scholarly journals The use of a score-based protocol in pediatric appendicitis decreases CT scan utilization when evaluating children in a community hospital

2021 ◽  
Vol 17 (1) ◽  
Author(s):  
Frieda Hulka ◽  
Bryn Morris ◽  
Paige Elliott ◽  
Bogna Targonska
Keyword(s):  
Abdominal Pain ◽  
Scoring System ◽  
Community Hospital ◽  
Pediatric Population ◽  
Retrospective Chart Review ◽  
Ct Scans ◽  
Suspected Appendicitis ◽  
Radiologic Evaluation ◽  
Institutional Review ◽  
The University

Abstract Background The Pediatric Appendicitis Score (PAS) is a validated scoring system assessing children with abdominal pain. Prior to 2016, children with abdominal pain in our community hospital were evaluated primarily using CT scans. A protocol using PAS and ultrasound (US) as the primary radiologic modality was adopted in 2016 for evaluating children with abdominal pain. The protocol consisted of three tiers with low PAS requiring no radiologic evaluation; moderate PAS requiring US and high PAS requiring initial surgical consultation. Retrospective chart review of children presenting with clinically suspected appendicitis was performed from January 2015 through December 2017, representing 1 year before and 2 years after implementation of PAS protocol. PAS scoring was assigned retrospectively to patients not scored in the emergency physician’s note, and statistical analysis of the patient cohorts was performed using SPSS, version 17. This study was approved by the University of Nevada Institutional Review Board. Results Application of PAS scoring system increased use of US as the primary radiologic test from 59% pre-protocol to 91% post protocol and decreased use of CT scans from 41 to 8% (p < .05). Physician adherence to protocol improved from 59 to 71%, increasing further to 81% in the 2nd year post-protocol (p < .05). The highest rate of non-compliance was noted when providers ordered an US in patients with a low PAS, followed by ordering any radiologic tests in patients with a high PAS. Conclusion Implementation of PAS-based protocol altered clinician behavior in a community hospital when evaluating children with clinically suspected appendicitis. Improved adherence to the protocol over time with significant decrease of CT scans ordered thereby reducing radiation exposure in the pediatric population. Future improvements will be aimed at decreasing radiologic testing in patients with a low PAS and involving surgeons earlier with patients who have a high PAS as clinical acceptance to the protocol matures.

scholarly journals Tongue Blade Bite Test Predicts Mandible Fractures

2016 ◽  
Vol 9 (2) ◽  
pp. 121-124 ◽  
Author(s):  
John Neiner ◽  
Rachael Free ◽  
Gloria Caldito ◽  
Tara Moore-Medlin ◽  
Cherie-Ann Nathan
Keyword(s):  
Predictive Value ◽  
Chart Review ◽  
Pediatric Patients ◽  
Pediatric Population ◽  
Retrospective Chart Review ◽  
High Sensitivity ◽  
Ct Scans ◽  
Facial Trauma ◽  
Institutional Review ◽  
Mandible Fractures

The aim of the study is to evaluate the utility of a simple tongue blade bite test in predicting mandible fractures and use this test as an alternative screening tool for further workup. This is a retrospective chart review. An institutional review board approved the retrospective review of patients evaluated by the Department of Otolaryngology at a single institution for facial trauma performed from November 1, 2011, to February 27, 2014. Patients who had a bite test documented were included in the study. CT was performed in all cases and was used as the gold standard to diagnose mandible fractures. Variables analyzed included age, sex, fracture type/location on CT, bite test positivity, and operative intervention. A total of 86 patients met the inclusion criteria and of those 12 were pediatric patients. Majority of the patients were male (80.2%) and adult (86.0%; average age: 34.3 years). Fifty-seven patients had a negative bite test and on CT scans had no mandible fracture. Twenty-three patients had a positive bite test and a CT scan confirmed fracture. The bite test revealed a sensitivity of 88.5% (95% CI: 69.8–97.6%), specificity of 95.0% (95% CI:86.1–99%), positive predictive value [PPV] of 88.5% (95% CI: 69.8–97.6%), and negative predictive value [NPV] of 95.0% (95% CI: 86.1–99.0%). Among pediatric patients, the sensitivity was 100% (95% CI: 29.9–100%), specificity was 88.9% (95% CI: 68.4–100%), PPV was 75.0% (95% CI: 19.4–99.4%), and NPV was 100% (95% CI: 63.1–100%). The tongue blade bite test is a quick inexpensive diagnostic tool for the otolaryngologist with high sensitivity and specificity for predicting mandible fractures. In the pediatric population, where avoidance of unnecessary CT scans is of highest priority, a wider range of data collection should be undertaken to better assess its utility.

