Linked Records of Children with Traumatic Brain Injury. Probabilistic Linkage without Use of Protected Health Information.

OBJECTIVE: Record linkage may create powerful datasets with which investigators can conduct comparative effectiveness studies evaluating the impact of tests or interventions on health. All linkages of health care data files to date have used protected health information (PHI) in their linkage variables. A technique to link datasets without using PHI would be advantageous both to preserve privacy and to increase the number of potential linkages. METHODS: We applied probabilistic linkage to records of injured children in the National Trauma Data Bank (NTDB, N = 156,357) and the Pediatric Health Information Systems (PHIS, N = 104,049) databases from 2007 to 2010. 49 match variables without PHI were used, many of them administrative variables and indicators for procedures recorded as International Classification of Diseases, 9th revision, Clinical Modification codes. We validated the accuracy of the linkage using identified data from a single center that submits to both databases. RESULTS: We accurately linked the PHIS and NTDB records for 69% of children with any injury, and 88% of those with severe traumatic brain injury eligible for a study of intervention effectiveness (positive predictive value of 98%, specificity of 99.99%). Accurate linkage was associated with longer lengths of stay, more severe injuries, and multiple injuries. CONCLUSION: In populations with substantial illness or injury severity, accurate record linkage may be possible in the absence of PHI. This methodology may enable linkages and, in turn, comparative effectiveness studies that would be unlikely or impossible otherwise.

Barriers to prenatal detection of congenital heart disease: a population-based study.

OBJECTIVE: To evaluate the extent and determinants of missed prenatal detection of congenital heart disease (CHD) in a population-based setting. METHODS: This was a retrospective cohort study of cases with CHD, excluding minor defects, identified between 1997 and 2007 by a statewide surveillance program. We examined a comprehensive list of potential risk factors for which data were available in the surveillance database from abstracted medical charts. We analyzed the association of fetal, maternal and encounter factors with 1) whether a prenatal ultrasound was performed and 2) prenatal detection of CHD. RESULTS: CHD was detected prenatally in only 39% of 1474 cases, with no improvement in detection rate over the 10-year period. Among the 97% (n = 1431) of mothers who underwent one or more ultrasound examinations, 35% were interpreted as abnormal; fetal echocardiography was performed in 27% of the entire cohort. Maternal and encounter factors increasing the adjusted odds of prenatal detection included: family history of CHD (OR, 4.3 (95% CI, 1.9-9.9)), presence of extracardiac defects (OR, 2.7 (95% CI, 1.9-3.9)) and ultrasound location i.e. high risk clinic vs clinic (OR, 2.1 (95% CI, 1.3-3.1)). Defects that would be expected to have an abnormal outflow-tract view were missed more often (64%) than were those that would be expected to have an abnormal four-chamber view (42%). CONCLUSION: The majority of CHD cases over the 10-year study period were missed prenatally and detection rates did not increase materially during that time. The failure to detect CHD prenatally was related to encounter characteristics, specifically involving screening ultrasound examinations, which may be targeted for improvement.

Using CT of the cervical spine for early evaluation of pediatric patients with head trauma.

OBJECTIVE: The purpose of this study was to assess the effectiveness of CT of the cervical spine in addition to radiography in pediatric patients with suspected head trauma at the time of the CT head examination. MATERIALS AND METHODS: We identified 63 pediatric patients admitted to the emergency department who had head trauma and who underwent both head CT and neck radiography. Those who underwent CT of the cervical spine at the time of the head CT examination during their initial evaluation were compared for demographics, clinical status, mechanism of injury, and number of excess radiographs (number required by protocol minus number of films obtained) required to evaluate the cervical spine with those patients who did not undergo early CT of the cervical spine. RESULTS: Twenty-one patients (33%) underwent cervical spine CT at the time of the head CT examination. The number of excess radiographs differed significantly between these patients (2.1 +/- 2.6 vs 3.6 +/- 2.7, p = 0.04) and the comparison group. Patients who did not undergo early CT for whom excess radiographs were obtained had the following characteristics: they were older than 8 years (p = 0.03), were unrestrained in a motor vehicle crash (p = 0.04), had a Glasgow coma score of 13-15 (p = 0.01), and were intubated (p = 0.02). CONCLUSION: The number of repeated radiographs required to ascertain that the cervical spine is free of injury after suspected head trauma is significantly fewer when initial CT of the neck is performed at the time of head CT examination. Including cervical spine CT in trauma protocols for subgroups of children with head injuries may lead to more effective clearance of the pediatric cervical spine.

