Research Note: Bovine lactoferrin in chickens: an investigation into its viability as an antibiotic alternative.

Finding effective antibiotic alternatives is crucial to managing the re-emerging health risk of Clostridium perfringens (CP) type A/G-induced avian necrotic enteritis (NE), a disease that has regained prominence in the wake of governmental restrictions on antibiotic use in poultry. Known for its antimicrobial and immunomodulatory effects, the use of bovine lactoferrin (bLF) in chickens is yet to be fully explored. In this study, we hypothesized that bLF can accumulate in the small intestines of healthy chickens through gavage and intramuscular supplementation and serves as a potential antibiotic alternative. Immunohistochemistry located bLF in various layers of the small intestines and ELISA testing confirmed its accumulation. Surprisingly, sham-treated chickens also showed the presence of bLF, prompting a western blotting analysis that dismissed the notion of cross-reactivity between bLF and the avian protein ovotransferrin. Although the significance of the route of administration remains inconclusive, this study supports the hypothesis that bLF is a promising and safe antibiotic alternative with demonstrated resistance to the degradative environment of the chicken intestines. Further studies are needed to determine its beneficial pharmacological effects in CP-infected chickens.

Characteristics and Outcomes Associated With Emergent Rectal Foreign Body Management: A Retrospective Cohort Analysis.

Background Bedside management and outcomes of rectal foreign bodies remain challenging due to the presentation and complexity of the inserted objects. Injuries, such as perforation of the colon and rectum, are among the most commonly reported complications. However, prior studies are unclear regarding the setting in which the complication rates may be minimized. This study aimed to assess whether there was a statistically significant difference among the various extraction methods with regard to complications in the emergency department and operating room. Materials and methods This was a retrospective study of all cases of rectal foreign bodies that were removed in the emergency department at a large county hospital between 1/1/2010 and 12/31/2020. Patients included in this study were adults who were evaluated and treated in the emergency department. Results A total of 78 patients were included in the final analysis. More than half (51.3%, n=40) of the patients were successfully treated in the emergency department. Compared with the emergency department, patients in the operating room were more likely to undergo exploratory laparotomy and colectomy (0% vs. 31.6%, p<0.0001), undergo general anesthesia (84.2% vs. 0%, p<0.0001), have higher complication rates (21% vs. 0%, p=0.0021), and have a longer hospital length of stay (median=1 vs. 0, p<0.0001). Conclusion This study revealed a >50% success rate of rectal foreign body removal in the emergency department without any reported complications. To improve the success rate of bedside retrieval and decrease complications, physicians need to be vigilant, communicative, and compassionate about their evaluations and clinical methodology.

The Effect of Glycemic Control on Morbidity and Mortality in Critically Ill COVID-19 Patients.

Background COVID-19 infection has caused a global pandemic affecting a group of patients with chronic conditions including diabetes with exacerbating insulin resistance and hyperglycemia. Investigators noted that pre-existing diabetes and newly diagnosed diabetes are associated with an increased risk of all-cause mortality in hospitalized patients with COVID-19 infection. Aim To evaluate the relationship between ICU patients infected with COVID-19 and mortality among those with high versus low glucose levels. Methods This is a retrospective study of critically ill adult patients infected with COVID-19 who were admitted to the ICU from April 5, 2020, to October 14, 2020. The participants were from San Bernardino County which is a diverse and underserved community. Overall, 84 patients were included in the final analysis. The average age was 59.67 (standard deviation=15.55) with 59.5% being males. Overall mortality was 44.1%. Results Around one-fifth of patients had glucose under control as measured by peak glucose level of <180 mg/dL during hospital stay. A statistically significant association was seen between tighter serum glucose control and mortality (p=0.0354). Patients with serum glucose maintained <180 mg/dL were associated with significantly lower mortality than their counterparts (22.2% vs. 50%). Conclusions This study suggests that maintaining a tighter control of the glycemic index in critically ill COVID-19 patients will improve morbidity and mortality.

