Association of initial assessment variables and mortality in severe pediatric traumatic brain injury.

Background: Predictive scales have been used to prognosticate long-term outcomes of traumatic brain injury (TBI), but gaps remain in predicting mortality using initial trauma resuscitation data. We sought to evaluate the association of clinical variables collected during the initial resuscitation of intubated pediatric severe patients with TBI with in-hospital mortality. Methods: Intubated pediatric trauma patients <18 years with severe TBI (Glasgow coma scale (GCS) score ≤8) from January 2011 to December 2020 were included. Associations between initial trauma resuscitation variables (temperature, pulse, mean arterial blood pressure, GCS score, hemoglobin, international normalized ratio (INR), platelet count, oxygen saturation, end tidal carbon dioxide, blood glucose and pupillary response) and mortality were evaluated with multivariable logistic regression. Results: Among 314 patients, median age was 5.5 years (interquartile range (IQR): 2.2-12.8), GCS score was 3 (IQR: 3-6), Head Abbreviated Injury Score (hAIS) was 4 (IQR: 3-5), and most had a severe (25-49) Injury Severity Score (ISS) (48.7%, 153/314). Overall mortality was 26.8%. GCS score, hAIS, ISS, INR, platelet count, and blood glucose were associated with in-hospital mortality (all p<0.05). As age and GCS score increased, the odds of mortality decreased. Each 1-point increase in GCS score was associated with a 35% decrease in odds of mortality. As hAIS, INR, and blood glucose increased, the odds of mortality increased. With each 1.0 unit increase in INR, the odds of mortality increased by 1427%. Conclusions: Pediatric patients with severe TBI are at substantial risk for in-hospital mortality. Studies are needed to examine whether earlier interventions targeting specific parameters of INR and blood glucose impact mortality.

Inequities in the Diagnosis of Pediatric Appendicitis in Tertiary Children's Hospitals and the Consequences of Delayed Diagnosis.

INTRODUCTION: Missed diagnosis (MD) of acute appendicitis is associated with increased risk of appendiceal perforation. This study aimed to investigate whether racial/ethnic disparities exist in the diagnosis of pediatric appendicitis by comparing rates of MD versus single-encounter diagnosis (SED) between racial/ethnic groups. METHODS: Patients 0-18 y-old admitted for acute appendicitis from February 2017 to December 2021 were identified in the Pediatric Health Information System (PHIS). International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes for Emergency Department visits within 7 d prior to diagnosis were evaluated to determine whether the encounter represented MD. Generalized mixed models were used to assess the association between MD and patient characteristics. A similar model assessed independent predictors of perforation. RESULTS: 51,164 patients admitted for acute appendicitis were included; 50,239 (98.2%) had SED and 925 (1.8%) had MD. Compared to non-Hispanic White patients, patients of non-Hispanic Black (odds ratio 2.5, 95% confidence interval 2.0-3.1), Hispanic (2.1, 1.8-2.5), and other race/ethnicity (1.6, 1.2-2.1) had higher odds of MD. There was a significant interaction between race/ethnicity and imaging (P < 0.0001). Among patients with imaging, race/ethnicity was not significantly associated with MD. Among patients without imaging, there was an increase in strength of association between race/ethnicity and MD (non-Hispanic Black 3.6, 2.7-4.9; Hispanic 3.3, 2.6-4.1; other 2.0, 1.4-2.8). MD was associated with increased risk of perforation (2.5, 2.2-2.8). CONCLUSIONS: Minority children were more likely to have MD. Future efforts should aim to mitigate the risk of MD, including implementation of algorithms to standardize the workup of abdominal pain to reduce potential consequences of implicit bias.

Myocardial Infarction Across COVID-19 Pandemic Phases: Insights From the Veterans Health Affairs System.

