Collaborative Implementation of Robotic Surgery Into an Academic Pediatric Surgery Practice.

INTRODUCTION: Robotic surgery continues to drive evolution in minimally invasive surgery. Due to the confined operative fields encountered, pediatric surgeons may uniquely benefit from the precise control offered by robotic technologies compared to open and laparoscopic techniques. We describe a unique collaborative implementation of robotic surgery into an academic pediatric surgery practice through adult robotic surgeon partnership. We compare robotic cholecystectomy (RC) and laparoscopic cholecystectomy (LC) outcomes, hypothesizing that RC will be equivalent to LC in key quality outcomes. METHODS: We evaluate 14 mo of systems development and training, and 24 mo of collaborative operative experience evoking a purposeful tiered case progression, establishing core robotic competencies, prior to advancing operative complexity. Univariate analyses compared LC versus RC. RESULTS: 36 robotic operations were performed in children aged 8-18 y, in a tiered progression from 24 cholecystectomies to 2 ileocecectomies, 2 paraesophageal hernia repairs, 1 anterior rectopexy, 1 spleen-preserving distal pancreatectomy, 1 Heller myotomy, 1 choledochal cyst resection with roux-en-y hepaticojejunostomy, 1 median arcuate ligament release, and 1 thoracic esophageal duplication cyst resection. For LC and RC, there were no significant differences in procedure duration, discharge opioids, hospital readmission, or rates of surgical site infection or bile duct injury. CONCLUSIONS: Robotic surgery has potential to significantly enhance pediatric surgery. RC appears equivalent to LC but presents multiple additional theoretical benefits in pediatric patients. Our pilot program experience supports the feasibility and safety of pediatric robotic surgery. We emphasize the importance of a stepwise progression in operative difficulty and collaboration with adult robotic surgery experts.

A systematic review of large language models and their implications in medical education.

INTRODUCTION: In the past year, the use of large language models (LLMs) has generated significant interest and excitement because of their potential to revolutionise various fields, including medical education for aspiring physicians. Although medical students undergo a demanding educational process to become competent health care professionals, the emergence of LLMs presents a promising solution to challenges like information overload, time constraints and pressure on clinical educators. However, integrating LLMs into medical education raises critical concerns and challenges for educators, professionals and students. This systematic review aims to explore LLM applications in medical education, specifically their impact on medical students' learning experiences. METHODS: A systematic search was performed in PubMed, Web of Science and Embase for articles discussing the applications of LLMs in medical education using selected keywords related to LLMs and medical education, from the time of ChatGPT's debut until February 2024. Only articles available in full text or English were reviewed. The credibility of each study was critically appraised by two independent reviewers. RESULTS: The systematic review identified 166 studies, of which 40 were found by review to be relevant to the study. Among the 40 relevant studies, key themes included LLM capabilities, benefits such as personalised learning and challenges regarding content accuracy. Importantly, 42.5% of these studies specifically evaluated LLMs in a novel way, including ChatGPT, in contexts such as medical exams and clinical/biomedical information, highlighting their potential in replicating human-level performance in medical knowledge. The remaining studies broadly discussed the prospective role of LLMs in medical education, reflecting a keen interest in their future potential despite current constraints. CONCLUSIONS: The responsible implementation of LLMs in medical education offers a promising opportunity to enhance learning experiences. However, ensuring information accuracy, emphasising skill-building and maintaining ethical safeguards are crucial. Continuous critical evaluation and interdisciplinary collaboration are essential for the appropriate integration of LLMs in medical education.

Characteristics and predictors of intensive care unit admission in pediatric blunt abdominal trauma.