The impact of impaired insulin regulation on severity of SARS-CoV-2 infection: a 2-year retrospective single-center analysis.

Background: The COVID-19 pandemic has caused an international healthcare crisis and produced a large healthcare burden. Diabetes mellitus (DM) is a common disease that can be controlled via pharmacologic agents; however, many patients have poor glycemic control, leading to disease-related complications. DM has been reported in the literature to be associated with increasing morbidity and mortality in COVID-19 patients. The authors aim to assess the associations between glucose homoeostasis and COVID-19 disease severity and mortality. Methods: A retrospective chart review of patients ages 18-100 years of age admitted with COVID-19 between January 2020 and December 2021 was performed. The primary outcome was COVID-19 mortality with respect to haemoglobin A1C levels of less than 5.7%, 5.7-6.4%, and 6.5% and greater. Disease severity was determined by degree of supplemental oxygen requirements (ambient air, low-flow nasal cannula, high-flow nasal cannula, non-invasive mechanical ventilation, and invasive mechanical ventilation). COVID-19 mortality and severity were also compared to blood glucose levels on admission as grouped by less than 200 mg/dl and greater than or equal to 200 mg/dl. Results: A total of 1156 patients were included in the final analysis. There was a statistically significant association between diabetic status and mortality (P=0.0002). Statistical significance was also noted between admission blood glucose ≥200 mg/dl and mortality (P=0.0058) and respiratory disease severity (P=0.0381). A multivariate logistic regression for predicting mortality showed increasing haemoglobin A1C was associated with increased mortality (odds ratio 1.72 with 95% CI of 1.122-2.635). Conclusions: In our 2-year retrospective analysis, there was an association between a diagnosis of DM and COVID-19-related mortality. Hyperglycaemia on admission was found to be statistically significant with mortality in patients diagnosed with COVID-19. Glucose homoeostasis and insulin dysregulation likely play a contributing factor to COVID-19 disease severity and mortality.

Predictive Ability of Ultrasound on Neonatal Diagnoses and Consequences on Prenatal Care Utilization.

ABSTRACT: Fetal anomalies suspected on fetal ultrasound may cause significant stress for patients. Some findings resolve or have minimal clinical significance for the neonate. Our purpose is to evaluate fetal ultrasound accuracy and false-positive results and determine the clinical impact on maternal counseling. A retrospective review was performed on electronic medical records for women receiving prenatal care at Harbor-UCLA Medical Center who had abnormal findings on fetal ultrasounds between January 2015 and December 2018. Corresponding neonatal medical records were reviewed for the suspected condition(s). χ2 and Fisher exact tests were conducted to assess associations between fetal ultrasounds and neonatal outcomes. Two hundred eight mothers and 237 babies (including all 29 sets of twins) were included in the final analysis. Fetal ultrasounds were significantly associated with neonatal findings for the following conditions (sensitivity, specificity): anatomical disorder of extremities (0.72, 0.97), anatomical disorder of the face/skull/brain (0.67, 0.91), congenital anomaly of gastrointestinal tract (0.75, 0.98), congenital heart disease (0.75, 0.91), genetic disorder (0.72, 1.00), growth restriction (1.00, 0.85), kidney disorder (0.55, 0.98), and large for gestational age (0.80, 0.98). The highest false-positive rates occurred in congenital heart disease (65.4%), anatomical disorder of the face/skull/brain (64.3%), and growth restriction (54%). Fetal ultrasound highly correlates with neonatal findings for many congenital conditions. However, it can also be associated with a high false-positive rate for certain diagnoses; maternal counseling should include the limitations of ultrasound, including the potential for false-positive results.

A role of point-of-care ultrasound in the emergency department diagnosis of vision loss due to traumatic cataract.

