Randall S. Burd

Blood transfusion is an independent predictor of increased mortality in nonoperatively managed blunt hepatic and splenic injuries.

BACKGROUND Management strategies for blunt solid viscus injuries often include blood transfusion. However, transfusion has previously been identified as an independent predictor of mortality in unselected trauma admissions. We hypothesized that transfusion would adversely affect mortality and outcome in patients presenting with blunt hepatic and splenic injuries after controlling for injury severity and degree of shock. METHODS We retrospectively reviewed records from all adults with blunt hepatic and/or splenic injuries admitted to a Level I trauma center over a 4-year period. Demographics, physiologic variables, injury severity, and amount of blood transfused were analyzed. Univariate and multivariate analysis with logistic and linear regression were used to identify predictors of mortality and outcome. RESULTS One hundred forty-three (45%) of 316 patients presenting with blunt hepatic and/or splenic injuries received blood transfusion within the first 24 hours. Two hundred thirty patients (72.8%) were selected for nonoperative management, of whom 75 (33%) required transfusion in the first 24 hours. Transfusion was an independent predictor of mortality in all patients (odds ratio [OR], 4.75; 95% confidence interval [CI], 1.37-16.4; p = 0.014) and in those managed nonoperatively (OR, 8.45; 95% CI, 1.95-36.53; p = 0.0043) after controlling for indices of shock and injury severity. The risk of death increased with each unit of packed red blood cells transfused (OR per unit, 1.16; 95% CI, 1.10-1.24; p < 0.0001). Blood transfusion was also an independent predictor of increased hospital length of stay (coefficient, 5.45; 95% CI, 1.64-9.25; p = 0.005). CONCLUSION Blood transfusion is a strong independent predictor of mortality and hospital length of stay in patients with blunt liver and spleen injuries after controlling for indices of shock and injury severity. Transfusion-associated mortality risk was highest in the subset of patients managed nonoperatively. Prospective examination of transfusion practices in treatment algorithms of blunt hepatic and splenic injuries is warranted.

National trends in the use of antireflux procedures for children.

OBJECTIVE. The purpose of this study was to analyze recent nationwide trends in the use of and outcomes after antireflux surgery for children. METHODS. We conducted a retrospective cohort study of children (age: <18 years) undergoing antireflux surgery by using data from 1996 to 2003 from the Nationwide Inpatient Sample. Census data were used to calculate the population-based rates of procedures stratified according to age and presence of neurologic impairment. Multivariate analyses were performed to determine factors associated with length of stay and in-hospital death. RESULTS. During the study period, 48 665 antireflux procedures were performed for children in the US. Although procedure rates were generally higher in 2003 than in 1996, no trends in rates were observed among different age groups and census regions during the study period. The highest population-based procedure rates were observed among infants (49–101 procedures per 100 000 population). There was a significant decrease in the percentages of children undergoing antireflux procedures who were neurologically impaired between 1996 and 2003 (53% vs 40%). Neurologically impaired children had longer lengths of stay and higher mortality rates than did neurologically normal children. CONCLUSIONS. Although procedure rates have not changed, the use of antireflux surgery has evolved during the laparoscopic era, with a decreasing percentage of neurologically impaired children undergoing this procedure. Antireflux procedures were performed predominantly for infants, most of whom were neurologically normal. Neurologically impaired children remain a group at high risk for death after antireflux procedures.

