Concussions, Appendicitis, Forearm Fractures – PediaCast 217

Join Dr Mike in the PediaCast Studio for another Research Round-Up! This week we discuss published articles on the following topics: predicting long-term concussion symptoms for football players, rapid vs interval appendectomy for children with perforated appendicitis, and conservative management of displaced and overriding distal radius fractures. If these terms sound complex or confusing, never fear… We always break it down so moms and dads can understand!


  • Predicting Long-Lasting Symptoms of Concussion

  • Treatment of Ruptured Appendicitis

  • Management of Childhood Forearm Fractures



Announcer 1: This is PediaCast.


Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!

Mike Patrick: Hello everyone! And welcome once again to PediaCast, a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the the campus of Nationwide Children's Hospital. We are in Columbus, Ohio, and it is episode 217, 2-1-7, for June 27th, 2012.

We're calling this one concussion, appendicitis, and forearm fractures. Now this is actually going to be a research round up show, and we haven't done one of these in several months.

So for those of you who are new to the program, our research round up shows they go something like this; we take recently published study from the World of Pediatric Research.


We explain the background, define some terms, sort of get you up to speed so that you can understand exactly what it is that we're talking about. Kind of demystified the science in that way. And then we explain what the researchers did, we talk about the results, and then put a little life application spin in there for you -the parent, so you can get a little something out of it, and to help you understand the science a little better.

So some of these -it's not necessarily direct application to your life on a daily basis like some of our shows are. But for those of you who are a little more science-minded, these are kind of fun shows to really sort of break apart science a little bit and talk about some research studies.

We don't do -maybe once a quarter, that's how often we do it. So it's not a weekly or monthly thing. But I think the last time we did when was back in February and the time before that was November.


So just a little fun and switching things up a little bit. And I do think that the topics that we're talking about today, the each individual article, they are pretty interesting. I gave you a little hint in the title of the program, concussions, appendicitis, forearm fractures.

But let's get a little bit more specific; concussion we're talking about concussion that follows after you have a head injury. And we did an entire show dedicated to concussion, it was back episode number 177, I think it was last summer that we did that. And still up to date and current, we'll put a link to that particular episode in the show notes for this one 217, so you can fine it easily.

Also since that time we've discussed -there was another research article we looked at in terms of how long concussion symptoms last. And the article that we talked about with that showed that some concussion symptoms can actually linger for like a year after the concussion in some situations.


But here's what we haven't looked at in the past, what if immediately after a concussion, and with these particular study we're going to look at football players. What if immediately after a concussion while the student athlete is still on the field, does the presence or absence of any specific sign or symptom such as loss of consciousness, headache, vomiting, dizziness, and amnesia -things like that.

Based on the presence or absence of certain symptoms, can we predict who will recover quickly, and who will have those lingering symptoms of concussion that can last weeks, months, or even out past a year. So this one actually is definitely applicable to parents as we head into summer and football conditioning begins in the weeks ahead.


So we're going to talk about that and we'll get some answers for you. And then we're going to move on to appendicitis, and in particular perforated appendicitis. Now, if you don't know what perforated appendicitis means, stay tune, we'll define and explain it for you.

The questions for the researchers with this one is, "If the appendix ruptures, does it matter if you take it out right away or can you treat the infection and take the appendix out few weeks down the road?" And another thought, "Could you just leave the appendix in and not take it out at all, and only treat the infection?"

In other words, do you need surgery if you're having a perforated appendicitis? So the answer to this may or may not surprise you, depending on if you are in the know, but definitely interesting. And I could say for most parents out there, I think you'll be a little surprise about the answer.

What about forearm fractures? These are very common in kids especially during warm weather months. And we're going to define some different types of forearm fractures for you.


Kind of break down the meaning of some anatomical and orthopedic terms, that way we're on a level playing field and can discuss the research together. And in this study in particular, I find very fascinating because it really sort of turns standard traditional treatment for some of these fractures on its head.

Are we doing too much? Do we really need to sedate kids and manipulate the arm so the bones line up perfectly before e apply a cast. What if you just put the cast on and let the bone heal as is, you'd certainly save a lot of money, you'd save exposure to sedation medication. But what about healing? What about function? What about complications?

Again, the answers may or may not surprise you. So that's all coming your way soon. But first I do want to remind you about a couple of things, the Autism Speaks National Conference for Families and Professionals is coming to Columbus, Ohio on August 3rd and 4th of this year.


It's going to be at the Hilton Columbus Easton, and it's brought to you by Autism Speaks, Nationwide Children's Hospital, the Ohio State University's Wexner Medical Center, the Health Resources and Services Administration of the U.S. Department of Health and Human Services, and The American Academy of Pediatrics.

So as I mentioned before, this conference is a big deal, great workshops, and speakers. We have separate tracks designed for families and professionals. And topic includes immune and metabolic dysfunction, gastrointestinal disorders, seizures, sleep issues, medical management, challenging behaviors, transition planning, and coordinating care between doctors and other professional providers.

So here's a cool thing, since Nationwide Children's Hospital is a sponsor, we have access to some free family vouchers, meaning you don't have to pay for the conference, it would be free. Now, you got to pay to get here, and for your overnight hotel.


But if you're in Central Ohio, you don't need those expenses, it would be really cheap for you because we do have some family vouchers. But here's the catch, I only have a limited number of these available. So if you are interested, make sure you head over to our contact page at, let me know of your interest and how we can contact you.

And as long as you hurry and we have vouchers left, then we'll get them into your hands. For more information about the conference itself, just head over to the show notes for this episode number 217,, and we'll have a link for you to the conference page so you can take a look at the speakers, and see what the tracks look like and decide if this is something that you would like to do.

I also want to remind you that if there's a topic you would like us to discuss, or you have a question for me, just really be an interactive part of this program, it's easy to do, just head over to, you can click on the contact link.


You can also email, or call the voice line at 347-404-KIDS, that's 347-404-K-I-D-S. If you do go that route and email us or use the voice line to leave a message instead of going through the contact page, just make sure you let us know your name, and where you're from. We always appreciate knowing those things.

Also want to remind you the information presented in PediaCast is for general educational purposes only, we do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, make sure you call your doctor and arrange a face to face interview and hands on physical examination.

Also your use of this audio program is subject to the PediaCast terms of use agreement which you can find at Al right. We are going to take a quick break and we'll be back with our research round up right after this.



Mike Patrick: All right. We are back. I'd like to welcome you to the program. So our first research article that we're going to be looking at, concussion, symptoms, and football players; is there some way to predict how long these are going to last?

And this is research that comes out of the University of Pittsburgh, it was published in the American Journal of Sports Medicine in November 2011, so not that long ago. And we do have a link to the pub-med abstract of this article. So it's a summary of med, although there are links there where you could go to get the full article.


