The purpose of our study was to describe children with life-threatening bleeding.
We conducted a prospective observational study of children with life-threatening bleeding events.
Twenty-four ...childrens hospitals in the United States, Canada, and Italy participated.
Children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under massive transfusion protocol were included.
Children were compared according bleeding etiology: trauma, operative, or medical.
Patient characteristics, therapies administered, and clinical outcomes were analyzed. Among 449 enrolled children, 55.0% were male, and the median age was 7.3 years. Bleeding etiology was 46.1% trauma, 34.1% operative, and 19.8% medical. Prior to the life-threatening bleeding event, most had age-adjusted hypotension (61.2%), and 25% were hypothermic. Children with medical bleeding had higher median Pediatric Risk of Mortality scores (18) compared with children with trauma (11) and operative bleeding (12). Median Glasgow Coma Scale scores were lower for children with trauma (3) compared with operative (14) or medical bleeding (10.5). Median time from bleeding onset to first transfusion was 8 minutes for RBCs, 34 minutes for plasma, and 42 minutes for platelets. Postevent acute respiratory distress syndrome (20.3%) and acute kidney injury (18.5%) were common. Twenty-eight-day mortality was 37.5% and higher among children with medical bleeding (65.2%) compared with trauma (36.1%) and operative (23.8%). There were 82 hemorrhage deaths; 65.8% occurred by 6 hours and 86.5% by 24 hours.
Patient characteristics and outcomes among children with life-threatening bleeding varied by cause of bleeding. Mortality was high, and death from hemorrhage in this population occurred rapidly.
To assess the impact of antifibrinolytics in children with life-threatening hemorrhage.
Secondary analysis of the MAssive Transfusion epidemiology and outcomes In Children study dataset, a ...prospective observational study of children with life-threatening bleeding events.
Twenty-four children's hospitals in the United States, Canada, and Italy.
Children 0-17 years old who received greater than 40 mL/kg of total blood products over 6 hours or were transfused under activation of massive transfusion protocol.
Children were compared according to receipt of antifibrinolytic medication (tranexamic acid or aminocaproic acid) during the bleeding event.
Patient characteristics, medications administered, and clinical outcomes were analyzed using Cox proportional hazard and Kaplan-Meier survival analysis. The primary outcome was 24-hour mortality. Of 449 patients analyzed, median age was 7 years (2-15 yr), and 55% were male. The etiology of bleeding was 46% traumatic, 34% operative, and 20% medical. Twelve percent received antifibrinolytic medication during the bleeding event (n = 54 unique subjects; n = 18 epsilon aminocaproic acid, n = 35 tranexamic acid, and n = 1 both). The antifibrinolytic group was comparable with the nonantifibrinolytic group on baseline demographic and physiologic parameters; the antifibrinolytic group had longer massive transfusion protocol duration, received greater volume blood products, and received factor VII more frequently. In the antifibrinolytic group, there was significantly less 6-hour mortality overall (6% vs 17%; p = 0.04) and less 6-hour mortality due to hemorrhage (4% vs 14%; p = 0.04). After adjusting for age, bleeding etiology, Pediatric Risk of Mortality score, and plasma deficit, the antifibrinolytic group had decreased mortality at 6- and 24-hour postbleed (adjusted odds ratio, 0.29 95% CI, 0.09-0.93; p = 0.04 and adjusted odds ratio, 0.45 95% CI, 0.21-0.98; p = 0.04, respectively).
Administration of antifibrinolytic medications during the life-threatening event was independently associated with improved 6- and 24-hour survivals in bleeding children. Consideration should be given to use of antifibrinolytics in pediatric patients with life-threatening hemorrhage.
Cervical spine injury patterns in children Leonard, Jeffrey R; Jaffe, David M; Kuppermann, Nathan ...
Pediatrics (Evanston),
05/2014, Letnik:
133, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Pediatric cervical spine injuries (CSIs) are rare and differ from adult CSIs. Our objective was to describe CSIs in a large, representative cohort of children.
