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Monitoring for the anticoagulant effect of unfractionated (UFH) at the point of care using activated clotting time in real time is vital where risk of thrombosis is high. Although monitoring UFH effect is a routine and important task, changing from one ACT instrument type or technology to another must be preceded by a clinical and statistical evaluation to determine the suitability and repeatability and establish normal and treatable ranges of this newer instrument. In this multi-center prospective evaluation we tested 1236 paired ACT+ samples, and 463 paired ACT-LR samples (1699 total) from enrolled study subjects. Clinical settings included CVOR cardiopulmonary bypass, at the beside in extracorporeal life support (ELS), the Cardiac Catheterization Lab (CCL) during diagnostic studies and percutaneous coronary interventions (PCI), interventional radiology procedures and EP interventions. This study found more consistent clinical performance from the GEM Hemochron 100 as compared to the current clinical model, the Hemochron Signature Elite. The bias of GEM Hemochron 100 for ACT+ and ACT-LR was greatest in the setting of the CVOR where ACT levels were high. ACT-LR measurements by the GEM Hemochron 100 were comparable to the SE when performed in settings of CCL, ECM, EP and ICU. Results obtained for both ACT-LR and ACT+ in all clinical settings in this study using the GEM Hemochron 100 are as accurate and more repeatable as those with the current clinically available Signature Elite.

BACKGROUND: Optic nerve hypoplasia (ONH) is a birth defect of unknown etiology and a leading cause of visual impairment in developed countries. Recent studies suggest that factors of deprivation and exposures of poor nutritional status, such as lower gestational weight gain (GWG), may be associated with increased risk of ONH. The present study describes the prenatal features of mothers of ONH cases, including pre-pregnancy BMI and GWG, and the associations with clinical features of disease severity. METHODS: Retrospective study of prenatal records for cases of ONH enrolled in a research registry. Pre-pregnancy BMI and gestational weight gain (GWG) were compared to maternal characteristics and clinical findings of ONH severity including bilaterality, hypopituitarism, and neuroradiographic abnormalities. RESULTS: Compared to population-based normative data of births in the U.S., mothers of ONH cases (n=55) were younger (23.3 vs 25.8 years; P=0.03), with higher incidence of inadequate GWG (34.0% vs 20.4%; P =0.03) predominantly in the 1(st) and 2(nd) trimesters. Presence of major brain malformations was associated with younger maternal age [21.6 (IQR 19.4,24.7) vs 24.9 years (IQR 22.1,28.5) (P=0.02)], primiparity (44.1% vs 13.3%; P=0.05) and decreased pre-pregnancy BMI [20.9 kg/m(2) (19,22.5) vs 25.5 kg/m(2) (21.3,28.2); P

· Background: The COVID-19 pandemic has significantly stressed the healthcare system since January 2020. There are questions whether there were racial disparities in the use of resources and procedures during this period and if so, did the disparities change over the pandemic. We focus on invasive ventilation (Mechanical Ventilation/MV and Extracorporeal Membrane Oxygenation/ECMO) and racial identity of the patient for the pre-Delta and Delta timeframes. · Methods: We used data available from the National COVID Cohort Collaborative (N3C) of COVID positive patients across the US. Cox regression models were used to estimate time to MV and ECMO as the dependent variables and race, age, gender, Comorbidity index as covariates. · Results: We did not find systematic patterns of racial disparity in time to MV. Asian and Hispanic patients, but not Black patients, received MV in a delayed manner compared to White patients in the pre-Delta period. These differences were not evident in the Delta period. · Conclusions: The results show a temporal change from the pre-Delta and Delta timeframes for the time to invasive ventilation implying that any observed racial disparities improved over time. We did not find statistically significant differences in the time to ECMO across the races or over timeframes.

Sedation with chloral hydrate or anesthesia using propofol allow ocular examination and testing in young children, but these drugs may affect electrophysiologic recordings. We compared the flash and pattern ERGs and VEPs recorded with each drug in a cohort of young children enrolled in a prospective study of optic nerve hypoplasia (ONH) syndrome. ERGs and VEPs to light-adapted, standard, full-field flashes, to standard and steady-state pattern-reversal (PR) were recorded with cycloplegia in 9 participants. Age range at the first session, with chloral hydrate was 8–23 mo; at the second session with propofol it was 20–29 mo. Examiners masked to the drug and clinical conditions measured the waveforms for longitudinal, paired comparisons between the sessions. Flash ERG amplitudes did not differ between sessions; peak times were longer at the second session (propofol) by clinically insignificant amounts ( 10 mo between sessions (n = 5, 10 eyes) but not for those with a shorter inter-test interval ( 0.05, n = 4). Magnitudes of the steady-state PERGs did not differ between tests but the waveforms had earlier peaks at the second test with propofol. Flash VEP waveforms were present in 10/18 eyes and showed 72% agreement for recordability between sessions. Standard pattern VEPs were recordable in only a few eyes in this cohort with ONH. Light-adapted flash ERG waveforms were generally similar with chloral hydrate and with propofol. Larger PERGs with later peaks, found in the second session (propofol) could reflect maturation of the PERG generators, as the differences found were associated with a greater age difference between the sessions, but we do not rule out that small differences in the waveforms may be drug-related. There are insufficient VEP data from these children with ONH to identify drug-related or maturational effects on VEPs.

IntroductionIn patients with optic nerve hypoplasia (ONH), the visualisation of the optic disc can be challenging and the definitive diagnosis difficult to ascertain without fundus photography. The use of MRI for diagnosis has been reported as a diagnostic alternative with conflicting results. We retrospectively analysed a disease registry to determine the reliability of orbital MRI measurements of the optic nerve diameter to diagnose ONH, and the correlation with vision outcomes.Materials and methodsFrom a cohort of 140 patients with ONH (13% unilateral) that had reached age 5 years, we identified 43 subjects who had orbital MRI in addition to fundus photography performed prior to 2 years of age. We compared measurements of the optic nerve diameter from orbital MRI scans to the standard relative optic disc size (disc diameter/disc-macula (DD/DM) distance) by fundus photography. All patients had visual acuity tested at age 5 years. Spearman’s correlation coefficient was used to determine the correlation of orbital MRI measurements and fundus photography with the diagnosis of ONH, and with vision outcomes.ResultsRelative disc size (DD/DM)s=0.471; ps=−0.869; ps=−0.635; pDiscussionOrbital optic nerve diameter from MRI scans has moderate reliability in diagnosing ONH and predicting vision outcomes. Fundus photography for measurements of the optic nerve size should remain the reference for diagnostic confirmation of ONH. These data further support the prognostic value of fundus photography for eventual vision outcomes in this population.

