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Evidence of Varicella Zoster Virus Reactivation in Children With Arterial Ischemic Stroke: Results of the VIPS II Study.
No full textBACKGROUND: Varicella zoster virus (VZV) has historically been associated with focal cerebral arteriopathy and arterial ischemic stroke (AIS) in children, and risk of AIS and myocardial infarction in adults. The VIPS (Vascular Effects of Infection in Pediatric Stroke) II study aimed to determine whether VZV remains a pediatric stroke trigger in an era of routine VZV vaccination.
METHODS: This 22-center prospective cohort study enrolled 205 patients (28 days to 18 years; median, 11.6 years) with spontaneous AIS (December 2016 to January 2022) in North America and Australia, performed parental interviews, and collected baseline (hyperacute [≤72 hours; n=194] and acute [4-6 days; n=181]) and convalescent (1-6 weeks; n=74) serum samples. A virology research laboratory measured VZV IgM and IgG titers by an in-house ELISA in patients with AIS and 95 unmatched well control children.
RESULTS: Baseline serologies indicated prior VZV exposure in 198 patients (97%). Parents recalled prior VZV vaccination in 160 (78%) and remote chickenpox in 3 (1.4%). Twenty patients (9.8%) had serologic evidence of recent VZV reactivation at the time of their stroke; all were asymptomatic. All had remote VZV exposure with VZV vaccination (median) 6.1 years prior. We observed recent VZV reactivation in patients with focal cerebral arteriopathy (4/32 [12.5%]) but not with arterial dissection or moyamoya. All 95 controls had serologic evidence of prior VZV exposure and 3 (3.1%) had recent VZV reactivation.
CONCLUSIONS: One in 10 patients with childhood AIS had recent, asymptomatic VZV reactivation. In a vaccinated population, VZV may continue to play a modest role in childhood stroke pathogenesis
Primary repair versus resection for American Association for the Surgery of Trauma grades I and II colon injuries: Does the management approach really matter? An Eastern Association for the Surgery of Trauma multicenter trial.
No full textBACKGROUND: The management of traumatic low-grade (American Association for the Surgery of Trauma [AAST] grades I and II) colon injuries has evolved. Recent data suggest that primary repair (PR) or resection over colostomy decreases morbidity and mortality. However, data comparing patients undergoing PR versus resection with anastomosis (RWA) are lacking. We hypothesized that patients presenting with low-grade colon injuries undergoing PR would have fewer postoperative complications than patients undergoing RWA.
METHODS: This was a retrospective, multicenter analysis of all patients presenting with AAST grades I and II colon injuries to 32 Level 1 trauma centers from 2011 to 2021. Based on operative documentation, patients were dichotomized into two groups, those who underwent PR or RWA. Outcomes included length of stay, infectious complications, and mortality. Multivariate logistic regression was performed to determine the independent effect of operative technique on outcomes.
RESULTS: A total of 2,022 patients met the inclusion criteria for this study. Most were young (36 [24-44] years), male (79.6%), and presented after penetrating trauma (58.2%). A total of 1,013 patients presented with a grade I injury, while 1,009 patients presented with a grade II injury. Furthermore, 1,314 patients underwent PR, and 708 underwent RWA. While there was no difference in Injury Severity Score between PR and RWA, RWA was associated with more adverse outcomes including surgical site infections, suture line failure/leak, fascial dehiscence, and a longer hospital length of stay (all p \u3c 0.001). When controlling for mechanism of injury, AAST grade, Injury Severity Score, and number of intra-abdominal injuries RWA were independently associated with more infectious complications including superficial, deep, and organ space surgical site infections.
CONCLUSION: Resection with anastomosis was independently associated with more adverse outcomes including multiple infectious complications and longer hospital length of stay compared with PR, suggesting that low-grade colon injuries can be safely managed with PR alone.
LEVEL OF EVIDENCE: Multicenter Retrospective Comparative Study; Level III
Guidance for the Primary Care Provider in Identifying Infants With Biliary Atresia by 2-4 Weeks of Life: Clinical Report.
No full textThis report helps pediatric primary care providers quickly identify infants with biliary atresia, which has the potential to improve outcomes and reduce need for liver transplant. The strategy is intended to be used between 2 and 4 weeks of life at the By 1 month well-child visit in the Bright Futures/American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care. The strategy involves examining every infant\u27s eye color, stool color, and prior laboratory results to determine whether measurement of a direct or conjugated bilirubin level is warranted
Handoffs and transitions of care in the intensive care unit: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document.
No full textOBJECTIVES: The American Association for the Surgery of Trauma (AAST) Critical Care Committee chose handoffs and transitions of care in the intensive care unit (ICU) as a clinically relevant topic for review. This clinical consensus document aims to provide practical guidance to the surgical intensivist on the best practices for patient handoffs and transitions of care.
METHODS: A working group was formed from the committee-at-large to complete this work. The members of the working group were each assigned a subtopic to review using research to date. The research on which the recommendations are based was compiled at the discretion of the working group. Any topic with discrepant or minimal supporting literature was reviewed by the AAST Critical Care Committee through an anonymous survey.
RESULTS: Recommendations for healthcare handovers include formally recognized handoffs at dedicated times, an interactive verbal exchange including all patients with a focus on what to anticipate or what is needs to be completed, tools to record and maintain information, and training to new providers on the handoff process and technology.
CONCLUSION: As clinicians, we strive to provide the best evidence-based care to our patients. It is essential to study these high states, ICU handoffs to enhance the safety, efficiency, and effectiveness of patient care transitions, ultimately leading to better patient outcomes and provider satisfaction.
LEVEL OF EVIDENCE: V
Deep Brain Stimulation Electrode Deviations are Associated With Brain Stiffness Interfaces Measured by Magnetic Resonance Elastography.
No full textBACKGROUND AND OBJECTIVES: The efficacy of deep brain stimulation (DBS) relies on accurate electrode placement. Unfortunately, electrode deviation poses a persistent problem, with most electrodes demonstrating some degree of bending. Although such bending does not always result in target deviation, an estimated 3% to 8% of patients still require revision surgery to address suboptimal electrode placement. DBS electrode deviation may occur at mechanical tissue interfaces, with denser internal capsule (IC) fibers being the most likely factor. Based on basic principles of physics, we hypothesized that the angle of a planned trajectory relative to tissue interfaces created by the IC induces deviation.
METHODS: Ten patients with Parkinson disease scheduled for DBS surgery underwent preoperative 3T magnetic resonance elastography (MRE) using synchronized external vibrations to measure brain tissue stiffness. The IC stiffness interface (ICSI) was defined as the transition between the corona radiata and IC on MRE. The rate of transition was calculated as the change in stiffness across the ICSI. Postoperative computed tomography was used to measure target deviation. The angle of approach was calculated as the angle between the planned trajectory and the normal vector to the ICSI. Pearson correlations and t-tests were performed to evaluate associations between the angle of approach and target deviation.
RESULTS: Twenty-one electrode trajectories were analyzed. The mean electrode deviation was 1.27 ± 0.63 mm. A significant correlation (r = 0.57, 95% CI [0.18, 0.80], P = .007) was found between angle of approach and target deviation, with larger angles associated with greater deviations. The rate of transition did not correlate with deviation (P = .874).
CONCLUSION: MRE effectively quantifies in vivo brain tissue stiffness in Parkinson disease. The angle between the planned trajectory and the ICSI correlates with target deviation, supporting the hypothesis that tissue mechanics influence electrode bending. MRE has potential to quantify the likelihood of DBS electrode deviation, which could reduce revision surgeries and enhance clinical outcomes