We conducted a 5-year retrospective ...review of children <16 years old with CSIs at 17 Pediatric Emergency Care Applied Research Network hospitals. Investigators reviewed imaging reports and consultations to assign CSI type. We described cohort characteristics using means and frequencies and used Fisher's exact test to compare differences between 3 age groups: <2 years, 2 to 7 years, and 8 to 15 years. We used logistic regression to explore the relationship between injury level and age and mechanism of injury and between neurologic outcome and cord involvement, injury level, age, and comorbid injuries.
A total of 540 children with CSIs were included in the study. CSI level was associated with both age and mechanism of injury. For children <2 and 2 to 7 years old, motor vehicle crash (MVC) was the most common injury mechanism (56%, 37%). Children in these age groups more commonly injured the axial (occiput-C2) region (74%, 78%). In children 8 to 15 years old, sports accounted for as many injuries as MVCs (23%, 23%), and 53% of injuries were subaxial (C3-7). CSIs often necessitated surgical intervention (axial, 39%; subaxial, 30%) and often resulted in neurologic deficits (21%) and death (7%). Neurologic outcome was associated with cord involvement, injury level, age, and comorbid injuries.
We demonstrated a high degree of variability of CSI patterns, treatments and outcomes in children. The rarity, variation, and morbidity of pediatric CSIs make prompt recognition and treatment critical.
Adult prediction rules for cervical spine injury (CSI) exist; however, pediatric rules do not. Our objectives were to determine test accuracies of retrospectively identified CSI risk factors in a ...prospective pediatric cohort and compare them to a de novo risk model.
We conducted a 4-center, prospective observational study of children 0 to 17 years old who experienced blunt trauma and underwent emergency medical services scene response, trauma evaluation, and/or cervical imaging. Emergency department providers recorded CSI risk factors. CSIs were classified by reviewing imaging, consultations, and/or telephone follow-up. We calculated bivariable relative risks, multivariable odds ratios, and test characteristics for the retrospective risk model and a de novo model.
Of 4091 enrolled children, 74 (1.8%) had CSIs. Fourteen factors had bivariable associations with CSIs: diving, axial load, clotheslining, loss of consciousness, neck pain, inability to move neck, altered mental status, signs of basilar skull fracture, torso injury, thoracic injury, intubation, respiratory distress, decreased oxygen saturation, and neurologic deficits. The retrospective model (high-risk motor vehicle crash, diving, predisposing condition, neck pain, decreased neck mobility (report or exam), altered mental status, neurologic deficits, or torso injury) was 90.5% (95% confidence interval: 83.9%-97.2%) sensitive and 45.6% (44.0%-47.1%) specific for CSIs. The de novo model (diving, axial load, neck pain, inability to move neck, altered mental status, intubation, or respiratory distress) was 92.0% (85.7%-98.1%) sensitive and 50.3% (48.7%-51.8%) specific.
Our findings support previously identified pediatric CSI risk factors and prospective pediatric CSI prediction rule development.
Food advertising is a major contributor to obesity, and fast food (FF) restaurants are top advertisers. Research on the impact of food advertising in adolescents is lacking and no prior research has ...investigated neural predictors of food intake in adolescents. Neural systems implicated in reward could be key to understanding how food advertising drives food intake.
To investigate how neural responses to both unhealthy and healthier FF commercials predict food intake in adolescents.
A cross-sectional sample of 171 adolescents (aged 13–16 y) who ranged from normal weight to obese completed an fMRI paradigm where they viewed unhealthy and healthier FF and nonfood commercials. Adolescents then consumed a meal in a simulated FF restaurant where foods of varying nutritional profiles (unhealthy compared with healthier) were available.
