Barriers and co-designed strategies for the implementation of negative pressure wound therapy in acute pediatric burn care in Australia: A mixed method study.

PURPOSE: Pediatric burn injuries are a global clinical issue causing significant morbidity. Early adjunctive negative pressure wound therapy improves re-epithelialization rates in children with burns, yet adoption in acute burn care is inconsistent. This investigation aimed to determine barriers to the implementation of adjunctive negative pressure wound therapy for the acute management of pediatric burns and co-design targeted implementation strategies. METHODS: A sequential mixed methods design was used explore barriers to adjunctive negative pressure wound therapy implementation in acute pediatric burn care. An online questionnaire was disseminated to healthcare professionals within four major Australian pediatric hospitals, each with a dedicated burns service. Barriers were coded according to the Consolidated Framework for Implementation Research (CFIR). Semi-structured interviews with senior clinicians tailored implementation strategies to local contexts. A stakeholder consensus meeting consolidated implementation strategies and local processes. RESULTS: Sixty-three healthcare professionals participated in the questionnaire, and semi-structured interviews involved nine senior burn clinicians. We identified eight implementation barriers across all five CFIR domains then co-designed targeted strategies to address identified barriers. Barriers included lack of available resources, limited access to knowledge and information, individual stage of change, patient needs and resources, limited knowledge and beliefs about the intervention, lack of external policies, intervention complexity, and poor implementation planning. CONCLUSION: Multiple contextual factors affect negative pressure wound therapy uptake in acute pediatric burn settings. Results will inform a multi-state stepped-wedge cluster randomized controlled trial. Additional resources, education, training, updated policies, and guidelines are required for successful implementation. It is anticipated that adjunctive negative pressure wound therapy, in conjunction with tailored implementation strategies, will enhance adoption and sustainability. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry: ACTRN12622000166774. Registered 1 February 2022.

1,25-Dihydroxyvitamin D3 Suppresses UV-Induced Poly(ADP-Ribose) Levels in Primary Human Keratinocytes, as Detected by a Novel Whole-Cell ELISA.

Photoprotective properties of 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) to reduce UV-induced DNA damage have been established in several studies. UV-induced DNA damage in skin such as single or double strand breaks is known to initiate several cellular mechanisms including activation of poly(ADP-ribose) (pADPr) polymerase-1 (PARP-1). DNA damage from UV also increases extracellular signal-related kinase (ERK) phosphorylation, which further increases PARP activity. PARP-1 functions by using cellular nicotinamide adenine dinucleotide (NAD+) to synthesise pADPr moieties and attach these to target proteins involved in DNA repair. Excessive PARP-1 activation following cellular stress such as UV irradiation may result in excessive levels of cellular pADPr. This can also have deleterious effects on cellular energy levels due to depletion of NAD+ to suboptimal levels. Since our previous work indicated that 1,25(OH)2D3 reduced UV-induced DNA damage in part through increased repair via increased energy availability, the current study investigated the effect of 1,25(OH)2D3 on UV-induced PARP-1 activity using a novel whole-cell enzyme- linked immunosorbent assay (ELISA) which quantified levels of the enzymatic product of PARP-1, pADPr. This whole cell assay used around 5000 cells per replicate measurement, which represents a 200-400-fold decrease in cell requirement compared to current commercial assays that measure in vitro pADPr levels. Using our assay, we observed that UV exposure significantly increased pADPr levels in human keratinocytes, while 1,25(OH)2D3 significantly reduced levels of UV-induced pADPr in primary human keratinocytes to a similar extent as a known PARP-1 inhibitor, 3-aminobenzamide (3AB). Further, both 1,25(OH)2D3 and 3AB as well as a peptide inhibitor of ERK-phosphorylation significantly reduced DNA damage in UV-exposed keratinocytes. The current findings support the proposal that reduction in pADPr levels may be critical for the function of 1,25(OH)2D3 in skin to reduce UV-induced DNA damage.

Discharge interventions for First Nations people with a chronic condition or injury: a systematic review.