Now a lot of times these articles aren't free, you have to pay to read them because they are in scientific journals, and the journals have to make money to cover their printing cost. And so, a lot of times this aren't available in terms of the full text, but it's usually not very expensive.

And if you are interested in reading the entire study, you can go that there, but at least the abstracts are available on pub-med, and we'll have a link for all of these studies in the show notes over at

All right. So we always start with, what is the question before the researchers? And for this particular study, the question was; among high school football players, which onfield -so immediately after the concussion, signs and symptoms are predictive or protracted which they define as greater than three weeks versus rapid, which they define as less than seven days recovery of all sports related concussion symptoms.


So among high school football players which onfield signs and symptoms are predictive of protracted versus rapid after they have a concussion. They looked at 176 male, high school football players, no powder puffers in the study, their mean age was 16 years, and they were all from the state of Pennsylvania.

And they were all diagnosed with a sports related concussion by a trained sports medical professional. This could be a certified athletic trainer, or a team physician. And they were all diagnosed on the field immediately after the head injury occurred, and this was during the pre-season or during the regular season between 2002 and 2006.

On field signs and symptoms observed and documented by the sports medicine professional at the time of injury included confusion, headache, loss of consciousness, amnesia, imbalance, dizziness, visual problems, personality changes, fatigue, sensitivity to light, sensitivity to noise, numbness, and vomiting.


So this all makes sense, I'm not sure if it's immediately after the head injury and the kids are still on the field, if they're really going to have fatigue. But the rest of them makes sense, and so basically it was a checklist.

And so the athletic trainer or the team physician would say, "Whoop! You just hit your head. I want to know whether you have these things or not." So the other thing that they did is each participant completed the immediate post concussion assessment and cognitive test also known as IMPACT, and they did this in an average of 2.4 days after the injury.

So we have the checklist, and then a couple of days later we have these IMPACT study which is another way to sort of assess if a concussion is there or not. Each player was then followed by a neuropsychologist from the study team until they were given clearance for return to play, based on International Clinical concussion Management Guidelines.


So they're going to follow these player, first we're going to say , "Do you have a concussion or don't you?" If you do have a concussion, what symptoms were present on the field, and then we're going to follow you and see how long those symptoms last and when you can return to play.

And then we'll look back at the list of symptoms and say, "For those who – the concussion symptoms lasted a long time, what was going on in the field that could maybe help us better predict which kids are going to have long term concussion symptoms versus those who are going to get better rapidly.

All right. So 69 of the participants which is 40% of them were actually lost to follow up, or they did not return to football during the season in which they were injured. So that just goes to show you that a lot of kids with concussions, the symptoms do last a long time and they don't make it back to play.


So the end result of these really was how long did it take them to get back to play? And so if they didn't get back to play for a year because the football season ended, then those kids were considered lost to follow up. So we lose 40% right of the bat, but that left 107 student athlete still left to study, so that's all right.

And on those 107 students, 62 experienced rapid recovery of their symptoms, meaning they were better in seven days or less with complete resolution of their symptoms. And 36 experienced protracted recovery, and that was again defined by the concussion symptoms lasted greater than three weeks.

Nine of them experienced intermediate recovery, so somewhere between one and three weeks is when they recovered. And they were dropped from the study because they really wanted to see what is the difference in terms of the symptoms on the field between rapid recovery and protracted recovery.


So they kind of get rid of that gray zone of the kids who recovered between one and three weeks. All right. Now incidentally, and this is important there were no significant differences between the rapid and the protracted guard to pre-injury history of headaches, migraine, ADHD, learning disability, or more than one previous concussion.

So they didn't want there really to be mitigating circumstances that beside the head injury itself might lead to prolonged concussion like symptoms. So again, no difference between the two groups in terms of pre-injury headache, migraine, ADHD, learning disabilities, or more than one previous concussion in the past.

All right. So let's take a look at the two groups and see what kind of differences we find. With the mean recovery time for the rapid group was 4.31 days, so that's the mean time it took for the kids in the rapid group to have their concussion symptoms completely go away.


In the protracted the mean recovery time was 29.61 days, so the rapid group was just four days or so they got better, the protracted group it took them a whole month to get better. So there's definitely something different going on between these two groups.

And so again if we can predict based on onfield symptoms immediately after the head injury, whether you're going to get better in four days, or whether you're going to get better in a month, that certainly would be something that is helpful. The most common onfield symptom and this is looking at both groups, was headache.

So 94.9% of all the kids with head injuries on the football field immediately complained of headache. so if it's something that you know, is that universal, it's not going to help you out because the kids in the rapid recovery group and the protracted group, they all have headache so that's not going to help you out.


The least common onfield symptom and this was also among both groups was loss of consciousness. And loss of consciousness was 13.3% which still seems pretty high to me. When a kid gets knocked in the head and they're laying unconscious on the field, that's a pretty dramatic thing for both the play on the field and the folks in the stand, and the parents in the stands, it kind oft raises your heart rate a little bit if the kids out there are not responding at all.

So 13.3% of the kids with head injuries playing football did have loss of consciousness. So the question becomes, did loss of consciousness predict those protracted recovery? And if you got a knocked out because of your head injury on the field, was that a good predictive thing in terms of the symptoms are going to last for a month rather than four days. And the answer is, No it didn't.


The presence of loss of consciousness really happened equally in both groups and did not predict that you were going to be in the protracted group versus the rapid recovery group. In fact, of all those symptoms that I mentioned of all them, in fact I'm going to mention it again so you have it in your mind.

Of all these there's only one that had a statistically significant, positive, predictive value. So as I'm reading through this, think about it, which one of these do you think was statistically significant at predicting if you were going to be a rapid recovery or a protracted or have protracted concussion symptoms clear out at a month.

OK. So we have confusion, headache, loss of consciousness, OK we know that one is not, amnesia, imbalance, dizziness, visual problems, personality changes, fatigue, sensitivity to light, sensitivity to noise, numbness, and vomiting.


All right. Make your decision, get it in your head, again only one of these symptoms had a statistically significant positive predictive value for prolonged symptoms and that symptom was – drum roll please. Try to make this as dramatic as I possibly can. OK. Drum roll – the answer, dizziness.

So the authors conclude that assessment of onfield dizziness may help identify high school football players at risk for a protracted recovery from concussion which may allow clinicians to manage and treat concussion more effectively in this at risk athletes. So at the end of the day, high school football players need to stay off the playing field until their concussion symptoms are gone.


And we said this before and I'm sure at some point in the future we'll say it again, concuss athletes need to be followed closely by their doctor and when all symptoms are gone, that's when they can return to play. Unless you're dealing with a multiple concussion scenario in which case they probably ought to be done for the season.

