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ABSTRACT: Unintentional injuries are one of the leading causes of death in the United States. Many of these injuries are preventable, and unintentional firearm injuries, in particular, may be responsive to prevention efforts. We investigated the relationship between unintentional firearm death and urbanicity among adults.
This study was a retrospective analysis of national death certificate data. Unintentional adult firearm deaths in the United States from 1999 to 2006 were identified using the Multiple Cause of Death Data files from the National Center for Health Statistics. Decedents were assigned to a county of death and classified along an urban-rural continuum defined by population density and proximity to metropolitan areas. Total unintentional firearm death rates by county were analyzed in adjusted analyses using negative binomial regression.
A total of 4,595 unintentional firearm injury deaths of adults occurred in the United States during the study period (a mean of 574.4 per year). Adjusted rates of unintentional firearm death showed increases from urban to rural counties. Americans in the most rural counties were significantly more likely to die of unintentional firearm deaths than those in the most urban counties (relative rate, 2.16; 95% confidence interval, 1.44-3.21, p = 0.002).
Rates of unintentional firearm death are significantly higher in rural counties than in urban counties. Prevention strategies should be tailored to account for both geographic location and manner of firearm injury.
Epidemiologic study, level III.
The journal of trauma and acute care surgery. 09/2012; 73(4):1006-10.
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ABSTRACT: This study aimed to develop and validate prognostic criteria to identify children at risk for persistence of mild traumatic brain injury (MTBI) impairment.
A prospective cohort study was conducted among 11- to 17-year-old emergency department (ED) patients admitted for MTBI. The Immediate Postconcussion Assessment and Cognitive Testing neurocognitive test was administered during hospitalization and at routine clinic follow-up (ImPACT). Logistic regression and receiver operating characteristic (ROC) analyses were used to develop prognostic criteria for MTBI-related impairment in 1 group and validate the criteria in a second group. Mild traumatic brain injury-related impairment was defined as any impairment (symptom score >8 or <25th percentile on at least 1 of 4 neurocognitive composite domains) or severe impairment (symptom score >12 or <25th percentile on at least 2 of 4 neurocognitive composite domains) present on follow-up.
The derivation and validation cohorts were 42 and 21 patients (median age, 14 years; 71.4% male). Using the mean of the validation cohort patients' 4 neurocognitive deficit composite percentiles at baseline, a cut point of less than 39 percentile had high sensitivity (0.89) and specificity (0.80) and an area under the ROC curve of 0.85 in predicting the presence of any impairment at follow-up; it discriminated equally well in the validation cohort. A cut point of less than 27 percentile had good sensitivity (0.67) and specificity (0.67) and area under the ROC curve of 0.67 in predicting the presence of severe impairment in the derivation cohort at follow-up; it discriminated equally well in the validation cohort.
This is the first study demonstrating prognostic criteria that may greatly help physicians identify patients who would benefit from structured follow-up care after MTBI.
Pediatric emergency care 05/2012; 28(6):498-502. · 0.92 Impact Factor
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ABSTRACT: Trauma system planners use patient home address as a proxy for injury location, although this proxy has not been validated. We sought to determine the precision of this proxy by evaluating the relationship between the location of injury death and the location of residence.
This national descriptive analysis used the Multiple Cause of Death data files from 1999 to 2006 to determine the proportion of subjects in which county of residence (RC) matched county of death for all US injury deaths. Subgroup analyses were completed by age and injury intentionality using two sample tests of proportions. χ(2) tests were used to evaluate differences in concordance over time and by size of the RC.
Analysis included 3,141 US counties and 1,255,881 subjects. A total of 73.4% of subjects died in the RC and 87.7% died in the RC or a contiguous county. Intentional injury deaths were more likely than unintentional to happen within a decedent's RC (85.1% vs. 68.1%, p < 0.001) and within the RC or contiguous county (93.4% vs. 85.2%, p < 0.001). Adult injury deaths were more likely than pediatric to happen within a decedent's RC (73.6% vs. 68.4%, p < 0.001) and within the RC or contiguous county (87.9% vs. 84.2%, p < 0.001). Subjects from larger counties were more likely to die within the RC or a contiguous county (same p < 0.001, same or adjacent p < 0.001).
