Factors Affecting Emergency Department Computed Tomography Use in Children.

BACKGROUND: Variability in computed tomography (CT) use during pediatric emergency department (ED) visits has been reported. Our objective was to identify patient and hospital characteristics associated with CT use during pediatric ED visits. METHODS: Patients <18 y treated and released from EDs in the 2006-2012 Nationwide Emergency Department Sample were included. Associations were evaluated between pediatric CT scan rate and patient/hospital factors using logistic mixed effects models. Independent predictors of being a high outlier (having a pediatric CT scan rate in the top 10%) were also evaluated using logistic regression models. RESULTS: There were 1543 EDs and 20,703,273 visits included. CT scans were prescribed in 4.7% of pediatric ED visits; the highest 10% of EDs prescribed CT scans in >7.63% of all pediatric visits. In multivariable analysis, older age, male gender, private insurance, higher zip code level median income, and higher injury severity were all associated with an increased probability of receiving a CT scan (all P < 0.001). The chance of receiving a CT scan also varied by diagnosis and was independently associated with geographic location and annual pediatric ED volume. Rates of CT use increased with increasing pediatric volume up to approximately 5400 annual pediatric visits, and then decreased with volume >5400 annual visits. CONCLUSIONS: Several patient-level and ED-level characteristics, including annual pediatric volume, are associated with the probability of a child having a CT scan during an ED visit. Future work should focus on determining drivers behind these associations to develop intervention strategies to decrease pediatric CT use.

Can fecal continence be predicted in patients born with anorectal malformations?

PURPOSE: The purpose of this study was to identify factors associated with attaining fecal continence in children with anorectal malformations (ARM). METHODS: We performed a multi-institutional cohort study of children born with ARM in 2007-2011 who had spinal and sacral imaging. Questions from the Baylor Social Continence Scale were used to assess fecal continence at the age of ≥4 years. Factors present at birth that predicted continence were identified using multivariable logistic regression. RESULTS: Among 144 ARM patients with a median age of 7 years (IQR 6-8), 58 (40%) were continent. The rate of fecal continence varied by ARM subtype (p = 0.002) with the highest rate of continence in patients with perineal fistula (60%). Spinal anomalies and the lateral sacral ratio were not associated with continence. On multivariable analysis, patients with less severe ARM subtypes (perineal fistula, recto-bulbar fistula, recto-vestibular fistula, no fistula, rectal stenosis) were more likely to be continent (OR = 7.4, p = 0.001). CONCLUSION: Type of ARM was the only factor that predicted fecal continence in children with ARM. The high degree of incontinence, even in the least severe subtypes, highlights that predicting fecal continence is difficult at birth and supports the need for long-term follow-up and bowel management programs for children with ARM. TYPE OF STUDY: Prospective Cohort Study. LEVEL OF EVIDENCE: II.

Disparities in Radiation Burden from Trauma Evaluation at Pediatric Versus Nonpediatric Institutions.

BACKGROUND: Computed tomography (CT) imaging protocols and prescribing practices vary across institutions. Pediatric trauma patients imaged at a pediatric trauma center (PTC) may receive less radiation than patients imaged at non-PTCs before transfer. Our objective was to determine differences in radiation exposure from imaging performed at a PTC versus non-PTCs. METHODS: This retrospective analysis included patients <18 y old who underwent CT imaging from January 2013 to August 2015 during a trauma-related encounter. Radiation doses from CT scans were estimated and compared between scans performed at our PTC and non-PTCs before patient transfer using propensity score-weighted median regression. RESULTS: Of 3530 CT scans, 3021 were performed at our PTC and 509 at non-PTCs. Patients imaged at non-PTCs were older and had higher injury severity (all P < 0.05). Patients imaged at non-PTCs more frequently had neck CT (29.0% versus 7.3%) and chest CT (8.3% versus 2.7%), less frequently had abdomen/pelvis CT (19.5% versus 27.9%, all P < 0.01), and had similar rates of head CT (83.9% versus 80.9%, P = 0.18). After propensity weighting, CT scanning was more frequent at non-PTCs and patients received higher cumulative radiation exposure overall (median effective dose 2.36 versus 1.57 mSv, P < 0.001) and for each body region imaged (17% more for head, 191% for neck, 81% for chest, and 33% for abdomen/pelvis). CONCLUSIONS: Pediatric trauma patients imaged at a PTC receive lower radiation burden from CT imaging than patients initially imaged at adult institutions. Broader adoption of pediatric dosing protocols or deferring noncritical CT scans until transfer may mitigate these disparities.