BACKGROUND: Ocular complaints, including acute or subacute vision loss, are commonly encountered in emergency departments (ED). These potentially time-sensitive complaints are difficult to diagnose and evaluate without adequate, specialized equipment and expertise. Additionally, a thorough evaluation often requires a more extensive and specialized physical exam, imaging, and ophthalmologic consultation, all of which may not be readily available in the acute setting. CASE PRESENTATION: This case report presented a patient in the emergency department with the chief complaint of vision loss. Point-of-care ultrasound (POCUS) using the 10-MHz-linear-array probe, in the ocular setting, demonstrated calcification of the lens, a finding consistent with cataract in the right eye. CONCLUSIONS: The use of POCUS can expedite the accurate identification of vision threatening pathology, such as cataracts, and streamline ED disposition and plan of care.

ABO blood group and rhesus factor association with inpatient COVID-19 mortality and severity: a two-year retrospective review.

Background: Early reports have indicated a relationship between ABO and rhesus blood group types and infection with SARS-CoV-2. We aim to examine blood group type associations with COVID-19 mortality and disease severity. Methods: This is a retrospective chart review of patients ages 18 years or older admitted to the hospital with COVID-19 between January 2020 and December 2021. The primary outcome was COVID-19 mortality with respect to ABO blood group type. The secondary outcomes were 1. Severity of COVID-19 with respect to ABO blood group type, and 2. Rhesus factor association with COVID-19 mortality and disease severity. Disease severity was defined by degree of supplemental oxygen requirements (ambient air, low-flow, high-flow, non-invasive mechanical ventilation, and invasive mechanical ventilation). Results: The blood type was collected on 596 patients with more than half (54%, N=322) being O+. The ABO blood type alone was not statistically associated with mortality (P=0.405), while the RH blood type was statistically associated with mortality (P<0.001). There was statistically significant association between combined ABO and RH blood type and mortality (P=0.014). Out of the mortality group, the O+ group had the highest mortality (52.3%), followed by A+ (22.8%). The combined ABO and RH blood type was statistically significantly associated with degree of supplemental oxygen requirements (P=0.005). The Kaplan-Meier curve demonstrated that Rh- patients had increased mortality. Conclusion: ABO blood type is not associated with COVID-19 severity and mortality. Rhesus factor status is associated with COVID-19 severity and mortality. Rhesus negative patients were associated with increased mortality risk.

Stress-Induced Auto-Cannibalism in Patients With a History of Moderate Traumatic Brain Injury.

A traumatic brain injury (TBI) is a significant factor in injury-related deaths in the United States and may lead to complex psychological disorders. Auto-cannibalism as a sequela of a TBI has yet to be reported in the literature. The current literature regarding such behavior is often associated with psychosis, intellectual disability, or substance use. A 35-year-old male had a past medical history significant for a TBI a decade ago. He was transferred to the emergency department due to a self-inflicted wound. The patient had been scratching his arms and legs for the last few months and displayed an intense new pattern of self-destructive behavior in the past week. He went through surgical wound debridement and psychiatric evaluation before he was discharged home. This case depicts the importance of regular, long-term psychiatric, and neurological follow-up for patients sustaining TBIs, regardless of whether or not they were previously deemed stable. A greater understanding of many factors leading to self-destructive behavior following TBIs is needed to improve patient outcomes.

Pharmacokinetics comparison of vardenafil as administered by an intranasal spray formulation vs a 10-mg oral tablet.