BACKGROUND: Pediatric trauma patients sustaining blunt abdominal trauma (BAT) with intra-abdominal injury (IAI) are frequently admitted to the intensive care unit (ICU). This study was performed to identify predictors for ICU admission following BAT. METHODS: Prospective study of children (< 16 years) who presented to 14 Level-One Pediatric Trauma Centers following BAT over a 1-year period. Patients were categorized as ICU or non-ICU patients. Data collected included vitals, physical exam findings, laboratory results, imaging, and traumatic injuries. A multivariable hierarchical logistic regression model was used to identify predictors of ICU admission. Predictive ability of the model was assessed via tenfold cross-validated area under the receiver operating characteristic curves (cvAUC). RESULTS: Included were 2,182 children with 21% (n = 463) admitted to the ICU. On univariate analysis, ICU patients were associated with abnormal age-adjusted shock index, increased injury severity scores (ISS), lower Glasgow coma scores (GCS), traumatic brain injury (TBI), and severe solid organ injury (SOI). With multivariable logistic regression, factors associated with ICU admission were severe trauma (ISS > 15), anemia (hematocrit < 30), severe TBI (GCS < 8), cervical spine injury, skull fracture, and severe solid organ injury. The cvAUC for the multivariable model was 0.91 (95% CI 0.88-0.92). CONCLUSION: Severe solid organ injury and traumatic brain injury, in association with multisystem trauma, appear to drive ICU admission in pediatric patients with BAT. These results may inform the design of a trauma bay prediction rule to assist in optimizing ICU resource utilization after BAT. STUDY DESIGN: Prognosis study.

Life-Threatening Bleeding in Children: A Prospective Observational Study.

OBJECTIVES: The purpose of our study was to describe children with life-threatening bleeding. DESIGN: We conducted a prospective observational study of children with life-threatening bleeding events. SETTING: Twenty-four childrens hospitals in the United States, Canada, and Italy participated. SUBJECTS: Children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under massive transfusion protocol were included. INTERVENTIONS: Children were compared according bleeding etiology: trauma, operative, or medical. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, therapies administered, and clinical outcomes were analyzed. Among 449 enrolled children, 55.0% were male, and the median age was 7.3 years. Bleeding etiology was 46.1% trauma, 34.1% operative, and 19.8% medical. Prior to the life-threatening bleeding event, most had age-adjusted hypotension (61.2%), and 25% were hypothermic. Children with medical bleeding had higher median Pediatric Risk of Mortality scores (18) compared with children with trauma (11) and operative bleeding (12). Median Glasgow Coma Scale scores were lower for children with trauma (3) compared with operative (14) or medical bleeding (10.5). Median time from bleeding onset to first transfusion was 8 minutes for RBCs, 34 minutes for plasma, and 42 minutes for platelets. Postevent acute respiratory distress syndrome (20.3%) and acute kidney injury (18.5%) were common. Twenty-eight-day mortality was 37.5% and higher among children with medical bleeding (65.2%) compared with trauma (36.1%) and operative (23.8%). There were 82 hemorrhage deaths; 65.8% occurred by 6 hours and 86.5% by 24 hours. CONCLUSIONS: Patient characteristics and outcomes among children with life-threatening bleeding varied by cause of bleeding. Mortality was high, and death from hemorrhage in this population occurred rapidly.

The Pediatric Critical Care Trauma Scientist Development: Building a Community of Scientists for the Fields of Pediatric Critical Care and Trauma Surgery.

OBJECTIVES: To assess the National Institute of Child Health and Human Development's Pediatric Critical Care Trauma Scientist Development Program national K12 program. DESIGN: Mixed-methods study. SETTING: Pediatric Critical Care Trauma Scientist Development Program participants from 2005 to 2018. SUBJECTS: Past participants in the Pediatric Critical Care Trauma Scientist Development Program, including those who received funding (scholars), those who did not receive funding (applicants), and those who participated as diversity fellows. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Thirty-four past scholars, participants, and fellows in the Pediatric Critical Care Trauma Scientist Development were interviewed, including 19 women (56%) and 15 men (44%) via Skype. Interviews were audio recorded and transcribed, with permission. Codes were developed, using qualitative methods, that included the following: Community Building and Mentorship, Career and Research Development, and Tensions and Growth Opportunities. Quantitative data about physician-scholar grant success were retrieved from the National Institutes of Health system to search for funded grants, RePORT, physician-scholar curriculum vitae, and university websites. Since inception of the program, 46 scholars have been appointed. Scholars are equally split between women and men. Four members of the total cohort (9%) are from under-represented minority groups in medicine. Among the total past 46 participants, 72% of those who completed the K12 achieved an National Institutes of Health K-award and 36% of those not on K-level funding achieved at least one Research Program Grant-level award. All scholars, except one, remain academically active, as noted by recent publications in the peer reviewed literature; scholars from 2005 to 2013 are progressing in their careers, with 60% promoted to associate or full professor. CONCLUSIONS: The Pediatric Critical Care Trauma Scientist Development Program is reaching its programmatic goals of buildin g a community of scientists in pediatric critical care and trauma surgery as shown by the qualitative analysis. Key challenges include increasing the diversity of applicants, encouraging applicants who are not funded, increasing the rate of K- to R-conversion, and preserving National Institute of Child Health and Human Development Program priorities for national K12 programs and individual K-awards.

