Prediction Of Important Clinical Events Research Articles

Comparative Study on Different Clinical Decision-Making Tools in Pediatric Head Injury Cases

Objective: To carry out a comparative study on effective clinical decision-making tools between Canadian Assessment of Tomography for Childhood Head injury, Pediatric Emergency Care Applied Research Network (PECARN) and Children's Head injury Algorithm for the prediction of Important Clinical Events in pediatrics head trauma cases. Study Design: Validation study. Place and Duration of Study: Department of Surgery, Saif Shaheed Hospital, Haveli Kahota, Azad Kashmir, Pakistan, from Oct 2021 to Nov 2022. Methodology: One hundred and fifty paediatric patients suffering from minor head injury were evaluated on clinical intervention decisions as per emergency procedures during the period of study. Sensitivity, Specificity, Positive Predictive Value and Negative Predictive Value of the selected diagnostic tests was checked. Results: Based on the head CT positivity, PECARN was found to be 81.8% sensitive and 61.9% specific. Canadian Assessment of Tomography for Childhood show sensitivity of 90.9 % and specificity of 65.5%. CHALICE had sensitivity and specificity of 63.6% and 61.5% respectively. CHALICE was unable to identify a pathological CT result with statistical significance (p=0.17) however PECARN and CATCH rule proved significant (p<0.05). CATCH rule show highest positive predictive score of 17.2% and negative predictive score of 98.8%. Conclusion: PECARN, CATCH, and CHALICE criteria are effective in deciding whether or not to perform Computerized Brain Tomography (CBT) scans on children with MHT, leading us to believe that employing these criteria could prevent unnecessary CBT scans.

Acil Servise Kafa Travmasi Nedeniyle Başvuran Çocuk Hastalarin Değerlendirilmesi

Aim: Head trauma is the most frequent reason for trauma related child deaths. Minor head traumas (MHT) form a considerable part of pediatric head traumas. Computed Brain Tomography (CBT) is the gold standard for demonstrating intracranial pathologies in patients with head trauma. It is necessary to avoid having unnecessary CT scans in order to reduce the cost and the harms of radiation. We aim to assess the pediatric patients that applied to the emergency service with complaints of head trauma in the light of Prediction of Important Clinical Events (CHALICE) clinical decision-making rules.
 Materials and Methods: 200 patients under 18 years old who applied to the emergency service with complaints of head trauma between 2016 and 2019 are included in this retrospective study. 
 Results: 200 patients in total were included in the study; of them, 128 are males and 72 are females. Of the patients, 3 have a Glaskow Coma Score (GCS) of 3-8, 2 have a GCS of 9-13, and the remaining 195 patients have a GCS of 14-15. Considering the symptoms, 35 patients had a headache, 28 patients had subcutaneous hematoma, and 26 patients had nausea-vomiting. The reason for trauma is motor vehicle accident for 99 patients and falling down from height for 95 patients. Four patients died. CHALICE (+) rate was found 67.82% in the patients having a CBT scan. 41.95% of asymptomatic patients had a CBT scan. 
 Conclusion: The results of our study showed that despite all academic efforts, unnecessary CT rates in pediatric head injuries could not be reduced.

The comparison of PECARN, CATCH, AND CHALICE criteria in children under the age of 18 years with minor head trauma in emergency department

