In mechanically ventilated pediatric patients divided by hospital volume quartiles, all three higher volume groups had lower mortality than the lowest volume group.

Although we were able to conduct this analysis in our systematic review as we included 11 studies, we decided against it. The main reason was based on several publications that suggest, due to statistical heterogeneity and other factors, the minimum number of studies to apply the test proposed by Egger et al (3) for evaluating for funnel plot asymmetry should be at least 25 (4, 5).Overall, this article is an excellent example that our systematic review presents data transparently. This allows readers to evaluate the body of evidence and form their own opinions.

Repeat head computed tomography (RHCT) is common and routine for pediatric traumatic brain injury (TBI) patients. In mild (Glasgow Coma Scale; GCS 13-15) to moderate (GCS 9-12) TBI, recent studies have shown that RHCT without clinical deterioration does not alter management. However, the effectiveness of routine RHCT for pediatric TBI patients under 2 years has not been investigated. This study aims to investigate whether routine RHCT changes management in mild-to-moderate TBI patients under 2 years. We performed a retrospective review at the emergency department of the National Center for Child Health and Development between January 2015 and December 2019. Mild-to-moderate TBI patients under 2 years with an acute intracranial injury on initial head CT scan and receiving follow-up CT scans were included. Mechanism, severity of TBI, indication for RHCT, and their findings were listed. Study outcome was intervention based on the findings of RHCT. Intervention was defined as intubation, ICP monitor placement, or neurosurgery. We identified 50 patients who met inclusion criteria and most patients (48/50) had mild TBI. The most common mechanism was 'fall' (68%). Almost all RHCT was routine and the overall incidence of radiographic progression on RHCT was 12%. RHCT without clinical deterioration did not lead to intervention, although one patient with moderate TBI required intervention due to radiographic progression with clinical symptoms. Our study showed that routine RHCT without clinical deterioration for mild TBI patients under 2 years may not alter clinical management. We suggest that RHCT be considered when there is clinical deterioration such as decrease in GCS.

Background A prolonged interval between onset of symptoms and diagnosis of childhood brain tumor is associated with worse neurological outcomes. Objectives of this study are to determine factors contributing to diagnostic delay and to find an interventional focus for further reduction in the interval between symptom onset and diagnosis in Japan. Methods We retrospectively analyzed 154 patients less than 18 years old with newly diagnosed brain tumors who visited our institution from January 2002 to March 2013. Results The median age at diagnosis was 6.2 years and the median total diagnostic interval (TDI) was 30 days. Patients with low-grade tumors and cerebral midline tumor location had significantly long TDI. Durations between the first medical consultation and diagnosis (diagnostic interval, DI) were exceedingly longer for patients with visual, hearing, or smell abnormalities as the first symptom (median 303 days). TDI and DI of patients who visited to ophthalmologists or otolaryngologist for the first medical consultation were significantly longer. Among these patient, longer DI was associated with worse visual outcome. Conclusion Raising awareness of brain tumor diagnosis among ophthalmologists and otolaryngologist may reduce diagnostic delay and may improve the neurological impairment of children with brain tumors in Japan. (197 words)