Background Cardiovascular procedural treatments were deferred at scale during the COVID-19 pandemic, with unclear impact on patients presenting with non-ST-segment-elevation myocardial infarction (NSTEMI). Methods and Results In a retrospective cohort study of all patients diagnosed with NSTEMI in the US Veterans Affairs Healthcare System from January 1, 2019 to October 30, 2022 (n=67 125), procedural treatments and outcomes were compared between the prepandemic period and 6 unique pandemic phases: (1) acute phase, (2) community spread, (3) first peak, (4) post vaccine, (5) second peak, and (6) recovery. Multivariable regression analysis was performed to assess the association between pandemic phases and 30-day mortality. NSTEMI volumes dropped significantly with the pandemic onset (62.7% of prepandemic peak) and did not revert to prepandemic levels in subsequent phases, even after vaccine availability. Percutaneous coronary intervention and coronary artery bypass grafting volumes declined proportionally. Compared with the prepandemic period, patients with NSTEMI experienced higher 30-day mortality during Phases 2 and 3, even after adjustment for COVID-19-positive status, demographics, baseline comorbidities, and receipt of procedural treatment (adjusted odds ratio for Phases 2 and 3 combined, 1.26 [95% CI, 1.13-1.43], P<0.01). Patients receiving Veterans Affairs-paid community care had a higher adjusted risk of 30-day mortality compared with those at Veterans Affairs hospitals across all 6 pandemic phases. Conclusions Higher mortality after NSTEMI occurred during the initial spread and first peak of the pandemic but resolved before the second, higher peak-suggesting effective adaptation of care delivery but a costly delay to implementation. Investigation into the vulnerabilities of the early pandemic spread are vital to informing future resource-constrained practices.

Procedural and Surgical Interventions for Esophageal Stricture Secondary to Caustic Ingestion in Children.

BACKGROUND: Esophageal injury after caustic ingestion can vary in severity and may result in significant long-term morbidity due to stricture development. The optimal management remains unknown. We aim to determine the incidence of esophageal stricture due to caustic ingestion and quantify current procedural and operative management strategies. METHODS: The Pediatric Health Information System (PHIS) was utilized to identify patients 0-18 years old who experienced caustic ingestion from January 2007-September 2015 and developed subsequent esophageal stricture until December 2021. Post-injury procedural and operative management was identified utilizing ICD-9/10 procedure codes for esophagogastroduodenoscopy (EGD), esophageal dilation, gastrostomy tube placement, fundoplication, tracheostomy, and major esophageal surgery. RESULTS: 1,588 patients from 40 hospitals experienced caustic ingestion of which 56.6% were male, 32.5% non-Hispanic White, and the median age at time of injury was 2.2 years (IQR: 1.4,4.8). Median length of initial admission was 1.0 day (IQR: 1.0, 3.0). 171/1,588 (10.8%) developed esophageal stricture. Among those who developed stricture, 144 (84.2%) underwent at least 1 additional EGD, 138 (80.7%) underwent dilation, 70 (40.9%) underwent gastrostomy tube, 6 (3.5%) underwent fundoplication, 10 (5.8%) underwent tracheostomy, and 40 (23.4%) underwent major esophageal surgery. Patients underwent a median of 9 dilations (IQR 3, 20). Major surgery was performed at a median of 208 (IQR: 74, 480) days after caustic ingestion. CONCLUSION: Many patients with esophageal stricture after caustic ingestion will require multiple procedural interventions and potentially major surgery. These patients may benefit from early multi-disciplinary care coordination and the development of a best-practice treatment algorithm. LEVEL OF EVIDENCE: III.

Questioning Prophylactic Antibiotic Use for Pyloromyotomy: Analysis of the Pediatric Health Information System Database.

BACKGROUND: Pyloromyotomy has a low rate of wound complications, yet antibiotic prophylaxis is still given. The Pediatric Health Information System (PHIS) database was queried to determine whether prophylactic antibiotics decreased wound complications. METHODS: Records for infants with pyloric stenosis between 2016 and 2021 were extracted from the PHIS database and analyzed for demographics, comorbid conditions, and complications within 30 days of pyloromyotomy. Logistic regression was used to evaluate the effect of antibiotic prophylaxis on complications. RESULTS: Among 14,247 infants who underwent pyloromyotomy, 29.5% had antibiotic prophylaxis. These patients were more likely to have been admitted to the NICU and have chronic conditions and prematurity (p < 0.01). Antibiotic utilization varied among hospitals from 2.3 to 58.5%. Complication rates among those who received antibiotics was 1.64% versus 1.62% for those who did not. The odds for developing complications in those who received prophylaxis compared to those who did not was 1.10, (0.73, 1.41, 95%, p = 0.93) suggesting there is no effect of antibiotics on complication rates. CONCLUSIONS: There was a wide variation among hospitals in the usage of prophylactic antibiotics for pyloromyotomy. There was no difference in complication rates whether or not patients received antibiotics. These results suggest antibiotic prophylaxis is unnecessary for pyloromyotomy. LEVEL OF EVIDENCE: III.