BACKGROUND: Aboriginal and Torres Strait Islander peoples have a unique place in Australia as the original inhabitants of the land. Similar to other First Nations people globally, they experience a disproportionate burden of injury and chronic health conditions. Discharge planning ensures ongoing care to avoid complications and achieve better health outcomes. Analysing discharge interventions that have been implemented and evaluated globally for First Nations people with an injury or chronic conditions can inform the implementation of strategies to ensure optimal ongoing care for Aboriginal and Torres Strait Islander people. METHODS: A systematic review was conducted to analyse discharge interventions conducted globally among First Nations people who sustained an injury or suffered from a chronic condition. We included documents published in English between January 2010 and July 2022. We followed the reporting guidelines and criteria set in Preferred Reporting Items for Systematic Review (PRISMA). Two independent reviewers screened the articles and extracted data from eligible papers. A quality appraisal of the studies was conducted using the Mixed Methods Appraisal Tool and the CONSIDER statement. RESULTS: Four quantitative and one qualitative study out of 4504 records met inclusion criteria. Three studies used interventions involving trained health professionals coordinating follow-up appointments, linkage with community care services and patient training. One study used 48-hour post discharge telephone follow-up and the other text messages with prompts to attend check-ups. The studies that included health professional coordination of follow-up, linkage with community care and patient education resulted in decreased readmissions, emergency presentations, hospital length of stay and unattended appointments. CONCLUSION: Further research on the field is needed to inform the design and delivery of effective programs to ensure quality health aftercare for First Nations people. We observed that discharge interventions in line with the principal domains of First Nations models of care including First Nations health workforce, accessible health services, holistic care, and self-determination were associated with better health outcomes. REGISTRATION: This study was prospectively registered in PROSPERO (ID CRD42021254718).

The CaSR Modulator NPS-2143 Reduced UV-Induced DNA Damage in Skh:hr1 Hairless Mice but Minimally Inhibited Skin Tumours.

The calcium-sensing receptor (CaSR) is an important regulator of epidermal function. We previously reported that knockdown of the CaSR or treatment with its negative allosteric modulator, NPS-2143, significantly reduced UV-induced DNA damage, a key factor in skin cancer development. We subsequently wanted to test whether topical NPS-2143 could also reduce UV-DNA damage, immune suppression, or skin tumour development in mice. In this study, topical application of NPS-2143 (228 or 2280 pmol/cm2) to Skh:hr1 female mice reduced UV-induced cyclobutane pyrimidine dimers (CPD) (p < 0.05) and oxidative DNA damage (8-OHdG) (p < 0.05) to a similar extent as the known photoprotective agent 1,25(OH)2 vitamin D3 (calcitriol, 1,25D). Topical NPS-2143 failed to rescue UV-induced immunosuppression in a contact hypersensitivity study. In a chronic UV photocarcinogenesis protocol, topical NPS-2143 reduced squamous cell carcinomas for only up to 24 weeks (p < 0.02) but had no other effect on skin tumour development. In human keratinocytes, 1,25D, which protected mice from UV-induced skin tumours, significantly reduced UV-upregulated p-CREB expression (p < 0.01), a potential early anti-tumour marker, while NPS-2143 had no effect. This result, together with the failure to reduce UV-induced immunosuppression, may explain why the reduction in UV-DNA damage in mice with NPS-2143 was not sufficient to inhibit skin tumour formation.

Local burn wound environment versus systemic response: Comparison of proteins and metabolites.

In this study, paired blood plasma (BP) and blister fluid (BF) samples from five paediatric burn patients were analysed using mass spectrometry to compare their protein and metabolite composition. The relative quantification of proteins was achieved through a label-free data independent acquisition mode. The relative quantification of metabolites was achieved using a Shimadzu Smart Metabolite Database gas chromatography mass spectrometry (GCMS) targeted assay. In total, 562 proteins and 141 individual metabolites were identified in the samples. There was 81% similarity in the proteins present in the BP and BF, with 50 and 54 unique proteins found in each sample type respectively. BF contained keratinocyte proliferation-related proteins and blood plasma contained abundant blood clotting proteins and apolipoproteins. BF contained more carbohydrates and less alpha-hydroxy acid metabolites than the BP. In this study, there were unique proteins and metabolites in BF and BP which were reflective of the local wound environment and systemic environments respectively. The results from this study demonstrate that the biomolecule content of BF is mostly the same as blood, but it also contains information specific to the local wound environment.

Review of the requirements for effective mass casualty preparedness for trauma systems. A disaster waiting to happen?

