Large Tertiary Children's Hospital Research Articles

Improving genetic testing utilization in a tertiary care neonatal intensive care unit through quality improvement.

There is an increasing recognition of the importance of diagnosing genetic conditions with an ever-growing list of genetic testing options. However, most providers do not have formal genetics training, which makes choosing the most appropriate test to order challenging. Our project sought to improve cytogenetic testing utilization in a tertiary care neonatal intensive care unit (NICU) through utilizing quality improvement techniques, specifically the Model for Improvement framework with rapid Plan-Do-Study-Act cycles. Our project utilized various interventions including the implementation of a NICU genetic testing algorithm. Interventions demonstrated improvement in all areas, specifically a 92% reduction in unnecessary cytogenetic testing with improvement in the diagnostic rate. Our work also resulted in a 59% decrease in charges with an estimated projected savings of $21,000 per year. Quality improvement can minimize redundancies and inefficiencies in genetic testing in a Level IV NICU in a large tertiary care children's hospital and result in substantial cost-savings.

Diabetic ketoacidosis in youth with diabetes mellitus during the COVID-19 pandemic.

We sought to determine if the early months of the coronavirus disease 2019 (COVID-19) pandemic influenced pediatric diabetic ketoacidosis (DKA) hospitalization characteristics. This is a cross-sectional study of youth with laboratory-confirmed DKA admitted to a large tertiary children's hospital in the USA. Data were collected from admissions in March through July 2019 and March through July 2020, respectively. We evaluated the clinical characteristics of hospitalization, including demographic data and DKA severity. We used univariable ordinal logistic regression followed by multiple ordinal logistic regression to adjust for potential confounders. We included 137 children with diabetes admitted for DKA in the relevant period in 2019 and 173 patients admitted for DKA in the same period in 2020. Hemoglobin A1C (HbA1c) upon admission was higher in 2020 (median=12.2 %) than in 2019 (11.5 %, p=0.018). Children who were admitted with DKA in 2020 were less likely to be autoantibody positive than those in 2019 (83 vs. 91 %, p=0.028). In the univariable model, being admitted in 2020 was significantly associated with more severe DKA (p=0.038), as was HbA1c (p=0.001). After adjusting for HbA1c upon admission, admission year was no longer significantly associated with more severe DKA. In this study of pediatric diabetes of any type and duration of diabetes, youth admitted for DKA at the start of the COVID-19 pandemic, compared with those admitted during the year before, were more likely to have autoantibody-negative diabetes and had significantly higher HbA1c. Additionally, higher HbA1c seemed to mediate more severe DKA during the pandemic.

Routine Postclinical Event Debriefings on Inpatient Pediatric Units.

Debriefings are an underutilized opportunity to enhance team performance and safety culture. Little is known about the impact of postclinical event debriefing programs in Pediatric Hospital Medicine (PHM). We sought to develop a standardized debriefing process with multidisciplinary involvement after all clinical events on PHM service lines. Our primary aim was to achieve 75% debriefing completion rate over 12 months with debriefing duration less than 10 minutes. A standardized postclinical event debriefing process was created at a large tertiary children's hospital. We aimed to debrief after clinical events on PHM services. The debriefing process was developed with key stakeholders and used a key driver diagram and Plan-Do-Study-Act cycles to refine the process. The project team reviewed the data monthly. During our 20-month study period, debriefing completion rate sustained a median of 66% with a median debriefing time of 7 minutes. Most debriefings (61%) had all core team members present with attending physicians (pediatric hospitalists) being absent most often. Barriers to debriefing with all core members present included service type, time of day, and shift change. Process changes were implemented based on concerns addressed in the debriefings. Multidisciplinary, postclinical event debriefings were successfully implemented on inpatient pediatric wards. Future steps include process implementation on non-PHM units in our hospital based on expressed interest and to further assess how debriefings optimize team performance and improve clinical outcomes.

