Study objective We compare test characteristics of abdominal computed tomography (CT) with and without oral contrast for identifying intra-abdominal injuries. Methods This was a planned subanalysis ...of a prospective, multicenter study of children (<18 years) with blunt torso trauma. Children imaged in the emergency department with abdominal CT using intravenous contrast were eligible. Oral contrast use was based on the participating centers’ guidelines and discretions. Clinical courses were followed to identify patients with intra-abdominal injuries. Abdominal CTs were considered positive for intra-abdominal injury if a specific intra-abdominal injury was identified and considered abnormal if any findings suggestive of intra-abdominal injury were identified on the CT. Results A total of 12,044 patients were enrolled, with 5,276 undergoing abdominal CT with intravenous contrast. Of the 4,987 CTs (95%) with documented use or nonuse of oral contrast, 1,010 (20%) were with and 3,977 (80%) were without oral contrast; 686 patients (14%) had intra-abdominal injuries, including 127 CTs (19%) with and 559 (81%) without oral contrast. The sensitivity in the detection of any intra-abdominal injury in the oral contrast versus no oral contrast groups was sensitivitycontrast 99.2% (95% confidence interval CI 95.7% to 100.0%) versus sensitivityno contrast 97.7% (95% CI 96.1% to 98.8%), difference 1.5% (95% CI –0.4% to 3.5%). The specificity of the oral contrast versus no oral contrast groups was specificitycontrast 84.7% (95% CI 82.2% to 87.0%) versus specificityno contrast 80.8% (95% CI 79.4% to 82.1%), difference 4.0% (95% CI 1.3% to 6.7%). Conclusion Oral contrast is still used in a substantial portion of children undergoing abdominal CT after blunt torso trauma. With the exception of a slightly better specificity, test characteristics for detecting intra-abdominal injury were similar between CT with and without oral contrast.
Objective To examine parental expectations and beliefs about diagnosis and management of pediatric concussion. Study design We conducted a cross-sectional web-based survey of a nationally ...representative panel of US parents in March 2014. Parents of 10- to 17-year-old children responded to questions about their expectations and beliefs about diagnosis and management of pediatric concussion in the emergency department (ED). Weighted percentages for descriptive statistics were calculated, and χ2 statistics were used for bivariate analysis. Results Survey participation was 53%, and of 912 parent respondents with a child 10-17 years of age who were presented with a scenario of their child having mild symptoms of concussion, 42% would seek immediate ED care. Parents who would seek immediate ED care for this scenario were more likely than parents who would consult their child's usual provider or wait at home to “definitely expect” imaging (65% vs 21%), definitive diagnosis of concussion (77% vs 61%), a timeline for return to activity (80% vs 60%), and a signed return to play form (55% vs 41%). Conclusions Many parents who bring children to the ED following a possible concussion are likely to expect comprehensive and definitive care, including imaging, a definitive diagnosis, a timeline for return to activity, and a signed return to play form. To manage these expectations, healthcare providers should continue to educate parents about the evaluation and management of concussion.
Study objective We determine whether intra-abdominal injury is rarely diagnosed after a normal abdominal computed tomography (CT) scan result in a large, generalizable sample of children evaluated in ...the emergency department (ED) after blunt torso trauma. Methods This was a planned analysis of data collected during a prospective study of children evaluated in one of 20 EDs in the Pediatric Emergency Care Applied Research Network. The study sample consisted of patients with normal results for abdominal CT scans performed in the ED. The principal outcome measure was the negative predictive value of CT for any intra-abdominal injury and those undergoing acute intervention. Results Of 12,044 enrolled children, 5,380 (45%) underwent CT scanning in the ED; for 3,819 of these scan the results were normal. Abdominal CT had a sensitivity of 97.8% (717/733; 95% confidence interval CI 96.5% to 98.7%) and specificity of 81.8% (3,803/4,647; 95% CI 80.7% to 82.9%) for any intra-abdominal injury. Sixteen (0.4%; 95% CI 0.2% to 0.7%) of the 3,819 patients with normal CT scan results later received a diagnosis of an intra-abdominal injury, and 6 of these underwent acute intervention for an intra-abdominal injury (0.2% of total sample; 95% CI 0.06% to 0.3%). The negative predictive value of CT for any intra-abdominal injury was 99.6% (3,803/3,819; 95% CI 99.3% to 99.8%); and for injury undergoing acute intervention, 99.8% (3,813/3,819; 95% CI 99.7% to 99.9%). Conclusion In a multicenter study of children evaluated in EDs after blunt torso trauma, intra-abdominal injuries were rarely diagnosed after a normal abdominal CT scan result, suggesting that safe discharge is possible for the children when there are no other reasons for admission.