Greater neural activation in reward-related regions (nucleus accumbens, r = 0.29; caudate nucleus, r = 0.27) to unhealthy FF commercials predicted greater total food intake. Greater responses to healthier FF relative to nonfood commercials in regions associated with reward (i.e., nucleus accumbens, r = 0.24), memory (i.e., hippocampus, r = 0.32), and sensorimotor processes (i.e., anterior cerebellum, r = 0.33) predicted greater total food and unhealthier food intake, but not healthier food intake. Lower activation in neural regions associated with visual attention and salience (e.g., precuneus, r = −0.35) to unhealthy relative to healthier FF commercials predicted healthier food intake.
These findings suggest that FF commercials contribute to overeating in adolescents through reward mechanisms. The addition of healthier commercials from FF restaurants is unlikely to encourage healthier food intake, but interventions that reduce the ability of unhealthy FF commercials to capture attention could be beneficial. However, an overall reduction in the amount of FF commercials exposure for adolescents is likely to be the most effective approach.
To compare the medical costs associated with risk stratification criteria used to evaluate febrile infants 29-90 days of age.
A cost analysis study was conducted evaluating the Boston, Rochester, ...Philadelphia, Step-by-Step, and PECARN criteria. The percentage of infants considered low risk and rates of missed infections were obtained from published literature. Emergency department costs were estimated from the Centers for Medicare and Medicaid Services. The Health Care Cost and Utilization Project databases were used to estimate the number of infants ages 29-90 days presenting with fever annually and costs for admissions related to missed infections. A probabilistic Markov model with a Dirichlet prior was used to estimate the transition probability distributions for each outcome, and a gamma distribution was used to model costs. A Markov simulation estimated the distribution of expected annual costs per infant and total annual costs.
For low-risk infants, the mean cost per infant for the criteria were Rochester: $1050 (IQR $1004-$1092), Philadelphia: $1416 (IQR, $1365-$1465), Boston: $1460 (IQR, $1411-$1506), Step-by-Step $942 (IQR, $899-$981), and PECARN $1004 (IQR, $956-$1050). An estimated 18 522 febrile 1- to 3-month-old infants present annually and estimated total mean costs for their care by criteria were: Rochester, $127.3 million (IQR, $126.1-$128.5); Philadelphia, $129.9 million (IQR, $128.7-$131.1); Boston, $128.7 million (IQR, $127.5-$129.9); Step-by-Step, $ 126.6 million (IQR, $125.4-$127.8); and PECARN, $125.8 million (IQR, $124.6-$127).
The Rochester, Step-by-step, and PECARN criteria are the least costly when evaluating infants 29-90 days of age with a fever.
Massive transfusion protocols (MTPs) have been developed to implement damage control resuscitation (DCR) principles. A survey of MTP policies from American College of Surgeons Trauma Quality ...Improvement Program (ACS-TQIP) participants was performed to establish which MTP activation, hemostatic resuscitation, and monitoring aspects of DCR are included in the MTP guidelines.
On October 10, 2013, ACS-TQIP administration administered a cross-sectional electronic survey to 187 ACS-TQIP participants.
Seventy-one percent (132 of 187) of responses were analyzed, with 62% designated as Level I and 38% designated as Level II ACS-TQIP trauma centers. Sixty-nine percent of sites indicated that they have plasma immediately available for MTP activation. By policy, in the first group of blood products administered, 88% of sites target high (≥1:2) plasma-to-red blood cell (RBC) ratios and 10% target low ratios. Likewise, 79% of sites target high platelet-to-RBC ratios and 16% target low ratios. Eighteen percent of sites reported incorporating point-of-care thromboelastogram into MTP policies. The most common intravenous hemostatic adjunct incorporated into MTPs was tranexamic acid (49%). Thirty-four percent of sites reported that some or all of their emergency medical service agencies have the ability to administer blood products or hemostatic agents during prehospital transport. There were minimal differences in MTP policies or capabilities between Level I and II sites.
The majority of ACS-TQIP participants reported having MTPs that support the use of DCR principles including high plasma-to-RBC and platelet-to-RBC ratios. Immediate availability of plasma and product use by emergency medical services are becoming increasingly common, whereas the incorporation of point-of-care thromboelastogram into MTP policies remains low.
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