Attitudes toward limitation of support in a pediatric intensive care unit.

OBJECTIVE: To prospectively determine opinions of members of a pediatric intensive care unit (PICU) team regarding the appropriateness of aggressive care. The types of support that caregivers sought to limit and their reasons for wanting these limits were collected over time. DESIGN: Prospective survey of caregiver opinions. SETTING: PICU in an academic tertiary care children's hospital. SUBJECTS: A total of 68 intensive care nurses, 11 physicians attending in the PICU, 10 critical care and anesthesia fellows, and 24 anesthesia and pediatric residents. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During a 6-month period, 503 patients were admitted to the PICU. Within this time period, 52.4% of all deaths were preceded by limitation of support, with 100% of noncardiac surgical deaths preceded by limitation of medical interventions. At least one caregiver wished to limit care for 63 of these patients (12.5%). When caregivers wished to limit support they most frequently wished to limit invasive modes of support such as cardiopulmonary resuscitation (94%) and hemodialysis (83%). The ethical rationales identified most often for wishing to limit support were burden vs. benefit (88%) and qualitative futility (83%). Preadmission quality of life was cited less frequently (50%). Caregivers were less likely to limit care on the basis of quality of life. Nurses and physicians in the PICU were very similar to each other in the types of support they thought should be limited and their ethical rationales. CONCLUSIONS: When making decisions about whether or not to limit care for a patient, caregivers were more likely to rely on the perceived benefit to the patient than preadmission quality of life.

Pulmonary function after modified venovenous ultrafiltration in infants: a prospective, randomized trial.

OBJECTIVE: We sought to examine the effects of modified venovenous ultrafiltration after cardiopulmonary bypass on pulmonary compliance in infants. METHODS: We prospectively enrolled 38 infants undergoing their first operation for congenital heart disease. Infants were randomized to receive 20 minutes of modified ultrafiltration after bypass or control. Static and dynamic compliance was measured after induction of anesthesia, before and immediately after filtration in the operating theater, 1 hour after return to the pediatric intensive care unit, and 24 hours after the operation. Length of time on the ventilator, inotropic requirements, and length of stay in the intensive care unit were recorded. RESULTS: Modified ultrafiltration produced a significant immediate improvement in dynamic (pre-ultrafiltration 2.5 +/- 1.9 mL/cm H(2)O to post-ultrafiltration 2.9 +/- 2.7 mL/cm H(2)O, P =.03) and static (pre-ultrafiltration 2.1 +/- 0.9 mL/cm H(2)O to post-ultrafiltration 2.9 +/- 2.1 mL/cm H(2)O, P =.04) compliance. However, there was no significant difference in the change in dynamic (P =.3) or static (P =.7) compliance in the ultrafiltration and control groups when compared before the operation, after the operation, and at 24 hours. There was no significant difference in the time to extubation between patients and control subjects (140 +/- 91 hours vs 90 +/- 58 hours) or the length of intensive care unit stay (10.0 +/- 9.1 days vs 7.4 +/- 5.7 days). CONCLUSIONS: Modified ultrafiltration produces an improvement in pulmonary compliance after bypass in infants. However, these improvements are not sustained past the immediate post-ultrafiltration period and do not lead to a decreased length of intubation or intensive care unit stay.

Outcome of children who require mechanical ventilatory support after bone marrow transplantation.