Murine β-defensin-3 is an inducible peptide with limited tissue expression and broad-spectrum antimicrobial activity

&bgr;-Defensins are cationic peptides produced by epithelial cells that have been proposed to be an important component of immune function at mucosal surfaces. Similarities between mammalian &bgr;-defensins may permit the use of murine models to further define the role of these peptides in innate host defense. Murine &bgr;-defensin-3 (mBD-3) is a peptide that exhibits homology at the gene level to human &bgr;-defensin-2 (hBD-2), one of four &bgr;-defensins identified in man. The purpose of this study was to determine the antimicrobial activity of mBD-3, the tissue distribution of mBD-3 expression, and the effect of gram-negative bacterial infection on mBD-3 expression. Based on the sequence deduced from mBD-3 cDNA, a 40-amino acid peptide was assembled using automated [n-(9-fluorenyl)methoxycarbonyl] solid-phase synthesis. The antimicrobial activity of synthetic mBD-3 was evaluated in microdilution broth assays using bacterial and fungal organisms. mBD-3 mRNA expression was assayed by polymerase chain reaction (PCR) using cDNA derived from a panel of tissues. Expression of mBD-3 was also evaluated in tissues obtained from mice 24 h after intraperitoneal infection with Escherichia coli using reverse transcriptase (RT)-PCR. Synthetic mBD-3 inhibited the growth of E. coli, Pseudomonas aeruginosa, Staphylococcus aureus, and Candida albicans at concentrations from 25 to 50 &mgr;g/mL. Constitutive expression of mBD-3 mRNA was not consistently found in any organ using RT-PCR. In an E. coli peritonitis model, expression of mBD-3 mRNA was upregulated only in the esophagus and tongue. We conclude that mBD-3 is an inducible peptide with limited tissue expression during E. coli peritonitis. Because it exhibits broad-spectrum antimicrobial activity, this peptide may serve as an innate defense against microbial invasion at specific mucosal surfaces in the mouse.

The utility of clinical and laboratory data for predicting intraabdominal injury among children.

BACKGROUND The initial assessment of the child with blunt injury should lead ideally to a low rate of missed intraabdominal injury (IAI) while avoiding unnecessary imaging among children without IAI. The purpose of this study was to determine the utility of clinical and laboratory data for predicting the risk for IAI. METHODS Among 351 children evaluated for possible blunt abdominal trauma, 23 variables potentially associated with IAI were determined retrospectively. Logistic regression and recursive partitioning were used to identify variables and develop predictive models. RESULTS Logistic regression identified four positive predictors (abdominal tenderness, abrasion, ecchymoses, and alanine aminotransferase) and two negative predictors (injury caused by a motor vehicle crash and hematocrit) for IAI. The recursive partitioning model predicted the absence of IAI with a sensitivity of 100% (95% CI confidence interval, 86-100%) and a specificity of 87% (95% CI confidence interval, 81-91%) using abdominal examination and aspartate aminotransferase as discriminating variables. CONCLUSIONS Physical examination combined with selected laboratory studies can be used to predict the risk of IAI accurately among children who sustain blunt trauma. Application of these findings may be useful in reducing costs and improving the accuracy of diagnosing IAI among children.

Methodology and analytic rationale for the American College of Surgeons Trauma Quality Improvement Program.

Received June 12, 2012; Revised August 12, 2012; Accepte 2012. From the Center for Policy and Research in Emergency Medi ment of Emergency Medicine, Oregon Health & Science Uni land, OR (Newgard), Department of Surgery, University of Vegas, NV (Fildes), American College of Surgeons, Chica Neal, Goble), Department of Surgery, University of Mich System, Ann Arbor, MI (Hemmila), Center for Clinical and Research, Departments of Surgery and Pediatrics, Childre Medical Center, Washington, DC (Burd), Intermountain In Research Center, University of Utah, Salt Lake City, UT (Ma ment of Surgery, University of Texas Southwestern Medical Sc TX (Shafi), Department of Surgery, Maine Medical Center, P (Clark), and Department of Surgery, University of Toron Ontario, Canada (Nathens). Correspondence address: Craig D Newgard, MD, MPH, FAC ment of Emergency Medicine, Center for Policy and Resea gency Medicine, Oregon Health & Science University, 31 Jackson Park Rd, Mail Code CR-114, Portland, OR 97239newgardc@ohsu.edu

Noninvasive monitoring of carbon dioxide during mechanical ventilation in older children : End-tidal versus transcutaneous techniques

