Le Bonheur Children's Hospital Research Articles

Comparing the Use of Crotaline-Polyvalent Immune Fab (Ovine) Versus Observation in Children.

In the United States, studies are inconclusive regarding the indications for polyvalent antivenom administration for crotaline envenomation. We compared polyvalent antivenom administration versus observation used at 2 separate institutions. We hypothesized that deferring antivenom leads to increased hospital length of stay and surgical interventions. Retrospective chart review of children who presented to Le Bonheur Children's Hospital (LBCH) in Memphis, Tennessee, and Monroe Carell Jr Children's Hospital at Vanderbilt (MCJCHV) in Nashville, Tennessee, from 2009 to 2021. Patient demographics, treatment utilization, bite location, and outcomes from both sites were statistically examined. A total of 183 patients met the inclusion criteria (123 at LBCH, 60 at MCJCHV). At LBCH, mean age was 9.2 years, 54% were male, and 79% of known snakes identified as copperheads. At MCJCHV, mean age was 8.9 years, 65% were male, and 88% of known snakes identified as copperheads. The most commonly envenomated areas for both sites were the foot (42%), hand (27%), and ankle (26%). Patients at LBCH were managed with antivenom only 25% of the time, whereas 75% were observed; 82% of MCJCHV patients were managed with antivenom (P < 0.001). There were no significant differences in length of stay (mean, 1.5 days at LBCH and 1.8 days at MCJCHV; P = 0.136) or surgical intervention (3.3% of LBCH encounters, 5.0% of MCJCHV encounters; P = 0.685). Secondary outcomes aside from coagulopathy and admission location (intensive care unit vs floor) were also not significant. The use of antivenom did not impact hospital length of stay or surgical interventions. Our results should be interpreted cautiously as our study reflects regional experiences with snake species in the Southeast United States and not North America as a whole. Other institutional differences in management and smaller n at MCJCHV may have contributed to different outcomes. Further study is needed to determine intermediate and long-term effects of deferring antivenom use.

Clinical Experience With Lacosamide as an Adjunct Treatment for Neonatal Seizures: A Retrospective Single-Center Study

BackgroundLacosamide (LCM) is a third-generation antiseizure medication (ASM) currently approved for the treatment of focal seizures in children aged greater than one month. There are limited data on its efficacy in the neonatal age group. We describe our experience with LCM as an adjunct ASM for the treatment of neonatal seizures. MethodsA retrospective chart review over a five-year period (2018 to 2022) was conducted at Le Bonheur Children's Hospital to identify neonates with electroencephalography (EEG)-proven seizures who were treated with LCM. Data were collected on electroclinical seizure characteristics, underlying etiology, ASMs, treatment response, and any adverse effects. ResultsA total of 15 neonates with EEG-confirmed seizures who were treated with LCM were included. Ten neonates achieved seizure cessation after LCM was added to their ASM regimen consisting of phenobarbital, levetiracetam, or both. No new treatment-related adverse effects were noted. ConclusionsLCM is effective as an adjunct treatment for neonatal seizures. Randomized controlled studies are needed to establish its effectiveness and adequate dosing regimen in this population.

Human versus machine: does artificial intelligence add value to identification of hypertrophic cardiomyopathy in pediatric patients?

Abstract Introduction An abnormal increase in left ventricular thickness is a hallmark of hypertrophic cardiomyopathy (HCM). Although standard measures of left ventricular voltage abnormalities on electrocardiograms (ECGs) have high false positive rates and poor correlation to left ventricular thickness, ECGs continue to be part of most screening programs. We developed a machine learning model for HCM classification from ECG in a pediatric cohort and compared its efficacy to that of clinician specialists. Purpose To compare clinician-based predictions of HCM to a machine learning model trained to classify pediatric patients with HCM utilizing 12-lead ECG. Methods ECGs from patients &amp;lt;19 years with HCM, including those with HCM gene mutations, were compared to those from age- and sex-matched controls with normal heart structure and function on echocardiogram. Patients with a known history of primary causes of left ventricular hypertrophy such as aortic stenosis or glycogen storage disease were excluded. A cascaded convolutional neural network was developed combining a residual neural network with a 2-layer dense neural network with 10-fold cross validation. The performance of the machine learning based HCM classification was compared to that of two independent clinicians. Results Analytic sample included data from 82 patients with clinical HCM compared to 91 healthy control subjects. The machine model AUC was 0.89 (0.84–0.94). Clinician inter-rater reliability was 0.8. The clinicians had a higher specificity (97% vs 82%) but lower sensitivity (50% vs 78%) than the machine learning model. Compared to clinician-classification, the positive predictive value was lower in the machine model (82% vs 93%). Conclusion In this preliminary study, machine learning classification of HCM utilizing 12-lead ECG had greater sensitivity than that of clinician interpretation. Machine learning may play a role in screening and diagnosis, including in subjects with normal-appearing ECG. Evaluation of its utility in a larger cohort is needed. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Le Bonheur Children's Hospital

