Recent Changes in the Management of High-Grade Blunt Pancreatic Injury in Children: A Nationwide Trend Analysis.

BACKGROUND: The optimal management of pediatric patients with high-grade blunt pancreatic injury (BPI) involving the main pancreatic duct remains controversial. This study aimed to assess the nationwide trends in the management of pediatric high-grade BPI at pediatric (PTC), mixed (MTC), and adult trauma centers (ATC). STUDY DESIGN: This is a retrospective observational study of the National Trauma Data Bank. We included pediatric patients (age 16 years or less) sustaining high-grade BPI (Abbreviated Injury Scale 3 or more) from 2011 to 2021. Patients who did not undergo pancreatic operation were categorized into the nonoperative management (NOM) group. Trauma centers were defined as PTC (level I/II pediatric only), MTC (level I/II adult and pediatric), and ATC (level I/II adult only). Primary outcome was the proportion of patients undergoing NOM, and secondary outcomes included the use of ERCP and in-hospital mortality. A Cochran-Armitage test was used to analyze the trend. RESULTS: A total of 811 patients were analyzed. The median age was 9 years (interquartile range 6 to 13), 64% were male patients, and the median injury severity score was 17 (interquartile range 10 to 25). During the study period, there was a significant upward linear trend in the use of NOM and ERCP among the overall cohort (range 48% to 66%; p trend = 0.033, range 6.1% to 19%; p trend = 0.030, respectively). The significant upward trend for NOM was maintained in the subgroup of patients at PTC and MTC (p trend = 0.037), whereas no significant trend was observed at ATC (p trend = 0.61). There was no significant trend in in-hospital mortality (p trend = 0.38). CONCLUSIONS: For the management of pediatric patients with high-grade BPI, this study found a significant trend toward increasing use of NOM and ERCP without mortality deterioration, especially at PTC and MTC.

Pancreatic Injury Is Associated with Poor Prognosis in Severe Fever with Thrombocytopenia Syndrome.

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease. Previous studies have primarily focused on the epidemiological and clinical characteristics of patients with SFTS, whereas pancreatic injury has received little attention. This study investigated the effects of pancreatic injury on the prognosis of patients with SFTS. A total of 156 patients diagnosed with SFTS between April 2016 and April 2022 were included in the analysis. Multivariate logistic regression analysis showed that pancreatic injury (odds ratio [OR] = 3.754, 95% confidence interval [CI]: 1.361-79.036, P = 0.024) and neurological symptoms (OR = 18.648, 95% CI: 4.921-70.668, P < 0.001) were independent risk factors for mortality. The receiver operating characteristic curve indicated that serum pancreatic enzymes were predictive of progression to death in patients with SFTS. The area under the curve (AUC) for amylase was 0.711, with an optimal cutoff value of 95.5 U/L, sensitivity of 96.4%, and specificity of 35.9%. Lipase had an AUC of 0.754, an optimal cutoff value of 354.75 U/L, sensitivity of 75%, and specificity of 67.2%. Thus, pancreatic injury was associated with a poor prognosis of SFTS and can be used as an important reference for SFTS determination and prognostic assessment.

Blunt Adrenal Injury is Not Associated With Worse Outcomes in Adult Trauma Patients.

INTRODUCTION: Blunt adrenal injury is rare. Given production of hormones including catecholamines, adrenal injury may lead to worse outcomes. However, there is a paucity of literature on this topic. As such, we compared blunt trauma patients (BTPs) with and without adrenal injuries, hypothesizing similar mortality and complications between cohorts. METHODS: The 2017-2019 Trauma Quality Improvement Program database was queried for adult (≥18-year-old) BTPs. Patients with penetrating trauma, traumatic brain injury, severe thoracic injury, or who were transferred from another hospital were excluded. Patients with adrenal injury were compared to those without using a 1:2 propensity score model. Matched variables included patient age, comorbidities, vitals on admission and concomitant injuries (i.e., liver, spleen, kidney, pancreas, and hollow viscus). Univariable logistic regression was then performed for associated risk of mortality. RESULTS: 2287 (0.2%) BTPs had an adrenal injury, with 1470 patients with adrenal injury matched to 2940 without adrenal injury. The rate of all complications including sepsis (0.1% versus 0.0%) was similar between cohorts (all P > 0.05). Patients with adrenal injury had a lower rate of mortality (0.1% versus 0.6%, P = 0.035) but increased length of stay (4 [3-6] versus 3 [2-5] days, P = 0.002). However, there was no difference in associated risk of mortality for patients with and without adrenal injury (odds ratio = 0.234; confidence interval = 0.54-1.015; P = 0.052). CONCLUSIONS: Blunt adrenal injury occurred in <1% of patients. After propensity matching, there was a similar associated rate of complications but longer hospital length of stay for patients with adrenal injury. Adrenal injury was not associated with an increased risk of mortality.