To determine associations between anticoagulation practices and bleeding and thrombosis during pediatric extracorporeal membrane oxygenation (ECMO), we performed a secondary analysis of prospectively collected data which included 481 children (80 ml/kg on any day, pulmonary hemorrhage, or intracranial bleeding, Thrombotic events included pulmonary emboli, intracranial clot, limb ischemia, cardiac clot, and arterial cannula or entire circuit change. Bleeding occurred in 42% of patients. Five percent of subjects thrombosed, of which 89% also bled. Daily bleeding odds were independently associated with day prior activated clotting time (ACT) (OR 1.03, 95% CI= 1.00, 1.05, p=0.047) and fibrinogen levels (OR 0.90, 95% CI 0.84, 0.96, p

ObjectiveTo elucidate the symptoms of laboratory-confirmed COVID-19 cases as compared with laboratory-confirmed negative individuals and to the untested general population among all participants who reported symptoms within a large prospective cohort study.Setting and designThis work was conducted within the framework of the Arizona CoVHORT, a longitudinal prospective cohort study conducted among Arizona residents.ParticipantsEligible participants were any individual living in Arizona and were recruited from across Arizona via COVID-19 case investigations, participation in testing studies and a postcard mailing effort.Primary and secondary outcome measuresThe primary outcome measure was a comparison of the type and frequency of symptoms between COVID-19-positive cases, tested but negative individuals and the general untested population who reported experiencing symptoms consistent with COVID-19.ResultsOf the 1335 laboratory-confirmed COVID-19 cases, 180 (13.5%) reported having no symptoms. Of those that did report symptoms, the most commonly reported were fatigue (82.2%), headache (74.6%), aches, pains or sore muscles (66.3%), loss of taste or smell (62.8) and cough (61.9%). In adjusted logistic regression models, COVID-19-positive participants were more likely than negative participants to experience loss of taste and smell (OR 12.1; 95% CI 9.6 to 15.2), bone or nerve pain (OR 3.0; 95% CI 2.2 to 4.1), headache (OR 2.6; 95% CI 2.2 to 3.2), nausea (OR 2.4; 95% CI 1.9 to 3.1) or diarrhoea (OR 2.1; 95% CI 1.7 to 2.6). Fatigue (82.9) and headache (74.9) had the highest sensitivities among symptoms, while loss of taste or smell (87.2) and bone or nerve pain (92.9) had the high specificities among significant symptoms associated with COVID-19.ConclusionWhen comparing confirmed COVID-19 cases with either confirmed negative or untested participants, the pattern of symptoms that discriminates SARS-CoV-2 infection from those arising from other potential circulating pathogens may differ from general reports of symptoms among cases alone.

We developed a curriculum of imaging informatics for clinical informatics fellows. While imaging informatics and clinical informatics are related fields, they have distinct bodies of knowledge. The aim of this curriculum is to prepare clinical informatics fellows for questions regarding imaging informatics on the clinical informatics board certification examination, prepare fellows to handle issues and requests involving imaging informatics in their future roles as clinical informaticists, and develop sufficient knowledge and skills in order to interface with imaging and radiology domain experts. We mapped ACGME core competencies for clinical informatics and the clinical informatics skills and attributes to topics covered in this curriculum. Topics covered included orders vs. encounter-based workflow, understanding imaging informatics operations and the differences between an IT department leading digital image management and the radiology department, clinical decision support for radiology, procuring and integrating new modalities into a PACS system, troubleshooting slow application performance in a PACS environment, imaging sharing, artificial intelligence (AI) in imaging including AI bias, validation of models within home institution and regulatory issues, and structured reporting vs. Natural Language Processing to mine radiology report data. These topics were covered in interactive didactic sessions as well as a journal club. Future work will expand to include hands-on learning and a formal evaluation of this curriculum with current fellows and recent graduates.

Accurate diagnosis of potential SARS-CoV-2 infections by symptoms is one strategy for continuing global surveillance, particularly in low-resource communities. We conducted a prospective, population-based cohort study, the Arizona CoVHORT, among Arizona residents to elucidate the symptom profile of laboratory-confirmed COVID-19 participants(16.2%) compared to laboratory-confirmed negative(22.4%) and untested general population participants(61.4%). Among the 1514 study participants, those who were COVID-19 positive were more likely to be Hispanic(33.5%) and more likely to report obesity > 30 kg/m2(34.7%) compared to COVID-19 negative participants(19.2%; 31.0%) and untested CoVHORT participants(13.8%; 23.8%). Of the 245 laboratory-confirmed COVID-19 cases, 15.0% reported having had no symptoms. Of those that did report symptoms, the most commonly-reported first symptoms were sore throat(19.0%), headache(15.5%), cough(12.7%), runny nose/cold-like symptoms(12.1%), and fatigue(12.0%). In adjusted logistic regression models, COVID-19 positive participants were more likely than negative participants to experience loss of taste and smell(OR:35.7; 95% CI 18.4-69.5); bone or nerve pain(OR:17.9; 95% CI 6.7-47.4), vomiting(OR:10.8; 95% CI 3.1-37.5), nausea(OR:10.5; 95% CI 5.5-19.9), and headache(OR:8.4; 95% CI 5.6-12.8). When comparing confirmed COVID-19 cases with confirmed negative or untested participants, the pattern of symptoms that discriminates SARS-CoV-2 infection from those arising from other potential circulating pathogens may differ from general reports of symptoms among cases alone.

BackgroundThere has been an increasing recognition of the influence of social, behavioral, economic, and environmental factors on overall patient health. The purpose of this project was to leverage the ICD-10 codes to identify and link social determinants of health (SDoH) to patients with a high probability of utilizing acute care services and to determine if social service intervention reduced care utilization.MethodsWe analyzed retrospective data for active patients at a Department of Veterans Affairs Medical Center (VAMC) from 2015-2017. Eleven categories of SDoH were developed based on existing literature of the social determinants; the relevant ICD-10 codes were divided among these categories. Emergency Room (ER) visits, hospital admissions, and social work visits were determined for each patient in the cohort.ResultsIn a cohort of 44,401 patients, the presence of ICD-10 codes within the EHR in the 11 SDoH categories was positively correlated with increased acute care utilization. Veterans with at least one SDoH risk factor were 71% (95%CI: 68% - 75%) more likely to use the ED and 71% (95%CI: 65%-77%) more likely to be admitted to the hospital. Utilization decreased with social service interventions.ConclusionThis project demonstrates a potentially meaningful method to capture patient social risk profiles through existing EHR data in the form of ICD-10 codes, which can be used to identify the highest risk patients for intervention with the understanding that not all SDoH codes are uniformly used and some SDoHs may not be captured.