OBJECTIVE: To identify clinically measurable factors that could predict outcome for pediatric patients undergoing mechanical ventilatory support after bone marrow transplant. DESIGN: Cohort study. SETTING: A referral center for bone marrow transplant patients in Seattle, Washington. PATIENTS: Children <17 yrs old who received a bone marrow transplant and subsequently required mechanical ventilatory support for > or =24 hrs between 1983 and 1996. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data were abstracted from the charts of 121 pediatric patients who received a bone marrow transplant and subsequently required mechanical ventilatory support. A total of 19 patients (16%) survived to be extubated and survived for > or =30 days postextubation. Major risk factors for death included respiratory failure as the reason for endotracheal intubation (4% survival), the presence of pulmonary infection (6% survival), and impairment of more than one organ system (2% survival if more than one organ system was dysfunctional on day 7 postintubation). CONCLUSIONS: Although the prognosis generally is poor among pediatric bone marrow transplant recipients who subsequently require mechanical ventilatory support, there appear to be some groups within this population in whom the likelihood of survival is close to 0. Because the chance of survival was so small for children with dysfunction of more than one organ system on day 7 after intubation, a recommendation to limit medical support for these children could be considered pending the results of other studies.

Does the face protect the brain? A case-control study of traumatic brain injury and facial fractures.

BACKGROUND: The relationship between facial fractures and traumatic brain injury is controversial. Some studies show an increased risk of brain injury with the presence of facial fractures while others claim that facial fractures protect against brain injury. OBJECTIVE: To examine the association between facial fractures and traumatic brain injuries. DESIGN: Case-control study. SETTING: Subjects were recruited from the emergency departments of 7 hospitals in the Seattle, Wash, area. PATIENTS: Three thousand eight hundred forty-nine injured bicyclists and 5 scene deaths were identified from March 1, 1992, to August 31, 1994, with complete data available on 3388 bicyclists. INTERVENTIONS: None. RESULTS: The study group was composed of 1602 cases with injuries to the head, face, or brain and 1540 control subjects. There were 203 bicyclists with traumatic brain injuries, of whom 62 had an identifiable intracranial injury and 141 suffered a concussion. A total of 81 patients sustained facial fractures. The odds ratio for the risk of intracranial injury associated with facial fractures after adjustment for significant confounders was 9.9 (95% confidence interval, 5.1-19.3). The effect was less strong but still present when all traumatic brain injuries including concussions were considered (odds ratio, 2; 95% confidence interval, 1.1-3.7). No association was found for concussion only. CONCLUSIONS: This study demonstrates no evidence that facial fractures help prevent traumatic brain injury. Data indicate that facial fractures are markers for increased risk of brain injury.

Delivery of hyperbaric oxygen therapy to critically ill, mechanically ventilated children.

PURPOSE: The purpose of this article is (1) to describe our method of mechanical ventilation and monitoring of critically ill children during administration of hyperbaric oxygen therapy (HBO2) in a multiplace chamber; and (2) to review the complications they experienced during transport to the HBO2 chamber and HBO2 treatment. MATERIALS AND METHODS: A case series from a university-affiliated children's hospital and regional hyperbaric medicine treatment facility. Patients studied included all children who required HBO2 therapy while mechanically ventilated at any time between April 1985 and June 1995. RESULTS: Thirty-two children were treated with HBO2 while mechanically ventilated. Ages ranged from 3 days to 11.3 years (mean 4.8+/-3.5 years). There were 22 males. Twenty-one children had necrotizing infections, 9 had carbon monoxide (CO) poisoning, and 2 had iatrogenic arterial air embolism. Complications or events occurring during HBO2 therapy included hypotension (63%), bronchospasm (34%), hemotympanum (13%), and progressive hypoxemia (6%). The only complication during transport was one accidental extubation (3%). CONCLUSION: Hyperbaric oxygen therapy can be administered safely to most critically ill children in a multiplace chamber if they are monitored closely. Although complications are not uncommon, most can be managed easily by a team skilled in treating ill children and knowledgeable of possible complications of HBO2 therapy.