The BIG Score and Prediction of Mortality in Pediatric Blunt Trauma.

OBJECTIVES: To examine the association between in-hospital mortality and the BIG (composed of the base deficit [B], International normalized ratio [I], Glasgow Coma Scale [G]) score measured on arrival to the emergency department in pediatric blunt trauma patients, adjusted for pre-hospital intubation, volume administration, and presence of hypotension and head injury. We also examined the association between the BIG score and mortality in patients requiring admission to the intensive care unit (ICU). STUDY DESIGN: A retrospective 2001-2012 trauma database review of patients with blunt trauma ≤ 17 years old with an Injury Severity score ≥ 12. Charts were reviewed for in-hospital mortality, components of the BIG score upon arrival to the emergency department, prehospital intubation, crystalloids ≥ 20 mL/kg, presence of hypotension, head injury, and disposition. RESULTS: 50/621 (8%) of the study patients died. Independent mortality predictors were the BIG score (OR 11, 95% CI 6-25), prior fluid bolus (OR 3, 95% CI 1.3-9), and prior intubation (OR 8, 95% CI 2-40). The area under the receiver operating characteristic curve was 0.95 (CI 0.93-0.98), with the optimal BIG cutoff of 16. With BIG <16, death rate was 3/496 (0.006, 95% CI 0.001-0.007) vs 47/125 (0.38, 95% CI 0.15-0.7) with BIG ≥ 16, (P < .0001). In patients requiring admission to the ICU, the BIG score remained predictive of mortality (OR 14.3, 95% CI 7.3-32, P < .0001). CONCLUSIONS: The BIG score accurately predicts mortality in a population of North American pediatric patients with blunt trauma independent of pre-hospital interventions, presence of head injury, and hypotension, and identifies children with a high probability of survival (BIG <16). The BIG score is also associated with mortality in pediatric patients with trauma requiring admission to the ICU.

A Canadian children's hospital's experience with cystic echinococcosis over 30 years: A case series.

Background: Cystic echinococcosis (CE) or hydatid disease caused by the cestode Echinococcus granulosus sensu lato is an uncommon infection in Canada especially among children. There are limited reports describing the clinical presentation and management in Canadian children. Methods: The medical records of all children diagnosed with CE at a quaternary paediatric centre in Ontario between January 1988 and August 2021 were retrospectively reviewed. The clinical course, management, and outcomes of each case were summarized. Results: We report two paediatric cases of cystic echinococcosis (CE) in detail and review four additional cases seen at our institution over 33.5 years. The first case was a previously healthy 12-year-old boy with pulmonary CE resulting in unilateral lung collapse and mediastinal shift, who was presumedly infected while living in the Middle East. The second case was a previously healthy 3-year-old girl with pulmonary CE acquired locally in southern Ontario. Four other cases of CE with hepatic involvement (median age 12.5 years) were identified during the study period. Five out of six patients received both surgical and medical therapy. Conclusion: CE is a rare but serious disease seen in southern Canada that has historically been associated with travel or migration. Due to changes in urban wildlife landscapes and increased global migration, CE may become more prevalent in Canadian children. We describe the first locally acquired case in rural southern Ontario diagnosed at our centre. Prompt recognition of this infection in children by health care providers is important to prevent morbidity and mortality.

Historique: L'échinococcose kystique (ÉK), ou hydatidose, causée par le cestode Echinococcus granulosus sensu lato, est une infection peu courante au Canada, particulièrement chez les enfants. Peu de rapports en décrivent la présentation clinique et la prise en charge chez les enfants canadiens. Méthodologie: Les auteurs ont procédé à l'analyse rétrospective des dossiers médicaux de tous les enfants ayant reçu un diagnostic d'ÉK dans un centre pédiatrique de soins quaternaires ontarien entre janvier 1988 et août 2021. Ils ont résumé l'évolution clinique, la prise en charge et le résultat clinique de chaque cas. Résultats: Les auteurs font un compte rendu détaillé de deux cas pédiatriques d'ÉK et analysent quatre autres cas observés à leur établissement sur une période de 33,5 ans. Le premier cas d'ÉK pulmonaire a touché un garçon de 12 ans auparavant en santé, probablement infecté alors qu'il habitait au Moyen-Orient, et a entraîné un collapsus pulmonaire unilatéral et une déviation médiastinale. Le deuxième cas d'ÉK pulmonaire a été observé chez une fillette de trois ans auparavant en santé qui a été infectée dans le sud de l'Ontario. Les auteurs ont relevé quatre autres cas d'ÉK comportant une atteinte hépatique (âge médian de 12,5 ans) pendant la période de l'étude. Cinq des six patients ont reçu à la fois un traitement chirurgical et médical. Conclusion: L'ÉK est une maladie rare, mais grave dans le sud du Canada. Elle était auparavant associée à un voyage ou une migration. En raison des changements aux paysages fauniques urbains et de la migration mondiale accrue, elle pourrait devenir plus prévalente chez les enfants canadiens. Les auteurs décrivent les premiers cas d'acquisition dans les régions rurales du sud de l'Ontario, diagnostiqués à leur centre. Il est important que les dispensateurs de soins dépistent cette infection rapidement chez les enfants pour éviter la morbidité et la mortalité.

Time to internal fixation of femoral neck fractures in patients under sixty years--does this matter in the development of osteonecrosis of femoral head?