Mass casualty incidents (MCIs) are diverse, unpredictable, and increasing in frequency, but preparation is possible and necessary. The nature of MCIs requires a trauma response but also requires effective and tested disaster preparedness planning. From an international perspective, the aims of this narrative review are to describe the key components necessary for optimisation of trauma system preparedness for MCIs, whether trauma systems and centres meet these components and areas for improvement of trauma system response. Many of the principles necessary for response to MCIs are embedded in trauma system design and trauma centre function. These include robust communication networks, established triage systems, and capacity to secure centres from threats to safety and quality of care. However, evidence from the current literature indicates the need to strengthen trauma system preparedness for MCIs through greater trauma leader representation at all levels of disaster preparedness planning, enhanced training of staff and simulated disaster training, expanded surge capacity planning, improved staff management and support during the MCI and in the post-disaster recovery phase, clear provision for the treatment of paediatric patients in disaster plans, and diversified and pre-agreed systems for essential supplies and services continuity. Mass casualty preparedness is a complex, iterative process that requires an integrated, multidisciplinary, and tiered approach. Through effective preparedness planning, trauma systems should be well-placed to deliver an optimal response when faced with MCIs.

Paediatric intestinal pseudo-obstruction: a scoping review.

Paediatric intestinal pseudo-obstruction (PIPO) encompasses a group of rare disorders in which patients present with the clinical features of bowel obstruction in the absence of mechanical occlusion. The management of PIPO presents a challenge as evidence remains limited on available medical and surgical therapy. Parenteral nutrition is often the mainstay of therapy. Long-term therapy may culminate in life-threatening complications including intestinal failure-related liver disease, central line thrombosis and sepsis. Intestinal transplantation remains the only definitive cure in PIPO but is a complex and resource-limited solution associated with its own morbidity and mortality. We conducted a scoping review to present a contemporary summary of the epidemiology, aetiology, pathophysiology, diagnosis, management and complications of PIPO.Conclusion: PIPO represents a rare disorder that is difficult to diagnose and challenging to treat, with significant morbitity and mortality. The only known cure is intestinal transplantation. What is Known: • Paediatric intestinal pseudo-obstruction is a rare, heterogeneous disorder that confers a high rate of morbidity and mortality • Complications of paediatric intestinal pseudo-obstruction include chronic pain, small intestine bacterial overgrowth and malrotation. Other complications can occur related to its management, such as line infections with parenteral nutrition or cardiac side effects of prokinetic medications What is New: • Progress in medical and surgical therapy in recent years has led to improved patient outcomes • Enteral autonomy has been reported in most patients at as early as 1 month post-transplantation.

Patient journey mapping to investigate quality and cultural safety in burn care for Aboriginal and Torres Strait Islander children and families - development, application and implications.

BACKGROUND: Quality and safety in Australian healthcare is inequitably distributed, highlighted by gaps in the provision of quality care for Aboriginal and Torres Strait Islander children. Burns have potential for long-term adverse outcomes, and quality care, including culturally safe care, is critical to recovery. This study aimed to develop and apply an Aboriginal Patient Journey Mapping (APJM) tool to investigate the quality of healthcare systems for burn care with Aboriginal and Torres Strait Islander children. STUDY DESIGN: Interface research methodology, using biomedical and cultural evidence, informed the modification of an existing APJM tool. The tool was then applied to the journey of one family accessing a paediatric tertiary burn care site. Data were collected through yarning with the family, case note review and clinician interviews. Data were analysed using Emden's core story and thematic analysis methods. Reflexivity informed consideration of the implications of the APJM tool, including its effectiveness and efficiency in eliciting information about quality and cultural safety. RESULTS: Through application of a modified APJM tool, gaps in quality care for Aboriginal and Torres Strait Islander children and families were identified at the individual, service and system levels. Engagement in innovative methodology incorporating more than biomedical standards of care, uncovered critical information about the experiences of culturally safe care in complex patient journeys. CONCLUSION: Based on our application of the tool, APJM can identify and evaluate specific aspects of culturally safe care as experienced by Aboriginal and Torres Strait Islander peoples and be used for quality improvement.

Monocyte M1/M2 profile is altered in paediatric burn patients with hypertrophic scarring.

