Cervical Collar Clearance in Obtunded Children Presenting Without a Known Traumatic Mechanism: Is Imaging Necessary?

BACKGROUND: Obtunded pediatric patients are often placed in cervical collars (c-collars) to protect their cervical spine (c-spine) while injury is being ruled out, even without a known traumatic injury. The goal of this study was to determine the necessity of c-collars in this population by determining the rate of c-spine injury among patients with suspected non-traumatic mechanisms of loss of consciousness. METHODS: A single institution, ten-year retrospective chart review was conducted including all obtunded patients admitted to the Pediatric Intensive Care Unit without a known traumatic event. Patients were categorized into five groups based on etiology of obtundation: respiratory, cardiac, medical/metabolic, neurologic, and other. Comparisons were made between those placed in a c-collar and a control group who were not, using Wilcoxon rank sum test for continuous measures, and Chi-square or Fisher's exact test for categorical measures. RESULTS: 464 patients were included, of which 39 (8.41%) were placed in a c-collar. There was a significant difference in whether a patient was placed in a c-collar based on diagnosis category (p < 0.001). Those placed in a-c-collar were more likely to undergo imaging studies than the control group (p < 0.001). The overall incidence of c-spine injury in this patient population in our study was zero. CONCLUSION: Cervical collar placement and radiographic evaluation is not necessary in obtunded pediatric patients who present without a known traumatic mechanism as the overall risk of injury is low. Consideration for collar placement should be given in cases when trauma cannot be definitively ruled out at initial evaluation. LEVELS OF EVIDENCE: III.

Are Routine Chest Radiographs After Chest Tube Removal in Thoracic Surgery Patients Necessary?

INTRODUCTION: The routine use of chest x-ray (CXR) to evaluate the pleural space after chest tube removal is a common practice driven primarily by surgeon preference and institutional protocol. The results of these postpull CXRs frequently lead to additional interventions that serve only to increase health care costs and resource utilization. We investigated the utility of these postpull CXRs in thoracic surgery patients and assessed their effectiveness in predicting the need for tube replacement. METHODS: Single-institution retrospective study comprising thoracic surgery patients requiring postoperative chest tube drainage over a 3-y period. Demographics and surgical characteristics, including surgical approach, procedure, and procedure type, were recorded. Outcomes included postpull CXR findings, interventions resulting from radiographic abnormalities, and the additional health resource utilization incurred by obtaining these studies on asymptomatic patients. RESULTS: The study included 433 patients. Postpull CXRs were performed in 87.1% of patients, with 33.2% demonstrating an abnormality compared with the prior study. Among these, 65.7% resulted only in repeat imaging and 25.7% resulted in discharge delay. Overall, a total of 13 patients (3%) required chest tube replacement, three during the index hospitalization and the other 10 requiring readmission. Among those requiring chest tube replacement, 75% had normal postpull imaging, and all were symptomatic. CONCLUSIONS: Recurrent pneumothorax after chest tube removal requiring immediate tube reinsertion is relatively rare and does not occur in the absence of symptoms. Our study suggests that routine postpull CXRs have limited clinical utility and can be safely omitted in asymptomatic patients with appropriate clinical observation.

Review of the Effect of Continuous Use and Limited Reuse of N95 Respirators on Respirator Fit.

Background: Coronavirus disease 2019 (COVID-19) has led to severe shortages of filtering facepiece respirators (FFRs). As a result, extended use, limited reuse, and FFR decontamination have been utilized to extend the life of single-use FFRs. Although some studies have raised concerns that reuse could affect the FFR's ability to form a seal, no comprehensive literature review of the effect of extended use or limited reuse on FFR seal exists. Objective: The goal of this review was to assess the effect of extended use and reuse on respirator fit, with and without decontamination. Methods: Searches of PubMed and Medrxiv yielded 24 papers that included assessment of fit after extended use or limited reuse on a human. One additional handpicked paper was added. Results: Studies report a wide variation in the number of donnings and doffings before fit failure between different models of respirators. Additionally, while seal checks lack sufficient sensitivity to reliably detect fit failures, individuals who failed fit testing were often able to pass subsequent tests by re-positioning the respirator. Even with failure, respirators often maintained a substantially higher level of fit than a surgical mask, so they may still provide a level of protection in crisis settings. Conclusion: Based on currently available data, this literature review was unable to establish a consensus regarding the amount of time a respirator can be worn or the number of uses before fit failure will occur. Furthermore, variations in reuses before fit failure between different models of N95 respirators limit the ability to offer a comprehensive recommendation of greater than one reuse or a specific amount of wear time.

Personality Traits and Social Supports in Adolescents With Persistent Postconcussion Symptoms.

OBJECTIVES: To determine whether adolescents with persistent postconcussion symptoms (PPCS) differ from healthy peers in their personality traits and social supports. SETTING: Specialty Concussion Clinic and Primary Care Clinic affiliated with an academic medical center. PARTICIPANTS: Ninety-seven adolescents (42 with PPCS, 55 healthy peers; age: 15 ± 2 years). DESIGN: Participants completed a web-based survey that included medical and demographic characteristics, mechanisms of concussion, 10-item Big Five Inventory, and Child and Adolescent Social Support Scale. A Student's 2-tailed t test with multiple testing corrections was used to compare the youths with PPCS to healthy peers. MAIN MEASURES: The primary outcome was PPCS, defined by the presence of 2 or more concussion-related symptoms on the Post-Concussion Symptom Scale (PCSS), lasting for more than 4 weeks after initial injury. The secondary outcome was perceived personality traits and social support, based on the 10-item Big Five Inventory and the Child and Adolescent Social Support Scale, respectively. RESULTS: The PPCS group had higher neuroticism scores on their Big Five Inventory than healthy peers. They also reported less social support from teachers and classmates than healthy peers. CONCLUSION: Youths with PPCS report specific personality and social support characteristics that differ from their peers. These findings suggest that individual personality and school-based social supports may influence concussion recovery.

Amyloid Beta Peptides Block New Synapse Assembly by Nogo Receptor-Mediated Inhibition of T-Type Calcium Channels.

Compelling evidence links amyloid beta (Aß) peptide accumulation in the brains of Alzheimer's disease (AD) patients with the emergence of learning and memory deficits, yet a clear understanding of the events that drive this synaptic pathology are lacking. We present evidence that neurons exposed to Aß are unable to form new synapses, resulting in learning deficits in vivo. We demonstrate the Nogo receptor family (NgR1-3) acts as Aß receptors mediating an inhibition of synapse assembly, plasticity, and learning. Live imaging studies reveal Aß activates NgRs on the dendritic shaft of neurons, triggering an inhibition of calcium signaling. We define T-type calcium channels as a target of Aß-NgR signaling, mediating Aß's inhibitory effects on calcium, synapse assembly, plasticity, and learning. These studies highlight deficits in new synapse assembly as a potential initiator of cognitive pathology in AD, and pinpoint calcium dysregulation mediated by NgRs and T-type channels as key components. VIDEO ABSTRACT.