Sedation with chloral hydrate or anesthesia using propofol allow ocular examination and testing in young children, but these drugs may affect electrophysiologic recordings. We compared the flash and pattern ERGs and VEPs recorded with each drug in a cohort of young children enrolled in a prospective study of optic nerve hypoplasia (ONH) syndrome.ERGs and VEPs to light-adapted, standard, full-field flashes, to standard and steady-state pattern-reversal (PR) were recorded with cycloplegia in 9 participants. Age range at the first session, with chloral hydrate was 8-23 mo; at the second session with propofol it was 20-29 mo. Examiners masked to the drug and clinical conditions measured the waveforms for longitudinal, paired comparisons between the sessions.Flash ERG amplitudes did not differ between sessions; peak times were longer at the second session (propofol) by clinically insignificant amounts ( 2 ms, p = 0.002). Standard PERGs had larger amplitudes and later peaks in the second session (propofol) than with chloral hydrate (P50 2.9 vs 4.7 μV, p = 0.016 and 43 vs 52 ms, p 0.001; N95 4.0 vs 6.1 μV, p = 0.003 and 91 vs 98.5 ms p = 0.034.). These differences were present for those with an interval of 10 mo between sessions (n = 5, 10 eyes) but not for those with a shorter inter-test interval ( 8 mo, p 0.05, n = 4). Magnitudes of the steady-state PERGs did not differ between tests but the waveforms had earlier peaks at the second test with propofol. Flash VEP waveforms were present in 10/18 eyes and showed 72% agreement for recordability between sessions. Standard pattern VEPs were recordable in only a few eyes in this cohort with ONH.Light-adapted flash ERG waveforms were generally similar with chloral hydrate and with propofol. Larger PERGs with later peaks, found in the second session (propofol) could reflect maturation of the PERG generators, as the differences found were associated with a greater age difference between the sessions, but we do not rule out that small differences in the waveforms may be drug-related. There are insufficient VEP data from these children with ONH to identify drug-related or maturational effects on VEPs.

Background and Objective Some individuals with migraine report the presence of speech changes during their migraine attacks. The goal of this study was to compare objective features of speech during the migraine pre-attack, the migraine attack, and during the interictal period. Methods This was a prospective, longitudinal, observational study of adults with episodic migraine and healthy non-migraine controls. Participants provided speech samples three times per day using a speech elicitation tool included within a mobile app. Six complementary speech features that capture articulation and prosody were extracted from speech samples. Participants with migraine maintained a daily headache diary using the same app. A mixed effects model and t-tests were used to investigate differences in speech features between controls, the migraine pre-attack phase, the migraine attack, and the interictal period. Results In total, 56,767 speech samples were collected, including 43,102 from 15 individuals with migraine and 13,665 from matched healthy controls. Significant group-level differences in speech features were identified between those with migraine and healthy controls and within the migraine group during the pre-attack vs. attack vs. interictal periods (all p Conclusions Changes in speech occurred in almost half of the individuals during migraine attacks. Once confirmed in subsequent studies, speech changes could be considered a feature of the migraine attack.

Background:The objective of this study was to ascertain the risk of hypoglycemia among youth with type 2 diabetes (T2D) on insulin therapy.Methods:Twenty-two youth with T2D on insulin therapy (M=12, F=10, age=14.4±4.0 years) were enrolled from a single pediatric endocrine practice. They were followed-up for 3 months with weekly phone calls and monthly in-person visits to review blood glucose logs and document any signs or symptoms of hypoglycemia (defined as finger stick glucose of ≤70 mg/dL). Episodes of hypoglycemia were categorized into five categories: severe, documented symptomatic, asymptomatic, probable symptomatic and relative hypoglycemia. In addition to examining the risk of hypoglycemia, the degree to which hypoglycemia was associated with patient demographics (e.g. age, gender and body mass index [BMI]) or clinical factors (i.e. duration of diabetes, duration of insulin treatment, glycemic control or insulin dose and regimen) was determined.Results:Nine hypoglycemic events occurred during the study period in five patients with an incidence rate of nine events per 5.3 patient-years. Of the hypoglycemic events, five were symptomatic and four were asymptomatic. No severe hypoglycemic events occurred. Hypoglycemia was not associated with age, ethnicity, duration of insulin treatment, insulin dose or initial hemoglobin (HbA1c). However, a significant difference in BMI was noted, with T2D youth who experienced hypoglycemia having a lower BMI than those who did not experience hypoglycemia.Conclusions:The results of this study suggest that the risk of hypoglycemia in youth with T2D on insulin therapy is low.

An enhanced dose range checking (DRC) system was developed to evaluate prescription error rates in the pediatric intensive care unit and the pediatric cardiovascular intensive care unit. An enhanced DRC system incorporating “soft” and “hard” alerts was designed and implemented. Practitioner responses to alerts for patients admitted to the pediatric intensive care unit and the pediatric cardiovascular intensive care unit were retrospectively reviewed. Alert rates increased from 0.3% to 3.4% after “go-live” (P < 0.001). Before go-live, all alerts were soft alerts. In the period after go-live, 68% of alerts were soft alerts and 32% were hard alerts. Before go-live, providers reduced doses only 1 time for every 10 dose alerts. After implementation of the enhanced computerized physician order entry system, the practitioners responded to soft alerts by reducing doses to more appropriate levels in 24.7% of orders (70/283), compared with 10% (3/30) before go-live (P = 0.0701). The practitioners deleted orders in 9.5% of cases (27/283) after implementation of the enhanced DRC system, as compared with no cancelled orders before go-live (P = 0.0774). Medication orders that triggered a soft alert were submitted unmodified in 65.7% (186/283) as compared with 90% (27/30) of orders before go-live (P = 0.0067). After go-live, 28.7% of hard alerts resulted in a reduced dose, 64% resulted in a cancelled order, and 7.4% were submitted as written. Before go-live, alerts were often clinically irrelevant. After go-live, there was a statistically significant decrease in orders that were submitted unmodified and an increase in the number of orders that were reduced or cancelled.