If you want to know more about the why's of that advice, why do you have to wait until the symptoms are completely gone?And if you have multiple concussions, why should you not play the rest of the season? If you want to know why, be sure to check out everything you ever wanted to know about concussions in episode 177, that's an entire concussion episode.

I think it's like an hour long discussion of concussions with a sports medicine physician, and an athletic trainer. And we'll put a link to that in the show notes for you so you can find it easily. All right. So dizziness on the field now doesn't guarantee that you'll have protracted recovery. And absence of dizziness is not a guarantee that you'll have rapid recovery.


I mean, ultimately there's lots of variables involved here, many of which we don't fully understand, but this is a nice study and at least it gives doctors, parents, and teenagers an idea of how long concussion symptoms might last based on what happens on the field immediately after you get hit in the head.

That just gives our predictions get at this point, so it's certainly not 100%, but it's interesting. All right. Let's move on to management of perforated appendicitis, this one comes out of a research study from the University of Tennessee and it was published in the Journal of the American College of Surgeons, in April of 2012.

And in the show notes we'll put a link to the study's abstract on pub-med. So the question before the researchers, "Among children with perforated appendicitis, is early appendectomy more cost effective than delayed interval appendectomy?"


So let's start with some definitions, the appendix is a blind pouch that's connected to the cecum. The cecum is the first portion of the large intestine, so this is – the appendix is located near the junction of the small intestine and the large intestine, and that's going to be in the right lower quadrant of the abdomen.

So if you take your belly button, and you draw a line straight across, and another line straight up and down, then your abdomen is divided into four quadrants. The right lower quadrant, it's on the right side of your body, below the belly button, underneath there is where the appendix is located. And again it's at the junction of the small and large intestine, it's a little uplined pouch, so an out pocket of the cecum which is the first part there of the large intestine.

Now appendicitis is when the appendix becomes swollen, inflamed, and pus filled. And it's treated surgically by removal of the appendix, but if there is some delay in diagnosing the appendicitis, the natural progression then is for the appendix to become more swollen, inflamed, and pus filled.


And eventually what happens is that it ruptures, and so it spills all the pus that was inside the appendix into the abdominal cavity because it gets a little hole in it and the pus leaks out, and this is what we call a perforated appendicitis. So that's what we're going to talk about is perforated appendicitis.

The sequence of events goes something like this, how do you get to the point where you have perforated appendicitis? Well the first thing that happens is the open end of the appendix becomes obstructed. So remember it's a blind pouch, think of it it's like a cave, OK. Coming off the large intestine, the cecum, it's a blind pouch that has one opening and if something obstructs it, then that could be a problem.

Now what obstructs it? Most cases we don't know, in some cases it can be a hard piece of stool, it could be inflammation from a gastrointestinal viral infection. So you may have just gastroenteritis and you get some inflammation of the internal lining of the bowel, and that inflammation of the lining can occlude or obstruct the opening into the appendix. So that's something else that can do it.


But a lot of times we don't really understand why the appendix becomes obstructed. Well the problem with an obstructed appendix, regardless of the cause of the construction a problem is it means that the bacteria that's inside the appendix can't get out, so they become trapped in the appendix.

And they reproduce, they fill the space, they keep reproducing, and eventually they overwhelm the appendix. So the appendix now is just full of bacteria, and the body says, "Hey, there is too many bacteria in there, we need to wipe them out." And so the body increases blood flow to the appendix, that's what causes the swelling.

So you started to get increased blood flow, you get inflammation, you get swelling just like you would in any other part of the body. And when white blood cells arrive, they kill the bacteria which results in the formation of pus.


So now we have a pus filled swollen inflamed appendix and it begins to hurt, and that pain is going to be in the right little quadrant. Now the swelling starts to get so bad that it occludes the appendix' blood supply.

So the appendix just like any other place in the body, you have to have blood vessels run into and from in order to supply nutrients and take away waste products. And so the appendix and the lining of the appendix has blood vessels. But if it gets really swollen, the swelling can push on those blood vessels and the delivery of nutrients to the appendix wall it stops.

And so what happens then is the cells in the wall of the appendix die because of lack of blood flow and they become necrotic. So they become weak, dead lining inside of the appendix, of the appendix wall.


With the pressure in the meantime is building and so eventually what happens is just the pus pops out to the dead wall and into the abdominal cavity. So now you have a perforated appendix or a perforated appendicitis. And then what can happen is the next thing is abscess conform around the appendix, so you have a collection of pus around the appendix now.

And then that can lead to what we call peritonitis. And peritonitis is a generalized infection of the space inside the abdomen. The peritoneum is a covering of abdominal organs, and so that becomes inflamed.

And then what happens is that can lead to sepsis, so now the infection actually gets into the blood stream from inside the abdominal cavity, reaches the bloodstream, so you can have sepsis that can lead to shock, and that can lead to death. So appendicitis is serious as most of you know. And you like to diagnose appendicitis before the appendix perforates.


And at that point there's no question, you surgically remove the appendix because you don't want it to rupture, you don't want a perforated appendicitis because of that sequence of events where you can lead to peritonitis, and sepsis, and shock, and death. So there's no question what you is you take the appendix out, there's no question about that.

But what happens if you make the diagnosis for whatever reason after perforation already occurs, what do you then? Well there's couple of options; option one, you still take the appendix out as soon as possible or at least within 24 hours from the time of presentation. But prior to surgery you get lots of fluids because you're worried about the development of shock and giving fluids can help that.

You also give them a strong antibiotics, but you do get them to the operating room to get their appendix out within the first 24 hours. And this is what we call early appendectomy in response to a perforated appendicitis. Now the other option is to admit to the child to the hospital, still do the fluid resuscitation, give them IV fluids, treat them with IV antibiotics.


If there's a known abscess that's large you can place a tube through the skin into the abdominal cavity to drain that pus. But you hold off on surgery, OK. You hold off while actually taking the appendix out, and the thought there is these kids are the pretty high risk of septic shock and the kids in shock are the higher risk for intra operative complications.

And so do you really have to get the appendix out? Now the reason you want to get the appendix out before it perforates is so that it doesn't perforate. But once it already has perforated, do you really need to subject the child to the risk of surgery especially when they're already at risk of sepsis and shock.

OK. So what you do in that case is get the infection under control and then when they're well and stable, like six to eight weeks after the event, at that point you bring them back into the hospital and remove the appendix. And this is called delayed interval appendectomy. So the question is, what approach is better?


Which has fewer complications? And which ends up costing more? And there are differences of opinion in the pediatric surgical world with regard to the answers to these questions. And so this study just seek to add its voice to the discussion.

So it certainly not – no individual study is usually is going to be a game changer in and of itself. If there's a certain treatment for a particular illness or condition, that's the standard of care. And once study show knows a different treatment maybe better.