BACKGROUND: Oral vardenafil (VDF) tablet is an effective treatment for erectile dysfunction (ED), but intranasal administration with a suitable formulation can lead to a faster onset of action and offer more convenient planning for ED treatment. AIM: The primary purpose of the present pilot clinical study was to determine whether intranasal VDF with an alcohol-based formulation can result in more "user-friendly pharmacokinetics" as compared with oral tablet administration. METHODS: This single-dose randomized crossover study was conducted in 12 healthy young volunteers receiving VDF as a 10-mg oral tablet or 3.38-mg intranasal spray. Multiple blood concentrations were obtained, and VDF concentrations were determined with a liquid chromatography-tandem mass spectrometry assay. Pharmacokinetic parameters following each treatment were compared and adverse events assessed. OUTCOMES: Pharmacokinetic parameters were obtained: apparent elimination rate constant, elimination half-life, peak concentration, peak time, total area under the curve, and relative bioavailability. RESULTS: Although mean apparent elimination rate constant, elimination half-life, peak concentration, and total area under the curve were similar between intranasal and oral administration, the median peak time from intranasal was much shorter (10 vs 58 minutes, P < .001, Mann-Whitney U test). The variability of the pharmacokinetic parameters was also less with intranasal than oral administration. The relative bioavailability of intranasal to oral was 1.67. Intranasal VDF caused transient but tolerable local nasal reactions in 50% of subjects. Other adverse events (eg, headache) were similar between the treatments. The incidence of adverse events was, however, significantly less in the second treatment after initial exposure to VDF. No serious adverse events were noted. CLINICAL IMPLICATIONS: Intranasal VDF potentially offers a more timely and lower dose for the treatment of ED in patients who can tolerate the transient local adverse reactions. STRENGTHS AND LIMITATIONS: The strength of this study is its randomized crossover design. Because the study was conducted in 12 healthy young subjects, the results may not reflect those observed in elderly patients who may be likely taking VDF for ED. Nevertheless, the changes of pharmacokinetic parameters in the present study are likely a reflection of the differences between intranasal and oral administration of the formulations. CONCLUSION: Our study indicated that the present VDF formulation, when administered intranasally, can achieve a more rapid but similar plasma concentration with only about one-third dose when compared with the oral administration.

Emergent surgical interventions in noncritical traumatic long bone fractures and lactate monitoring: a retrospective cohort study.

Serum lactate levels have been recommended as a standard in guiding resuscitation and management of post-traumatic orthopedic injuries. Studies have suggested an increased incidence of postoperative complications in trauma patients with injury severity scores (ISSs) greater than 18. However, in trauma patients without an elevated ISS, the role of lactate in guiding operative timing has not been explored. This study considers the role of lactate measurement with respect to surgical timing and predicting postoperative complications in trauma patients with long bone fractures and an ISS less than 16. Materials and methods: A total of 164 patients, ages 18 and above with long bone fractures and ISS less than 16 were sampled in the last 5 years. Demographic data was ascertained. Patients were placed into two cohorts with a serum preoperative lactate greater than or equal to 2.0 mmol/l and a serum preoperative lactate less than 2.0 mmol/l. Key endpoints included hospital mortality, length of hospitalization (LOH), discharge designation, and postoperative complications. Results: A total of 148 patients had a lactate level less than 2.0 mmol/l and 16 had a lactate greater than or equal to 2.0 mmol/l. There was no significant difference in demographics between these two preoperative lactate groups. There was no statistical difference when considering mortality, discharge designation, LOH, and postoperative complications. Conclusion: Lactate levels assist providers in guide resuscitative efforts in trauma patients. However, this study finds that preoperative lactate measurements and efforts made to normalize lactate level are not correlated with mortality, LOH, and postoperative complications in trauma patients with an ISS less than 16. This study does not support preoperative lactate normalization in guiding surgical timing.

Methamphetamine-induced encephalopathy in the absence of hyperammonemia.

BACKGROUND: Methamphetamine is an addictive drug with various effects on the neurotransmitters in the central nervous system. Methamphetamine-induced encephalopathy in the absence of hyperammonemia presents a unique challenge in a clinical setting. Previously published cases of methamphetamine-induced encephalopathy suggested that methamphetamine-induced hepatotoxicity and subsequent hyperammonemia may be the cause of encephalopathy. However, the literature is limited on methamphetamine-induced encephalopathy without hyperammonemia. CASE: This case presents a disoriented patient with methamphetamine use disorder in acute toxicity, unable to ambulate independently, and poorly responsive to verbal stimuli. The patient was found to have normal ammonia levels. DISCUSSION: This patient's presentation and laboratory findings, namely normal ammonia levels, suggest a different pathophysiological pathway for methamphetamine-induced encephalopathy. One potential pathway is through the direct action of methamphetamine on the central nervous system through acute disruption of neurotransmitter signaling and disruption of the blood-brain barrier. CONCLUSION: Further research should be conducted into the prevalence and pathophysiology of methamphetamine-induced encephalopathy in the absence of hyperammonemia. KEY POINTS: Methamphetamine-induced encephalopathy (MIE) in the absence of hyperammonemia presents a unique challenge in a clinical setting. Previously published cases of MIE suggest that methamphetamine-induced hepatotoxicity and subsequent hyperammonemia may be the cause of encephalopathy. Further research should be conducted into the prevalence and pathophysiology of MIE in the absence of hyperammonemia.

