Cost of Unnecessary Testing in the Evaluation of Pediatric Syncope.

Syncope is a common and a typically benign clinical problem in children and adolescents. The majority of tests ordered in otherwise healthy pediatric patients presenting with syncope have low diagnostic yield. This study quantifies testing and corresponding patient charges in a group of pediatric patients presenting for outpatient evaluation for syncope. Patients seen between 3/2011 and 4/2013 in the multi-disciplinary Syncope Clinic at Cincinnati Children's Hospital Medical Center were enrolled in a registry which was reviewed for patient information. The electronic medical record was used to determine which syncope patients underwent cardiac (electrocardiogram, echocardiogram, or exercise testing) or neurologic (head CT/MRI or electroencephalogram) testing within the interval from 3 months before to 3 months after the Syncope Clinic visit. Testing charges were obtained through hospital billing records. 442 patients were included for analysis; 91% were Caucasian; 65.6% were female; median age was 15.1 years (8.1-21.2 years). Cardiac and neurologic testing was common in this population. While some testing was performed during the Syncope Clinic visit, 46% of the testing occurred before or after the visit. A total of $1.1 million was charged to payers for cardiac and neurological testing with an average total charge of $2488 per patient. Despite the typically benign etiology of pediatric syncope, patients often have expensive and unnecessary cardiac and/or neurologic testing. Reducing or eliminating this unnecessary testing could have a significant impact on healthcare costs, especially as the economics of healthcare shift to more capitated systems.

The Evaluation and Management of Pediatric Syncope.

Syncope is a common problem in children and adolescents. It is typically caused by benign neurally mediated hypotension, but other, more concerning, etiologies of syncope must be considered. In most instances, the underlying cause of syncope in the pediatric patient can be determined by obtaining a thorough history and physical examination. Attention to the cardiac, neurological, and psychological history and examination can rule out more rare causes of loss of consciousness. Most individuals with neurally mediated hypotension can be treated with lifestyle measures including aggressive hydration, dietary salt, and an exercise program. In instances where lifestyle modification fails, medications may offer symptomatic improvement.

Dynamic properties of functional connectivity in the rodent.

Functional connectivity mapping with resting-state magnetic resonance imaging (MRI) has become an immensely powerful technique that provides insight into both normal cognitive function and disruptions linked to neurological disorders. Traditionally, connectivity is mapped using data from an entire scan (minutes), but it is well known that cognitive processes occur on much shorter time scales (seconds). Recent studies have demonstrated that the correlation between the blood oxygenation level-dependent (BOLD) MRI signal from different areas varies over time, motivating a further exploration of these fluctuations in apparent connectivity. However, it has also been shown that similar changes in correlation can arise when the timing relationships between voxels are randomized (Handwerker et al., 2012 ). In this work, we show that functional connectivity in the anesthetized rat exhibits dynamic properties that are similar to those previously observed in awake humans (Chang and Glover, 2010 ) and anesthetized monkeys (Hutchison et al., 2012 ). Sliding window correlation between BOLD time courses obtained from bilateral cortical and subcortical regions of interest results in periods of variable positive and negative correlation for most pairs of areas except homologous areas in opposite hemispheres, which exhibit a primarily positive correlation. A comparison with sliding window correlation of randomly matched time courses suggests that with the exception of homologous areas and sensorimotor connections, the dynamics cannot be distinguished from random fluctuations in correlation over time, supporting the idea that some of these dynamic patterns may be due to inherent properties of the signal rather than variations in neural coherence. Within the pairs of areas where the dynamics are most different from those of randomly matched time courses, ten common patterns of connectivity are identified, and their occurrence as a function of time is plotted for all animals. The observation of time-varying correlation in the rodent model will facilitate the future multimodal experiments needed to determine whether the changes in apparent connectivity are linked to underlying neural variability.

FLACC Behavioral Pain Assessment Scale: a comparison with the child's self-report.

The purpose of this study was to further test the validity of the Faces, Legs, Activity, Cry and Consolability (FLACC) Behavioral Pain Assessment Scale for use with children. Thirty children aged 3-7 years (5.01 +/- 1.44) who had undergone a variety of surgical procedures were observed and assessed for pain intensity at 20 + 2 hours after surgery. FLACC scores were assigned by one of the nurse investigators, and a self-report of pain using the FACES scale was obtained from the child. There were significant and positive correlations between the FLACC and FACES scores for the entire sample and for the scores of children 5-7 years of age, but not for children < age 5. These findings provide additional support for the construct validity of the FLACC Pain Assessment Tool.