Kara Hennelly

Advanced Radiologic Imaging for Pediatric Appendicitis, 2005-2009: Trends and Outcomes

OBJECTIVES To examine the variability in the use of computed tomography (CT) and ultrasound (US) for children with appendicitis and identify associations with clinical outcomes, and to demonstrate any trends in diagnostic imaging between 2005 and 2009. STUDY DESIGN This was a retrospective review of children evaluated for appendicitis in an emergency department between 2005 and 2009 using an administrative database of 40 pediatric institutions in the United States. Imaging utilization by institutions was studied for association with 3 clinical outcomes. RESULTS A total of 55 238 children with appendicitis were studied. Utilization of CT and US varied widely across institutions, with medians of 34% (IQR, 21%-49%) for CT and 6% (IQR, 2%-26%) for US. Increased use of US or a combination of CT and US (but not of CT use alone) was associated with a lower negative appendectomy rate. Imaging was not associated with other clinical outcomes. In children with appendicitis, the use of US has increased since 2007, whereas that of CT has decreased. CONCLUSION There is considerable variation in the use of CT and US for children with appendicitis at major pediatric institutions. At the institutional level, increased use of US or combined US and CT is associated with a lower negative appendectomy rate. Despite the better diagnostic accuracy of CT compared with US, the use of CT is decreasing.

Diagnostic Imaging and Negative Appendectomy Rates in Children: Effects of Age and Gender

BACKGROUND AND OBJECTIVES: Diagnostic imaging is often used in the evaluation of children with possible appendicitis. The utility of imaging may vary according to a patient’s age and gender. The objectives of this study were (1) to examine the use of computed tomography (CT) and ultrasound for age and gender subgroups of children undergoing an appendectomy; and (2) to study the association between imaging and negative appendectomy rates (NARs) among these subgroups. METHODS: Retrospective review of children presenting to 40 US pediatric emergency departments from 2005 to 2009 (Pediatric Health Information Systems database). Children undergoing an appendectomy were stratified by age and gender for measuring the association between ultrasound and CT use and the outcome of negative appendectomy. RESULTS: A total of 8 959 155 visits at 40 pediatric emergency departments were investigated; 55 227 children had appendicitis. The NAR was 3.6%. NARs were highest for children younger than 5 years (boys 16.8%, girls 14.6%) and girls older than 10 years (4.8%). At the institutional level, increased rates of diagnostic imaging (ultrasound and/or CT) were associated with lower NARs for all age and gender subgroups other than children younger than 5 years, The NAR was 1.2% for boys older than 5 years without any diagnostic imaging. CONCLUSIONS: The impact of diagnostic imaging on negative appendectomy rate varies by age and gender. Diagnostic imaging for boys older than 5 years with suspected appendicitis has no meaningful impact on NAR. Diagnostic strategies for possible appendicitis should incorporate the risk of negative appendectomy by age and gender.

Booster Seat Laws and Fatalities in Children 4 to 7 Years of Age

OBJECTIVE: To determine whether state booster seat laws were associated with decreased fatality rates in children 4 to 7 years of age in the United States. METHODS: Retrospective, longitudinal analysis of all motor vehicle occupant crashes involving children 4 to 7 years of age identified in the Fatality Analysis Reporting System from January 1999 through December 2009. The main outcome measure was fatality rates of motor vehicle occupants aged 4 to 7 years. Because most booster laws exclude children 6 to 7 years of age, we performed separate analyses for children 4 to 5, 6, and 7 years of age. RESULTS: When controlling for other motor vehicle legislation, temporal and economic factors, states with booster seat laws had a lower risk of fatalities in 4- to 5-year-olds than states without booster seat laws (adjusted incidence rate ratio 0.89; 95% confidence interval [CI] 0.81–0.99). States with booster seat laws that included 6-year-olds had an adjusted incidence rate ratio of 0.77 (95% CI 0.65–0.91) for motor vehicle collision fatalities of 6-year-olds and those that included 7-year-olds had an adjusted incidence rate ratio of 0.75 (95% CI, 0.62–0.91) for motor vehicle collision fatalities of 7-year-olds. CONCLUSIONS: Booster seat laws are associated with decreased fatalities in children 4 to 7 years of age, with the strongest association seen in children 6 to 7 years of age. Future legislative efforts should extend current laws to children aged 6 to 7 years.

