Management of complex pediatric and adolescent liver trauma: adult vs pediatric level 1 trauma centers.

PURPOSE: Management of high-grade pediatric and adolescent liver trauma can be complex. Studies suggest that variation exists at adult (ATC) vs pediatric trauma centers (PTC); however, there is limited granular comparative data. We sought to describe and compare the management and outcomes of complex pediatric and adolescent liver trauma between a level 1 ATC and two PTCs in a large metropolitan city. METHODS: A retrospective review of pediatric and adolescent (age < 21 years) patients with American Association for the Surgery of Trauma (AAST) Grade 4 and 5 liver injuries managed at an ATC and PTCs between 2016 and 2022 was performed. Demographic, clinical, and outcome data were obtained at the ATC and PTCs. Primary outcomes included rates of operative management and use of interventional radiology (IR). Secondary outcomes included packed red blood cell (pRBC) utilization, intensive care unit (ICU) length of stay (LOS), and hospital LOS. RESULTS: One hundred forty-four patients were identified, seventy-five at the ATC and sixty-nine at the PTC. The cohort was predominantly black (65.5%) males (63.5%). Six injuries (8.7%) at the PTC and forty-five (60%) injuries at the ATC were penetrating trauma. Comparing only blunt trauma, ATC patients had higher Injury Severity Score (median 37 vs 26) and ages (20 years vs 9 years). ATC patients were more likely to undergo operative management (26.7% vs 11.0%, p = 0.016) and utilized IR more (51.9% vs 4.8%, p < 0.001) compared to the PTC. The patients managed at the ATC required higher rates of pRBC transfusions though not statistically significant (p = 0.06). There were no differences in mortality, ICU, or hospital LOS. CONCLUSION: Our retrospective review of high-grade pediatric and adolescent liver trauma demonstrated higher rates of IR and operating room use at the ATC compared to the PTC in the setting of higher Injury Severity Score and age. While the PTC successfully managed > 95% of Grade 4/5 liver injuries non-operatively, prospective data are needed to determine the optimal algorithm for management in the older adolescent population. LEVEL OF EVIDENCE: Level IV.

Increases in adolescent firearm injuries were associated with school closures during COVID-19.

BACKGROUND: Mitigation measures, including school closures, were enacted to protect the public during the COVID-19 pandemic. However, the negative effects of mitigation measures are not fully known. Adolescents are uniquely vulnerable to policy changes since many depend on schools for physical, mental, and/or nutritional support.  This study explores the statistical relationships between school closures and adolescent firearm injuries (AFI) during the pandemic. METHODS: Data were drawn from a collaborative registry of 4 trauma centers in Atlanta, GA (2 adult and 2 pediatric). Firearm injuries affecting adolescents aged 11-21 years from 1/1/2016 to 6/30/2021 were evaluated. Local economic and COVID data were obtained from the Bureau of Labor Statistics and the Georgia Department of Health. Linear models of AFI were created based on COVID cases, school closure, unemployment, and wage changes. RESULTS: There were 1,330 AFI at Atlanta trauma centers during the study period, 1,130 of whom resided in the 10 metro counties. A significant spike in injuries was observed during Spring 2020. A season-adjusted time series of AFI was found to be non- stationary (p = 0.60). After adjustment for unemployment, seasonal variation, wage changes, county baseline injury rate, and county-level COVID incidence, each additional day of unplanned school closure in Atlanta was associated with 0.69 (95% CI 0.34- 1.04, p < 0.001) additional AFIs across the city. CONCLUSION: AFI increased during the COVID pandemic. This rise in violence is statistically attributable in part to school closures after adjustment for COVID cases, unemployment, and seasonal variation. These findings reinforce the need to consider the direct implications on public health and adolescent safety when implementing public policy.

miR-542-5p targets c-myc and negates the cell proliferation effect of SphK1 in intestinal epithelial cells.