Journey to a new era: An innovative academic-practice partnership.

Successful academic-clinical partnerships are mutually beneficial for academic nursing and clinical organizations, supporting the long-term success of nursing programs while simultaneously improving patient outcomes. Advocated by the American Association of Colleges of Nursing in their 2016 report, Advancing Healthcare Transformation: New Era for Academic Nursing, this position paper provides six actions for transforming academic nursing. However, developing sustainable academic-practice models has proven challenging despite this roadmap, as research has not substantiated their benefits. This article describes an innovative academic-practice model that transitioned advanced practice registered nurses practicing at Le Bonheur Children's Hospital to full-time faculty, with a continued primary clinical practice role, in the College of Nursing at the University of Tennessee Health Science Center. We present the origin, development, and implementation of this academic-practice partnership model, offering recommendations for its replication by other universities and clinical agencies on this journey. Creating a sustainable model requires a shared vision, buy-in at all levels, frequent and transparent communication, planning that considers the individual policies of the partnering agencies, and persistence despite leadership changes. Two years into the partnership and remaining intact despite critical leadership changes within the clinical agency, the next phase of the relationship will permit us to document the model's impact on academic and clinical outcomes.

Pediatric Dog Bites: A Review of 1422 Cases Treated at a Level One Regional Pediatric Trauma Center.

Children under the age of 14 account for over 40% of the almost 900,000 annual hospital visits associated with dog bites. Care for dog bites ranges from simple wound irrigation to complex surgical reconstruction. Due to a number of factors, children frequently sustain dog bites to highly vulnerable regions, often necessitating intervention by plastic surgeons. This retrospective study analyzed data from the 1422 pediatric patients who sustained dog bites and presented to the Le Bonheur Children's Hospital Emergency Room from January 2011 to May 2017. The typical pediatric dog bite case was male (63.5%), African-American (57.4%), and less than 10 years old (69.4%). The head and neck were the most commonly affected areas (64.7%). Of the head and neck regions, the cheeks and lips were the most frequently injured structures (34.5%). Hospital admission was required for 188 patients (13.2%) and operative repair was deemed necessary in 16.9% of all cases. Of the patients requiring inpatient operative repair, most (78.3%) were discharged in less than 24 hours. Operative complications occurred in 5.8% of all cases, with infections accounting for the majority (92.9%). No fatal dog bites occurred in this study. Age, bite location, and number of bites sustained are several factors of significance, which may aid the novice plastic surgeon in identifying, which pediatric dog bite cases will require surgical intervention.

DMD/BMD - GENETICS: EP.112 Genotype-phenotype correlation for cognitive and neurodevelopmental comorbidities in Duchenne and Becker muscular dystrophy

