Association of hyperchloremia and acute kidney injury in pediatric patients with moderate and severe traumatic brain injury.

PURPOSE: Acute kidney injury (AKI) is an established complication of adult traumatic brain injury (TBI) and known risk factor for mortality. Evidence demonstrates an association between hyperchloremia and AKI in critically ill adults but studies in children are scarce. Given frequent use of hypertonic saline in the management of pediatric TBI, we believe the incidence of hyperchloremia will be high and hypothesize that it will be associated with development of AKI. METHODS: Single-center retrospective cohort study was completed at an urban, level 1 pediatric trauma center. Children > 40 weeks corrected gestational age and < 21 years of age with moderate or severe TBI (presenting GCS < 13) admitted between January 2016 and December 2021 were included. Primary study outcome was presence of AKI (defined by pediatric Kidney Disease: Improving Global Outcomes criteria) within 7 days of hospitalization and compared between patients with and without hyperchloremia (serum chloride ≥ 110 mEq/L). RESULTS: Fifty-two children were included. Mean age was 5.75 (S.D. 5.4) years; 60% were male (31/52); and mean presenting GCS was 6 (S.D. 2.9). Thirty-seven patients (71%) developed hyperchloremia with a mean peak chloride of 125 (S.D. 12.0) mEq/L and mean difference between peak and presenting chloride of 16 (S.D. 12.7) mEq/L. Twenty-three patients (44%) developed AKI; of those with hyperchloremia, 62% (23/37) developed AKI, while among those without hyperchloremia, 0% (0/15) developed AKI (difference 62%, 95% CI 42-82%, p < 0.001). Attributable risk of hyperchloremia leading to AKI was 62.2 (95% CI 46.5-77.8, p = 0.0015). CONCLUSION: Hyperchloremia is common in the management of pediatric TBI and is associated with development of AKI. Risk appears to be associated with both the height of serum chloride and duration of hyperchloremia.

Prevalence of tobacco smoking among health-care physicians in Bahrain.

BACKGROUND: There is a clear shift in smoking habits among the Middle Eastern population with a recent and alarming increase in the prevalence of waterpipe (shisha) smoking. This phenomenon has not yet been studied sufficiently across the physician population. Therefore, we set out to establish the smoking status of primary healthcare physicians in the kingdom of Bahrain. METHODS: A self-administered questionnaire was distributed to a random sample of 175 out of the total 320 primary care physicians. Descriptive analysis was performed on all data and associations between variables were tested using Fishers Exact t test with statistical significance set as P-value < 0.05. RESULTS: One hundred and fifty two physicians agreed to participate in the study. Sixty seven percent of physicians were females and the mean (SD) age was 45 (10) years. The majority of the physicians were married (93%) and of Bahraini nationality (76%). Ever-smokers were 11% of the population while current smokers corresponded to 8.6%. Waterpipe was the most common method of tobacco smoking followed by cigarettes. Among male physicians, the prevalence of current 'waterpipe only' smokers was 12%, followed by 4% and 2% corresponding to 'cigarette only' smokers and both, respectively. There were only three female smokers in the population, two 'waterpipe only' smokers and one cigar smoker. Of those who smoked waterpipe (n = 9; 6%), 33% smoked daily, 44% smoked weekly and 22% smoked at least once a month. Current smoking status was associated with male gender (P < 0.001) and showed a male to female smoking ratio of (10:1). CONCLUSION: Waterpipe smoking rates exceeded cigarette smoking among the population of physicians in Bahrain. Prevalence of smoking remains unacceptably high among male physicians. Assessment of physicians' knowledge of the harmful effects of waterpipe tobacco smoking is warranted to plan future interventions.

Clinical Outcomes in Neurologically Intact Children With Small Intracranial Bleeds and Simple Skull Fractures.

Introduction Children with minor intracranial hemorrhage (ICH) and/or simple skull fractures are often hospitalized for monitoring; however, the majority do not require any medical, surgical, or critical care interventions. Our purpose was to determine the rate of significant clinical sequela (SCS) and identify associated risk factors in neurologically intact children with close head trauma. Methods This is a retrospective observational study. Children (≤ 3 years of age) admitted with closed head trauma, documented head injuries (ICH ≤ 5mm and/or simple skull fracture), and a Glasgow Coma Scale (GCS) score of ≥14, between January 2015 and January 2020, were included. We collected demographics, resource utilization, and patient outcomes variables. SCS was defined as any radiologic progression, and/or clinically important medical or neurological deterioration. Results A total of 205 patients were enrolled in the study (65.4% male, mean age 7.7 months). Repeat neuroimaging was obtained in 41/205 patients (20%) with radiologic progression noted in 5/205 (2.4%). Thirteen out of 205 patients (6.3%) experienced SCS. Patients with SCS were more likely to be males (92.3% vs 63.5% in females, P=0.035) to have had a report filed with child protective services due to a concern for abuse/neglect (92.3% vs 61.5% in females, P=0.025), and to have had a non-linear skull fracture (P<0.001). No other factors were shown to be predictive of SCS with enough statistical significance. Conclusion Neurologically intact children with traumatic closed head injury are at low risk for developing SCS. This study suggests that most of these children may not need ICU monitoring. This study also showed that a certain subset might be at an increased risk of developing SCS.

Humans with inherited MyD88 and IRAK-4 deficiencies are predisposed to hypoxemic COVID-19 pneumonia.