Should surgeon-performed intraoperative ultrasound be the preferred test for detecting main pancreatic duct injuries in operative trauma cases?

BACKGROUND: The diagnostic performance of multiple tests for detecting the presence of a main pancreatic duct injury remains poor. Given the central importance of main duct integrity for both subsequent treatment algorithms and patient outcomes, poor test reliability is problematic. The primary aim was to evaluate the comparative test performance of computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and intraoperative ultrasound (IOUS) for detecting main pancreatic duct injuries. METHODS: All severely injured adult patients with pancreatic trauma (2010-2021) were evaluated. Patients who received an IOUS pancreas-focused evaluation, with Grades III, IV, and V injuries (main duct injury) were compared with those with Grade I and Grade II trauma (no main duct injury). Test performances were analyzed. RESULTS: Of 248 pancreatic injuries, 74 underwent an IOUS. The additional mix of diagnostic studies (CT, MRCP, ERCP) was variable across grade of injury. Of these 74 IOUS cases for pancreatic injuries, 48 (64.8%) were confirmed as Grades III, IV, or V main duct injuries. The patients were predominantly young (median age = 33, IQR:21-45) blunt injured (70%) males (74%) with severe injury demographics (injury severity score = 28, (IQR:19-36); 30% hemodynamic instability; 91% synchronous intra-abdominal injuries). Thirty-five percent of patients required damage-control surgery. Patient outcomes included a median 13-day hospital length of stay and 1% mortality rate. Test performance was variable across groups (CT = 58% sensitive/77% specific; MRCP = 71% sensitive/100% specific; ERCP = 100% sensitive; IOUS = 98% sensitive/100% specific). CONCLUSION: Intraoperative ultrasound is a highly sensitive and specific test for detecting main pancreatic duct injuries. This technology is simple to learn, readily available, and should be considered in patients who require concurrent non-damage-control abdominal operations. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level III.

Injury characteristics and predictors of mortality in patients undergoing pancreatic excision after abdominal trauma: A National Trauma Data Bank (NTDB) study.

Pancreatic tumors and pancreatitis are the main indications for pancreatic excision (PE). However, little is known about this type of intervention in the context of traumatic injuries. Surgical care for traumatic pancreatic injuries is challenging because of the location of the organ and the lack of information on trauma mechanisms, vital signs, hospital deposition characteristics, and associated injuries. This study examined the demographics, vital signs, associated injuries, clinical outcomes, and predictors of in-hospital mortality in patients with abdominal trauma who had undergone PE. Following the Strengthening the Reporting of Observational Studies in Epidemiology guidelines, we analyzed the National Trauma Data Bank and identified patients who underwent PE for penetrating or blunt trauma after an abdominal injury. Patients with significant injuries in other regions (abbreviated injury scale score ≥ 2) were excluded. Of the 403 patients who underwent PE, 232 had penetrating trauma (PT), and 171 had blunt trauma (BT). The concomitant splenic injury was more prevalent in the BT group; however, the frequency of splenectomy was comparable between groups. In particular, concomitant kidney, small intestine, stomach, colon, and liver injuries were more common in the PT group (all P < .05). Most injuries were observed in the pancreatic body and tail regions. The trauma mechanisms also differed between the groups, with motor vehicles accounting for most of the injuries in the BT group and gunshots accounting for most of the injuries in the PT group. In the PT group, major liver lacerations were approximately 3 times more common (P < .001). The in-hospital mortality rate was 12.4%, with no major differences between the PT and BT groups. Furthermore, there was no difference between BT and PT with respect to the location of the injuries in the pancreas, with the pancreatic tail and body accounting for almost 65% of injuries. Systolic blood pressure, Glasgow Coma Scale score, age, and major liver laceration were revealed by logistic regression as independent predictors of mortality, although trauma mechanisms and intent were not linked to mortality risk.