Mental Health Diagnoses Risk Among Children and Young Adults With Cerebral Palsy, Chronic Conditions, or Typical Development

Mental health (MH) issues in children with cerebral palsy (CP) are poorly understood compared with other pediatric populations. To examine MH diagnosis code assignment among children and young adults with CP and compare with typically developing (TD) and chronic condition (CC) pediatric populations. This case-control study used International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes to create a CP case set and CC and TD control sets using electronic health record data of children and young adults from a large tertiary care children's hospital in the midwestern United States between 2010 and 2022. Case-control matching was performed to control for demographic factors. Data were analyzed from June to December 2023. All MH diagnosis codes were mapped to ICD-10-CM and categorized using Clinical Classifications Software Refined (CCSR). The incidence rates of MH CCSR categories were calculated. Descriptive and comparative statistics were used to evaluate the significance and odds associated with factors. Data from 216 794 individuals (mean [SD] baseline age, 4.3 [5.1] years; 118 562 [55%] male) were analyzed, including 3544 individuals with CP, 142 160 individuals with CC, and 71 080 TD individuals. The CP cohort spread across Gross Motor Function Classification System (GMFCS) levels I (981 individuals [28%]), II (645 individuals [18%]), III (346 individuals [10%]), IV (502 individuals [14%]), and V (618 individuals [17%]). Rates varied significantly for anxiety (824 individuals with CP [23%]; 25 877 individuals with CC [9%]; 6274 individuals with TD [18%]), attention-deficit/hyperactivity disorder (534 individuals with CP [15%]; 22 426 individuals with CC [9%]; 6311 individuals with TD [16%]); conduct or impulse disorder (504 individuals with CP [14%]; 13 209 individuals with CC [5%]; 3715 individuals with TD [9%]), trauma or stress disorders (343 individuals with CP [10%]; 18 229 individuals with CC [8%]; 5329 individuals with TD [13%]), obsessive-compulsive disorder (251 individuals with CP [7%]; 3795 individuals with CC [1%]; 659 individuals with TD [3%]), depression (108 individuals with CP [3%]; 12 224 individuals with CC [5%]; 4007 individuals with TD [9%]), mood disorders (74 individuals with CP [2%]; 4355 individuals with CC [2%]; 1181 individuals with TD [3%]), and suicidal ideation (72 individuals with CP [2%]; 7422 individuals with CC [5%]; 3513 individuals with TD [5%]). There was significant variation in odds of MH diagnoses by GMFCS level (I-II vs III-V: odds ratio [OR], 1.23; 95% CI, 1.09-1.40; P = .001). Among individuals with CP, males were more likely than females to have diagnosis codes for conduct or impulse disorders (OR, 1.41; 95% CI, 1.16-1.73) and attention-deficit/hyperactivity disorder (OR, 1.41 [95% CI, 1.15-1.73]). Black individuals, compared with White individuals, were more likely to have diagnoses for obsessive-compulsive disorder (OR, 1.57 [95% CI, 1.14-2.16]), other mood disorders (OR, 1.85 [95% CI, 1.01-3.38]), and trauma or stress disorders (OR, 1.94 [95% CI, 1.44-2.63]). Odds for trauma or stress disorders were elevated for individuals who identified as other races compared with White individuals (OR, 2.80 [95% CI, 2.03-3.87]). In this case-control study of children and young adults with CP and matched comparisons, anxiety and conduct or impulse diagnoses were higher in individuals with CP. The lower diagnosis rates of depression and suicidal ideation may indicate underdiagnosis among individuals with CP. There is likely a need for assessment tools that are more suitable for children with CP.

Factors contributing to telemedicine efficacy in pediatric urology

Despite swift implementation of telemedicine with the coronavirus disease 2019 pandemic, there is a paucity of research on its use for management of pediatric urology patients. Specifically, there is limited knowledge and inconsistent data on the effectiveness of telemedicine for various pediatric urologic conditions. Our aim was to evaluate the efficacy of pediatric urological care provided via video visits (VVs) at a large tertiary care children's hospital. We performed a prospective assessment of pediatric urology patients younger than 21 years who had a VV between 5/18/2022 and 5/17/2023. New patients with a testicular diagnosis were not eligible for VVs. After entering the diagnosis and submitting billing using a modifier for telemedicine, clinicians were mandated to select whether the VV allowed for: complete case management (CCM), suboptimal case management (SCM), or incomplete case management (ICM) requiring an in-person visit. Case management categorizations were analyzed according to patient pathology, visit type (i.e., new or established), and patient-centered variables including age, sex, race, insurance type, need for an interpreter, and distress score [a proxy for socioeconomic status]. During the one-year period, there were 3267 telemedicine patients with a median age of 9 years (IQR 3-13) and 57.0% were male. Most VVs (89.3%) were established encounters. Almost 12% of telemedicine patients had external organ pathology (EOP, e.g., phimosis), 43.0% had internal organ pathology (IOP, e.g., hydronephrosis), and 45.1% had functional urological pathology (FUP, e.g., dysfunctional voiding). Clinicians deemed 96.9%, 2.7%, and 0.5% of VVs as having CCM, SCM or ICM, respectively. Telemedicine patients with IOP or FUP were more likely to have CCM, than those with EOP (98.5% and 97.8% vs 87.1%, p<0.0001). On multivariable analysis, patient age, pathology, and visit type were predictive of VV efficacy. Now that telemedicine use has slowed, it is necessary to evaluate and establish its optimal role in pediatric urology. Factors associated with VV efficacy included older patient age, internal organ or functional urological pathology, and established encounters. The long-term success of telemedicine requires suitable patient selection. Telemedicine is quite effective for the management of a wide variety of pediatric urology patients. Continued evaluation of telemedicine, including multi-institutional investigation and corroboration, is necessary for the development of evidence-based best practice guidelines regarding appropriate, safe, and effective integration of telemedicine that drives pediatric urological care forward to meet the demands of the future.

