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 Incisco and I'm M. Tom Bash. 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 3 or 4 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 Doctor Nicole Chandler. Hi, my name is Nicole Chandler. I'm the division chief for pediatric surgery at John. Johns Hopkins All Children's Hospital in Saint 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 4 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 State Home Orders on non-Accidental trauma, and Multi-institutional Study. And for those not familiar with the term non-accidenal trauma, it's basically another term for child abuse. This study is coming from Midwest Pediatric Surgery Consortium. What is the Midwest P Paediatric 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 talk with the first author. Hi, I'm Amelia Collins. 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. Collins is explaining how everything has started. Anecdotally, each of these sites started to 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 their methodology has unique aspects of it. Let's listen to it from Doctor 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-accidenal 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 Doctor Todd Ponsky. He's a pediatric surgeon at Cincinnati. Children's Hospital. And initially they did see the non-acciental trauma rates drop 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 Doctor 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 5 years who would most Uh, commonly be in school, um, minority children and lower socioeconomic 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 neighborhood's vulnerability during times of crises. 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. Doctor Chandler has also similar recommendations to Doctor Collins. 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 crises where kids are not afforded the normal protections that they would typically have during school and whatnot. Before we move to the next article, Doctor Finn O'Brien has an important No, 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, 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. OK, our next article is on hepatblastoma. It's called Metastatic Human Hepatoblastoma Cells exhibit enhanced tumorogenicity, invasiveness, and a stem cell-like phenotype. This study comes out of the University of Alabama. He talked to the senior author, Doctor Elizabeth Berley. 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 hepatocellular carcinoma. So they generated a new hepatoblastoma cell line, particularly metastatic hepatblastoma 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 hepatblastoma continues. pose significant treatment challenges. And again, that's Doctor Chandler, the editor who helped us choose these articles. Here, Doctor Berley 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 a cell line that's established that will grow in culture and that will rely. lead to metastases 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 tumorgenicity, 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. That is really cool. Doctor Byerly 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 hepatblastoma 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 and what we're talking about here. And the next paper is coming from PSOP, 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 of Pittsburgh. He's also the pediatric surgical oncology director. And Doctor. Malik told us a little bit more about PSOC. 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, Doctor Chandler? What they found is that the most common techniques for 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. Be a resident or I've worked at a couple of 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 5 years from now, they'll find that ICG is becoming much more popular, and more effective. And before the next article, Doctor Chandner 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 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 Doctor 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 parental nutrition for 60 days or more at any time. And that's Doctor Biran 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 8 years of age, and then we looked at them only if they were older than 8 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 pubertal 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 pubertal onset earlier than the CDC 50th percentile. Here are Todd's thoughts. This is shocking to me cause I would have always thought that all of these kids would be severely underweight, undersized, on everything. Sounds like they might be slightly short statured, but it's not like they're severely undersized compared to the general population, which is very surprising. 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. And 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 Podcasts or Spotify, wherever you're listening. Don't forget to subscribe to our YouTube channel. Download the Stay Current and pediatric surgery app where you'll find a lot more podcasts and videos. Until next time, I'm Ellen. And I'm Ann. And remember, knowledge should be free.