Reductions in spoken language complexity have been associated with the onset of various neurological disorders. The objective of this study is to analyze whether similar trends are found in professional football players who are at risk for chronic traumatic encephalopathy. We compare changes in linguistic complexity (as indexed by the type-to-token ratio and lexical density) measured from the interview transcripts of players in the National Football League (NFL) to those measured from interview transcripts of coaches and/or front-office NFL executives who have never played professional football. A multilevel mixed model analysis reveals that exposure to the high-impact sport (vs no exposure) was associated with an overall decline in language complexity scores over time. This trend persists even after controlling for age as a potential confound. The results set the stage for a prospective study to test the hypothesis that language complexity decline is a harbinger of chronic traumatic encephalopathy.

Introduction The United States (US) leads all high income countries in gunshot wound (GSW) deaths. However, as a result of two decades of reduced federal support, study of GSW has been largely neglected. In this paper we describe the current state of GSW hospitalizations in the US using population-based data. Patients and methods We conducted an observational study of patients hospitalized for GSW in the National (Nationwide) Inpatient Sample (NIS) 2004 −2013. Our primary outcome is mortality after admission and we model its associations with gender, race, age, intent, severity of injury and weapon type, as well as providing temporal trends in hospital charges. Results Each year approximately 30,000 patients are hospitalized for GSW, and 2500 die in hospital. Men are 9 times as likely to be hospitalized for GSW as women, but are less likely to die. Twice as many blacks are hospitalized for GSW as non-Hispanic whites. In-hospital mortality for blacks and non-Hispanic whites was similar when controlled for other factors. Most GSW (63%) are the result of assaults which overwhelmingly involve blacks; accidents are also common (23%) and more commonly involve non-Hispanic whites. Although suicide is much less common (8.3%), it accounts for 32% of all deaths; most of which are older non-Hispanic white males. Handguns are the most common weapon reported, and have the highest mortality rate (8.4%). During the study period, the annual rate of hospitalizations for GSW remained stable at 80 per 100,000 hospital admissions; median inflation-adjusted hospital charges have steadily increased by approximately 20% annually from $30,000 to $56,000 per hospitalization. The adjusted odds for mortality decreased over the study period. Although extensively reported, GSW inflicted by police and terrorists represent few hospitalizations and very few deaths. Conclusions The preponderance GSW hospitalizations resulting from assaults on young black males and suicides among older non-Hispanic white males have continued unabated over the last decade with escalating costs. As with other widespread threats to the public wellbeing, federally funded research is required if effective interventions are to be developed.

To develop a prognostic model for predicting mortality at time of extracorporeal membrane oxygenation initiation for children which is important for determining center-specific risk-adjusted outcomes.Multivariable logistic regression using a large national cohort of pediatric extracorporeal membrane oxygenation patients.The ICUs of the eight tertiary care children's hospitals of the Collaborative Pediatric Critical Care Research Network.Five-hundred fourteen children (19 yr old), enrolled with an initial extracorporeal membrane oxygenation run for any indication between January 2012 and September 2014.None.A total of 514 first extracorporeal membrane oxygenation runs were analyzed with an overall mortality of 45% (n = 232). Weighted logistic regression was used for model selection and internal validation was performed using cross validation. The variables included in the Pediatric Extracorporeal Membrane Oxygenation Prediction model were age (pre-term neonate, full-term neonate, infant, child, and adolescent), indication for extracorporeal membrane oxygenation (extracorporeal cardiopulmonary resuscitation, cardiac, or respiratory), meconium aspiration, congenital diaphragmatic hernia, documented blood stream infection, arterial blood pH, partial thromboplastin time, and international normalized ratio. The highest risk of mortality was associated with the presence of a documented blood stream infection (odds ratio, 5.26; CI, 1.90-14.57) followed by extracorporeal cardiopulmonary resuscitation (odds ratio, 4.36; CI, 2.23-8.51). The C-statistic was 0.75 (95% CI, 0.70-0.80).The Pediatric Extracorporeal Membrane Oxygenation Prediction model represents a model for predicting in-hospital mortality among children receiving extracorporeal membrane oxygenation support for any indication. Consequently, it holds promise as the first comprehensive pediatric extracorporeal membrane oxygenation risk stratification model which is important for benchmarking extracorporeal membrane oxygenation outcomes across many centers.

In many hospitals, children with suspected nonaccidental trauma (sNAT) are admitted to nonsurgical services (NSS). Although the surgical service (SS) initially admitted sNAT patients at our American College of Surgeons (ACS)-verified level 1 pediatric trauma center (vPTC), a change in hospital policy allowed admission to NSS. The objective of this study was to determine if the rate of care-related indicators (CRIs) varies by admission to an SS vs an NSS in the sNAT patient population.We conducted a retrospective review of patients admitted to an ACS vPTC with a final diagnosis of sNAT between January 2009 and December 2013. The primary study outcome was the presence of a CRI. Surgical service and NSS admissions were compared on age, Injury Severity Score, and Abbreviated Injury Scale to account for population differences among admissions by service and type of CRIs, using chi-square or Fisher's exact and Mann-Whitney tests. Rates of CRIs over time were also evaluated.During the study period, 5,340 total patients were admitted-671 (13%) with sNAT. Nonsurgical services admitted 306 patients (46%) of these patients, but 71% (n = 102) of the CRIs occurred in patients admitted to an NSS. The rate of CRIs per 100 patients was 33 for NSS compared with 12 for SS (p0.001). The overall rate of CRIs for sNAT increased from 18 to 26 (p = 0.07) per 100 patients after the policy change.Nonaccidental trauma patients admitted to an NSS were shown to have more CRIs than those admitted to an SS. This study supports an ACS requirement of admission of sNAT to an SS.

