Effects of Feed-Through Sulfur on Growth Performance, Atmospheric Ammonia Levels, and Footpad Lesions in Broilers Raised Beginning with Built-Up Litter.

To the poultry industry, ammonia accumulation within poultry houses can be a costly issue, as this can lead to problems with bird performance, damage to economically important parts such as paws, and customer disapproval due to animal welfare concerns. Common management practices for ammonia control can be quite effective; however, these methods are used variably from farm to farm, which necessitates ammonia control measures that poultry companies can more uniformly implement across all contract growers. One possible measure is ammonia control through feed additives, which would allow poultry companies more direct control over the treatment. This project explored the efficacy of elemental sulfur added directly to the feed (feed-through sulfur) in controlling litter ammonia levels, live performance, and paw quality of broilers raised on built-up litter over three successive flocks. Feed-through sulfur on its own showed inconsistent effects on performance or footpad lesions after 38 days of production compared to sodium bisulfate or control treatments. However, combination of feed-through sulfur and sodium bisulfate showed a potential synergistic effect on ammonia levels and litter pH, although there were few differences between treatments and controls; therefore, additional research must be explored to confirm these observations.

Golf cart injuries in children: the experience of trauma centers in a single state in the USA.

Golf carts remain a source of morbidity in children. We aimed to establish the incidence and injury characteristics of pediatric patients injured due to golf cart usage over an 11-year period. This is a retrospective study using a single state trauma database of patients ages 0-17 years admitted to a trauma center and who sustained injures while a golf cart was in use. Thirteen Pediatric and Adult Trauma Centers within the state of Pennsylvania were evaluated from 1 January 2004 to 31 December 2014. The inclusion criteria were met by 108 patients. The mean annual incidence of injuries was 0.35/100 000. The median age of patients was 11 years. The median hospital length of stay and injury severity score were 2 days and 9.5, respectively. The majority of the patients (75.9%) sustained at least one bone fracture. Skull fractures were more prevalent (43.5%), whereas extremity fractures were sustained by 26.9% of patients. Intracranial hemorrhages were sustained by 29.6% of patients. Ejections and rollovers accounted for 58.3% and 31.4% of patient injuries, respectively. The concussion rate was 26.9%. Neither age group nor sex was associated with a difference in fractures, intracranial hemorrhage or concussions. Golf cart injuries in pediatric patients commonly stem from ejections and rollover mechanisms resulting in skull fractures, extremity fractures, intracranial hemorrhages and concussions. The overall incidence of injury was 0.35 cases per 100 000. Further efforts are needed to increase awareness of these injuries and modify regulations regarding the use of golf carts in the pediatric population.

Established Primary Care Provider Improves Odds of Survival to Discharge for Injured Patients.

INTRODUCTION: The average age and number of comorbidities is increasing among trauma patients. Primary care providers (PCPs) provide pre-injury diagnosis and management of comorbidities that may affect outcomes for injured patients. The role of primary care in trauma systems is currently unknown. METHODS: Observational retrospective review of an institutional trauma databank from 2013 - 2019. PCP was extracted from the electronic medical record and combined with trauma data. Case-control matching was performed to compare outcomes between patients with and without primary care based on age, injury severity score, sex, and injury mechanism. Mann-Whitney U test, chi-square test, and multivariate regression described differences between subgroups. Primary outcome was difference in mortality rate for injured patients with and without PCPs. RESULTS: Within the study period, 19,096 patients were included. 6,626 (34.7%) had a PCP recorded. Of these, 2,158 were matched in a case-control design. Patients with PCPs had a lower mortality rate (1.6%) compared to patients without PCPs (3.6%, P < 0.01). PCP retention was associated with longer length of stay overall, equivalent rates of complications (5.4% vs. 5.7%, P = 0.63), and similar numbers of ICU and ventilator days. Multivariate logistic regression controlling for case-control factors, insurance, and comorbidities conferred an odds ratio of 2.58 (95% Confidence Interval: 1.59 - 4.19, P < 0.001) for survival to discharge. CONCLUSION: Pre-injury primary care significantly improves the odds of survival to discharge for injured patients. Prospective study of this relationship may identify strategies to promote primary care within health systems.