The preponderance of fatal injury deaths occur close to home. This supports the practice of trauma system's planning using home location available in administrative data to proxy injury location.
The Journal of trauma 05/2011; 71(5):1428-34. · 2.48 Impact Factor
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ABSTRACT: Children are the most frequent victims of dog bites presenting to hospital emergency departments (ED), but there are gaps in understanding of the circumstances of such bites. The objective of this study was to characterise the behavioural circumstances of dog bites by interviewing children ≤17 years (or parent proxies for children ≤6 years) presenting with dog bite injuries to The Children's Hospital of Philadelphia about the bite incident, its setting and associated interactions. Of 203 children enrolled, 51% were <7 years old and 55% were male. 72% of children knew the biting dog. Most bites to younger children occurred during positive interactions, initiated by the child, with stationary, familiar dogs, indoors. Most older bitten children had been active (eg, outdoors), unfamiliar with the dog and not interacting. Whereas face bites predominated (70%) in the younger group (<7 years), bites to extremities predominated (72%) in the older group. Recognition of the two distinctive behavioural and circumstantial subgroups of dog bites that emerged can lead to more effective prevention strategies.
Injury Prevention 03/2011; 17(5):348-53. · 1.39 Impact Factor
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Injury Prevention 02/2011; 17(1):69-70. · 1.39 Impact Factor
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ABSTRACT: Roux-en-Y hepaticojejunostomy (HJ) is currently the favored reconstructive procedure after resection of choledochal cysts. Hepaticoduodenostomy (HD) has been argued to be more physiologically and technically easier but is feared to have associated complications. Here we compare outcomes of the 2 procedures.
A retrospective chart review identified 59 patients who underwent choledochal cyst resection within our institution from 1999 to 2009. Demographic and outcome data were compared using t tests, Mann-Whitney U tests, and Pearson χ(2) tests.
Fifty-nine patients underwent repair of choledochal cyst. Biliary continuity was restored by HD in 39 (66%) and by HJ in 20 (34%). Open HD patients required less total operative time than HJ patients (3.9 vs 5.1 hours, P = .013), tolerated a diet faster (4.8 days compared with 6.1 days, P = .08), and had a shorter hospital stay (7.05 days for HD vs 9.05 days for HJ, P = .12). Complications were more common in HJ (HD = 7.6%, HJ = 20%, P = .21). Three patients required reoperation after HJ, but only one patient required reoperation after HD for a stricture (HD = 2.5%, HJ = 20%, P = .037).
In this series, HD required less operative time, allowed faster recovery of bowel function, and produced fewer complications requiring reoperation.
Journal of Pediatric Surgery 01/2011; 46(1):209-13. · 1.45 Impact Factor
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ABSTRACT: Head injury is the most common cause of death for child occupants in motor vehicle crashes (MVCs). The morbidity associated with nonlethal MVC-related head injuries is of great clinical consequence as well. The purpose of this study was to identify the frequency of, and risk factors for, clinically significant head injury (CSHI) in child occupants in MVCs.
A large, child-specific crash surveillance system linking insurance claims data to telephone survey data was utilized. Qualifying crashes involved model year 1990 or newer vehicles in crashes with one or more child occupants (age 4 to 15 years) occurring in 15 U.S. states. Data were accrued between March 2000 and December 2007. A probability sample of crashes was selected for telephone survey with the driver of the insured vehicle. A clinically significant head injury, as reported by the child's parent using a validated survey, included concussions, skull fractures, and intracranial hemorrhages. Multivariate logistic regression was used to identify factors associated with a CSHI.