The effects of untreated reflux on the incidence of dysphagia, oral aversion, and feeding difficulty in the NICU population.

To determine whether late-preterm and full-term neonates in the neonatal intensive care unit (NICU) with diagnosed gastroesophageal reflux (GERD) have an increased incidence of feeding difficulties, dysphagia, and oral aversion. To determine the incidence of reflux medication use in late-preterm and full-term neonates in the NICU. Neonates greater than 34 weeks gestational age (GA) diagnosed with reflux, who were hospitalized for at least five days, were included in the study. Neonates with anatomical anomalies that interfere with feeding are excluded. The control group included neonates greater than 34weeksGA not diagnosed with reflux. The key outcome variables were subjective ease of feeding, oral aversion, and placement on nasogastric (NG), orogastric (OG), or requirement of total parenteral nutrition (TPN). Statistical analysis was performed using chi-squared and t-test to compare incidence of feeding difficulties between the groups. A p-value <0.05 was considered significant. In neonates with a diagnosis of reflux, 42.02% had feeding difficulties (66 patients). In the control group, 30.49% of neonates had feeding difficulties (218 patients). Feeding difficulties in neonates with reflux was 11.55% higher than in the control group (p=0.001). Late-preterm and full-term neonates diagnosed with reflux have a higher incidence of feeding difficulties than those who did not have reflux. Only 0.86% of neonates diagnosed with reflux were treated with anti-reflux medications at this large tertiary care children's hospital.

Steering the Titanic: One tertiary care children's hospital's experience navigating safe sleep for hospitalized infants

BackgroundSudden Unexpected Infant Death (SUID) is the leading cause of death in infants 1 month to 1 year of age in the United States. Despite extensive efforts in research and public education, rates of sleep-related infant death have plateaued since the late-1990s, largely due to unsafe sleep practices and environments. Local problemA multidisciplinary team assessed our institution's compliance with its own infant safe sleep policy. Data was collected on infant sleep practices, nurses' knowledge and training on the hospital policy, and teaching practices for parents and caregivers of hospitalized infants. Zero crib environments from our baseline observation met all the American Academy of Pediatrics recommendations for infant safe sleep. MethodsA comprehensive safe sleep program was implemented in a large pediatric hospital system. The purpose of this quality improvement project was to improve compliance with safe sleep practice from 0% to 80%, documentation of infant sleep position and environment every shift from 0% to 90%, and documentation of caregiver education from 12% to 90% within 24 months. InterventionsInterventions included revision of hospital policy, staff education, family education, environmental modifications, creation of a safe sleep taskforce, and electronic health record modifications. ResultsDocumented compliance with infant safe sleep interventions at the bedside improved from 0% to 88%, while documentation of family safe sleep education improved from 12% to 97% during the study period. ConclusionsA multifaceted, multidisciplinary approach can lead to significant improvements in infant safe sleep practices and education in a large tertiary care children's hospital system.

Emergency Department utilisation and diagnoses in adolescents with postural orthostatic tachycardia syndrome.

