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Incidental Findings Uncovered in Pediatric CT Scans Prove to be Significant

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A large scale study of computed tomographic (CT) scans taken in emergency departments across the country for children with head injuries depicts the pervasiveness of "incidental findings," results that were unanticipated from the injury and classifies them based on severity.

The article, titled "Incidental findings in children with blunt head trauma evaluated with cranial CT scans," was published in the August issue of Pediatrics, and offers a framework for physicians in emergency departments who come across these sort of circumstances.

"Incidental findings are a rare but significant event. It is important for doctors to look for abnormalities other than what they expect to find and to be prepared to interpret and communicate these findings to families,” said professor and chair of emergency medicine at the UC Davis Medical Center and principal investigator of the study, Nathan Kuppermann.

The study included around 44,000 children admitted for a head injury in 25 different hospital emergency departments nationwide. Almost 16,000 underwent a CT scan to determine the urgency of the injury; and around 4 percent of the scans showed incidental findings ranging from enlarged tonsils to life-threatening cancers. Children with a known pre-existing brain abnormality were not included in the analysis of the study.

The researchers also grouped the incidental findings into three different categories: 1) those that require immediate assessment or treatment, 2) those that require suitable timely outpatient follow ups, and 3) those that warranted further investigation only if the problems were causing symptoms. Only 0.1 percent of the overall samples of CTs were cast into the most serious category. 

And because of the small percentage of patients with the most severe incidental findings, the study’s researchers suggest any changes to the current CT scan guidelines. They trust that emergency medicine physicians should continue to perform CT scans in children as long as it is medically acceptable for their injury because a CT scan contains a small, yet known long-term risk of cancer from radiation exposure.

Genetic analysis, high-technology imaging studies and other tests have made it possible to retrieve information that neither the doctor nor patient expects. Knowing what to do with these findings, particularly if they are likely to be insignificant to a patient's overall health, can be somewhat of a quandary for doctors.

Yet the study’s authors believe physicians should determine what best course of action to take when coming across such incidental findings that don’t negatively affect financial cost and negative health effects on the patient via anxiety, additional testing and possibly even unnecessary treatment brought on by learning of the findings.

"Because the practice of medicine has embraced technologies that provide information beyond the actual clinical question, a need to develop strategies to handle unexpected information now exists. Particularly in the emergency room, doctors must decide quickly whether and how to disclose information to a family with whom they have no prior relationship and do not know what their response is likely to be,” said assistant professor of pediatric emergency medicine at the University of Michigan Health System and lead author of the study, Alexander Rogers.

This study is one of the largest pediatric multicenter description of the occurrence of incidental findings on head CT scans. It is also a secondary analysis of a study that was geared to establish a decision rule for determining which children who are admitted to the emergency room with a head injury should have a CT scan to assess it. The resulting Pediatric Head Injury/Trauma Algorithm has become a standard in emergency departments worldwide and has helped diminish the number of superfluous CT scans in children.

Both studies were part of the Pediatric Emergency Care Applied Research Network (PECARN), the only federally-funded pediatric emergency medicine research network. By participating in academic and metropolitan hospitals across the country, the network has access to a large number of demographically diverse populations of children being seen in various emergency departments.

"The large size of this study enhances the value and generalizability of our findings. Without the large, multicenter network provided by PECARN, we would be unable to have undertaken such a definitive study,” said Kuppermann, who was the founding chair of PECARN and served as its chair until 2008.

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