During the period of study, completed interviews were obtained on 19,075 children aged 4-15, representing 318,527 children involved in 219,511 crashes. The overall rate of CSHI in child occupants was 1.08 percent. Factors associated with an increased risk of head injury included rollover (odds ratio [OR] = 8.60, 95% confidence interval [CI] 6.40-11.57) and near-side impact crashes (OR = 2.39, 95% CI 1.73-3.30) vs. frontal impact; lack of restraint (OR = 3.13, 95% CI 2.26-4.33) vs. restrained; and driver age < 25 years (OR = 1.43, 95% CI 1.12-1.81) vs. driver age ≥ 25 years. Some factors varied based on occupant age, and younger child age had a protective effect on the risk for head injury.
The risk of CSHI for 4- to 15-year-old child occupants was 1.08 percent. Several demographic and crash factors were associated with CSHI in child occupants. This information may help inform design safety initiatives.
Traffic injury prevention 12/2010; 11(6):600-5.
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ABSTRACT: The majority of previous studies that described the neuropsychological effects of cardiopulmonary bypass (CPB) in children were performed after surgery in infancy for complex congenital heart disease (CHD). We sought to limit confounding variables and isolate potential independent effects of CPB by describing neuropsychological function in school-aged children after repair of acyanotic CHD.
This was a prospective study of patients who were aged 5 to 18 years and undergoing repair of acyanotic CHD. Neuropsychological testing battery included assessment of intelligence, memory, motor, attention, executive function, and behavior before and 6 months after CPB. The independent effects of anesthesia, surgery, and hospitalization on neuropsychological function were assessed by testing a surgical control group of patients who were undergoing repair of pectus deformities. In addition, an outpatient group of children with mild CHD were enrolled to assess the practice effects of serial testing.
Patients included CPB (n = 35), surgical control (n = 19), and nonsurgical (n = 12). Groups were comparable in age, gender, and race and demonstrated similar unadjusted group mean scores on baseline and 6-month follow-up neuropsychological testing. When adjusted for practice effects, the CPB group performed similar to the non-CPB groups in all assessed neuropsychological domains, with the exception of 1 of 4 tests of executive function.
When controlling for the non-CPB effects of surgery (eg, hospitalization, anesthesia, thoracotomy) and the practice effects of serial testing, there were no consistent independent effects of CPB on neuropsychological status in a cohort of children and adolescents 6 months after repair of acyanotic CHD.
PEDIATRICS 08/2010; 126(2):e351-9. · 4.47 Impact Factor
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ABSTRACT: Injury is a leading cause of pediatric death and disability. Although adult trauma care in the United States has been celebrated as a model system of emergency care, it is not clear that pediatric trauma care is as well organized. We seek to describe in this review the current state of pediatric trauma care and suggest next steps required to ensure the efficient delivery of pediatric trauma care.
Eighty-four percent of adults in the United States have access to a level 1 or 2 trauma center within an hour, and 71.5% of pediatric patients have access to a verified pediatric trauma center within an hour assuming ground and air transport. These results are variable depending on state, region, and population density. An estimated 17.4 million children do not have access to a pediatric trauma center within 60 min.
Trauma centers improve outcome for injured patients with care at pediatric-focused centers superior to that provided at nonpediatric centers. However, access to high-level trauma care varies geographically and is not available to all children in a timely fashion. Future studies should correlate access to outcome and guide policy makers to optimize trauma systems for children.
Current opinion in pediatrics 06/2010; 22(3):326-31. · 2.01 Impact Factor
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ABSTRACT: We examined whether firearm mortality rates among children varied across US counties along a rural-urban continuum.
US vital statistics data were accessed for all pediatric (age: 0-19 years) firearm deaths from 1999 through 2006. Deaths were analyzed according to a modified rural-urban continuum code (based on population size and proximity to metropolitan areas) assigned to each county (3141 counties).
