Journal of Pediatric Surgery Article Review: June 2022, AAP Issue

Hi everyone, welcome back to the Stay Current podcast. This is another in our series on article reviews from the Journal of Pediatric Surgery. We are reviewing articles from the June 2022 issue. June issue was the AAP issue or American Academy of Pediatrics. I'm Ellen Ensisco. And I'm M. Tombash. We're research fellows at Cincinnati Children's Hospital Medical Center. And this is Stay Current Podcast. These articles are chosen by the editorial board. We enlist their help to pick three or four articles every month that are significant for us to talk about in the podcast and highlight for you all. This month, the editor who helped us choose articles was Dr. Nicole Chandler. Hi, my name's Nicole Chandler. I'm the division chief for a pediatric surgery at Johns Hopkins All Children's Hospital in St. Petersburg, Florida. And she's the publications chair for AAP, and so these are studies that were presented at their latest meeting, um, and are being highlighted in this issue. As we're going through, don't forget to read along the articles with us. All articles we're talking about today are linked in the description below. So we have four articles coming up for you. We have one about the impact of stay-at-home orders on non-accidental trauma during the COVID-19 pandemic. Then we'll have a basic science article on hepatoblastoma. Then we'll have an oncology article on localization techniques for small pulmonary nodules, and finally an article on pediatric intestinal failure and related outcomes. So, let's get started with our first article. This one's titled as Impact of Stay-At-Home Orders on Non-Accidental Trauma, a Multi-Institutional Study. And for those not familiar with the term non-accidental trauma, it's basically another term for child abuse. This study is coming from Midwest Pediatric Surgery Consortium. What is the Midwest Pediatric Surgery Consortium? The Midwest Pediatric Surgery Research Consortium or MWPSC, was established by the departments of pediatric surgery from 11 children's hospitals. That are able to harness the power of multiple institutions for research in a number of different areas, and this one is about trauma. And for this paper, we talked with the first author. Hi, I'm Amelia Collings. She's the Midwest Consortium's research fellow. And the last author? I'm Katie Flynn O'Brien. She's a pediatric surgeon at Children's Wisconsin. Here Dr. Collings is explaining how everything had started. Anecdotally, each of these sites, um, started discussing how they saw different patterns in pediatric trauma that were coming through their doors. And, um, they were especially concerned about the changes they saw, um, personally from child abuse. And so, um, they decided to work together, um, to take a look at, um, what was actually occurring during the beginning of the pandemic. They looked at all patients under 18 years old who presented with traumatic injury, as defined by the National Trauma Data Bank. And then we narrowed this cohort based on ICD-10 diagnosis codes for suspected and confirmed child abuse. Um, we then created two cohorts, a historical cohort and a COVID cohort. And the methodology has unique aspects of it. Let's listen it from Dr. Flynn O'Brien. We used the historical patterns of NAT as captured by these trauma registries to predict what the volume should be and should have been during the initial COVID time period. Again, NAT stands for non-accidental trauma, which is another term for child abuse. And then compared that to the actual or the observed rates. Um, and I think that was a really interesting aspect of the study. NAT was higher after the lockdown, not during the lockdown. That was Dr. Todd Ponsky. He's a pediatric surgeon at Cincinnati Children's Hospital. And initially they did see the non-accidental trauma rates drop, um, a little bit, but after that actually the rate increased above what they had expected during the stay-at-home orders. And again, that's Dr. Chandler, the editor who helped us choose these articles. And the patients that were disproportionately affected were, um, the older kids who were older than five years, who would most, uh, commonly be in school, minority children and lower socio-economic groups, as they determined by the social vulnerability index. I think this article brings up, you know, an interesting question for the future as far as how do we avoid this problem? Another issue is not just the fact that people aren't noticing, but, you know, the stay-at-home orders were pretty burdensome, you know, on families where people have to continue going to work. You know, they still have to continue making money, you know, how do we support these families? Maybe this could be an answer for all of us, Ellen. CDC has a measure called social vulnerability index. It was uniquely created to see neighborhoods' vulnerability during times of crisis. This is another way that we can potentially look for patients at risk and, um, really target those, um, supportive resources