Although intellectual disability was included in the first description of Duchenne muscular dystrophy (DMD), the cognitive and neurodevelopmental (ND) components of DMD and Becker muscular dystrophy (BMD) remain overshadowed by their motor, cardiac, and pulmonary manifestations. To assess the ND comorbidity burden in dystrophinopathy patients at Le Bonheur Children's Hospital neuromuscular clinic, abstraction of the electronic medical record was performed for 46 patients. Diagnoses of ADHD, epilepsy, autism spectrum, obsessive compulsive, oppositional defiant, mood, anxiety, and sleep disorders, along with discussion of any cognitive difficulties, shyness, or other maladaptive behaviors, were recorded for each patient. Patients were stratified into groups based on their genetic alteration and DMD isoforms predicted to be affected: 1) exons 1-29 (Dp427 impacted alone), 2) exons 30-50 (Dp427 through untranslated region of Dp140 impacted), and 3) exons 51-79 (Dp427 through Dp40 impacted). Mention of cognitive difficulties, spanning from repeating grades to specific learning disorders to severe intellectual disability, and other behavioral problems not meeting a formal diagnosis (including aggression, self-injurious behavior, emotional lability) were present for 74% (34/46) and 61% (28/46) of patients, respectively. The number of patients affected by any type of cognitive difficulty in Group 1 versus 3 was statistically significant (p = 0.01; Fisher exact test) with all members of Group 3 having some cognitive difficulty. Similarly, there is a statistically significant difference in the number of comorbidities between Groups 1 and 3 (p = 0.002; Mann-Whitney U test) with a stair-step increase in comorbidity burden as more isoforms are disrupted. These findings highlight that learning difficulties and behavior problems may be encountered more frequently than previously reported and that distal genotypes merit more extensive and earlier neuropsychological evaluation.

Repair of Ebstein's anomaly-The devils in the fine print.

Journal of Cardiac SurgeryVolume 36, Issue 9 p. 3146-3146 COMMENTARY Repair of Ebstein's anomaly—The devils in the fine print Christopher J. Knott-Craig MD, FACS, Corresponding Author Christopher J. Knott-Craig MD, FACS cknottcr@uthsc.edu orcid.org/0000-0002-5959-2085 University of Tennessee Health Sciences Center and Le Bonheur Children's Hospital, Memphis, Tennessee, USA Correspondence Christopher J. Knott-Craig, MD, FACS, University of Tennessee Health Sciences Center and Le Bonheur Children's Hospital, St 332, 3rd Floor, POB, 49 N Dunlap, Memphis, TN 38105, USA. Email: cknottcr@uthsc.eduSearch for more papers by this author Christopher J. Knott-Craig MD, FACS, Corresponding Author Christopher J. Knott-Craig MD, FACS cknottcr@uthsc.edu orcid.org/0000-0002-5959-2085 University of Tennessee Health Sciences Center and Le Bonheur Children's Hospital, Memphis, Tennessee, USA Correspondence Christopher J. Knott-Craig, MD, FACS, University of Tennessee Health Sciences Center and Le Bonheur Children's Hospital, St 332, 3rd Floor, POB, 49 N Dunlap, Memphis, TN 38105, USA. Email: cknottcr@uthsc.eduSearch for more papers by this author First published: 30 May 2021 https://doi.org/10.1111/jocs.15679Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume36, Issue9September 2021Pages 3146-3146 RelatedInformation

Pediatric Orbital Roof Fractures: A Ratio of Orbital Dimensions Correlated to Prevalence of Fracture.

Objective Orbital roof fractures are more likely to occur in younger children, specifically younger than 7 years. Cranium to face ratio decreases with age; however, there is no definition for measurement of the neurocranium or face. We propose using the length of the orbital roof as a measurement of the neurocranium and length of the orbital floor as a tool to estimate midface size. The purpose of this study is to test this measurement as a correlation rate of orbital roof fractures within the pediatric population. Design This is a retrospective study. Setting This study was done at the LeBonheur Children's Hospital. Participants Sixty-six patients with orbital roof fractures were identified and stratified by gender and age, specifically younger than 7 years and 7 years or older. Main Outcome Measures The main outcome measures were orbital roof length, floor length, and ratio thereof. Results Mean orbital roof length was 43.4 ± 3.06 and 45.1 ± 3.94 mm for patients <7 and ≥7 years, respectively ( p = 0.02). Mean orbital floor length was 41.3 ± 2.99 and 47.7 ± 4.19 for patients <7 and ≥7 years, respectively ( p < 0.00001). The mean roof to floor ratio (RTFR) for patients <7 years was 1.051 ± 0.039 and for patients ≥ 7 years was 0.947 ± 0.031 ( p < 0.00001). Conclusion As children age, the relative length of the orbital roof decreases when compared with the orbital floor. The RTFR was more than 1.0 in children younger than 7 years. These differences were statistically significant when compared with children 7 years and older. This measurement shift follows the differences noted in orbital fracture patterns during childhood.

Single Institution Experience With International Referrals for Pediatric Cardiac Surgery.

