as appendectomy with positive histology. Outcomes were ascertained by review of the pathology reports from the surgery specimens for children undergoing surgery and by telephone follow-up for children who were discharged home. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated. The overall performance of the score was assessed by a receiver operator characteristic (ROC) curve. RESULTS: Of the enrolled children who met inclusion criteria (n = 246), 83 (34%) had pathology-proven appendicitis. Using the single cut-point suggested in the derivation study (PAS 5) resulted in an unacceptably high number of false positives (37.6%). The score's performance improved when two cut-points were used. When children with a PAS of or=8 determined the need for appendectomy, the score's specificity was 95.1% with a PPV of 85.2%. Using this strategy, the negative appendectomy rate would have been 8.8%, the missed appendicitis rate would have been 2.4%, and 41% of imaging investigations would have been avoided. CONCLUSIONS: The PAS is a useful tool in the evaluation of children with possible appendicitis. Scores of or=8 help predict appendicitis. Patients with a PAS of 5-7 may need further radiologic evaluation.

Previously suicidal adolescents: predictors of six-month outcome.

OBJECTIVE: To determine the baseline variables, including borderline personality disorder (BPD), associated with the six-month outcome of previously suicidal adolescents (n=263) presenting to an emergency department and treated predominantly as out-patients. METHODS: Multivariate logistic regression was used to analyze the associations between baseline variables and suicidality at six-month follow-up. RESULTS: BPD, previous suicide attempt(s), drug use and female gender were associated with subsequent suicidality. CONCLUSIONS: These findings corroborate previously reported risk factors for recurring suicidality among adolescents and broaden their generalizability to those presenting to an emergency department, many diagnosed with BPD.

Postpartum depression symptoms in newcomers.

OBJECTIVES: To determine if postpartum depression (PPD) symptoms are more common in newcomer women than in Canadian-born women. METHODS: Refugee, nonrefugee immigrant, asylum-seeking, and Canadian-born new mothers were administered questionnaires for depression, social support, interpersonal violence, and demographic information. We created a PPD variable based on a score of > or = 10 on the Edinburgh Postnatal Depression Scale (EPDS) and performed a logistic regression analysis for PPD. RESULTS: Immigrants (35.1%), asylum seekers (31.1%), and refugees (25.7%) were significantly more likely than Canadian-born (8.1%) women to score > or = 10 (P = 0.008) on the EPDS, with the regression model showing an increased risk (odds ratio) for refugee (4.80), immigrant (4.58), and asylum-seeking (3.06) women. Women with less prenatal care were also more likely to have an EPDS of > or = 10 (P = 0.03). Newcomer women with EPDS scores of > or = 10 had lower social support scores than Canadian-born women (P < 0.0001). CONCLUSIONS: Newcomer mothers have an increased risk for PPD symptoms. Social support interventions should be tested for their ability to prevent or alleviate this risk.

Refugee and refugee-claimant women and infants post-birth: migration histories as a predictor of Canadian health system response to needs.

BACKGROUND: Minority women from conflict-laden areas with limited host-country knowledge are among the most vulnerable migrants. Their risk status and that of their infants is magnified during pregnancy, birth, and post-birth. We conducted a study to determine whether women's postnatal health concerns were addressed by the Canadian health system differentially based on migration status (refugee, refugee-claimant, immigrant, and Canadian-born) or city of residence. METHODS: Women speaking any of 13 languages were recruited (with their infants) from postpartum units in the main Canadian receiving cities for newcomers (Toronto, Montreal, Vancouver; total n = 341 pairs from 10 hospitals) and followed at home after birth. Our primary interest was 'unaddressed concerns'; nurse-identified health concerns based on standards of postpartum care for the woman/infant at 7-10 days post-birth, for which no professional attention had been given or planned. RESULTS: A difference in unaddressed concerns by migration status was not found in our primary model [OR refugees vs. Canadian-born = 1.40 (95% CI: 0.67-2.93); refugee-claimants, 1.20 (0.61-2.34); immigrants, 1.02 (0.56-1.85)] although differences by city of residence remained after controlling for migration status, income, education, maternal region of birth, language ability, referral status, and type of birth [Toronto vs. Vancouver OR = 3.63 (95% CI: 2.00-6.57); Montreal, 1.88 (1.15-3.09)]. The odds of unaddressed concerns were greater in all migrant groups [OR refugees vs. Canadian-born = 2.42 (95% CI: 1.51-3.87); refugee-claimants, 1.64 (1.07-2.49); immigrants, 1.54 (1.00-2.36)] when analyses excluded variables which may be on the causal pathway. INTERPRETATION: Women and their newborn infants living in Toronto or Montreal may require additional support in having their health and social concerns addressed. The definitive effect of migrant group needs confirmation in larger studies.