Interactive Education is Associated With Lower Incidence of Pedestrian-Related Injury in Children.

BACKGROUND: Pedestrian-related injuries are a significant contributor to preventable mortality and disability in children. We hypothesized that interactive pedestrian safety education is associated with increased knowledge, safe crosswalk behaviors, and lower incidence of pedestrian-related injuries in elementary school-aged children. METHODS: An interactive street-crossing simulation was implemented at target elementary schools in Los Angeles County beginning in 2009. Mixed-methods were used to evaluate the impact of this intervention. Multiple-choice examinations were used to test pedestrian safety knowledge, anonymous observations were used to assess street-crossing behaviors, and statewide traffic records were used to report pedestrian injuries in elementary school-aged (4-11 y) children in participating school districts. Pedestrian injury incidence was compared 1 y before and after the intervention, standardized to the incidence in the entire City of Los Angeles. RESULTS: A total of 1424 and 1522 children completed the pretest and post-test, respectively. Correct answers increased for nine of ten questions (all P < 0.01). Children more frequently looked both ways before crossing the street after the intervention (10% versus 41%, P < 0.001). There were 6 reported pedestrian-related injuries in intervention school districts in the year before the intervention and 2 injuries in the year after the intervention, resulting in a significantly lower injury incidence (standardized rate ratio 0.28; 95% CI, 0.11-0.73). CONCLUSION: Pedestrian safety education at Los Angeles elementary schools was associated with increased knowledge, safe street-crossing behavior, and lower incidence of pediatric pedestrian-related injury. Formal pedestrian safety education should be considered with injury prevention efforts in similar urban communities.

Pediatric dog bites: a population-based profile.

BACKGROUND: Previous studies have identified risk factors for dog bites in children, but use data from individual trauma centers, with limited generalizability. This study identifies a population risk profile for pediatric dog bites using the National Trauma Data Bank. We hypothesized that the population at risk was younger boys, that such bites occur at home, are moderately severe, and are on the face or neck. METHODS: For this retrospective cross-sectional study, a sample of 7912 children 17 years old and younger with International Classification of Diseases (ICD)-9 event code E906.0, for dog bites, were identified. Datasets from 2007 to 2014 were used. Data included patient's gender, age, ICD-9 primary and location E-codes, AIS body region and AIS severity. RESULTS: Most children were 6-12 years old and female, but a similar number fell into the narrower range of 0-2 years old. Injuries in the younger group frequently occurred at home, on the face and head, and with minor severity. Age of the child predicts the location of incident (P<0.001), the severity of injury (P<0.001) and the body region of the injury (P<0.001). Body region of the injury predicted its severity (P<0.001). DISCUSSION: Younger children are more likely to receive dog bites, and bites incurred are likely of greater severity. Children this young cannot yet be taught how to properly interact with a dog. CONCLUSIONS: Dog bites are a significant source of morbidity for children. Based on the population risk factors profile generated, this study recommends targeting live dog education towards the parents of young children.

Formative research experiences in pediatric surgeons: a mixed methods study of Pediatric Trauma Society members.

PURPOSE: A career in pediatric surgery has historically required extensive research experience, but the optimal research training is not well defined. The purpose of this study was to explore the formative research experiences among pediatric surgeons. METHODS: A 1-h focus group was held with 14 pediatric surgeons at the 2017 Pediatric Trauma Society annual meeting. A 17-item survey was also administered. Questions were intended to elicit discussion of prior research experiences. A qualitative analysis of the dialogue was performed. RESULTS: Seventy-seven percent of respondents completed a research fellowship. Most (77%) currently conduct clinical research. Participants most frequently desired additional training in study design (50%), NIH funding (43%), and grant preparation (43%). Seven themes were identified from the focus group: (1) Early research exposure is rudimentary; (2) Resume-building was a motivation; (3) Mentorship is important; (4) Institutional resources are vital; (5) Independent learning is necessary; (6) Protected time is limited; and (7) Basic science research is not always practical. CONCLUSIONS: Many pediatric surgeons feel that their research training can be improved upon. Formal mentorship, dedicated research time, and institutional resources were perceived to be important factors. Education in research study design, grant writing, and NIH funding may be beneficial. LEVEL OF EVIDENCE: V, expert opinion.

