Shelter in Place and an Alarming Increase in Penetrating Trauma in Children and Concerning Decrease in Child Abuse

BACKGROUND

On March 14, 2020, schools across North Carolina (NC) closed in response to Covid-19, forcing completion of the school year at home. Most pediatric trauma occurs at home with a higher prevalence when children are out of school. We queried the state trauma database to assess if the 2020 "shelter in place" was associated with an increase in pediatric trauma statewide.

METHODS

The NC trauma database was queried for injuries in children (age < 18 yrs) from 13 March-1 August 2020, and the corresponding months of 2018 and 2019. The number and type of injuries were compared. We also queried the NC death certificate and child welfare databases. Data were analyzed by standard statistical methods using chi-squared or Kruskal-Wallis test.

RESULTS

Total pediatric trauma cases were lower during 2020 (71.6 per 100,000) compared to 2018 (92.4 per 100,000) and 2019 (80 per 100,000) (P < .001); however, average injury severity score (ISS) was higher (P = .001). A significant increase in firearm injuries were seen in 2020 (P = .016), with an increase in mortality (P = .08) and ISS (P = .013). The rate of child abuse trauma decreased in 2020 (P = .005) as did the number of child abuse and neglect reports (P < .001). There were also significant decreases in trauma due to sports, burns, falls, and motor vehicle accidents.

CONCLUSION

While overall pediatric trauma decreased during the Covid-19 pandemic, there was an alarming increase in penetrating injuries in children. Child abuse trauma and reports decreased, which is concerning for lower identification of abuse.

Facility Size and Risk Factors for Mortality in Pediatric Trauma

BACKGROUND

Pediatric trauma outcomes can vary across facilities, yet evidence on the relationship between facility bed size and pediatric trauma outcomes has been mixed. We aimed to identify how facility bed size might modify the impact of patient-level risk factors on mortality in pediatric trauma. We hypothesized that patient-level risk factors would have a stronger association with mortality at smaller trauma centers, and a weaker association with mortality at larger centers.

METHODS

We used deidentified data obtained from the 2017-2018 Trauma Quality Programs registry, including patients ages 0-18 years of age who were admitted to the hospital. The primary outcome was in-hospital mortality. Facility bed size was dichotomized as large (>600 beds) vs small/medium (≤600 beds). Sensitivity analyses used 200 and 400 beds as alternative cutoffs. Interaction between facility bed size and patient characteristics was assessed using unadjusted logistic regression, with statistically significant interactions entered in a final, fully adjusted model.

RESULTS

The analysis included 171 810 patients (mean age 10 ± 5 years; 65%/35% male/female), including 28% treated in a large hospital and 1.2% who died during the hospitalization. Controlling for trauma center level (or subsetting to pediatric trauma centers only), larger bed size did not reduce mortality risk associated with patient characteristics such as injury mechanism, injury severity, or patient demographics.

CONCLUSIONS

Contrary to our hypothesis, greater facility bed size was not associated with reduced mortality risk associated with patient characteristics. Future studies are needed to identify hospital practices or characteristics that can attenuate the excess risk of known patient-level risk factors.

Pediatric emergency resuscitative thoracotomy: A Western Trauma Association, Pediatric Trauma Society, and Eastern Association for the Surgery of Trauma collaborative critical decisions algorithm

LEVEL OF EVIDENCE

Literature synthesis and expert opinion, Level V.

In-person school attendance and adolescent exposure to injury-related risk behaviors during the COVID-19 pandemic in the United States

School closures during the COVID-19 pandemic have been reported to influence adolescents' behavioral health and may have altered their exposure to injury risk. We aimed to determine how in-person school attendance of individual adolescents in the United States during the pandemic was correlated with a range of risky health behaviors. We used self-reported data from adolescents 14-18 years old enrolled in grades 9-12 who participated in the 2020 Adolescent Behaviors and Experiences Survey. The exposure of interest was in-person vs remote school attendance in the previous 30 days. Risk behavior outcomes included not wearing a seatbelt when riding in a car; riding with someone who was drinking and driving; suffering intimate partner violence (IPV); forced sexual encounters; suicidal ideation; suicidal planning; electronic bullying; gun carrying; and physical fighting. Based on a multivariable analysis of 5202 students (65% attending school in-person) adjusted for age, sex, race, ethnicity, sexual orientation, parental unemployment, food insecurity, and homelessness, we found that in-person school attendance was associated with increased odds of every risk behavior except suicidal ideation and electronic bullying, with adjusted odds ratios ranging from 1.40 (95% confidence interval [CI]: 1.04, 1.88) for not wearing a seatbelt to 3.43 for IPV (95% CI: 1.97, 5.97). Our analyses demonstrate that in-person school attendance during the COVID-19 pandemic was associated with higher rates of risk behavior among adolescents. Further research is needed explore if this relationship is causal, and how these risks could be mitigated, as most adolescents have now returned to in-person schooling.

