Addressing Health-Care Disparities in Pediatric Disaster Planning: A Qualitative Study.

OBJECTIVE: The Western Regional Alliance for Pediatric Emergency Medicine (WRAP-EM) is a multi-state, Administration for Strategic Preparedness and Response (ASPR) funded pediatric disaster center of excellence. WRAP-EM set out to determine the impact of health disparities on its 11 core areas. METHODS: We conducted 11 focus groups during April 2021. Discussions were led by an experienced facilitator, and participants could also include their thoughts on a Padlet throughout the discussion. Data were analyzed to determine overarching themes. RESULTS: Responses focused on health literacy, health disparities, resource opportunities, addressing obstacles, and resilience building. Health literacy data highlighted the need for development of readiness and preparedness plans, community engagement in cultural and language appropriate means, and increasing diversity in training. Obstacles faced included funding; inequitable distribution of research, resources, and supplies; lack of prioritization of pediatric needs; and fear of retribution from the system. Multiple already existing resources and programs were referenced highlighting the importance of best practice sharing and networking. A stronger commitment to mental health-care delivery, empowerment of individuals and communities, use of telemedicine, and ongoing cultural and diverse education were recurring themes. CONCLUSIONS: Results of the focus groups can be used to prioritize efforts to address and improve health disparities in pediatric disaster preparedness.

Experience with acute diaphragmatic trauma and multiple rib fractures using routine thoracoscopy.

BACKGROUND: Diaphragmatic injury is mostly caused by blunt or penetrating traumas. It is an uncommon diagnosis and therefore carries the risk of being misdiagnosed or delayed in diagnosis. In our institution, we perform routine thoracoscopy for the management of patients with traumatic rib fractures. We have noted several cases of occult diaphragmatic injuries and hypothesize that these injuries may be more of a penetrating injury from rib fractures as opposed to the high velocity blunt trauma typically associated with diaphragmatic injuries. METHODS: A retrospective review of medical records was performed on all patients admitted to our facility with rib fractures and traumatic diaphragmatic injuries. We looked at our trauma experience between January 2015 and January 2018. RESULTS: Twenty-three patients with traumatic diaphragmatic injuries were found. Twenty-one of the diaphragmatic injuries were from blunt trauma. A total of 15 had associated rib fractures. Six of the blunt traumatic diaphragm injuries did not have rib fractures but had evidence of intra-abdominal injuries. The rib fracture pattern in the diaphragmatic injury group consistently involved rib fractures at or below the fifth rib. CONCLUSIONS: We conclude that thoracoscopy may prove to be helpful in the algorithm for the work up of an occult diaphragmatic injury. The diagnostic yield appears to be greatest in patients with multiple rib fractures involving the lower chest wall even in the absence of intra-abdominal injuries or radiographic evidence of diaphragmatic abnormalities.

Intravenous injection of urocortin 1 induces a CRF2 mediated increase in circulating ghrelin and glucose levels through distinct mechanisms in rats.

Urocortins (Ucns) injected peripherally decrease food intake and gastric emptying through peripheral CRF(2) receptors in rodents. However, whether Ucns influence circulating levels of the orexigenic and prokinetic hormone, ghrelin has been little investigated. We examined plasma levels of ghrelin and blood glucose after intravenous (iv) injection of Ucn 1, the CRF receptor subtype involved and underlying mechanisms in ad libitum fed rats equipped with a chronic iv cannula. Ucn 1 (10 µg/kg, iv) induced a rapid onset and long lasting increase in ghrelin levels reaching 68% and 219% at 0.5 and 3h post injection respectively and a 5-h hyperglycemic response. The selective CRF(2) agonist, Ucn 2 (3 µg/kg, iv) increased fasting acyl (3h: 49%) and des-acyl ghrelin levels (3h: 30%) compared to vehicle while the preferential CRF(1) agonist, CRF (3 µg/kg, iv) had no effect. Ucn 1's stimulatory actions were blocked by the selective CRF(2) antagonist, astressin(2)-B (100 µg/kg, iv). Hexamethonium (10 mg/kg, sc) prevented Ucn 1-induced rise in total ghrelin levels while not altering the hyperglycemic response. These data indicate that systemic injection of Ucns induces a CRF(2)-mediated increase in circulating ghrelin levels likely via indirect actions on gastric ghrelin cells that involves a nicotinic pathway independently from the hyperglycemic response.

Abdominal surgery inhibits circulating acyl ghrelin and ghrelin-O-acyltransferase levels in rats: role of the somatostatin receptor subtype 2.

Clinical studies are evaluating the efficacy of synthetic ghrelin agonists in postoperative ileus management. However, the control of ghrelin secretion under conditions of postoperative gastric ileus is largely unknown. Peripheral somatostatin inhibits ghrelin secretion in animals and humans. We investigated the time course of ghrelin changes postsurgery in fasted rats and whether somatostatin receptor subtype 2 (sst(2)) signaling is involved. Abdominal surgery (laparotomy and 1-min cecal palpation) induced a rapid and long-lasting decrease in plasma acyl ghrelin levels as shown by the 64, 67, and 59% reduction at 0.5, 2, and 5 h postsurgery, respectively, compared with sham (anesthesia alone for 10 min, P < 0.05). Levels were partly recovered at 7 h and fully restored at 24 h. The percentage of acyl ghrelin reduction was significantly higher than that of desacyl ghrelin at 2 h postsurgery and not at any other time point. This was associated with a 48 and 23% decrease in gastric and plasma ghrelin-O-acyltransferase protein concentrations, respectively (P < 0.001). Ghrelin-positive cells in the oxyntic mucosa expressed sst(2a) receptor and the sst(2) agonist S-346-011 inhibited fasting acyl ghrelin levels by 64 and 77% at 0.5 and 2 h, respectively. The sst(2) antagonist S-406-028 prevented the abdominal surgery-induced decreased circulating acyl ghrelin but not the delayed gastric emptying assessed 0.5 h postinjection. These data show that activation of sst(2) receptor located on gastric X/A-like cells plays a key role in the rapid inhibition of circulating acyl ghrelin induced by abdominal surgery while not being primarily involved in the early phase of postoperative gastric ileus.

