Outcomes After Transfer of Pediatric Trauma Patients: Does Everyone Need to Visit the Trauma Bay?

INTRODUCTION

Critically injured children and teens often present to adult trauma centers or nontrauma facilities prior to transfer to a pediatric trauma center. For pediatric patients wanting transfer to the intensive care unit (ICU), there is little data to guide which can be safely transferred directly to the unit, and which should be evaluated first in the trauma bay.

METHODS

We used our institutional trauma registry to evaluate transferred trauma patients over a three year period. We compared time to imaging, time to operating room, and overall mortality between the group evaluated first in the emergency room and those transferred directly to the ICU.

RESULTS

When adjusted for other variables, there was no increased mortality in those transferred directly to the ICU. While there was a higher nonadjusted mortality in those transferred to the ICU (13% versus 3.7%), these nonsurvivors had a lower GCS (3 versus 13), higher Pediatric Risk of Mortality scores, and a high rate of severe head trauma. There was no significant delay in ordered imaging or procedures.

CONCLUSIONS

In patients, who have been assessed at another institution prior to transfer to the pediatric ICU, transfer directly to the ICU, bypassing the emergency department, does not delay interventions and does not appear to worsen outcomes.

Unintended Consequences of COVID-19 on Pediatric Falls from Windows: A Multicenter Study

Introduction

In attempts to quell the spread of COVID-19, shelter-in-place orders were employed in most states. Increased time at home, in combination with parents potentially balancing childcare and work-from-home duties, may have had unintended consequences on pediatric falls from windows. We aimed to investigate rates of falls from windows among children during the first 6 mo of the COVID-19 pandemic.

Methods

Patients <18 y old admitted to three pediatric trauma centers (two - level 1, one - level 2) between 3/19/20 and 9/19/20 (COVID-era) were compared to a pre-COVID cohort (3/19/19 to 9/19/19). The primary outcome was the rate of falls from windows. Secondary outcomes included injury severity score (ISS), injuries sustained, and mortality.

Results

Of 1011 total COVID-era pediatric trauma patients, 36 (3.6%) sustained falls from windows compared to 23 of 1108 (2.1%) pre-COVID era patients (OR 1.7, P = 0.05). The median ISS was seven pre-COVID versus four COVID-era (P = 0.43). The most common injuries sustained were skull fractures (30.5%), extremity injuries (30.5%), and intracranial hemorrhage (23.7%). One-fifth of patients underwent surgery (21.7% pre-COVID versus 19.4% COVID-era, P = 1.0). There was one mortality in the COVID-era cohort and none in the pre-COVID cohort (P = 1.0).

Conclusions

Despite overall fewer trauma admissions during the first 6 mo of the COVID-19 pandemic, the rate of falls from windows nearly doubled compared to the prior year, with substantial associated morbidity. These findings suggest a potential unintended consequence of shelter-in-place orders and support increased education on home safety and increased support for parents potentially juggling multiple responsibilities in the home.

Statewide impact of the COVID pandemic on pediatric appendicitis in California: A multicenter study

BACKGROUND

The COVID-19 pandemic has resulted in delays in presentation for other urgent medical conditions, including pediatric appendicitis. Several single-center studies have reported worse outcomes, but no state-level data is available. We aimed to determine the statewide effect of the COVID-19 pandemic on the presentation and management of pediatric appendicitis patients.

MATERIALS AND METHODS

Patients < 18 years old with acute appendicitis at four tertiary pediatric hospitals in California between March 19, 2020 to September 19, 2020 (COVID-era) were compared to a pre-COVID cohort (March 19, 2019 to September 19, 2019). The primary outcome was the rate of perforated appendicitis. Secondary outcomes were symptom duration prior to presentation, and rates of non-operative management.

RESULTS

Rates of perforated appendicitis were unchanged (40.4% of 592 patients pre-COVID versus 42.1% of 606 patients COVID-era, P = 0.17). The median symptom duration was 2 days in both cohorts (P = 0.90). Computed tomography (CT) use rose from 39.8% pre-COVID to 49.4% during COVID (P = 0.002). Non-operative management increased during the pandemic (8.8% pre-COVID versus 16.2% COVID-era, P < 0.0001). Hospital length of stay (LOS) was longer (2 days pre-COVID versus 3 days during COVID, P < 0.0001).

CONCLUSIONS

Pediatric perforated appendicitis rates did not rise during the first six months of the COVID-19 pandemic in California in this multicenter study, and there were no delays in presentation noted. There was a higher rate of CT scans, non-operative management, and longer hospital lengths of stay.