Outcomes of farm compared to nonfarm pediatric injuries: A propensity-matched analysis

OBJECTIVES

Pediatric farm-related injuries are rare but tend to be severe relative to other types of pediatric injury and may result in worse clinical outcomes. However, the comparison of farm and nonfarm injuries is confounded by different injury mechanisms, patient characteristics, and treating facilities. Therefore, we used propensity score matching to compare outcomes of pediatric farm and nonfarm injuries in the United States.

METHODS

Data were obtained from the 2017-2019 Trauma Quality Program database. Farm as compared to nonfarm injury was defined as the location of an injury and served as the independent variable analyzed in this study. The outcome variables analyzed were in-hospital mortality, hospital length of stay (LOS), and admission to the intensive care unit (ICU).

RESULTS

We identified 2,040 farm injuries and 201,865 nonfarm injuries meeting inclusion criteria. In this cohort, the mortality rate was 1%, median LOS was 2 days, and 14% of patients were admitted to the ICU. In the propensity-matched analysis (including 2,039 farm cases matched to 2,039 nonfarm controls), farm as compared to nonfarm injuries were associated with 5% longer LOS (95% CI: 1%, 8%; P = .01), but not mortality or ICU admission.

CONCLUSIONS

In a propensity-matched analysis, pediatric farm injuries resulted in prolonged hospital stay compared to nonfarm injuries. Identifying patient- and health care system-level factors contributing to prolonged LOS may help optimize the care of children injured on farms.

Spontaneous perforation of Meckel’s diverticulum causing a partial small bowel obstruction: A case report

Background: Meckel’s diverticulum is a common congenital malformation in young children. Perforation of Meckel’s diverticulum in a neonate is a rarity and poses diagnostic and management challenges. Case Presentation: This patient is a former 26 5/7 week estimated gestational age infant who presented at 41 weeks corrected gestational age with abdominal distension and was discovered to have a perforated Meckel’s diverticulum that presented as a partial small bowel obstruction. Resection of the involved bowel and ileo-ileal anastomosis was performed. Conclusion: Small bowel obstructions should be considered as a potential presentation of a perforated Meckel’s diverticulum.

Lack of Health Insurance Coverage and Emergency Medical Service Transport for Pediatric Trauma Patients

INTRODUCTION

Pediatric trauma patients who lack insurance coverage may have less access to transport other than emergency medical services (EMS) or face financial barriers that prevent utilization of these services. We analyzed the association between health insurance coverage and EMS transport while controlling for injury and patient characteristics.

MATERIALS AND METHODS

De-identified Trauma Quality Programs registry data were queried for pediatric trauma patients age <18 y. The primary outcome was arrival by EMS (excluding interfacility transfer) versus private transport or walk-in, and the primary exposure was insurance coverage (any versus none). After exact matching on injury and facility characteristics, propensity matching was used to balance demographic covariates and comorbidities between insured and uninsured patients.

RESULTS

Of the 130,246 patients analyzed, 9501 (7%) did not have insurance coverage. After matching 9494 uninsured cases to 9494 insured controls, fixed-effects logistic regression found that uninsured patients had 18% greater odds of using EMS transport, compared to insured patients (odds ratio: 1.18; 95% confidence interval: 1.11, 1.26; P < 0.001). Results were similar when comparing uninsured patients to privately insured or publicly insured patients only.

CONCLUSIONS

Uninsured pediatric trauma patients have a higher likelihood of using EMS transport compared to insured patients with similar demographic and clinical characteristics, including the exact same score of injury severity. Lack of access to private transport may drive higher EMS utilization in uninsured patients with minor injuries and contribute to higher costs of pediatric trauma care borne by institutions and families.

Atropine: A Cure for Persistent Post Laparoscopic Pyloromyotomy Emesis?

Background: Atropine has been used as a successful primary medical treatment for hypertrophic pyloric stenosis. Several authors have reported a higher rate of incomplete pyloromyotomy with the laparoscopic approach compared to open. In this study, we evaluated the use of atropine as a medical treatment for infants with emesis persisting greater than 48 hours after a laparoscopic pyloromyotomy.

Materials and Methods: We performed a retrospective chart review of infants receiving a laparoscopic pyloromyotomy between November 1998 and November 2012. Infants with emesis that persisted beyond 48 hours postoperatively were given 0.01mg/kg of oral atropine 10 minutes prior to feeding. Infants remained inpatient until they tolerated two consecutive feedings without emesis.

Results: 965 patients underwent laparoscopic pyloromyotomy; 816 (84.6%) male and 149 (15.4%) female. Twenty-four (2.5%) received oral atropine. The mean length of stay for patients who received atropine was 5.6 ± 2.6 days, an average of 3 additional days. They were discharged home with a one-month supply of oral atropine. Follow up evaluation did not reveal any complications from receiving atropine. The median follow up was 21 days. None returned to the operating room for incomplete pyloromyotomy. There were 17 (1.8%) operative complications in our series; 9 mucosal perforations, 2 duodenal perforations, and 6 conversions to open for equipment failure or poor exposure. There were 4 (0.4%) post-operative complications: 2 episodes of apnea requiring reintubation and 2 incisional hernias that required a second operation. There were no deaths.

