Predicting pediatric length of stay and acuity of care in the first ten minutes with artificial neural networks.

OBJECTIVE: To evaluate the efficacy of artificial neural networks in categorizing pediatric trauma patients into four distinct acuity of care groups and in determining the length of stay (LOS) within specific areas of the hospital. DESIGN: Using historical information from >8,000 pediatric trauma patient records, train and evaluate artificial neural networks to predict the injury severity and LOS for each patient in pediatric intensive care units (PICUs), step-down units, and floor units. Each artificial neural network is evaluated for categorization accuracy and mean absolute error difference on the predicted LOS. SUBJECTS: A total of 10,353 patient records from the National Pediatric Trauma registry, representing all pediatric trauma patients treated at affiliated hospitals from April 1994 through December 1996. Records with incomplete information were eliminated from the study, leaving 8,081 usable patient records. MEASUREMENTS: A total of 14 variables are selected from the 81 values present in the National Pediatric Trauma Registry as independent variables for the artificial neural networks. Each neural network produces nine output values: five for categorizing the patient's injury severity, three for the LOS in the PICU, step-down unit, and floor units, and one for the patient's total LOS. RESULTS: A fuzzy ARTMAP neural network accurately categorizes 88% of mortality patients and 58.3% of critical PICU patients. A backpropagation neural network succeeded in predicting the total LOS to within 1 day for 51.4% and the ICU LOS to within 1 day for 70.4% of all evaluated patients. CONCLUSION: Information available in the first 10 mins of a patient's presentation at the emergency room can be used by an artificial neural network to predict injury severity and LOS. Artificial neural networks enable more effective resource planning and patient management.

Vaginal agenesis discovered during repair of high imperforate anus: operative management.

A girl born with laryngeal stenosis, tracheal esophageal fistula and esophageal atresia, imperforate anus, duodenal atresia, and Mayer-Rokitansky-Kuster-Hauser syndrome is presented. An explanation of the abnormalities and the surgical approach are presented.

Blunt cardiac injuries in children: a postmortem study.

We reviewed the records of the Chief Coroner for all pediatric (< 16 years of age) trauma fatalities in Ontario (pediatric population of 2 million) for the period January 1, 1988 through December 31, 1990. Forty-one (14.5%) of 282 patients for which complete autopsy data were available had sustained cardiac injuries. Nineteen patients (46%) died at the scene of the accident, 15 patients (37%) died in an emergency department, and seven patients (17%) died during hospitalization. Rupture of a cardiac chamber occurred in 16 cases; it was the main cause of death in eight cases and a contributing factor in the remainder. Cardiac contusion without chamber rupture was present in 25 cases, but in none of the cases was it the cause of death. Brain injury was the cause of death in 16 (64%) of the cases of cardiac contusion. Cardiac injuries are more common among children who die from blunt trauma than previous reports have suggested. However, because these injuries are often rapidly fatal, many patients die before they reach a hospital. With improvements in emergency medical services and the resulting reduction in transit time, more patients may reach trauma centers alive. A high index of suspicion and rapid diagnosis and treatment of these injuries can save the lives of some of these patients.

Pyloromyotomy: comparison between laparoscopic and open surgical techniques.

Several reports have appeared in the literature recently describing various techniques of performing pyloromyotomy laparoscopically. Although there is no doubt that this is now technically feasible, there are unanswered questions with regard to its safety, efficacy, and potential benefits or otherwise to the patient. In an attempt to resolve some of these issues, we compared the results in 37 infants who underwent open pyloromyotomy with 26 who underwent laparoscopic pyloromyotomy. The two groups were similar in terms of sex, age, weight, and presenting pH, although they could not be randomized. The time from feeding to discharge was less for the laparoscopic group (1.4 days) compared with the open group (1.8 days) (p = 0.04). Postoperative vomiting was not significantly different between the two groups. The operating time was identical for groups, 29 min vs 27 min. There were 3 complications in the open surgical group and 1 in the laparoscopic group. On the criteria measured, our results suggests that laparoscopic pyloromyotomy is at least as good as conventional surgery, and offers the potential benefits of shortened hospital stay and minimal cosmetic deformity.