Factors Associated With the Use of Cervical Spine Computed Tomography Imaging in Pediatric Trauma Patients

OBJECTIVES The objectives were to identify patient and hospital characteristics associated with the use of computed tomography (CT) imaging of the cervical spine (c-spine) in the evaluation of injured children and, in particular, to examine the influence of hospital setting. METHODS This was a retrospective cohort of children younger than 19 years of age from the Massachusetts Hospital Emergency Department (ED) database who were discharged from the ED with an injury diagnosis from 2005 through 2009. Multivariable logistic regression was used to analyze characteristics associated with CT imaging of the c-spine. RESULTS Of the 929,626 pediatric patients diagnosed with an injury in Massachusetts EDs and then discharged home, 1.3% underwent CT imaging of the c-spine. Rates of CT imaging nearly doubled over the 5 years. In the multivariable model, patient age (adjusted odds ratio [AOR] = 2.3, 95% confidence interval [CI] = 2.0 to 2.7 for children age 12 to 18 years vs. under 1 year of age) and evaluation outside of a pediatric Level I trauma center (AOR = 2.2, 95% CI = 1.1 to 4.3 for children evaluated at non Level I trauma centers vs. pediatric Level I trauma centers; AOR = 2.1, 95% CI = 0.93 to 4.7 for children evaluated at adult Level I trauma centers vs. pediatric Level I trauma centers) were associated with higher rates of CT imaging of the c-spine. CONCLUSIONS Cervical spine CT imaging for children discharged from the ED with trauma diagnoses increased from 2005 through 2009. Older age and evaluation outside a Level I pediatric trauma center were associated with a higher c-spine CT rate. Educational interventions focused outside pediatric trauma centers may be an effective approach to decreasing CT imaging of the c-spine of pediatric trauma patients.

Detection of Pulmonary Embolism in High-Risk Children.

OBJECTIVE To evaluate 2 commonly used adult-based pulmonary embolism (PE) algorithms in pediatric patients and to derive a pediatric-specific clinical decision rule to evaluate children at risk for PE, given the paucity of data to guide diagnostic imaging in children for whom PE is suspected. STUDY DESIGN We performed a single-center retrospective study among 561 children <22 years of age undergoing either D-dimer testing or radiologic evaluation (computed tomography or ventilation-perfusion scan) in the emergency department setting for concern of PE. A diagnosis of PE required radiologic confirmation and anticoagulant treatment. We evaluated the test characteristics of the Wells criteria and Pulmonary Embolism Rule-out Criteria (PERC) low-risk rule and used recursive partition analysis to derive a clinical decision rule. RESULTS Among the 561 patients included in the study, 36 (6.4%) were diagnosed with PE. The Wells criteria demonstrated a sensitivity and specificity of 86% and 60%, respectively. The sensitivity and specificity of the PERC were 100% and 24%, respectively. A clinical decision rule including the presence of oral contraceptive use, tachycardia, and oxygen saturation <95% demonstrated a sensitivity and specificity of 90% and 56%, respectively, a positive and negative likelihood ratio of 2.0 and 0.2, and a positive and negative predictive value of 0.12 and 0.99, respectively. CONCLUSIONS The risk of PE is low among children not receiving estrogen therapy and without tachycardia and hypoxia in those with an initial suspicion of PE. Application of the PERC rule and Wells criteria should be used cautiously in the pediatric population.

A 3-MONTH-OLD FEMALE WITH AN INGUINAL MASS

BACKGROUND Inguinal masses are a common finding among infants. The differential diagnosis of these masses in infants is broad, with inguinal hernia being the most common diagnosis in both males and females. However, the evaluation and management of males vs. females with inguinal masses is somewhat different due to the greater potential for gonad involvement in males. OBJECTIVES The pathophysiology and management of inguinal hernias is discussed with a specific focus on inguinal hernias in females. CASE REPORT We present a case of a 3-month-old girl with an inguinal hernia and a mass, found to be an incarcerated ovary. CONCLUSIONS Inguinal masses in infancy are common, with inguinal hernia being the most common cause by far. A female infant with suspected inguinal hernia should be thoroughly evaluated to determine whether ovarian content is present.

Incidence of Morbidity From Penetrating Palate Trauma

BACKGROUND: The true rate of neurologic sequelae and infection from penetrating palatal trauma in children is unknown, which leads to significant variation in testing and treatment. OBJECTIVES: To (1) determine the incidence of stroke and infection in well-appearing children with penetrating palatal trauma and (2) describe patterns of testing and treatment for uncomplicated palatal trauma. METHODS: We assembled a retrospective cohort of children aged 9 months to 18 years with palatal trauma seen in the emergency department (ED) at a tertiary care pediatric hospital. Patients met the following definition: well-appearing with normal neurologic examination and a palate laceration but no findings requiring immediate operative care. Stroke was defined as any abnormal neurologic examination secondary to palatal trauma. Infection was defined as cellulitis or abscess secondary to palatal injury. All abnormal computed tomographic angiography (CTA) findings, except for free air, were considered positive and potentially significant. RESULTS: We identified 1656 potential subjects. A total of 995 of 1656 subjects were screened, and 205 of 995 met the case definition. A total of 122 of 205 had follow-up through at least 1 week after injury. The incidence of stroke in our study population was 0% (95% confidence interval [CI]: 0–2.5). One of 116 patients developed infection, for an incidence of 0.9% (95% CI: 0–5.3). A total of 90 of 205 (44%) subjects had CTA scans; the results of 9 (10%) were positive. No patients with positive CTA findings required operative care. No patients received anticoagulant medications. CONCLUSIONS: The incidence of morbidity from penetrating palatal trauma in the well-appearing child is extremely low. Diagnostic evaluation in the ED did not prompt clinical interventions other than antibiotics.

