National Analysis of Outcomes for Adult Trauma Patients With Isolated Severe Blunt Traumatic Brain Injury Following Venous Thromboembolism Prophylaxis.

INTRODUCTION: We aim to evaluate the association of early versus late venous thromboembolism (VTE) prophylaxis on in-hospital mortality among patients with severe blunt isolated traumatic brain injuries. METHODS: Data from the American College of Surgeons Trauma Quality Program Participant Use File for 2017-2021 were analyzed. The target population included adult trauma patients with severe isolated traumatic brain injury (TBI). VTE prophylaxis types (low molecular weight heparin and unfractionated heparin) and their administration timing were analyzed in relation to in-hospital complications and mortality. RESULTS: The study comprised 3609 patients, predominantly Caucasian males, with an average age of 48.5 y. Early VTE prophylaxis recipients were younger (P < 0.01) and more likely to receive unfractionated heparin (P < 0.01). VTE prophylaxis later than 24 h was associated with a higher average injury severity score and longer intensive care unit stays (P < 0.01). Logistic regression revealed that VTE prophylaxis later than 24 h was associated with significant reduction of in-hospital mortality by 38% (odds ratio 0.62, 95% confidence interval 0.40-0.94, P = 0.02). Additionally, low molecular weight heparin use was associated with decreased mortality odds by 30% (odds ratio 0.70, 95% confidence interval 0.55-0.89, P < 0.01). CONCLUSIONS: VTE prophylaxis later than 24 h is associated with a reduced risk of in-hospital mortality in patients with severe isolated blunt TBI, as opposed to VTE prophylaxis within 24 h. These findings suggest the need for timely and appropriate VTE prophylaxis in TBI care, highlighting the critical need for a comprehensive assessment and further research concerning the safety and effectiveness of VTE prophylaxis in these patient populations.

National analysis of over and under-triage rates in relation to trauma population risk factors and associated outcomes across various levels trauma centers.

INTRODUCTION: Over and under-triage represent a misallocation of resources that can affect patient outcomes. The purpose of this study is to evaluate over and under-triage rates in relation to risk factors and associated outcomes of trauma patients nationwide. METHODS: A retrospective cohort study using the Trauma Quality Improvement Program from 2017 to 2020. Multivariable regression models were used to assess predictors of over-triage (activation when unnecessary) and under-triage (limited activation when full activation was necessary). RESULTS: 22.2 % (32,782) of the study population were over-triaged and 20.3 % (29,996) were under-triaged. Most over-triaged patients were Black, with Medicaid, or had a penetrating injury, whereas most under-triaged patients were White, with private/commercial insurance, or had a blunt injury. With covariates adjusted for, Pacific Islander (p = 0.024) and American Indian patients (p = 0.015) were associated with higher odds of over-triage, and Hispanic patients had higher odds of under-triage (p<0.001). Patients with Medicare (p<0.001) had higher odds of over-triage, and patients with private/commercial insurance (p<0.001) had higher odds of under-triage compared to Medicaid patients. Patients in level II (p<0.001) and level III (p<0.001) trauma hospitals were associated with higher odds of over-triage. CONCLUSION: Pacific Islander and American Indian patients, Medicare, and level II and III trauma centers are at increased risk of over-triage rates, while Hispanic and privately insured trauma patients had a higher risk for under-triage. Future studies should further investigate factors contributing to poor outcomes linked to under-triage practices and methods to improve consistency and standardization of triage tools across various levels of trauma centers.

Clinical Characteristics and Outcomes of SARS-CoV-2 Positive Neonates Born to Persons With SARS-CoV-2 Infection in Pregnancy in Los Angeles County, California, May 22, 2020-February 22, 2021.