Management and Outcome of Blunt Pancreatic Trauma: A Retrospective Cohort Study.

BACKGROUND: Pancreatic injury is rare, but it has a high mortality rate and its optimal treatment remains controversial. This study aimed to evaluate the clinical characteristics, management strategies, and outcomes of patients with blunt pancreatic injury. METHODS: This retrospective cohort study was performed on patients with a confirmed blunt pancreatic injury who were admitted to our hospital from March 2008 to December 2020. The clinical characteristics and outcomes of patients receiving different management strategies were compared. The risk factors for in-hospital mortality were evaluated by performing a multivariate regression analysis. RESULTS: A total of 98 patients diagnosed with blunt pancreatic injury were identified, with 40 patients having undergone nonoperative treatment (NOT) and 58 patients having undergone surgical treatment (ST). The overall in-hospital deaths were 6 (6.1%), including 2 (5.0%) and 4 (6.9%) in the NOT and ST groups, respectively. Pancreatic pseudocysts occurred in 15 (37.5%) and 3 (5.2%) of the NOT and ST groups, respectively, showing a significant difference between the two groups (P < 0.001). In the multivariate regression analysis, concomitant duodenal injury (OR = 14.42, 95% CI 1.27-163.52; P = 0.031) and sepsis (OR = 43.47, 95% CI, 4.15-455.75; P = 0.002) were independently associated with in-hospital mortality. CONCLUSIONS: Except for the higher incidence of pancreatic pseudocysts in the NOT group than in the ST group, there were no significant differences in the other clinical outcomes between the two groups. Concomitant duodenal injury and sepsis were the risk factors for in-hospital mortality.

[Diagnosis and treatment of pancreatic trauma]. / Diagnóstico y tratamiento del traumatismo de páncreas.

Pancreatic trauma is a rare but potentially lethal entity which requires a high level of clinical suspicion. Early diagnosis and assessment of the integrity of the pancreatic duct are essential since ductal injury is a crucial predictor of morbimortality. Overall mortality is 19%, which can rise to 30% in cases of ductal injury. The diagnostic and therapeutic approach is multidisciplinary and guided by a surgeon, imaging specialist and ICU physician. Laboratory analysis shows that pancreatic enzymes are frequently elevated, which is a low specificity finding. In hemodynamically stable patients, the posttraumatic condition of the pancreas is firstly evaluated by the multidetector computed tomography. Moreover, in case of suspicion of ductal injury, more sensitive studies such as Endoscopic Retrograde Cholangiopancreatography or cholangioresonance are needed. This narrative review aims to analyze the etiopathogenesis and pathophysiology of pancreatic trauma and discuss its diagnosis and treatment. Also, the most clinically relevant complications will be summarized.

Traumatic pancreas, kidney, liver, spleen, gastric and diaphragma rupture with enterothorax after blunt trauma caused by falling in an adolescent: a case report.

Injury of almost all intra-abdominal organs in blunt trauma without bone and brain injury is very rare. This is the case report of a 16-year-old adolescent with severe abdominal trauma who was hit on his abdomen by a falling maytree. After admission to a Level I trauma center, emergency room treatment according to ATLS and after this emergency surgery was performed. Blood coagulation diagnostics was done using thrombo-elastography and factors and blood products have been applied according to its results keeping guidelines in mind. Damage-control surgery stopped the bleeding, and he was admitted to ICU. After second and third look surgery, the abdomen was closed. Structured diagnostics and treatment were crucial in this case. The education of trauma surgeons should include general surgery skills. These skills and knowledge of blood coagulation diagnostics and therapy saved the patient's life in this case.

Surgical management of duodenal injury: experience from 92 cases.