Data for Emergency Department utilisation and diagnoses in adolescents with postural orthostatic tachycardia syndrome are lacking, making prevention of these visits more difficult to achieve. We performed a retrospective study of patients with postural orthostatic tachycardia syndrome between ages 12 and 18 years seen in the Emergency Department at a large tertiary care children's hospital. These subjects were age- and sex-matched with controls, with volume of primary and total diagnoses assessed. Due to the relatively small number of subjects, a ± 3-year variance was used among control patients for age matching. A total of 297 patients in each group were evaluated. The percentage of female patients was 80.5%. The median age of the subjects was 15.1 years (interquartile range 14.1-15.9), and the median age of controls was 16.1 years (interquartile range 14.4-17.4) (p < 0.00001). Patients with postural orthostatic tachycardia syndrome had greater gastroenterologic and headache diagnoses (p < 0.00001); controls had greater autonomic and psychiatric diagnoses. Adolescent patients with postural orthostatic tachycardia syndrome who present to the Emergency Department have a preponderance of gastroenterologic and headache complaints versus controls.

A Review of Covered Abdominal Wall Defects: Cord Hernias Are Associated With Major Anomalies

IntroductionCovered abdominal wall defects (CAWD) can be categorized into giant omphaloceles (GOs), nongiant omphaloceles (NGOs), and umbilical cord hernias (UCHs). We sought to evaluate differences in management and outcomes of the different CAWD, treated at a large tertiary children's hospital, with regards to survival and association with other major congenital anomalies. MethodsA retrospective review of CAWD patients between January 2010 and January 2021 was conducted. GO was defined as a fascial defect >5 cm or >50% liver herniation. UCH were defined as fascial defects ≤ 2 cm. All others were classified as NGO. Type of repair, time to fascial closure, index hospitalization length of stay (LOS), and survival rates were compared. Four major anomaly categories were identified: cardiac, midline, Beckwith-Weidemann Syndrome, and other genetic anomalies. ResultsWe identified 105 CAWD patients (UCH n = 40; GO n = 34; and NGO n = 31). Ninety percent of UCH underwent primary repair, 10% were never repaired. NGOs were repaired by primary or staged methods in 92.9% of cases and 7.1% by delayed repair. Primary or staged repair occurred in 32.4% of GOs and delayed repair occurred in 67.6%. The median days to repair was 181 [24,427] GO, 1 [1,3] NGO, and 1 [0,1] UCHs (P < 0.01). Index hospitalization median LOS (days) was 90 [55,157] GO, 23 [10,48] NGO, 9 [5,22] UCH, (P < 0.01). There were no statistical differences in survival rates, number of patients with major anomalies (GO 35.4%, NGO 51.5%, UCH 50%), or types of anomalies. ConclusionsUCHs and omphaloceles have similar incidences of major associated anomalies. Thus, all patients with a covered abdominal wall defect should undergo workup for associated anomalies.

Assessment of Menstrual Health and Bleeding Symptoms in Adolescent Girls and Young Women with Sickle Cell Disease