And individual study -these studies aren't perfect, but when you start to have more and more studies all saying the same thing, and they're larger, and they're well done, that starts to change management and starts to be a game changer in terms of what the standard of care is as medicine is practiced.

But individual studies can have issues. So certainly we're not going to answer absolutely what is the best way to deal with the perforated appendicitis just on one study. But this study just seeks to add its voice to the discussion.


OK. So what do the researchers do and what do they find out? Well, they looked at 113 kids who presented with perforated appendicitis, and they randomize them into two groups, early appendectomy, so these group is going to get their appendix out within 24 hours, and delayed interval appendectomy meaning we're just going to admit them to the hospital, IV fluids, give them IV antibiotics which the other kids are going to get that too.

But we're not going to take their appendix out, we're going to wait and bring them back into the hospital in six to eight weeks and get their appendix out at that point. All right. Inclusion criteria, so you have to meet these criteria in order to be included in the study and randomize into one of the two groups.

All the kids had to be less than 19 years old, and they all had to have a presumptive diagnosis of a acute perforated appendicitis based on clinical presentation, laboratory data, and radiographic imaging. Children were excluded from the study of they had been initially been treated some place else and then transferred after they have already been treated.


Now if they just present with symptoms of appendicitis and the outlying hospital send you to the children's hospital, that's OK. But if they had actually been treated somewhere, so if they had their appendix out and have a complication of their appendicitis where they had antibiotics for a couple of days somewhere else, and then were transferred in, those kids were not included in the study.

So all of these kids were initial presentation of their perforated appendicitis. They were also excluded if they had an initial large well formed abscess. And the reason for that is because those kids really -you know you go on with surgery and you're much more likely to just spread the pus all over the place.

And so really the standard of care if there's a large well formed abscess already around the appendix is just to go ahead and drain that with first before you go to the operating room. So if they had the initial well formed abscess, they were included in this study because the interval waiting a while to get the appendix is known to be the better way to go.


So these are just kids who the perforation just happened, it didn't happen a week ago, and now they have this big, well formed abscess it's there. They were also excluded if they were unavailable for subsequent follow up, so they wanted to see how these kids did long term, and if they didn't show up to let the researchers know how they were doing long term, then they were excluded from the study.

OK. So all together they looked at 113 kids. Actually there were 131, they were initially enrolled, but based on the exclusion criteria they got it down to 113 kids. OK. So the data collected for each of these kids were details of their clinical management. So did they have the early appendectomy or the interval delay?

And then they looked at adverse events such as the development of abscess well being followed as oppose to presenting with the well formed abscess. But did they then subsequently develop an abscess.


They also looked at other adverse events including bowel obstruction, and unplanned re-operation, wound infection, central line complications, the need for intervention al radiologic procedures, and recurrence of their acute appendicitis.

So if you do the delayed interval, do they come back two or three weeks later with another acute appendicitis. So they looked at all of those kind of adverse events and complications for both of the groups. And then they also looked at the total hospital charges and cost for both of the groups. All right. So what did they find out?

Well, of the 131 enrolled patients, they got that down to 113 all together. And 64 of those went into the early appendectomy group, and 67 went into the interval appendectomy group. So about half of them had their appendix out within 24 hours, and about half of them got the IV antibiotics and fluids at home, brought back six to eight weeks later and had their appendix out at that point.


So which do you think is better? Which one do you think had more complications and adverse events, and which one do you think cost more? So which one seems to be the better way to go?

So you might be surprised I think that initially for a long time it was take the appendix out, and then they saw, 'Well there's some issues and problems with that, so let's just treat the infection and wait and take the appendix out later. And so sort of the newer way to do it is more of the interval delay.

So you think, well that one since that's kind of been the trend to go on that direction maybe that is the better way to go. But as it turns out the early appendectomy group came out on top, they had a lower overall cost so the median cost for the kids in the rapid appendectomy group was $17,000 for their total care.


It's a lot, isn't it. I know, the cost of medicine is up there. $17,000 to have their appendix out immediately versus the delayed group was $22,000. So there was a saving of about $5,000 of you just went ahead and took their appendix out rapidly within the first 24 hours, rather than waiting and treating the infection and bringing them back and get the appendix out down the road.

So saving about $5,000, so it was more cost efficient to get the appendix out right away. What about adverse events? Well, there was a lower incidence of adverse events in the early appendectomy groups.

So the incidence of adverse events of the ones I mentioned was about 30% of the early get your appendix out group versus 55% for the wait to get your appendix out group. So from 30% adverse events to 55% events if we waited.


That may seem high, you know, so a third to half of the patients had complications and adverse events, that should really surprise you. Again we're talking about perforated appendicitis, so these are kids that the appendix ruptured, they had pus inside their abdominal cavity, you're going to have pretty high numbers of adverse events happening from that, in fact it can be deadly.

But there's fewer adverse events in the group that had their appendix out rapidly rather than waiting. Now incidentally the reason for the interval group, the delayed group costing more was because there were more adverse events in that group. So if you consider both groups -so again we looked at it from a cost standpoint and from an adverse event standpoint.

Well, the reason that the delayed group cost more is because they had more adverse events. And if you're taken care of these adverse events it's going to cost more.


So if you look at instead of dividing them up by getting it out rapidly, waiting to get your appendix out, if you instead look at all commerce. So you look at all the kids that were involved in this study without regard to a group that they're in, and you just look to see whether they had an adverse event or they didn't have an adverse event.

The median cost for perforated appendicitis without an adverse event, regardless of when you took the appendix out was $15,245, whereas if you had adverse event with your appendicitis regardless of when your appendix was taken out, then the median cost jumped up to $35,391.

So from $15,000 to $35,000, so it's over twice the cost now if you're dealing with an adverse event. Also unplanned readmissions to the hospital were another source of cost increase and these two were higher in the interval group. Well of course they were, I mean -well this is unplanned, so I'm sorry.


You know, with the interval group they're going to come home and then come back and get their appendix out in six to eight weeks, but these are unplanned re-admissions. And unplanned re-admissions because of some complications or an adverse event that happens once you went home, like recurrence of your appendicitis or adhesions and bowel obstruction that kind of thing.

If that happened, those unplanned readmissions were higher in the interval group, that group that waited to get their appendix out. But when you consider both groups, if you didn't need to be re-admitted regardless of when you had your appendix our or you didn't have to be readmitted, the median cost was $18,219.

And if you have an unplanned re-admission then the median cost was $27,287. So it makes sense if you have to be re-admitted, it's going to cost more, if you have an adverse event, it's going to cost more.


But the kids who waited to get their appendix out, they were more likely to have the adverse events, they were more likely to have to be re-admitted in an unplanned fashion, and so the cost of that was more.