Screening practices and associated anomalies in infants with anorectal malformations: Results from the Midwest Pediatric Surgery Consortium.

BACKGROUND: This study evaluates screening practices and the incidence of associated anomalies in infants with anorectal malformations (ARM). METHODS: We performed a multi-institutional retrospective cohort study of children born between 2007 and 2011 who underwent surgery for ARM at 10 children's hospitals. ARM type was classified based on the location of the distal rectum, and all screening studies were reviewed. RESULTS: Among 506 patients, the most common ARM subtypes were perineal fistula (40.7%), no fistula (11.5%), and vestibular fistula (10.1%). At least 1 screening test was performed in 96.6% of patients, and 11.3% of patients underwent all. The proportion of patients with ≥1 abnormal finding on any screening test varied by type of ARM (p<0.001). Screening rates varied from 15.2% for limb anomalies to 89.7% for renal anomalies. The most commonly identified anomalies by screening category were: spinal: tethered cord (20.6%); vertebral: sacral dysplasia/hemisacrum (17.8%); cardiac: patent foramen ovale (58.0%); renal: hydronephrosis (22.7%); limb: absent radius (7.9%). CONCLUSION: Screening practices and the incidence of associated anomalies varied by type of ARM. The rate of identifying at least one associated anomaly was high across all ARM subtypes. Screening for associated anomalies should be considered standard of care for all ARM patients. TYPE OF STUDY: Multi-institutional retrospective cohort study. LEVEL OF EVIDENCE: III.

Sclerotherapy for splenic cysts in children.

BACKGROUND: Sclerotherapy has been described as a treatment option for nonparasitic pediatric splenic cysts; however, there are limited data on its long-term effectiveness. METHODS: We performed a retrospective review and prospective follow-up imaging study of children treated for nonparasitic splenic cysts at our institution during 2006-2015. Included patients had International Classification of Disease, Ninth Revision, Clinical Modification diagnosis code 289.59 or 759.0 and underwent either sclerotherapy or a partial splenic operation (partial splenectomy, cyst excision, or marsupialization). Charts were reviewed for demographics, imaging, treatments, and complications. Identified patients were contacted and asked to return for splenic ultrasonography. RESULTS: Six surgical patients and 19 sclerotherapy patients were identified. Sclerotherapy patients underwent a median of four treatments with a decrease in the size of the cyst or complete ablation in 89.5% (17/19). Of the two patients who underwent unsuccessful sclerotherapy, one patient had sclerotherapy with sotradecol and ethanol for eight treatments, developed infection, and underwent total splenectomy. The other patient did not improve with sclerotherapy and underwent partial splenectomy. Nine patients (eight patients treated with sclerotherapy and one patient treated with partial splenectomy) were successfully contacted and underwent follow-up imaging at a median follow-up of 2.4 y since last treatment. Of the eight patients treated with sclerotherapy, four patients remained cyst-free, three had small residual asymptomatic cysts stable in size, and one developed a recurrent small asymptomatic cyst; the patient treated with surgery had no recurrence. CONCLUSIONS: Sclerotherapy appears to be an effective and durable alternative treatment for children with splenic cysts.

How to identify high radiation burden from computed tomography: an example in obese children.

BACKGROUND: Radiation burden from the use of computed tomography (CT) imaging may not be evenly distributed. We tested whether overweight and obese children receive higher radiation burden from CT imaging. METHODS: An automated software tool (DoseWizard) assessed patient-level radiation dose from CT and merged results with clinical data from the electronic health record. CT scans of the head, chest, and abdomen/pelvis (A/P) performed at our institution from January 2013 to August 2015 on patients aged <16 y were processed using this software. Patients were categorized as overweight/obese if they had a body mass index (BMI) greater than the 85th percentile for age. Radiation exposures were compared between groups. Higher dose CT scans were identified as having a radiation dose in the top decile. Multivariate analysis identified factors associated with high-dose CT scans. RESULTS: About 7212 CT scans were included. Overweight/obese patients received similar radiation dose for head CT as compared with normal weight patients (1.51 versus 1.49 mSv, P = 0.04) but higher radiation dose for chest (1.14 versus 0.81 mSv, P < 0.001) and A/P (1.97 versus 1.43 mSv, P < 0.001). In multivariable regression models, being overweight/obese increased the odds of a higher dose chest CT (odds ratio 2.24, P < 0.001) and A/P CT (odds ratio 7.24, P < 0.001). CONCLUSIONS: Overweight and obese children receive higher radiation burden from CT imaging and are one group that deserves consideration of dose monitoring. This software tool can be used to measure changes in radiation exposure and run clinical decision support in future studies targeting high radiation exposure to children.