to those neighborhoods that need it most. Dr. Chandler has also similar recommendations to Dr. Collings. During these times of public health crises, it's important to maintain systems of protection for children. Um, and that's really important as pediatric surgeons, we need to keep an eye on in the future during, um, maybe other public criseses where kids are not afforded the normal protections that they would typically have during school and whatnot. Before we move to the next article, Dr. Flynn O'Brien has an important note. I think you can't talk about NAT without acknowledging the limitations of trauma registry data and ICD-9 codes and 10 codes. You know, you one has to be careful not to make too strong of conclusions based on any data, no matter how many institutions and how long the evaluation period was when it's related to simply ICD-10 codes. Okay, our next article is on hepatoblastoma. It's called metastatic human hepatoblastoma cells exhibit enhanced tumorogenicity, invasiveness and a stem cell-like phenotype. Or this study comes out of the University of Alabama. We talked with the senior author, Dr. Elizabeth Bierly. I'm a professor of surgery and pediatrics at the University of Alabama in Birmingham, Alabama. And this is a basic science article. So, the impetus behind this work was there are very, very few cell lines available to be used to study hepatoblastoma and a number of the cell lines that are touted to be hepatoblastoma are actually hepato cellular carcinoma. So they generated a new hepatoblastoma cell line, particularly metastatic hepatoblastoma cell line to look more deeper at it and look at its characteristics and, you know, basically find out more about it. Because management of metastatic hepatoblastoma continues to pose significant treatment challenges. And again, that's Dr. Chandler, the editor who helped us choose these articles. Here Dr. Bierly explains how they did it. We took a cell line that we know is hepatoblastoma and we labeled it with a marker that we can detect with, um, fluorescence. The cells light up the same way that, you know, a firefly will light up. It's really cool and it's really interesting what they were able to do here. We took these cells and injected them into the tail vein of the mouse and then they will preferentially go and set up housekeeping in the lungs. And then we harvest the lungs and we chop the lungs up and we put them in culture and then the cells that survive that also express this same luciferase gene, we take those and we inject those into another mouse. They repeated that process over and over again until they get an a cell line that's established that will grow in culture and that will reliably lead to metastasis when injected into the tail vein of a mouse. And when they evaluated it, the compared to the original human cell line, this new cell line that they were able to create exhibited increased tumorogenicity, invasiveness and an increased resistance to chemotherapy. And here's what Todd had to say. I can't believe that we never had a hepatoblastoma cell line mouse model before. So, I mean, this could be a big breakthrough actually. Yeah, it is really cool. Dr. Bily also said, but I hope that the one little pearl that they would take from it is that we really still need to, to concentrate on hepatoblastoma and try to move the field forward, even though it's not that common of a tumor and even though there's only a small subset of children that maybe need to really be focused on or have our research efforts focused on. It's not practice changing right away, but ideally lead to practice changing findings. You want to learn more, click the link below because there's a lot more details to the articles than what we're talking about here. And the next paper is coming from Psorp, Pediatric Surgical Oncology Research Collaborative. It's called interhospital variability in localization techniques for small pulmonary nodules in children. And we talked to the senior author. My name is Marcus Malik. I'm a pediatric surgeon at the Children's Hospital Pittsburgh. He's also the pediatric surgical oncology director. And Dr. Malik told us a little bit more about Psorc. Psorc is the Pediatric Surgical Oncology Research Collaborative. It's a multi-institutional consortium of North American pediatric surgeons who are, you know, really fully focused and dedicated on advancing the care of children with cancer. And Dr. Malik gives us the reason why Psorc has founded. We just felt that there was a need to really amalgamate the data of all these institutions to better study surgical questions in pediatric cancer. And here's the main idea behind this study. So, obviously as surgeons across, you know, North America, we've sort of decided we need to figure out a way to do this, but there has not been consistency. Uh, we're all sort of doing our own thing. And so I thought, let's just kind of get a sense of what's happening, you know, throughout North America, how are people doing this? And then, you know, make an effort to compare the