X-linked recessive deficiency of TLR7, a MyD88- and IRAK-4-dependent endosomal ssRNA sensor, impairs SARS-CoV-2 recognition and type I IFN production in plasmacytoid dendritic cells (pDCs), thereby underlying hypoxemic COVID-19 pneumonia with high penetrance. We report 22 unvaccinated patients with autosomal recessive MyD88 or IRAK-4 deficiency infected with SARS-CoV-2 (mean age: 10.9 yr; 2 mo to 24 yr), originating from 17 kindreds from eight countries on three continents. 16 patients were hospitalized: six with moderate, four with severe, and six with critical pneumonia, one of whom died. The risk of hypoxemic pneumonia increased with age. The risk of invasive mechanical ventilation was also much greater than in age-matched controls from the general population (OR: 74.7, 95% CI: 26.8-207.8, P < 0.001). The patients' susceptibility to SARS-CoV-2 can be attributed to impaired TLR7-dependent type I IFN production by pDCs, which do not sense SARS-CoV-2 correctly. Patients with inherited MyD88 or IRAK-4 deficiency were long thought to be selectively vulnerable to pyogenic bacteria, but also have a high risk of hypoxemic COVID-19 pneumonia.

The Impact of Waived Cost-Sharing Policy on COVID-19 Daily Testing and Deaths.

Introduction Coronavirus disease 2019 (COVID-19) is a public health problem that threatens the world since December of 2019. Several studies demonstrated that enacting waived cost-sharing policies positively impacts the utilization rates of preventative services, but its impact on COVID-19 deaths and tests is largely unknown. Methods We hypothesize that applying a waived cost-sharing policy for COVID-19 testing and treatment leads to an increase in the number of COVID-19 tests and a reduction in daily COVID-19 deaths in the State of Michigan. Total test results increase, and total deaths increased were compared pre and post-policy enactment in the State of Michigan and compared to that of the State of Illinois where no such policy existed. Data were obtained from the Coronavirus resources center page at the John Hopkins University of Medicine. A difference in differences approach was employed and linear regression was used to assess data pre and post the policy enactment. Statistical significance was assessed at the 0.05 level. Results The state of Michigan had fewer daily COVID-19-related deaths with fewer daily COVID-19 tests than the State of Illinois by 50.19 cases and 28,879 tests respectively. The post-policy period had more daily COVID-19 tests than the pre-policy period by 51,350 tests. Conclusion A waived cost-sharing policy for COVID-19 testing and treatment had a positive effect on increasing COVID-19 testing and reducing COVID-19-related deaths at the state level as evident from the experience of two mid-western states.

Atypical Posterior Nutcracker Syndrome in a 17-Year-Old Male Without Hematuria.

Retro-aortic left renal vein (RLRV) is an anatomical variation, where the left renal vein (LRV) courses posterior to the aorta and anterior to the vertebrae before it eventually drains into the inferior vena cava (IVC). RLRV is a rare finding, with a prevalence of around 1%-2%, and only a small minority of RLRVs cause symptoms. RLRV symptoms occur secondary to compression of the LRV between the abdominal aorta and vertebrae, otherwise known as posterior nutcracker syndrome (PNCS). The most common symptoms of PNCS are hematuria and flank pain. We present a 17-year-old male, who came in with recurring left flank pain without hematuria, initially thought to be renal colic secondary to nephrolithiasis. On further investigations, an aberrant posterior renal vein was seen on CT suggestive of PNCS. The patient was treated successfully with RLRV vascular stent placement by interventional radiology. This case report adds to the limited number of PNCS cases observed in children and to the even rarer cases of PNCS without hematuria. This case also acts as a reminder for pediatricians to keep a wide scope of differentials in patients presenting with flank pain and provides an outline of both diagnostic and treatment modalities available for these patients.

Effect of Weather on Frequency of Vaso-Occlusive Crisis in Children With Sickle Cell Disease.

Introduction Sickle cell disease (SCD) is characterized by acute vaso-occlusive crisis (VOC) often manifested as painful episodes. Environmental factors are known to play a role in the frequency and severity of VOC. Methods The aim of this study is to analyze the relationship between weather changes and VOC in children with SCD. Data on daily temperature, humidity, and wind speed in Brooklyn, New York was collected over one year. Daily census data of children < 20 years of age with SCD presenting with VOC during the study period was retrieved from the Health Information Systems database. Data was analyzed to determine correlations of daily temperature, humidity, and wind speed with the number of VOCs using Pearson correlation co-efficient and time-series statistics. Results The total number of episodes of VOC was 344, with 218 outpatients and 126 inpatients. Total episodes of VOC peaked during January (n=44), while they were lowest in July (n=16). We observed a negative correlation of VOC with temperature (r= -0.05, p=0.04) and no correlation with humidity (r=0.01, p=0.85) was noted. Analysis of wind speed showed a negative correlation with VOC which is not significant. Conclusion No significant correlation was found between changes in humidity or wind speed and VOC. As this study was performed in an urban environment with extreme weather changes, results may be different in other geographic areas.

Primary non-typhoidal Salmonella infection presenting as a splenic abscess in a healthy adolescent male.

Isolated splenic abscess in a previously healthy patient is a rare clinical condition and remains a diagnostic dilemma. Clinical presentation is often non-specific and leads to a delay in diagnosis. Imaging studies help to elucidate the condition. Despite advances in medical diagnostics and therapeutics, splenic abscesses can cause significant morbidity and can be fatal. Although splenectomy was considered the treatment of choice in the past, recent trends have seen a shift towards more conservative management. We present the clinical case of a patient who presented to our emergency room with a chief complaint of left shoulder and left upper quadrant abdominal pain. Abdominal imaging showed an intrasplenic collection suspicious for a hemorrhage or an abscess. Percutaneous drainage was successfully performed, followed by conservative management with intravenous antibiotics. The culture of the fluid drained from the spleen was positive for Salmonella Saintpaul. The patient improved and was discharged. A high degree of clinical suspicion is necessary for early identification of a splenic abscess. Splenectomy can be avoided with the use of interventional radiological drainage.