So the authors concluded that early appendectomy is less costly and associated with fewer adverse events, than interval or delayed appendectomy. So in other words, get the appendix out ASAP at least according to the study. I still think however there's going to be debate and the difference of opinion for some time to come.

Why? Because there are those who maintain that this was not looked at in the study, but there are those who maintain that you don't need to take the appendix out at all. In the case of perforation you treat the infection, you give them fluid, you give them IV antibiotics, you manage the shock expectantly, and you let the perforated necrotic appendix stay put allowing it to sort of whither away inside the body.


And the folks who are on that side, again this was not looked at in the study so we can't really comment on whether that's advantageous or not. But people people who looked at it that way say that would really be the cheapest way to go because you eliminate surgery al together and then the cost of the interval group would be less than the rapid group because you don't take them to the operating room at all.

There are detractors to that because if you do that, then what happens with your adverse events. You know, what happens then to unplanned re-admission and having to go to the OR or mortality and morbidity. Is there more suffering because you do that down the road?

And so I think we need more studies and if people are going to say you don't need your appendix out at all, then we're going to have to compare to getting it out rapidly in the interval delay.


So you have a lot of options here for the treatment of perforated appendicitis, this is certainly the study by itself does not make a huge difference on the practice of your average pediatric surgeon out there, they're going to continue to do it, how they've been trained to do it.

And until there is more and more information out there really leading to one clear way to do it that's best, they're probably going to keep doing it the way they do it. For you the parent, how does this make a difference? Well, just know that there is more than one way to skin a cat – oh, I know it's bad 41:40 my kids are going to write in right now, and say, "Can't believe you said that."

But there is more than one way to do things, and so if your child has a perforated appendicitis, you may have a surgeon that says, "We need to get it out right away." You may have a surgeon that says, "Let's treat the infection and watch for a shock and we'll get it out down the road."


And you know at this point you can make a good argument either way, and so just so as a parent you're informed and you know there's more than one way to do things, and there's no clear evidence that one way is absolutely better than the other at this point.

This one kind of looks at it and says, "Well, there's less complications and less cost associated with getting your appendix out right away." But it's not enough to argue with the expert who's giving you their advice on what they want to do. Again, let's just look at 100 and some patients, not thousands and thousands of patients.

So if you're at a hospital you trust and you're being seen by a pediatric surgeon, go with what they wanted to do, don't argue with them based on a study you heard on PediaCast, just warning you. All right. Let's turn our attention to the final item in this week's research round up, and this one is very, very interesting, it really is.


This is regarding the treatment of distal radius fractures. The institution involve with this particular study was the Poli Momi Medical Center in Hawaii. And I hope I'm saying it right because I don't want to offend these people in case they ever invite me out to a visit to their facility.

So they are in Hawaii, the Poli Momi Medical Center. And this particular study was published in the Journal of Bone and Joint Surgery the American Volume in February 2012. And as with the other studies, we'll put a link to the pub-med abstract of this particular study.

So the question before the researchers; Among the children less than 11 years old with an overriding distal radius fracture, what is the outcome and cost when the fracture is not reduced? So we're going to have to start with some definitions, and by the way as prepare this talk I realized just how difficult it is to define bone and fracture terms without visual aids.


So it's really stretched mind, this really stretched my ability to describe things in terms that parents can understand. So you're going to have to bear with me here. Use your imagination, close your eyes, and picture these things, unless you're driving if you're listening to me while driving don't take that advice.

Look down to your own arm as I'm describing some of the stuff. Hopefully you aren't too squeamish, there are going to be some times when I think a lot of people out there are going to squirm as we talk about these things. If you start to get lightheaded, put it on pause, get some water, sit down, make sure you're in a safe place, you don't pass out because we are going to talk about some pretty descriptive things here.

All right. So let's start with the definitions; the radius -the radius is one of two bones in the forearm, it's on the thumb side, and the ulna is the other bone on the forearm, that's on the pinky side.


So you got your radius, and your ulna in the forearm, radius on the thumb side, ulna on the pinky side. We're going to be talking about the radius on the thumb side. OK. Got to know what distal means in proximal.

Distal is the end of a bone that's farthest from the center of the body as opposed to proximal which is the end that's closest to the center of the body. So if we're talking about the forearm, the distal end is the wrist, and the proximal end is the elbow end. OK. So we're going to be talking about the distal radius.

So forearm, thumb side from anywhere between the middle of the forearm to the wrist, OK, that's what we're talking about. Fracture of course is a break in the bone. So a distal radius fracture is a break in the thumb side -the bone that's on the thumb side of the forearm, and the bone break is located somewhere between the mid forearm and the wrist. So picture that in your mind or look down at your arm.


Now, this isn't just any fracture at that location, we're specifically talking about an overriding fracture. So what does that mean? Well to help us understand this, let's define a few more terms related to extremity fractures, OK? A transverse fracture is a complete break in the bone that runs mostly perpendicular to the bones.

So the bone breaks in half and end up with two bone fragments, one is located on -one bone fragment is located on the distal part of the fracture line. So on the wrist side of the fracture, and the other fragment is going to be proximal to the fracture line, so that's going to be the elbow side of the fracture.

So we have transverse fracture, he get two, it goes all the way to the bone, you get two fragments a proximal one and a distal one. There are other types of fractures that you can have a avulsion fractures are small chunk of bones breaks off of the main mass of bone, that's not what we're talking about here.


A buckle fracture is a dent in the bone. A green stick fracture is kind of like a transverse fracture, but the break disk can go all the way through, the bone remains intact on one side, and bends instead of breaks. Kind of like what would happen if you try to snap a green stick.

A fresh stick that has a lot of water content in it, rather than a dried out stick, you're going to get a green stick type fracture. There's also growth plate fractures, or what we call Salter-Harris type fractures. These are a bit more complicated, there's five different types of these, we'll save those for a different type of day.

But the ones we are focusing on today are transverse fracture. So a complete break perpendicular to the link of the bone on the thumb side of the forearm, somewhere between the mid forearm and the wrist. Now there's two more terms we have to define related to transverse fractures of a long bone, and these two terms that really help us understand what we're talking about here is displacement and angulation.


So let's tackle displacement first. Imagine an intact long bone in the forearm, and you break it all the way through perpendicular or right angle to the long access of the bone. You'll end up with those two fragments of bone, a distal fragment on the wrist side of the fracture, and a proximal fragment on the elbow side of the fracture like how I brought in and used those terms again just to reinforce them in your mind.

I know, the parents in the audience are appreciative, the clinicians are rolling their eyes right now. But I say to the clinicians, stay with me it's going to be worth the journey, OK. I know you got to listen to all these definitions and you know what we're talking about. But when we get to the dessert here, it's going to be worth it.