We prospectively compared the accuracy of end-tidal CO2 (ETco2) and transcutaneous CO2 (TCco2) monitoring in older pediatric patients (4 yr or older) receiving mechanical ventilation for respiratory failure. ETco2 and TCco2 were simultaneously monitored and compared with arterial CO2 (Paco2) values when arterial blood gas analysis was performed. Eighty-two sample sets were compared. The ETco2 to Paco2 difference was 6.4 ± 6.3 mm Hg, whereas the TCco2 to Paco2 difference was 2.6 ± 2.0 mm Hg (P < 0.0001). The absolute difference of ETco2 and Paco2 was 5 or less in 47 of 82 measurements, whereas the absolute TCco2 to Paco2 difference was 5 or less in 76 of 82 measurements (P < 0.00001). Regression analysis of ETco2 and Paco2 values revealed a correlation coefficient of 0.5418 and an r value of 0.8745. Regression analysis of TCco2 and Paco2 values revealed a correlation coefficient of 1.0160 and an r value of 0.9693. Bland-Altman analysis revealed a bias of −5.68 with a precision of ±6.93 when comparing ETco2 with Paco2 and a bias of 0.02 with a precision of ±3.27 when comparing TCco2 and Paco2 (P < 0.00001). TCco2 monitoring provided an accurate estimation of Paco2 over a wide range of CO2 values and was superior to ETco2 monitoring in older pediatric patients with respiratory failure. TCco2 monitoring may be considered as a useful adjunct to monitoring of ventilation in this patient population.

Pediatric surgery workforce: supply and demand

INTRODUCTION Recent studies report a shortage of pediatric surgeons in the United States. We surveyed members of the American Pediatric Surgical Association (APSA) to estimate current workforce and demand and to provide data for workforce planning. METHODS We conducted a survey of 849 APSA members to provide workforce data on their communities as follows: the number of active, retired, or inactive APSA surgeons; non-APSA fellowship graduates; surgeons without accredited fellowship training; and the estimated demand for additional pediatric surgeons. Internet search engines identified surgeons and practices offering pediatric surgical services. The US Census Metropolitan Statistical Areas (MSAs) defined service areas with populations of 100,000 or more. RESULTS Of 137 MSAs with APSA members in practice, we obtained data from 113 (83%), with 247 (29%) of 849 surgeons responding. We estimate that the current pediatric surgical workforce consists of 1150 surgeons, with APSA members in active practice (60%) forming the single largest group, followed by general surgeons (21%). The percentage of active APSA surgeons was greater than the percentage of general surgeons in the 50 largest MSAs (76% vs 2%, respectively), whereas the opposite was observed in the smaller MSA ranked more than 51 in population (37% vs 46%, respectively). American Pediatric Surgical Association respondents estimated a national demand for 280 additional pediatric surgeons. Active APSA surgeons plan to delay retirement (8% of respondents) because it would leave their group or community shorthanded; 2% reported that retirement would leave the community without a pediatric surgeon. DISCUSSION Workforce shortage in pediatric surgery is a problem of number and distribution. Incentives to direct trainees to underserved areas are needed. General surgeons provide pediatric services in many communities. Surgical training should include additional training in pediatric surgery.

Introducing RFID technology in dynamic and time-critical medical settings

We describe the process of introducing RFID technology in the trauma bay of a trauma center to support fast-paced and complex teamwork during resuscitation. We analyzed trauma resuscitation tasks, photographs of medical tools, and videos of simulated resuscitations to gain insight into resuscitation tasks, work practices and procedures. Based on these data, we discuss strategies for placing RFID tags on medical tools and for placing antennas in the environment for optimal tracking and activity recognition. Results from our preliminary RFID deployment in the trauma bay show the feasibility of our approach for tracking tools and for recognizing trauma team activities. We conclude by discussing implications for and challenges to introducing RFID technology in other similar settings characterized by dynamic and collocated collaboration.