Abdominal Organ Injuries in Youth Soccer: A Case Series and Review of Literature.

ABSTRACT: We describe 13 children who presented to the Penn State Health Milton S. Hershey Medical Center (HMC) with pediatric soccer-related abdominal organ injuries. A review of the Pennsylvania Trauma System Foundation's Trauma Registry was performed between 2001 and 2015 for children with soccer injuries hospitalized at trauma centers across Pennsylvania. Out of 52 children at Hershey Medical Center, 13 suffered abdominal organ injuries. Injuries included the spleen [5], kidney [4], liver [2], and combined organ involvement [2]. All patients presented with abdominal and/or flank pain. All patients with kidney injuries presented with hematuria. All patients presented after a player-to-player (P2P) contact. Nearly all patients (12/13) were treated nonsurgically. Our findings showed that abdominal organ injuries constitute a substantial portion of pediatric soccer injuries requiring hospitalization, with spleen being the organ injured most frequently. Soccer-related abdominal organ injuries should be suspected in players who suffer abdominal and/or flank pain, and/or hematuria after a P2P contact.

Avoiding Cribari gridlock 2: The standardized triage assessment tool outperforms the Cribari matrix method in 38 adult and pediatric trauma centers.

OBJECTIVES: The Cribari Matrix Method (CMM) is the current standard to identify over/undertriage but requires manual trauma triage reviews to address its inadequacies. The Standardized Triage Assessment Tool (STAT) partially emulates triage review by combining CMM with the Need For Trauma Intervention, an indicator of major trauma. This study aimed to validate STAT in a multicenter sample. METHODS: Thirty-eight adult and pediatric US trauma centers submitted data for 97,282 encounters. Mixed models estimated the effects of overtriage and undertriage versus appropriate triage on the odds of complication, odds of discharge to a continuing care facility, and differences in length of stay for both CMM and STAT. Significance was assessed at p <0.005. RESULTS: Overtriage (53.49% vs. 30.79%) and undertriage (17.19% vs. 3.55%) rates were notably lower with STAT than with CMM. CMM and STAT had significant associations with all outcomes, with overtriages demonstrating lower injury burdens and undertriages showing higher injury burdens than appropriately triaged patients. STAT indicated significantly stronger associations with outcomes than CMM, except in odds of discharge to continuing care facility among patients who received a full trauma team activation where STAT and CMM were similar. CONCLUSIONS: This multicenter study strongly indicates STAT safely and accurately flags fewer cases for triage reviews, thereby reducing the subjectivity introduced by manual triage determinations. This may enable better refinement of activation criteria and reduced workload.

Femur, Tibia, and Fibula Fractures Secondary to Youth Soccer: A Descriptive Study and Review of the Literature.

Objectives Soccer is the most popular sport in the world and is one of the top sports with increased participation. Despite the vast and increasing numbers of soccer players, limited data are available on pediatric lower extremity injuries. In particular, the purpose of the study is to describe the epidemiology of femur, tibia, and fibula fractures secondary to youth soccer. Methods A retrospective review concerning soccer-related femur, tibia, and fibula fractures was conducted in children under the age of 18 years from January 1, 2000 to December 31, 2015 with statewide data from the Pennsylvania Trauma Systems Foundation (PTSF), Mechanicsburg, PA. Results A total of 258 youth soccer players were admitted for femur, tibia, and fibula fractures from 2000 to 2015. These fractures constituted 33% of soccer-related injuries in youth admitted at trauma centers. Sixty-five percent of the fractures involved the tibia and 34% involved the femur. Body contact injury resulted in 54% of the fractures and non-body contact injury resulted in 46% of the fractures. Athletes the age of 13 and older sustained 67% of the fractures and were more likely to incur contact injuries (p-value=0.000041) than those less than 13. Males sustained 67% of the fractures, and gender was not associated with the mechanism of injury (p-value=0.43). Open fractures included 10% of tibia fractures and did not occur in femur fractures. The growth plate was involved in 24% of the femur fractures and 17% of the tibia fractures. Conclusion Youth soccer has the potential for serious femur, tibia, and fibula fractures. Intervention programs should aim at reducing non-body contact mechanism in children < 13 years of age and body contact mechanism in children ≥ 13 years of age. Further research should investigate injury prevention methods such as potentially reducing body contact mechanism by improving the effectiveness of shin guards.