In the 8-year study period, there were 23649 pediatric firearm deaths (15190 homicides, 7082 suicides, and 1377 unintentional deaths). Pediatric nonfirearm mortality rates were significantly higher in the most-rural counties (adjusted rate ratio: 1.36 [95% confidence interval [CI]: 1.13-1.64]), compared with the most-urban counties. The most-rural counties demonstrated virtually identical pediatric firearm mortality rates (adjusted rate ratio: 0.91 [95% CI: 0.63-1.32]), compared with the most-urban counties. The most-rural counties had higher rates of pediatric firearm suicide (adjusted rate ratio: 2.01 [95% CI: 1.43-2.83]) and unintentional firearm death (adjusted rate ratio: 2.19 [95% CI: 1.27-3.77]), compared with the most-urban counties. Pediatric firearm homicides rates were significantly higher in the most-urban counties (adjusted rate ratio: 3.69 [95% CI: 2.00-6.80]), compared with the most-rural counties.
Children in the most-rural US counties had firearm mortality rates that were statistically indistinguishable from those for children in the most-urban counties. This finding reflects a greater homicide rate in urban counties counterbalanced by greater suicide and unintentional firearm death rates in rural counties. Nonfirearm mortality rates were significantly greater outside the most-urban US counties.
PEDIATRICS 06/2010; 125(6):1112-8. · 4.47 Impact Factor
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ABSTRACT: Traumatic brain injury is common in children. Fortunately, most patients suffer mild traumatic brain injury (MTBI). Appropriate guidelines for follow-up care are not well established. We sought to determine practice experience and preferences of general pediatricians related to follow-up care of MTBI.
Members of the American Academy of Pediatrics Council of Community Pediatrics and general pediatricians in the Pennsylvania Chapter of the American Academy of Pediatrics participated in a web-based survey regarding practice setting, level of comfort caring for patients with MTBI, and referral patterns for such patients.
A total of 298 pediatricians responded. An urban or suburban practice setting was reported by 83.3% with a wide distribution in practice experience (0-10 years 40.5%, 11-20 years 24.5%, >21 years 35%). Most respondents (54.5%) had cared for at least 2 to 5 patients with MTBI in the past 6 months but only 8% had seen >10 patients. Fifty-nine percent had not participated in continuing medical education activities related to MTBI and 62.2% did not use neurocognitive tests. The majority (89%) thought that they were the appropriate provider for follow-up; this declined to 61.2% for patients with loss of consciousness and only 5.4% if patients had persistent symptoms. Neurologists (75%) were the consultant of choice for referral. Increased practice experience was associated with an increased comfort in determining return to play status.
In this survey, pediatricians thought that they were the most appropriate clinicians to follow-up patients with MTBI. However, most accepted this responsibility without the benefit of specific continuing medical education or using neurocognitive tests. Ensuring the availability of appropriate resources for pediatricians to care for these patients is important.
The Journal of trauma 06/2010; 68(6):1396-400. · 2.48 Impact Factor
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Rafael Pieretti-Vanmarcke,
George C Velmahos, Michael L Nance,
Saleem Islam,
Richard A Falcone,
Paul W Wales,
Rebeccah L Brown,
Barbara A Gaines,
Christine McKenna,
Forrest O Moore, [......],
Mary E Fallat,
David S Foley,
Joseph A Iocono,
Heather M Bennett,
Kenneth Waxman,
Kelly Kam,
Lisa Bakhos,
Laurie Petrovick,
Yuchiao Chang,
Peter T Masiakos
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ABSTRACT: Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years.
The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third.
Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study.
CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.
The Journal of trauma 09/2009; 67(3):543-9; discussion 549-50. · 2.48 Impact Factor
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ABSTRACT: The aim of the study is to test the effect of age and preextracorporeal membrane oxygenation (pre-ECMO) days of ventilation on ECMO survival in the pediatric population.