Introduction: Minor head traumas constitute a significant part of childhood injuries. The incidence of intracranial pathologies in children with minor head trauma varies in the range of 3%–5%, but it is higher among younger infants. The criteria of the Pediatric Emergency Care Applied Research Network, Canadian Assessment of Tomography for Childhood Head Injury, and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events are the most frequently accepted clinical decision-making criteria that were developed for selective computerized tomography requests. This study was conducted to assess the diagnostic performances of the Pediatric Emergency Care Applied Research Network, Canadian Assessment of Tomography for Childhood Head Injury, and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events criteria in Turkish society, determine their validity, and find the most suitable algorithm for cranial imaging in children with minor head trauma. Methods: This study retrospectively examined the data of patients under the age of 18 years who were admitted to the Emergency Medicine Department of Uludağ University Medical Faculty due to minor head trauma; 530 patients were included as they complied with the criteria. The exclusion criteria were being any trauma patients above the age of 18 years, Glasgow Coma Scale <13, pregnant patients, hemorrhagic diathesis, using anticoagulants, patients with penetrant trauma, patients with priorly known brain tumor, and patients with neurological diseases. The patients were divided into group based on the Pediatric Emergency Care Applied Research Network, Canadian Assessment of Tomography for Childhood Head Injury, and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events Criteria. Results: Among all patients, 37.40% were female and 62.60% were male. Abnormal computed tomography findings such as epidural bleeding, subdural bleeding, and skull fractures were detected in 44 of the patients. The sensitivity of the Pediatric Emergency Care Applied Research Network criteria was 72.4%, the specificity was 54.5%, the sensitivity of the Canadian Assessment of Tomography for Childhood Head Injury criteria was 57.8%, the specificity was 50%, the sensitivity of the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events criteria was 87.7%, and the specificity was 20%. Conclusion: Given the populations to which the rules apply, it is understood that the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events criteria is more determinative in detecting pathological computed tomography outcomes compared to Pediatric Emergency Care Applied Research Network and Canadian Assessment of Tomography for Childhood Head Injury.

Traumatic brain injury in young children with isolated scalp haematoma

ObjectiveDespite high-quality paediatric head trauma clinical prediction rules, the management of otherwise asymptomatic young children with scalp haematomas (SH) can be difficult. We determined the risk of intracranial injury when...

A Cost-Effectiveness Analysis Comparing Clinical Decision Rules PECARN, CATCH, and CHALICE With Usual Care for the Management of Pediatric Head Injury

To determine the cost-effectiveness of 3 clinical decision rules in comparison to Australian and New Zealand usual care: the Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE), the Pediatric Emergency Care Applied Research Network (PECARN), and the Canadian Assessment of Tomography for Childhood Head Injury (CATCH). A decision analytic model was constructed from the Australian health care system perspective to compare costs and outcomesof the 3 clinical decision rules compared with Australian and New Zealand usual care. The study involved multicenter recruitment from 10 Australian and New Zealand hospitals; recruitment was based on the Australian Pediatric Head Injury Rules Study involving 18,913 children younger than 18 years and with a head injury, and with Glasgow Coma Scale score 13 to 15 on presentation toemergency departments (EDs). We determined the cost-effectiveness of the 3 clinical decision rules compared with usual care. Usual care, CHALICE, PECARN, and CATCH strategies cost on average AUD $6,390, $6,423, $6,433, and $6,457 per patient, respectively. Usual care was more effective and less costly than all other strategies and is therefore the dominant strategy. Probabilistic sensitivity analyses showed that when simulated 1,000 times, usual care dominated all clinical decision rules in 61%, 62%, and 60% of simulations (CHALICE, PECARN, and CATCH, respectively). The difference in cost between all rules was less than $36 (95% confidence interval -$7 to $77) and the difference in quality-adjusted life-years was less than 0.00097 (95% confidence interval 0.0015 to 0.00044). Results remained robust under sensitivity analyses. This evaluation demonstrated that the 3 published international pediatric head injury clinical decision rules were not more cost-effective than usual care in Australian and New Zealand tertiary EDs. Understanding the usual care context and the likely cost-effectiveness is useful before investing in implementation of clinical decision rules or incorporation into a guideline.

