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.

Obesity Protects Against Operation in Pediatric Penetrating Trauma to the Torso.

BACKGROUND: Studies in the adult population are conflicting regarding whether obesity is protective in penetrating trauma. In the pediatric population, data on obesity and penetrating trauma are limited. We sought to determine if there is a different rate of operation or of survival in pediatric and adolescent patients with obesity. METHODS: We queried the National Trauma Data Bank research data set from 2013 to 2016 for all patients aged 2-18 who sustained traumatic penetrating injuries to the thorax and abdomen. The cohort was divided into body mass index percentiles for gender and age using Center for Disease Control definitions. Outcomes included overall survival, whether or not an operative procedure was performed, and hospital and intensive care unit (ICU) length of stay. RESULTS: We analyzed 9611 patients with penetrating trauma, of which 4285 had an operative intervention. When adjusted for other variables (age, gender, race, ICU length of stay, hospital length of stay, and Injury Severity Score), children of every body mass index percentile had similar survival. Healthy weight patients were more likely to get an operation than patients in the obese category. Length of hospital stay was similar between groups, but the ICU length of stay was longer in the overweight and obese groups compared with healthy weight and underweight groups. CONCLUSIONS: Children and adolescents with obesity are less likely to undergo operation after penetrating thoracoabdominal trauma. Further study is needed to determine the reason for this difference.

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.

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.

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.

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.

Bicycle helmet legislation and injury patterns in trauma patients under age 18.

BACKGROUND: The California statewide helmet law was enacted in 1994, and required all cyclists under age 18 y to be helmeted when riding a bicycle. The purpose of this study is to describe helmet use patterns, rates of head and intra-abdominal injury in Los Angeles County before and after helmet legislation, and to determine if increasing helmet use is changing injury patterns. METHODS: We conducted a retrospective review of trauma patients under age 18 y in the Los Angeles County trauma database between 1992 and 2009 injured while riding bicycles. We examined the variables of age, gender, race, Glasgow Coma Score, Injury Severity Score, presence of head injury, presence of abdominal injury, and use of protective helmet. RESULTS: During this time period, there were 44,187 injured children less than 18 y of age, and there were 1684 bike-related traumas with data on helmet use. Injury patterns did not change after the helmet law, with head injuries predominating. CONCLUSIONS: The rate of helmet use did not change after California legislation, and head injury remains a major source of morbidity. Rates of abdominal injury over this time period did not change. Novel strategies are needed to increase helmet use in at-risk populations.

P-glycoprotein induction by breast milk attenuates intestinal inflammation in experimental necrotizing enterocolitis.

P-glycoprotein (Pgp), a product of the multi-drug resistance gene MDR1a, is a broad specificity efflux ATP cassette transmembrane transporter that is predominantly expressed in epithelial tissues. Because mdr1a(-/-) mice tend to develop spontaneous colitis in bacteria-dependent manner, Pgp is believed to have a role in protection of the intestinal epithelium from luminal bacteria. Here we demonstrate that levels of Pgp in the small intestine of newborn rodents dramatically increase during breastfeeding, but not during formula feeding (FF). In rats and mice, levels of intestinal Pgp peak on days 3-7 and 1-5 of breastfeeding, respectively. The mdr1a(-/-) neonatal mice subjected to FF, hypoxia, and hypothermia have significantly higher incidence and pathology, as well as significantly earlier onset of necrotizing enterocolitis (NEC) than congenic wild type mice. Breast-fed mdr1a(-/-) neonatal mice are also more susceptible to intestinal damage caused by the opportunistic pathogen Cronobacter sakazakii that has been associated with hospital outbreaks of NEC. Breast milk, but not formula, induces Pgp expression in enterocyte cell lines in a dose- and time-dependent manner. High levels of ectopically expressed Pgp protect epithelial cells in vitro from apoptosis induced by C. sakazakii. Taken together, these results show that breast milk-induced expression of Pgp may have a role in the protection of the neonatal intestinal epithelium from injury associated with nascent bacterial colonization.

Laparotomy complications on extracorporeal life support: Surgical site bleeding does not increase mortality.

PURPOSE: The risks of laparotomy during extracorporeal life support (ECLS) are poorly defined. We examined risk factors associated with bleeding and mortality after laparotomy on ECLS. METHODS: The Extracorporeal Life Support Organization (ELSO) database was queried for all pediatric patients [0-17 years] with a procedure code for laparotomy. Outcome data were analyzed to define factors contributing to laparotomy complications and mortality while on ECLS. Univariate and multivariate analyses were applied to determine independent risk factors. RESULTS: 196 patients who met inclusion criteria were identified. The mortality rate in the entire cohort was 67.3%. In both univariate and multivariate analyses, surgical site bleeding did not significantly increase the risk of mortality (OR 0.8; 95% CI 0.4-1.7). Logistic regression analysis revealed that lower gestational age, infectious complications and nonsurgical site hemorrhagic complications were independently increased mortality risk (all p < 0.05). CONCLUSION: Mortality following laparotomy on ECLS is not independently associated with surgical site bleeding, but is associated with lower gestational age, infectious and nonsurgical site hemorrhagic complications. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

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.