Introduction: Sickle Cell Disease (SCD) is traditionally associated with thrombotic events such as venous thromboembolism and cerebrovascular events. However, adults with SCD have an increased cumulative incidence of bleeding complications by 40 years of age, including heavy menstrual bleeding (HMB). HMB affects 40% of adolescent girls in the general population and is a common reason for referral to pediatric hematology clinics. Whether adolescent girls and young women with SCD are similarly affected by HMB and other bleeding manifestations have not been well described. This purpose of this study was to assess the menstrual health status of this population and to estimate the prevalence of HMB and other bleeding symptoms. Methods: Menarchal adolescent girls and young women aged 12-21 years old, diagnosed with any SCD genotype, and followed in one of three pediatric hematology clinics at a large tertiary care children's hospital were approached for a cross-sectional study. The study consisted of a 5-part questionnaire administered through the Research Electronic Data Capture (REDCap) system. The questionnaire included collection of demographic information, menstrual health knowledge assessment, menstrual bleeding medication rating profile, and validated instruments for patient-reported HMB outcomes and historical bleeding symptoms. The patient-reported outcome instruments consisted of the one-month recall Menstrual Bleeding Questionnaire (MBQ) and Self-Administered Bleeding Assessment Tool (Self-BAT). Statistical procedures involved chi-squared test and Kruskal-Wallis test. Statistical significance was set at p<0.05. Results: To date, 38 participants have completed the questionnaire. The mean age of the study cohort was 15.9 ± 2.3 years. Individuals with SCD genotype HbSS comprised the majority of the cohort and 53% (n = 20) reported hydroxyurea use (Table 1). Mean age of menarche was 13 years (min-max 10-15 years). On the menstrual health knowledge assessment, 6 participants (16%) correctly identified all four characteristics of normal menstruation per American College of Obstetricians and Gynecologists (ACOG) definitions. Specifically, 50% correctly identified the expected duration of menses and 45% identified all of the pharmacologic categories available for menstrual regulation. Parents/guardians were the primary source of menstrual health knowledge (84%), while social media/internet was the predominant secondary source (29%). The mean MBQ score was 14.1 ± 8.5. For comparison, the MBQ validation study performed in adult women with and without HMB reported a mean MBQ score of 30.8 ± 14 and 10.6 ± 8.6, respectively. Approximately 55% of participants reported moderate or severe pain related to menstrual cycles. Pain was not significantly associated with age, hydroxyurea use, or self-reported history of HMB. Ibuprofen (16%) and acetaminophen (11%) were the main medications listed for menstrual pain relief. For the Self-BAT, abnormal bleeding scores are classified as ≥3 in children and ≥6 in women. The cohort mean Self-BAT score was 1.6 (min-max 0-8) and 29% (n = 11) had abnormal bleeding scores. Bleeding symptoms reported were post-surgical/trauma-induced bleeding, epistaxis, prolonged bleeding from small cuts, and bleeding after tooth extraction. Interestingly, 12 participants (32%) reported a history of HMB on the Self-BAT. There were no significant differences in MBQ or Self-BAT scores by age and hydroxyurea use, although individuals with HMB had significantly higher MBQ and Self-BAT scores (Table 2). Six participants (50%) with HMB attempted ≥1 hormonal therapy method for menstrual regulation. One additional participant without HMB received hormonal therapy. Conclusions: In this study, we demonstrate that 32% of adolescent girls and young women with SCD reported a history of HMB and the majority of participants reported moderate/severe pain related to their menstrual cycle. Yet, only 50% with HMB attempted a hormonal therapy. Furthermore, most of the participants had reduced knowledge of normal menstrual health. These findings suggest a critical need for improved education and patient/provider discussion regarding menstruation. Ultimately, incorporating menstrual health assessment into SCD care is important for optimizing patient health and addressing health inequities in the adolescent and SCD population. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Management of Magnet Ingestions at a Large Tertiary Care Children's Hospital.

To review the clinical management and outcomes of magnet ingestions at a large tertiary children's hospital. To determine the association of frequency of high-powered magnet ingestion with the regulation of these magnets. Children <18 years who presented to the emergency room and were admitted to the Children's Hospital of Philadelphia for ingestion of single or multiple magnets from January 2008 to December 2020 were included. Demographics, symptoms, management, and outcomes were analyzed. The frequency of magnet ingestion was compared over 3 eras: (1) pre-ban (2008-2012), (2) intra-ban (2013-2016), and (3) post-ban (2017-2020). There were 167 magnet ingestions, including 99 with multiple magnets. Most patients (59%) were male and median age was 6 (interquartile range, 3-9) years. Most single magnet ingestions (86%) were discharged with outpatient monitoring, and none experienced severe outcomes. Multiple magnet ingestions led to significant morbidity including hospitalizations (68%), endoscopic procedures (48%), surgical procedures (14%), and severe outcomes (12%). Most patients (75%) were asymptomatic, however, there was a higher risk of surgery and severe complications based on the presence of symptoms ( P = 0.003). The rate of surgical intervention was higher with ≥3 magnets (31.7%) compared to 2 magnets (2.4%) ( P < 0.003). Additionally, we found an 160% increase in children with magnet ingestions in the post-ban period ( P = 0.021). Multiple magnet ingestion is associated with high morbidity and rate of severe outcomes. There is a relationship between public policy of magnet sale and frequency of magnet ingestion.

Density map estimation with convolutional neural networks to count radiopaque markers on colonic transit studies.

A radiopaque marker study measures colonic transit time for work-up of primary constipation. It requires the patient to ingest multiple tiny radiopaque markers, which the radiologist must count manually on follow-up abdominal radiographs. Counting these markers is tedious but cognitively simple. To develop a convolutional neural network (CNN) capable of counting the number of radiopaque markers on abdominal radiographs. The image archive at a large tertiary children's hospital was searched to identify abdominal radiographs performed in children for the indication of a radiopaque marker study. To establish the ground truth, a radiologist manually labeled the coordinates of the radiopaque markers in each radiograph and thereby generated a density map for that radiograph. A CNN was trained to estimate this density map from its corresponding abdominal radiograph. Spatially integrating the output density map provided an estimate of the number of markers in the radiograph. To assess model accuracy, mean absolute error and root mean square error were calculated. The study cohort consisted of 436 radiographs (mean number of markers per radiograph: 34). This cohort was randomly divided into training, validation and testing sets consisting of 306, 65 and 65 radiographs, respectively. Based on the testing set, the CNN accurately estimated the number of markers in each radiograph with mean absolute error=2.6 markers and root mean square error=3.9 markers. The proposed CNN generated promising results in counting the number of radiopaque markers on abdominal radiographs and offers the potential of automating the interpretation of colonic transit studies.