techniques and see maybe there's one technique that's really clearly better than the others. What did they found, Dr. Chandler? What they found is that the most common techniques were wire and methylene blue dye, followed by methylene blue dye only. And in comparing these techniques, there was no difference in successful IR localization or successful resection of the pulmonary nodules. Yeah, it's pretty straightforward article. I didn't imagine that all these different techniques would pretty much be equal. So I think what was interesting, time under anesthesia can be it can be long and it can certainly be quite variable. So some institutions are doing this in in like a hybrid OR. You know, so you've done your localization and then you're immediately going right over into the operation. But that's not the case for every hospital. Some have hybrid ORs, some have IR in different floor, and some in the same floor as the operating rooms. Being a resident or I've worked at a couple different hospitals and I feel like every time I'm working in those hospitals, you think like, oh, this is the way to do it. And then you learn that there are lots of ways to do it and this study shows that all of the ways really work pretty well. And Todd has shared his expectations about the future of localization of lung nodules. So I'm not surprised that there's no difference, but repeat this study in five years from now, they'll find that ICG is becoming much more popular and more effective. And before the next article, Dr. Chandler has an important comment. Image guided localization techniques varied significantly among institutions, that all of them were wildly successful, showing that the experience is probably more, uh, important than the actual technique itself. The final article is on pediatric intestinal failure. This is puberty and growth in patients with pediatric intestinal failure. This comes from Boston Children's Hospital. The authors looked at pediatric intestinal failure and wanted to evaluate the downstream impact on puberty, which has been unstudied up till this point. And again, that's Dr. Chandler, the editor who helped us choose these articles. And they were really looking at how intestinal failure might affect their puberty and growth. Uh, we focused on patients who had a diagnosis of pediatric intestinal failure, which we defined as a requirement of perentral nutrition for 60 days or more at any time. And that's Dr. Beran Modi. He's the senior author on the publication and he's a pediatric surgeon at Boston Children's Hospital. And associate director of Center for Advanced Intestinal Rehabilitation. But they had to have that diagnosis before they reached eight years of age. And then we looked at them only if they were older than eight at the time of our study. The purpose being to look at kids in the normal window of when puberty would happen. And so they looked at a couple of different outcomes, including peak height velocity, the age at peak height velocity and their age at puberal onset. We know that puberty is at least partially dependent on having good nutritional stores based on the hormonal drivers of puberty. Our hypothesis was the fact that having chronic pediatric intestinal failure would delay puberty and potentially dull, sharp spike of puberty in terms of the the peak height velocity. But their findings were quite different than what they were expecting. They found that peak height velocity occurred at significantly younger ages for both males and females, and that puberty onset occurred significantly earlier compared to established norms for males. Meaning that they reached puberal onset earlier than the CDC 50th percentile. Here are Todd's thoughts. This is shocking to me because I would have always thought that all these kids would be severely underweight, undersized, on everything. Sounds like they might be slightly short stature, but it's not like they're severely undersized compared to the general population, which is very surprising to me. There is a high incidence of short stature in chronic intestinal failure and so the finding that that is not necessarily because kids are missing out on their pubertal timing and on the peak height velocity that occurs during puberty, suggests that we need to do a better job at setting them up to go into puberty with uh, you know, working on their height and their linear growth. Hey, so we had a variety of different articles here, all super interesting and I think all thought provoking in terms of what to do in the future. I don't think any of them are necessarily things that right away we can do differently, but they're good questions and investigations. As always, if you liked or didn't like this podcast or this series, don't forget to leave us a comment on Apple podcast or Spotify wherever you're listening. Don't forget to subscribe to our YouTube channel. Download the Stay Current in Pediatric Surgery app where you'll find a lot more podcasts and videos. Until next time, I'm Ellen. And I'm M. And remember, knowledge should be free.