Management and outcomes of peripancreatic fluid collections and pseudocysts following non-operative management of pancreatic injuries in children.

BACKGROUND: Peripancreatic fluid collection and pseudocyst development is a common sequela following non-operative management (NOM) of pancreatic injuries in children. Our purpose was to review management strategies and assess outcomes. METHODS: A multicenter, retrospective review was conducted of children treated with NOM following blunt pancreatic injury at 22 pediatric trauma centers between the years 2010 and 2015. Organized fluid collections were called "acute peripancreatic fluid collection" (APFC) if identified < 4 weeks and "pseudocyst" if > 4 weeks following injury. Data analysis included descriptive statistics Wilcoxon rank-sum, Kruskal-Wallis and t tests. RESULTS: One hundred patients with blunt pancreatic injury were identified. Median age was 8.5 years (range 1-16). Forty-two percent of patients (42/100) developed organized fluid collections: APFC 64% (27/42) and pseudocysts 36% (15/42). Median time to identification was 12 days (range 7-42). Most collections (64%, 27/42) were observed and 36% (15/42) underwent drainage: 67% (10/15) percutaneous drain, 7% (1/15) needle aspiration, and 27% (4/15) endoscopic transpapillary stent. A definitive procedure (cystogastrostomy/pancreatectomy) was required in 26% (11/42). Patients with larger collections (≥ 7.1 cm) had longer time to resolution. Comparison of outcomes in patients with observation vs drainage revealed no significant differences in TPN use (79% vs 75%, p = 1.00), hospital length of stay (15 vs 25 median days, p = 0.11), time to tolerate regular diet (12 vs 11 median days, p = 0.47), or need for definitive procedure (failure rate 30% vs 20%, p = 0.75). CONCLUSIONS: Following NOM of blunt pancreatic injuries in children, organized fluid collections commonly develop. If discovered early, most can be observed successfully, and drainage does not appear to improve clinical outcomes. Larger size predicts prolonged recovery. LEVEL OF EVIDENCE: III STUDY TYPE: Case series.

Variability in the evalution of pediatric blunt abdominal trauma.

PURPOSE: To describe the practice pattern for routine laboratory and imaging assessment of children following blunt abdominal trauma (BAT). METHODS: Children (age < 16 years) presenting to 14 pediatric trauma centers following BAT over a 1-year period were prospectively identified. Injury, demographic, routine laboratory and imaging utilization data were collected. Descriptive, comparative, and correlation analysis was performed. RESULTS: 2188 children with a median age of 8 (4,12) years were included and the median injury severity score was 5 (1,10). There were significant differences in activation status, injury severity, and mechanism across centers; however, there was no correlation of level of activation, injury severity, or severe mechanism with test utilization. Routine laboratory and imaging utilization for hematocrit, hepatic enzymes, pancreatic enzymes, base deficit urine microscopy, chest and pelvis X-ray, and abdominal computed tomography (CT) varied significantly among centers. Only obtaining a hematocrit had a moderate correlation with CT use. There was no correlation between centers that were high or low frequency laboratory utilizers with CT use. CONCLUSIONS: Wide variability exists in the routine initial laboratory and imaging assessment in children following BAT. This represents an opportunity for quality improvement in pediatric trauma. LEVEL OF EVIDENCE: Level II.

Identifying Targets to Improve Coding of Child Physical Abuse at a Pediatric Trauma Center.

Child physical abuse is a leading cause of morbidity and mortality in young children. Identification of abused children is challenging, and can affect risk-adjusted benchmarking of trauma center performance. The purpose of this project was to understand diagnosis coding capture rates for child abuse and develop a standardized approach to clinician documentation to improve trauma registry capture. A retrospective cohort was obtained including all admitted trauma patients with injuries from known or suspected abusive mechanism in 2017. Patients who received forensic workup for child physical abuse were classified as "no abuse," "suspected abuse," and "confirmed abuse" using narratives from social work notes. Our trauma registry was used to abstract International Classification of Diseases, Tenth Revision (ICD-10) diagnostic and external cause codes for each patient. Abuse classifications defined by chart review were then compared with coding in the registry using crosstabs. A total of 115 patients were identified as having a forensic workup for child physical abuse. Patients who underwent forensic workup were classified as: 40% no abuse, 37% suspected abuse, and 23% confirmed abuse at the time of discharge. Three patients (6%) with a negative forensic workup were overcoded as suspected abuse in our trauma registry. Among patients with clinically confirmed abuse, our trauma registry identified only 63% by diagnostic codes and only 33% by external cause codes. Child physical abuse is frequently undercoded, and clear clinical documentation of the level of suspicion of abuse at discharge is needed to accurately identify abused patients.