Diagnostic challenges with central venous catheter studies.

A central venous catheter is typically made of silicone rubber or polyurethane and inserted into a large central vein to provide prolonged and direct access to central venous circulation. These catheters provide a safe and effective method to administer intravenous medications, nutritional supplements, fluids and blood products. However, a myriad of complications is associated with central venous catheters, including, but not limited to, mechanical malfunction or fracture, kinking, erroneous placement, line infection, fibrin sheath formation and venous thrombosis. Following clinical and radiographic evaluation, contrast-enhanced line studies constitute the next best diagnostic tool to assess the functionality of central venous catheters. However, there is a lack of standardization in the literature outlining how these studies should be performed. In addition, the interpretation of these studies can be problematic for general pediatric radiologists, many of whom are often not familiar with placement or manipulation of these catheters. In this pictorial review, we highlight the challenges associated with performing and interpreting fluoroscopically guided contrast injection studies, using case studies drawn from a large tertiary children's hospital database for illustration. Revealing these challenges and understanding their causative mechanisms can improve the performance of these line studies.

Pediatric appendicitis in the time of the COVID-19 pandemic: A retrospective chart review.

AimConduct a time trend analysis that describes 2 groups of patients admitted to a large tertiary children's hospital that presented with appendicitis and determine if there was an increase in complicated appendicitis when compared between 2 time periods before and during the early coronavirus disease 2019 (COVID‐19) pandemic of 2020.MethodsWe conducted a retrospective analysis of all children presenting to a single‐center site with appendicitis between March 23 and August 31, 2020, in the Central Texas region. We compared 507 patients presenting with appendicitis from the non‐COVID‐19 era in 2019 with n = 249 to patients presenting during the COVID time period with n = 258. All patients with appendicitis within those time periods were reviewed with analysis of various characteristics in regard to presentation, diagnosis of uncomplicated versus complicated appendicitis, and management outcomes.ResultsThere were no significant demographic differences or change in the number of appendicitis cases noted between the 2 time periods of comparison. There was no significant difference in rates of complicated appendicitis or presentation time following symptom onset between the 2 eras. There was no significant difference in intraoperative or postoperative complications. There was a statistically significant increase in the use of computed tomography (CT) scans (P‐value = 0.004) with patients 1.81 times more likely to have a CT scan in the pandemic era after adjusting for patient‐level factors. The effect of severe acute respiratory syndrome coronavirus 2 status on outcomes was not part of the data analysis.ConclusionOur study is the largest to date examining appendicitis complications in the era of COVID. In the time of the COVID‐19 pandemic, we found no delay in presentation in children presenting to the emergency department and no increase in complicated appendicitis. We did identify an increase in the use of CT scans for definitive diagnosis of appendicitis noted in the pandemic era. Although COVID‐19 status was not studied, the finding of increased CT use for a definitive diagnosis of appendicitis was a distinctive finding of this study showing a change in practice in pediatric emergency medicine.

Machine learning to identify distal tibial classic metaphyseal lesions of infant abuse: a pilot study.

The classic metaphyseal lesion (CML) is an injury that is highly specific for infant abuse, and the distal tibia is one of the most common sites of occurrence. A machine learning tool that identifies distal tibial CMLs on infant skeletal surveys could assist radiologists in the diagnosis of infant abuse. To develop and evaluate a machine learning-based classification algorithm to identify distal tibial CMLs on skeletal surveys performed for suspected infant abuse. We reviewed medical records of infants (≤1year old) who had skeletal surveys for suspected abuse at a large tertiary children's hospital over the past 13years to identify those at low and high risk for abuse. Normal distal tibial radiographs from the low-risk group formed the normal study cohort; radiographs with distal tibial CMLs from the high-risk group formed the abnormal study cohort. We used these two cohorts to train a machine learning algorithm to classify distal tibial radiographs as normal or abnormal. We systematically evaluated this algorithm using a fivefold cross-validation procedure and statistically analyzed the results. The normal study cohort consisted of 177 radiographs from 89 infants, and the abnormal study cohort consisted of 73 radiographs from 35 infants. Our machine learning algorithm showed an overall performance accuracy of 93% and Kappa of 0.84. The overall sensitivity and specificity of the model were 88% and 96%, respectively. Our developed machine learning model shows encouraging results as an automated tool to identify CMLs of the distal tibia on skeletal surveys performed for suspected infant abuse.