Intestinal epithelial barrier defects occur commonly during a variety of pathological conditions, though their underlying mechanisms are not completely understood. Sphingosine-1-phosphate (S1P) has been shown to be a critical regulator of proliferation and of maintenance of an intact intestinal epithelial barrier, as is also sphingosine kinase 1 (SphK1), the rate-limiting enzyme for S1P synthesis. SphK1 has been shown to modulate its effect on intestinal epithelial proliferation through increased levels of c-myc. We conducted genome-wide profile analysis to search for differential microRNA expression related to overexpressed SphK1 demonstrating adjusted expression of microRNA 542-5p (miR-542-5p). Here, we show that miR-542-5p is regulated by SphK1 activity and is an effector of c-myc translation that ultimately serves as a critical regulator of the intestinal epithelial barrier. miR-542-5p directly regulates c-myc translation through direct binding to the c-myc mRNA. Exogenous S1P analogs administered in vivo protect murine intestinal barrier from damage due to mesenteric ischemia reperfusion, and damaged intestinal tissue had increased levels of miR-542-5p. These results indicate that miR-542-5p plays a critical role in the regulation of S1P-mediated intestinal barrier function, and may highlight a novel role in potential therapies.

Utility of ventriculogallbladder shunts in complex cases of hydrocephalus related to extreme prematurity.

OBJECTIVE: The management of hydrocephalus resulting from intraventricular hemorrhage related to extreme prematurity remains demanding. Given the complexities of controlling hydrocephalus in this population, less commonly used procedures may be required. The authors examined the utility of ventriculogallbladder (VGB) shunts in a series of such children. METHODS: The authors retrospectively reviewed the medical records of all children who underwent surgery for hydrocephalus in the period from 2011 through 2019 at Children's Healthcare of Atlanta. Six patients who underwent VGB shunt placement were identified among a larger cohort of 609 patients who had either a new shunt or a newly changed distal terminus site. The authors present an analysis of this series, including a case of laparoscopy-assisted distal VGB shunt revision. RESULTS: The mean age at initial shunt placement was 5.1 months (range 3.0-9.4 months), with patients undergoing a mean of 11.8 shunt procedures (range 5-17) prior to the initial VGB shunt placement at a mean age of 5.3 years (range 7.9 months-12.8 years). All 6 patients with VGB shunt placement had hydrocephalus related to extreme prematurity (gestational age < 28 weeks). At the time of VGB shunt placement, all had complex medical and surgical histories, including poor venous access due to congenital or iatrogenic thrombosis or thrombophlebitis and a peritoneum hostile to distal shunt placement related to severe necrotizing enterocolitis. VGB complications included 1 case of shunt infection, identified at postoperative day 6, and 2 cases of distal shunt failure due to retraction of the distal end of the VGB shunt. In all, there were 3 conversions back to ventriculoperitoneal or ventriculoatrial shunts due to the 2 previously mentioned complications, plus 1 patient who outgrew their initial VGB shunt. Three of 6 patients remain with a VGB shunt, including 1 who underwent laparoscopy-assisted distal shunt revision 110.5 months after initial VGB shunt insertion. CONCLUSIONS: Placement of VGB shunts should be considered in the armamentarium of procedures that may be used in the particularly difficult cohort of children with hydrocephalus related to extreme prematurity. VGB shunts show utility as both a definitive treatment and as a "bridge" procedure until the patient is larger and comorbid abdominal and/or vascular issues have resolved sufficiently to allow conversion back to ventriculoperitoneal or ventriculoatrial shunts, if needed.

Perceived Parameters of Christian Pharmacy Students' Faith-Sharing in Clinical Settings.

Our interdisciplinary team (which included professionals from nursing, pharmacy, allied health, and psychology) conducted in-depth, semi-structured interviews with pharmacy students (n = 14) who were presently in a clinical rotation. When conducting the phenomenological, qualitative research study, we explored how students framed their respective experiences of incorporating spirituality into their clinical work. Three themes emerged from the interviews: (1) The students reportedly viewed their main role as being more of a support person than an evangelist, (2) They framed their influence from the perspective of so-called faith flags, and (3) They perceived more opportunities for influence with their coworkers than with patients. We discuss the findings in light of published findings and also in terms of how health care workers frame the concept of "ministry."

Correlates of bird collisions with buildings across three North American countries.