Abstract The objective of this study was to utilize the electronic medical record system to identify frequent lower acuity patients presenting to the Pediatric Emergency Department and to evaluate ...their impact on Pediatric Emergency Department overcrowding and resource utilization. The electronic medical records (EMR) of two pediatric emergency centers were reviewed from August 2002 to November 2004. Pediatric Emergency Department encounters that met any of the following criteria were classified as Visits Necessitating Pediatric Emergency Department care (VNEC): • Disposition of admission, transfer or deceased • Intravenous fluids (IVF) or medications (excluding single antipyretic or antihistamine) • Radiology or laboratory tests (excluding Rapid Strep) • Fractures, dislocations, and febrile seizures All other visits were classified as non-VNEC. ICD-9 (International Classification of Diseases, Ninth Revision) codes from the Pediatric Emergency Department encounters were defined as representing chronic or non-chronic conditions. Patients were then evaluated for utilization patterns, frequency of Emergency Department (ED) visits, chronic illness, and VNEC status. There were 153,390 patients identified, representing 255,496 visits (1.7 visits/patient, range 1–49). Overall, 189,998 visits (74%) required defined ED services and were categorized as VNEC, with the remaining 65,498 visits (26%) categorized as non-VNEC. With increasing visits, a steady decline in those requiring ED services was observed, with a plateau by visit six (VNEC 77% @ one visit, 64% @ six visits, p < 0.001). There were 141,765 patients seen fewer than four times, representing 92% of the patients and 74% of all visits (1.3 visits/patient, 225 visits/day). In contrast, 2664 patients disproportionately utilized the ED more than six times (maximum 49), representing 1.7% of patients and 9.8% of visits (9.4 visit/patient, 30 visits/day, p < 0.001). Excluding patients with chronic illness, 1074 patients also disproportionately utilized the ED more than six times (maximum 28), representing 0.7% of patients and 3.6% of visits (8.6 visit/patient, 11 visits/day, p < 0.001). While representing < 2% of patients, frequent lower acuity utilizers of ED services accounted for nearly 10% of all visits (30/day). Low acuity patients may require only limited additional marginal resources for their individual care. However, in aggregate, inefficiencies occur, especially when systems reach capacity constraints, at which point these patients utilize limited resources (manpower and space) that could more effectively be directed toward the more acutely ill and injured patients. Therefore, identification of these patients utilizing the electronic medical record will allow for targeted interventions of this subgroup to improve future resource allocation.
BACKGROUND:Residents in many surgical disciplines express a strong preference for hands-on learning, but no studies have focused on plastic surgery. This initial study aims to ascertain the learning ...styles of plastic surgery residents, and identify potential trends that may better guide curriculum development.
METHODS:Kolb Learning Style Index v. 3.1 was administered to plastic surgery residents across all training levels at three residency programs. The Kolb Learning Style Index is a 12-item questionnaire that characterizes an individual’s learning style into 1 of 4 major categoriesconverging; accommodating; assimilating; and diverging.
RESULTS:The surveyed cohort of plastic surgery residents (n = 45) demonstrated a diverse mix of learning stylesconverging (38%, n = 17); accommodating (24%, n = 11); diverging (20%, n = 9); and assimilating (16%, n = 7). One resident was balanced between converging and accommodating (2%, n = 1). Despite varied learning styles, the majority (64%, n = 29) demonstrated a preference for “active experimentation,” for example, hands-on learning.
CONCLUSIONS:A preliminary assessment of learning styles among plastic surgery residents suggests that they have mixed learning styles. This contrasts with the existing literature from other surgical specialties where a single learning style dominates. However, like these other specialties, active experimentation is particularly valued. As such, it behooves the plastic surgery educator to continue to strive for balance between book learning and hands-on experience for residents at all levels of training, to engage residents with all learning styles.
Blood Pressure Response to the Valsalva Maneuver Forfia, Paul R., MD, MS; Opotowsky, Alexander R., MD, MPH; Ojeda, Jason, MD ...
