IntroductionWe wished to characterize the relationship of advanced age to clinical outcomes and to transcriptomic responses after severe blunt traumatic injury with hemorrhagic shock.MethodsWe performed epidemiological, cytokine, and transcriptomic analyses on a prospective, multi-center cohort of 1,928 severely injured patients.ResultsWe found that there was no difference in injury severity between the aged (age ≥55, n = 533) and young (age <55, n = 1395) cohorts. However, aged patients had more comorbidities. Advanced age was associated with more severe organ failure, infectious complications, ventilator days, and intensive care unit length of stay, as well as, an increased likelihood of being discharged to skilled nursing or long-term care facilities. Additionally, advanced age was an independent predictor of a complicated recovery and 28-day mortality. Acutely after trauma, blood neutrophil genome-wide expression analysis revealed an attenuated transcriptomic response as compared to the young; this attenuated response was supported by the patients’ plasma cytokine and chemokine concentrations. Later, these patients demonstrated gene expression changes consistent with simultaneous, persistent pro-inflammatory and immunosuppressive states.ConclusionsWe concluded that advanced age is one of the strongest non-injury related risk factors for poor outcomes after severe trauma with hemorrhagic shock and is associated with an altered and unique peripheral leukocyte genomic response. As the general population’s age increases, it will be important to individualize prediction models and therapeutic targets to this high risk cohort.

Pythiosis is an infection caused by the aquatic oomycete Pythium insidiosum. Commonly known as 'swamp cancer' in veterinary pathology, pythiosis is now considered an emerging human disease associated with significant morbidity and mortality. However, because clinical information is limited, many healthcare providers, including dermatologists, are unfamiliar with this diagnosis. To increase awareness of this life-threatening infection, a case of cutaneous pythiosis is presented. We describe a middle-aged man with acute myeloid leukaemia who presented with necrotizing haemorrhagic plaques on his thighs after a weekend of freshwater boating. Histological examination of a biopsy specimen showed invasive fungal hyphae associated with dense perivascular inflammation and vessel damage. Diagnostic testing on tissue culture revealed growth of P. insidiosum. Despite multiple debridements and antifungal therapy, the patient died within 2 weeks of presentation. There are four clinical presentations reported in human pythiosis. Pythium insidiosum infection should be considered in any patient with a suggestive exposure history and fungal elements found on histological examination or in culture. Identification of the organism can be difficult, so polymerase chain reaction and serological assays can be useful in making a diagnosis. To improve clinical outcomes, early combination therapy with antifungals and surgery is needed.

Many pediatric psoriasis patients suffer from nail involvement and psoriatic arthritis. In adults, biologic agents have demonstrated success in treating refractory nail psoriasis and arthritis, but studies are limited in children. In this report, we present a pediatric patient with severe, recalcitrant nail and joint psoriasis, successfully treated with secukinumab. | 385Pediatric Dermatology BRIEF REPORT moderate-to-severe nail psoriasis in adults. 2 Traditionally, options for systemic therapies include acitretin, methotrexate, and cyclosporine. However, emerging data in adults suggest biologic agents are more effective in combating nail psoriasis than these therapies. 2 Biologics have also been shown in adults to improve refractory psoriatic arthritis. 3 IL-17 inhibitors, such as secukinumab, are newer biologics that have shown success in treatment of adult nail psoriasis and psoriatic arthritis, making them an excellent choice for our patient with refractory joint and nail disease. 4,5 Trials evaluating the effectiveness and safety of secukinumab in children are forthcoming. Our case demonstrates the efficacy of secukinumab in pediatric psoriatic nail disease that was refractory to numerous therapies.

A patient with post-Cesarean wound complication was treated for necrotizing fasciitis (NF) with sharp debridement and broad-spectrum antibiotics. Several operations and three weeks later, her abdominal skin, subcutaneous fat, right-sided rectus abdominus, and underlying fascia had been removed without any improvement in granulation tissue. Original pathology samples demonstrated sheets of necrosis consistent with NF, but were re-reviewed by a dermatopathologist who diagnosed the patient with pyoderma gangrenosum (PG). She was started on high-dose steroids and dapsone, and her wound quickly showed signs of improvement. Anchor bias delayed the initiation of steroids and diagnosis of PG as the surgical, medical, and consulting teams were hesitant to stray from the diagnosis of NF.LEARNING POINTSPyoderma gangrenosum is often confused with other dermatological disorders in the hospital setting.It is vital to recognize the tendency towards anchoring bias, and how this can greatly affect our patient care.

protocol" (SP)) of septic shock that includes gentamicin as part of the empiric antibiotic regimen in high-risk patients as previously described (1). Gentamicin is a well-known nephrotoxin and could lead to increased AKI in already susceptible hosts. Methods: Retrospective review of children with septic shock triaged into a SP in the ED and subsequently admitted to the ICU at a tertiary care children's hospital. AKI was defined by pRIFLE creatinine criteria (2). Results: 104 patients were included, 51% males, mean age 7.3 ± 5.4, mean PELOD 10.2 ± 8.4, mean PRISM 4.2 ± 12.9. 56% (n=59) patients had at least one comorbidity. 29% (n=30) of patients developed AKI (R=20, I=7, F=3), 86% (n=26) in the first 24 hours of ICU admission. Three patients died (2.9%), all had AKI, there were no deaths in patients without AKI. AKI pts had higher PELOD scores (13.5 ± 11.5 vs 8.9 ± 6.4, p=0.001) and higher PRISM scores (10.9 ± 22.8 vs 1.4 ± 1.6, p< 0.001). No patient received renal replacement therapy. 22% (n=23) of patients had fluid refractory shock and were started on vasoactive infusions in the ED, 52% of these patients had AKI. 65% (n= 68) of the patients received gentamicin. There was no difference in AKI frequency in patients who received gentamicin versus who did not (18/68 vs 12/36, p=0.46). 43% (n=13) of the patients had resolution of AKI within 72 hours, 6 received gentamicin, 7 did not. However, all patients who developed AKI after the first week of ICU stay (n=3, 10%) had received gentamicin. Age, gender, admission PELOD scores, and gentamicin use was not associated with AKI development but PRISM score was (p<0.001). In multivariate analysis, only the PRISM score was independently associated with AKI development when controlled for age, gender, and gentamicin use (OR=1.29, 95% CI 1.06-1.56). Conclusions: Development of septic-shock associated AKI is associated with severity of illness but not independently associated with the use of gentamicin in a protocol-driven early goal-directed resuscitation bundle in critically ill children. However, closer monitoring of renal function and therapeutic drug levels is warranted in children receiving gentamicin as later-onset AKI may develop in this patient population. Further studies are needed to determine the at risk sub-populations. 1. AT Cruz, AM Perry, EA Williams, et al. Implementation of goal directed therapy for children with suspected sepsis in the emergency department. Pediatrics 2011;127;e758 2. A Akcan Arikan, M Zappitelli, LL Loftis, et al. Modified RIFLE criteria in critically ill children with aute kidney injury.