scholarly journals Utilizing the Predictive Value of the 4T Scoring System to Reduce Unnecessary HIT Panel Costs in the Community Hospital Setting

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 5001-5001 ◽  
Author(s):  
Rashmika Potdar ◽  
Sorab Gupta ◽  
Jia Hwei Ng ◽  
Schoepe Robert ◽  
Andrew Berson ◽  
...  
Keyword(s):  
Scoring System ◽  
Community Hospital ◽  
Conflicts Of Interest ◽  
Hospital Setting ◽  
Immunological Response ◽  
Retrospective Chart Review ◽  
Turnaround Time ◽  
Study Objective ◽  
Heparin Administration ◽  
4T Score

Abstract Abstract Study Objective-Heparin Induced Thrombocytopenia (HIT) is a life-threatening immunological response to heparin. The objectives for this study were to determine if the 4T scoring system was being utilized as a tool for predicting HIT, and to look at the costs associated with HIT panels. Methods-This was a retrospective chart review of patients greater than 18 years of age who had HIT panels performed between January 2013 and June 2014 in a community hospital. Any duplicate HIT panels sent during the same admission period were excluded. Study investigators were trained in two 30-minute intervals in the area of data collection and retrospective calculation of 4T score. Results- Of the 154 patients studied, 73 (47.4%) were male, and 81 (52.6%)were female. All patients had a 4T score calculated by study investigators during data analysis, and 1.29% (n=2) had a 4T score calculated before a HIT panel was sent by the team taking care of the patient. 62.3% (n=96) of patients had a low 4T score and 37. 7%( n=58) had an intermediate to high 4T score. Hematology was consulted on 57.7% (n=89) and anticoagulant administration was stopped on 74 % (n=114), while in 26 % ( 40/ 154) heparin was continued despite sending HIT. 25.4%(29/114) were started on alternate anti- coagulants after stopping heparin . Throughout the course of the study, 20 patients died, with only 1 of these patients being HIT positive. If 100 unnecessary HIT panels were performed in a year, the hospital would be charged more than $20,000 by the diagnostic lab. Additional costs include the halting of Heparin administration and starting an alternate anticoagulant such as Argatroban. 24 hour administration of Argatroban costed $1,000 for continuous infusion. HIT panels have a turnaround time of 4-5 days, resulting in the additional charge of $5,000 just for Argatroban administration. A lengthened stay in the hospital due to HIT panel turnaround time is also a source of increased costs. Combined, the ordering of a HIT panel, alternate anticoagulant administration, and bed charges could amount to $40,000 over the course of four days. This time and money could be put to better use treating the underlying disease of the patient, instead of focusing on the testing for HIT. Conclusion-Management of HIT in community hospital was sub-optimal. Lack of utilization of the 4T scoring system led to unnecessary ordering of HIT panels. This increased duration of hospital stay, elevated the cost of treatment, and resulted in the holding of prophylactic anticoagulants. Disclosures No relevant conflicts of interest to declare.

scholarly journals P066: Outcomes of non-operative versus operative management in pediatric acute uncomplicated appendicitis

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S100
Author(s):  
W. Janjua ◽  
A. Janjua ◽  
E. Loubani ◽  
N. Merritt ◽  
K. Van Aarsen
Keyword(s):  
Abdominal Pain ◽  
Acute Appendicitis ◽  
Pediatric Population ◽  
Retrospective Chart Review ◽  
Operative Management ◽  
Final Diagnosis ◽  
Uncomplicated Appendicitis ◽  
Long Term Follow Up ◽  
Ed Visits ◽  
Non Operative Management