EAST multicenter trial of simulation-based team training for pediatric trauma: Resuscitation task completion is highly variable during simulated traumatic brain injury resuscitation.

BACKGROUND: Best practices for benchmarking the efficacy of simulation-based training programs are not well defined. This study sought to assess feasibility of standardized data collection with multicenter implementation of simulation-based training, and to characterize variability in pediatric trauma resuscitation task completion associated with program characteristics. METHODS: A prospective multicenter observational cohort of resuscitation teams (N = 30) was used to measure task completion and teamwork during simulated resuscitation of a child with traumatic brain injury. A survey was used to measure center-specific trauma volume and simulation-based training program characteristics among participating centers. RESULTS: No task was consistently performed across all centers. Teamwork skills were associated with faster time to computed tomography notification (r = -0.51, p < 0.01). Notification of the operating room by the resuscitation team occurred more frequently in in situ simulation than in laboratory-based simulation (13/22 versus 0/8, p < 0.01). CONCLUSIONS: Multicenter implementation of a standardized pediatric trauma resuscitation simulation scenario is feasible. Standardized data collection showed wide variability in simulated resuscitation task completion.

Rethinking the definition of major trauma: The need for trauma intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers.

BACKGROUND: Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS. METHODS: Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS greater than 15, RTS less than 7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS). RESULTS: The NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios [99.5% confidence interval]: NFTI = 9.44 [8.46-10.53]; ISS = 5.94 [5.36-6.60], RTS = 4.79 [4.29-5.34]; LOS incidence rate ratios (99.5% confidence interval): NFTI = 3.15 [3.08-3.22], ISS = 2.87 [2.80-2.94], RTS = 2.37 [2.30-2.45]). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk [99.5% confidence interval]: NFTI = 2.59 [2.52-2.66], ISS = 2.51 [2.44-2.59], RTS = 2.37 [2.28-2.46]). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS greater than 15 or RTS less than 7.84. CONCLUSION: In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS greater than 15 and RTS less than 7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments. LEVEL OF EVIDENCE: Prognostic, level IV.

Preliminary results of a novel hay-hole fall prevention initiative.

BACKGROUND: Hay-hole falls are a prevalent source of trauma among Anabaptists-particularly Anabaptist youth. We sought to decrease hay-hole falls in South Central Pennsylvania through the development and distribution of all-weather hay-hole covers to members of the at-risk Anabaptist community. METHODS: Following the creation of a rural trauma prevention syndicate, hay-hole cover prototypes co-designed and endorsed by the Pennsylvania Amish Safety Committee were developed and distributed throughout South Central Pennsylvania. Preintervention and postintervention surveys were distributed to recipients to gain an understanding of the hay-hole fall problem in this population, to provide insight into the acceptance of the cover within the community, and to determine the efficacy of the cover in preventing falls. RESULTS: A total of 231 hay-hole covers were distributed throughout eight rural trauma-prone counties in Pennsylvania. According to preintervention survey data, 52% of cover recipients reported at least one hay-hole fall on their property, with 46% reporting multiple falls (median fall rate, 1.00 [1.00-2.00] hay-hole falls per respondent). The median self-reported distance from hay-hole to ground floor was 10.0 (8.00-12.0) feet, and the median number of hay-holes present on-property was 3.00 (2.00-4.00) per respondent. Postintervention survey data found 98% compliance with hay-hole cover installation and no subsequent reported hay-hole falls. CONCLUSION: With the support of the Pennsylvania Amish Safety Committee, we developed a well-received hay-hole cover which could effectively reduce fall trauma across other rural communities in the United States. LEVEL OF EVIDENCE: Epidemiological study, Level III.