OK. So we have those two bone fragments, and as long as the bone doesn't move after it's broken, those fragments are going to be positioned in the end. So on an x-ray the bone is going to appear intact, there's just a little fracture line running across it. Well unfortunately the force that breaks the bone oftentimes moves the bone as well so that the fracture fragments are no longer resting perfectly end to end.


And that's where these terms displacement and angulation come into play. There's basically two ways in which the fracture fragments can move into a relationship to one another. They can move in the same plane so each fragments long access is still running in the same direction, they just aren't perfectly end to end anymore.

But they're still going in the same direction, they are not angled at all, they are still straight, but they are just not perfectly end to end. And this is what we call displacement, and we measure displacement as a percentage. And a percentage is how much of the width of the bone is no longer lined up end to end.

So if you have 10% displacement, the bone is moved just a little bit,OK. Only 10% of it is no longer lined up end to end. If you have 15% displacement, well now half of the width of the bone is no longer lined up end to end.


If you have 90% displacement, then only 10% of the bone is still lined up end to end, but 90% of it now is not lined up end to end. And you can have a 100% displacement where the two fracture fragments aren't lined up at all, they're still running in the same direction, the long access of each fragment is still parallel to the other, but they aren't end to end.

And that's what we're going to be talking about with these fractures. So this is a distal radius fracture that is 100% displaced. Now, if the fragments are no longer come end to end, they are 100% displaced, OK. Now the fragments are kind of sitting next to each other, they can also move toward each other, and when that happens the fragments are now overlapping.

So we have the two bones parallel to one another, they are not lined up end to end, in fact they're overlapping. And we actually call this overriding, OK. So an overriding fracture means the two fragments they are still parallel to one another, but they're overriding each other.


And the amount that they are overriding each other is what we call shortening. And shortening is measured in millimeters or centimeters depending on how much shortening exist. Now another way the bones can move relative to one another is in such a way that the long axis of each bone is no longer parallel to the other, this is what we call angulation.

And how is angulation measured? It's measured in degrees. So five degrees of angulation is just a little bit, but 40 degrees of angulation is a lot. So are you with me still? These things are all important because it's how orthopedic surgeons or bone doctors decide how they're going to treat the fracture.

So let's round out our definitions with the look at fracture treatment options because as we're going through this study, we're going to be using these terms, and so that's why I just want you to really understand what we're talking about. So different ways that you can treat a fracture one's with the splint. A splint is simply a length of non flexible material could be made out of plaster, or fiber glass, or pre-formed plastic.


And it is applied to the extremity and held in place with a wrapping. And the goal is to protect the fracture site and keep it from moving and to immobilize the joint that's closest to the fracture to keep that the fragment from moving.

So in our example that would be the wrist, and oftentimes we'll also immobilize the joint further from the fracture, so in our example that would be the elbow in order to really keep those bones still. Now if we only immobilize the wrist, we call that a short arm splint, and if we immobilize both the wrist and the elbow, we call that a long arm splint.

Although technically since we're talking about the distal radius here, we would usually immobilize the thumb because it too can move the wrist in which case we call that a thumb spica splint. So these are different splints. The other thing that we can use is a cast, everybody knows what a cast is. So instead of a length of non flexible material, the entire circumference is rigid, it's soft when it's applied so we can shape it around the joints that we want to keep still -the elbow and the wrist.


But it dries quickly to form a rigid appliance and we all know what a cast is. It can be made of plaster or fiberglass, and it too can be fashioned in a short arm or long arm version just like splints.

So as long as the fracture fragments remain end to end or as long as there's only a small amount of displacement and/or a small amount of angulation then we can just go with the splint or the cast to keep things still and let healing occur. Now interestingly you can tolerate some displacement and angulation, so especially in kids.

So you would think the bone has to be perfectly together in order for me just to get the splint or the cast. But you can tolerate some displacement and angulation because bones do a remarkable job of healing and remodeling themselves into a functional shape in kids.


And it's really kind of cool how they do this, the fracture site becomes surrounded with a big ball of bone making tissue, and we call this a callus. The fracture heals inside of the callus, new bone is laid down by cells called osteoblast and some of the old bone is eaten away by different cells called osteoclast.

So osteoblast make bone, osteoclast eat bone and in this way the body can actually reshape bones. Now of course there are some limitations to that process, so if there is a significant amount of displacement or a significant amount of angulation, then the orthopedic doctor will usually want to move the bone the bone fragments to get them closer to their end to end configuration.

And they can do this in a couple of ways. One way is called 'close reduction',basically they achieve pain control and sedation, and then they manipulate the extremity to move the bones to get them closer to being end to end. Then they verify the alignment with more x-rays, and then they apply a cast.


Now, if that doesn't work or if they think it is unlikely to work, then they can take the patient to the operating room and do what's called an open reduction where they get general anesthesia, they open the skin, they move the bones in place, they close the skin, and then they apply the cast.

Sometimes they'll apply internal plates or pins, or wires to the bone, in which case we call it internal fixation. And in that case the skin is closed and a cast may or may not be used depending on the particular procedure that was done. OK. So we have close reduction which is done in the emergency department, usually with a little sedation.

Open reduction which is done in an operating room, like they open it up and put the bones back together, and internal fixation. So everybody now and again that's when they use pins, wires or plates.


All right. So everybody out there now is orthopedic smart. And as long as you have a good understanding of all those terms, then you're ready to hear about the study. So the terms that you should know and this is a really cool and interesting study I think.

The terms that you should know, distal versus proximal, radius versus ulna, transverse fracture, displacement, angulation, overriding, shortening, short arm cast, long arm cast, close reduction, open reduction, internal fixation and callus. So we covered all those, if you aren't sure about any of those definitions, rewind, listen to the definitions again and then come back.

Go. Do it now. We'll wait for you. All right. Everybody else let's move on they'll catch up. All right. So let's repeat the question now before the researchers, "Among the children less than 11 years old with an overriding distal radius fracture, what is the outcome and cost when the fracture is not reduced?" Hey, that makes sense know, right?


Among children less than 11 years old, when an overriding distal radius fracture, what is the outcome and cost when the fracture is not reduced? So if that doesn't make sense, then you probably didn't go back and listen to the definitions again which means you don't follow direction very well. Which means I really can't help you anymore, then you can hang with us, but please don't disrupt the group.

All right. so what exactly do these researchers do? Well, they looked at 54 kids, all of them less than 11 years old, all of them in Hawaii between 2004 and 2009. So all the kids had a distal radius fracture with 100% displacement, the fragments were overriding. But there was a small amount of shortening, less than a centimeter.

And the fragments had minimal or no angulation – no more than five degrees of angulation. Now the traditional treatment for this kind of injury would be pain control and sedation, close reduction to get the fragments positioned in the end again, and followed up with a long arm cast.