Introduction: The purpose of this study was to look at outcomes of pediatric patients with early, acute appendicitis who were treated with non-operative management (NOM) with antibiotics. Primary outcomes were subsequent appendectomy or Emergency Department (ED) visits. Methods: The method used for this study was a retrospective chart review of children under the age of 18, looking at outcomes of those who received non-operative management (NOM) for early acute appendicitis between April 2014-April 2015. The inclusion criteria included: (a) Age 0-17, (b) US or CT suggested acute uncomplicated appendicitis (c) Final diagnosis of appendicitis during April 2014-2015. Outcomes that were investigated were repeat ED visits and need for subsequent appendectomy. Results: Data extracted from the EMR found 209 charts with an ED diagnosis of appendicitis. Two charts (.9%) were excluded as they were duplicates. Sixty-seven patients (32%) were excluded after appendicitis was ruled out. One hundred and forty patients (67%) had a final diagnosis of appendicitis, 124 patients (88.6%) were taken directly to the operating room for appendectomy, 16 patients (11.4%) were treated with antibiotics instead of operative management. Three patients who received non-operative management had complex appendicitis, 13 had acute uncomplicated appendicitis. Six patients out of 13 (46%) were successfully treated with antibiotics with no repeat visits to the ED or Pediatric Surgery for appendectomy, 7 patients (54%) required appendectomy after initial treatment with antibiotics. Two patients who underwent appendectomy after initial NOM had no evidence of clinical appendicitis, one patient was taken to the OR based on parent preference and one patient had an episode of abdominal pain that prompted an interval appendectomy four weeks post the episode of abdominal pain. Conclusion: Treatment of acute uncomplicated appendicitis with NOM remains a management option in the pediatric population. Further studies and long term follow up are required to better identify appropriate patients for non-operative management versus operative management.

scholarly journals Bevacizumab and etoposide combination chemotherapy in patients with recurrent malignant gliomas who failed bevacizumab

2012 ◽  
Vol 2 (1) ◽  
pp. 6
Author(s):  
Beverly D. Fu ◽  
Mark E. Linskey ◽  
Daniela Annenelie Bota
Keyword(s):  
Malignant Glioma ◽  
Tumor Progression ◽  
Malignant Gliomas ◽  
Retrospective Chart Review ◽  
Progression Free Survival ◽  
Standard Of Care ◽  
Current Standard ◽  
Institutional Review ◽  
Standard Of Care Treatment ◽  
The University

Bevacizumab is the current standard of care treatment for recurring malignant glioma patients. However, most of the tumors become resistant to bevacizumab, and there is no standardized, effective chemotherapy for the malignant glioma patients after bevacizumab failure. Retrospective chart review was performed in order to identify the malignant glioma patients treated with oral, metronomic etoposide in combination with bevacizumab after being diagnosed with progressive disease while on bevacizumab. This review was approved by the Institutional Review Board (IRB) of the University of California, Irvine. Six malignant gliomas patients met the inclusion criteria. The median progression-free survival (PFS) for the anaplastic astrocytoma (AA) patients was eight months, and the overall survival was 28 months. The two Glioblastoma Multiforme (GBM) patients showed tumor progression after four to eight weeks of treatment with bevacizumab and etoposide, and died within four months of beginning the etoposide/bevacizumab regimen. In this limited study, patients with AA demonstrated prolonged control on combination treatment with bevacizumab and oral etoposide, despite initial tumor progression on bevacizumab. These results may warrant further investigation on a prospective clinical trial of this combination in AA patients who developed resistance to bevacizumab.

scholarly journals Investigating the necessity of computed tomographic scans in children with headaches: a retrospective review

CJEM ◽  
2015 ◽  
Vol 17 (2) ◽  
pp. 148-153 ◽  
Author(s):  
Rohit Gandhi ◽  
Evan Cole Lewis ◽  
Jeanette W. Evans ◽  
Erick Sell
Keyword(s):  
Pediatric Population ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Primary Headache ◽  
Ct Scanning ◽  
Ct Scans ◽  
Primary Headaches ◽  
Tertiary Care Centre ◽  
Medical Practitioners ◽  
Computed Tomographic