Evaluating effects of burn injury characteristics on quality of life in pediatric burn patients and caregivers.

OBJECTIVES: The purpose of this study was to evaluate pediatric burn patients' and caregivers' quality of life (QoL), while identifying clinical characteristics correlated with psychological stress. METHODS: Pediatric burn patients at an ABA-verified institution from November 2019-January 2021 were included. Caregivers of patients 0-4 years completed the Infant's Dermatology QoL Index (IDQOL). Patients> 4-16 years completed the Children's Dermatology Life Quality Index (CDLQI). The Short Post-Traumatic Stress Disorder Rating Interview (SPRINT) measured caregivers' stress. Generalized linear mixed models evaluated associations between assessment scores and burn characteristics. RESULTS: Overall, 27.3% (39/143) of IDQOL and 53.1.% (41/96) of CDLQI scores indicated that patients' burns caused moderate to extremely large effects on QoL. In caregivers, 4.5% (7/159) scored> 14 on the SPRINT, warranting further PTSD evaluation. For the IDQOL, each additional 1% TBSA burn was associated with a 2.75-point increase (p = 0.05), and patients sustaining 2nd degree deep partial thickness burns scored an average of 3.3 points higher compared to 2nd degree superficial partial thickness burns (P < 0.01). CLDQI and SPRINT scores demonstrated a similar pattern. CONCLUSIONS: QoL is impacted in a substantial proportion of pediatric burn patients. Larger TBSA and increased burn depths cause significantly more psychological stress in children, and caregivers may require more extensive psychological evaluation.

Contrast Challenge Algorithms for Adhesive Small Bowel Obstructions Are Safe in Children: A Multi-Institutional Study.

OBJECTIVE: The purpose of this study was to evaluate the safety of a water-soluble contrast challenge as part of a nonoperative management algorithm in children with an adhesive small bowel obstruction (ASBO). BACKGROUND: Predicting which children will successfully resolve their ASBO with non-operative management at the time of admission remains difficult. Additionally, the safety of a water-soluble contrast challenge for children with ASBO has not been established in the literature. METHODS: A retrospective review was performed of patients who underwent non-operative management for an ASBO and received a contrast challenge across 5 children's hospitals between 2012 and 2020. Safety was assessed by comparing the complication rate associated with a contrast challenge against a pre-specified maximum acceptable level of 5%. Sensitivity, specificity, negative (NPV) and positive (PPV) predictive values of a contrast challenge to identify successful nonoperative management were calculated. RESULTS: Of 82 children who received a contrast challenge, 65% were successfully managed nonoperatively. The most common surgical indications were failure of the contrast challenge or failure to progress after initially passing the contrast challenge. There were no complications related to contrast administration (0%; 95% confidence interval: 0-3.6%, P = 0.03). The contrast challenge was highly reliable in determining which patients would require surgery and which could be successfully managed non-operatively (sensitivity 100%, specificity 86%, NPV 100%, PPV 93%). CONCLUSION: A contrast challenge is safe in children with ASBO and has a high predictive value to assist in clinical decision-making.

Extracorporeal Membrane Oxygenation in Pediatric Burn Patients Without Inhalation Injury: A Unique Population?

Prolonged mechanical ventilation (MV) before the initiation of extracorporeal membrane oxygenation (ECMO) is associated with decreased survival. Pediatric burn patients without inhalational injury are a unique population as they may be intubated for longer durations due to frequent interventions such as dressing changes and burn excisions. This study utilized the Extracorporeal Life Support Organization registry and evaluated patients 0 to 18 years old placed on ECMO and with a burn injury from January 2010 to December 2020. Inhalation injury was excluded. Descriptive statistics and bivariate analyses were performed. Multivariable logistic regression was used to assess the association between mortality and precannulation MV duration before ECMO cannulation, and odds ratios and predicted probabilities of mortality were estimated. Our cohort of 47 patients had a median age of 2.7 years old. Mortality occurred in 48.9% of the cohort. The overall median number of days on ECMO was 6.3 days, with no difference between survivors and non-survivors (6.8 days vs 6.3 days; P = .67). Survivors were ventilated for 4.1 days and non-survivors for 4.8 days before cannulation (P = .25). Regression modeling demonstrated that with each additional day on MV before ECMO cannulation, the odds of mortality increases by 12% (P = .03). Our study suggests that, similar to pediatric patients without thermal injury, increasing precannulation MV duration is associated with an increasing risk of mortality in pediatric burn patients without inhalational injury. Though the pediatric burn population is unique, evaluation of burn patients with respiratory failure for ECMO should be similar to the general population.

