Stressing the System: Pediatric Trauma Centers May Be Unready to Implement Comprehensive Acute Stress Screening Programs for Pediatric Trauma Patients.

BACKGROUND: Children experiencing trauma are at risk of developing acute and chronic stress disorders. In 2022, the American College of Surgeons Committee on Trauma required verified pediatric trauma centers to screen at-risk patients and provide mental health provider referrals as needed. OBJECTIVE: The study objective is to assess the current readiness of pediatric trauma centers to meet the new American College of Surgeons requirements. METHODS: This study used an exploratory, electronic, cross-sectional survey design. The Pediatric Trauma Society distributed a survey on mental health screening practices to its members in February 2023. Results were summarized with descriptive statistics. Chi-square test was used to compare responses of Levels I and II pediatric trauma centers. RESULTS: There were 91 survey responses from the PTS membership of 1247 (response rate of 7.3%). Fifty-nine participants were from Level I and 27 from Level II pediatric trauma centers. 63.8% of Level I and 51.9% of Level II center respondents currently screened for acute stress (χ2(1) = 1.09, p = .30). Of these, 75.7% of Level I and 57.1% of Level II center respondents routinely screened all admitted trauma patients (χ2(1) = 1.68, p = .19). However, only 32.4% of Level I and 21.4% of Level II respondents reported having outpatient acute stress referral protocols. For pediatric trauma centers currently without screening, 65% of Level I and 46.2% of Level II pediatric trauma center respondents felt they needed more than six months to establish a program (χ2(1) = 1.15, p = .28). Most respondents (68.9%) reported staff shortages as a barrier to the delivery of acute stress services. CONCLUSIONS: Pediatric trauma center compliance with acute stress screening requirements for verification is variable. Pediatric trauma centers may benefit from technical assistance with acute stress screening.

The Neonatal Innate Immune Response to Sepsis: Checkpoint Proteins as Novel Mediators of This Response and as Possible Therapeutic/Diagnostic Levers.

Sepsis, a dysfunctional immune response to infection leading to life-threatening organ injury, represents a significant global health issue. Neonatal sepsis is disproportionately prevalent and has a cost burden of 2-3 times that of adult patients. Despite this, no widely accepted definition for neonatal sepsis or recommendations for management exist and those created for pediatric patients are significantly limited in their applicability to this unique population. This is in part due to neonates' reliance on an innate immune response (which is developmentally more prominent in the neonate than the immature adaptive immune response) carried out by dysfunctional immune cells, including neutrophils, antigen-presenting cells such as macrophages/monocytes, dendritic cells, etc., natural killer cells, and innate lymphoid regulatory cell sub-sets like iNKT cells, γδ T-cells, etc. Immune checkpoint inhibitors are a family of proteins with primarily suppressive/inhibitory effects on immune and tumor cells and allow for the maintenance of self-tolerance. During sepsis, these proteins are often upregulated and are thought to contribute to the long-term immunosuppression seen in adult patients. Several drugs targeting checkpoint inhibitors, including PD-1 and PD-L1, have been developed and approved for the treatment of various cancers, but no such therapeutics have been approved for the management of sepsis. In this review, we will comparatively discuss the role of several checkpoint inhibitor proteins, including PD-1, PD-L1, VISTA, and HVEM, in the immune response to sepsis in both adults and neonates, as well as posit how they may uniquely propagate their actions through the neonatal innate immune response. We will also consider the possibility of leveraging these proteins in the clinical setting as potential therapeutics/diagnostics that might aid in mitigating neonatal septic morbidity/mortality.