Postoperative respiratory adverse events in children after endoscopic laryngeal cleft repair

Due to the serious nature of respiratory adverse events, understanding their incidence can help in decisions regarding safe postoperative disposition. There have been no studies, however, evaluating the risk of postoperative respiratory adverse events (PRAEs) in children undergoing endoscopic laryngeal cleft (LC) repair, which is the primary objective of this study. We conducted a retrospective chart review of all patients who underwent LC repair at a large tertiary children's hospital from 2015 to 2020. PRAEs were defined as having at least one of the following: remained intubated, required reintubation, required positive pressure ventilation, required high flow O2 nasal cannula, or required more than one dose of racemic epinephrine. Univariate analyses compared demographic, preoperative characteristics, and intraoperative characteristics between those with and without a PRAE. Overall, 8/26 (31%) patients had a PRAE and there were no differences between patients who did and did not have a PRAE and most comorbidities. Younger age (p = 0.03), being male (p = 0.07), and being admitted preoperatively (p = 0.07) were potentially associated with PRAEs. Need for intraoperative intubation for any reason or duration was associated with increased incidence of PRAEs (p = 0.02). The overall 31% incidence of postoperative respiratory adverse events reaffirms the appropriateness of PICU disposition for a large proportion of children undergoing endoscopic LC repair. Further studies with increased sample sizes are needed to tease apart patient or procedure-specific factors that significantly increase the risk of respiratory adverse events to have more definitive evidence regarding safe postoperative disposition.

Pediatric otolaryngology telemedicine amid a pandemic – And beyond

IntroductionThe coronavirus disease of 2019 (COVID-19) pandemic catalyzed an unprecedented redesign and innovative overhaul of health care delivery thrusting from fringe to mainstream virtual care. With a return to conventional practice, we now must create a research and policy agenda using the changes wrought by COVID-19 to help create a better health care system in its aftermath. The purpose of this study was to assess satisfaction of otolaryngology outpatient visits during the pandemic. MethodsA prospective survey study was performed on caregivers of all patients ages 0–26 years old seen in the Division of Pediatric Otolaryngology at our large tertiary care children's hospital from February–April 2020. The three study groups were those seen in-person 6 weeks before telemedicine was implemented (IBTM), those seen in telemedicine during the first 6 weeks (TM) it was implemented at our hospital, and those seen in-person during the telemedicine period (IDTM) in the same timeframe. The survey consisted of satisfaction questions related to their visit, if their child was recommended surgery at the time of the visit, and if the caregiver agreed with the recommendation. A medical record review was also performed. ResultsA total of 176 caregivers completed the survey with 113(64.2%) completing the survey for an IBTM appointment, 59(33.5%) for a TM appointment, and 4(2.3%) for an IDTM appointment. There were 100(56.8%) male patients and 167(94.9%) were white. Families gave a higher response for the statement “The ability to communicate with the physician” (p = .012) and “The overall outpatient experience” (p = .004) in the IBTM cohort compared to the TM group. There were no significant differences for the other statements regarding the ability to understand recommendations, courtesy, and knowledge of the physician. Regardless of group, 98.6% of caregivers agreed with surgical recommendation when surgery was recommended. However, when surgery was not recommended at the appointment, caregivers were 11x more likely to disagree with the surgical recommendations, OR:11.49,95%CI:1.44–91.38,p = .005. ConclusionWe conclude that telemedicine was equally well received by patients as compared to traditional live assessments suggesting that virtual care is a viable post-pandemic paradigm change. Satisfaction was rated as “Good” or “Excellent”, however, messaging when surgery is not recommended was less acceptable and must be improved to obtain increased caregivers’ agreement in an era of shared decision making.

Increased paediatric emergency mental health and suicidality presentations during COVID-19 stay at home restrictions.