Pericardial Tamponade in a Patient With a History of Pneumonectomy.

Shock is the clinical presentation of circulatory failure with impaired perfusion that results in inadequate cellular oxygen utilization. Treatment requires properly identifying the type of shock that is impacting the patient (obstructive, distributive, cardiogenic, and/or hypovolemic). Complex cases may involve numerous contributors to each type of shock and/or multiple types of shock which can present interesting diagnostic and management challenges to the clinician. In this case report, we present a 54-year-old male with a remote history of a right lung pneumonectomy presenting with multifactorial shock including cardiac tamponade, with initial compression of the expanding pericardial effusion by the postoperative fluid accumulation within the right hemithorax. While in the emergency department, the patient gradually became hypotensive with worsening tachycardia and dyspnea. A bedside echocardiogram revealed an increase in size of the pericardial effusion. An emergent ultrasound-guided pericardial drain was inserted with gradual improvement of his hemodynamics followed by placement of thoracostomy tube. This unique case highlights the importance of utilizing point-of-care ultrasound along with emergent intervention in critical resuscitation.

Validation of a novel 3D printed positioning device and dynamic radiographic technique to quantify rotational laxity of the stifle in dogs.

Cranial cruciate ligament deficiency (CCLD) results in internal rotational instability of the stifle (RLS). By contrast, tibial torsion (TT) is an anatomical feature of the tibia along its longitudinal axis. The objective of this study was to validate a dynamic radiographic technique to measure internal rotational laxity of the stifle and differentiate it from TT. Models included transection of the CCL for RLS and an osteotomy for TT. One limb within eight pairs of canine cadaveric hind limbs was randomly assigned to CCLD. The contralateral limb underwent TT, followed by CCLD. Neutral and stress radiographs were taken with the limb in a custom rotating 3-D printed positioning device before and after each modification. The position of the calcaneus on neutral views and the magnitude of its displacement under standardized torque were compared within limbs and between groups. Transection of the CCL increased the magnitude of displacement of the calcaneus by 1.6 mm (0.3-3.1 mm, p < 0.05) within limbs. The lateral calcaneal displacement (dS-dN) tended to be greater when CCLD limbs were compared to limbs with intact CCL. A magnitude of calcaneal displacement of 3.45 mm differentiated limbs with RLS from intact limbs with 87.5% sensitivity and 68.7% specificity. The calcaneus was displaced further laterally by about 3 mm on neutral radiographs (dN) when limbs with experimental TT were compared to those without TT (p < 0.05). A calcaneus located at least 3.25 mm from the sulcus differentiated limbs with TT from intact limbs with 87.5% sensitivity and 87.5% specificity. The technique reported here allowed detection of RLS, especially within limbs. A calcaneus located at least 3.25 mm on neutral radiographs of large dogs should prompt a presumptive diagnosis of TT.

A Mixed Methods Investigation on the Relationship Between Perceived Self-Regard, Self-Efficacy, and Commitment to Serve Among Military Medical Students.