Creation of a globally informed and locally relevant KMC implementation model for population-impact in Amhara, Ethiopia.

AIM: As part of a multi-country implementation trial, we tested a regionally specific model of kangaroo mother care (KMC). Effective KMC was defined as ≥8 h of newborn-caregiver skin-to-skin contact daily plus exclusive breast feeding. The study was designed to achieve ≥80+% effective KMC coverage at the population level. METHODS: The Amhara KMC model was designed using global evidence, formative research in the region and input from government officials, clinicians, newborn families and global scientists. We optimised the initial model using continuous quality improvement with process feedback, outcome measurement and collaborative re-design. Outcomes from the evaluation period are reported. RESULTS: At discharge, the final model resulted in a median of 16 h per day of skin-to-skin contact with 63% effective KMC coverage. Fifty-three percent sustained effective KMC to 7 days post-discharge. CONCLUSIONS: It is possible to achieve high coverage (63%), high-quality KMC at public hospitals without prior KMC services using government-owned, multisectoral collaborative design. Targeted co-design, real-time data and customisation of KMC interventions with input from impacted stakeholders was critical in achieving high coverage and sustained quality.

Pediatric Sickle Cell Disease Patients on Hydroxyurea Have Higher Rates of Surgical Splenectomy.

INTRODUCTION: We sought to investigate whether hydroxyurea therapy is associated with the need for surgical splenectomy among patients with sickle cell disease (SCD). We hypothesized that as hydroxyurea gained widespread use, surgical splenectomy among pediatric patients with SCD occurred at a higher rate and older age among those taking hydroxyurea. METHODS: In this retrospective cross-sectional study, the Pediatric Health Information System was queried for all SCD International Classification of Diseases 9/10 diagnosis codes and splenectomy procedure codes from January 1, 2005, to December 31, 2020. Hydroxyurea use was defined as at least one hospital admission with hydroxyurea listed as a medication. The rates of surgical splenectomy, age at splenectomy, hospital length of stay, and incidence of blood transfusion during the splenectomy admission were compared among patients receiving hydroxyurea versus those not receiving hydroxyurea. Additional subanalysis was performed in the Hemoglobin-SS, Hemoglobin-SC, and Other cohorts separately. RESULTS: During the study period, 28,520 patients were identified. All patients with SCD receiving hydroxyurea had a significantly higher rate of surgical splenectomy compared with the nontreatment group (7.2% versus 3.2%, P = 0.01). The age at surgical splenectomy was significantly younger among Hemoglobin-SS patients receiving hydroxyurea (5.7 [5.1, 6.4] y versus 6.6 [5.8, 7.4] y; P < 0.01). There were no significant differences in length of stay or incidence of blood transfusion during the surgical splenectomy admission between treatment groups. CONCLUSIONS: Hydroxyurea use in children is associated with higher rates of surgical splenectomy and occurs at a younger age in the Hemoglobin-SS population. Although these findings warrant further investigation for causality, it provides useful information to clinicians and patients alike, allowing for more informed decision-making.

Rates of Air Embolism in Pediatric Patients Undergoing Surgical Procedures of the Peritoneum.

Background: Air embolism during laparoscopic surgery is a rare but feared complication in the pediatric population. The objective of this study was to identify rates of air embolus in pediatric patients during hospitalization for laparoscopic or open surgical procedures of the peritoneal cavity. Materials and Methods: Patients 0-18 years old within the Pediatric Health Information System who underwent a predefined, common inpatient laparoscopic or open surgical procedure involving the peritoneal cavity from 2015 to 2020 were studied. International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for air embolism were then searched among patients during the same admission. Firth logistic regression was used to compare rates of air embolism in open and laparoscopic cohorts and in patients >1 and ≤1 year. Results: Unadjusted rates of air embolism were higher in patients undergoing open compared with laparoscopic surgery (open: 9/45,080; 20.0/100,000 patients versus laparoscopic: 3/101,892; 2.9/100,000 patients). In patients ≤1 year (45,726), 2 patients undergoing open surgery (2/1,031; 9.5/100,000 patients) and all 3 patients undergoing laparoscopic surgery had an air embolism diagnosis (3/22,329; 13.4/100,000 patients). For laparoscopic surgery, a suggested lower relative risk (RR) of air embolism was demonstrated for children >1 year compared with children ≤1 year (RR: 0.05, P = .05). Conclusion: Air embolism associated with common pediatric surgical procedures of the peritoneum is rare and patients undergoing laparoscopic and open surgery have similar risks for air embolism. Although rare, the risk should be considered during surgical planning and abdominal access, especially in children ≤1 year old.