PURPOSE: Osteonecrosis of femoral head remains a major complication of femoral neck fractures. It has been postulated that early internal fixation drastically reduces the incidence of osteonecrosis of the femoral head. However, there is a paucity of literature looking at the effect of time delay to internal fixation on the development of this late complication. In this study, we aim to assess the effect of time delay and method of internal fixation on the development of osteonecrosis in those less than 60 years of age. METHODS: We retrospectively analysed 92 patients less than 60 years of age who presented with intracapsular neck of femur fractures that underwent internal fixation between 1999 and 2009. RESULTS: Of the 92 intracapsular fractures, 50 underwent fixation using cannulated screws, 32 using a dynamic hip screw, and ten using a dynamic hip screw with a derotation screw. In total, 13 patients (14.1 %) developed osteonecrosis of the femoral head, the highest incidence being in the cannulated screw fixation group with an osteonecrosis rate of 24 %. We did not find the time delay to internal fixation to be a significant predictor of the development of osteonecrosis. CONCLUSION: Our study demonstrated that the method of internal fixation rather than delay in internal fixation was more predictive of osteonecrosis of the femoral head. We did not find support to the current belief that early surgical fixation of neck of femur fractures reduces the risk of osteonecrosis in patients less than 60 years.

Teaching skills training for medical students.

BACKGROUND: The UK General Medical Council has recommended that medical students be taught how to teach; however, the current state of teaching skills training in England has not yet been investigated. AIMS: To explore the current state of undergraduate teaching skills training at medical schools in England. METHODS: A questionnaire survey was sent to all 24 medical schools in England, enquiring about the basic structure, content areas, staffing, delivery and assessment methods of compulsory courses. RESULTS: A response rate of 22/24 (92%) was achieved, and 18/22 (82%) of the responding institutions offered some form of teaching skills training. The most frequently covered content areas were small group facilitation skills, large group teaching skills and use of effective feedback. Teaching was delivered by a combination of hospital doctors, non-physician educators or general practitioner educators in the majority of courses. Six of the nine (67%) compulsory courses featured student assessments. The main barriers to implementing these courses were staffing limitations, insufficient time and lack of student engagement. CONCLUSIONS: Our study demonstrates both the similarities and variation between undergraduate teaching skills courses across England. However, further research will be necessary to determine whether the long-term impact of such training will result in better educators, and ultimately in improved patient care.

Emotion enhanced retention of cognitive skill learning.

Ample evidence suggests that emotional arousal enhances declarative/episodic memory. By contrast, there is little evidence that emotional enhancement of memory (EEM) extends to procedural skill based memory. We examined remote EEM (1.5-month delay) for cognitive skill learning using the weather prediction (WP) probabilistic classification task. Participants viewed interleaved emotionally arousing or neutral pictures during WP acquisition. Arousal retarded initial WP acquisition. While participants in the neutral condition showed substantial forgetting of WP learning across the 1.5-month delay interval, the arousal condition showed no evidence of forgetting across the same time period. Thus, arousal during encoding determined the mnemonic fate of cognitive skill learning. Emotional enhancement of WP retention was independent of verbally stated knowledge of WP learning and EEM for the picture contexts in which learning took place. These results reveal a novel demonstration of EEM for cognitive skill learning, and suggest that emotional arousal may in parallel enhance the neural systems that support procedural learning and its declarative context.

High beta-cell mass prevents streptozotocin-induced diabetes in thioredoxin-interacting protein-deficient mice.

Thioredoxin-interacting protein (TxNIP) is an endogenous inhibitor of thioredoxin, a ubiquitous thiol oxidoreductase, that regulates cellular redox status. Diabetic mice exhibit increased expression of TxNIP in pancreatic islets, and recent studies suggest that TxNIP is a proapoptotic factor in beta-cells that may contribute to the development of diabetes. Here, we examined the role of TxNIP deficiency in vivo in the development of insulin-deficient diabetes and whether it impacted on pancreatic beta-cell mass and/or insulin secretion. TxNIP-deficient (Hcb-19/TxNIP(-/-)) mice had lower baseline glycemia, higher circulating insulin concentrations, and higher total pancreatic insulin content and beta-cell mass than control mice (C3H). Hcb-19/TxNIP(-/-) did not develop hyperglycemia when injected with standard multiple low doses of streptozotocin (STZ), in contrast to C3H controls. Surprisingly, although beta-cell mass remained higher in Hcb-19/TxNIP(-/-) mice compared with C3H after STZ exposure, the relative decrease induced by STZ was as great or even greater in the TxNIP-deficient animals. Consistently, cultured pancreatic INS-1 cells transfected with small-interfering RNA against TxNIP were more sensitive to cell death induced by direct exposure to STZ or to the combination of inflammatory cytokines interleukin-1beta, interferon-gamma, and tumor necrosis factor-alpha. Furthermore, when corrected for insulin content, isolated pancreatic islets from TxNIP(-/-) mice exhibited reduced glucose-induced insulin secretion. These data indicate that TxNIP functions as a regulator of beta-cell mass and influences insulin secretion. In conclusion, the relative resistance of TxNIP-deficient mice to STZ-induced diabetes appears to be because of an increase in beta-cell mass. However, TxNIP deficiency is associated with sensitization to STZ- and cytokine-induced beta-cell death, indicating complex regulatory roles of TxNIP under different physiological and pathological conditions.

Rapid consolidation of motor memory in the vestibuloocular reflex.

Motor memory is relatively labile immediately after learning but can become more stable through consolidation. We investigated consolidation of motor memory in the vestibuloocular reflex (VOR). Cats viewed the world through telescopic lenses during 60 min of passive rotation. Learned decreases (gain-down learning) and increases in the VOR gain (gain-up learning) were measured during sinusoidal rotation at 2 Hz. We found that if rotation in darkness immediately followed learning, the gain of the VOR reverted toward its prelearning value, indicating that expression of the memory was disrupted. If after gain-down learning the cat spent another 60 min stationary without form vision, subsequent disruption did not occur, suggesting that memory had consolidated. Consolidation was less robust for gain-up learning. We conclude that memory in the VOR is initially labile but consolidates rapidly and consistently after gain-down learning.