Retrospective analysis of noncardiac, pediatric (age >30 days) ECMO patients for the period January 1984 to June 2006. Pre-ECMO demographic, ventilatory, and lung injury severity variables were modeled with stepwise logistic regression to estimate survival probabilities associated with pre-ECMO ventilation duration and patient age. Patients were excluded from review for the following: pre-ECMO cardiac arrest, pre-ECMO ventilation of more than 30 days (chronic), or multiple runs on ECMO.
For the period of review, 2550 patients met inclusion/exclusion criteria. The population had a mean age of 3.6 +/- 5.1 years (median age, 1 year). The mean pre-ECMO days of ventilation were 5.2 +/- 4.9 (median, 4 days). The overall survival probability was 58.6%. The mean oxygen index and Pao(2)/Fio(2) ratio were 62.2 +/- 48.2 and 95.5 +/- 48.2, respectively. The population overall demonstrated a statistically significant, exponential decline in survival as pre-ECMO days of ventilation increased (P < .05). For each additional year of age, survival decreased by an average of 2.5%. For each additional day of pre-ECMO ventilation, survival decreased by an average of 2.9%. Younger ages were generally associated with higher survival probabilities at each ventilation day.
In the pediatric population, survival decreases significantly as pre-ECMO ventilator days increase. Survival is also inversely related to patient age. Thus, patient age and duration of ventilation should be considered when evaluating suitability for ECMO.
Journal of Pediatric Surgery 08/2009; 44(8):1606-10. · 1.45 Impact Factor
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ABSTRACT: To catalog trauma center resources and estimate access to age-specific trauma care for children younger than 15 years in the United States.
Cross-sectional study collating information from national, state, and local trauma systems authorities to create a catalog of verified pediatric trauma centers (PTCs) and self-designated "candidate" trauma centers. Access-to-care calculations were estimated using all US block groups and prior validated methods.
United States.
Children in the US younger than 15 years.
The PTC statuses of hospitals in the United States. Percentages of pediatric populations (by state and population density) having access (by ground or air) within 60 minutes to a PTC.
A total of 170 verified PTCs were identified in 41 states (including the District of Columbia). An estimated 71.5% of pediatric patients were within 60 minutes of a verified PTC by air or ground transport, 43% if ground transportation only was considered. An estimated 17.4 million children did not have access to a PTC within 60 minutes. Access ranged from 22.9% of the population in the most rural areas of the United States to 93.5% in the most urban. The addition of 24 candidate centers increased coverage to 77.4% of the pediatric population being within 60 minutes of a PTC.
Current pediatric trauma resources vary greatly by state and population density, with many children, particularly in rural areas, underserved. A thorough standardized catalog of verified PTCs is necessary to accurately assess pediatric trauma needs now and to optimize future trauma system planning for children.
Archives of pediatrics & adolescent medicine 07/2009; 163(6):512-8. · 3.73 Impact Factor
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ABSTRACT: Mild traumatic brain injury (MTBI) is common in the pediatric population. The symptom complex that might be expected in children after MTBI is not well documented. We sought to clarify the frequency and severity of concussive symptoms reported by children who required hospitalization for MTBI.
Pediatric blunt trauma patients (age, 11-17 years) admitted for treatment of MTBI (GCS 14-15) were prospectively enrolled over a 2-year period. Consented patients were administered a 22-question Likert-based concussion symptom scale (normal, total score 0-8). The symptom scale was repeated at the time of routine follow-up trauma clinic visit. The frequency and severity of concussive symptoms were analyzed at both time-points.
