Alexander Feliz

NONINVASIVE HEMOGLOBIN MEASUREMENT IN PEDIATRIC TRAUMA PATIENTS.

INTRODUCTION Hemorrhage is a major cause of preventable death secondary to traumatic injury. Diagnosis often requires multiple blood draws, which are psychologically stressful in pediatric patients. The Pronto device is a pulse co-oximeter that measures the total hemoglobin level using multiple wavelengths of light. The purpose of this study was to evaluate the accuracy of the noninvasive hemoglobin measurements relative to current invasive and point of care testing methods in pediatric trauma patients. METHODS We performed a prospective observational trial involving patients younger than 17 years presenting to a Level I pediatric trauma center. Following admission, blood was sampled from each patient for testing using an i-Stat device (point-of-care hemoglobin) and a complete blood count within our core laboratory (invasive hemoglobin). Noninvasive hemoglobin analysis was performed within 15 minutes of phlebotomy. Data were evaluated using Spearman correlation and Bland-Altman analysis. RESULTS Over 2 years, 114 patients had attempted noninvasive hemoglobin measurements, with a success rate of 89%. Mean ± SD age was 9.2 ± 5.1 years. Ninety percent of admissions were for blunt injury, 3% penetrating, 5% near drowning, and 1% burns. Mean invasive hemoglobin was 12.6 ± 1.9 g/dL, mean point-of-care hemoglobin was 12.2 ± 2.0 g/dL, and mean noninvasive hemoglobin was 12.3 ± 1.6 g/dL. Noninvasive hemoglobin values were strongly correlated with both invasive and point of care measurements (R = 0.672 and R = 0.645, respectively; p < 0.001). Bland-Altman analysis comparing noninvasive to point-of-care and invasive hemoglobin levels resulted in an estimated bias of −0.39 and −0.49, respectively. CONCLUSION Noninvasive hemoglobin values had excellent correlation with both invasive and point-of-care hemoglobin measurements, although the device was not successful for all patients. Given the rapid availability of results and the lack of requirement of venipuncture, noninvasive hemoglobin monitoring may be a valuable adjunct in the initial evaluation and monitoring of pediatric trauma patients. LEVEL OF EVIDENCE Diagnostic test study, level II.

Health Disparities in the Appropriate Management of Cryptorchidism

Objective To assess regional practices in management of cryptorchidism with regard to timely fixation by the current recommended age of 18 months. Study design A retrospective study was performed. Charts of all patients who underwent surgical correction for cryptorchidism by a pediatric general surgeon or urologist within a tertiary pediatric hospital in an urban setting were systematically reviewed. Results We identified 1209 patients with cryptorchidism. The median age of surgical correction was 3.7 years (IQR: 1.4, 7.7); only 27% of patients had surgical correction before 18 months of age. Forty‐six percent of our patients were white, 40% were African American, and 8% were Hispanic. African American and Hispanic patients were less likely to undergo timely repair (P = .01), as were those with public or no insurance (P < .0001). A majority (72%) of patients had no diagnostic imaging prior to surgery. A majority of patients had palpable testes at operation (85%) and underwent inguinal orchiopexy (76%); 82% were operated on by a pediatric urologist. Only 35 patients (3%) experienced a complication; those repaired late were significantly less likely to develop a complication (P = .03). There were no differences in age at time of surgery by surgeon type. Conclusions A majority of our patients were not referred for surgical intervention in a timely manner, which may reflect poor access to care in our region. Public and self‐pay insurance status was associated with delayed repair. Education of community physicians and families could be potentially beneficial.

Successful Repair of Hypoplastic Left Heart Syndrome with Intact Atrial Septum, Congenital Diaphragm Hernia, and Anomalous Origin of Coronary Artery: Defying the Odds

We report a case of an infant who was postnatally diagnosed with hypoplastic left heart syndrome and an intact atrial septum who underwent emergent atrial decompression followed by the Norwood operation. She was also found to have a congenital diaphragmatic hernia on the left side and a congenital eventration of the right diaphragm, both requiring surgical repair. She was later found to have an anomalous origin of the left circumflex coronary artery from the right pulmonary artery that was ligated at the time of the bilateral bidirectional Glenn operation. She is currently thriving at home, defying all odds.

A comparison between non-powder gun and powder-gun injuries in a young pediatric population

INTRODUCTION Non-powder guns (NPG) are viewed as toys for children by the general public. Literature on firearm injuries in the pediatric population is increasing, however there are still large gaps in the published literature regarding NPG. We intended to identify and compare the epidemiology, circumstances of injury and outcomes of children with NPG versus powder-gun injuries (GSW). PATIENTS AND METHODS We performed a 6-year retrospective analysis of children 0-14 years old treated for NPG and GSW injuries at our level one pediatric trauma center. Mann-Whitney U test and Pearsons X2 were used to compare continuous and categorical variables, respectively. RESULTS There were 43 NPG and 112 GSWs. Patients were predominantly male (36 children; 84%) NPG vs. 92 children; 82% GSW) with a median age in both groups of 11 years. Analysis of residential zip codes showed that 74% (32 children) NPG injuries and 85% (95 children) GSW lived in regions with higher poverty than the national level. Children with NPG injuries were more likely to be Caucasian (24 children; 56%) and to have suffered an unintentional injury (36 children; 84%), while children with GSW were African-American (80 children; 71%; p=0.0002) and victims of assault (50 children; 45%; p<0.0001). When compared with NPG, children with GSW had more severe injuries, longer hospital stays, and higher overall mortality. There were no significant differences in rate of emergent OR intervention and ED mortality between the two groups. CONCLUSION Our results highlight two important findings. First, NPG injuries were accidental and thus preventable with improved legislation and public education. Second, health disparities related to gun violence among African-Americans are prevalent even in early childhood and prevention efforts should include this younger population.

Health disparities in infants with hypertrophic pyloric stenosis

BACKGROUND This study investigates whether health disparities exist in infants with hypertrophic pyloric stenosis (HPS), to identify factors affecting definitive treatment, and if more morbidity occurs. METHODS A 6-year retrospective analysis was performed on infants with HPS. Analysis of variance was used to evaluate the impact of socioeconomic factors on disease severity and hospitalization. General linear models were used to assess the impact of risk factors on the outcomes. RESULTS There were a total of 584 infants. African-Americans had lower serum chloride (P < .001), higher bicarbonate (P = .001), and sodium levels (P = .006), adding to longer hospitalization than whites (P = .03). Uninsured infants had lower sodium and chloride (P < .001) and higher bicarbonate (P < .001), resulting in a longer time to operation (P = .05) than privately insured infants. In multivariable analyses, African-Americans were associated with chloride (P = .002) and higher bicarbonate (P = .009), and uninsured status remained significantly associated with all electrolyte abnormalities. CONCLUSIONS African-American and poorly insured infants with HPS had greater risk of metabolic derangements. This required more time to correct dehydration and electrolytes, adding to longer hospitalizations.