PURPOSE: Duodenal injury increases with traffic accidents, and delayed diagnosis or inappropriate operation increase mortality and complications. This study aimed to explore early recognition and timely surgical intervention. METHODS: All patients with duodenal injuries treated operatively during the past 10 years were reviewed, and the data were analyzed retrospectively regarding the mechanism of injury, diagnostic and therapeutic methods, and outcome. RESULTS: A total of 92 patients with duodenal injuries accounted for 7.3% of 1258 patients with abdominal injury. Of the 92 patients, 71 (77.17%) experienced blunt trauma, with traffic accidents accounting for 59.2% (42/71). In 35 patients, a preoperative diagnosis was obtained by reviewing abdominal signs, peritoneocentesis, and imaging. The remaining 57 patients underwent urgent laparotomy, through which a definitive diagnosis of duodenal injury was confirmed during the operation. In all 92 patients, the surgical procedures involved simple sutures; pedicled jejunal piece coverings; and various anastomoses following resection of the injured duodenal portion, including the Whipple procedure and damage-control surgery principles. The overall mortality rate was 12.0% (11/92) with deaths mainly occurring due to associated injuries. When excluding 2 cases of intraoperative death, there were 47 cases in the double-tube gastrostomy group and 43 cases in the traditional triple-tube group, with mortality rates of 10.64% and 9.30% in the two groups, respectively (χ2 = 0.045, P > 0.05). Postoperative complications occurred in 15 patients (18.5%). There was a high incidence of duodenal (or pancreatic/biliary) leakage. CONCLUSION: Early diagnosis and operation of duodenal injury are crucial to reducing complications and mortality. Surgical methods should be based on injury grade, associated injuries, and vital signs. Double-tube gastrostomy can reduce complications such as intestinal obstruction.

Paediatric pancreatic trauma in North Queensland: a 10-year retrospective review.

PURPOSE: To establish the incidence of pancreatic trauma in North Queensland to the region's only tertiary paediatric referral centre, and to determine the patient's outcomes based on their management. METHODS: A single centre, retrospective cohort study of patients < 18 years with pancreatic trauma from 2009 to 2020 was performed. There were no exclusion criteria. RESULTS: Between 2009 and 2020 there were 145 intra-abdominal trauma cases, 37% from motor vehicle accidents (MVA), 18.6% motorbike or quadbike, and 12.4% bicycle or scooter accidents. There were 19 cases of pancreatic trauma (13%), all from blunt trauma and with associated injuries. There were 5 AAST grade I, 3 grade II, 3 grade III, 3 grade IV injuries, and 4 with traumatic pancreatitis. Twelve patients were managed conservatively, 2 were managed operatively for another reason, and 5 were managed operatively for the pancreatic injury. Only 1 patient with a high grade AAST injury was successfully managed non-operatively. Complications included pancreatic pseudocyst (n = 4/19; 3 post-op), pancreatitis (n = 2/19; 1 post op), and post-operative pancreatic fistula (POPF) (n = 1/19). CONCLUSION: Due to North Queensland's geography, diagnosis and management of traumatic pancreatic injury is often delayed. Pancreatic injuries requiring surgery are at high risk for complications, prolonged length of stay, and further interventions.

[Diagnosis and treatment of blunt high-grade pancreatic trauma].

The clinical data of 20 patients with blunt high-grade pancreatic trauma who were admitted to the Department of Hepatobiliary and Pancreatic Surgery of Changhai Hospital Affiliated to Naval Military Medical University from December 2003 to February 2022 were retrospectively analyzed. There were 15 males and 5 females with a median age of 39 years (range: 14-54 years). The degree of pancreatic injury was graded according to the American Association for the Surgery of Trauma (AAST) scale, including 10 cases of grade Ⅲ (50%), 8 cases of grade Ⅳ (40%), and 2 cases of grade Ⅴ (10%). Then, the strategy of diagnosis and treatment for blunt high-grade pancreatic trauma was summarized. The diagnostic rate of CT was 78.9%. Finally, 17 cases (85%) were cured and 3 cases (15%) died. Among the 10 patients with grade Ⅲ pancreatic injury, 7 cases received distal pancreatectomy and splenectomy, 1 case received distal pancreatectomy with spleen preserved, 1 case received pancreatic duct stent placement under endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous catheter drainage (PCD), and 1 case received only PCD. Among 8 cases of grade Ⅳ, 3 cases underwent Roux-en-Y pancreaticojejunostomy, 1 case received distal pancreatectomy and splenectomy, 1 case underwent distal pancreatectomy with spleen preserved, 2 cases received necrotic tissue removal+external drainage of pancreatic duct+abdominal drainage, and 1 case received exploratory laparotomy and gauze packing hemostasis. For 2 cases of grade Ⅴ, 1 underwent pylorus preserving pancreaticoduodenectomy, and the other case underwent pancreaticoduodenectomy combined with right hemicolectomy and splenectomy. Therefore, the treatment of blunt high-grade pancreatic trauma should follow the individualized treatment strategy, pay attention to the control of bleeding, extensive external drainage, appropriate debridement and resection and rational application of damage control surgery, select appropriate patients for conservative treatment, and ultimately benefit the patient.