Neuroimaging and genetics of borderline personality disorder: a review.

Borderline personality disorder (BPD) is a highly prevalent psychiatric disorder that carries a severe risk factor for adolescent and young adult suicide. Relatively little research has examined its biological etiology. Differences in the volume and activity in brain structures related to emotion and impulsivity have been observed between individuals who have BPD and those who do not. The present study seeks to assess current research on the neuroanatomical differences observed between individuals with and without BPD and the genes that may play a role in the development of this disorder.

Management of febrile neutropenia in pediatric oncology patients: a Canadian survey.

BACKGROUND: Traditionally, febrile neutropenia in pediatric oncology patients has been managed aggressively with hospital admission and intravenous antibiotics. Recent studies suggest that less intensive interventions are effective for selected children. Study of Canadian practice patterns may help better understand the current context of care for these patients. PROCEDURE: We carried out a cross-sectional mailed survey of the 17 tertiary pediatric centers in Canada. A 36-item questionnaire gathered information on oncology department characteristics, the existence of protocols for management of febrile neutropenia, use of outpatient therapy or early discharge, criteria used to identify patients at low risk, and opinions of oncologists. RESULTS: A total of 16 (94%) completed questionnaires were returned, reflecting a treatment population of approximately 2,100 children with febrile neutropenia/year. Three out of seventeen centers carry out exclusively traditional management. The remaining 14 offer modified treatment for low risk children. The majority (n = 10) carry out an early discharge approach. Two thirds of the episodes of febrile neutropenia are treated this way with good results. The rest (n = 4) implement complete outpatient management. Approximately 120 patients benefit from this annually, with a reportedly high success rate. Most specialists agreed on the benefits of decreased hospitalization for children with cancer. However, about half considered the level of evidence is not sufficient to fully implement complete outpatient management. CONCLUSIONS: Variations in the treatment of pediatric febrile neutropenia have been extensively implemented across Canada. However more evidence, ideally in the form of multicenter clinical trials, appears to be needed to further safely modify practice.

The childbearing health and related service needs of newcomers (CHARSNN) study protocol.

BACKGROUND: Refugee and asylum-seeking women in Canada may have significant harmful childbearing health outcomes and unmet health and social care needs. The most vulnerable of these women are: those who have left their countries by force (e.g., war, rape or abuse histories), are separated from their families, have limited knowledge of the host country languages, and are visible minorities. Asylum-seekers face additional stresses related to their unknown future status and are marginalized with regards to access to provincial health care systems. The prevalence and severity of health issues in this population is not known nor is the extent of response from social service and health care systems (including variation in provincial service delivery). Understanding the magnitude of health and social concerns of newcomers requires data from a representative sample of childbearing refugee and asylum-seeking women resettling in Canada to permit comparisons to be made with non-refugee immigrant and Canadian-born women. Our research questions are: (1) Do refugee or asylum-seeking women and their infants, experience a greater number or a different distribution of harmful health events during pregnancy, at birth, and during the postpartum period than non-refugee immigrant or Canadian-born women? (2) Are the harmful health events experienced postpartum by asylum-seeking women and their infants, addressed less often (compared to refugees, non-refugee immigrants, and Canadian-born women) by the Canadian health care system as delivered in each of the three major receiving cities for newcomers? METHODS/DESIGN: This is a four-year multi-site prospective cohort study (pregnancy to 4 months postpartum). We will seek to recruit 2400 women [200 in each of 4 groups (refugees, asylum-seekers, non-refugee immigrants, and Canadian-born) from 1 of 12 postpartum hospital units across the 3 largest receiving cities for newcomers to Canada - Montreal, Toronto, and Vancouver]. DISCUSSION: Knowledge of the extent of harmful health events occurring to asylum-seeking, refugee, immigrant, and Canadian-born women, and the response of the health care system to those events and group differences, if they exist, will inform immigration and health policy makers as well as providers of services.

