External validation of clinical decision rules for children with wrist trauma

Background: Clinical decision rules help to avoid potentially unnecessary radiographs of the wrist, reduce waiting times and save costs. Objective: The primary aim of this study was to provide an overview of all existing non-validated clinical decision rules for wrist trauma in children and to externally validate these rules in a different cohort of patients. Secondarily, we aimed to compare the performance of these rules with the validated Amsterdam Pediatric Wrist Rules. Materials and methods: We included all studies that proposed a clinical prediction or decision rule in children presenting at the emergency department with acute wrist trauma. We performed external validation within a cohort of 379 children. We also calculated the sensitivity, specificity, negative predictive value and positive predictive value of each decision rule. Results: We included three clinical decision rules. The sensitivity and specificity of all clinical decision rules after external validation were between 94% and 99%, and 11% and 26%, respectively. After external validation 7% to 17% less radiographs would be ordered and 1.4% to 5.7% of all fractures would be missed. Compared to the Amsterdam Pediatric Wrist Rules only one of the three other rules had a higher sensitivity; however both the specificity and the reduction in requested radiographs were lower in the other three rules. Conclusion: The sensitivity of the three non-validated clinical decision rules is high. However the specificity and the reduction in number of requested radiographs are low. In contrast, the validated Amsterdam Pediatric Wrist Rules has an acceptable sensitivity and the greatest reduction in radiographs, at 22%, without missing any clinically relevant fractures

The Amsterdam wrist rules: The multicenter prospective derivation and external validation of a clinical decision rule for the use of radiography in acute wrist trauma

Background: Although only 39 % of patients with wrist trauma have sustained a fracture, the majority of patients is routinely referred for radiography. The purpose of this study was to derive and externally validate a clinical decision rule that selects patients with acute wrist trauma in the Emergency Department (ED) for radiography. Methods: This multicenter prospective study consisted of three components: (1) derivation of a clinical prediction model for detecting wrist fractures in patients following wrist trauma; (2) external validation of this model; and (3) design of a clinical decision rule. The study was conducted in the EDs of five Dutch hospitals: one academic hospital (derivation cohort) and four regional hospitals (external validation cohort). We included all adult patients with acute wrist trauma. The main outcome was fracture of the wrist (distal radius, distal ulna or carpal bones) diagnosed on conventional X-rays. Results: A total of 882 patients were analyzed; 487 in the derivation cohort and 395 in the validation cohort. We derived a clinical prediction model with eight variables: age; sex, swelling of the wrist; swelling of the anatomical snuffbox, visible deformation; distal radius tender to palpation; pain on radial deviation and painful axial compression of the thumb. The Area Under the Curve at external validation of this model was 0.81 (95 % CI: 0.77-0.85). The sensitivity and specificity of the Amsterdam Wrist Rules (AWR) in the external validation cohort were 98 % (95 % CI: 95-99 %) and 21 % (95 % CI: 15 %-28). The negative predictive value was 90 % (95 % CI: 81-99 %). Conclusions: The Amsterdam Wrist Rules is a clinical prediction rule with a high sensitivity and negative predictive value for fractures of the wrist. Although external validation showed low specificity and 100 % sensitivity could not be achieved, the Amsterdam Wrist Rules can provide physicians in the Emergency Department with a useful screening tool to select patients with acute wrist trauma for radiography. The upcoming implementation study will further reveal the impact of the Amsterdam Wrist Rules on the anticipated reduction of X-rays requested, missed fractures, Emergency Department waiting times and health care costs. Trial registration: This study was registered in the Dutch Trial Registry, reference number NTR2544 on October 1st, 2010

A clinical decision rule for the use of plain radiography in children after acute wrist injury: development and external validation of the Amsterdam Pediatric Wrist Rules

Background: In most hospitals, children with acute wrist trauma are routinely referred for radiography. Objective: To develop and validate a clinical decision rule to decide whether radiography in children with wrist trauma is required. Materials and methods: We prospectively developed and validated a clinical decision rule in two study populations. All children who presented in the emergency department of four hospitals with pain following wrist trauma were included and evaluated for 18 clinical variables. The outcome was a wrist fracture diagnosed by plain radiography. Results: Included in the study were 787 children. The prediction model consisted of six variables: age, swelling of the distal radius, visible deformation, distal radius tender to palpation, anatomical snuffbox tender to palpation, and painful or abnormal supination. The model showed an area under the receiver operator characteristics curve of 0.79 (95% CI: 0.76-0.83). The sensitivity and specificity were 95.9% and 37.3%, respectively. The use of this model would have resulted in a 22% absolute reduction of radiographic examinations. In a validation study, 7/170 fractures (4.1%, 95% CI: 1.7-8.3%) would have been missed using the decision model. Conclusion: The decision model may be a valuable tool to decide whether radiography in children after wrist trauma is required