BACKGROUND: It is well established that pregnant persons with SARS-CoV-2 are at an increased risk for preterm birth, however, less is known about perinatal outcomes for neonates with intrauterine exposure to SARS-CoV-2. METHODS: Characteristics of 50 SARS-CoV-2 positive neonates born to SARS-CoV-2 pregnant persons positive between May 22, 2020, and February 22, 2021, in Los Angeles County, CA, were assessed. Pattern of neonate SARS-CoV-2 test results and time to positive test was analyzed. Objective clinical severity criteria were applied to assess neonatal disease severity. RESULTS: Median gestational age was 39 weeks with 8 (16%) neonates born preterm. Most (74%) were asymptomatic, while 13 (26%) were symptomatic from any cause. Four (8%) symptomatic neonates met criteria for severe disease, of which 2 (4%) were likely secondary to COVID-19. The other 2 with severe disease had more likely alternate diagnoses, and 1 of these neonates subsequently died at 7 months of life. Among 12 (24%) that were positive within 24 hours after birth, one was persistently positive and represented likely intrauterine transmission. Sixteen (32%) were admitted to the neonatal intensive care unit. CONCLUSION: In this case series of 50 SARS-CoV-2 positive mother-neonate pairs, we found that most neonates were asymptomatic regardless of when they tested positive during the 14 days after birth, that there was relatively low risk of COVID-19 associated severe disease, and that intrauterine transmission can occur in rare cases. Although short-term outcomes are mostly promising, more research is needed to study long-term consequences of SARS-CoV-2 infection in neonates born to positive pregnant persons.

Epidemiology of Exposures, Preceding Illness and Testing History in Children With Multisystem Inflammatory Syndrome in Children in the First 18 Months of the COVID-19 Pandemic, Los Angeles County, California.

We describe the epidemiology of COVID-19 exposure, preceding illness, and SARS-CoV-2 testing in a large population with MIS-C during the first 18 months of the COVID-19 pandemic. The majority of cases had exposure, preceding illness, or positive SARS-CoV-2 testing 4-8 weeks before MIS-C onset. Serology can help establish epidemiological link to COVID-19 when past infection or exposure are unknown.

A Qualitative Study of Pediatricians' Adverse Childhood Experiences Screening Workflows.

BACKGROUND & OBJECTIVE: Adverse childhood experiences (ACEs) are associated with poor health outcomes over the life course. Interest in ACEs screening is growing, but standard ACEs screening workflows have yet to be established. We aimed to describe common workflow processes and variation among pediatricians who have successfully implemented ACEs screening and response protocols. METHODS: We conducted semi-structured interviews with members of the American Academy of Pediatrics who practiced in clinical pediatric settings that implemented standardized ACEs screening (n = 18 physicians). Interviews were coded and analyzed using thematic content analysis and clinical processes were examined for differences across ACEs screening workflow processes. RESULTS: ACEs screening workflows varied considerably, hinging primarily on determination of a positive screen, the type of interventions recommended in response, and protocolization of the workflow. We identified 5 major theme domains related to ACEs screening workflows: 1) degree of protocolization of the workflow, 2) screening tool(s) used, 3) timing of screening, 4) clinic staff involvement, and 5) interventions recommended and/or initiated by the physician. Common workflow processes were identified and grouped based on determination of and thresholds for response to a positive screen. Clinicians used symptoms, ACE score, or a combination of the 2 as criteria for deciding when to intervene and to what degree, though protocolization of this approach varied. CONCLUSIONS: ACEs screening workflow variability was largely driven by clinical feasibility and availability of ACEs intervention resources. This variability demonstrates that a one-size-fits-all standardized screening protocol may not be universally feasible or appropriate across practices.

Predictors of Dual E-Cigarette and Cigarette Use.