A comparison of management and outcomes following blunt versus penetrating pancreatic trauma: A secondary analysis from the Western Trauma Association Multicenter Trials Group on Pancreatic Injuries.

BACKGROUND: The impact of injury mechanism on outcomes of pancreatic trauma has not been well studied, and current guidelines do not differentiate recommendations for blunt and penetrating injuries. The purpose of this study was to analyze interventions and outcomes as they relate to mechanism. We hypothesized that penetrating pancreatic trauma results in greater morbidity than blunt trauma because of more frequent operative exploration without imaging and thus more aggressive surgical management. METHODS: Secondary analysis of a multicenter retrospective review of pancreatic injuries in patients 15 years and older from 2010 to 2018 was performed. Deaths within 24 hours of admission were excluded from analysis of the primary outcome, pancreas-related complications (PRCs). Data were analyzed by injury mechanism using various statistical tests where appropriate. RESULTS: Thirty-three centers reported on 1,240 patients (44% penetrating). Penetrating trauma patients were twice as likely to undergo resection (45% vs. 23%) and suffer PRCs (39% vs. 20%). However, differences varied widely based on injury grade and management. There were fewer resections and more nonoperative management in blunt grades I to III injury. Pancreas-related complications occurred in 40% of high-grade injuries with no difference between mechanisms and in 40% of patients after resection, regardless of mechanism or injury grade. High-grade pancreatic injury (odds ratio [OR], 2.39; 95% confidence interval [CI], 1.55-3.67), penetrating injury (OR, 1.99; 95% CI, 1.31-3.05), and management in a low-volume center (i.e., five or fewer cases/year) (OR, 1.65; 95% CI, 1.16-2.35) were independent predictors of PRCs. CONCLUSION: Management of grades I to III, but not grades IV/V, pancreatic injuries varies based on mechanism. Penetrating injury is an independent risk factor for PRCs, but main pancreatic duct injury and resection are associated with high rates of PRCs regardless of the injury mechanism. Resection appears to offer better outcomes for grade IV/V injuries, and grade I and II injuries should be managed nonoperatively. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Consequences of COVID-19 for the Pancreas.

Although coronavirus disease 2019 (COVID-19)-related major health consequences involve the lungs, a growing body of evidence indicates that COVID-19 is not inert to the pancreas either. This review presents a summary of the molecular mechanisms involved in the development of pancreatic dysfunction during the course of COVID-19, the comparison of the effects of non-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on pancreatic function, and a summary of how drugs used in COVID-19 treatment may affect this organ. It appears that diabetes is not only a condition that predisposes a patient to suffer from more severe COVID-19, but it may also develop as a consequence of infection with this virus. Some SARS-CoV-2 inpatients experience acute pancreatitis due to direct infection of the tissue with the virus or due to systemic multiple organ dysfunction syndrome (MODS) accompanied by elevated levels of amylase and lipase. There are also reports that reveal a relationship between the development and treatment of pancreatic cancer and SARS-CoV-2 infection. It has been postulated that evaluation of pancreatic function should be increased in post-COVID-19 patients, both adults and children.

Resection versus drainage in the management of patients with AAST-OIS grade IV blunt pancreatic injury: A single trauma centre experience.