Management of Complicated Gastric Bezoars in Children and Adolescents

BACKGROUND

Gastric bezoars in children are infrequent. Most are trichobezoars. Surgical intervention is sometimes necessary.

OBJECTIVES

To describe the clinical findings and radiological workup, as well as treatment and outcome of patients with complicated gastric bezoars who underwent surgery in our institution.

METHODS

We conducted a retrospective review of all cases of surgery for gastric bezoars performed in our institution between 2000 and 2010. Data collected included gender and age of the patients, composition and extent of the bezoar, presenting signs and symptoms, imaging studies used, performance of endoscopy, and surgical approach. Outcome was measured by the presence of postoperative complications.

RESULTS

We identified seven patients with gastric bezoars who underwent surgery. All were females aged 4-19 years. Six had trichobezoars and one had a mass composed of latex gloves. Presenting symptoms included abdominal pain, vomiting, weight loss, and halitosis. All patients had a palpable epigastric mass. A large variety of imaging modalities was used. Endoscopic removal was attempted in three patients and the laparoscopic approach in one patient, but both routes failed. All patients eventually underwent laparotomy with gastrotomy and recovered without complications.

CONCLUSIONS

The presence of gastric bezoars should be suspected in any child with unexplained abdominal pain, vomiting, weight loss, or halitosis, or with a palpable abdominal mass, especially in girls. A variety of imaging modalities can aid in diagnosis. Endoscopic removal might be attempted, although failure of this approach is frequent, necessitating surgical intervention, preferably laparotomy and gastrotomy, which has an excellent outcome.

The ErbB4 ligand neuregulin-4 protects against experimental necrotizing enterocolitis

Necrotizing enterocolitis (NEC) affects up to 10% of premature infants, has a mortality of 30%, and can leave surviving patients with significant morbidity. Neuregulin-4 (NRG4) is an ErbB4-specific ligand that promotes epithelial cell survival. Thus, this pathway could be protective in diseases such as NEC, in which epithelial cell death is a major pathologic feature. We sought to determine whether NRG4-ErbB4 signaling is protective in experimental NEC. NRG4 was used i) in the newborn rat formula feeding/hypoxia model; ii) in a recently developed model in which 14- to 16-day-old mice are injected with dithizone to induce Paneth cell loss, followed by Klebsiella pneumoniae infection to induce intestinal injury; and iii) in bacterially infected IEC-6 cells in vitro. NRG4 reduced NEC incidence and severity in the formula feed/hypoxia rat model. It also reduced Paneth cell ablation-induced NEC and prevented dithizone-induced Paneth cell loss in mice. In vitro, cultured ErbB4(-/-) ileal epithelial enteroids had reduced Paneth cell markers and were highly sensitive to inflammatory cytokines. Furthermore, NRG4 blocked, through a Src-dependent pathway, Cronobacter muytjensii-induced IEC-6 cell apoptosis. The potential clinical relevance of these findings was demonstrated by the observation that NRG4 and its receptor ErbB4 are present in human breast milk and developing human intestine, respectively. Thus, NRG4-ErbB4 signaling may be a novel pathway for therapeutic intervention or prevention in NEC.

Low doses of celecoxib attenuate gut barrier failure during experimental peritonitis

The intestinal barrier becomes compromised during systemic inflammation, leading to the entry of luminal bacteria into the host and gut origin sepsis. Pathogenesis and treatment of inflammatory gut barrier failure is an important problem in critical care. In this study, we examined the role of cyclooxygenase-2 (COX-2), a key enzyme in the production of inflammatory prostanoids, in gut barrier failure during experimental peritonitis in mice. I.p. injection of LPS or cecal ligation and puncture (CLP) increased the levels of COX-2 and its product prostaglandin E2 (PGE2) in the ileal mucosa, caused pathologic sloughing of the intestinal epithelium, increased passage of FITC-dextran and bacterial translocation across the barrier, and increased internalization of the tight junction (TJ)-associated proteins junction-associated molecule-A and zonula occludens-1. Luminal instillation of PGE2 in an isolated ileal loop increased transepithelial passage of FITC-dextran. Low doses (0.5-1 mg/kg), but not a higher dose (5 mg/kg) of the specific COX-2 inhibitor Celecoxib partially ameliorated the inflammatory gut barrier failure. These results demonstrate that high levels of COX-2-derived PGE2 seen in the mucosa during peritonitis contribute to gut barrier failure, presumably by compromising TJs. Low doses of specific COX-2 inhibitors may blunt this effect while preserving the homeostatic function of COX-2-derived prostanoids. Low doses of COX-2 inhibitors may find use as an adjunct barrier-protecting therapy in critically ill patients.