Identifying children at high risk for psychological sequelae after pediatric intensive care unit hospitalization.

OBJECTIVE: To identify those patients in a pediatric intensive care unit who may be at highest risk for developing persistent psychological sequelae after hospital discharge. DESIGN: A secondary data analysis was conducted to examine data gathered in an earlier study of children's psychological responses after critical illness. The current study focused exclusively on patients who required pediatric intensive care unit hospitalization. PATIENTS: Sixty children, aged 6 to 17 yrs, hospitalized in two Canadian pediatric intensive care units. PROCEDURES: Children were categorized as either high risk or low risk for developing persistent psychological sequelae after discharge based on their level of illness severity and the number of invasive procedures to which they were exposed. Outcome data were analyzed using descriptive statistics, followed by an assessment of group differences at baseline, 6 wks, and 6 mos postdischarge. Combined effects of invasive procedures and illness severity on the outcome variables were explored. OUTCOME MEASURES: Three questionnaires were completed by all children 6 wks and 6 mos postdischarge, including the Children's Impact of Events Scale, the Children's Medical Fears Scale, and the Children's Health Locus of Control Scale. RESULTS: Children in the high risk group demonstrated more psychological sequelae 6 wks and 6 mos postdischarge. Exposure to high numbers of invasive procedures was the most important predictor of group differences 6 wks postdischarge. CONCLUSIONS: Findings suggest there is a group of children in the pediatric intensive care unit who are at higher risk for developing persistent psychological sequelae postdischarge. Exposure to high numbers of invasive procedures may be the driving force behind group differences, particularly at 6 wks postdischarge. These children warrant closer observation and follow-up.

Randomized trial of postpartum care after hospital discharge.

OBJECTIVE: Harmful effects of short postpartum hospital stays include dehydration and malnutrition of breastfed infants. These may be prevented by adequate breastfeeding frequency; however, rigorous research to determine the relative effectiveness of various follow-up strategies in supporting breastfeeding frequency is absent. This study addressed the question, "Is there a difference in breastfeeding frequency or infant weight gain for singleton infants discharged within 36 hours' postpartum who received either community nurse (home visit) or hospital nurse (clinic) follow-up?" METHODS: A randomized, controlled trial was conducted at a university teaching hospital (3700 births/y) and affiliated community health centers. A consecutive sample of 586 healthy mother-infant pairs were recruited from January 1997 to September 1998 before discharge; 513 (87.5%) contributed data on 1 or more outcomes. Forty-eight-hour postpartum telephone contact and day 3 nurse contact in the home (experimental) or at the hospital (control) were provided. The main outcomes measured were breastfeeding frequency and infant weight gain assessed at 2 weeks' postpartum by maternal diary and weight at home by research assistants, masked to group allocation. RESULTS: No clinically important or statistically significant group differences were found in daily breastfeeding frequency (mean difference experimental minus control = 0.1 feeds [95% confidence interval: -0.1-0.3]) or daily rate of infant weight gain (-1.1 g [-2.5-0.3]) based on intention-to-treat analyses. CONCLUSIONS: Follow-up by nurses after short postpartum hospital stays, in either the home or a hospital-based clinic, of healthy infants discharged at <36 hours seems associated with satisfactory infant breastfeeding outcomes.

Children's psychological responses after critical illness and exposure to invasive technology.