INTRODUCTION: Routinely faced with potentially traumatizing situations, resilience is critical for military physicians. However, related studies are limited in scope. The current study distinctively combines hyper-realistic immersion training for military medical students with emotional intelligence and hardiness measures. With self-reflection shown to improve performance, qualitative inquiry was concurrently conducted in a mixed methodology approach to provide a uniquely comprehensive perspective on the resilience training needs of this population. MATERIALS AND METHODS: Thirty-four osteopathic military medical students participated in a week-long training simulating real-life combat and mass casualty events. The Emotional Quotient-Inventory 2.0 (EQ-i 2.0) and Hardiness Resilience Gauge were administered as pre- and post-test measures. Paired t-tests were used to determine statistically significant gains, and a multiple case study analysis of a six-student focus group allowed for the synchronization of quantitative and qualitative data. Institutional Review Board approval for the study was obtained through Rocky Vista University with a reciprocal agreement with Touro University California's Institutional Review Board. All students participating in the study received written informed consent. RESULTS: Qualitative findings for this study aligned with this current year's findings of statistically significant results in the improvement of the Overall EQ-i and Overall Hardiness. Qualitative responses thematically analyzed demonstrated environmental realism, adaptation, increased awareness, and positive interpersonal and clinical outlook. Notable increases occurred in all EQ-i domains except Decision-Making and Stress Tolerance. The Self-Perception domain saw significant increases in Self-Regard and Emotional Self-Awareness while Well-Being and Optimism simultaneously improved. CONCLUSION: This unique pilot study showed that quantitative and qualitative results aligned, supporting the finding that a safe trauma-related training environment can improve the confidence and resilience in military medical students. The goal of this training was to promote resilience and mitigate trauma. Results demonstrate improved self-efficacy and enhanced commitment. Increases in self-awareness and confidence made participants more inclined to see their worth and strengthened their sense of duty as described in their qualitative responses. Pervasive gains suggest that the training aligned well with its purpose, and the methods employed enhanced participant experience. Long-term follow-up studies are needed to assess outcome sustainability.

Body stuffing during apprehension resulting in distal esophageal impaction: a case report and review of the literature.

BACKGROUND: Body stuffing and body packing are two methods of concealing illicit drugs. Body stuffing is defined as the oral ingestion of illicit drugs, typically to avoid law enforcement detection or other consequences of possession, and may present a serious medical emergency in patients. Most commonly, body stuffers ingest possibly large or unknown quantities of illicit substances to avoid detection of the drugs during apprehension. This ingestion is typically hasty or impulsive, and therefore the substances ingested are rarely packaged in a way that would be considered safe for ingestion. CASE PRESENTATION: This case highlights a series of rare complications of impacted esophageal foreign body including esophageal edema, pericarditis, and hydro-pneumothorax for a 16-year-old Hispanic male who was booked into a county juvenile detention and rehabilitation facility. He complained of persistent intractable epigastric pain, along with pleuritic chest pain with multiple episodes of vomiting over the previous 4 days. He denied swallowing any foreign body. He underwent esophagogastroduodenoscopy, and a plastic bag with content suspicious for marijuana was discovered in the distal esophagus and removed. CONCLUSIONS: Failure to consider body stuffing and foreign body impaction in individuals during medical evaluation in detention centers with complaints of chest pain, abdominal pain, dysphagia, and/or certain toxidromes can delay diagnosis and lead to a variety of medical complications.

The Role of the Urinary Bladder in the Diagnosis of Abdominal Compartment Syndrome: A Prospective Study in Trauma Patients.

Purpose The aim of this study was to evaluate the accuracy of bladder pressures in the diagnosis and management of abdominal compartment syndrome (ACS). Methods After Institutional Review Board (IRB) approval, nine operative abdominal trauma patients were prospectively studied over an 18-month period. Bladder pressures were compared to pressures obtained from intra-operatively placed electronic transducer located in the pelvis. Statistical analysis was performed using methods described by Bland and Altman. Results A Bland-Altman plot was used to assess the differences between bladder and transducer pressures. There was little agreement between the two methods at low (10-15 mmHg) and high (30-70 mmHg) pressures. At higher pressures, there was a notable difference between these two types of pressure. No patients required repeated operation. One patient died from severe traumatic brain injury. Conclusion Measurements obtained from the urinary bladder did not agree well with those obtained from within the peritoneal cavity. Furthermore, abdominal pressures greater than 20 mmHg did not show signs of ACS in this selected population, raising doubts about the utility of using abdominal pressures alone in the management of ACS.