Collisions with buildings cause up to 1 billion bird fatalities annually in the United States and Canada. However, efforts to reduce collisions would benefit from studies conducted at large spatial scales across multiple study sites with standardized methods and consideration of species- and life-history-related variation and correlates of collisions. We addressed these research needs through coordinated collection of data on bird collisions with buildings at sites in the United States (35), Canada (3), and Mexico (2). We collected all carcasses and identified species. After removing records for unidentified carcasses, species lacking distribution-wide population estimates, and species with distributions overlapping fewer than 10 sites, we retained 269 carcasses of 64 species for analysis. We estimated collision vulnerability for 40 bird species with ≥2 fatalities based on their North American population abundance, distribution overlap in study sites, and sampling effort. Of 10 species we identified as most vulnerable to collisions, some have been identified previously (e.g., Black-throated Blue Warbler [Setophaga caerulescens]), whereas others emerged for the first time (e.g., White-breasted Nuthatch [Sitta carolinensis]), possibly because we used a more standardized sampling approach than past studies. Building size and glass area were positively associated with number of collisions for 5 of 8 species with enough observations to analyze independently. Vegetation around buildings influenced collisions for only 1 of those 8 species (Swainson's Thrush [Catharus ustulatus]). Life history predicted collisions; numbers of collisions were greatest for migratory, insectivorous, and woodland-inhabiting species. Our results provide new insight into the species most vulnerable to building collisions, making them potentially in greatest need of conservation attention to reduce collisions and into species- and life-history-related variation and correlates of building collisions, information that can help refine collision management.

Correlaciones de las Colisiones de Aves contra Edificios en Tres Países de América del Norte Resumen Las colisiones contra los edificios causan hasta mil millones de fatalidades de aves al año en los Estados Unidos y en Canadá. Sin embargo, los esfuerzos por reducir estas colisiones se beneficiarían con estudios realizados a grandes escalas espaciales en varios sitios de estudio con métodos estandarizados y considerando las variaciones relacionadas a la historia de vida y a la especie y las correlaciones de las colisiones. Abordamos estas necesidades de investigación por medio de una recolección coordinada de datos sobre las colisiones de aves contra edificios en los Estados Unidos (35), Canadá (3) y México (2). Recolectamos todos los cadáveres y los identificamos hasta especie. Después de retirar los registros de cadáveres no identificados, las especies sin estimaciones poblacionales a nivel distribución y las especies con distribuciones traslapadas en menos de diez sitios, nos quedamos con 269 cadáveres de 64 especies para el análisis. Estimamos la vulnerabilidad a colisiones para 40 especies con ≥2 fatalidades con base en la abundancia poblacional para América del Norte, el traslape de su distribución entre los sitios de estudio y el esfuerzo de muestreo. De las diez especies que identificamos como las más vulnerables a las colisiones, algunas han sido identificadas previamente (Setophaga caerulescens), y otras aparecieron por primera vez (Sitta carolinensis), posiblemente debido a que usamos una estrategia de muestreo más estandarizada que en los estudios previos. El tamaño del edificio y el área del vidrio estuvieron asociados positivamente con el número de colisiones para cinco de ocho especies con suficientes observaciones para ser analizadas independientemente. La vegetación alrededor de los edificios influyó sobre las colisiones solamente para una de esas ocho especies Catharus ustulatus). Las historias de vida pronosticaron las colisiones; el número de colisiones fue mayor para las especies migratorias, insectívoras y aquellas que habitan en las zonas boscosas. Nuestros resultados proporcionan una nueva perspectiva hacia las especies más vulnerables a las colisiones contra edificios, lo que las pone en una necesidad potencialmente mayor de atención conservacionista para reducir estas colisiones y de estudio de las variaciones relacionadas con la especie y la historia de vida y las correlaciones de las colisiones contra edificios, información que puede ayudar a refinar el manejo de colisiones.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporization of hemorrhage in adolescent trauma patients.

BACKGROUND/PURPOSE: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as an alternative technique for traumatic hemorrhage control in the adult population. The purpose of this study is to describe the details of REBOA placement in adolescent trauma patients. METHODS: Patients 18 years of age or less who received REBOA for aortic occlusion (AO) from August 2013 to February 2017 at 2 urban tertiary care centers were included. RESULTS: 7 adolescent trauma patients received REBOA by trauma surgeons for both blunt (n = 4) and penetrating mechanisms (n = 3); mean age was 17 + 1.5 years, mean admission lactate 13.0 + 4.85 mmol/L, and mean Hgb 10.7 + 2.7 g/dL. 3 patients received REBOA through a 12Fr sheath and 4 through a 7Fr sheath. AO occurred mostly at the distal thoracic aorta (Zone I) (85.7%) and also in the distal abdominal aorta (Zone III) (14.3%). 57% of patients were in arrest with ongoing CPR at the time of REBOA. In-hospital mortality was 57%; all of these patients were in arrest at the time of REBOA, had return of spontaneous circulation (ROSC), and survived to the operating room. No complications from REBOA were identified. CONCLUSION: REBOA appears to be feasible for use in adolescents despite their smaller caliber vessels, even with use of a 12Fr sheath. REBOA results in improved physiology and can bridge adolescent trauma patients presenting in extremis to the operating room. TYPE OF STUDY: Treatment/therapeutic study LEVEL OF EVIDENCE: Level IV.