Hypertrophic scars (HTS) remain a common outcome of burn injury, particularly in children. They can arise from variations in the wound healing stages, such as an excessive inflammatory response or inefficient remodelling. Of the cells contributing to these healing stages, macrophages and fibrocytes are crucial. Specifically, the inflammatory phase is dominated by M1 macrophages, the proliferation/remodelling stages by M2 macrophages, and scar tissue contains numerous fibrocytes. As the progenitors to these cells, monocytes, can also exhibit M1- and M2-skewing, we proposed that their profile, or circulating fibrocyte counts, could be used to predict poor healing outcomes. To investigate this, we obtained blood samples from paediatric controls and burns patients, which were then divided into HTS and NoHTS groups upon scar assessment at 12 months. The samples were assessed by whole blood flow cytometry to quantify fibrocytes and monocyte subset proportions and to determine monocyte levels of M1 (CD86, CD120b, CD319) and M2 (CD93, CD163, CD200R) markers. Both burns groups had higher proportions of classical monocytes compared to controls, indicating increased cell turnover and/or entry of other subsets into the wound. In burns patients who took more than 21 days to heal, the HTS group had lower M2 (CD200R) expression with the ratio of M1/M2 (CD86/CD200R) being significantly higher. These results suggest an elevated early inflammatory monocyte response contributes to development of HTS. Correlations of marker expression with remaining healing time revealed a significant positive correlation with M1 (CD120b) and M1/M2 (CD120b/CD200R), suggesting a potential role for CD120b as an indicator of healing delay. Fibrocytes did not significantly differ between the groups. In conclusion, increased monocyte inflammation likely contributes to slower healing and development of scarring, but further studies are needed to determine the predictive power of monocyte inflammatory profile.

Paediatric chemical burns: a clinical review.

Although they account for a small proportion of burns in paediatrics, injuries from chemicals can be just as devastating as other mechanisms of burn injury. At least 25,000 chemicals exist which can cause burns: in children, they are often caused by household chemicals via accidental exposure. The mechanism by which corrosive substances produce chemical burns highlights the importance of early and plentiful irrigation of the burn area, removal of contaminated clothes and careful clinical assessment. Surgical intervention is uncommon but often follows the principles for thermal burns. This article reviews the aetiology, incidence, clinical presentation, management, complications and prevention of chemical burns. What is Known • Chemical burns in paediatrics are often caused by accidental exposure to chemicals available at home • Differences in the pathophysiology of chemical burns reinforces the need for early irrigation What is New • New irrigation fluids show promise in adults and need further study in children • The nature of chemical cutaneous burns can make assessment of wound depth difficult. Laser Doppler Imaging (LDI) is an accurate technique that can be used clinically to determine burn depth in thermal burns and is an area of future interest in the assessment of chemical burns.

Observational study of falls in children from windows and balconies: What has changed?

AIM: To describe patterns of injury from window and balcony falls in children presenting to a tertiary paediatric trauma centre in New South Wales. METHODS: A retrospective review of cases of children <15 years who had sustained injuries in a fall from a building, identified from the trauma database between 1998 and 2019. RESULTS: A total of 381 falls from windows and balconies were recorded over the 22-year study period. There were 218 falls from windows (57%) and 163 from balconies. The majority (64%) were children under 4 years of age. The male to female ratio was 2:1. While many children sustained simple abrasions, contusions and lacerations, 17% sustained injuries with an injury severity scores of ≥12. There were four deaths. CONCLUSIONS: This study identified that children falling from buildings remains a problem in Australia. Although many injuries were minor, severe injuries and fatalities continue to occur.

Paediatric adhesive bowel obstruction: a systematic review.

Adhesions following abdominal surgery remain a common cause of bowel obstruction. The incidence is between 1 and 12.6% in children who have had previous abdominal surgery. While conservative management is usually trialled in all patients (including children) suspected of having ASBO, the majority will require surgical intervention. New materials such as Seprafilm® have been studied in the paediatric population, with promising results of its use in index abdominal surgeries to prevent the formation of adhesions. In this article, we conducted a systematic review to present an overview of the current knowledge on the incidence, aetiology, pathophysiology, clinical presentation, and management of ASBO.

Balanitis xerotica obliterans: an update for clinicians.

Lichen sclerosus (LS) is a severe, chronic, dermatosis characterised by inflammatory, sclerotic, pruritic lesions that causes significant morbidity in patients of all genders and ages. In boys, the lesions typically affect the foreskin and glans (termed balanitis xerotica obliterans (BXO)), leading to phimosis and potentially meatal stenosis. The incidence of the disease is not well reported but the average age of affected boys is 8 years (range 1-16). Diagnosis can often be made clinically, although histological study remains important to rule out important differential diagnoses. Complications include genital scarring, urinary and sexual dysfunction as well as the development of carcinomas in adult life. Circumcision has been regarded as definitive management of BXO in boys, but this may be supplemented with medical therapies such as topical steroids, immune modulators, intralesional triamcinolone and ozonated olive oil. Supportive measures including emollients, avoidance of irritants, surveillance of complications and recurrence as well as education and counselling remain important.Conclusion: BXO remains an important cause of phimosis in boys. The frequency of this condition appears unclear but seems likely to be less than 1% of males. Treatment generally involves circumcision, with some evidence that topical steroids or immunomodulators may decrease the incidence of recurrent meatal stenosis.What is Known:• Surgical circumcision is considered the definitive management of BXO• Many aspects of BXO are still in contention or require further study including the epidemiology and aetiology.What is New:• There is increasing awareness of non-surgical modalities that may be used in adjunct to surgery including topical corticosteroids, immune modulators, intralesional triamcinolone and ozonated olive oil• Awareness of meatal stenosis-related BXO has led to the development of surgical techniques such as preputioplasty as well as buccal mucosal inlay grafts.