Incidence of biopsy-proven bone tumors in children - A report based on the dutch pathology registration "PALGA"

Introduction: Data on childhood bone tumors are mainly confined to reports on malignant tumors or on institutional registries. Incidence figures on both benign and malignant bone tumors in childhood are lacking. Methods: From January 1999 to December 2003, 1474 newly diagnosed bone tumors in children up to 18 years were registered in Pathologisch Anatomisch Landelijk Geautomatiscerd Archief (the nationwide network and registry of histopathology and cytopathology in The Netherlands). Data provided were diagnosis, date of birth, age at diagnosis, and localization. For incidence calculations, data on age and sex in each year of investigation were obtained from the StatLine database of Statistics Netherlands (www.cbs.nl). Results/Conclusions: Incidence of pathology-proven bone tumors in children is low. Incidence of pathology-proven bone tumors in The Netherlands is 79.3 per 1,000,000. From the very first year of life, incidence increases from 3.9 per 1,000,000 to a peak at 13 to 15 years of 142.9 per 1,000,000. Osteochondromas are the most prevalent tumors, followed by aneurysmal bone cysts. The overall incidence is higher for male compared with female patients, mainly due to different frequencies found in aneurysmal bone cysts, Ewing sarcoma, and osteochondroma. Shifts in incidence differ among the various tumors. In infants, bone tumors are mainly chondromas and fibrous dysplasia, which both show a steady increase at older ages. Tumors most prevalent at older ages are osteochondromas, osteosarcomas, osteoid osteomas, and chondromas. A peak incidence at approximately the age of 10 is noted for solitary bone cysts, nonossifying fibromas, and osteoblastomas. Small children more often have localizations in the skull and facial bones. Comparison with literature data showed significant differences due to referral-based institutionally bias, whereas tumor registries only give data for specific tumor type

Qualitative analysis of studies concerning quality of life in children and adults with anorectal malformations

Anorectal malformations are relatively common congenital anomalies in pediatric surgery. After definitive surgery constipation, soiling, and fecal incontinence are frequently seen problems. Quality of life (QoL) can be influenced by these problems. In the last decades QoL has become an important aspect in the treatment and follow-up of patients with anorectal malformations. This has resulted in various reports concerning QoL. In order to deduce whether the drawn conclusions in the different studies are correct and can be used to adjust standard care for patients with ARM, a qualitative analysis of the studies was performed. A literature study was performed in PubMed, Psychinfo, Web of Science, and the Cochrane Library (240 hits). Thirty articles were used, following application of our inclusion criteria and in-depth analysis of the articles. A methodological qualitative analysis was also performed and QoL outcome assessed. Six authors (20.0%) used validated QoL questionnaires. Four articles were longitudinal and had more than one measure moment. Eleven studies (36.7%) used only non-validated questionnaires, and eight studies (26.6%) used only validated questionnaires. Nineteen studies correlated fecal continence to QoL, and seven studies established no correlation. Three of these seven studies used validated QoL questionnaires. All twelve studies, which did establish a correlation, used non-validated QoL questionnaires. Approximately 83% of the studies had not used validated QoL questionnaires. Further, conclusions concerning QoL were often based on functional outcomes, for example fecal incontinence. So far, longitudinal high quality research on QoL in this group has not been achieve

Results of Diagnostic Review in Pediatric Bone Tumors and Tumorlike Lesions

Background: Histological examination of bone tumors is one of the most difficult subjects in pathology. In this manuscript, correctness of initial histological diagnosis in pediatric bone tumors and tumorlike lesions was investigated. Procedure: All 262 bone tumor specimens of children up to the age of 19 years reviewed from 1999 to 2003 by the Netherlands Committee on Bone Tumors were included. Initial diagnosis and diagnosis after review were compared. Results: Only 60% of original diagnoses proved to be correct. After classification according to the main categories of the World Health Organization classification, only 75% of tumors were correctly categorized. Thirteen of the 60 malignant tumors were not recognized as malignant. Seven of 198 benign lesions were reclassified as malignant. kappa Values were indicative for good agreement in the (by the Ministry of Health designated) bone tumor centers. For nondesignated hospital kappa values, a substantial lower level of agreement was noted. Agreement was almost perfect in Ewing/primitive neuroectodermal tumors. For cartilaginous, osteogenic, and fibrous tumors, agreement was lower. Adamantinomas were not recognized in non-bone tumor centers. For the remaining group composed of miscellaneous tumors, poor levels of agreement were noted. Conclusions: We conclude that correct diagnosis of childhood bone tumors requires review by a multidisciplinary team of experts. Specifically in non-bone tumor centers, the correctness of the initial diagnosis can be questione

Triage tools for detecting cervical spine injury in pediatric trauma patients

This is the protocol for a review and there is no abstract. The objectives are as follows: This review aims to determine the diagnostic accuracy of the NEXUS criteria and the Canadian C-spine rule in a pediatric population evaluated for CSI following blunt trauma