Pediatric ATV Injuries in a Statewide Sample: 2004 to 2014.

OBJECTIVES: To establish the incidence, mortality rate, and fracture location of pediatric patients injured while using an all-terrain vehicle (ATV) over an 11-year period. METHODS: A retrospective study using a state trauma database for patients ages 0 to 17 years who sustained injuries while using an ATV. Thirty-two pediatric and adult trauma centers within the state were evaluated from January 1, 2004, to December 31, 2014. RESULTS: The inclusion criteria were met by 1912 patients. The estimated mean annual incidence during the period of the study was 6.2 patients per 100 000 children in the pediatric population <18 years of age. There was a decrease of 13.4% in the mean incidence when comparing the first 5 years of the study with the last 6 years. The median age of patients was 14 years. The median hospital length of stay and injury severity score were 3 days and 9, respectively. There were 28 fatalities (1.5%). The mean mortality incidence was 0.09 deaths per 100 000 children and remained relatively constant. The majority of patients (55.4%) sustained at least 1 bone fracture at or below the cervical spine. The femur and tibia were more commonly fractured (21.6% and 17.7% of the patients, respectively). CONCLUSIONS: Despite current guidelines by the American Academy of Pediatrics, patients younger than 16 years of age remain victims of ATV injuries. Although there was a 13.4% reduction in the incidence of ATV-related injuries in recent years, continued preventive guidelines are still necessary to avert these injuries in children and adolescents.

Lawnmowers Versus Children: The Devastation Continues.

BACKGROUND: Accidents with lawnmowers can cause mutilating injuries to children. Safety guidelines regarding the use of lawnmowers were promoted by professional organizations beginning in 2001. The Pennsylvania Trauma Systems Foundation maintains a database including all admissions to accredited Levels 1 to 4 trauma centers in the state. The annual rates of admission for children in our state and the severity of injuries subsequent to introduction of safety guidelines have not been reported, to our knowledge. Ride-on lawnmowers have been associated with more severe injuries in children. QUESTIONS/PURPOSES: We asked: (1) What was the incidence of hospital admissions for children with lawnmower-related injuries during 2002 to 2013 and did the incidence vary by age? (2) What was the severity of injuries and did the severity vary by age? (3) How often did these injuries result in amputation? (4) What types of lawnmowers were involved? METHODS: This was a retrospective study using a statewide trauma registry. We queried the Pennsylvania Trauma Outcome Study database for children 0 to 17 years old admitted to trauma centers in Pennsylvania between January 2002 and January 2014 with injuries resulting from lawnmower-related accidents. All accredited Levels 1 to 4 trauma centers in the state are required to submit their data to the Pennsylvania Trauma Systems Foundation which maintains the Pennsylvania Trauma Outcome Study database. Demographic information, Injury Severity Scores, International Classification of Diseases procedure codes, and injury location codes were recorded. Type of lawnmower was determined from the narratives and was identified in 60% (119/199) of patients. Traumatic and surgical amputations performed during the index hospitalization were included in the analysis. Information on later surgeries was not available. Subjects were stratified by age: 0 to 6, 7 to 12, and 13 to 17 years old. RESULTS: The incidence of lawnmower injuries in Pennsylvania was a median five of 100,000 children (range, 4-12/100,000) during the study period. The median age was 6 years (range, 1-17 years). The median Injury Severity Score was 4 (range, 1-75). Children 0 to 6 years old had higher median Injury Severity Scores (median, 8; range, 1-75) compared with those 13-17 years old (median, 4; range, 1-20; difference of the medians, 4; p < 0.001). A total of 53% of the patients (106/199) underwent at least one amputation. There were 83 amputations in or of the foot, 18 in the leg, 14 in the hand, and three in the arm. Ride-on lawnmowers accounted for 92% (110/119) of mowers identified by type. CONCLUSIONS: The incidence of serious injuries to children owing to lawnmower-related trauma did not change during the 12-year study period. If children younger than 6 years had not been near the lawnmower and those younger than 12 years had not been operating one, at least 69% of the accidents might have been prevented. We recommend annual publicity campaigns during spring to remind the public of the dangers of lawnmowers to children. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Macromolecular Interactions Control Structural and Thermal Properties of Regenerated Tri-Component Blended Films.

