Clinical Practice Guideline Recommendations For Pediatric Multisystem Trauma Care: A Systematic Review

OBJECTIVE

To systematically review clinical practice guidelines (CPGs) for pediatric multisystem trauma, appraise their quality, synthesize the strength of recommendations and quality of evidence, and identify knowledge gaps.

BACKGROUND

Traumatic injuries are the leading cause of death and disability in children, who require a specific approach to injury care. Difficulties integrating CPG recommendations may cause observed practice and outcome variation in pediatric trauma care.

METHODS

We conducted a systematic review using Medline, Embase, Cochrane Library, Web of Science, ClinicalTrials, and grey literature, from January 2007 to November 2022. We included CPGs targeting pediatric multisystem trauma with recommendations on any acute care diagnostic or therapeutic interventions. Pairs of reviewers independently screened articles, extracted data, and evaluated the quality of CPGs using "Appraisal of Guidelines, Research, and Evaluation II."

RESULTS

We reviewed 19 CPGs, and 11 were considered high quality. Lack of stakeholder engagement and implementation strategies were weaknesses in guideline development. We extracted 64 recommendations: 6 (9%) on trauma readiness and patient transfer, 24 (38%) on resuscitation, 22 (34%) on diagnostic imaging, 3 (5%) on pain management, 6 (9%) on ongoing inpatient care, and 3 (5%) on patient and family support. Forty-two (66%) recommendations were strong or moderate, but only 5 (8%) were based on high-quality evidence. We did not identify recommendations on trauma survey assessment, spinal motion restriction, inpatient rehabilitation, mental health management, or discharge planning.

CONCLUSIONS

We identified 5 recommendations for pediatric multisystem trauma with high-quality evidence. Organizations could improve CPGs by engaging all relevant stakeholders and considering barriers to implementation. There is a need for robust pediatric trauma research, to support recommendations.

finP and fisO mutations in FinP anti-sense RNA suggest a model for FinOP action in the repression of bacterial conjugation by the Flac plasmid JCFL0

Expression of the transfer operon in the F plasmids is negatively regulated by FinOP which has two components, the finP and finO gene products. Mutations in either gene result in increased expression of the positive regulator of transcription, traJ, leading to derepressed levels of conjugal transfer. Five mutations in the finP gene have been previously characterised by Finnegan and Willetts (1971). Three were complementable in trans and were named finP mutations and two were complementable at low levels (fisO) presumably because they affected the site of action of the finO gene product. In this study, DNA sequence analysis revealed three different mutations shared by the five mutants which were located in the stems of the predicted stem-and-loop structures in the finP anti-sense RNA. The properties of three mutants created by site-specific mutagenesis suggested that the stability of the stem structure was important in FinP action and that a small region in one of the stems appears to be the target of the finO gene product. Analysis of wild-type and fisO FinP RNA showed that FinO increased the amount of an 80 nuceotide FinP RNA, probably by stabilizing this transcript or preventing its degradation. The fisO mutation decreased the amount of 80 nucleotide RNA substantially. FinP transcripts from either the finP promoter of the lac promoter appeared to be stabilized by FinO.