OBJECTIVE: To compare prevalence of e-cigarette and cigarette use and to determine predictors of dual use. DESIGN, SETTING, AND PARTICIPANTS: Using a countywide random digit dial telephone health survey conducted during January 2018 to March 2019, we analyzed data from a random sample of 6966 adults. Bivariate analyses described vaping, cigarette use, and sociodemographics. A multivariable logistic regression model examined dual use. RESULTS: Young adults 18 to 24 years of age had the highest prevalence of e-cigarette-only use (11.5%), the second-highest prevalence of dual use (3.9%), and the lowest prevalence of cigarette-only use (5.8%). Males were more likely than females to use e-cigarettes (5.1% vs 2.7%), traditional cigarettes (11.1% vs 6.9%), or be dual users (3.6% vs 1.1%). Of those who used e-cigarettes or both, approximately half had also used marijuana in the past 30 days. CONCLUSIONS: E-cigarette use among young adults is concerning because it could lead to eventual dual use of e-cigarettes and traditional cigarettes.

Seroprevalence of Severe Acute Respiratory Syndrome Coronavirus 2 Among Skilled Nursing Facility Residents and Staff Members-Los Angeles County, August-September 2020.

BACKGROUND: The prevalence of current or past coronavirus disease 2019 in skilled nursing facility (SNF) residents is unknown because of asymptomatic infection and constrained testing capacity early in the pandemic. We conducted a seroprevalence survey to determine a more comprehensive prevalence of past coronavirus disease 2019 in Los Angeles County SNF residents and staff members. METHODS: We recruited participants from 24 facilities; participants were requested to submit a nasopharyngeal swab sample for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) testing and a serum sample for detection of SARS-CoV-2 antibodies. All participants were cross-referenced with our surveillance database to identify persons with prior positive SARS-CoV-2 results. RESULTS: From 18 August to 24 September 2020, we enrolled 3305 participants (1340 residents and 1965 staff members). Among 856 residents providing serum samples, 362 (42%) had current or past SARS-CoV-2 infection. Of the 346 serology-positive residents, 199 (58%) did not have a documented prior positive SARS-CoV-2 PCR result. Among 1806 staff members providing serum, 454 (25%) had current or past SARS-CoV-2 infection. Of the 447 serology-positive staff members, 353 (79%) did not have a documented prior positive SARS-CoV-2 PCR result. CONCLUSIONS: Past testing practices and policies missed a substantial number of SARS-CoV-2 infections in SNF residents and staff members.

Genomic characterization of canine circovirus associated with fatal disease in dogs in South America.

Canine circovirus (CanineCV) was detected, together with canine parvovirus (CPV), in samples from an outbreak of fatal gastroenteritis in dogs in Argentina. We obtained the full-length genome of this recently discovered virus by overlapping PCR, designated strain UBA-Baires. Sequence analysis revealed a highly conserved genome but also showed several unique mutations in amino acids from the capsid protein that have not been previously reported. Phylogenetic analysis shows that this strain is more closely related to European strains than to viruses detected in North America or Asia. Although the pathogenic role of CanineCV in dogs is still unclear, this study highlights the importance of CanineCV as a coinfecting virus in disease development. To our knowledge, this is the first report of the involvement of CanineCV in severe clinical disease in dogs in South America. Our results expand our information on the geographical extent of this virus and contribute to the understanding of its role in disease.

Plan to Have No Unplanned: A Collaborative, Hospital-Based Quality-Improvement Project to Reduce the Rate of Unplanned Extubations in the Pediatric ICU.

BACKGROUND: Although under-reported and understudied, unplanned extubations carry a significant risk of patient harm and even death. They are an important yardstick of quality control of care of intubated patients in the ICU. A unit-based risk assessment and multidisciplinary approach is required to decrease the incidence of unplanned extubations. METHODS: As part of a quality-improvement initiative of Children's Hospital at Montefiore, all planned and unplanned extubations in a multidisciplinary 20-bed pediatric ICU were evaluated over a 12-month period (January to December 2010). At the end of 6 months, an interim analysis was performed, and high-risk patient groups and patient care factors were identified. These factors were targeted in the second phase of the project. RESULTS: Over this period, there were a total of 267 extubations, of which 231 (87%) were planned extubations and 36 (13%) were unplanned. A patient care policy targeting the risk factors was instituted, along with extensive nursing and other personnel education in the second phase. As a result of this intervention, the unplanned extubation rate in the pediatric ICU decreased from 3.55 to 2.59/100 intubation days. All subjects who had an unplanned extubation during nursing procedures or transport required re-intubation, whereas none of the unplanned extubations during ventilator weaning required re-intubation. CONCLUSIONS: A targeted approach based on unit-specific risk factors is most effective in quality-improvement projects. A specific policy for sedation and weaning can be very helpful in managing intubated patients and preventing unintended harm.