Triage tools for detecting cervical spine injury in pediatric trauma patients

Pediatric cervical spine injury (CSI) after blunt trauma is rare. Nonetheless, missing these injuries can have severe consequences. To prevent the overuse of radiographic imaging, two clinical decision tools have been developed: The National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule (CCR). Both tools are proven to be accurate in deciding whether or not diagnostic imaging is needed in adults presenting for blunt trauma screening at the emergency department. However, little information is known about the accuracy of these triage tools in a pediatric population. To determine the diagnostic accuracy of the NEXUS criteria and the Canadian C-spine Rule in a pediatric population evaluated for CSI following blunt trauma. We searched the following databases to 24 February 2015: CENTRAL, MEDLINE, MEDLINE Non-Indexed and In-Process Citations, PubMed, Embase, Science Citation Index, ProQuest Dissertations & Theses Database, OpenGrey, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment, and the Aggressive Research Intelligence Facility. We included all retrospective and prospective studies involving children following blunt trauma that evaluated the accuracy of the NEXUS criteria, the Canadian C-spine Rule, or both. Plain radiography, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and follow-up were considered as adequate reference standards. Two review authors independently assessed the quality of included studies using the QUADAS-2 checklists. They extracted data on study design, patient characteristics, inclusion and exclusion criteria, clinical parameters, target condition, reference standard, and the diagnostic two-by-two table. We calculated and plotted sensitivity, specificity and negative predictive value in ROC space, and constructed forest plots for visual examination of variation in test accuracy. Three cohort studies were eligible for analysis, including 3380 patients ; 96 children were diagnosed with CSI. One study evaluated the accuracy of the Canadian C-spine Rule and the NEXUS criteria, and two studies evaluated the accuracy of the NEXUS criteria. The studies were of moderate quality. Due to the small number of included studies and the diverse outcomes of those studies, we could not describe a pooled estimate for the diagnostic test accuracy. The sensitivity of the NEXUS criteria of the individual studies was 0.57 (95% confidence interval (CI) 0.18 to 0.90), 0.98 (95% CI 0.91 to 1.00) and 1.00 (95% CI 0.88 to 1.00). The specificity of the NEXUS criteria was 0.35 (95% CI 0.25 to 0.45), 0.54 (95% CI 0.45 to 0.62) and 0.2 (95% CI 0.18 to 0.21). For the Canadian C-spine Rule the sensitivity was 0.86 (95% CI 0.42 to 1.00) and specificity was 0.15 (95% CI 0.08 to 0.23). Since the quantity of the data was small we were not able to investigate heterogeneity. There are currently few studies assessing the diagnostic test accuracy of the NEXUS criteria and CCR in children. At the moment, there is not enough evidence to determine the accuracy of the Canadian C-spine Rule to detect CSI in pediatric trauma patients following blunt trauma. The confidence interval of the sensitivity of the NEXUS criteria between the individual studies showed a wide range, with a lower limit varying from 0.18 to 0.91 with a total of four false negative test results, meaning that if physicians use the NEXUS criteria in children, there is a chance of missing CSI. Since missing CSI could have severe consequences with the risk of significant morbidity, we consider that the NEXUS criteria are at best a guide to clinical assessment, with current evidence not supporting strict or protocolized adoption of the tool into pediatric trauma care. Moreover, we have to keep in mind that the sensitivity differs among several studies, and individual confidence intervals of these studies show a wide range. Our main conclusion is therefore that additional well-designed studies with large sample sizes are required to better evaluate the accuracy of the NEXUS criteria or the Canadian C-spine Rule, or both, in order to determine whether they are appropriate triage tools for the clearance of the cervical spine in children following blunt traum

Plain radiography in children with spoke wheel injury: A retrospective cohort study

Bicycle spoke injury (BSI) mostly occurs in children as a result of entrapment of the leg in the bicycle spokes. No guideline or protocol exists that defines what type of radiography is indicated to diagnose or rule out a fracture commonly associated with these injuries. The aim of this study was (1) to evaluate the type of radiographs that are obtained in children with BSI, (2) to assess in which anatomical regions fractures occur and (3) to evaluate on which radiographs a fracture can be detected in children with BSI. A retrospective cohort study was performed in paediatric patients presenting at the Emergency Department (ED) of a university hospital with a paediatric surgery department between June 2008 and December 2013. In 99 of the 320 children (31.4%) evaluated with radiography following BSI a fracture was diagnosed. In almost two third of the patients (63%) radiographic imaging of two or more anatomical regions was performed. In 98 children (99%) the fracture was located at the distal tibia or fibula. All fractures were diagnosed on a radiograph of the ankle or lower leg (including the ankle region). No fractures of the foot were diagnosed. We suggest that in children with a clinical suspicion of a fracture at the ankle region, in which no fracture is seen at the radiograph of the ankle, no additional radiographs are necessar