Pediatric cardiac surgery in developing countries poses many challenges. The practice of referring patients from abroad via nongovernmental organizations has occurred for many years. We describe our experience with international referrals for pediatric cardiac surgery via Gift of Life Mid-South to the Heart Institute, Le Bonheur Children's Hospital in Memphis, Tennessee. We performed a retrospective descriptive review of data collected in our Society of Thoracic Surgeons Congenital Heart Surgery Database (STS CHSD) along with data from our electronic medical record from January 1, 2007, to December 31, 2017. Available data included patient demographics, diagnoses, surgical procedure, entire inpatient length of stay (LOS), complications, and operative mortality. Cardiac surgeries were grouped according to the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Categories (STAT Mortality Categories). Complications were defined according to the STS CHSD. In this retrospective descriptive study, case complexity level varied; however, 38% cardiac surgeries were in STAT Mortality Category 3 or 4. Honduras was the most common referral source with a total of 18 countries represented. Operative mortality remained very low (1 [1.4%] of 71 cardiac surgeries) despite patients being referred beyond infancy. There were an increasing number of complications and longer inpatient LOS (with greater variance) in STAT Mortality Category 4. International patients referred for congenital heart surgery can be successfully treated with an acceptable mortality rate despite late referrals. Inpatient LOS is related to surgical complexity. Follow-up studies are needed to determine the long-term outcomes of these patients.

Surgical Management of Tumors Involving the Cerebello-Medullary Angle: Anatomical Classification, Technique and Retrospective Analysis of 90 Pediatric Patients

Abstract INTRODUCTION Extent of resection (EOR) remains the most crucial factor in determining long-term and progression-free survivals for most pediatric posterior fossa tumors. The lateral cerebello-medullary region harbors complex anatomical relationships, making radical resection challenging. Indeed, the cerebella-medullary angle (CMA) was found to be a common area for residual disease in ependymomas and medulloblastomas. We examine a series of pediatric tumors in the region, and classify them anatomically regardless of their pathological diagnosis. METHODS We reviewed preoperative MRI scans of 347 elective posterior fossa craniotomies performed at Le Bonheur Children's Hospital between January 2010 and June 2018. We defined the lateral cerebellomedullary angle (CMA) as the region involving the foramen of Luschka (FL) and/or the cerebellomedullary cistern (CMC). Tumors in that area were classified according to their extension: type 1 (FL), 2 (CMC), 3A (premedullary cistern), 3B (cerebellopontine angle), and 3C (all compartments). Demographic, preoperative, intraoperative, and postoperative data were recorded. The primary endpoints were EOR and any resultant surgical complications. RESULTS A total of 90 patients met inclusion criteria, of which 37 (41%) had prior surgery with residual disease. Ependymomas (45%) and medulloblastomas (27%) formed the majority of tumors. There were 25 type 1 tumors, 23 type 2, and 42 patients type 3 tumors. Cerebella-Medullary fissure dissection was necessary in all cases, but type 2 and 3 tumors were more likely to be treated using an extended or a lateral sub occipital approach (P = .04). Residual disease on intraoperative and immediate postoperative MRI requiring re-exploration was consistent with the anatomical type, and occurred more frequently in type 3 (P = .043). However, gross-total or near-total resection was achieved in 81% of cases, with no intergroup difference. Group 3 had more postoperative cranial nerve (CN) deficits (P = .0003) with longer ICU stays (P = .01). CONCLUSION Although modern research is shifting towards molecular and genomic subtyping, anatomical factors remain the most crucial determinant of EOR. Lateral tumors can exhibit different genetic, anatomic and clinical characteristics compared to median tumors, but may be sub-classified further based on their anatomical extension. Such sub-classification has implications on residual disease in predictable anatomical blind spots, approach selection, and expected postoperative deficits.