Blood transfusion is an independent predictor of mortality after blunt trauma.

Allogeneic blood transfusion is associated with increased morbidity and mortality. The authors evaluated the affect of blood transfusion, independent of injury severity on mortality. The authors conducted a retrospective review of all patients, age > or =18 years with blunt injury admitted to their Level 2 trauma center from 1994 to 2004 by query of the NTRACS trauma registry. Initial systolic blood pressure and heart rate determined the shock index. Logistic regression was used to model the affect of blood transfusion on mortality. Transfusion requirements were categorized as follows: A, 0 U; B, 1 to 2 U; C, 3 to 5 U; D, > or =6 U blood. In this sample of 8215 blunt trauma patients, 324 patients received blood transfusion. Mortality rates between the transfused and nontransfused groups were 15.12 per cent and 1.84 per cent (P < 0.000) respectively. In the logistic regression model, transfusion category B did not have a significant affect on the odds of death (P = 0.176); the affect of transfusing 3 to 5 U and > or =6 U had a mortality odds ratio of 3.22 (P = 0.002). and 4.87 (P = 0.000) respectively. Transfusing > or =2U blood was strongly associated with mortality in this blunt trauma population. There must be a continuous attempt to limit blood transfusion when feasible and physiologically appropriate.

LPS inhibits fasted plasma ghrelin levels in rats: role of IL-1 and PGs and functional implications.

LPS injected intraperitoneally decreases fasted plasma levels of ghrelin at 3 h postinjection in rats. We characterized the inhibitory action of LPS on plasma ghrelin and whether exogenous ghrelin restores LPS-induced suppression of food intake and gastric emptying in fasted rats. Plasma ghrelin and insulin and blood glucose were measured after intraperitoneal injection of LPS, intravenous injection of IL-1beta and urocortin 1, and in response to LPS under conditions of blockade of IL-1 or CRF receptors by subcutaneous injection of IL-1 receptor antagonist (IL-1Ra) or astressin B, respectively, and prostaglandin (PG) synthesis by intraperitoneal indomethacin. Food intake and gastric emptying were measured after intravenous injection of ghrelin at 5 h postintraperitoneal LPS injection. LPS inhibited the elevated fasted plasma ghrelin levels by 47.6 +/- 4.9%, 58.9 +/- 3.3%, 74.4 +/- 2.7%, and 48.9 +/- 8.7% at 2, 3, 5, and 7 h postinjection, respectively, and values returned to preinjection levels at 24 h. Insulin levels were negatively correlated to those of ghrelin, whereas there was no significant correlation between glucose and ghrelin. IL-1Ra and indomethacin prevented the first 3-h decline in ghrelin levels induced by LPS, whereas astressin B did not. IL-1beta inhibited plasma ghrelin levels, whereas urocortin 1 had no influence. Ghrelin injected intravenously prevented an LPS-induced 87% reduction of gastric emptying and 61% reduction of food intake. These data showed that IL-1 and PG pathways are part of the early mechanisms by which LPS suppresses fasted plasma ghrelin and that exogenous ghrelin can normalize LPS-induced-altered digestive functions.

Falciform ligament hernia after laparoscopic cholecystectomy: a rare case and review of the literature.

The occurrence of an internal hernia through a congenital or iatrogenic defect in the falciform ligament is extremely rare. In the era of minimally invasive surgery, we present an unusual case of small bowel obstruction after laparoscopic cholecystectomy. An 85-year-old white male presented to the emergency room 2 weeks after an uneventful cholecystectomy and complaining of a colicky, nonradiating right upper quadrant abdominal pain. Hydroxyiminodiacetic acid (HIDA) scan and endoscopic retrograde cholangiopancreatography (ERCP) performed revealed an open ductal system. Abdominal computed tomography (CT) scan was suggestive of a high-grade small bowel obstruction. Exploratory laparotomy revealed a herniated loop of distal ileum, passing from right to left through a defect in the falciform ligament created by the subxyphoid trochar. The surgeon should consider dividing the inferior leaf of the free edge of the falciform ligament, including the round ligament, should an aperture be created during laparoscopic port placement.

Gallbladder volvulus: report of two original cases and review of the literature.

Gallbladder volvulus is defined as the rotation of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery. It is an unusual and rare occurrence with a predilection for women in their seventh or eight decades of life. Only about 300 cases have been reported in the literature ranging from ages 2 to 100 years old. The etiology of gallbladder volvulus remains speculative; however, the presence of a redundant mesentery is a prerequisite for torsion. Gall-bladder volvulus leads to occlusive obstruction of biliary drainage and blood flow. With early diagnosis and surgical intervention, the disease maintains a low mortality of approximately 5 per cent. We present two original cases of acute gallbladder volvulus successfully treated with cholecystectomy, as well as a review of the literature.