A staged US and CT imaging protocol in which US is performed first in children suspected of having acute appendicitis is highly accurate and offers the opportunity to substantially reduce radiation.

The survival advantage for patients transferred who received treatment was eclipsed by increased mortality of the transfer process. Including 17% of transferred patients who died without receiving definitive repair, mortality was increased for patients transferred for rAAA repair compared with those not transferred after adjusting for demographic, clinical, and hospital factors. Transferred patients used significantly more hospital resources. Improving systems and guidelines for interfacility transfer may further improve the outcomes for these patients and decrease associated hospital resource utilization.

No abstract

Background Trauma centers (TC) have been shown to decrease mortality in adults, but this has not been demonstrated at a population-level in all children. We hypothesized that seriously injured children would have increased survival in a TC vs. non-trauma center (nTC), but there would be no increased benefit from pediatric-designated vs. adult TC care. Methods This was a retrospective study of the unmasked California Office of Statewide Health and Planning Department patient discharge database (1999–2011). International Classification of Disease, Ninth Revision (ICD-9) diagnostic codes indicating trauma were identified for children (0–18) and injury severity was calculated from ICD-9 codes using validated algorithms. To adjust for hospital case mix, we selected patients with ICD-9 codes that were capable of causing death, and which appeared at both TCs and nTCs. Instrumental variable analysis using differential distance between the child’s residence to a trauma center and to the nearest hospital was applied to further adjust for unobservable differences in TC and nTC populations. IV regression models analyzed the association between mortality and TC vs. nTC care, as well as for pediatric vs. adult TC designations, adjusting for demographic and clinical variables. Results Unadjusted mortality for the entire population of children with nontrivial trauma (n=445,236) was 1.2%. In the final study population (n=77,874), mortality was 5.3%; 3.8% in nTCs and 6.1% in TCs. IV regression analysis demonstrated a 0.79 percentage point (95% CI −0.80 to −0.30; p=.044) decrease in mortality for children cared for in TC vs. nTC. No decrease in mortality was demonstrated for children cared for in pediatric vs. adult TCs. Conclusion Our IV TC outcome models use improved injury severity and case mix adjustment to demonstrate decreased mortality for seriously injured California children treated in TCs. These results can be used to take evidence-based steps to decrease disparities in pediatric access to, and subsequent outcomes for, trauma care. Level of Evidence Level III Therapeutic/Care Management.

No abstract

We view our study as a fundamental part of the incremental progress to understand how best to use US and CT imaging to diagnose pediatric appendicitis while minimizing ionizing radiation. Children at low risk for appendicitis with equivocal US are amenable to observation and reassessment prior to reimaging with US or CT.

No abstract

Djenkolism is an uncommon but important cause of acute kidney injury. It sporadically occurs after an ingestion of the djenkol bean (Archidendron pauciflorum), which is native to Southeast Asia. The clinical features defining djenkolism include: spasmodic suprapubic and/or flank pain; urinary obstruction; and acute kidney injury. The precise pathogenesis of acute kidney injury following djenkol ingestion remains unknown. However, it is proposed that an interaction between the characteristics of the ingested beans and the host factors causes hypersaturation of djenkolic acid crystals within the urinary system, resulting in subsequent obstructive nephropathy with sludge, stones, or possible spasms. We report a case of djenkolism from our rural clinic in Borneo, Indonesia. Our systematic literature review identified 96 reported cases of djenkolism. The majority of patients recovered with hydration, bicarbonate therapy, and pain medication. Three patients required surgical intervention; one patient required ureteral stenting for the obstructing djenkolic acid stones. Four of the 96 reported patients died from acute kidney failure. We stress the importance of awareness of djenkolism to guide medical practitioners in the treatment of this rare disease in resource-poor areas in Southeast Asia.