Sullivan, Georgia

OBJECTIVES: Many PICU admissions start with presentation in the emergency department (ED). However, we do not know whether there are any ED-related factors associated with the subsequent development of pediatric delirium (PD) within 24 hours of PICU admission. DESIGN: Retrospective cohort study. SETTING: Single-center ED and PICU serving a quaternary referral center in the United States. PATIENTS: Children younger than 18 years old presenting to the ED between January 2022 and December 2023 who required direct admission to the PICU, and who had at least one positive delirium screening within 24 hours of the admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The presence of delirium in the PICU was defined as a Cornell Assessment of Pediatric Delirium (CAPD) score of 9 and higher. We identified 138 patients for the final analysis. Overall, 51 of 138 patients (37%) developed PD within 24 hours of admission. The majority of delirium cases were classified as hypoactive (53%, 27/51) and mixed (31%, 16/51) subtypes, while only 16% (8/51) were identified as hyperactive delirium. Factors associated with greater odds (95% CI) of delirium in the PICU in multivariable analysis were use of mechanical ventilation (odds ratio [OR], 3.42 [95% CI, 1.09–10.78]; p = 0.04) and intermittent urinary catheterization (OR, 3.7 [95% CI, 1.21–11.30]; p = 0.02). Initial CAPD score positively correlated with PICU length of stay (LOS; r = 0.32; p < 0.01), Pediatric Index of Mortality 3 (PIM 3) score ( r = 0.26; p < 0.01), and negatively correlated with emergency severity index (ESI) in the ED ( r = –0.35; p < 0.01). CONCLUSIONS: Mechanical ventilation and intermittent urinary catheterization in the ED are associated with greater odds of PD within 24 hours of PICU admission. CAPD at admission positively correlates with PICU LOS, PIM 3 scores, and negatively correlates with ESI in the ED.

ABSTRACTBackground and ObjectivesMedicaid reimbursement to physicians has been demonstrated to be lower than reimbursement from Medicare and private insurance. Studies on Medicaid reimbursement for orthopedic oncology procedures, however, are limited. This study compares Medicaid reimbursement rates to Medicare for 38 common musculoskeletal oncology procedures and assesses variability among states.MethodsWe collected 38 current procedural terminology (CPT) codes for commonly performed orthopedic oncology procedures. Medicare rates were obtained from the 2023 Centers for Medicare and Medicaid physician (CMS) fee schedule. Medicaid rates were collected from electronic state website fee schedules. Reimbursement for the two insurance types were compared with state and national averages. Dollar differences were adjusted for work relative value units (RVU) to ascertain procedural variability. The Medicare Wage Index, representing differences in wages across states, was used to adjust medicaid rates to compare more accurately to medicare. Coefficient of variation values, calculated by dividing the standard deviation by the mean, were calculated to assess variation among procedures.ResultsMedicaid reimbursed orthopedic oncologists 22.1% less than medicare on average, increasing to 33.0% when adjusting for wage differences. State Medicaid reimbursement ranged from 37% to 131% of Medicare, with 38 states reimbursing less than Medicare on average. The coefficient of variation for Medicaid procedures ranged from 0.24 to 0.46, indicating wide variability among states and procedures, while for Medicare, the coefficient of variation was low at 0.06 to 0.07.ConclusionsMedicaid reimbursement for common orthopedic oncology procedures is substantially lower and more variable than Medicare, despite the often urgent nature of these surgeries. Disparities in reimbursement may impact access to care for this population, highlighting the need for policy reform.

Background: Because of growing concerns regarding repeated head trauma, in 2016, the United States Soccer Federation (USSF) banned headers for athletes aged ≤10 years and limited athletes aged 11 to 13 years to practicing headers for 30 minutes per week. Purpose: To assess whether the USSF header policy was associated with fewer soccer-related concussions after the 2015 season. Study Design: Descriptive epidemiology study. Methods: A retrospective cohort from the National Electronic Injury Surveillance System database was assessed. Age, sex, and injury type were extracted for all soccer-related emergency department visits between January 1, 2012, and December 31, 2023. Univariate and multiple regression analyses were used to assess concussions as a percentage of all soccer-related injuries based on sex, age group (6-9, 10-13, and 14-17 years), and year. The following time frames were assessed: 2012-2015, 2016-2019, and 2020-2023. Results: The proportion of concussions decreased from 8.2% of all soccer-related injuries in 2012-2015 to 6.1% in 2020-2023 ( P < .01). The relative risk reduction for soccer-related concussions presenting to an emergency department in 2020-2023 compared with 2012-2015 was 25.6%. Overall, the proportion of concussions among 10- to 13-year-old and 14- to 17-year-old players was higher than for 6- to 9-year-old players (6.6% and 8.9% vs 4.9%, respectively; P < .01). Despite having a lower frequency of soccer-related injuries overall, female players had a greater proportion of concussions than male players (9.6% vs 6.2% of all soccer-related injuries; P < .01). In the multiple regression analysis, injuries that occurred in 2020-2023 were associated with lower odds of concussion compared with 2012-2015 (odds ratio [OR], 0.75 [95% CI, 0.69-0.81]). Compared with 6- to 9-year-old and male players, the 10- to 13-year-old (OR, 1.30 [95% CI, 1.16-1.45]), 14- to 17-year-old (OR, 1.79 [95% CI, 1.61-1.99]), and female players (OR, 1.53 [95% CI, 1.43-1.63]) were associated with higher odds of concussion. Conclusion: A 25.6% reduction in the relative risk of presenting to the emergency department with a soccer-related concussion was found when comparing 2020-2023 (after USSF header policy implementation) with 2012-2015 (before policy implementation). The USSF youth soccer header policy may improve player safety by reducing head impacts in the pediatric population.

Purpose To systematically review the relationship between functional testing at the time of return to sport (RTS) and short‐term outcomes, such as second anterior cruciate ligament (ACL) tear and return to a preinjury level of sport, among athletes who underwent anterior cruciate ligament reconstruction (ACLR). Methods A systematic literature search was performed in MEDLINE, EMBASE, Scopus, and Web of Science to identify studies examining athletes who underwent functional RTS testing and were followed for at least 12 months following ACLR. Studies were screened by 2 reviewers. A standardized template was used to extract information regarding study characteristics, ACLR information, functional test results, and risk factors associated with retear or reduced RTS. Results Of the 937 studies identified, 22 met the inclusion criteria. The average time between ACLR and RTS testing was 8.5 months. Single leg hop for distance performance had no association with retear risk in any study and no association with RTS rates in most studies. Quadriceps strength had conflicting results in relation to retear risk, whereas it had no relationship with RTS rates. Rates of reinjury and RTS were similar between patients who passed and did not pass combined hop and strength batteries. Asymmetric knee extension and hip moments, along with increased knee valgus and knee flexion angles, demonstrated increased risk of retear. Conclusions Individual hop and strength tests that are often used in RTS protocols following ACLR may have limited and inconsistent value in predicting ACL reinjury and reduced RTS when used in isolation. Combined hop and strength test batteries also demonstrate low sensitivity and negative predictive value, highlighting conflicting evidence to suggest RTS testing algorithm superiority. Level of Evidence Level IV, systematic review of Level I‐IV studies.