LPS PROMOTES ASC‐SPECK FORMATION IN TREK‐1‐DEFICIENT MACROPHAGES

BACKGROUNDTREK‐1 is a 2‐pore potassium channel that we previously showed played a protective role against hyperoxia‐induced lung injury. To determine whether this protective effect was related to reduced inflammasome activation, we investigated LPS‐induced responses. Our preliminary studies with macrophages from TREK‐1−/− mice indicated a reduction in NLRP3 inflammasome priming and activation compared with wt mice, but we found that prolonged LPS exposure promoted increased IL‐1β release. We therefore investigatElied non‐canonical inflammasome pathways.METHODSWe stimulated alveolar macrophages (AMs) and bone marrow derived macrophages (BMDMs) using both a short‐term LPS+/−ATP model of inflammasome priming and activation and a prolonged‐LPS exposure. wt, TREK‐1−/−, and NLRP3−/− AMs and BMDMs were pre‐treated with a TREK‐1‐inhibitor (SPADIN), a TREK‐1‐activator, a Pannexin inhibitor, a P2X channel inhibitor, an ASC‐oligomerization inhibitor, or a JNK‐inhibitor. We measured IL‐1β, NLRP3, caspase‐1, ASC, TNFα as well as caspase−8, −7, and −11, and phosphorylated‐JNK using western blot, immunostaining, and ELISA. We used a membrane permeable potassium indicator to measure potassium efflux during ATP exposure. Using a caspase‐luciferace assay, we then measured caspase‐activity +/− MG132 (a proteasome inhibitor).RESULTSATP treatment of LPS‐primed TREK‐1‐inhibited and ‐deficient BMDMs exaggerated caspase‐7 and caspase‐11 activity compared to wt BMDMs, but both were dampened with co‐treatment with Pannexin and P2X inhibitors. Both TREK1 inhibition and deficiency caused elevated potassium efflux after short term LPS + ATP. With prolonged LPS exposure, both wt and TREK‐1−/− BMDMs contained more intracellular potassium than unstimulated wt BMDMs, with the LPS‐treated TREK‐1−/− BMDMs containing the highest concentration. Prolonged LPS exposure increased casp1‐p20, IL‐1β, and ASC‐speck formation in TREK‐1−/− BMDMs and AMs, compared with wt. Similarly, TREK‐1 inhibition with SPADIN increased ASC‐speck formation in both wt and NLRP3−/− BMDMs after prolonged LPS exposure. Additionally, MG132 completely blocked caspase activity in wt BMDMs treated with SPADIN after LPS treatment. JNK inhibition decreased ASC‐oligomerization in both wt and TREK‐1−/− BMDMs. However, prolonged LPS exposure led to increased caspase‐7 and JNK activity in TREK‐1−/− BMDMs compared to wt. Additionally, TREK‐1 inhibition increased caspase‐7 and caspase‐8 activity after LPS exposure in both wt and NLRP3−/− BMDMs.CONCLUSIONThese results suggest that the protective effect of TREK‐1 may be associated with regulation of apoptotic association ASC‐speck formation.Support or Funding InformationSupported by NIH grants HL123540, HL131526, and HL118118, and by the Le Bonheur Children's Hospital Research Foundation.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Intranasal Fentanyl and Midazolam for Procedural Analgesia and Anxiolysis in Pediatric Urgent Care Centers.

Intranasal fentanyl and midazolam use is increasing in the acute care setting for analgesia and anxiolysis, but there is a lack of literature demonstrating their use, alone or in combination, at pediatric urgent care centers. This retrospective study investigated intranasal fentanyl and midazolam use at an urgent care center located within Le Bonheur Children's Hospital and 2 affiliated off-site centers from September 22, 2011, to December 30, 2015. Data collected included patient demographics, initial fentanyl dose, initial midazolam dose, type of procedure, and serious adverse drug reactions. Of the 490 patients who met the inclusion criteria, 143 patients received intranasal fentanyl alone, 92 received intranasal midazolam alone, and 255 received fentanyl in combination with midazolam. The overall patient population was 50% male with a median (range) age of 4.5 (0.2-17.9) years, and most patients were black at 57.1%. The median (range) initial intranasal fentanyl dose was 2.02 (0.99-4.22) μg/kg, and the median initial (range) intranasal midazolam dose was 0.19 (0.07-0.42) mg/kg. In cases where fentanyl and midazolam were administered in combination, the median (range) initial fentanyl dose was 2.23 (0.6-4.98) μg/kg and median (range) initial midazolam dose was 0.2 (0.03-0.45) mg/kg. There were no serious adverse drug reactions reported. Intranasal fentanyl and midazolam when administrated alone and in combination can provide analgesia and anxiolysis for minor procedures in pediatric patients treated in the urgent care setting.

Decreased Identification of Vesicoureteral Reflux: A Cautionary Tale.