Accuracy of Clinician Practice Compared With Three Head Injury Decision Rules in Children: A Prospective Cohort Study

Three clinical decision rules for head injuries in children (Pediatric Emergency Care Applied ResearchNetwork [PECARN], Canadian Assessment of Tomography for Childhood Head Injury [CATCH], and Children's Head Injury Algorithm for the Prediction of Important Clinical Events [CHALICE]) have been shown to havehigh performance accuracy. The utility of any of these in a particular setting depends on preexisting clinician accuracy. Wetherefore assess the accuracy of clinician practice in detecting clinically important traumatic braininjury. This was a planned secondary analysis of a prospective observational study of children younger than 18 years with head injuries at 10 Australian and New Zealand centers. In a cohort of children with mild head injuries (Glasgow Coma Scale score 13 to 15, presenting in <24 hours) we assessed physician accuracy (computed tomography [CT] obtained in emergency departments [EDs]) for the standardized outcome of clinically important traumatic brain injury and compared this with the accuracy of PECARN, CATCH, and CHALICE. Of 20,137 children, 18,913 had a mild head injury. Of these patients, 1,579 (8.3%) received a CT scan duringthe ED visit, 160 (0.8%) had clinically important traumatic brain injury, and 24 (0.1%) underwent neurosurgery. Clinician identification of clinically important traumatic brain injury based on CT performed had a sensitivity of 158 of160, or 98.8% (95% confidence interval [CI] 95.6% to 99.8%) and a specificity of 17,332 of 18,753, or 92.4% (95% CI 92.0% to 92.8%). Sensitivity of PECARN for children younger than 2 years was 42 of 42 (100.0%; 95% CI 91.6% to 100.0%), and for those 2 years and older, it was 117 of 118 (99.2%; 95% CI 95.4% to 100.0%); for CATCH (high/medium risk), it was 147 of 160 (91.9%; 95% CI 86.5% to 95.6%); and for CHALICE, 148 of 160 (92.5%; 95% CI 87.3%to 96.1%). In a setting with high clinician accuracy and a low CT rate, PECARN, CATCH, or CHALICE clinical decision rules have limited potential to increase the accuracy of detecting clinically important traumatic brain injury and may increase the CT rate.

乳児頭部外傷における外傷性脳損傷と頭蓋骨骨折の危険因子の比較検討(Comparison of risk factors between traumatic brain injury and skull fracture in infant head injury)

要旨【目的】小児頭部外傷に対する大規模CT適応基準は，外傷性脳損傷（TBI）の発見を目的としており，頭蓋骨単独骨折（ISF）は見落とされる可能性がある。このため，本研究では2歳未満児のTBIとISFの危険因子を比較するため検討を行った。【対象】2013–2015年の3年間に頭部外傷で救急受診し，CTが施行された2歳未満児416例を後方視的に検討した。対象症例をTBI群：25例，ISF群：30例，異常所見なし群（以下NAF群）：361例の3群に分け特徴を比較した。また多変量解析でTBIとISFの危険因子を検討した。【結果】年齢は，TBI群は0–3か月で，ISF群は6–12か月で，NAF群は12か月以降で多かった。受傷機転は，ISF群で墜落が多く，TBI群では抱っこでの転倒・受傷機転不明が多かった。TBI群・ISF群ともに前頭部以外の皮下血腫がNAF群より多く，径も大きかった。多変量解析では，TBIと関連する因子は低年齢，受傷機転不明，2回以上の嘔吐，痙攣，前頭部以外の皮下血腫であったが，ISFと関連する因子は，経過時間（24時間以降または不明），前頭部以外の皮下血腫，5cm以上の皮下血腫であった。【結語】乳児頭部外傷におけるTBIとISFの危険因子は異なり，大規模基準で低リスクであってもISFを疑う場合は，経過観察もしくはCTが必要である。

External Validation of Three Decision Rules for Pediatric Head Injury

Minor head trauma is a common reason for children to visit the emergency department (ED), but the vast majority of computed tomography (CT) scans are negative. Researchers prospectively compared and externally validated three clinical decision rules aimed at reducing avoidable CT: PECARN (Pediatric Emergency Care Applied Research Network), CATCH (Canadian Assessment of Tomography for Childhood Head Injury), and CHALICE (Children's Head Injury Algorithm for the Prediction of Important Clinical Events). …

Presenting characteristics of children who required neurosurgical intervention for head injury.