Percutaneous localization of small pulmonary metastases, enabling limited resection.

An adolescent patient with Ewing's sarcoma, who had undergone three previous thoracotomies for pulmonary metastases, presented with two further left-sided pulmonary metastases, measuring 5 mm and 10 mm in diameter. Chemotherapeutic options were limited, and pulmonary irradiation was inadvisable because of compromised respiratory function. Surgical resection was the favored therapeutic option. A method of accurately localizing the small lesions was devised, using a percutaneous needling technique under computed tomography guidance and the injection of barium and methylene blue. This localization enabled resection of the lesions, with minimal excision and manipulation of the surrounding normal parenchyma. This technique is useful for removal of small impalpable metastases when other modalities of therapy are not appropriate.

Pyloromyotomy: why make an easy operation difficult?

Recently Ohri et al. advocated a modification to the standard pyloromyotomy for pyloric stenosis which they believed reduced postoperative vomiting. Their study had no control group to support their contention. We therefore compared 37 infants with hypertrophic pyloric stenosis who underwent a conventional longitudinal pyloromyotomy with the 37 infants reported by Ohri et al. who underwent a modified Ramstedt's pyloromyotomy. Data were recorded prospectively and the postoperative vomiting was assessed using the same scale as in the previous report. The incidence of vomiting was significantly less in the children undergoing the conventional operation (P = 0.03), suggesting that there is no justification for performing a double V-shaped pyloric incision in pyloric stenosis.

The physical, psychological, and socioeconomic costs of pediatric trauma.

This prospective study examined the physical, psychological, and socioeconomic effects of injuries on children and their immediate families. Ninety-two injured children admitted with minor (ISS less than 16) or major (ISS greater than or equal to 16) injuries were compared with a control group of 59 children admitted during the same period with acute appendicitis. The two populations were similar in mean age, sex ratio, parental age and work status, and number of siblings. The parents of the injured children had a lower level of education than those of the controls. Fifty-four percent of the minor injury patients and 71% of the major injury patients had persistent physical limitations at 12 months in contrast to none of the controls. Thirty-eight percent of minor injury patients had pre-existing behavioral disturbances compared with 14% of major injury patients and 10% of controls. Behavioral disturbances among major trauma patients showed a sharp rise to 41% at 12 months and tended to persist in cases with continuing physical limitations. The major injury patients and those with significant head injuries exhibited a decrease in academic performance; minor injury patients and those without head injury showed no change. Maternal malaise rose sharply to about 40% in both injury groups in contrast to 7% in the controls and was more common in the presence of persistent physical limitations. Only 73% of families in the major injury group had returned to normal family life compared with 87% of the minor injury group and 100% of controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Blunt trauma during pregnancy: factors affecting fetal outcome.

During a 9 1/2-year period, 76 pregnant women who sustained blunt trauma were admitted to a level-I trauma center. Fetal outcome was ascertained in 59 patients (78%). Successful delivery was noted in 35 patients (46%). Eight patients (11%) elected to undergo abortion for nonmedical reasons. Sixteen patients (21%) sustained fetal loss, and 17 patients (22%) were lost to follow-up. The 51 patients who either delivered successfully or experienced a fetal loss were studied to determine the factors that affected fetal outcome. Variables analyzed included gestational age and maternal age, Glasgow Coma Scale score, serum bicarbonate level, pH, PCO2, PO2, blood pressure, heart rate, Injury Severity Score, and performance of surgery or diagnostic peritoneal lavage. Logistic regression analysis revealed that ISS (p less than 0.01) and admission serum bicarbonate level (p less than 0.02) have the most significant correlation with fetal outcome. No other variable exhibited a statistically significant influence on fetal outcome. This information documents that fetal demise is related to severity of maternal injury as characterized by ISS. A low serum bicarbonate level corresponds to maternal hypoperfusion and hypoxia, which may be otherwise unrecognized because of the normal physiologic changes occurring during pregnancy. Based on these findings, routine serum bicarbonate determination in all pregnant patients being evaluated for trauma is advocated. Performance of DPL and surgery do not have a significant association with fetal loss and therefore should not be withheld when indicated in a pregnant patient.