Antimicrobial Resistance of Staphylococci at Animal Human Interface in Smallholders and Dairy Farms in Central Oromia, Ethiopia.

Purpose: Staphylococcus species come from a variety of sources and can contaminate milk during milking, cause mastitis and other diseases in animals and humans. The enterotoxins they produce cause food poisoning. Our objectives were to isolate, biochemically characterize, and determine antimicrobial susceptibility profiles of Staphylococcus species from dairy farms in central Oromia, Ethiopia. Methods: A total of 339 samples (n = 135 [raw milk], n = 135 [udders' swabs], n = 25 [milkers' hands swabs], n = 44 [pooled milking utensils' swabs]) were collected from smallholders and dairy farms. Bacteriological culture and biochemical tests were performed to isolate and identify Staphylococcus species, and the Kirby Bauer disk diffusion method was used for antimicrobial susceptibility testing. Results: Across all sample types and dairy farms, 247 (72.9%) Staphylococcus isolates were obtained which comprised of 101 (74.8%) isolates from raw milk, 98 (72.6%) from udder swabs, 30 (68.2%) from pooled utensil swabs, and 18 (72%) from milkers' hand swabs. Fifty coagulase-positive Staphylococcus isolates (20 S. aureus, 20 S. hyicus and 10 S. intermedius) subjected to antimicrobial susceptibility tests have shown various degrees of resistance. All S. aureus isolates were 100% resistant to ampicillin and penicillin. Out of 20 S. hyicus isolates, 90% were resistant to ampicillin and 85% to penicillin. S. intermedius isolates (n=10) were 70% resistant to nalidixic acid and penicillin whilst remaining 100% resistant to ampicillin. Five S. aureus, three S. intermedius and two S. hyicus isolates from raw milk, milk utensil swabs and milkers' hand swabs were multidrug-resistant (resistance to at least three classes of antimicrobials). Conclusion: This study revealed a high prevalence of staphylococci in the dairy cattle, milkers and milking utensils with multidrug-resistant coagulase-positive Staphylococcus species suggesting the significance of pasteurization. Further research is encouraged on the factors leading to antibiotic resistance in Staphylococcus species.

Impact of Neurodevelopmental Disorders on Bowel Management Outcomes in Children with Functional Constipation.

OBJECTIVES: Patients experiencing functional constipation (FC) can participate in structured bowel management programs (BMPs) to manage constipation or fecal incontinence when standard management fails. We sought to evaluate the efficacy of BMPs for children with FC with and without neurodevelopmental disorders. METHODS: We performed a retrospective review of children with FC who participated in our BMP from 2014 to 2021. Stool/urinary continence, bowel regimen, surgical history, parent-reported outcomes measures (PROMs: Cleveland Clinic Constipation Score, Baylor Continence Scale, Vancouver Symptom Score for Dysfunctional Elimination), and Pediatric Quality of Life Inventory (PedsQL) were assessed pre- and at least 9 months post-BMP. RESULTS: The cohort included 156 patients with a median age of 9 years and follow-up of 627 days (IQR: 389-808 days). Two sub-cohorts included patients with FC only (69%) and FC plus a neurodevelopmental disorder (31%): 59% attention-deficit/hyperactivity disorder, 33% autism spectrum disorder, and 8% obsessive-compulsive disorder. Both groups had significantly improved follow-up bowel movement frequency and continence (39%-90% neurodevelopmental, 44%-82% FC only, P < 0.001) and urinary continence (65%-90% neurodevelopmental, 69%-91% FC only, P < 0.02). There was a significant improvement in most of the PROMs at follow-up. Both groups experienced a clinically meaningful improvement in overall PedsQL scores (pre- and postBMP difference of >4.5). CONCLUSIONS: Patients with FC with and without a neurodevelopmental disorder had significant improvement in stool and urinary continence after undergoing a BMP. Further studies are needed to see if this improvement is durable over a longer period of time in this challenging cohort.