Pathological prognostication of paediatric adrenocortical tumours: Is a gold standard emerging?

BACKGROUND: Criteria for the pathological classification of adult adrenocortical tumours (ACTs) have been found to overestimate the malignant potential of childhood ACTs. We sought to evaluate the accuracy and utility of criteria developed for paediatric ACT compared to current criteria for adults. METHODS: ACTs treated between January 2006 and December 2016 in two paediatric institutions were evaluated. Patients classified clinically as malignant (CM) had locally invasive disease at surgery requiring extensive en bloc resection to achieve clear margins, had local recurrence or distant metastasis. Slides were reviewed by pathologists blinded to the clinical outcome. A grade was assigned to each tumor according to the Weiss, Aubert, Wieneke and Dehner-Hill criteria. The pathological grade was compared to the clinical outcome. RESULTS: The median follow-up was 60 months (interquartile range 25-80 months). Based on clinical criteria, of 22 patients 14 (64%) had a benign course and eight (34%) behaved malignant. The malignant potential was overestimated by Weiss criteria in 23% and Aubert criteria in 27%. Wieneke and Dehner-Hill criteria showed good clinicopathological correlation; no child who had a benign course was classified as malignant. The Dehner-Hill criteria, however, classified five (23%) children as intermediate risk of which three had a clinically benign and two a CM course. CONCLUSION: The Wieneke criteria accurately predicts the clinical course in childhood ACTs and could be considered the gold standard in their pathological characterization.

Surgical Procedures Performed by Emergency Medical Teams in Sudden-Onset Disasters: A Systematic Review.

BACKGROUND: Emergency medical teams (EMTs) frequently provide surgical care after sudden-onset disasters (SODs) in low- and middle-income countries. The purpose of this review is to describe the types of surgical procedures performed by EMTs with general surgical capability in order to aid the recruitment and training of surgeons for these teams. METHODS: A search of electronic databases (PubMed, MEDLINE, and EMBASE) was carried out to identify articles published between 1990 and 2018 that describe the type of surgical procedures performed by EMTs in the impact and post-impact phases of a SOD. Further relevant articles were obtained by hand searching reference lists. RESULTS: A total of 16 articles met the inclusion criteria. Articles reporting on EMTs from a number of different countries and responding to a variety of SODs were included. There was a high prevalence of procedures for extremity soft tissue injuries (46.8%) and fractures (28.3%), although a number of abdominal and genitourinary/obstetric procedures were also reported. CONCLUSIONS: Based upon this review, deployment of surgeons or teams with experience in the management of soft tissue wounds, orthopaedic trauma, abdominal surgery, and obstetrics is recommended.

Publishing trends in Journal of Paediatric Surgery, Pediatric Surgery International and European Journal of Pediatric Surgery over the past three decades.

The aim of this study was an analysis of the changing publication trends over the last three decades in the Journal of Pediatric Surgery (JPS), Pediatric Surgery International (PSI) and European Journal of Pediatric Surgery (EJPS) by studying the bibliometric variables, authorship, collaboration, and citation trends. A previously applied methodology using intermittent years was applied to review the archives of JPS, PSI and EJPS over the last 30 years. Citation data were collected from the Web of Science database. Statistical analysis was performed using SAS 9.4 software. A total of 1917 articles originating from 63 countries met the inclusion criteria. The number of articles published every year increased significantly in the last three decades from 336 in 1987 to 626 in 2017 (P < 0.0001). Multinational papers made up 5% of the total, of which 58% involved more than one continent. A majority of papers (75%) were single institution papers, there was strong evidence of an increase in multi-institution publications over time. There was a statistically significant increase in the number of female first and corresponding author. The publishing landscape of paediatric surgery has evolved to be more inclusive with increased collaboration, female authors and mentors and more publications from developing nations.

Developmental outcome at 3 years of age of infants following surgery for infantile hypertrophic pyloric stenosis.