The purpose of this study is to describe the presenting characteristics of a large group of children who required neurosurgical intervention (NSI) following a head injury and to retrospectively assess which of the criteria for imaging from Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE), Pediatric Emergency Care Applied Research Network (PECARN), and Canadian Assessment of Tomography for Childhood Head Injury (CATCH) clinical decision rules (CDRs) were met by these patients. We retrospectively reviewed all patients undergoing NSI following a head injury, between 2000 and 2008, at a large tertiary pediatric trauma center. We excluded patients having non-accidental injury, other neurosurgical interventions, penetrating injuries, and patients with incomplete data. To those who presented initially with mild head injury (GCS 14-15), we retrospectively applied the criteria for imaging of the CHALICE, PECARN, and CATCH CDRs. Out of 289 patients undergoing NSI, 182 met inclusion criteria and comprised our cohort. Of the 72 (39.6%) with mild head injury (GCS 14-15), 71 (98.6%) met at least one criteria for imaging from each of the three CDRs, including severe mechanism of injury (68, 94.4%), clinically evident skull fracture (35, 48.6%), neurological deficit (19, 26.3%), or severe headache (6, 8.3%). Of the 182 patients in the entire cohort, only 1 (0.5%) did not present with an obvious indication for CT on all three CDRs. In a large sample of children requiring NSI after head trauma, the vast majority met CT criteria listed in each of the three CDRs. The most common indication for CT was a severe mechanism of injury. This, combined with clinically evident skull fracture, neurological deficit, and severe headache, identifies almost all patients requiring NSI.

Clinical Decision Rules for Paediatric Minor Head Injury: Are CT Scans a Necessary Evil?

High performing clinical decision rules (CDRs) have been derived to predict which head-injured child requires a computed tomography (CT) of the brain. We set out to evaluate the performance of these rules in the Singapore population. This is a prospective observational cohort study of children aged less than 16 who presented to the emergency department (ED) from April 2014 to June 2014 with a history of head injury. Predictor variables used in the Canadian Assessment of Tomography for Childhood Head Injury (CATCH), Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) and Pediatric Emergency Care Applied Research Network (PECARN) CDRs were collected. Decisions on CT imaging and disposition were made at the physician's discretion. The performance of the CDRs were assessed and compared to current practices. A total of 1179 children were included in this study. Twelve (1%) CT scans were ordered; 6 (0.5%) of them had positive findings. The application of the CDRs would have resulted in a significant increase in the number of children being subjected to CT (as follows): CATCH 237 (20.1%), CHALICE 282 (23.9%), PECARN high- and intermediate-risk 456 (38.7%), PECARN high-risk only 45 (3.8%). The CDRs demonstrated sensitivities of: CATCH 100% (54.1 to 100), CHALICE 83.3% (35.9 to 99.6), PECARN 100% (54.1 to 100), and specificities of: CATCH 80.3% (77.9 to 82.5), CHALICE 76.4% (73.8 to 78.8), PECARN high- and intermediate-risk 61.6% (58.8 to 64.4) and PECARN high-risk only 96.7% (95.5 to 97.6). The CDRs demonstrated high accuracy in detecting children with positive CT findings but direct application in areas with low rates of significant traumatic brain injury (TBI) is likely to increase unnecessary CT scans ordered. Clinical observation in most cases may be a better alternative.