Improving Disaster Preparedness of Families With a Parenteral Nutrition-dependent Child.

OBJECTIVES: Disruption in the care of special healthcare needs children may lead to life-threatening situations or preventable secondary conditions. California averages more than 100 earthquakes per week. Subsequent power outages, damage to utility systems, and road damage after an earthquake can have grave consequences for families with parenteral nutrition (PN)-dependent children. The purpose of the study was to demonstrate that we could improve disaster preparedness of families with PN-dependent children utilizing individualized family education and distribution of personalized disaster survival toolkits. METHODS: We administered a baseline survey to assess disaster preparedness of our families with PN-dependent children followed by individualized disaster survival toolkit distribution and education. We followed up with these families with phone call surveys at 2 and 4 months. A generalized estimating equation with both logistic and linear regression was used to analyze data over the follow-up period. RESULTS: We found statistically significant improvements in developing a family emergency plan (P < 0.0001), having a basic emergency supply kit (P < 0.0001), having a completed emergency information form from the child's provider (P < 0.0001), and the confidence level or readiness for a disaster (P < 0.0001). All participants had extra batteries for PN infusion pumps. Having alternative power sources, such as a generator, did not significantly change over time. CONCLUSIONS: Individualized disaster education helped families with PN-dependent children not only to prepare for a possible earthquake, but also to feel more confident in their ability to handle a natural disaster.

Heads Up, Phones Down: A Pedestrian Safety Intervention on Distracted Crosswalk Behavior.

Cell phone use has been implicated in driver distraction and motor vehicle crashes, and more recently has been associated with distracted pedestrians. There are limited data on interventions aimed at this important public health issue. We hypothesized that the use of a visual intervention near street crossings would decrease the frequency of distracted behaviors of pedestrians. We performed a prospective observational cohort study examining painted sidewalk stencils reading, "Heads Up, Phones Down" as an intervention to decrease cell phone distractions amongst pedestrians. These stenciled messages were placed at a children's hospital, middle school, and high school in Los Angeles County. Anonymous observations of pedestrian distractions (texting, talking on a phone, headphone use, and other) were conducted before, 1 week after, and 4 months after the intervention. Distractions were compared before and after intervention using Chi square tests. A total of 11,533 pedestrians were observed, with 71% children and 29% adults. Total distractions decreased from 23% pre-intervention to 17% 1 week after stencil placement (p < 0.01), but this was not sustained at 4 months (23%, p = 0.4). A sustained decrease was observed only for texting at 4 months post-intervention (8.5% vs. 6.8%, p < 0.01). A simple visual intervention reduced distracted cell phone usage in pedestrians crossing the street, but this was most effective early after the intervention. Future studies are warranted to determine how to sustain this effect over time and how to minimize other types of distractions.

Retrospective Cohort Comparison of Fall Height in Children in the Greater Los Angeles Area: Targeting Populations for Injury Prevention.

The purpose of this study was to determine whether falls from significant height occur more frequently in young children. We conducted a 10-year (2004-2014), comparative study using a retrospective cohort of 4713 children (< 18 years) from the Los Angeles county trauma database who were evaluated for a fall. Exposure was fall height, dichotomized into < 10 ft/low-risk fall and > 10 ft/high-risk fall. Primary outcome was age of fall. Secondary outcomes were disposition from emergency department, injuries, resource utilization, and mortality. Of all falls, 4481 (95%) were low-risk and 232 (5%) high-risk. High-risk falls were more frequent in children 1-3 years old (58 vs. 30%, p < 0.01), associated with higher frequency of intracranial hemorrhage (19 vs. 10%, p < 0.01), intubation (11 vs. 1%, p < 0.01), and neurosurgical procedure (2 vs. 0.8%, p = 0.04). There was no difference in mortality (0.86 vs. 0.13%, p = 0.06). In Los Angeles County, children 1-3 years old are most likely to suffer high-risk falls, which are associated with serious injury. Integration of fall prevention education into routine anticipatory guidance should be strongly considered for children 1-3 years old.