Pattern electroretinograms (PERGs) have inherently low signal-to-noise ratios and can be difficult to detect when degraded by pathology or noise. We compare an objective system for automated PERG analysis with expert human interpretation in children with optic nerve hypoplasia (ONH) with PERGs ranging from clear to undetectable. PERGs were recorded uniocularly with chloral hydrate sedation in children with ONH (aged 3.5–35 months). Stimuli were reversing checks of four sizes focused using an optical system incorporating the cycloplegic refraction. Forty PERG records were analysed; 20 selected at random and 20 from eyes with good vision (fellow eyes or eyes with mild ONH) from over 300 records. Two experts identified P50 and N95 of the PERGs after manually deleting trials with movement artefact, slow-wave EEG (4–8 Hz) or other noise from raw data for 150 check reversals. The automated system first identified present/not-present responses using a magnitude-squared coherence criterion and then, for responses confirmed as present, estimated the P50 and N95 cardinal positions as the turning points in local third-order polynomials fitted in the −3 dB bandwidth [0.25 … 45] Hz. Confidence limits were estimated from bootstrap re-sampling with replacement. The automated system uses an interactive Internet-available webpage tool (see http://clinengnhs.liv.ac.uk/esp_perg_1.htm ). The automated system detected 28 PERG signals above the noise level (p ≤ 0.05 for H0). Good subjective quality ratings were indicative of significant PERGs; however, poor subjective quality did not necessarily predict non-significant signals. P50 and N95 implicit times showed good agreement between the two experts and between experts and the automated system. For the N95 amplitude measured to P50, the experts differed by an average of 13 % consistent with differing interpretations of peaks within noise, while the automated amplitude measure was highly correlated with the expert measures but was proportionally larger. Trial-by-trial review of these data required approximately 6.5 h for each human expert, while automated data processing required

Background and Objective: Pediatric traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Computed tomography (CT) is the modality of choice to screen for brain injuries. MRI may provide more clinically relevant information. The purpose of this study was to compare lesion detection between CT and MRI after TBI. Methods: Retrospective cohort of children (0–21 years) with TBI between 2008 and 2010 at a Level 1 pediatric trauma center with a head CT scan on day of injury and a brain MRI scan within 2 weeks of injury. Agreement between CT and MRI was determined by κ statistic and stratified by injury mechanism. Results: One hundred five children were studied. Of these, 78% had mild TBI. The MRI scan was obtained a median of 1 day (interquartile range, 1–2) after CT. Overall, CT and MRI demonstrated poor agreement (κ = −0.083; P = .18). MRI detected a greater number of intraparenchymal lesions (n = 36; 34%) compared with CT (n = 16; 15%) (P < .001). Among patients with abusive head trauma, MRI detected intraparenchymal lesions in 16 (43%), compared with only 4 (11%) lesions with CT (P = .03). Of 8 subjects with a normal CT scan, 6 out of 8 had abnormal lesions on MRI. Conclusions: Compared with CT, MRI identified significantly more intraparenchymal lesions in pediatric TBI, particularly in children with abusive head trauma. The prognostic value of identification of intraparenchymal lesions by MRI is unknown but warrants additional inquiry. Risks and benefits from early MRI (including sedation, time, and lack of radiation exposure) compared with CT should be weighed by clinicians.

Background The objective of this work was to examine current oxygenation index (OI) data and outcomes using electronic medical record data to identify a specific OI value associated with mortality. Methods This study was a retrospective electronic medical record data review from the pediatric ICU of Phoenix Children's Hospital, with data mining for variables to calculate OIs on subjects age 1 month to 20 y mechanically ventilated > 24 h, excluding those with known intracardiac shunts or cyanotic heart disease. Age, length of hospital stay, duration of mechanical ventilation, and outcomes were also assessed. The Wilcoxon signed-rank test was used to compare continuous variables, receiver operating characteristic analysis was used in determining discriminant ability, and logistic regression was conducted to determine the odds ratio (OR) for risk of death with increasing OI. Results OI was calculated on 65 subjects, of whom 6 died (9%). The median maximum OI was 10 for all subjects, 17 for non-survivors, and 8 for survivors (P = .14 via Wilcoxon rank-sum test). ORs indicated a 2.4-fold increase in the odds of death (P = .09, 95% CI 0.9-6.6) for each increasing point in maximum OI. Mean OI OR revealed a 1.9-fold increase in the odds of death (P = .25, 95% CI 0.6-5.9). Receiver operating characteristic analysis indicated a higher discriminate ability for maximum OI (area under the curve = 0.68) than mean OI (area under the curve = 0.58). OI cut-points for mortality were established. Mortality was unchanged until maximum OI > 17, for which mortality nearly tripled at a value of 18% versus 6-7% for range 0-17. Conclusions Limitations exist in obtaining serial OI values from current electronic medical records. Serial assessment of OI values may allow creation of alert values for increased mortality risk. Consideration of escalation of therapies for respiratory failure, such as high-frequency ventilation, inhaled nitric oxide, or extracorporeal membrane oxygenation may be warranted at lower OIs than historically reported.

Extracorporeal membrane oxygenation (ECMO) is used for respiratory and cardiac failure in children but is complicated by bleeding and thrombosis.(1) To measure the incidence of bleeding (blood loss requiring transfusion or intracranial hemorrhage) and thrombosis during ECMO support; (2) to identify factors associated with these complications; and (3) to determine the impact of these complications on patient outcome.This was a prospective, observational cohort study in pediatric, cardiac, and neonatal intensive care units in eight hospitals, carried out from December 2012 to September 2014.ECMO was used on 514 consecutive patients under age 19 years. Demographics, anticoagulation practices, severity of illness, circuitry components, bleeding, thrombotic events, and outcome were recorded. Survival was 54.9%. Bleeding occurred in 70.2%, including intracranial hemorrhage in 16%, and was independently associated with higher daily risk of mortality. Circuit component changes were required in 31.1%, and patient-related clots occurred in 12.8%. Laboratory sampling contributed to transfusion requirement in 56.6%, and was the sole reason for at least one transfusion in 42.2% of patients. Pump type was not associated with bleeding, thrombosis, hemolysis, or mortality. Hemolysis was predictive of subsequent thrombotic events. Neither hemolysis nor thrombotic events increased the risk of mortality.The incidences of bleeding and thrombosis are high during ECMO support. Laboratory sampling is a major contributor to transfusion during ECMO. Strategies to reduce the daily risk of bleeding and thrombosis, and different thresholds for transfusion, may be appropriate subjects of future trials to improve outcomes of children requiring this supportive therapy.

Background: Optic nerve hypoplasia (ONH), a leading cause of pediatric blindness, is associated with brain malformations and hypopituitarism in the constellation known as septo-optic dysplasia. Neuroimaging is used to anticipate hypopituitarism, but with unconfirmed reliability. We report prospective findings on the association of hypopituitarism with brain malformations. Methods: Children (n = 146; 87% bilateral) underwent baseline MRI and annual examinations and hormonal testing. Hypopituitarism status at age 5 years was classified. Results: A total of 74% had brain malformation(s). Hypopituitarism (69%) was not associated with brain malformations (p = 0.351); this persisted after adjusting for the laterality of ONH and the timing of MRI (padj = 0.869). No association was noted for absent septum pellucidum (38%; p = 0.073), corpus callosum abnormality (51%; p = 0.625), and major malformations (22%; p = 0.407). A malformation conferred a positive predictive value of 71% (95% CI: 62%, 80%), and a negative predictive value of 37% (95% CI: 22%, 54%). Overall, 10% (n = 15) of the cohort presented with a triad of absent septum pellucidum, corpus callosum abnormality, and other major malformation; only half (n = 8) of these had hypopituitarism. All 13 subjects with pituitary malformations manifested hypopituitarism, conferring predictive values of 100% (positive) and 34% (negative). Conclusions: Hypopituitarism and brain malformations are highly prevalent, but have unrelated associations with ONH. Brain MRI in infants and toddlers with ONH is an unreliable screen for hypopituitarism risk.