Comparison of emergency airway management techniques in the performance of emergent Cricothyrotomy.

INTRODUCTION: Emergent cricothyrotomy (EC) is a rare and lifesaving procedure to secure a difficult airway when other methods have failed. Many techniques have been discussed in the literature. This study aimed to identify major techniques used to perform EC in a regional trauma center and evaluate outcomes associated with the techniques. METHODS: Patients who underwent EC at Arrowhead Regional Medical Center between 1-1-2009 and 1-1-2019 were reviewed for eligibility for this study. Patients' data were extracted from the trauma database. Chi-square tests were conducted to assess the difference on variables between the techniques. RESULTS: A total of 51 (0.17%) of these patients required EC and were included in the database. The two most prevalent techniques were the scalpel-bougie-tube (SBT) and the surgical cricothyrotomy technique (SCT). More than half (n = 27, 52.9%) of the cohort received the SBT. There was no statistically significant difference between the two techniques with regards to demographic variables, including age (p = 0.7528), injury severity score (ISS, p = 0.896), gender (p = 0.3709), and race (p = 0.8935). However, the SCT group had a statistically higher Glasgow Coma Scale (GCS) than the SBT group (p = 0.0036). There was no statistically significant difference in mortality or complications between these two groups (p = 0.2172 for mortality). DISCUSSION: Two techniques of EC were identified as preferred techniques. Both procedures were successful in securing an emergency airway, noting a difference in the time to completion of the two techniques. Given the rarity of the procedure, practitioners may choose the method based on their training and the availability of appropriate instruments.

Pediatric Intussusception Following COVID-19 Infection: A Rare Presentation.

Pediatric intussusception has been reported to be associated with coronavirus disease 2019 (COVID-19) infection in the literature since the start of the pandemic in the past two years. Although this occurrence is exceptionally rare, rapid diagnosis based on recognition of gastrointestinal manifestations, clinical examination, and ultrasound confirmation can expedite appropriate care and prevent delayed complications. Intussusception is the most common cause of intestinal obstruction and acute abdomen in pediatric patients. Without prompt identification, the disease process can lead to necrosis, bowel perforation, shock, and, subsequently, multiorgan failure. Intussusception has previously been associated with viral upper respiratory infections, which can cause mesenteric lymphadenopathy as a lead point to allow the bowel to telescope upon itself. The mechanism of how COVID-19 can contribute to intussusception without respiratory symptoms remains unknown. Here, we present a case of pediatric intussusception associated with COVID-19.

Variation in Trauma Team Response Fees in United States Trauma Centers: An Additional Undisclosed Variable Cost in Trauma Care.

BACKGROUND: The rising costs associated with trauma care in the United States is an important topic in today's healthcare environment. Factors such as innovations in technology, increasing governmental and organizational regulations, and the specialization of care have led to increasing costs to the patient. A component of trauma cost is the one-time trauma team response fee (TTRF). The determination process of the TTRF's dollar amount is elusive as no apparent standardized process exists and the literature is scant regarding this aspect of trauma care. METHODS: A nationwide cross-sectional convenience sample was conducted using SurveyMonkey. Surveys were sent to 525 trauma centers in the continental United States, including Alaska and Hawaii, between October 8, 2019 and March 11, 2020. Additionally, hospital medical directors and trauma medical directors were queried on their knowledge of their facility's TTRF amount. RESULTS: Only 46 out of 525 trauma centers, or 8.8% of those surveyed shared their scheduled fees. Comparisons of TTRFs among different trauma centers, activation levels, and geographical locations were not statistically significant. CONCLUSIONS: Understanding the true costs of trauma care and fees for patients in the United States remains elusive due to inadequate data and low response rates. Trauma centers struggle to maintain financial viability as regulatory agencies and the public push for transparency of TTRFs. Collaboration between trauma centers and regulatory agencies is needed to ensure a balance between providing quality trauma care with justified associated charges and financial sustainability.