Does bedside sonographic measurement of the inferior vena cava diameter correlate with central venous pressure in the assessment of intravascular volume in children?

OBJECTIVES: Previous studies demonstrated that the collapsibility index (percent decrease in inferior vena cava [IVC] diameter with inspiration) of 50% or greater and an IVC/aorta ratio of 0.8 or less correlated with a low intravascular volume. Our study sought to determine if bedside ultrasound (BUS) measurements of the IVC diameter correlate with central venous pressure (CVP) measurements as an indicator of intravascular volume status in acutely ill children. METHODS: A convenience sample of children younger than 21 years who were admitted to the pediatric critical care unit and required CVP monitoring had BUS measurements of both IVC and aortic diameters with simultaneous CVP measurement. The collapsibility index (sagittal view) and IVC/aorta ratio (transverse view) were calculated from these measurements. A CVP of 8 mm Hg or less was considered as a marker for decreased intravascular volume. RESULTS: Of the 51 participants, 21 (43%) had a CVP of 8 mm Hg or less. Eight (16%) of 51 children had a collapsibility index 50% or greater, and 8 (18%) of 43 had an IVC/aorta ratio of 0.8 or less. The sensitivity of a collapsibility index 0.5 or greater to predict a CVP of 8 mm Hg or less was 14%, the specificity was 83%, the positive predictive value was 38%, and the negative predictive value was 57%. Neither collapsibility index (r = -0.23, P = 0.11) nor IVC/aorta (r = -0.19, P = 0.22) correlated with CVP in assessing intravascular volume in our study population. CONCLUSIONS: Based on these data, the IVC and aortic measurements by BUS are not reliable indicators of intravascular volume (as determined by CVP) in acutely ill children.

Activation of AMP-activated protein kinase by metformin improves left ventricular function and survival in heart failure.

Clinical studies have reported that the widely used antihyperglycemic drug metformin significantly reduces cardiac risk factors and improves clinical outcomes in patients with heart failure. The mechanisms by which metformin exerts these cardioprotective effects remain unclear and may be independent of antihyperglycemic effects. We tested the hypothesis that chronic activation of AMP-activated protein kinase (AMPK) with low-dose metformin exerts beneficial effects on cardiac function and survival in in vivo murine models of heart failure. Mice were subjected to permanent left coronary artery occlusion or to 60 minutes left coronary artery occlusion followed by reperfusion for 4 weeks. High-resolution, 2D echocardiography was performed at baseline and 4 weeks after myocardial infarction to assess left ventricular dimensions and function. Metformin (125 microg/kg) administered to mice at ischemia and then daily improved survival by 47% (P<0.05 versus vehicle) at 4 weeks following permanent left coronary artery occlusion. Additionally, metformin given at reperfusion and then daily preserved left ventricular dimensions and left ventricular ejection fraction (P<0.01 versus vehicle) at 4 weeks. The improvement in cardiac structure and function was associated with increases in AMPK and endothelial nitric oxide synthase (eNOS) phosphorylation, as well as increased peroxisome proliferator-activated receptor-gamma coactivator (PGC)-1alpha expression in cardiac myocytes. Furthermore, metformin significantly improved myocardial cell mitochondrial respiration and ATP synthesis compared to vehicle. The cardioprotective effects of metformin were ablated in mice lacking functional AMPK or eNOS. This study demonstrates that metformin significantly improves left ventricular function and survival via activation of AMPK and its downstream mediators, eNOS and PGC-1alpha, in a murine model of heart failure.