The biological prosthesis is a viable option for abdominal wall reconstruction in pediatric high risk defects.

BACKGROUND: Our aim was to explore the indications for and outcome of biological prostheses to repair high risk abdominal wall defects in children. METHODS: A retrospective chart review was performed of all cases of abdominal wall reconstruction in a single institution between 2007 and 2015. Demographic and clinical variables, technique and complications were described and compared between prosthesis types. RESULTS: A total of 23 patients underwent abdominal wall reconstruction using a biological prosthesis including 17 neonates. The main indication was gastroschisis (17 patients) followed by ruptured omphalocele and miscellaneous conditions. Alloderm™ was most commonly used followed by Surgisis™, Strattice™, Flex-HD™ and Permacol™. In 22 cases wounds were contaminated or infected. Open bowel/stomas were present in 9 cases. Skin was not closed in 11 cases. Post-operative complication rate was 30% and hernia recurrence rate was 17% after a mean follow-up time of 16 months. CONCLUSIONS: The use of a biological prosthesis may offer advantages over a synthetic mesh in pediatric high risk abdominal wall defects. The surgeon should be ready to consider its use in selected cases.

Tubularized Gastric Conduit is More Desirable in Pediatric Patients Treated with Minimally Invasive Esophagectomy and Gastric Pull-Up.

INTRODUCTION: Conditions requiring an esophagectomy and esophageal replacement are rare in children. The preferred method and ideal replacement organ continue to be debated. We present long-term outcomes in children treated with esophagectomy and gastric pull-up. METHODS: We conducted a retrospective review of all the patients who underwent a esophagectomy and gastric pull-up at two major pediatric institutions from 2004 to 2015. Follow-up data were obtained for children when available, including any postoperative complications, need for dilation of strictures, and current feeding method. RESULTS: Minimally invasive procedures were performed on 7 patients (5 female and 2 male) with a median age of 3 years (range 2-20, standard deviation = 8). Three patients successfully underwent laparoscopic transhiatal esophagectomy and cervical gastric pull-up, and three patients successfully underwent combined laparoscopic and right thoracoscopic (Ivor-Lewis) esophagectomy and cervical gastric pull-up. We identified an additional 3 patients who had an open esophagectomy and gastric pull-up. Seven patients had tubularized gastric conduits, six without pyloroplasty and one with pyloroplasty. For those patients with tubularized conduits, the average time to achieve full oral feeds was 16 days, with 1 patient with pyloroplasty who took 27 days. Of the three whole-stomach conduits, one reached oral independence at 19 days and the other two had yet tolerated anything per os. Follow-up data were available for all patients. At the average 5 years follow-up (ranging from 1 month to 7 years), all but two were thriving well with full oral feeds. CONCLUSIONS: Minimally invasive esophagectomy and gastric pull-up is a good alternative in managing pediatric patients in need of esophagectomy and replacement; it offers acceptable early and long-term outcomes. Tubularized conduit appears to be superior to using the whole stomach and potentially avoids pyloroplasty. Ongoing study is needed to validate our findings.

Combined laparoscopic-endoscopic placement of primary gastrojejunal feeding tubes in children: a preliminary report.

BACKGROUND: Placement of a primary gastrojejunal tube (GJT) can be technically challenging and often requires an open procedure to negotiate the tube past the duodenal sweep into the jejunum. The alternative approach is to first place a gastrostomy tube (GT), which is then changed to a GJT under endoscopic or fluoroscopic guidance after waiting 6-8 weeks to allow the stoma to mature. We report a case series of primary GJT placement using a combined laparoscopic-endoscopic approach. SUBJECTS AND METHODS: We retrospectively reviewed patients who underwent a combined laparoscopic-endoscopic primary GJT placement. Patients' demographics and relevant clinical information were analyzed. RESULTS: Six patients (4 male, 2 female) were identified. The median age at the time of operation was 30.2 months (range, 28 days-10 years). Five GJTs were successfully placed laparoscopically/endoscopically, and one procedure was converted to open. The mean operative time was 84 minutes (range, 63-102 minutes). Postoperative abdominal radiography confirmed post-pyloric tube position in all patients. Feedings were initiated on the first postoperative day. One intraoperative complication required conversion to an open procedure. No patients developed postoperative complications. CONCLUSIONS: Laparoscopic-endoscopic primary GJT placement is technically feasible and an excellent alternative in patients who require transpyloric feeding access.

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.