Impact of simulation-based training on perceived provider confidence in acute multidisciplinary pediatric trauma resuscitation.

PURPOSE: Simulation-based training has the potential to improve team-based care. We hypothesized that implementation of an in situ multidisciplinary simulation-based training program would improve provider confidence in team-based management of severely injured pediatric trauma patients. METHODS: An in situ multidisciplinary pediatric trauma simulation-based training program with structured debriefing was implemented at a free-standing children's hospital. Trauma providers were anonymously surveyed 1 month before (pre-), 1 month after (post-), and 2 years after implementation. RESULTS: Survey response rate was 49% (n = 93/190) pre-simulation, 22% (n = 42/190) post-simulation, and 79% (n = 150/190) at 2-year follow-up. These providers reported more anxiety (p = 0.01) and less confidence (p = 0.02) 1-month post-simulation. At 2-year follow-up, trained providers reported less anxiety (p = 0.02) and greater confidence (p = 0.01), compared to untrained providers. CONCLUSIONS: Implementation of an in situ multidisciplinary pediatric trauma simulation-based training program may initially lead to increased anxiety, but long-term exposure may lead to greater confidence. LEVEL OF EVIDENCE: II, Prospective cohort.

Specific Etiologies Associated With the Multiple Organ Dysfunction Syndrome in Children: Part 1.

OBJECTIVE: To describe a number of the conditions associated with multiple organ dysfunction syndrome presented as part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development multiple organ dysfunction syndrome workshop (March 26-27, 2015). DATA SOURCES: Literature review, research data, and expert opinion. STUDY SELECTION: Not applicable. DATA EXTRACTION: Moderated by an expert from the field, issues relevant to the association of multiple organ dysfunction syndrome with a variety of conditions were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities. DATA SYNTHESIS: Summary of presentations and discussion supported and supplemented by the relevant literature. CONCLUSIONS: There is a wide range of medical conditions associated with multiple organ dysfunction syndrome in children. Traditionally, sepsis and trauma are the two conditions most commonly associated with multiple organ dysfunction syndrome both in children and adults. However, there are a number of other pathophysiologic processes that may result in multiple organ dysfunction syndrome. In this article, we discuss conditions such as cancer, congenital heart disease, and acute respiratory distress syndrome. In addition, the relationship between multiple organ dysfunction syndrome and clinical therapies such as hematopoietic stem cell transplantation and cardiopulmonary bypass is also considered. The purpose of this article is to describe the association of multiple organ dysfunction syndrome with a variety of conditions in an attempt to identify similarities, differences, and opportunities for therapeutic intervention.

Specific Etiologies Associated With the Multiple Organ Dysfunction Syndrome in Children: Part 2.

OBJECTIVE: To describe a number of conditions and therapies associated with multiple organ dysfunction syndrome presented as part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Multiple Organ Dysfunction Workshop (March 26-27, 2015). In addition, the relationship between burn injuries and multiple organ dysfunction syndrome is also included although it was not discussed at the workshop. DATA SOURCES: Literature review, research data, and expert opinion. STUDY SELECTION: Not applicable. DATA EXTRACTION: Moderated by an expert from the field, issues relevant to the association of multiple organ dysfunction syndrome with a variety of conditions and therapies were presented, discussed, and debated with a focus on identifying knowledge gaps and the research priorities. DATA SYNTHESIS: Summary of presentations and discussion supported and supplemented by relevant literature. CONCLUSIONS: Sepsis and trauma are the two conditions most commonly associated with multiple organ dysfunction syndrome both in children and adults. However, many other pathophysiologic processes may result in multiple organ dysfunction syndrome. In this article, we discuss conditions such as liver failure and pancreatitis, pathophysiologic processes such as ischemia and hypoxia, and injuries such as trauma and burns. Additionally, therapeutic interventions such as medications, blood transfusions, transplantation may also precipitate and contribute to multiple organ dysfunction syndrome. The purpose of this article is to describe the association of multiple organ dysfunction syndrome with a variety of conditions and therapies in an attempt to identify similarities, differences, and opportunities for therapeutic intervention.

