Clinician's Guide for Pediatric Anti-obesity Medications.

The recent advent of highly effective anti-obesity medications (AOM) provides pediatric clinicians a powerful tool to augment the treatment of obesity and improve outcomes. The 2023 American Academy of Pediatrics guidelines state clinicians "should offer adolescents 12 years and older with obesity weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment". This article will provide an update on the integration of AOM into practice, emphasizing clinical pearls and practical tips.

Pharmacotherapeutic options for weight regain after bariatric surgery.

PURPOSE OF REVIEW: We sought to critically evaluate the recent literature published over the past 3 years on the topic of weight regain after bariatric surgery in children, adolescents, and adults, with an emphasis on clinically- relevant information for pharmacologic treatment of weight regain after metabolic and bariatric surgery. FINDINGS: There are multiple pharmacotherapeutic agents available to treat obesity in children, adolescents, and adults; these agents have varying efficacy and indications for use and have been studied in a variety of clinical and research scenarios. We present an overview of these findings. SUMMARY: This review represents a comprehensive compilation of the recently published data on efficacy of anti-obesity pharmacotherapy in the treatment of weight regain after bariatric surgery for children, adolescents, and adults.

The new metric to define large-volume hemorrhage: results of a prospective study of the critical administration threshold.

BACKGROUND: Definitions of massive transfusion (MT), 10 or more units of packed red blood cells (PRBCs) in 24 hours, focus on static volumes over fixed times. This arbitrary volume definition promotes survivor bias and fails to identify the "massively" transfused patient. In previous work, the critical administration threshold (CAT) was created to incorporate both rate and volume of transfusion. CAT proved a superior predictor of mortality compared with traditional MT. The purpose of this study was to prospectively validate CAT in a larger trauma population. METHODS: Patients receiving at least 1 U of PRBCs within the first day of admission were identified prospectively. Administration time of each unit of PRBCs was recorded in minutes. CAT status, defined as receipt of at least 3 U of blood in a 60-minute period, was identified for the first 24 hours. CAT+ patients were quantified by the number of times CAT+ was reached, that is, once (CAT1), twice (CAT2), three times (CAT3), or 4 or more times (CAT4). A multivariable Cox proportional hazard model with a time-varying covariate was used to quantify a patient's risk of death with increasing CAT status. RESULTS: A total of 316 met inclusion criteria, 161 of whom were CAT+. Seventy-six percent were male, mean age was 38 years, and median Injury Severity Score (ISS) was 15. CAT+ was associated with a twofold increased risk of death (hazard ratio, 1.809; 95% confidence interval, 1.020-3.209). Ninety-one patients were CAT+ and received less than 10 U of blood, thereby MT- (CAT+/MT-). CAT+/MT- had significant injury patterns, with a median ISS of 14, 43% penetrating injury, and 10% mortality. CONCLUSION: CAT allows early identification of injured patients at greatest risk of death. Encompassing both rate and volume of transfusion, CAT is a tool more sensitive than common MT definitions. Studies examining large-volume blood transfusions should use CAT to identify patients, to accurately identify cohorts of interest. LEVEL OF EVIDENCE: Diagnostic tests, level II.

Blunt cerebrovascular injury screening with 64-channel multidetector computed tomography: more slices finally cut it.

BACKGROUND: Aggressive screening to diagnose blunt cerebrovascular injury (BCVI) results in early treatment, leading to improved outcomes and reduced stroke rates. While computed tomographic angiography (CTA) has been widely adopted for BCVI screening, evidence of its diagnostic sensitivity is marginal. Previous work from our institution using 32-channel multidetector CTA in 684 patients demonstrated an inadequate sensitivity of 51% (Ann Surg. 2011,253: 444-450). Digital subtraction angiography (DSA) continues to be the reference standard of diagnosis but has significant drawbacks of invasiveness and resource demands. There have been continued advances in CT technology, and this is the first report of an extensive experience with 64-channel multidetector CTA. METHODS: Patients screened for BCVI using CTA and DSA (reference) at a Level 1 trauma center during the 12-month period ending in May 2012 were identified. Results of CTA and DSA, complications, and strokes were retrospectively reviewed and compared. RESULTS: A total of 594 patients met criteria for BCVI screening and underwent both CTA and DSA. One hundred twenty-eight patients (22% of those screened) had 163 injured vessels: 99 (61%) carotid artery injuries and 64 (39%) vertebral artery injuries. Sixty-four-channel CTA demonstrated an overall sensitivity per vessel of 68% and specificity of 92%. The 52 false-negative findings on CTA were composed of 34 carotid artery injuries and 18 vertebral artery injuries; 32 (62%) were Grade I injuries. Overall, positive predictive value was 36.2%, and negative predictive value was 97.5%. Six procedure-related complications (1%) occurred with DSA, including two iatrogenic dissections and one stroke. CONCLUSION: Sixty-four-channel CTA demonstrated a significantly improved sensitivity of 68% versus the 51% previously reported for the 32-channel CTA (p = 0.0075). Sixty-two percent of the false-negative findings occurred with low-grade injuries. Considering complications, cost, and resource demand associated with DSA, this study suggests that 64-channel CTA may replace DSA as the primary screening tool for BCVI. LEVEL OF EVIDENCE: Diagnostic study, level III.