RESUMO
OBJECTIVE: To develop consensus on diagnostic criteria for LUMBAR syndrome, the association of segmental infantile hemangiomas that affect the Lower body with Urogenital anomalies, Ulceration, spinal cord Malformations, Bony defects, Anorectal malformations, Arterial anomalies and/or Renal anomalies. STUDY DESIGN: These diagnostic criteria were developed by an expert multidisciplinary and multi-institutional team based on analysis of peer-reviewed data, followed by electronic-Delphi consensus of a panel of 61 international pediatric specialists. RESULTS: After 2 Delphi rounds, a 92% or higher level of agreement was reached for each Delphi statement. 98% of panelists agreed with the diagnostic criteria, and 100% agreed the criteria would be useful in clinical practice. The diagnosis of LUMBAR requires the presence of a segmental, or patterned, infantile hemangioma of the lumbosacral, sacrococcygeal, or pelvic cutaneous regions plus one additional criterion of the urogenital, spinal, bony, anorectal, arterial, or renal organ systems. CONCLUSIONS: These diagnostic criteria will enhance clinical care by improving screening, detection, and overall awareness of this poorly understood neurocutaneous disorder. The criteria can be utilized by a wide variety of pediatric subspecialists. In addition, formal criteria will improve phenotypic uniformity among LUMBAR syndrome cohorts and a patient registry, allowing investigators to assess clinical features, long-term outcomes, and results of genetic sequencing in a standardized manner. Finally, these criteria will serve as a starting point for prospective studies to establish formal screening and management guidelines.
Assuntos
Consenso , Técnica Delphi , Humanos , Síndrome , Anormalidades Urogenitais/diagnóstico , Região Lombossacral , Hemangioma/diagnóstico , Anormalidades Múltiplas/diagnósticoRESUMO
OBJECTIVE: To estimate the impact of the PediBIRN (Pediatric Brain Injury Research Network) 4-variable clinical decision rule (CDR) on abuse evaluations and missed abusive head trauma in pediatric intensive care settings. STUDY DESIGN: This was a cluster randomized trial. Participants included 8 pediatric intensive care units (PICUs) in US academic medical centers; PICU and child abuse physicians; and consecutive patients with acute head injures <3 years (n = 183 and n = 237, intervention vs control). PICUs were stratified by patient volumes, pair-matched, and randomized equally to intervention or control conditions. Randomization was concealed from the biostatistician. Physician-directed, cluster-level interventions included initial and booster training, access to an abusive head trauma probability calculator, and information sessions. Outcomes included "higher risk" patients evaluated thoroughly for abuse (with skeletal survey and retinal examination), potential cases of missed abusive head trauma (patients lacking either evaluation), and estimates of missed abusive head trauma (among potential cases). Group comparisons were performed using generalized linear mixed-effects models. RESULTS: Intervention physicians evaluated a greater proportion of higher risk patients thoroughly (81% vs 73%, P = .11) and had fewer potential cases of missed abusive head trauma (21% vs 32%, P = .05), although estimated cases of missed abusive head trauma did not differ (7% vs 13%, P = .22). From baseline (in previous studies) to trial, the change in higher risk patients evaluated thoroughly (67%â81% vs 78%â73%, P = .01), and potential cases of missed abusive head trauma (40%â21% vs 29%â32%, P = .003), diverged significantly. We did not identify a significant divergence in the number of estimated cases of missed abusive head trauma (15%â7% vs 11%â13%, P = .22). CONCLUSIONS: PediBIRN-4 CDR application facilitated changes in abuse evaluations that reduced potential cases of missed abusive head trauma in PICU settings. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03162354.
Assuntos
Maus-Tratos Infantis , Traumatismos Craniocerebrais , Criança , Maus-Tratos Infantis/diagnóstico , Traumatismos Craniocerebrais/diagnóstico , Cuidados Críticos , Humanos , Unidades de Terapia Intensiva Pediátrica , Programas de RastreamentoRESUMO
OBJECTIVE: Children who live, work, and play on farms with barn design that includes hay-holes are at risk for a particular type of fall. This study retrospectively reviews all children admitted to a pediatric trauma center with injuries due to fall through a hay-hole over a 19-year period. This study is the first to specifically describe hay-hole fall injuries. METHODS: A retrospective review from a 19-year period at a rural pediatric trauma center identified 66 patients who sustained injuries from a hay-hole fall. Charts were reviewed for patient demographics, injuries, interventions, and hospital course. RESULTS: Sixty-six patients sustained injuries from hay-hole falls. Median patient age was 4 years, and median Injury Severity Score was 14. Forty-one percent of patients were admitted to the intensive care unit, and 26% of patients were intubated. Injuries included skull fracture (73%), facial fracture (27%), intracranial hemorrhage (53%), and noncraniofacial injuries (12%). Eighteen percent required a therapeutic intervention. There was 1 fatality (2%). CONCLUSIONS: Hay-hole fall appears to be a distinct injury mechanism, and patients present with different injury patterns than other types of falls. In this study, a high proportion of patients were young, and craniofacial injuries accounted for the majority of injuries. Only a small proportion of patients sustained noncraniofacial injuries. Injury prevention strategies should be targeted to this unique agrarian injury.
Assuntos
Acidentes por Quedas , Agricultura , Ferimentos e Lesões/etiologia , Ferimentos e Lesões/terapia , Pré-Escolar , Ossos Faciais/lesões , Feminino , Hospitalização/estatística & dados numéricos , Hospitais Rurais , Humanos , Escala de Gravidade do Ferimento , Hemorragias Intracranianas/etiologia , Hemorragias Intracranianas/terapia , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Estudos Retrospectivos , Fatores de Risco , Fraturas Cranianas/etiologia , Fraturas Cranianas/terapia , Centros de TraumatologiaRESUMO
OBJECTIVE: To conduct a retrospective, theoretical comparison of actual pediatric intensive care unit (PICU) screening for abusive head trauma (AHT) vs AHT screening guided by a previously validated 4-variable clinical prediction rule (CPR) in datasets used by the Pediatric Brain Injury Research Network to derive and validate the CPR. STUDY DESIGN: We calculated CPR-based estimates of abuse probability for all 500 patients in the datasets. Next, we demonstrated a positive and very strong correlation between these estimates of abuse probability and the overall diagnostic yields of our patients' completed skeletal surveys and retinal examinations. Having demonstrated this correlation, we applied mean estimates of abuse probability to predict additional, positive abuse evaluations among patients lacking skeletal survey and/or retinal examination. Finally, we used these predictions of additional, positive abuse evaluations to extrapolate and compare AHT detection (and 2 other measures of AHT screening accuracy) in actual PICU screening for AHT vs AHT screening guided by the CPR. RESULTS: Our results suggest that AHT screening guided by the CPR could theoretically increase AHT detection in PICU settings from 87%-96% (P < .001), and increase the overall diagnostic yield of completed abuse evaluations from 49%-56% (P = .058), while targeting slightly fewer, though not significantly less, children for abuse evaluation. CONCLUSIONS: Applied accurately and consistently, the recently validated, 4-variable CPR could theoretically improve the accuracy of AHT screening in PICU settings.