ObjectiveAnecdotal reports indicate an increase in mental health presentations and acuity to EDs during the COVID‐19 pandemic and associated stay at home restrictions. Paediatric and adolescent data to confirm this are unavailable in the Australian setting.MethodsRetrospective electronic medical record review of all ED patients with mental health discharge codes at a large tertiary children's hospital in Australia during the period of stay at home restrictions from 1 April to 30 September 2020 compared with the same dates in 2019.ResultsWe found a 40% decrease in ED presentations (18 935–11 235) with a concurrent 47% increase in mental health presentations (809–1190) to ED during the study periods between 2019 and 2020. This resulted in an increase of 100 mental health admissions from ED. Diagnoses with greatest percentage increases were eating disorders, social issues and suicidality. We found suicidality presentation numbers were highest in June to September 2020 compared with 2019. Patients with a diagnosis of suicidality had a higher rate of re‐presentation in 2020 (1.83 presentations per patient) compared to 2019 (1.38 presentations per patient).ConclusionsDespite an overall decrease in ED presentations, the absolute increase in mental health presentations for children and adolescents during the stay at home restriction period was pronounced. It is unclear how sustained this change and the impact on mental health resource use will be post‐pandemic.

Pediatric Tracheostomy Care Simulation: Real-Life Scenarios in a Safe Learning Environment.

Pediatric patients require tracheostomy tube placement as a last resort for critical airway management. Around-the-clock care is needed at discharge because of the high risk of morbidity and mortality associated with a tracheostomy. The potential for catastrophic sequalae can create a high stress home environment. A simulation program that used a high-fidelity manikin was implemented to reduce complications, morbidity and mortality, and improve skills for real-life medical scenarios. A tracheostomy care simulation program was implemented at a large tertiary care children's hospital from October 2019 to October 2020. Caregivers participated in a pre-post program survey and rated 9 statements on a 5-point scale with regard to knowledge, confidence, and comfort level of taking care of their child at home. Emergency scenarios included accidental tracheostomy tube dislodgement, tracheostomy tube plugging, cardiac arrest, and ventilator failure. Classes were recorded for objective start-to-finish scenario time stamps and prompt rates. A medical chart review was performed 90 d after discharge. Eighteen caregivers for 10 children participated. For the 10 children, there was a 9.1% increase in the average total score agreement from pre to post survey, with scores going from "agree" to "strongly agree" (P = .001). Each subset of questions had a significant increase in scores after participation: knowledge, P = .002; confidence, P = .006; and comfort, P = .01. The caregivers required an average 20% prompt rate for the next step in the scenario. Children were 70% female, 80% white, and 60% had public insurance and had their tracheostomy tube placed at a median age of 4 months (range, 0 months to 24 years). Three children (n = 3/9 [33.3%]) were readmitted for tracheitis within 90 d after being discharged to home. Caregiver knowledge, confidence, and comfort levels were increased after participation. Pediatric patients with a tracheostomy are medically fragile, therefore, it is important for caregivers to be aware of and prepared for common tracheostomy emergencies and to "experience" emergency situations firsthand.

Bicycle injuries presenting to the emergency department during COVID-19 lockdown.

AimSince the start of the COVID‐19 pandemic, there have been many changes in the presenting complaints in paediatric emergency departments (EDs). We sought to characterise the impact of the COVID‐19 pandemic on bicycle‐related injuries in children presenting to a tertiary care paediatric ED.MethodsWe conducted a descriptive, cross‐sectional study of ED visits to a large urban tertiary children's hospital, comparing March to October 2020 (the study period) to the same date range 2 years prior (i.e. March to October 2018–2019). We included children 0–17.99 years presenting for a bicycle‐related injury. We compared absolute visit counts of bike injuries per month, demographics, triage acuity, injury type and disposition.ResultsA total of 1215 bike‐related visits were analysed. There were 234 presentations in 2018 (March to October), 305 in 2019, and 676 in 2020. Overall, the mean age was 9.5 years (standard deviation 5.5–13.5), there were 67% males, median Canadian Emergency Department Triage and Acuity Scale score was 3 (interquartile range 3–4) and the most common injuries were fractures (n = 471, 38.8%). There were significantly more bike injuries presenting to the ED per month in the COVID group, 33.7(17.9) versus 84.5(61.4) (two‐tailed P value = 0.041). There was no statistical difference in ‘severe injuries’ pre‐ versus post‐COVID (odds ratio 0.815 (95% confidence interval 0.611–1.088), P = 0.165).ConclusionThere was a significant increase in bicycle‐related injuries presenting to our ED during the pandemic, compared to previous years. Evaluating these trends will allow for the exploration of harm reduction strategies for preventing future bicycle‐related injuries.