Journal of the American College of Cardiology,
10/2010, Letnik:
56, Številka:
16
Journal Article
Study objective Cervical spine injuries in children are rare. However, immobilization and imaging for potential cervical spine injury after trauma are common and are associated with adverse effects. ...Risk factors for cervical spine injury have been developed to safely limit immobilization and radiography in adults, but not in children. The purpose of our study is to identify risk factors associated with cervical spine injury in children after blunt trauma. Methods We conducted a case-control study of children younger than 16 years, presenting after blunt trauma, and who received cervical spine radiographs at 17 hospitals in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2000 and December 2004. Cases were children with cervical spine injury. We created 3 control groups of children free of cervical spine injury: (1) random controls, (2) age and mechanism of injury-matched controls, and (3) for cases receiving out-of-hospital emergency medical services (EMS), age-matched controls who also received EMS care. We abstracted data from 3 sources: PECARN hospital, referring hospital, and out-of-hospital patient records. We performed multiple logistic regression analyses to identify predictors of cervical spine injury and calculated the model's sensitivity and specificity. Results We reviewed 540 records of children with cervical spine injury and 1,060, 1,012, and 702 random, mechanism of injury, and EMS controls, respectively. In the analysis using random controls, we identified 8 factors associated with cervical spine injury: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle crash. Having 1 or more factors was 98% (95% confidence interval 96% to 99%) sensitive and 26% (95% confidence interval 23% to 29%) specific for cervical spine injury. We identified similar risk factors in the other analyses. Conclusion We identified an 8-variable model for cervical spine injury in children after blunt trauma that warrants prospective refinement and validation.
Study objective We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. ...Methods We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. Results We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval CI 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). Conclusion A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.
Previous studies show that reverse shoulder arthroplasty (RSA) may improve forward elevation (FE) but external rotation may remain impaired with substantial teres minor fatty infiltration. The ...purpose of this study was to examine the influence of fatty infiltration on postoperative range of motion (ROM) and patient-reported outcomes (PROs) after RSA with a more lateralized center of rotation.
About 69 patients (average age 69 years; 44 women, 25 men) with preoperative MRI, 1-year postoperative ROM, 2-year Veteran’s Rand Survey, American Shoulder and Elbow Surgeons subjective form, and Single Alpha-Numeric Evaluation scores who underwent RSA with a lateralized glenoid component between 2010 and 2014 were identified. Patients with Fuchs stage 3 fatty degeneration were compared with patients with Fuchs stage ≤ 2 using a one-way ANOVA.
Eleven patients had Fuchs stage 3 in the teres minor and 28 with stage 3 in the infraspinatus. Charlson comorbidity indices, Veteran’s Rand Survey scores, age, and BMI were not different between groups. There were no differences after one year (follow-up = 15 ± 14 months) in FE (FE = 128 ± 29) or external rotation (33 ± 13) between groups. There were no differences in two-year minimum (follow-up = 42.9 ± 17.9 months) American Shoulder and Elbow Surgeons scores between degenerated teres minor (76.4 ± 20) or infraspinatus (69.1 ± 24) groups.
This is the first study to assess the influence of teres minor and infraspinatus fatty infiltration on the postoperative ROM and PROs with a more lateralized glenoid RSA implant. Our results show that in a more lateralized RSA, neither teres minor nor infraspinatus fatty infiltration appear to negatively influence ROM or PROs.
It is unclear whether deviations in brain and behavioral development, which may underpin elevated substance use during adolescence, are predispositions for or consequences of substance use ...initiation. Here, we examine behavioral and neuroimaging indices at early and mid-adolescence in drug-naive youths to identify possible predisposing factors for substance use initiation and its possible consequences.
Among 304 drug-naive adolescents at baseline (age 14 years) from the IMAGEN dataset, 83 stayed drug-naive, 133 used alcohol on 1 to 9 occasions, 42 on 10 to 19 occasions, 27 on 20 to 39 occasions, and 19 on >40 occasions at follow-up (age 16 years). Baseline measures included brain activation during the Monetary Incentive Delay task. Data at both baseline and follow-up included measures of trait impulsivity and delay discounting.
From baseline to follow-up, impulsivity decreased in the 0 and 1- to 9-occasions groups (p < .004), did not change in the 10- to 19-occasions and 20- to 29-occasions groups (p > .294), and uncharacteristically increased in the >40-occasions group (p = .046). Furthermore, blunted medial orbitofrontal cortex activation during reward outcome at baseline significantly predicted higher alcohol use frequency at follow-up, above and beyond behavioral and clinical variables (p = .008).
These results suggest that the transition from no use to frequent drinking in early to mid-adolescence may disrupt normative developmental changes in behavioral control. In addition, blunted activity of the medial orbitofrontal cortex during reward outcome may underscore a predisposition toward the development of more severe alcohol use in adolescents. This distinction is clinically important, as it informs early intervention efforts in preventing the onset of substance use disorder in adolescents.
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