To find the trend in patient's visits to our centers for vesicoureteral reflux (VUR). We hypothesize that VUR diagnosis and hence possible nephropathy recognition may be diminishing because of changing practice patterns. Data were extracted from electronic medical records for new and follow-up patients aged 0-18 years with ICD-9/10 codes to correspond with VUR, VUR unilateral, VUR bilateral, and VUR with reflux nephropathy, as well as new patients with diagnoses of urinary tract infections (UTI) and pyelonephritis at two major pediatric centers from 2012 to 2015. Figures and statistics to reflect absolute clinic visits and annual trends were created with SPSS 2010. Linear regression was applied. Annually, Le Bonheur Children's Hospital and Nationwide Children's Hospital experienced an average decrease of 13 and 17% in total VUR visits, and an average decrease of 22 and 27% in VUR nephropathy visits, respectively, for each institution. Patient visits for UTIs were reduced an average of 16% annually in both centers. Linear regression demonstrated that number of patients (patients/year ± SE) decreased annually 69 ± 19 (P = 0.02), 7 ± 2 (P = 0.02), and 67 ± 25 (P = 0.04) for VUR, VUR nephropathy, and UTI, respectively. We conclude that the decreased number of VUR and VUR nephropathy cases identified in subspecialty clinics (Nephrology/Urology) at two major children's hospitals reflect a possible decreased identification of VUR. This trend may also be due to decreased referral of low grade cases of VUR. We cannot conclude that "undifferentiated UTI" referrals increased concomitantly to account for the decreased VUR as our data reflects a decreased trend in those visits as well. We suggest that clinicians following the American Academy of Pediatrics guidelines ensure that all UTI are accounted for and surveillance is appropriately escalated for recurrent UTI or abnormal imaging results.

Abusive head trauma: an epidemiological and cost analysis.

OBJECTIVE Research on pediatric abusive head trauma (AHT) has largely focused on clinical presentation and management. The authors sought to review a single-institution experience from a public health perspective to gain a better understanding of the local population affected, determine overall incidence and seasonal trends, and provide details on the initial hospitalization, including extent of injuries, neurosurgical interventions, and hospital charges. METHODS All cases of AHT involving patients who presented to Le Bonheur Children's Hospital (LBCH) from 2009 through 2014 were identified. AHT was defined as skull fracture or intracranial hemorrhage in a child under the age of 5 years with a suspicious mechanism or evidence of other intentional injuries, such as retinal hemorrhages, old or new fractures, or soft-tissue bruising. Injuries were categorized as Grade I (skull fracture only), Grade II (intracranial hemorrhage or edema not requiring surgical intervention), or Grade III (intracranial hemorrhage requiring intervention or death due to brain injury). RESULTS Two hundred thirteen AHT cases were identified. The demographics of the study population are similar to those reported in the literature: the majority of the patients involved were 6 months of age or younger (55%), male (61%), African American (47%), and publicly insured (82%). One hundred one neurosurgical procedures were performed in 58 children, with the most common being bur hole placement for treatment of subdural collections (25%) and decompressive hemicraniectomy (22%). The annual incidence rate rose from 2009 (19.6 cases per 100,000 in the population under 5 years of age) to 2014 (47.4 cases per 100,000) and showed seasonal peaks in January, July, and October (6-year average single-month incidence, respectively, 24.7, 21.7, and 24.7 per 100,000). The total hospital charges were $13,014,584, with a median cost of $27,939. Treatment costs for children who required surgical intervention (i.e., those with Grade III) were up to 10 times those of children with less severe injuries. CONCLUSIONS In the authors' local population, victims of AHT are overwhelmingly infants, are more often male than female, and are disproportionately from lower socioeconomic ranks. The incidence is increasing and initial hospitalization charges are substantial and variable. The authors introduce a simple 3-tiered injury classification scheme that adequately stratifies length of hospital stay and cost.

The Preventable Shunt Revision Rate: a potential quality metric for pediatric shunt surgery.