Association between Tulathromycin Treatment for Bovine Respiratory Disease and Antimicrobial Resistance Profiles among Gut Commensals and Foodborne Bacterial Pathogens Isolated from Feces of Beef Steers.

ABSTRACT: This study was conducted to evaluate the association between a therapeutic dose of tulathromycin for bovine respiratory disease in beef steers and the antimicrobial and multidrug resistance profiles of the gastrointestinal tract commensals Escherichia coli and Enterococcus spp. and the foodborne pathogens Salmonella enterica and Campylobacter spp. isolated from fecal samples. Individual fecal samples were collected on days 0, 14, and 28 from 70 beef steers that were housed in a single pen and had been treated or not treated with tulathromycin. Samples were cultured for bacterial isolation, and isolates were tested for antimicrobial susceptibility with the broth microdilution method to determine the MICs of clinically relevant antimicrobials used in both human and veterinary medicine. Generalized linear mixed effects models were fitted to estimate the prevalence of the bacterial species and the prevalence of resistant isolates over time and between treated and nontreated cattle and of multidrug-resistant isolates. Model-adjusted mean prevalences of E. coli, Enterococcus spp., S. enterica, and Campylobacter spp. were 99.5, 85.9, 1.5, and 17.7%, respectively. The prevalence of erythromycin-resistant Enterococcus spp. was significantly higher on day 14 (59.7%) than on day 28 (22.2%). A higher prevalence of erythromycin-resistant Enterococcus spp. was found in samples from treated (59.3%) than in samples from nontreated (27.6%) animals. Multidrug resistance (three or more antimicrobial classes) was observed in 8.4% of E. coli isolates and 62.7% of Enterococcus isolates. The administration of tulathromycin was significantly associated with an increased prevalence of erythromycin-resistant Enterococcus spp. isolates.

Interfacility helicopter transport to a tertiary pediatric trauma center.

BACKGROUND: Helicopter emergency medical services (HEMS) are intended to expedite care to definitive management. Studies are inconclusive in demonstrating appropriate use. We aimed to examine emergent interventions after interfacility helicopter transport (IHT) to our pediatric trauma center. METHODS: Trauma patients 0-18 years undergoing IHT or interfacility ground transport (IGT) to our institution from January 2011-December 2020 were studied. We evaluated the rate of IHT patients undergoing emergent (1 h), urgent (6 h), and semi urgent (48 h) operating room (OR) intervention compared to IGT as a measure of appropriate transport. RESULTS: Inclusion was met by 1003 IHT and 7829 IGT patients. OR intervention was required in 29.6% of IHT patients, emergent in 1.3%, urgent in 12.6%, and semi urgent in 10.6%. Overall, IHT patients had higher mean injury severity score (ISS; IHT:14.5; SD:11.0 vs. IGT:6.0; SD:5.0; p < 0.01) and lower GCS (IHT:12.0; SD:4.9 vs. IGT:14.8; SD:1.4; p < 0.01), though over triage (ISS ≤ 15) occurred in 67.9% of patients. CONCLUSION: More interfacility helicopter transport patients underwent emergent and urgent procedures compared to interfacility ground transport patients; however, emergent intervention was not required in 98.7% of interfacility helicopter transport patients and over two thirds had ISS ≤ 15, possibly suggesting overutilization of interfacility helicopter transport for pediatric trauma patients at our center. LEVEL OF EVIDENCE: Level III.

Pilot study of an adult bowel management program for fecal incontinence.

OBJECTIVE: Bowel management programs are efficacious in pediatric patients with fecal incontinence or intractable constipation unresponsive to standard treatment. No studies have been done examining outcomes in adults. The objective of this study was to assess continence and quality of life outcomes in adults who have underwent bowel management program. METHODS: A retrospective review of patients 16 or older at the time they underwent a bowel management program for fecal incontinence or constipation was performed. Data collected included intake and follow-up stool and urinary continence, patient-reported outcomes measures (Cleveland Clinic Constipation Score, Baylor Continence Scale, Vancouver Symptom Score for Dysfunctional Elimination), and an age-adjusted health-related quality of life measure. RESULTS: The cohort included 38 patients with a median age of 19 years (range: 16-55) when they underwent our program. 50% of patients were female and the majority (33, 87%) were White. The most common diagnosis was anorectal malformation (16, 42%) followed by functional constipation (10, 27%). Stool continence rates improved after undergoing the program (52.7% prior to 87.6% at follow-up, p<0.01). There was significant improvement in the Baylor Continence Scale, Cleveland Clinic Constipation Score, and PedsQL (p<0.05). CONCLUSIONS: Adult patients who underwent a bowel management program for severe fecal incontinence or constipation show significant improvement in stool continence rates, patient-reported outcomes measures, and quality of life. A bowel management program (in-person or via telemedicine) is a feasible treatment strategy for adult patients who fail standard management of fecal incontinence or constipation and should be offered when appropriate. LEVEL OF EVIDENCE: III.