AbstractObjective: Headaches are a common problem in the pediatric population. In 2002, the American Academy of Neurology (AAN) developed guidelines on neuroimaging for patients presenting with headache. Our objective was to determine the frequency of computed tomographic (CT) scanning ordered by a range of medical practitioners for pediatric patients presenting with primary headache.Methods: A retrospective chart review was conducted at the Children’s Hospital of Eastern Ontario (CHEO), a tertiary care centre in Ontario. One hundred fifty-one records of patients referred to the outpatient neurology clinic at CHEO with ‘‘headache’’ or ‘‘migraine’’ as the primary complaint from 2004 to 2009 were randomly selected. Ninety-nine patients with normal neurologic examinations were ultimately included.Results: Thirty-four patients (34%; 95% CI 25–45) had undergone CT scanning. None of the 34 CT scans (0%; 95% CI 0–10) showed significant findings, and none changed the headache diagnosis or management. Eleven (32%) of the CT scans were ordered by CHEO neurologists, 15 (44%) by community physicians, and 8 (24%) by CHEO emergency physicians.Conclusion: A high proportion of children presenting with primary headaches and a normal neurologic examination undergo CT scanning, despite well-established AAN guidelines regarding neuroimaging. Most of these CT scans do not appear to alter diagnosis and management. A variety of non–evidencebased factors may be encouraging physicians to overinvestigate this population and, as a result, increasing the risk of adverse events due to radiation exposure. Implementing initiatives at a site-based level that promote the use of established guidelines before performing CT scanning in this population may be beneficial.

scholarly journals Pediatric meningiomas: 65-year experience at a single institution

2017 ◽  
Vol 20 (1) ◽  
pp. 42-50 ◽  
Author(s):  
Andrew J. Grossbach ◽  
Kelly B. Mahaney ◽  
Arnold H. Menezes
Keyword(s):  
Pediatric Population ◽  
Retrospective Chart Review ◽  
Recurrence Rates ◽  
University Of Iowa ◽  
Who Grade ◽  
History Of ◽  
Grade Ii ◽  
The University ◽  
Pediatric Meningiomas

OBJECTIVEMeningiomas are relatively common, typically benign neoplasms in adults; however, they are relatively rare in the pediatric population. Pediatric meningiomas behave very differently from their adult counterparts, tending to have more malignant histological subtypes and recur more frequently. The authors of this paper investigate the risk factors, pathological subtypes, and recurrence rates of pediatric meningiomas.METHODSA retrospective chart review was conducted at the University of Iowa to identify patients 20 years old and younger with meningiomas in the period from 1948 to 2015.RESULTSSixty-seven meningiomas in 39 patients were identified. Eight patients had neurofibromatosis, 2 had a family history of meningioma, and 3 had prior radiation exposure. Twelve (31%) of the 39 patients had WHO Grade II or III lesions, and 15 (38%) had recurrent lesions after resection.CONCLUSIONSPediatric meningiomas should be considered for early treatment and diligent follow-up.

scholarly journals Risk factors for hemorrhage associated with external ventricular drain placement and removal

2017 ◽  
Vol 126 (1) ◽  
pp. 289-297 ◽  
Author(s):  
Catherine Miller ◽  
Ramachandra P. Tummala
Keyword(s):  
Risk Factors ◽  
External Ventricular Drain ◽  
Retrospective Chart Review ◽  
University Of Minnesota ◽  
Factors Associated ◽  
Institutional Review ◽  
Time Period ◽  
Increased Risk ◽  
Risk Of Hemorrhage ◽  
The University