Comparison of PECARN, CATCH, and CHALICE Rules for Children With Minor Head Injury: A Prospective Cohort Study

We evaluate the diagnostic accuracy of clinical decision rules and physician judgment for identifying clinically important traumatic brain injuries in children with minor head injuries presenting to the emergency department. We prospectively enrolled children younger than 18 years and with minor head injury (Glasgow Coma Scale score 13 to 15), presenting within 24 hours of their injuries. We assessed the ability of 3 clinical decision rules (Canadian Assessment of Tomography for Childhood Head Injury [CATCH], Children's Head Injury Algorithm for the Prediction of Important Clinical Events [CHALICE], and Pediatric Emergency Care Applied Research Network [PECARN]) and 2 measures of physician judgment (estimated of <1% risk of traumatic brain injury and actual computed tomography ordering practice) to predict clinically important traumatic brain injury, as defined by death from traumatic brain injury, need for neurosurgery, intubation greater than 24 hours for traumatic brain injury, or hospital admission greater than 2 nights for traumatic brain injury. Among the 1,009 children, 21 (2%; 95% confidence interval [CI] 1% to 3%) had clinically important traumatic brain injuries. Only physician practice and PECARN identified all clinically important traumatic brain injuries, with ranked sensitivities as follows: physician practice and PECARN each 100% (95% CI 84% to 100%), physician estimates 95% (95% CI 76% to 100%), CATCH 91% (95% CI 70% to 99%), and CHALICE 84% (95% CI 60% to 97%). Ranked specificities were as follows: CHALICE 85% (95% CI 82% to 87%), physician estimates 68% (95% CI 65% to 71%), PECARN 62% (95% CI 59% to 66%), physician practice 50% (95% CI 47% to 53%), and CATCH 44% (95% CI 41% to 47%). Of the 5 modalities studied, only physician practice and PECARN identified all clinically important traumatic brain injuries, with PECARN being slightly more specific. CHALICE was incompletely sensitive but the most specific of all rules. CATCH was incompletely sensitive and had the poorest specificity of all modalities.

The cost-effectiveness of diagnostic management strategies for children with minor head injury

AimTo estimate the cost-effectiveness of diagnostic management strategies for children with minor head injury and identify an optimal strategy.MethodsA probabilistic decision analysis model was developed to estimate the costs and...

Applicability of the CATCH, CHALICE and PECARN paediatric head injury clinical decision rules: pilot data from a single Australian centre

BackgroundClinical decision rules (CDRs) for paediatric head injury (HI) exist to identify children at risk of traumatic brain injury. Those of the highest quality are the Canadian assessment of tomography...

029 Clinical decision rules for children with minor head injury: a systematic review

Objectives and BackgroundClinical decision rules aid clinicians with the management of head injured patients. This study aimed to identify clinical decision rules for children with minor head injury and compare...

Diagnostic management strategies for adults and children with minor head injury: a systematic review and an economic evaluation

BACKGROUND Patients with minor head injury [Glasgow Coma Scale (GCS) score 13-15] have a small but important risk of intracranial injury (ICI) that requires early identification and neurosurgical treatment. Diagnostic assessment can use either a clinical decision rule or unstructured assessment of individual clinical features to identify those who are at risk of ICI and in need of computerised tomography (CT) scanning and/or hospital admission. Selective use of CT investigations helps minimise unnecessary radiation exposure and resource use, but can lead to missed opportunities to provide early treatment for ICI.

Clinical decision rules for children with minor head injury: a systematic review

IntroductionClinical decision rules aid clinicians with the management of head injured patients. This study aimed to identify clinical decision rules for children with minor head injury and compare their diagnostic...

CHALICE head injury rule: an implementation study

IntroductionPaediatric head injury is a common presentation to emergency departments (ED), and the 2007 National Institute for Health and Clinical Excellence head injury guidelines included a paediatric section to deal...

Application of the CHALICE clinical prediction rule for intracranial injury in children outside the UK: impact on head CT rate

ObjectiveThe children's head injury algorithm for the prediction of important clinical events (CHALICE) is one of the strongest clinical prediction rules for the management of children with head injuries. The...

Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children

Background: A quarter of all patients presenting to emergency departments are children. Although there are several large, well-conducted studies on adults enabling accurate selection of patients with head injury at...