Purpose To evaluate the effectiveness of stem cell therapy in improving visual acuity or optic nerve function in children with optic nerve hypoplasia (ONH). Methods Subjects with ONH aged 7-17 years who voluntarily elected to undergo stem cell therapy in China were matched with controls on age, visual acuity, and communication level. Visual acuity, optic nerve size, and sensitivity to light were assessed before stem cell therapy and twice after. Controls were evaluated on the same schedule. Results Two case–control pairs were enrolled. There were no clinically significant changes in pupillary constriction or optic nerve measurements in any participant eye. Improvement in visual acuity was noted in study participants regardless of treatment status. Conclusions On the basis of this small sample, there is no evidence that stem cell therapy improves visual acuity in children with ONH.

Background Hypopituitarism and obesity are causes of major lifelong morbidity in patients with optic nerve hypoplasia (ONH). Growth hormone deficiency (GHD) affects the majority of children with ONH, though the degree of deficiency and variability of early growth patterns range from early severe retardation to normal initial growth. The utility of early GH replacement for improving anthropometric, body composition, and lipid outcomes in patients with ONH and GHD, especially those with normal initial height velocity, is unknown. This study examines the effects of GH replacement in a cohort of children with ONH and GHD. Methods Controlled clinical trial from 2005–2014. The study included 17 children with ONH and untreated GHD. Those meeting criteria for growth deceleration were assigned to treatment with recombinant human growth hormone (n = 5) while those with normal height velocity were randomized either to treatment (n = 5) or to observation (no intervention, n = 7). Study duration was 3 years. Primary outcome measures included stature, weight, weight-for-stature, and BMI standard deviation score (SDS) at study completion. Results Subjects on GH, irrespective of entry growth trajectory, grew more on average in stature than controls by a difference of 0.98 SDS by study end; this effect persisted after adjusting for baseline overweight status. Treatment had an effect on weight SDS only after adjusting for initial overweight status, resulting in an average increase of 0.83 SDS more than controls. Subjects who were overweight at the outset experienced greater gains in both weight and stature SDS. Treatment had no statistically significant impact on weight-for-stature or BMI SDS. A reduction in body fat percentage was observed in those treated, both before (−6.1 %) and after (−4.3 %) adjustment for initial overweight status. Conclusion Early GH replacement has a positive effect on short-term statural outcomes in children with ONH and GHD, even in those exhibiting normal initial linear growth. Results were less conclusive regarding treatment effects on body composition and lipids.

Background BIRC5 (Survivin), an inhibitor of apoptosis protein (IAP), is over-expressed in several human cancers and increased expression is associated with poor prognosis. The goal of the current study was to evaluate the role of BIRC5 in Ewing sarcoma (ES), the second most common pediatric bone sarcoma. Procedure BIRC5 protein expression was determined in ES cell lines using Western Blot analysis. Functional role of survivin on growth and viability of ES cells was assessed by siRNA knockdown of BIRC5 and by using a small molecule inhibitor YM155. Immunohistochemical analysis for BIRC5 protein was performed on patient tumor samples using an anti-survivin antibody. The degree of BIRC5 protein expression was correlated with clinical parameters and patient outcome. Results BIRC5 is over-expressed in a panel of ES cell lines. Gene silencing of BIRC5 in the ES cell line TC-71 decreases cell growth by more than 50% for each BIRC5 siRNA construct compared to non-silencing siRNA control constructs. YM155 also reduces ES cell growth and viability with an EC50 ranging from 2.8 to 6.2 nM. BIRC5 protein is expressed in majority of the ES tumor samples with minimal expression in normal tissue (P

Background Research on the impact of pediatric trauma centers (PTCs) on mortality has been conflicting, most likely owing to differing methodologies. Using a population-based approach, we assessed whether American College of Surgeons (ACS)-verified trauma centers are associated with reduced overall state pediatric injury mortality rates. Methods A population-based study of state pediatric injury mortality rates (per 100,000 children ≤ 18 years) using data for 2008 from Centers for Disease Control and Prevention-National Center for Injury Prevention and Control. The availability of verified PTCs (vPTCs) and ACS-verified adult trauma centers in each state was determined and compared with mortality rates using regression, adjusting for injury mortality covariates. Correlation of mortality with type of trauma centers available was determined. The mortality versus number of PTCs per pediatric population was also examined. Results vPTCs were present in 36% of states, including 24% of states with Level I vPTCs. The mean (SD) pediatric injury mortality for the 32 states without a vPTC was 20.6 (6.6) per 100,000 children 18 years or younger. Presence and higher verification level of vPTC within a state correlated with decreasing pediatric injury mortality (p(unadjusted)= 0.005; p(adjusted) = 0.004). Mortality was 37% lower among states with only Level I vPTCs (12.9 [2.2]). Mortality was inversely correlated with the number of Level I vPTCs (p(unadjusted) = 0.006; p(adjusted) = 0.06) and lowest for states with two Level I vPTCs (11.8 [1.7]). Higher ratios of Level I vPTCs per population correlated with lower mortality rates (β = -3.53, p = 0.003). Conclusion The findings highlight a correlation between state pediatric injury mortality rates and presence of ACS-verified Level I PTCs. Level of evidence Prognostic study, level IV.