OBJECTIVE External ventricular drains (EVDs) have an important role in the management of neurological disease, and their placement is a frequently performed neurosurgical procedure. Hemorrhage is a common complication of EVD placement and occurs more frequently than originally believed. There is also risk of hemorrhage with removal of an EVD, which has not been well described. The authors investigated the risk factors associated with placement and removal of EVDs at their institution. METHODS A database was created including patients who required EVD placement from March 2008 to June 2014 at the University of Minnesota. A retrospective chart review was completed, and data were collected for each patient. All cranial imaging studies during the index hospitalization were reviewed to identify hemorrhages associated with either EVD placement or removal. The study was performed using a research protocol approved by the University of Minnesota's institutional review board. RESULTS Four hundred eighty-two EVDs were placed during the designated time period. Among the cases in which patients underwent imaging after the placement procedure, hemorrhage was found in 94 (21.6%). The hemorrhage volume ranged from 0.003 cm3 to 45.9 cm3 (mean [± SD] 1.96 ± 6.48 cm3). Two of these hemorrhages resulted in additional interventions: 1 surgical evacuation and 1 contralateral EVD. In 55 (22.5%) of the 244 cases in which imaging was performed after EVD removal, hemorrhage associated with removal was identified. The mean volume of these hemorrhages was 8.25 ± 20.34 cm3 (range 0.012–82.08 cm3). Two EVDs were replaced, and 1 patient died as a result of a large hemorrhage. Large hemorrhages (> 30 cm3) occurred in 2 patients on placement (0.46%) and in 5 patients on removal (2.0%). In this series, decreased platelet levels on admission and an increasing number of EVD placement attempts correlated with an increased risk of hemorrhage on placement. Only those with an EVD placed at bedside were more likely to have hemorrhage on EVD removal. CONCLUSIONS Multiple studies have reported varying EVD hemorrhage rates while very few studies have described hemorrhage secondary to EVD removal. This is the first reported analysis of risk factors associated with hemorrhage on EVD removal. Hemorrhages occur relatively frequently following EVD placement and removal, though clinical significance of these events seems to be low.

scholarly journals Incidence of hemorrhage in the pediatric population with placement and removal of external ventricular drains

2015 ◽  
Vol 16 (6) ◽  
pp. 662-667 ◽  
Author(s):  
Catherine Miller ◽  
Daniel Guillaume
Keyword(s):  
Pediatric Population ◽  
Retrospective Chart Review ◽  
Pediatric Neurosurgery ◽  
Shunt Infection ◽  
Patients Âgés ◽  
Institutional Review ◽  
Time Period ◽  
Hemorrhage Volume ◽  
Risk Of Hemorrhage ◽  
Volume Range

OBJECT External ventricular drains (EVDs) are regularly used in pediatric neurosurgery for diagnostic and therapeutic purposes. Hemorrhage caused by placing an EVD is a common complication noted in the adult literature. In the pediatric literature, on the other hand, only a few articles have assessed the risk of hemorrhage with placement, and none have reported the occurrence of hemorrhage with removal of an EVD. The authors investigated the incidence of hemorrhage with both placement and removal of the EVD in a pediatric population. METHODS After obtaining institutional review board approval, a comprehensive database was created to include all pediatric patients who required EVD placement between March 2008 and June 2014 at the authors’ institution. A retrospective chart review was completed, and all imaging was reviewed for evidence of hemorrhage with placement and removal of the EVD. RESULTS During the designated time period, 73 EVDs were placed in 63 patients (ages 2 weeks–17 years). Indications for EVD placement were as follows: shunt infection/malfunction (21), tumor (12), hydrocephalus (18), hemorrhage (12), edema (4), trauma (1), and other (5). Hemorrhage with placement was noted in 5 of the 50 patients who underwent imaging, with a volume ranging from 0.48 cm3 to 7.7 cm3. Thirty-two patients had imaging after EVD removal, and 7 of these patients were noted to have hemorrhage (volume range 0.012 cm3 to 81.5 cm3). CONCLUSIONS The authors found the incidence of hemorrhage at EVD placement to be 10%, and the incidence of hemorrhage on EVD removal to be 21.9% in those patients who underwent imaging after each event. Although none of the hemorrhages were of obvious clinical significance, these data can be useful in decision making, and in discussing the risks of EVDs with the patient’s family.