For the 2-year period, 116 children participated in the study including 63 who returned for clinic follow-up. The overall population had mean age of 14.1 years (median 14) and was 69.8% male. The mean symptom score (sum of Likert scores [scale 0-6] for 22 questions) was 27.9 (median, 23.5) at hospitalization and 9.2 (median, 4.0) at follow-up. An abnormal symptom score (>8) was reported in 83.6% of hospitalized patients and 38.1% at follow-up. Girls had a significantly higher mean symptom score at initial testing than boys (33.9 vs 25.3, respectively; P < .05). This difference disappeared by the time of follow-up (girls 9.2 vs boys 9.1, P = .98) The most common initial symptom was headache (71.5% of patients) and most severe (highest mean score) was fatigue (mean, 2.0; median, 2.0). At follow-up, the most common symptom was excess sleep (38.1%) and most severe symptom falling asleep (mean, 1.0; median, 0). There were no significant differences in initial scores based on reported loss of consciousness, prior concussion history, or GCS 14 vs 15.
Symptoms after MTBI are quite common at the time of hospitalization. Symptom scores improve to near normal for most by outpatient follow-up. The most common symptom was headache, but the most severe was fatigue, in this hospitalized pediatric population. Thoughtful assessment and follow-up of this patient population are warranted.
Journal of Pediatric Surgery 07/2009; 44(6):1223-8. · 1.45 Impact Factor
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ABSTRACT: To improve insight into fatal child cervical spine injuries (CSI) caused by motor vehicle collisions.
Two large national mortality datasets were linked at the level of the individual decedent to analyse and compare anatomical injuries and vehicle crash characteristics for fatally injured child occupants.
Cervical spine injury was identified among 176 of 6065 child (age 0-15 years) motor vehicle occupant fatalities. Presence compared with absence of CSI had significant association with female gender, traumatic brain injury and seat restraint, but not with age, vehicle model, year or type, exposure to airbag, severe vehicle intrusion, collision speed or direction, drivability of the vehicle or seating position.
Cervical spine injury, which was uncommon in the studied subset of child decedents, was associated with female gender, the use of passenger restraints and the presence of traumatic brain injury.
Injury 05/2009; 40(8):864-7. · 1.98 Impact Factor
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ABSTRACT: To determine the effectiveness of child safety seat checkpoints in generating change in child restraint practice to reduce the prevalence and extent of misuse.
Child safety seats underwent an initial checkpoint evaluation and participants received a training session. Participants were asked to return within 6-12 months to a checkpoint for follow-up evaluation. During each visit, a data collection sheet was used to assess the participants' use of their child safety seat, and to subsequently calculate a restraint misuse score to characterize the child safety seat's usage before and after the intervention.
During the period of study, 42 participants underwent both the initial and follow-up child safety seat check. Before the intervention, at least one misuse was identified in 100% of installed child safety seats. After the intervention, there was a significant reduction in the proportion of rear-facing child safety seats (18.8%) and forward-facing child safety seats (64.0%) that had at least one misuse (p<0.001). Almost all (93.4%) of those using rear-facing child safety seats and the majority (64.0%) of those using forward-facing child safety seats improved their safety score as measured after the intervention.
Although misuse was universally observed, child safety seat checkpoint events were successful in improving usage practices.
Accident; analysis and prevention 12/2008; 40(6):1908-12. · 1.65 Impact Factor
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ABSTRACT: Blunt cervical spine injury (CSI) is rare in the pediatric population. The objective of this study was to better characterize the incidence and type of CSI in young children (age <3 years) using a large, trauma center-based data set.
The National Trauma Data Bank (NTDB) was reviewed for the period January 2001 to December 2005 for patients younger than 3 years of age with a blunt CSI (International Classification of Diseases, Ninth Revision, 805x, 806x, 952x). Demographic, injury, and outcome information were reviewed. Data management was performed using SAS (SAS, Cary, NC) and Stata (Stata Corp, College Station, TX). Patients with CSI were compared to patients without CSI of similar age. Means were compared with the Wilcoxon rank sum test, medians were compared with a nonparametric test, and count data were compared with the chi(2) test, with significance set at <.05.