The objective of the study was to determine the diagnostic accuracy of pediatric emergency physicians in diagnosing clavicle fractures by bedside ultrasound (US).This was a prospective study of pediatric emergency department (ED) patients with suspected clavicle fractures conducted in a tertiary-care, freestanding pediatric hospital. A convenience sample of patients younger than 17 years underwent bedside US for detection of clavicle fracture by pediatric emergency physicians with limited US training. Ultrasound findings were compared with standard radiographs, which were considered the criterion standard. Pain scores using the validated color analog scale (0-10) were determined before and during US. Total length of stay in the ED, time to US, and time to radiograph were recorded.Fifty-eight patients were enrolled, of which 39 (67%) had fracture determined by radiograph. Ultrasound interpretation gave a sensitivity of 89.7% (95% confidence interval [CI], 75.8%-97.1%) and specificity of 89.5% (95% CI, 66.9%-98.7%). Positive and negative predictive values were 94.6% (95% CI, 81.8%-99.3%) and 81.0% (95% CI, 58.1%-94.5%), respectively. Positive and negative likelihood ratios were 8.33 and 0.11, respectively. Pain scores averaged 4.7 before US and 5.2 during US (P = 0.204). There was a statistically significant difference between mean time to US (76 minutes) and mean time to radiograph (107 minutes) (P0.001).Pediatric emergency physicians with minimal formal training can accurately diagnose clavicle fractures by US. In addition, US itself is not associated with an increase in pain and may reduce length of stay in the ED.

The objective of the study was to evaluate residents' and practicing physicians' medical knowledge of child abuse and maltreatment.In a freestanding pediatric hospital and community hospital, a 30-question survey was administered to pediatric residents, general pediatricians (GPs), and pediatric emergency medicine (PEM) physicians. The institution's child protection team developed the questions, which were pilot tested for validity. Question content covered major concepts in child abuse and neglect. Information on previous training of child abuse was also collected.There were 95 respondents, 64.2% (n = 61) were residents, 19% (n = 18) were GPs, and 16.8% (n = 16) were PEM physicians. Overall, the average score was 63.3% (SD, 13.8%). There was a statistically significant difference in the knowledge of child abuse and neglect across physician categories (P0.001). Pediatric emergency medicine physicians scored the highest (76.9 [SD, 9.1]) compared with GPs (66.7 [SD, 12.4]; P = 0.018) and pediatric residents (60.4 [SD, 12.9]; P0.001). There was no difference in the level of knowledge across residency training years (P = 0.076).With a mean score in our study of 63.3%, there appears to be an overall lack of knowledge in child abuse. These findings highlight the need for increased education in child maltreatment.

The purpose of the study is to characterise retinal function using light-adapted electroretinograms (ERGs) in a series of young children with ONH, congenital dysplasia of retinal ganglion cells. ERGs were recorded with chloral hydrate sedation in 27 children with ONH (18 with bilateral and 9 with unilateral ONH, age 4-35 months) and an adult reference population (n = 12). Stimuli included ISCEV standard flash, oscillatory potentials (OPs) and standard flicker as well as a light-adapted luminance-response series (photopic hill). The disc diameter to disc macula (DD:DM) ratio was measured from fundus photographs. The results are eyes with ONH, classified by DD:DM, were severe (or=0.15, n = 22), moderate (0.16-0.30, n = 22), mild (0.31-0.35, n = 1), and fellow eyes (0.35, n = 9), all had prolonged ERG implicit times and smaller i-waves than those of adults. Eyes with moderate or severe ONH also had smaller amplitudes for OPs and flicker ERGs and required stronger flashes to obtain the peak b-wave amplitude. Abnormalities of the photopic hill were a common but inconsistent feature of ONH and were not indicative of ONH severity. Abnormalities of the photopic hill of the ERG suggest that some cases of ONH may have retinal dysfunction with specific deficits in the ON or OFF pathways of the retina. ONH is a complex and heterogeneous condition that may involve dysfunction distal to the retinal ganglion cells.

The congenital malformation known as optic nerve hypoplasia (ONH) has been recognized in the past 30 years as an epidemic cause of congenital blindness. It was believed to occur either as an isolated anomaly or as a component of the syndrome of septo-optic dysplasia, which has evolved to include midline brain malformations and hypopituitarism. Evidence now suggests that ONH infrequently occurs in isolation. Most afflicted children will have hypothalamic dysfunction and/or neurodevelopmental impairment, regardless of MRI findings or severity of ONH. Adverse outcomes can often be ameliorated with early intervention. Thus, the syndrome of ONH should be suspected in all infants with signs of hypothalamic dysfunction or vision impairment.

BACKGROUND. Developmental delay has been reported to occur with optic nerve hypoplasia, a leading cause of pediatric blindness, but has not been systematically examined for its prevalence and correlation with associated pathologies of optic nerve hypoplasia.OBJECTIVE. The purpose of this study was to determine the developmental outcomes of children with optic nerve hypoplasia and the correlation of development with neuroradiographic, endocrinologic, and ophthalmic findings.METHODS. We conducted a prospective analysis of 73 subjects diagnosed with optic nerve hypoplasia at RESULTS. At 5 years of age, developmental delay was present in 71% of subjects with optic nerve hypoplasia. Of patients with unilateral (18%) and bilateral optic nerve hypoplasia, 39% and 78%, respectively, experienced developmental delay. Corpus callosum hypoplasia and hypothyroidism were significantly associated with poor outcome in all of the developmental domains and an increased risk of delay. Absence of the septum pellucidum was not associated with adverse development. Six subjects had neither a neuroradiographic nor an endocrinologic abnormality, and of those, 4 were developmentally delayed.CONCLUSIOONS. These prospective data confirm the significant association of developmental delay with optic nerve hypoplasia and identify corpus callosum hypoplasia and hypothyroidism as strong correlates. A diagnosis of optic nerve hypoplasia warrants neuroradiographic and endocrinologic testing for risk factors of delay and developmental assessments for early intervention planning.

Nonoperative management of liver and spleen injury should be achievable for more than 95% of children. Large national studies continue to show that some regions fail to meet these benchmarks. Simultaneously, current guidelines recommend hospitalization for injury grade + 2 (in days). A new treatment algorithm, the ATOMAC guideline, is in clinical use at many centers but has not been prospectively validated.A literature review conducted through MEDLINE identified publications after the American Pediatric Surgery Association guidelines using the search terms blunt liver trauma pediatric, blunt spleen trauma pediatric, and blunt abdominal trauma pediatric. Decision points in the new algorithm generated clinical questions, and GRADE [Grading of Recommendations, Assessment, Development, and Evaluations] methodology was used to assess the evidence supporting the guideline.The algorithm generated 27 clinical questions. The algorithm was supported by six 1A recommendations, two 1B recommendations, one 2B recommendation, eight 2C recommendations, and ten 2D recommendations. The 1A recommendations included management based on hemodynamic status rather than grade of injury, support for an abbreviated period of bed rest, transfusion thresholds of 7.0 g/dL, exclusion of peritonitis from a guideline, accounting for local resources and concurrent injuries in the management of children failing to stabilize, as well as the use of a guideline in patients with multiple injuries. The use of more than 40 mL/kg or 4 U of blood to define end points for the guideline, and discharging stable patients before 24 hours received 1B recommendations.The original American Pediatric Surgery Association guideline for pediatric blunt solid organ injury was instrumental in improving care, but sufficient evidence now exists for an updated management guideline.Expert opinion, guideline, grades I to IV.