Patient characteristics associated with differences in radiation exposure from pediatric abdomen-pelvis CT scans: a quantile regression analysis.

BACKGROUND: Computed tomography (CT) is a widely used diagnostic tool in pediatric medicine. However, due to concerns regarding radiation exposure, it is essential to identify patient characteristics associated with higher radiation burden from CT imaging, in order to more effectively target efforts towards dose reduction. Our objective was to identify the effects of various demographic and clinical patient characteristics on radiation exposure from single abdomen/pelvis CT scans in children. METHODS: CT scans performed at our institution between January 2013 and August 2015 in patients under 16 years of age were processed using a software tool that estimates patient-specific organ and effective doses and merges these estimates with data from the electronic health record and billing record. Quantile regression models at the 50th, 75th, and 90th percentiles were used to estimate the effects of patients' demographic and clinical characteristics on effective dose. RESULTS: 2390 abdomen/pelvis CT scans (median effective dose 1.52mSv) were included. Of all characteristics examined, only older age, female gender, higher BMI, and whether the scan was a multiphase exam or an exam that required repeating for movement were significant predictors of higher effective dose at each quantile examined (all p<0.05). The effects of obesity and multiphase or repeat scanning on effective dose were magnified in higher dose scans. CONCLUSIONS: Older age, female gender, obesity, and multiphase or repeat scanning are all associated with increased effective dose from abdomen/pelvis CT. Targeted efforts to reduce dose from abdominal CT in these groups should be undertaken.

Sacral nerve stimulation allows for decreased antegrade continence enema use in children with severe constipation.

BACKGROUND: Sacral nerve stimulation (SNS) can be beneficial for children with constipation, but no studies have focused on children with constipation severe enough to require antegrade continence enemas (ACEs). Our objective was to evaluate the efficacy of SNS in children with constipation treated with ACE. METHODS: Using a prospective patient registry, we identified patients <21years old who were receiving ACE prior to SNS placement. We compared ACE/laxative usage, PedsQL Gastrointestinal Symptom Scale (GSS), Fecal Incontinence Quality of Life Scale (FIQL), Fecal Incontinence Severity Index (FISI), and Vancouver Dysfunctional Elimination Syndrome Score (DES) at baseline and progressive follow-up time intervals. RESULTS: Twenty-two patients (55% male, median 12years) were included. Median ACE frequency decreased from 7 per week at baseline to 1 per week at 12months (p<0.0001). Ten children (45%) had their cecostomy/appendicostomy closed. Laxative use, GSS, FIQL, and DES did not change. FISI improved over the first 12months with statistical significance reached only at 6months (p=0.02). Six (27%) children experienced complications after SNS that required further surgery. CONCLUSIONS: In children with severe constipation dependent on ACE, SNS led to a steady decrease in ACE usage with nearly half of patients receiving cecostomy/appendicostomy closure within 2years. LEVEL OF EVIDENCE: IV.

Lymphocyte depression as a predictor of postoperative intraabdominal abscess after appendectomy in children.

BACKGROUND: This study evaluated the efficacy of lymphopenia to predict postappendectomy intraabdominal abscess (IAA) in pediatric complex appendicitis. METHODS: This single-center retrospective cohort study included appendectomy patients with complex appendicitis from 4/2012 to 10/2014. IAA was diagnosed based on imaging or undergoing a drainage procedure. Labs were used from the closest day prior to abscess diagnosis or day of discharge from index admission. Lymphocyte percentage was categorized based on age-specific cutoffs with lymphopenia defined as a low percentage. Comparisons were made using chi-square or Fisher exact tests for categorical variables and Mann-Whitney U-tests for continuous variables. RESULTS: Of 611 appendectomy patients with complicated appendicitis, 551 had WBC and differential. IAA was identified in 79 (12.9%) patients. There were no significant differences in demographics between IAA and non-IAA groups. Patients with IAA had higher rates of leukocytosis (44.3% versus 12.3%, p<0.001) and higher rates of age-based lymphopenia (84% vs. 46%, p<0.001). IAA was independently associated with leukocytosis (OR 3.65, p<0.001) and lymphopenia (OR 4.46, p<0.001). Patients with leukocytosis and lymphopenia had the highest abscess rate (36%), and those with normal labs had the lowest (3%, p<0.001). CONCLUSIONS: Lymphocyte depression is a useful adjunct to predict postoperative IAA in patients with complicated appendicitis. LEVEL OF EVIDENCE: III.