OBJECTIVE Shunt surgery consumes a large amount of pediatric neurosurgical health care resources. Although many studies have sought to identify risk factors for shunt failure, there is no consensus within the literature on variables that are predictive or protective. In this era of "quality outcome measures," some authors have proposed various metrics to assess quality outcomes for shunt surgery. In this paper, the Preventable Shunt Revision Rate (PSRR) is proposed as a novel quality metric. METHODS An institutional shunt database was queried to identify all shunt surgeries performed from January 1, 2010, to December 31, 2014, at Le Bonheur Children's Hospital. Patients' records were reviewed for 90 days following each "index" shunt surgery to identify those patients who required a return to the operating room. Clinical, demographic, and radiological factors were reviewed for each index operation, and each failure was analyzed for potentially preventable causes. RESULTS During the study period, there were 927 de novo or revision shunt operations in 525 patients. A return to the operating room occurred 202 times within 90 days of shunt surgery in 927 index surgeries (21.8%). In 67 cases (33% of failures), the revision surgery was due to potentially preventable causes, defined as inaccurate proximal or distal catheter placement, infection, or inadequately secured or assembled shunt apparatus. Comparing cases in which failure was due to preventable causes and those in which it was due to nonpreventable causes showed that in cases in which failure was due to preventable causes, the patients were significantly younger (median 3.1 vs 6.7 years, p = 0.01) and the failure was more likely to occur within 30 days of the index surgery (80.6% vs 64.4% of cases, p = 0.02). The most common causes of preventable shunt failure were inaccurate proximal catheter placement (33 [49.3%] of 67 cases) and infection (28 [41.8%] of 67 cases). No variables were found to be predictive of preventable shunt failure with multivariate logistic regression. CONCLUSIONS With economic and governmental pressures to identify and implement "quality measures" for shunt surgery, pediatric neurosurgeons and hospital administrators must be careful to avoid linking all shunt revisions with "poor" or less-than-optimal quality care. To date, many of the purported risk factors for shunt failure and causes of shunt revision surgery are beyond the influence and control of the surgeon. We propose the PSRR as a specific, meaningful, measurable, and-hopefully-modifiable quality metric for shunt surgery in children.

Harnessing the power of advanced hospital pharmacy technicians to improve patient care

Pharmacy technician roles have evolved rapidly over the past 40 years. At Le Bonheur Children's Hospital in Memphis, TN, technicians have taken on innovative and advanced roles that range from disease specialization to administration.

Head injuries following television-related accidents in the pediatric population.

Current data indicate the rate of head injuries in children caused by falling televisions is increasing. The authors describe these injuries and the cost incurred by them. In a single-institution retrospective review, all children treated for a television-related injury at LeBonheur Children's Hospital, a Level I pediatric trauma center, between 2009 and 2013 were identified through the institution's trauma registry. The type, mechanism, and severity of cranial injuries, surgical interventions, outcome, and costs were examined. Twenty-six patients were treated for a television-related injury during the study period. Most injuries (22 cases, 85%) occurred in children aged 2-4 years (mean age 3.3 years), and 19 (73%) of the 26 patients were male. Head injuries occurred in 20 patients (77%); these injuries ranged from concussion to skull fractures and subdural, subarachnoid, and intraparenchymal hemorrhages. The average Glasgow Coma Scale score on admission was 12 (range 7-15), and 3 patients (12%) had neurological deficits. Surgical intervention was required in 5 cases (19%). The majority of patients made a full recovery. There were no deaths. The total cost for television-related injuries was $1.4 million, with an average cost of $53,893 per accident. A high occurrence of head injuries was seen following television-related accidents in young children. This injury is ideal for a public education campaign targeting parents, health care workers, and television manufacturers.

New pharmacists: Take care of those babies

As a hospital pharmacy resident in 1979–80, I never missed an opportunity to round in pediatrics. Even though "clinical" was just a few weeks of my yearlong experience at the University of Texas Medical Branch (UTMB) at Galveston, I followed one of the pediatric teams all year, changing service when they did and showing up for rounds at 7:00am on any morning when I could take the beeper and slip away from my assigned area.

Pediatric pharmacist draws inspiration from young patients

Michael L. Christensen, PharmD, has dedicated his career to helping kids feel better. He divides his time between caring for young patients with parenteral nutrition needs and working as the principal investigator on clinical trials focused on understanding the pharmacokinetics of various medications in pediatric populations. "The best thing about being in pediatrics is that everyone cares about the children and wants what's best for them," said Christensen, Clinical Pharmacy Specialist at Le Bonheur Children's Hospital in Memphis, TN.

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