Identification of severely injured children at very low risk of emergent surgery: A national trauma registry study.

OBJECTIVE: The number of pediatric trauma patients requiring surgical interventions has been steadily decreasing allowing for a judicious approach to immediately available resources. This study aimed to derive and validate a prediction rule that reliably identifies injured children who are at very low risk for requiring emergency surgery upon emergency department (ED) arrival. METHODS: A retrospective cohort study of data included in the Israeli National Trauma Registry from January 1, 2011, through December 31, 2020, was conducted. We included children aged 0-14 years who presented to EDs from the scene of injury and were hospitalized. We excluded patients transferred between facilities or with isolated burns. The primary outcome was emergency operative intervention (EOI) performed within one hour of ED arrival. We tested mechanism, GCS, heart rate, and blood pressure as candidate predictors. We then randomized patients to two cohorts, derived and internally validated a prediction rule. RESULTS: During the study period, 83,859 children met enrollment criteria. The median age was 6 years (IQR 2-10) and 56,867 (67.8 %) were male; 75,450 (90.0 %) sustained blunt trauma. One hundred sixty-nine (0.20 %) children underwent EOI. In the derivation and validation cohorts, 34,138 (81.4 %) and 34,271 (81.7 %) patients, were classified as low risk based on blunt trauma mechanism, normal GCS (15), and low-risk heart rate (according to age). Of those, 8 (0.02 %) and 13 (0.04 %) required an EOI, respectively. In the validation cohort, the prediction rule for EOI had a sensitivity of 84 % (95 % CI 75-91), a specificity of 82 % (95 % CI 81-82), and a negative predictive value of 99.96 % (95 % CI 99.94-99.98). Among children with an Injury Severity Score>15, the sensitivity was 87 % (95 % CI 77-94), the specificity of 57 % (95 % CI 54-59), and the negative predictive value was 98.97 % (95 % CI 98.13-99.44). CONCLUSIONS: A limited set of physiologic parameters, readily available at hospital admission can effectively identify injured children at very low risk for emergent surgery. For these children, immediate deployment of surgical resources may not be necessary.

Serologic response to COVID-19 infection or vaccination in pediatric kidney transplant recipients compared to healthy children.

BACKGROUND: Differences in serologic response to COVID-19 infection or vaccination were reported in adult kidney transplant recipients (KTR) compared to non-immunocompromised patients. This study aims to compare the serologic response of naturally infected or vaccinated pediatric KTR to that of controls. METHODS: Thirty-eight KTR and 42 healthy children were included; aged ≤18 years, with a previously confirmed COVID-19 infection or post COVID-19 vaccination. Serological response was measured by anti-spike protein IgG antibody titers. Response post third vaccine was additionally assessed in KTR. RESULTS: Fourteen children in each group had previously confirmed infection. KTR were significantly older and developed a 2-fold higher antibody titer post-infection compared to controls [median (interquartile range [IQR]) age: 14.9 (7.8, 17.5) vs. 6.3 (4.5, 11.5) years, p = 0.02; median (IQR) titer: 1695 (982, 3520) vs. 716 (368, 976) AU/mL, p = 0.03]. Twenty-four KTR and 28 controls were vaccinated. Antibody titer was lower in KTR than in controls [median (IQR): 803 (206, 1744) vs. 8023 (3032, 30,052) AU/mL, p < 0.001]. Fourteen KTR received third vaccine. Antibody titer post booster in KTR reached similar levels to those of controls post two doses [median (IQR) 5923 (2295, 12,278) vs. 8023 (3034, 30,052) AU/mL, p = 0.37] and to KTR post natural infection [5282 AU/mL (2583, 13,257) p = 0.8]. CONCLUSION: Serologic response to COVID-19 infection was significantly higher in KTR than in controls. Antibody level in KTR was higher in response to infection vs. vaccination, contrary to reports in the general population. Response to vaccination in KTR reached levels comparable to controls only after third vaccine.

Early Hypocalcemia in Pediatric Major Trauma: A Retrospective Cohort Study.

OBJECTIVE: Early hypocalcemia (EH) is common in adult major trauma patients and has been associated with coagulopathy, shock, increased transfusion requirements, and mortality. The incidence of EH in pediatric severe trauma has not been investigated. We aimed to explore the incidence of EH among severely injured children. METHODS: We conducted a retrospective cohort study at a tertiary children's hospital and a level 1 pediatric trauma center. We extracted the medical records of all pediatric major trauma patients, defined as an age less than 18 years and an Injury Severity Score (ISS) greater than 15, admitted after trauma team activation from January 2010 to December 2020.The primary outcome was the presence of EH. Patients were classified into 3 groups: severe hypocalcemia (ionized calcium [iCa] <1 mmol/L), hypocalcemia (1 < iCa < 1.16 mmol/L), and normal calcium (iCa ≥1.16 mmol/L). RESULTS: During the study period, 5126 children were hospitalized because of trauma. One hundred eleven children met the inclusion criteria. The median age was 11 years (interquartile range [IQR], 4-15), and 78.4% (87) were male. The median ISS was 21 (IQR, 17-27).Hypocalcemia was found in 19.8% (22) and severe hypocalcemia in 2.7% (3) of the patients.Although not statistically significant, hypocalcemic pediatric trauma patients had higher ISS (25.5 [IQR, 17-29] vs 21 [IQR, 17-26], P = 0.39), lower Glasgow Coma Scale (11 [IQR, 3-15] vs 13 [IQR, 7-15], P = 0.24), a more prolonged hospital stay (8 days [IQR, 2-16] vs 6 days [IQR, 3-13], P = 0.36), a more frequent need for blood products (27.3% vs 20.2%, P = 0.74), and higher mortality rates (9.1% vs 1.1%, P = 0.18) compared with normocalcemic patients. CONCLUSIONS: Our data suggest that in the setting of major trauma, EH is less frequent in children than previously reported in adults. Our preliminary data suggest that pediatric patients with EH may be at risk of increased morbidity and mortality compared with children with normal admission iCa requiring further studies.