Factors affecting pediatric patient transfer in testicular torsion.

BACKGROUND: Testicular torsion is a surgical emergency, and interhospital transfer could delay care and increase the risk of orchiectomy. This study identifies factors associated with transfer for pediatric testicular torsion. METHODS: This retrospective cross-sectional study examined emergency department (ED) visits for testicular torsion by men aged 1-21 y in National Emergency Department Sample from 2006 to 2012. Freestanding children's hospitals were excluded. Analyses were weighted to produce nationally representative estimates. Patient- and institutional-level predictors of transfer were evaluated using Rao-Scott chi-square tests and multivariable logistic regression. RESULTS: There were 11,435 ED visits for testicular torsion resulting in admission or transfer. In multivariable regression, the probability of transfer decreased with increasing age but remained higher for patients aged 15-17 y than for those aged 18-21 y (odds ratio [OR] = 1.51, P < 0.001) and was lower for patients living in zip codes in the highest income quartile (OR = 0.69 versus lowest, P = 0.003) or with listed comorbidities (OR = 0.55, P < 0.001). Transfer was less likely in the Northeast (OR = 0.28 versus Midwest, P < 0.001), at urban hospitals (OR = 0.31, P < 0.001), teaching institutions (OR = 0.55, P < 0.001), and level I or II trauma centers (OR = 0.31, P < 0.001). Transfer was less common with increasing annual pediatric ED volume (OR = 0.95 per 1000 patients, P < 0.001). Transfer rates increased significantly over the study period (23.6%-38.8%, P < 0.001). CONCLUSIONS: Older adolescents with testicular torsion are more likely to be transferred than young adults. Interhospital transfers in these patients may represent a potential target for improving care. Future work should focus on evaluating the effect of transfer on the risk for undergoing orchiectomy.

High failure rate of nonoperative management of acute appendicitis with an appendicolith in children.

BACKGROUND: The purpose of this study was to investigate the feasibility of nonoperative management of acute appendicitis in children with an appendicolith identified on preoperative imaging. STUDY DESIGN: We performed a prospective nonrandomized trial of nonoperative management of uncomplicated acute appendicitis with an appendicolith in children aged 7 to 17years. The primary outcome was the failure rate of nonoperative management, defined as having undergone an appendectomy. Early termination was set to occur if the lower limit of the 95% confidence interval of the failure rate was greater than 20% at 30days or 30% at 1year. RESULTS: Recruitment for this study was halted after enrollment of 14 patients (N=5 nonoperative; N=9 surgery). The failure rate of nonoperative management was 60% (3/5) at a median follow-up of 4.7months (IQR 1.0-7.6) with a 95% CI of 23%-88%. None of the three patients that failed nonoperative management had complicated appendicitis at the time of appendectomy, while six out of nine patients who chose surgery had complicated appendicitis (0/3 vs. 6/9, p=0.18). The trial was stopped for concerns over patient safety. CONCLUSIONS: Nonoperative management of acute appendicitis with an appendicolith in children resulted in an unacceptably high failure rate.

Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis.