But for this study, kids they use a different protocol. They simply applied a short arm cast made of fiberglass -that was it, no pain control, no sedation, no reduction, just a short arm fiberglass cast.

And they continued this cast until radiograph showed the callus formation, and the fracture site was non tender, and then they removed the cast. And they followed each child for one year after that, and they looked at patient and parent satisfaction with the treatment. They looked at range of motion of the wrist, and they looked at a return to normal activities.

So with the range of motion and a return to activities, they're really looking at function. So does the healed forearm, and the wrist work properly. And then they also looked at the total cost of treatment for this, for the initial treatment, not for the follow up.


Unfortunately they did not include a control group in their study. So we can't directly compare outcomes, and that's a little disappointing. But they did do one thing that's very interesting -for the cost comparison, they looked at the average cost of their initial protocol, not counting follow up.

For just putting the short arm cast on versus traditional approaches. So the close reductions or open reduction as reported by a large insurance carrier. So they didn't looked at the cost of the kids in their study group, they just said, "OK. What we're doing, we're just putting a short arm cast on them in the emergency department.

"What is that typically cost? What's the average cost of that? Across the country based on the reports of large insurance companies. And then let's look at the alternative, the close reduction with sedation in the emergency department, and then the cast, or taking them to the OR and doing open reduction and possibly internal fixation.


And then let's look at for those procedures what's the average cost across the country based on the report of large insurance companies. And the reason that's kind of a cool thing is it doesn't tie the cost to the researcher's institution.

OK. The cost of treatment to the hospital on the north end of town isn't necessarily the same as the cost of treatment at a hospital on the south side of town. So this is really looking at more of the average cost across the country. The other thing that's interesting is it's not what the hospital is charging, it's what the actual cost, and we all know that what a hospital charges isn't always what the get paid because of pre-arranged agreements, you know what I'm talking about.

So the question here is what's the real cost, not what are we charging, what's the actual cost. So I think that's kind of interesting. All right. So what do they find? Of the 54 kids, three were excluded from the final analysis, one parent declined the treatment protocol, one of the reduction done.


And two families moved out of state, mid study. And I can just hear their new orthopedic doctor now who removed the cast, "They did what? They didn't put that bone together? They just put a cast on? What were they thinking?" So two families moved out of state, and did not complete the study.

OK. So we're left with 51 kids, 21of them were boys, 23 of them were girls. The age range was three to 10 years, and the average was seven. Six kids had an isolated distal radius fracture, 45 of them also had an ulnar fracture as well. So both bones in the forearm were broken which is common.

Actually having both bones is really -especially if the radius is completely broken all the way through with overriding and some shortening. It's most likely there is enough force there to break the ulna as well. So 45 of these kids also had an ulnar fracture as well. The most common mechanism of injury for these kids were simple falls and sporting activities.


The average length of shortening of the radius was five millimeters. And the average radial angulation was between three and four degrees. So again this is not a lot of shortening, not a lot of angulation, but there's a 100% displacement with overriding of the two ends of the radius on each side of the fracture.

So how did these kids do? Well, all 51 kids achieve clinical and radiographic union with complete remodeling. So in other words, at the end of the day -well, not the end of the day. By the end of the study, the bones had grown back together, they looked mostly normal on the x-ray.

The arm look normal upon inspection, and all 51 kids had full pain free range of motion at the wrist, and returned to normal activities without any restrictions. So the bone not only look good, but it worked well and correctly in addition to looking good.


All 51 parents reported being satisfied with their child's treatment. That's a little disappointing they didn't grade any of these things. So it was -do you have pain free range of motion, yes or no? Not well -yes there's no grading of this stuff. And with regard to satisfaction it was either are you satisfied or are you not satisfied?

There was no grading, so that's a little disappointing that they didn't grade these things which should really like is really to randomize kids to two groups; one group you do the reduction and the cast, the other group you just cast. And then you look at the difference between the two groups on the long term basis to see how well did they return to function and how well were parents satisfied.

That would have been a better way to do it which again they didn't do, which is a little disappointing. But what about cost? And again we're looking at the average costs reported by large insurance carriers for specific procedures across multiple institutions.


So the study protocol was short arm cast in the emergency room. And the average cost of that across multiple institution and regions is $1,027. So about a grand to go to the emergency room get a short arm cast to put on, about $1,000.

Now let's compare that to the alternatives, so if you go to the emergency -now the biggest thing that would happen if someone showed up in an emergency room, a kid with the injury that we're describing the standard of care really is to sedate them and do the close reduction and put the cast on, get the bones back end to end and put the cast on.

That's the most common thing that's going to get done. So what does that cost? Well, the average cost of that is almost $5,000. So in fact it was $4,846, close reduction in the operating rooms. So now if you're going to take them to the operating room, open the skin and put the bones back together, now we're talking $6,415. And if you do close reduction with internal fixation in the operating room, the average cost of that is going to be $8,742.


So the authors conclude that this conservative treatment protocol provides a simple and cost effective treatment for overriding distal forearm fractures in children. So I think this is interesting, a simple short arm cast versus close reduction with sedation in the emergency department saves close to $4,000 per patient.

And this is significant especially when you considering that so many families today have high out of pocket deductibles. And they're footing a large part if not all of this cost. And there's a lot of things families would rather do with four grand.

It's also significant when you consider just how common these fractures are on a typical summer evening in an emergency department at a children's hospital anywhere in the country kids are lined up for sedation and close reduction of their distal forearm fractures.


Many of you listening right now know exactly what I'm talking about, you've been there, you've lived it, you've paid for it. OK. So it's cheaper, but that doesn't really matter if doesn't work. But who cares if cost less if the kid ends up with a crooked arm or he can't use his wrist, and he can't throw or catch a ball.

Well according to this study there was full recover with expected healing and perfect function, and perfect satisfaction. And by the way as it turns out this isn't the only study with these results. In 2003 a similar, but smaller study showed similar results. So the question then becomes if the study in 2003 and this recent study have shown this, then why aren't we changing our practice?

Why is the standard approach still to sedate and to close reduction and cast them that way? Why are we spending more money? Why are we exposing kids to sedation drugs? Why are we performing close reductions of these injuries in the emergency department?


These are all good questions and the best answer I can give you is this; remember we're talking about a very specific fracture here. So many forearm fractures involve the growth plates, and the wrist or their significantly angulated, or they're significantly shortened. And this study is not addressing those fracture.

OK. So it's a very specific fracture that we're talking about, and it's really not a game changing study. A game changing study in my opinion would look at lots more than 50 kids. It would include multiple institutions with hundreds even thousands of kids, it would randomize children to a study group versus a control group. And the study group will get a short arm cast only, the control group would get the sedation, the close reduction, and the cast.