scholarly journals Impact of the COVID-19 pandemic and its related psychological effect on orthopedic surgeries conducted in different types of hospitals in Taiwan

2021 ◽  
Vol 29 (1) ◽  
pp. 230949902199607 ◽  
Author(s):  
Chia-Lung Shih ◽  
Peng-Ju Huang ◽  
Hsuan-Ti Huang ◽  
Chung-Hwan Chen ◽  
Tien-Ching Lee ◽  
...  
Keyword(s):  
Community Hospital ◽  
University Hospital ◽  
Total Knee Arthroplasties ◽  
Peak Period ◽  
Number Of Patients ◽  
Total Knee ◽  
Investigation Period ◽  
Orthopedic Diseases ◽  
The University ◽  
The Impact

Aim: Taiwan’s response to the coronavirus disease 2019 (COVID-19) differed in that it successfully prevented the spread without having to shutdown or overburden medical services. Patients’ fear regarding the pandemic would be the only reason to reduce surgeries, so Taiwan could be the most suitable place for research on the influence of psychological factors. This study aimed to assess the impact of patients’ fear on orthopedic surgeries in Taiwan amid the peak period of the COVID-19 pandemic. Patients and Methods: The investigation period included the COVID-19 pandemic (March 2020 to April 2020) and the corresponding period in the previous year. The following data on patients with orthopedic diseases were collected: outpatient visits, hospital admission, and surgical modalities. Results: The COVID-19 pandemic led to a 22%–29% and 20%–26% reduction in outpatients, 22%–27% and 25%–37% reduction in admissions, and 26%–35% and 18%–34% reduction in surgeries, respectively, at both hospitals. The weekly mean number of patients was significantly smaller during the COVID-19 pandemic for all types of surgery and elective surgeries at the university hospital, and for all types of surgery, elective surgeries, and total knee arthroplasties at the community hospital. Further, patients visiting the community hospital during the pandemic were significantly younger, for all types of surgery, elective surgeries, and total knee arthroplasties. Conclusions: The reduction in orthopedic surgeries in Taiwan’s hospitals during COVID-19 could be attributed to patients’ fear. Even without restriction, the pandemic inevitably led to a reduction of about 20%–30% of the operation volume.

scholarly journals Barriers to Development of an App for Improving Staff-Family Communication at Israeli Geriatric Facilities

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 192-193
Author(s):  
Rinat Cohen ◽  
Gal Maydan ◽  
Shai Brill ◽  
Jiska Cohen-Mansfield
Keyword(s):  
Mobile App ◽  
Institutional Review Boards ◽  
Staff Members ◽  
Institutional Review ◽  
Implementation Planning ◽  
Institutional Adoption ◽  
Communication Needs ◽  
The University ◽  
And Control ◽  
To Receive

Abstract Family caregivers (FCs) of institutionalized noncommunicative older persons reported multiple unmet communication needs focusing on the need to receive reliable and regular updates on the patient’s condition. We have developed a mobile app for improving communication between FCs and healthcare professionals (HPs), based on 152 interviews with FCs and 13 discussion groups with HPs from four Israeli geriatric facilities. Both parties participated in app planning, tailoring it to their needs and abilities. App use implementation encountered major obstacles including the bureaucratic process concerning signing contracts between the university and software development firms, which hindered the process for a full year; data security department required disproportionate security levels that interfered with user experience and delayed the development process; the study’s definition varied across different ethics/Helsinki committees (Institutional Review Boards; IRBs), which led to different demands, e.g., insurance for medical clinical trials although no drugs or medical device were involved; lack of cooperation by mid-level staff members despite the institutional adoption of the app project; low utilization by HPs resulted in FCs not receiving timely responses. Despite these and other obstacles, we tested app use for 15 months in one facility in a pre-post-design with intervention and control groups, and we have since begun testing it in another facility. FCs who had used the app had positive feedback and wished to continue using it. App use optimization requires implementation planning, assimilating changes in each facility’s work procedures and HP’s engagement and motivation and thus depends on institutional procedures and politics.

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