Rabies Elimination in Rural Kenya: Need for Improved Availability of Human Vaccines, Awareness and Knowledge on Rabies and Its Management Among Healthcare Workers.

Background: In Africa, rabies causes an estimated 24,000 human deaths annually. Mass dog vaccinations coupled with timely post-exposure prophylaxis (PEP) for dog-bite patients are the main interventions to eliminate human rabies deaths. A well-informed healthcare workforce and the availability and accessibility of rabies biologicals at health facilities are critical in reducing rabies deaths. We assessed awareness and knowledge regarding rabies and the management of rabies among healthcare workers, and PEP availability in rural eastern Kenya. Methodology: We interviewed 73 healthcare workers from 42 healthcare units in 13 wards in Makueni and Kibwezi West sub-counties, Makueni County, Kenya in November 2018. Data on demographics, years of work experience, knowledge of rabies, management of bite and rabies patients, and availability of rabies biologicals were collected and analyzed. Results: Rabies PEP vaccines were available in only 5 (12%) of 42 health facilities. None of the health facilities had rabies immunoglobulins in stock at the time of the study. PEP was primarily administered intramuscularly, with only 11% (n = 8) of the healthcare workers and 17% (7/42) healthcare facilities aware of the dose-sparing intradermal route. Less than a quarter of the healthcare workers were aware of the World Health Organization categorization of bite wounds that guides the use of PEP. Eighteen percent (n = 13) of healthcare workers reported they would administer PEP for category I exposures even though PEP is not recommended for this category of exposure. Only one of six respondents with acute encephalitis consultation considered rabies as a differential diagnosis highlighting the low index of suspicion for rabies. Conclusion: The availability and use of PEP for rabies was sub-optimal. We identified two urgent needs to support rabies elimination programmes: improving availability and access to PEP; and targeted training of the healthcare workers to improve awareness on bite wound management, judicious use of PEP including appropriate risk assessment following bites and the use of the dose-sparing intradermal route in facilities seeing multiple bite patients. Global and domestic funding plan that address these gaps in the human health sector is needed for efficient rabies elimination in Africa.

Implementation of a Level 1 Neuro Trauma Activation at a Tertiary Pediatric Trauma Center.

INTRODUCTION: Timely management improves outcomes in patients with traumatic brain injury (TBI), especially those requiring operative intervention. We implemented a "Level 1 Neuro" (L1N) trauma activation for severe TBI, aiming to decrease times to intervention. METHODS: We evaluated whether an L1N activation was associated with shorter times to operating room (OR) incision and pediatric intensive care unit (PICU) admission using multivariable regression models. Trauma patients with severe TBI undergoing operative intervention or PICU admission from January 2008-October 2020 met inclusion. The L1N cohort included patients meeting our institution's L1N criteria. The L1 and L2 cohorts included head injury patients with hAIS ≥3 and an L1 or L2 activation, respectively. RESULTS: Median hAIS, GCS, Rotterdam CT score, and ISS were 4.5 (4-5), 8 (3-15), 2 (1-3), and 17 (11-26), respectively. We demonstrate clinically shorter times to OR incision among L1N traumas (93.3 min) compared to L1 (106.7 min; P = 0.73) and L2 cohorts (133.5 min; P = 0.03). We also demonstrate clinically shorter times to anesthesia among L1N traumas (51.9 min) compared to L1 (70.1 min; P = 0.13) and L2 cohorts (101.3 min; P < 0.01). Median GCS, ISS and hAIS in the PICU patients were 10 (IQR:3-15), 17 (11-26), and 4 (3-4), respectively. We demonstrate clinically shorter times to PICU among L1N traumas (82.1 min) and the L2 cohort (154.7 min; P < 0.01). CONCLUSIONS: An L1N activation is associated with shorter times to anesthesia and OR management. Enhancing communication with standardized neurotrauma activation has the potential to improve timeliness of care in severe pediatric TBI.