INTRODUCTION: We aimed to compare outcomes of pancreatic resection with that of peripancreatic drainage for American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) grade IV blunt pancreatic injury in order to determine the optimal treatment method. MATERIALS AND METHODS: Nineteen surgical patients with AAST-OIS grade IV blunt pancreatic injury between 1994 and 2016 were retrospectively studied. RESULTS: Among the 19 patients, 14 were men and 5 were women (median age: 33 years). Twelve patients underwent pancreatic resection (spleen-sacrificing distal pancreatectomy, n = 6; spleen-preserving distal pancreatectomy, n = 3; and central pancreatectomy with Roux-en-Y anastomosis, n = 3), and seven underwent peripancreatic drainage. After comparing these two groups, no significant differences were found in terms of gender, shock at triage, laboratory data, injury severity score, associated injury, length of hospital stay, and complication. The only significant difference was that in the drainage group, the duration from injury to surgery was longer than that from injury to resection (median, 48 hours vs. 24 hours; P = 0.036). In the drainage group, three patients required reoperation, and another three required further pancreatic duct stent therapy. CONCLUSIONS: In the surgery of the grade IV blunt pancreatic injury, pancreatic resection is warranted in early, conclusive MPD injury; if surgery is delayed or MPD injury has not been clearly assessed, peripancreatic drainage is an alternative method. However, peripancreatic drainage alone is not adequate and further pancreatic duct stent or reoperation is required. Further studies should be conducted to confirm our conclusions.

Pirfenidone increases IL-10 and improves acute pancreatitis in multiple clinically relevant murine models.

Despite decades of research, there is no specific therapy for acute pancreatitis (AP). In the current study, we have evaluated the efficacy of pirfenidone, an antiinflammatory and antifibrotic agent that is approved by the FDA for treatment of idiopathic pulmonary fibrosis (IPF), in ameliorating local and systemic injury in AP. Our results suggest that treatment with pirfenidone in therapeutic settings (e.g., after initiation of injury), even when administered at the peak of injury, reduces severity of local and systemic injury and inflammation in multiple models of AP. In vitro evaluation suggests that pirfenidone decreases cytokine release from acini and macrophages and disrupts acinar-macrophage crosstalk. Therapeutic pirfenidone treatment increases IL-10 secretion from macrophages preceding changes in histology and modulates the immune phenotype of inflammatory cells with decreased levels of inflammatory cytokines. Antibody-mediated IL-10 depletion, use of IL-10-KO mice, and macrophage depletion experiments confirmed the role of IL-10 and macrophages in its mechanism of action, as pirfenidone was unable to reduce severity of AP in these scenarios. Since pirfenidone is FDA approved for IPF, a trial evaluating the efficacy of pirfenidone in patients with moderate to severe AP can be initiated expeditiously.

Temporal-spatial organ response after blast-induced experimental blunt abdominal trauma.

Abdominal trauma (AT) is of major global importance, particularly with the increased potential for civil, terroristic, and military trauma. The injury pattern and systemic consequences of blunt abdominal injuries are highly variable and frequently underestimated or even missed, and the pathomechanisms remain still poorly understood. Therefore, we investigated the temporal-spatial organ and immune response after a standardized blast-induced blunt AT. Anesthetized mice were exposed to a single blast wave centered on the epigastrium. At 2, 6, or 24 h after trauma, abdominal organ damage was assessed macroscopically, microscopically, and biochemically. A higher degree of trauma severity, determined by a reduction of the distance between the epigastrium and blast inductor, was reflected by a reduced survival rate. The hemodynamic monitoring during the first 120 min after AT revealed a decline in the mean arterial pressure within the first 80 min, whereas the heart rate remained quite stable. AT induced a systemic damage and inflammatory response, evidenced by elevated HMGB-1 and IL-6 plasma levels. The macroscopic injury pattern of the abdominal organs (while complex) was consistent, with the following frequency: liver > pancreas > spleen > left kidney > intestine > right kidney > others > lungs and was reflected by microscopic liver and pancreas damages. Plasma levels of organ dysfunction markers increased during the first 6 h after AT and subsequently declined, indicating an early, temporal impairment of the function on a multi-organ level. The established highly reproducible murine blunt AT, with time- and trauma-severity-dependent organ injury patterns, systemic inflammatory response, and impairment of various organ functions, reflects characteristics of human AT. In the future, this model may help to study the complex immuno-pathophysiological consequences and innovative therapeutic approaches after blunt AT.