With a growing need for sustainable resources research has become highly interested in investigating the structure and physical properties of biomaterials composed of natural macromolecules. In this study, we assessed the structural, morphological, and thermal properties of blended, regenerated films comprised of cellulose, lignin, and hemicellulose (xylan) using the ionic liquid 1-allyl-3-methylimidazolium chloride (AMIMCl). Attenuated total reflectance Fourier transform infrared (ATR-FTIR) analysis, scanning electron microscopy (SEM), atomic force microscopy (AFM), X-ray scattering, and thermogravimetric analysis (TGA) were used to qualitatively and quantitatively measure bonding interactions, morphology, and thermal stability of the regenerated films. The results demonstrated that the regenerated films' structural, morphological, and thermal character changed as a function of lignin-xylan concentration. The decomposition temperature rose according to an increase in lignin content and the surface topography of the regenerated films changed from fibrous to spherical patterns. This suggests that lignin-xylan concentration alters the self-assembly of lignin and the cellulose microfibril development. X-ray scattering confirms the extent of the morphological and molecular changes. Our data reveals that the inter- and intra-molecular interactions with the cellulose crystalline domains, along with the amount of disorder in the system, control the microfibril dimensional characteristics, lignin self-assembly, and possibly the overall material's structural and thermal properties.

Transmission of surfactant protein variants and haplotypes in children hospitalized with respiratory syncytial virus.

Severity of lung injury with respiratory syncytial virus (RSV) infection is variable and may be related to genetic variations. This preliminary report describes a prospective, family-based association study of children hospitalized secondary to RSV, aimed to determine whether intragenic and other haplotypes of surfactant proteins (SP)-A and SP-D are transmitted disproportionately from parents to offspring with RSV disease. Genomic DNA was genotyped for several SP-A and SP-D single nucleotide polymorphisms (SNPs). Transmission disequilibrium test analysis was used to determine transmission of variants and haplotypes from parents to affected offspring. Three hundred seventy-five individuals were studied, including 148 children with active RSV disease and one or both parents. The SP-A2 intragenic haplotype 1A was found to be protective (p = 0.013). The SP-D SNP DA160_A may possibly be an "at-risk" marker (p = 0.0058). Additional two- and three-marker haplotypes were associated with severe RSV disease, with two being protective (DA11_T/DA160_G and DA160_G/SP-A2 1A/SP-A1 6A). We conclude that there may be associations between SP-A and SP-D and RSV disease. Further study is required to determine whether these variants can be used to target a high-risk patient population in clinical trials aimed at reducing either the symptoms of acute infection or long-term pulmonary sequelae.

Haplotypes of the surfactant protein genes A and D as susceptibility factors for the development of respiratory distress syndrome.

AIMS: Polymorphisms of genes are transmitted together in haplotypes, which can be used in the study of the development of complex diseases such as respiratory distress syndrome (RDS). The surfactant proteins (SPs) play important roles in lung function, and genetic variants of these proteins have been linked with lung diseases, including RDS. To determine whether haplotypes of SP-A and SP-D are transmitted disproportionately from parents to offspring with RDS, we hypothesized that previously unstudied genetic haplotypes of these SP genes are associated with the development of RDS. METHODS: DNA was collected from 132 families of neonates with RDS. Genotyping was performed, and haplotype transmission from parent to offspring was determined by transmission disequilibrium test. RESULTS: The two-marker SP-D/SP-A haplotype DA160_A/SP-A2 1A(1) is protective against the development of RDS (p = 0.035). Four three- and four-marker haplotypes containing one or both loci from the significant two-marker haplotype are also protective against the development of RDS. CONCLUSIONS: These data identify protective haplotypes against RDS and support findings related to SP genetic differences in children who develop RDS. Study of haplotypes in complex diseases with both genetic and environmental risk factors may lead to better understanding of these types of diseases.