Objective:Changes in technology and increased reports of successful extracorporeal life support use in patient populations, such as influenza, cardiac arrest, and adults, are leading to expansion of extracorporeal life support. Major limitations to extracorporeal life support expansion remain bleedi

Objective To determine the prevalence of endocrinopathies, neuroradiographical findings, and growth derangements in young children with optic nerve hypoplasia (ONH). Study design A prospective observational study examined the prevalence of endocrinopathies at study enrollment and growth patterns in children with ONH. Subjects (n = 47, mean ± SD 15.2 ± 10.6 months) were followed until 59.0 ± 6.2 months of age. Results The prevalence of endocrinopathies was 71.7%: 64.1% of subjects had growth hormone (GH) axis abnormalities, 48.5% hyperprolactinemia, 34.9% hypothyroidism, 17.1% adrenal insufficiency, and 4.3% diabetes insipidus (DI). Endocrinopathies were not associated with ONH laterality, absence of the septum pellucidum, or pituitary abnormalities on neuroimaging. End height standard deviation score (SDS) was similar to start length SDS independent of GH surrogate status. A significant increase in end weight SDS was found for the cohort (p 85th percentile was noted in 44.4% of the cohort and in 52.1% of subjects with GH axis abnormalities. Initial hyperprolactinemia was positively associated with increased end BMI SDS (p = .004). Conclusions These prospective findings confirm the high prevalence of pituitary endocrinopathies in children with ONH reported in previous retrospective studies. Our data reveal that some of these children maintain normal height velocity despite GH axis abnormalities, and, as a group, they are at high risk for increased BMI.

Background Endocrinologic abnormalities are a common co-morbidity in patients with optic nerve hypoplasia (ONH), however the impact on puberty is unknown. The purpose of this study was to examine rates of endocrine dysfunction and pubertal disturbances in a pediatric population of ONH. Methods A retrospective chart review was conducted on a cohort of children with ONH between January 2005 and March 2013. Endocrine dysfunction was determined based on laboratory evidence of hormone deficiency or hormone replacement. Pubertal disturbances were characterized based on presence of micropenis, tanner staging, menarche and hormone replacement. Pituitary abnormalities were classified using MRI findings. Descriptive statistics were used, and comparisons between groups were performed using the chi-square test. Results During the study period, 101 patients underwent an endocrine evaluation (median age: 2.3 years [0.76 – 6.5]). Hypopituitarism was present in 73% of patients with growth hormone deficiency (56%) and hypothyroidism (54%) being the most common. Pubertal disturbances (n = 19) were common; micropenis in 31% (13/42) of males and 2% with precocious puberty. Half of adolescents (n = 4/8) were diagnosed with gonadotropin deficiency. Patients with MRI pituitary abnormalities were more likely to have endocrine dysfunction than those without (p = 0.004). The sensitivity and specificity of MRI pituitary abnormalities for hypopituitarism was 54% and 92%, respectively. Conclusions A significant proportion of children with ONH have endocrine dysfunction. The high frequency of pubertal disturbances in this study emphasizes the need for long-term monitoring of developing endocrinopathy. While pituitary gland abnormalities are a good predictor of endocrine dysfunction, a normal pituitary gland does not rule out endocrinopathy.

To determine whether the ratio of optic disk diameter to disk-to-macula distance (DD/DM) in children with optic nerve hypoplasia (ONH) changes over time.Fifteen subjects (29 eyes) enrolled in a prospective registry study on ONH had fundus photography performed under the age of 24 months and again at 60 months. Using the ratio of the DD/DM method, the relative size of the optic disk was assessed twice for each photo by one masked expert examiner to determine whether any change in relative disk size occurred over time.There was no change in relative optic disk size between initial and final fundus photographs. The average (± SD) age at the time of initial and final fundus photography was, respectively, 11.6 ± 5.2 months and 60.6 ± 1.3 months. Strong concordance was noted between the average DD/DM of the initial and the final photographs (ρ=0.939; 95% CI: 0.893, 0.981). There was negligible difference between the individual time point measurements (-0.011 ± 0.03) (95% LOA: -0.07, 0.04).There were no clinically significant changes in relative optic disk size over time in children with ONH; thus, DD/DM measurements need not be adjusted by age beyond 1 year in children with this disorder.

Blunt cerebrovascular injury (BCVI) has been well described in the adult trauma literature. The risk factors, proper screening, and treatment options are well known. In pediatric trauma, there has been very little research performed regarding this injury. We hypothesize that the incidence of BCVI in children is lower than the 1% reported incidence in adult studies and that many children at risk are not being screened properly.This is a multi-institutional retrospective cohort study of pediatric patients (15 years) admitted with blunt trauma to six American College of Surgeons-verified Level 1 pediatric trauma centers between October 2009 and June 2011. All patients with head, neck, or face injuries who were high risk for BCVI based on Memphis criteria were analyzed.Of 5,829 blunt trauma admissions, 538 patients had at least one of the Memphis criteria. Only 89 (16.5%) of these patients were screened (16 patients had more than one test) by angiography (64 by computed tomography angiography, 39 by magnetic resonance angiography, and 2 by conventional angiography), while 459 (83.5%) were not screened. Screened patients differed from unscreened patients in Injury Severity Score (ISS) (22.6 ± 13.3 vs. 13.3 ± 9.9, p0.0001) and head and neck Abbreviated Injury Scale (AIS) score (3.7 ± 1.2 vs. 2.8 ± 1.2, p0.0001). The incidence of BCVI in our total population was 0.4% (23 patients). Of the 23 patients with BCVI, 3 (13%) had no risk factors for the injury. The odds of having sustained BCVI in a patient with one or more of the risk factors was 4.0 (95% confidence interval, 1.1-14.2).BCVI in Level 1 pediatric trauma centers is diagnosed less frequently than in adult centers. However, screening was performed in a minority of high-risk patients who may explain the reported lower incidence of BCVI in children. Pediatric surgeons need to become more vigilant about screening pediatric patients with high-risk criteria for BCVI.Prognostic/epidemiologic study, level III; therapeutic study, level IV.