Children hospitalized in pediatric intensive care units (PICUs) are subjected to highly invasive interventions necessary in overcoming the critical period of their illness, yet little is known about their subsequent psychological adjustment. The purposes of this study were to compare the psychological responses of children hospitalized in a PICU with those of children hospitalized on a general ward and to identify clinically relevant factors that might be associated with psychological outcome. A prospective cohort design was used to follow 120 children for 6 months after PICU and ward discharge. Groups were compared on the children's sense of control over their health, their medical fears, posttraumatic stress, and changes in behavior. Relationships between children's responses and their age, the invasive procedures to which they were exposed, severity of illness, and length of hospital stay were also examined. No significant group differences were found. However, children who were younger, more severely ill, and who endured more invasive procedures had significantly more medical fears, a lower sense of control over their health, and ongoing posttraumatic stress responses for 6 months postdischarge. Findings indicate that regardless of the hospital setting, invasiveness coupled with length of stay and severity of illness in young children may have adverse long-term effects.

Screening of infants and mortality due to neuroblastoma.

BACKGROUND: Neuroblastoma, the most common extracranial solid tumor that occurs in early childhood, can be identified in the preclinical stages by the detection of catecholamines in the urine. However, it is unknown whether routine screening for neuroblastoma reduces mortality due to this disease. METHODS: Through their parents, we offered screening for neuroblastoma at three weeks and six months of age to all 476,654 children born in the province of Quebec, Canada, during a five-year period (May 1, 1989, through April 30, 1994). The participation rate was 92 percent. The rate of death due to neuroblastoma was determined and compared with the rates in several unscreened control populations born during the same period. RESULTS: Among children younger than eight years of age in the Quebec cohort, there were 22 deaths due to neuroblastoma; the cumulative (+/-SE) mortality rate due to neuroblastoma was 4.78+/-1.14 per 100,000 children over a period of nine years. The standardized incidence ratios for death due to neuroblastoma for the Quebec cohort were 1.11 (95 percent confidence interval, 0.64 to 1.92) as compared with a control group in Ontario, Canada; 0.90 (95 percent confidence interval, 0.48 to 1.70) as compared with a control group in Minnesota; 1.40 (95 percent confidence interval, 0.81 to 2.41) as compared with a control group in Florida; and 0.96 (95 percent confidence interval, 0.56 to 1.66) as compared with a control group in the Greater Delaware Valley. The standardized mortality ratio for the Quebec cohort as compared with the rest of Canada was 1.39 (95 percent confidence interval, 0.85 to 2.30); the odds ratio for the comparison with a cohort born in Quebec before the screening program began was 0.98 (95 percent confidence interval, 0.54 to 1.77). CONCLUSIONS: Screening infants for neuroblastoma does not appear to reduce mortality due to this disease.

Lacunarity analysis of spatial pattern in CT images of vertebral trabecular bone for assessing osteoporosis.

The structural integrity of vertebral trabecular bone is determined by the continuity of its trabecular network and the size of the holes comprising its marrow space, both of which determine the apparent size of the marrow spaces in a transaxial CT image. A model-independent assessment of the trabeculation pattern was determined from the lacunarity of thresholded CT images. Using test images of lumbar vertebrae from human cadavers, acquired at different slice thicknesses, we determined that both median thresholding and local adaptive thresholding (using a 7 x 7 window) successfully segmented the grey-scale images. Lacunarity analysis indicated a multifractal nature to the images, and a range of marrow space sizes with significant structure around 14-18 mm(2). Preliminary studies of in vivo images from a clinical CT scanner indicate that lacunarity analysis can follow the pattern of bone loss in osteoporosis by monitoring the homogeneity of the marrow spaces, which is related to the connectivity of the trabecular bone network and the marrow space sizes. Although the patient sample was small, derived parameters such as the maximum deviation of the lacunarity from a neutral (fractal) model, and the maximum derivative of this deviation, seem to be sufficiently sensitive to distinguish a range of bone conditions. Our results suggest that these parameters, used with bone mineral density values, may have diagnostic value in characterizing osteoporosis and predicting fracture risk.