Assessment of parental presence during bedside pediatric intensive care unit rounds: effect on duration, teaching, and privacy.

OBJECTIVE: There is a paucity of literature evaluating the effects of family member presence during bedside medical rounds in the pediatric intensive care unit. We hypothesized that, when compared with rounds without family members, parental presence during morning medical rounds would increase time spent on rounds, decrease medical team teaching/education, increase staff dissatisfaction, create more stress in family members, and violate patient privacy in our open unit. DESIGN: Prospective, blinded, observational study. SETTING: Academic pediatric intensive care unit with 12 beds. PARTICIPANTS: A total of 105 admissions were studied, 81 family members completed a survey, and 187 medical team staff surveys were completed. INTERVENTIONS: Investigators documented parental presence and time allocated for presentation, teaching, and answering questions. Surveys related to perception of goals, teaching, and privacy of rounds were distributed to participants. MEASUREMENTS: Time spent on rounds, time spent teaching on rounds, and medical staff and family perception of the effects of parental presence on rounds. RESULTS: There was no significant difference between time spent on rounds in the presence or absence of family members (p = NS). There is no significant difference between the time spent teaching by the attending physician in the presence or absence of family members (p = NS). Overall, parents reported that the medical team spent an appropriate amount of time discussing their child and were not upset by this discussion. Parents did not perceive that their own or their child's privacy was violated during rounds. The majority of medical team members reported that the presence of family on rounds was beneficial. CONCLUSIONS: Parental presence on rounds does not seem to interfere with the educational and communication process. Parents report satisfaction with participation in rounds, and privacy violations do not seem to be a concern from their perspective.

Characterization of a human surfactant protein A1 (SP-A1) gene-specific antibody; SP-A1 content variation among individuals of varying age and pulmonary health.

The human surfactant protein A (SP-A) locus consists of two functional genes (SP-A1, SP-A2) with gene-specific products exhibiting qualitative and quantitative differences. The aim here was twofold: 1) generate SP-A1 gene-specific antibody, and 2) use this to assess gene-specific SP-A content in the bronchoalveolar lavage fluid (BALF). An SP-A1-specific polyclonal antibody (hSP-A1_Ab(68-88)_Col) was raised in chicken, and its specificity was determined by immunoblot and ELISA using mammalian Chinese hamster ovary (CHO) cell-expressed SP-A1 and SP-A2 variants and by immunofluorescence with stably transfected CHO cell lines expressing SP-A1 or SP-A2 variants. SP-A1 content was evaluated according to age and lung status. A gradual decrease (P < 0.05) in SP-A1/SP-A ratio was observed in healthy subjects (HS) with increased age, although no significant change was observed in total SP-A content among age groups. Total SP-A and SP-A1 content differed significantly between alveolar proteinosis (AP) patients and HS, with no significant difference observed in SP-A1/SP-A ratio between AP and HS. The cystic fibrosis (CF) ratio was significantly higher compared with AP, HS, and noncystic fibrosis (NCF), even though SP-A1 and total SP-A were decreased in CF compared with most of the other groups. The ratio was higher in culture-positive vs. culture-negative samples from CF and NCF (P = 0.031). A trend of an increased ratio was observed in culture-positive CF (0.590 +/- 0.10) compared with culture-positive NCF (0.368 +/- 0.085). In summary, we developed and characterized an SP-A1 gene-specific antibody and used it to identify gene-specific SP-A content in BALFs as a function of age and lung health.