The Role of Adult Perceptions and Supervision Behavior in Preventing Child Injury.

Supervision is an important factor in reducing injury risk. There are multiple factors that can affect the appropriate level of supervision including risk perception, anticipation of injury, and distracted behaviors. This study examined the perceived risks of child injury among parents and child caregivers and their supervision behavior among adults in an urban playground. Participant data from 25 individuals were collected through observations and anonymous self-reported surveys. More than half of the participants indicated practice of appropriate supervisory behavior, including attentiveness to their child's behavior and proximity to their child during play. Caregivers were more likely to report more careful levels of supervision. One-fourth of participants reported a change in the supervisory behavior during periods of distraction, specifically with phone use. Of the variables tested, there was a significant association between the variable 'talking to other adults' during supervision and 'prior injury' (P value = 0.04, 95% CI 0.03-0.91). Parents were more likely to report that they would leave their child unattended if they believed that the playground was a safe environment for play. There was a difference between self-reported behaviors and actual observed behavior, which is likely due to varying perspectives regarding child safety and injury prevention. In regards to injury risk, findings highlight the important role of appropriate supervisory behaviors and risk perceptions in preventing child injuries.

Re-evaluation of liver transaminase cutoff for CT after pediatric blunt abdominal trauma.

PURPOSE: Current guidelines for computed tomography (CT) after blunt trauma were developed to capture all intra-abdominal injuries (IAI). We hypothesize that current AST/ALT guidelines are too low leading to unnecessary CT scans for children after blunt abdominal trauma (BAT). METHODS: Patients who received CT of the abdomen after blunt trauma at our Level I Pediatric Trauma Center were stratified into a high risk (HR) (liver/spleen/kidney grade ≥III, hollow viscous, or pancreatic injuries) and low risk (LR) (liver/kidney/spleen injuries grade ≤II, or no IAI) groups. RESULTS: 247 patients were included. Of the 18 patients in the HR group, two required surgery (splenectomy and sigmoidectomy). Transfusion was required in 30% of grade III and 50% of grade IV injuries. Eleven (5%) patients in LR group were transfused for indications other than IAI, and none were explored surgically. Both AST (r = 0.44, p < 0.001) and ALT (r = 0.43, p < 0.001) correlated with grade of liver injury. Using an increased threshold of AST/ALT, 400/200 had a negative predictive value of 96% in predicting the presence of HR liver injuries. CONCLUSION: The current cutoff of liver enzymes leads to over-identification of LR injuries. Consideration should be given to an approach that aims to utilize CT in pediatric BAT that identifies clinically HR injury.

Critical Violent Injury in the United States: A Review and Call to Action.

OBJECTIVE: This review provides an overview of what is known about violent injury requiring critical care, including child physical abuse, homicide, youth violence, intimate partner violence, self-directed injury, firearm-related injury, and elder physical abuse. DATA SOURCES: We searched PubMed, Scopus, Ovid Evidence-Based Medicine Reviews, and the National Guideline Clearinghouse. We also included surveillance data from the Centers for Disease Control and Prevention and National Trauma Data Bank. STUDY SELECTION: Search criteria limited to articles in English and reports of humans, utilizing the following search terms: intentional violence, intentional harm, violence, crime victims, domestic violence, child abuse, elder abuse, geriatric abuse, nonaccidental injury, nonaccidental trauma, and intentional injury in combination with trauma centers, critical care, or emergency medicine. Additionally, we included relevant articles discovered during review of the articles identified through this search. DATA EXTRACTION: Two hundred one abstracts were reviewed for relevance, and 168 abstracts were selected and divided into eight categories (child physical abuse, homicide, youth violence, intimate partner violence, self-directed injury, firearm-related injury, and elder physical abuse) for complete review by pairs of authors. In our final review, we included 155 articles (139 articles selected from our search strategy, 16 additional highly relevant articles, many published after we conducted our formal search). DATA SYNTHESIS: A minority of articles (7%) provided information specific to violent injury requiring critical care. Given what is known about violent injury in general, the burden of critical violent injury is likely substantial, yet little is known about violent injury requiring critical care. CONCLUSIONS: Significant gaps in knowledge exist and must be addressed by meaningful, sustained tracking and study of the epidemiology, clinical care, outcomes, and costs of critical violent injury. Research must aim for not only information but also action, including effective interventions to prevent and mitigate the consequences of critical violent injury.