Management of rectal pyogenic granuloma with transanal mucosal sleeve resection

In children, pyogenic granulomas are most commonly cutaneous benign vascular lesions but can also present in the gastrointestinal tract. When they occur in the intestine, they can cause acute or chronic gastrointestinal bleeding. We present an unusual case of rectal pyogenic granuloma and our management strategy.

Right-sided congenital diaphragmatic hernia, hepatic pulmonary fusion, duodenal atresia, and imperforate anus in an infant

We present a case of a neonate with VACTERL-like association, with the VACTERL association defined as the non-random association of vertebral, anal, cardiac, esophageal, renal/kidney, and limb defects, as manifested by a hemivertebra, imperforate anus, and digit anomalies, in rare association with duodenal atresia and right-sided diaphragmatic hernia. This constellation is previously undescribed and may offer insight into the pathogenesis of VACTERL and associated birth defects.

Robotic-assisted thymectomy

Thymectomy is an established therapy for myasthenia gravis. Minimally invasive surgery for thymectomy has been reported, but not clearly shown to be equivalent to open resection. Robotic-assisted thymectomy may provide the benefit of a full resection of thymic tissue and anterior mediastinal tissue for the treatment of myasthenia gravis by a minimally invasive approach. We present a review of the experience of robotic thymectomy.

First and second generation total synthesis of the teicoplanin aglycon

Full details of studies leading to the total synthesis of the teicoplanin aglycon are provided. Key elements of the first generation approach (26 steps from constituent amino acids, 1% overall) include the coupling of an EFG tripeptide precursor to the common vancomycin/teicoplanin ABCD ring system and sequential DE macrocyclization of the 16-membered ring with formation of the diaryl ether via a phenoxide nucleophilic aromatic substitution of an o-fluoronitroaromatic (80%, 3:1 atropisomer diastereoselection) followed by 14-membered FG ring closure by macrolactamization (66%). Subsequent studies have provided a second generation total synthesis which is shorter, more convergent, and highly diastereoselective (22 steps, 2% overall). This was accomplished by altering the order of ring closures such that FG macrolactamization (95%) preceded coupling of the EFG tripeptide to the ABCD ring system and subsequent DE ring closure. Notably, DE macrocyclization via diaryl ether formation on substrate 57, the key intermediate in the latter approach incorporating the intact FG ring system, occurred with exceptional diastereoselection for formation of the natural atropisomer (>10:1, 76%) without problematic C(2)(3) epimerization provided the basicity of the reaction is minimized.

Synthesis of the vancomycin CDE ring system

A first generation synthesis of 22 is described constituting the first disclosure of the preparation of an appropriately protected and fully functionalized vancomycin CDE ring system complete with the C and E ring monochloro substitution pattern. The approach, which is based on two aromatic nucleophilic substitution reactions for sequential CD and DE macrocyclization, provided the opportunity to define and indirect solution to the control of the CDE atropisomer stereochemistry through selective thermal equilibration of the DE versus unaltered CD ring system. Its success provides a rationale for a preferred order to the CD and DE ring system introductions.

An extended survey of the genetic polymorphism at the human coagulation factor XIII: a subunit structural locus

The distribution of the three previously reported alleles, with normal products at the factor XIII A subunit structural locus, FXIIIA*1, FXIIIA*2 and FXIIIA*4 has been studied in populations from the region extending from the Indonesian archipelago through Papua New Guinea, Australia and New Zealand to the Pacific Islands of Micronesia, Melanesia and Polynesia. In addition a population from the Caspian Littoral of Iran and a population of South American Indians were studied. The FXIIIA*1 and FXIIIA*2 alleles were polymorphic in all populations studied. The distribution of the FXIIIA*4 allele suggests that it may be a Melanesian marker.

Biochemical characterisation of genetically variant and abnormal blood coagulation factor XIII A subunits

The products of the FXIIA*1 and FXIIIA*2 alleles were purified and compared for their substrate specificities, heat stability and pH optima. Although some differences were apparent in the heat stability and pH optima of the purified protein, the differences were not apparent in unpurified plasma samples. It, therefore, appears that there are no physiologically important differences between the products of the two alleles. The unpurified product of the FXIIIA*3 allele was compared for its pH optimum and heat stability with unpurified plasma samples of the other two alleles. The pH optimum of the Type 3 A subunits was pH 9.10 compared to pH 8.38 for the Type 1 and Type 2 A subunits. In addition, The Type 3 A subunits were more rapidly heat inactivated.