Can time to healing in pediatric blunt splenic injury be predicted?

BACKGROUND: Current consensus guidelines do not recommend routine follow-up imaging for blunt splenic injury (BSI) in children. However, repeat imaging is recommended based on persistent symptoms. Wide variation of practice continues to exist among surgeons. By defining the natural evolution of BSI, we sought to identify patients at higher risk for delayed healing who could benefit from outpatient imaging. METHODS: A retrospective review of all children with BSI at a Level 1 Pediatric Trauma Center was completed. Grade of injury, hospital course, laboratory values and follow-up imaging results were obtained. Injured spleens were classified as 'healed', 'healing' (with echogenic scar), or 'non-healing' with persistence of parenchymal abnormalities. RESULTS: Between 2000 and 2014, 222 patients with BSI were identified. Seven patients (3%) underwent immediate splenectomy. Packed red blood cell transfusion was required in 13 (6%) of the 222 patients, and 3 (2%) of 145 with isolated splenic injuries. Seventy-one percent of patients underwent additional imaging 2-74 weeks post-injury. A receiver operating characteristics (ROC) curve was used to establish the relationship between sensitivity and specificity of capturing non-healing spleens over time. Optimal timing for post-injury imaging for grades I-II was 7-8 weeks; healing of higher-grade injuries could not accurately be predicted. CONCLUSIONS: If return to full physical activity, in particular contact sports, is contingent upon documented healing of the splenic parenchyma after blunt trauma in the pediatric population, follow-up imaging for low-grade injuries is best obtained around 7-8 weeks. No such recommendations can be made for high-grade splenic injuries, as the exact time to healing cannot be predicted based on initial data. LEVEL OF EVIDENCE: IV. Diagnostic test.

Gut microbiota, tight junction protein expression, intestinal resistance, bacterial translocation and mortality following cholestasis depend on the genetic background of the host.

Failure of the intestinal barrier is a characteristic feature of cholestasis. We have previously observed higher mortality in C57BL/6J compared with A/J mice following common bile duct ligation (CBDL). We hypothesized the alteration in gut barrier function following cholestasis would vary by genetic background. Following one week of CBDL, jejunal TEER was significantly reduced in each ligated mouse compared with their sham counterparts; moreover, jejunal TEER was significantly lower in both sham and ligated C57BL/6J compared with sham and ligated A/J mice, respectively. Bacterial translocation to mesenteric lymph nodes was significantly increased in C57BL/6J mice vs. A/J mice. Four of 15 C57BL/6J mice were bacteremic; whereas, none of the 17 A/J mice were. Jejunal IFN-γ mRNA expression was significantly elevated in C57BL/6J compared with A/J mice. Western blot analysis demonstrated a significant decrease in occludin protein expression in C57BL/6J compared with A/J mice following both sham operation and CBDL. Only C57BL/6J mice demonstrated a marked decrease in ZO-1 protein expression following CBDL compared with shams. Pyrosequencing of the 16S rRNA gene in fecal samples showed a dysbiosis only in C57BL/6J mice following CBDL when compared with shams. This study provides evidence of strain differences in gut microbiota, tight junction protein expression, intestinal resistance and bacterial translocation which supports the notion of a genetic predisposition to exaggerated injury following cholestasis.

Sphingosine kinase 1 overexpression stimulates intestinal epithelial cell proliferation through increased c-Myc translation.

Sphingosine-1-phosphate (S1P), through mechanisms that are not completely understood, is shown to modulate cellular proliferation, which is critically important for maintaining the integrity of intestinal epithelium. Here, we show that increased S1P promotes proliferation in intestinal epithelial cells. We found that overexpression of sphingosine kinase 1 (SphK1), the rate-limiting enzyme for S1P synthesis, significantly increased cell proliferation and that this occurred through enhanced expression of c-Myc. Further, we found that the increased pattern of expression of c-Myc occurred predominantly due to its increased translation. The overexpressed SphK1 led to increased checkpoint kinase 2 and enhanced HuR phosphorylation which allowed for increased translation of c-Myc mRNA through HuR binding at the 3'-untranslated regions. Our findings demonstrate that S1P modulates intestinal cell proliferation and provides new insights as to the mechanistic actions of SphK1 and S1P in maintaining intestinal epithelial homeostasis.