IMPORTANCE: Current evidence suggests that nonoperative management of uncomplicated appendicitis is safe, but overall effectiveness is determined by combining medical outcomes with the patient's and family's perspective, goals, and expectations. OBJECTIVE: To determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children. DESIGN, SETTING, AND PARTICIPANTS: Prospective patient choice cohort study in patients aged 7 to 17 years with acute uncomplicated appendicitis presenting at a single pediatric tertiary acute care hospital from October 1, 2012, through March 6, 2013. Participating patients and families gave informed consent and chose between nonoperative management and urgent appendectomy. INTERVENTIONS: Urgent appendectomy or nonoperative management entailing at least 24 hours of inpatient observation while receiving intravenous antibiotics and, on demonstrating improvement of symptoms, completion of 10 days of treatment with oral antibiotics. MAIN OUTCOMES AND MEASURES: The primary outcome was the 1-year success rate of nonoperative management. Successful nonoperative management was defined as not undergoing an appendectomy. Secondary outcomes included comparisons of the rates of complicated appendicitis, disability days, and health care costs between nonoperative management and surgery. RESULTS: A total of 102 patients were enrolled; 65 patients/families chose appendectomy (median age, 12 years; interquartile range [IQR], 9-13 years; 45 male [69.2%]) and 37 patients/families chose nonoperative management (median age, 11 years; IQR, 10-14 years; 24 male [64.9%]). Baseline characteristics were similar between the groups. The success rate of nonoperative management was 89.2% (95% CI, 74.6%-97.0%) at 30 days (33 of 37 children) and 75.7% (95% CI, 58.9%-88.2%) at 1 year (28 of 37 children). The incidence of complicated appendicitis was 2.7% in the nonoperative group (1 of 37 children) and 12.3% in the surgery group (8 of 65 children) (P = .15). After 1 year, children managed nonoperatively compared with the surgery group had fewer disability days (median [IQR], 8 [5-18] vs 21 [15-25] days, respectively; P < .001) and lower appendicitis-related health care costs (median [IQR], $4219 [$2514-$7795] vs $5029 [$4596-$5482], respectively; P = .01). CONCLUSIONS AND RELEVANCE: When chosen by the family, nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis, incurring less morbidity and lower costs than surgery. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01718275.

Variation in Utilization of Computed Tomography Imaging at Tertiary Pediatric Hospitals.

BACKGROUND: Recent efforts have focused on reducing computed tomography (CT) imaging in children. Although published reports show variability in CT scanning for specific indications, an assessment of the effects of institutional factors (case-mix or hospital volume) on the rate of CT scanning for any indication is necessary to better understand variability across pediatric hospitals. METHODS: Data from 2009 to 2013 on inpatient, observation, and emergency department (ED) encounters were extracted from the Pediatric Health Information System. Chronological trends and institutional variability in CT scan rates were examined by using negative binomial regression models. Case-mix was adjusted by using All Patient Refined Diagnosis Related Groups and severity level. RESULTS: Thirty hospitals were included. There were 12 531 184 patient encounters and 701 644 CT scans resulting in a mean of 56 scans per 1000 encounters (range: 26-108). The most common scan types were head (60.1%) and abdomen/pelvis (19.9%). There was an inverse relationship between the CT scan rate and hospital volume (P = .002) and a direct relationship between the CT scan rates for inpatient/observation and ED encounters (P < .001). The rate of CT imaging decreased from 69.2 to 49.6 scans per 1000 encounters during the study period (P < .001). CONCLUSIONS: The overall use of CT imaging is decreasing, and significant variability remains in CT use across tertiary pediatric hospitals. Hospital volume and institutional-level practices account for a significant portion of the variability. This finding suggests an opportunity for standardization through multi-institutional quality improvement projects to reduce CT imaging.

Current surgical management of intestinal rotational abnormalities.

PURPOSE OF REVIEW: At present, there is a debate as to the management of malrotation in pediatric patients. This review highlights recent literature including the role of laparoscopy, and the management of asymptomatic patients with and without congenital cardiac disease. RECENT FINDINGS: Symptomatic patients are still recommended to undergo open Ladd's procedure. Laparoscopic Ladd's procedure in asymptomatic patients confers a shorter time to tolerating feeds, shorter length of stay, and a decreased rate of bowel obstruction and other complications. It may, however, carry a higher risk of postoperative volvulus. Diagnostic laparoscopy is recommended in asymptomatic patients in whom the diagnosis is uncertain on upper gastrointestinal imaging. Asymptomatic patients with congenital heart disease may be managed with initial observation or operation, based upon individualized risk benefit assessment. If an elective Ladd's procedure is performed, it should take place after palliative cardiac operations have resulted in stable cardiac function. Screening upper gastrointestinal studies in heterotaxy patients may be unnecessary as the reported rates of volvulus in recent studies are low. SUMMARY: Laparoscopic Ladd's procedure may be an acceptable alternative to an open procedure for asymptomatic patients. Observation of asymptomatic patients with congenital cardiac disease is a reasonable alternative in selected patients.