Pediatric Cervical Spine Injury Evaluation After Blunt Trauma: A Clinical Decision Analysis

STUDY OBJECTIVE Although many adult algorithms for evaluating cervical spine injury use computed tomography (CT) as the initial screening modality, this may not be appropriate in low-risk children, considering radiation risks. We determine the optimal initial evaluation strategy for cervical spine injury in pediatric blunt trauma. METHODS We constructed a decision analysis tree for a hypothetical population of patients younger than 19 years with blunt trauma, using 3 strategies: clinical stratification, screening radiographs followed by focused CT if the radiograph result was positive, and CT. For the model inputs, we used the current literature to determine the probabilities of cervical spine injury and estimate the long-term risks of malignancy after CT, as well as test characteristics of radiographic imaging. We used published utilities and conducted 1- and 2-way sensitivity analyses to determine the optimal strategy for evaluation of pediatric cervical spine injury. RESULTS In our model of a population with blunt trauma, the expected value of a clinical stratification strategy was the highest of the 3 strategies, making it the overall preferred management. One-way sensitivity analysis of several contributing factors revealed that the only independent factor that altered the dominant strategy was the sensitivity of clinical clearance criteria, lowering the threshold at which screening-radiograph strategy is optimal. Within the patient population considered as having non-negligible risk by clinical stratification and thus requiring imaging, the preferred imaging modality was screening radiograph/focused CT. The probability of cervical spine injury above which CT became the preferred strategy was 24.9%. CONCLUSION The model highlights that clinical clearance and screening radiographs in a hypothetical trauma pediatric population are preferred strategies, whereas CT scanning is rarely the initial optimal evaluation.

Risks of radiation versus risks from injury: A clinical decision analysis for the management of penetrating palatal trauma in children

Penetrating palatal trauma in children presents a diagnostic dilemma regarding the small but severe risk of injury to carotid vessels. Decisions regarding which children require computed tomography with angiography must be balanced against the risk of radiation‐induced malignancy. Our objectives were to compare outcomes between children with and without computed tomography with angiography in the evaluation of palatal trauma and to identify thresholds where the ideal strategy changes in the management of children with palatal trauma through sensitivity analyses.

Outcomes of pediatric patients with persistent midline cervical spine tenderness and negative imaging result after trauma.

BACKGROUND There is little evidence to guide management of pediatric patients with persistent cervical spine tenderness after trauma but with negative initial imaging study findings. Our objective was to determine the prevalence of clinically significant cervical spine injury among pediatric blunt trauma patients discharged from the emergency department with negative imaging study findings but persistent midline cervical spine tenderness. METHODS We performed a single-center, retrospective study of subjects 1 year to 15 years of age discharged in a rigid cervical spine collar after blunt trauma over a 5-year period. We included patients with negative imaging results who were maintained in a collar because of persistent midline cervical spine tenderness. Primary outcome was clinically significant cervical spine injury. Secondary outcome was continued use of the collar after follow-up. Outcomes were ascertained from the medical record or self-report via telephone call. RESULTS A total of 307 subjects met inclusion criteria, of whom 289 (94.1%) had follow-up information available (89.6% in chart, 10.4% via telephone call). Of those with follow-up information, 189 (65.4%) had subspecialty follow-up in the spine clinic. Of those with spine clinic follow-up, 84.6% had the hard collar discontinued at the first visit (median time to visit, 10 days). Of subjects with spine clinic follow-up, 10.1% were left in the collar for persistent tenderness without findings on imaging and 2.1% had imaging findings related to their injury; none required surgical intervention. CONCLUSION A very small percentage of subjects with persistent midline cervical spine tenderness and normal radiographic study findings have a clinically significant cervical spine injury identified at follow-up. Referral for subspecialty evaluation may only be necessary in a small number of patients with persistent tenderness or concerning signs/symptoms. LEVEL OF EVIDENCE Therapeutic study, level IV.