PURPOSE: The study compared neurodevelopmental outcome at 3 years of age of infants with infantile hypertrophic pyloric stenosis (IHPS) who underwent pyloromyotomy with healthy control infants in New South Wales, Australia. METHODS: Infants with IHPS as well as controls were recruited between August 2006 and July 2008. Developmental assessments were performed using the Bayley scales of infant and toddler development (version III) (BSITD-III) at 1 and 3 years of age. RESULTS: Of the 43 infants originally assessed at 1 year, 39 returned for assessment at 3 years (90%). The majority were term infants (77%). Assessments were also performed on 156 control infants. Infants with IHPS scored significantly lower on four of the five Bayley subsets (cognitive, receptive and expressive language and fine motor) compared to control infants. Analysis of co-variance showed statistically significant results in favour of the control group for these four subsets. CONCLUSION: Compared with the outcomes at 1 year, infants with IHPS at 3 years of age continue to score below controls in four of the BSITD-III subscales. This suggests they should have developmental follow-up with targeted clinical intervention. There is a need for further studies into functional impact and longer term outcomes.

Advances in paediatric urology.

Paediatric urological surgery is often required for managing congenital and acquired disorders of the genitourinary system. In this Series paper, we highlight advances in the surgical management of six paediatric urological disorders. The management of vesicoureteral reflux is evolving, with advocacy ranging from a less interventional assessment and antimicrobial prophylaxis to surgery including endoscopic injection of a bulking agent and minimally invasive ureteric reimplantation. Evidence supports early orchidopexy to improve fertility and reduce malignancy in boys with undescended testes. A variety of surgical techniques have been developed for hypospadias, with excellent outcomes for distal but not proximal hypospadias. Pelvi-ureteric junction obstruction is mostly detected prenatally; indications for surgery have been refined with evidence, and minimally invasive pyeloplasty is now standard. The outlook for patients with neurogenic bladder has been transformed by a combination of clean intermittent catheterisation, algorithms of diagnostic investigations, and innovative medical and surgical therapies. Posterior urethral valves are associated with considerable mortality; fetal diagnosis allows stratification of candidates for intervention, but ongoing bladder dysfunction in patients after valve ablation remains a cause of long-term morbidity.

Factors that impact access to ongoing health care for First Nation children with a chronic condition.

BACKGROUND: Access to multidisciplinary health care services for First Nation children with a chronic condition is critical for the child's health and well-being, but disparities and inequality in health care systems have been almost impossible to eradicate for First Nation people globally. The objective of this review is to identify the factors that impact access and ongoing care for First Nation children globally with a chronic condition. METHODS: An extensive systematic search was conducted of nine electronic databases to identify primary studies that explored factors affecting access to ongoing services for First Nation children with a chronic disease or injury. Due to the heterogeneity of included studies the Mixed Method Appraisal Tool (MMAT) was used to assess study quality. RESULTS: A total of six studies from Australia, New Zealand and Canada were identified and included in this review. Four studies applied qualitative approaches using in-depth semi structured interviews, focus groups and community fora. Two of the six studies used quantitative approaches. Facilitators included the utilisation of First Nation liaison workers or First Nation Health workers. Key barriers that emerged included lack of culturally appropriate health care, distance, language and cultural barriers, racism, the lack of incorporation of First Nation workers in services, financial difficulties and transport issues. CONCLUSION: There are few studies that have identified positive factors that facilitate access to health care for First Nation children. There is an urgent need to develop programs and processes to facilitate access to appropriate health care that are inclusive of the cultural needs of First Nation children.

A bibliometric analysis of pediatric liver transplantation publications.

Citation counts can identify landmark papers. The aim of this study was to identify and characterize the top-cited articles in the pediatric liver transplantation literature. A search strategy for the Scopus® database was designed for pediatric liver transplantation publications from 1945 to 2014. The 50 top-cited articles were analyzed. Author co-citation analysis was performed using VOSviewer techniques. There were 2896 articles published between 1969 and 2015. The mean citation count of the top 50 cited articles was 166 (range 95-635). There were three case reports in this top-cited list. There were 15 collaborations in this top-cited list with nine being international. The top-cited publications originated in 12 countries, with the USA and the UK contributing 31 and seven articles, respectively. There were 14 authors with four or more publications in this list. There was a single author with nine publications in the top-cited list. These top-cited papers were found in 16 journals, with three journals collectively publishing over 50% of these publications. Pediatric liver transplantation research is an evolving entity. Surgical techniques and case reports are influential articles. Collaborations at a national and international level produce highly cited articles, which are found in influential journals.