And then it would compare the two groups with regard to outcome, and it would grade the outcome rather than an all or nothing approach. You know, it would really look and compare arm length, arm strength, risk range of motion, return to activities, and it would follow the kids longer than a year it would follow them really into adulthood.


And that study may come one day, but it's not here now. So, in the meantime if your child breaks his or her forearm and you go to the emergency department,, and an x-ray reveals that distal transverse radial fracture with 100% displacement and some overriding, but there's minimal shortening and minimal angulation.

You can try asking the doctor for a simple short arm cast, but I can pretty much guarantee the person at the other end of your question is going to raise his or her eyebrows, show you the picture of the x-ray, and ask if you are crazy. Don't be offended if they do, it only means that you are actually more knowledgeable on this subject than they are.

Final question; what would I do if it were my kid inn the emergency department with that specific fracture. Here's what I would do; I would trust the opinion of the the expert taking care of my kid. Of course I can say that because it would probably happen here at Nationwide Children's Hospital. And I feel very comfortable trusting the experts here.


All right. So I think it's interesting though, and I think that we'll be hearing more about this in the years to come as some fracture care begins to change. And the orthopedic doctors may resist this to some degree, I mean, they make their living doing procedures, and so to suggest, are we just going to sort of bypass seeing orthopedics and just putting the cast on and letting a primary care doctor follow up with this?

That's a long time away, and there's going to be a lot of resistance and push back to that. And understandably so, because you can have complications. We talked at the end of the last program about sports physicals and going to a grocery store clinic and seeing a nurse practitioner versus seeing your pediatrician.

And the pediatrician is much more likely to find subtle problems, well the orthopedic doctor is going to be better equipped to say, "Hey you know what, it's subtle, but I really worry that this complication could happen. And this particular case we really need to reduce it because of of X, Y, or Z.


So I mean, I understand there's a lot more at play here and you really do want the best expert for your kid. But you're going to get what you paid for and it's going to cost more to do it this way and we just have to accept that or change it based on our tolerance for the cost. All right. So that wraps up this weeks research round up.

We're going to come back and wrap up the show. Make sure that you do stick around because I do have a special request from my loyal listeners. And if you're still listening now this deep into a research round up show, by definition you are a loyal listener. So if that discourage you, don't go anywhere, I'll be back right after this.



All right. We are back to wrap up the show. A few reminders for you. You can still take a virtual tour of our new hospital and you can also make a wish on the Columbus Wishing tree project, we'll have links to both of those in the show notes.

So check out Nationwide Children's new free and comprehensive mobile app, it's called mychildrens, it's available in the iTunes store and Google play. It offers instant access to PediaCast as well as our other podcast, our blogs, our social media channels, educational materials, physician profiles, referral information, locations, directions, hints on how to prepare your child for a hospital visit and what to bring.

See, I told you it was comprehensive, and again that's available for iPhone, iPad, as well as Android devices, and you can look for it, it's free in the iTunes store and Google play.


Speaking of iTunes reviews of course are helpful, they don't take long, and we always appreciate your love in iTunes. And this is important aimed at my loyal listeners, I really do have a favor to ask you. iTunes now defaults to listing reviews by most helpful instead of most recent. And I have to admit there have been times in the past when some of my opinions could be considered controversial.

Once upon a time I criticized the president of the United States for making a big deal about getting his flu shot at a time when there's a national shortage vaccine and some kids couldn't get them. I may in the past have made some critical comments regarding the government's ability to run a national healthcare program.


I may have offended with my pro-vaccine leanings which is based on evidence and current standard of care recommendations. And I don't expect people to agree with me on every position that I make. And the positions that I make when I do which is not that often really are my own, and are not indicative of the opinions of Nationwide Children's Hospital or any other institution or facility.

So they are my own personal opinions, and like I said it didn't happen very often, but sometimes it does and sometimes people disagree with me. And you know, I welcome those with different ideas and thought. I welcome them to express and back up their point of view. And we have a place for that in the show notes and on Facebook.

Now unfortunately some of those who have disagreed with me in the past have decided that iTunes reviews is the place to express their discontent. And so few people have given us one start reviews based not on the shows quality, but instead on their difference of opinion and their own agenda.


There aren't very many, as it turns out we only have 10 one star reviews in our iTunes reviews, compared with hundreds of five star reviews. The problem is that the one star reviewers have friends. And they recruit their friends to push the yes button to the question, "Did you find this review helpful?

And so the one star reviews are showing up on page one of the PediaCast iTunes reviews because iTunes now lists the views by those that are most helpful. So I'm pretty sure the one star people aren't hanging around for the end of the show. In fact I think they'd probably moved on and are listening to shows that agree with their opinion a little bit more.

So those of you who are listening now, my loyal fans, I would just ask would you consider going to iTunes and finding a few reviews which you think truly represent this show and just push the yes button that you did find this review helpful.


It doesn't have to be a five star review, one that you truly feel are helpful and accurate. I'm not asking you to lie, I'm asking that you vote your conscience. But I just like to get the front page reviews to really reflect the quality of the show, and not based on opinions of people who disagree with me. Again if you disagree with me on anything that's fine.

You know, I've changed my mind on lots of things before based on someone else's well thought out argument, you know, I'm humble in that way. I've been wrong before, but the best place to disagree is in the show notes and on Facebook. iTunes reviews help new listeners take a chance on the show.

I believe once moms and dads listen, the one that keep tuning in, the challenge really is getting them to listen in the first place, and that's where the iTunes reviews are helpful. So if you've never done me a favor, please just consider going to iTunes, writing an honest review, and feel free to sample a long winded and sometimes like now that I can ramble that's fine.


And why are there just pick a handful of other reviews that you agree with, and just click yes; this review was helpful. And in that way we can get some accurate and representative reviews on the front page of our iTunes home. And thanks in advance for your consideration in helping us in that fashion.

Again, really it will take five minutes of your time, unless you really want to be extremely thoughtful about which ones, which reviews you agree with. And that's fine too, if you want to take more than five minutes, hey by all means do it. All right. I want to thank all of you3 really for taking the time out of your busy summer day to listen to the program, we really appreciate it.

Especially a program with this much science as our research round up programs have just to really appreciate you sticking with this. If you haven't joined our Facebook page we would encourage you to do that.


Facebook is a great place to add your thoughts to any topic we cover. We're also on Twitter and Google +, and don't forget to share the show with your child's doctor the next time you're in the office for a sick visit or a well child check.

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You can also email, or call the voice line at 347-404-KIDS, 347-404-K-I-D-S. And until next time. This is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody!



Announcer 2: This program is a production of Nationwide Children's. Thanks for listening! We'll see you next time on PediaCast.

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