Conclusion: Oral atropine is a viable treatment for persistent emesis after a pyloromyotomy and reduces the need for a second operation due to incomplete pyloromyotomy.

Chest tube placement in children during extracorporeal membrane oxygenation (ECMO)

BACKGROUND

Pleural collections of air and fluid are frequent in infants and children treated with extracorporeal membrane oxygenation (ECMO). In this anticoagulated population, chest tube placement is potentially hazardous, and catastrophic hemorrhage has been reported. We sought to define the risks associated with chest tube placement in a large population of children managed with ECMO.

METHODS

The records of 189 consecutive children managed with ECMO at two children's hospitals were reviewed. Demographics, indications for ECMO, and ECMO courses were reviewed. In particular, the occurrence of pleural collections and the frequency and technique of chest tube placement were evaluated. The incidence of complications and mortality were determined.

RESULTS

The median age of the subjects was 2days. The overall mortality was 26.5%. A pneumothorax was found in 19 (10.1%), a pleural effusion in 26 (13.8%), and a hemothorax in 2 (1.0%). A chest tube was placed in 27 (19 by a needle-guide wire technique and 8 by cut-down). Major bleeding complications occurred in 6 subjects (22%).

CONCLUSIONS

There was a significant incidence of major bleeding complications and death in subjects in whom chest tubes were placed. The placement of a chest tube during ECMO should be done only if it is likely to improve pump flow or promote weaning of support.

Regulation of retinoblastoma protein (Rb) by p21 is critical for adaptation to massive small bowel resection

BACKGROUND

Adaptation following massive intestinal loss is characterized by increased villus height and crypt depth. Previously, we demonstrated that p21-null mice do not adapt after small bowel resection (SBR). As retinoblastoma protein (Rb) levels are elevated in p21-null crypt cells, we first sought to determine whether Rb is required for normal adaptation. Next, we tested whether Rb expression is responsible for blocked adaptation in p21-nulls.

METHODS

Genetically manipulated mice and wild-type (WT) littermates underwent either 50% SBR or sham operation. The intestine was harvested at 3, 7, or 28 days later and intestinal adaptation was evaluated. Enterocytes were isolated and protein levels evaluated by Western blot and quantified by optical density.

RESULTS

Rb-null mice demonstrated increased villus height, crypt depth, and proliferative rate at baseline, but there was no further increase following SBR. Deletion of one Rb allele lowered Rb expression and restored resection-induced adaptation responses in p21-null mice.

CONCLUSION

Rb is specifically required for resection-induced adaptation. Restoration of adaptation in p21-null mice by lowering Rb expression suggests a crucial mechanistic role for Rb in the regulation of intestinal adaptation by p21.

Retinoblastoma protein (pRb), but not p107 or p130, is required for maintenance of enterocyte quiescence and differentiation in small intestine

The function of retinoblastoma protein (pRb) in the regulation of small intestine epithelial cell homeostasis has been challenged by several groups using various promoter-based Cre transgenic mouse lines. Interestingly, different pRb deletion systems yield dramatically disparate small intestinal phenotypes. These findings confound the function of pRb in this dynamic tissue. In this study, Villin-Cre transgenic mice were crossed with Rb (flox/flox) mice to conditionally delete pRb protein in small intestine enterocytes. We discovered a novel hyperplasia phenotype as well as ectopic cell cycle reentry within villus enterocytes in the small intestine. This phenotype was not seen in other pRb family member (p107 or p130) null mice. Using a newly developed crypt/villus isolation method, we uncovered that expression of pRb was undetectable, whereas proliferating cell nuclear antigen, p107, cyclin E, cyclin D3, Cdk2, and Cdc2 were dramatically increased in pRb-deficient villus cells. Cyclin A, cyclin D1, cyclin D2, and Cdk4/6 expression was not affected by absent pRb expression. pRb-deficient villus cells appeared capable of progressing to mitosis but with higher rates of apoptosis. However, the cycling villus enterocytes were not completely differentiated as gauged by significant reduction of intestinal fatty acid-binding protein expression. In summary, pRb, but not p107 or p130, is required for maintaining the postmitotic villus cell in quiescence, governing the expression of cell cycle regulatory proteins, and completing of absorptive enterocyte differentiation in the small intestine.

HIV-related characteristics of migrant workers in rural South Carolina

After finding human immunodeficiency virus (HIV) infection in a migrant worker named as a syphilis contact, the South Carolina Department of Health and Environmental Control offered HIV counseling and testing and syphilis screening to migrant workers in the surrounding two-county area. In addition, a brief questionnaire was administered to document demographics and risk behavior. Of the 265 workers aged 16 and older in 15 migrant camps, 198 (75%) consented to the survey and testing. Of the 198 tested, 85% were male and 75% single. The median age was 39, with a range of 16 to 69 years. Twenty-five (13%) were HIV antibody positive, and 32 (16%) had reactive serologic tests for syphilis. Of the 166 workers who reported the frequency of condom use, 77 (46%) indicated they never use condoms. We conclude that there is a relatively high rate of HIV infection in these rural South Carolina migrant workers, whose behavior puts them at risk for HIV infection and other sexually transmitted diseases.