• Comparison of 64‐Slice EKG‐Gated Computed Tomographic Angiography, Transthoracic Echocardiography, and Transesophageal Echocardiography for Detection and Complete Characterization of Anomalous Coronary Arteries in Infants with Comorbid Congenital Cardiac Malformations

      Sridhar, Shravan; The University of Arizona College of Medicine - Phoenix; Richardson, Randy R. (The University of Arizona., 2016-03-25)
      Background and Objective: Computed tomographic angiography (CTA) offers several benefits over echocardiography in the detection of CAAs (coronary artery anomalies). These include higher spatial resolution, operator independency, non‐invasiveness, and the availability of reconstructive techniques to track the entire arterial course.1,4,9 Accordingly, standard clinical practice (per ACC/AHA guidelines for adults with CAAs) for adults with suspected CAAs includes use of CTA as a first‐line imaging modality.6 Currently, there is no evidence favoring either CTA, transthoracic echocardiography (TTE), or transesophageal echocardiography (TEE) for initial imaging of infants with suspected CAAs. Therefore, the aims of this retrospective study include investigating the efficacy of CTA, TTE, and TEE in the detection and complete characterization of CAAs. Methods: Imaging and surgical data for 27 patients who presented for evaluation of congenital heart disease between 2006 and 2011 were evaluated. Patients had a mean age of 2.2 ± 0.7 months at initial evaluation and had undergone EKG‐gated 64‐slice cardiac CTA with 3D reconstruction in addition to multiple TTE and TEE studies. Performance metrics (including sensitivity, specificity, positive predictive value, negative predictive value, and accuracy) of each modality in CAA detection were computed. Concordance between each modality and surgical/conventional angiographic diagnosis in the characterization of anatomy along the origin, course, and termination of anomalous coronary arteries was evaluated. The rate of limitations of each modality in the imaging and interpretation of coronary anatomy was also reported. Results: Using surgical/angiographic diagnosis as the gold standard, CTA produced a sensitivity, specificity, and accuracy of 80%, 50%, and 74%, respectively. TTE produced a sensitivity, specificity, and accuracy of 20%, 50%, and 26%, respectively. TEE produced a sensitivity, specificity, and accuracy of 27%, 100%, and 42%, respectively. CTA outperformed TTE and TEE at characterizing anatomy at the origin and course of an anomalous coronary artery. At characterizing anatomy at the termination of an anomalous coronary artery, CTA outperformed TEE but did not significantly outperform TTE. CTA had a higher rate of documented limitations to imaging/interpretation compared to TTE and TEE but a lower rate when compared to conventional angiography. Conclusion and Impact: CTA is a rapid, non‐invasive, operator‐independent imaging modality that offers high resolution, 3‐dimensional imaging of CAAs in infants. The results of this study indicate that CTA is the most sensitive and accurate modality for detection of CAAs in infants and is optimal for characterizing anatomy along the entire length of an anomalous coronary artery. As such, CTA may be the optimal modality for first‐line coronary artery imaging in infants with suspected anomalous coronary artery anatomy who have a high pretest probability for having a CAA.
    • Implementation of a Pediatric Stroke Team: Outcomes and Resource Utilization

      Esque, Jacquelin; The University of Arizona College of Medicine - Phoenix; Buttram, Sandra (The University of Arizona., 2016-04)
      Background and Significance: Pediatric stroke is associated with significant morbidity and mortality. In an effort to improve diagnosis and patient management, we established a Pediatric Stroke Team (PST) available 24/7 in January 2012. Outcomes of patients before and after PST implementation are reported. Methods: Retrospective review of pediatric stroke patients (Jan 2009 ‐Dec 2012) at Phoenix Children’s Hospital in Phoenix, Arizona. Primary outcomes assessed were Glasgow Outcome Scale‐Extended Pediatric Revision (GOS‐E Peds) and discharge disposition. Hospital length of stay, time to neuroimaging, stroke therapies, and adherence to neuroprotective strategies (sodium, glucose, temperature) were also evaluated. Data were analyzed by Wilcoxon rank sum, Fisher’s exact, and chi‐square. Results: There were 64 patients pre‐PST and 30 post‐PST. Overall, GOS‐E Peds was improved post‐PST 2 [1, 3] vs. pre‐PST 3 [2, 6] (p = 0.004) with no change if deaths were excluded (post‐PST (2 [1, 2]) vs. pre‐PST (2 [1, 6]) (p = 0.030)). Discharge to home was more common in the post‐PST group (p = 0.018). Definitive neuroimaging tended to occur more quickly post‐PST 2h [1, 2.6] compared to pre‐PST 4.7h [1.3, 16.5] (p =0.16). Post‐PST patients appropriately received heparin (23%) more often than pre‐PST (6%) (p = 0.034) and had fewer episodes of hyperglycemia (3%) compared to pre‐PST (20%) (p = 0.033). There were no differences in episodes of fever, hyponatremia or hypoglycemia. Conclusions: Availability of a PST improved patient care and outcomes. Time to definitive neuroimaging was decreased, appropriate therapies were administered and adverse events (hyperglycemia) were decreased with PST management. We continue to strive for improved care of pediatric stroke patients.
    • The Role of Injection Laryngoplasty (IL) in Treating Deep Interarytenoid Notch (DIN) Associated Dysphagia in Young Children