Mortality Among Injured Children Treated at Different Trauma Center Types.

IMPORTANCE Trauma is the leading cause of death among US children. Whether pediatric trauma centers (PTCs), mixed trauma centers (MTCs), or adult trauma centers (ATCs) offer a survival benefit compared with one another when treating injured children is controversial. Ascertaining the optimal care environment will better inform quality improvement initiatives and accreditation standards. OBJECTIVE To evaluate the association between type of trauma center (PTC, MTC, or ATC) and in-hospital mortality among young children (5 years and younger), older children (aged 6-11 years), and adolescents (aged 12-18 years). DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, injured children aged 18 years or younger who were hospitalized in the United States from January 1, 2010, to December 31, 2013, were observed for the duration of their admission until discharge or death. We included patients with an Abbreviated Injury Score of 2 or greater in at least 1 body region. Random-intercept multilevel regression was used to evaluate the association between center type and in-hospital mortality after adjusting for confounders. Stratified analyses in young children, older children, and adolescents were performed. We conducted secondary analyses limited to patients with severe injuries (Injury Severity Score ≥25). Both analyses were performed between January 1 and August 31, 2014. Data were derived from 252 US level I and II trauma centers voluntarily participating in the American College of Surgeons adult or pediatric Trauma Quality Improvement Program. MAIN OUTCOME AND MEASURE In-hospital mortality. RESULTS We identified 175 585 injured children. Crude mortality rates were 2.3% for children treated at ATCs, 1.8% for children treated at MTCs, and 0.6% for children treated at PTCs. After adjustment, children had higher odds of dying when treated at ATCs (odds ratio [OR], 1.57; 95% CI, 1.15-2.14) and MTCs (OR, 1.45; 95% CI, 1.05-2.01) compared with those treated at PTCs. In stratified analyses, young children had higher odds of death when treated at ATCs vs PTCs (OR, 1.78; 95% CI, 1.05-3.40), but there was no association between center type and mortality among older children (OR, 1.17; 95% CI, 0.65-2.11) and adolescents (OR, 1.23; 95% CI, 0.82-1.85). Results were similar in analyses of severely injured children: those treated at ATCs (OR, 1.75; 95% CI, 1.25-2.44) and MTCs (OR, 1.62; 95% CI, 1.15-2.29) had higher odds of death when compared with those treated at PTCs. CONCLUSIONS AND RELEVANCE Injured children treated at ATCs and MTCs had higher in-hospital mortality compared with those treated at PTCs. This association was most evident in younger children and remained significant in severely injured children. Quality improvement initiatives geared toward ATCs and MTCs are required to provide optimal care to injured children.

Socioeconomic disparities in infant mortality after nonaccidental trauma: a multicenter study.

BACKGROUND While disparities in abuse-related mortality between minority and white infants have been reported, the influence of socioeconomic status on outcome has not been evaluated. The goal of this study was to determine the impact of socioeconomic status and race on outcomes for abused infants using multiinstitutional data. METHODS Data on infants (<12 months old) with abusive injuries over a 5-year period were obtained from nine U.S. pediatric trauma centers. Demographics, insurance status, Injury Severity Scores, Glasgow Coma Scale scores, median household income and outcomes were recorded. Logistic regression was used to evaluate the impact of race, income and insurance status on mortality. RESULTS There were 867 patients identified with a mortality of 8.8%. Patients without private insurance had a 3.8 times greater odds (give 95% confidence interval) of dying. Those in the lower three quartiles of income also had a higher odds of death even after controlling for race, injury severity, and Glasgow Coma Scale. Although African American infants had a higher overall mortality than whites (11.2% vs. 7.8%, p = 0.14), race was not an independent predictor of mortality (p = 0.98). CONCLUSIONS There are significant differences in mortality among abused infants associated with insurance status and income even after controlling for injury severity. These associations show a need to better understand and address socioeconomic variations in outcome.