For the period of review, 95,654 young children (age <3 years) with blunt trauma were identified in the NTDB. The overall population had a median Injury Severity Score (ISS) of 4, and most patients (77.01%) had a Glasgow Coma Score (GCS) of 15. There were 1523 (1.59%) patients with a CSI (spinal cord and/or column), including 366 patients (0.38%) with a spinal cord injury (with or without column injury) and 182 (0.19%) with an isolated spinal cord injury (SCIWORA). The CSI and non-CSI populations did not differ regarding median GCS (15 for both groups), but the CSI population had a significantly higher median ISS (14 vs 4, respectively; P < .001). Compared to patients without CSI, the CSI population was more likely to die in the emergency department (2.04% vs 1.25%; P = .007) or be admitted to the intensive care unit (45.3% vs 16.9%; P < .001). Nearly half of all cervical spine fractures (48%) and more than half of cervical spinal cord injuries (53%) were in the lower cervical spine (C5-7). MVCs were the most common injury mechanism (66%) followed by falls (15%). A CSI was observed in 3.2% of all motor vehicle crashes (MVCs).
In this trauma center population, these findings confirm the infrequency of blunt CSI in the youngest (age <3 years) trauma patients. The frequency of injuries to the lower cervical spine is higher than previously appreciated. MVCs are the most likely injury mechanism for this potentially devastating injury.
Journal of Pediatric Surgery 09/2008; 43(9):1718-21. · 1.45 Impact Factor
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ABSTRACT: Biliary dyskinesia (BD) is a consideration as a cause of chronic abdominal pain in the pediatric population. We sought to correlate the results of cholecystokinin-diisopropyl iminodiacetic acid (CCK-DISIDA) scanning, the basis for diagnosis of BD, with outcome after laparoscopic cholecystectomy.
A retrospective review was performed of all patients who underwent a laparoscopic cholecystectomy from May 2000 through March 2007. The diagnosis of BD was based on CCK-DISIDA scan demonstrating a gallbladder ejection fraction (GBEF) of less than 35% and/or reproduction of pain on CCK administration or no filling of the gall bladder with a normal ultrasound examination. Hospital, General Surgery office, and Gastroenterology Office charts were reviewed for demographic and management data points. We used chi(2) and Mann-Whitney tests for statistical analysis.
For the period of review, 430 patients underwent a laparoscopic cholecystectomy including 75 patients with a preoperative diagnosis of BD. The mean age of the BD population was 14 (range, 9-19) years. Female to male ratio was 2.4:1. The mean body mass index was 24.4 kg/m(2). On average, patients had abdominal symptoms for 15.5 (range, 0.25-72) months. Each patient underwent nearly 2.5 studies (computed tomography, ultrasound, esophagogastroduodenoscopy, or upper gastrointestinal series) before diagnosis by CCK-DISIDA. The mean GBEF was 17.4%. When commented on (n = 41), pain on CCK administration was noted in 25 (61%) patients. Pathology revealed chronic cholecystitis in 44%. After laparoscopic cholecystectomy, 58 (77.33%) patients reported resolution of their abdominal pain (mean follow-up 4 months). Of the 17 patients without improvement, 7 were later diagnosed with other underlying pathology (Crohn's, hiatal hernia, cyclic vomiting). There was no difference in GBEF, age, histopathology, or sex between the two groups. There were no complications.
Laparoscopic cholecystectomy is a safe and effective treatment for the majority of children diagnosed with BD. Although CCK-DISIDA was used to identify biliary dysfunction, it did not correlate with outcome.
Journal of Pediatric Surgery 07/2008; 43(6):1057-9. · 1.45 Impact Factor
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ABSTRACT: Acute posttraumatic headache is common and can evolve into chronic posttraumatic headache, which is associated with medication overuse and disability. However, there are few studies to guide treatment management of acute posttraumatic headache. We describe an adolescent with acute posttraumatic headache that did not respond to several initial medications but had rapid and sustained improvement in headache and associated migrainous features with subcutaneous sumatriptan.
Journal of Child Neurology 05/2008; 23(4):438-40. · 1.75 Impact Factor