      Frantz, Garrett; The University of Arizona College of Medicine - Phoenix; Williams, Dana (The University of Arizona., 2016-04)
      BACKGROUND Deep Interarytenoid Notch (DIN) is the mildest form of laryngotracheoesophageal cleft defect and is frequently found in young children with dysphagia and aspiration. Treatment guidelines are not defined. Injection laryngoplasty (IL) is a surgical procedure injecting polymer gel into the issue around the defect. Our objective was to evaluate the efficacy of IL in pediatric populations with severe dysphagia and aspiration. METHODS We conducted a pilot retrospective chart review of DIN patients under 36 months who underwent IL at PCH. Severity of dysphagia before and after IL was measured using modified barium swallows (MBS) (scale 0‐10) and documented symptoms. Statistical analysis was done using paired two sample t‐test with a p value of 5 percent. RESULTS Patients with initial MBS above double honey (7) improved an average of 2.6 ±1.38 points while those with initial scores below 7 did not see a statistical change in MBS. At the end of the study period, the final MBS scores for both groups were statistically similar.CONCLUSIONS IL treatment for DIN associated dysphagia results in improvement of MBS scores and symptoms in toddlers with severe aspiration. Careful timing of IL impacts morbidity. Future prospective controlled studies are necessary to evaluate the role of IL and medical interventions in thickener wean and clinical improvement.
    • Skin Disorders Encountered at a Pediatric Homeless Clinic: A Retrospective Chart Review

      Balasuriya, Lilanthi; The University of Arizona College of Medicine - Phoenix; O’Haver, Judy (The University of Arizona., 2016-03-23)
      BACKGROUND AND SIGNIFICANCE: Limited information about skin problems in homeless children exists in the current literature. RESEARCH QUESTION: Our objective was to classify the types of skin conditions commonly seen in a pediatric homeless clinic as compared to that of a large tertiary care children’s hospital dermatology clinic. METHODS: We conducted a retrospective cohort study of all children treated by pediatric dermatologists at a homeless clinic, and compared the diagnoses to what was seen at a general pediatric dermatology clinic. RESULTS: There were 100 visits for 75 patients at the homeless clinic during the study period of 33 months. Within the homeless clinic visits, 62% of patient’s reported living in a shelter. In the homeless population the most common diagnoses were atopic dermatitis (31.0%), acne (27.0%), other dermatitis (7.0%), molluscum (6.0%), warts (5.0%) and nevi (4.0%). In the nonhomeless population, the most common diagnoses were atopic dermatitis (19.2%), contact dermatitis (9.7%), hemangioma (9.5%), acne (9.4%), nevus, non‐neoplastic (6.8%) and benign neoplasm of the skin (6.3%). CONCLUSION: Homeless and non‐homeless children suffer from similar conditions such as atopic dermatitis, acne and nevi. With the growing homeless pediatric population and their exposure to unsheltered environments, further studies are needed to investigate the skin conditions affecting this population.
    • Variability in the Interpretation of Elbow Fractures in Children

      Kraynov, Liliya; The University of Arizona College of Medicine - Phoenix; Zebulon, Timothy; Bulloch, Blake (The University of Arizona., 2016-03-25)
      Background and Significance The first physician to encounter a child with an elbow fracture is usually the emergency medicine (EM) physician. Many hospitals may not have access to immediate orthopedic consultation or “real-time” radiology reads, therefore, EM physicians have a great responsibility for an accurate diagnosis. Unfortunately, many EM physicians have little training in pediatric orthopedic injuries. The elbow's anatomy and radiographic features of the growing elbow increase the difficulty in determining an accurate diagnosis and proper treatment. Inaccurate interpretation of elbow fractures in children may lead to unnecessary or improper medical decisions. Accurate interpretation is especially important in rural settings where patients may need transportation to facilities with higher levels of care. Research Question This study aims to survey EM physicians and determine if certain elbow fractures are diagnosed inaccurately more frequently and if some physician characteristics share a relationship with the accuracy of diagnosis of pediatric fractures. The characteristics include area of specialization, annual ED volume, years of experience post residency training, and working in an academic versus non-academic department. Different types of fractures, including type 1 supracondylar, type 2 supracondylar, type 3 supracondylar, medial epicondyle, lateral epicondyle, and olecranon along with uninjured elbows were evaluated to determine if a particular type was misdiagnosed more frequently. Methods A 16-question multiple-choice paper survey was distributed to physicians working in academic and non-academic centers within adult or pediatric emergency departments. Questions included radiographs and asked the physician to determine which fracture existed, if any.Results Lateral epicondyle fractures were the most likely fractures to be misdiagnosed (22.12%), while type 3 supracondylar fractures were the most likely to be accurately diagnosed (95.5%). There was no significant difference in accuracy of diagnosis based on physicians working either in an academic department, non-academic department, or both. Those physicians who were board certified or board eligible in two or more specialties had a higher mean percent correct, as well as those who worked in pediatric emergency medicine. Conclusions While this study served to start clarifying the most frequently misdiagnosed pediatric fractures and whether physicians with particular characteristics were more likely to diagnose fractures accurately, further steady is necessary to draw a definitive conclusion. This study does shed light on which pediatric elbow fractures physicians misdiagnose more frequently. It is important for all emergency medicine physicians to keep in mind the types of fractures that are most commonly misdiagnosed as it can affect medical decision-making. This is an area where additional education about elbow fractures in the developing pediatric elbow may be needed.