Marshall W. Wallace

Introduction: Biliary atresia ( BA ) is the most common indication for pediatric liver transplantation. Pediatric end‐stage liver disease ( PELD ) scores primarily determine deceased donor liver transplant ( DDLT ) waitlist priority. Due to persistent donor supply–demand mismatch, children typically have advanced disease and high PELD scores at the time of DDLT . Proactive living donor liver transplant ( LDLT ) may facilitate transplantation before critical illness. We hypothesized that early, low PELD , LDLT is associated with improved graft and patient survival in children with BA. Methods: We retrospectively reviewed children undergoing liver transplantation for BA in the SRTR database, comparing DDLT to LDLT , stratified by PELD . Early transplant was defined as transplant with a PELD ≤ 12. Four groups were analyzed: low PELD LDLT , low PELD DDLT , high PELD LDLT , and high PELD DDLT . Kaplan–Meier and Cox‐proportional hazards analyses evaluated patient‐ and graft‐survival. Results: 4733 children meeting inclusion criteria were included ( n = 249 Low PELD LDLT, n = 1152 Low PELD DDLT, n = 708 High PELD LDLT, n = 2624 High PELD DDLT). Prior to transplant, Low PELD LDLT recipients had lower INR and bilirubin levels, and required less life support ( p < 0.01). Kaplan–Meier analyses showed the highest 5‐year graft and patient survival in the Low PELD LDLT ( p < 0.01). Cox modeling revealed an independent association between low PELD LDLT and decreased graft loss (adjusted HR 0.45, p < 0.01) and mortality (adjusted HR 0.43, p = 0.03). Conclusions: A proactive approach to LDLT in children with BA is associated with improved long‐term graft and patient survival. Low PELD LDLT should be considered to increase early transplant access for children with BA .

BACKGROUND: Previous data suggest that there may be increased use of invasive interventions for pediatric blunt solid organ injury at nonpediatric trauma centers. In pediatric high-grade (AAST Grades III–V) blunt hepatic injuries (BHI), specifically, previous single-center and state-level studies have demonstrated that presentation to adult trauma centers independently predicts increased use of angioembolization and hemorrhage control laparotomy, but this observation has not been validated using a large, nationwide dataset. This study evaluated the use of invasive interventions (hemorrhage control laparotomy and/or hepatic angioembolization) and mortality in children with BHI across pediatric, adult, and hybrid trauma centers (PTCs, ATCs, and HTCs). METHODS: We retrospectively reviewed children aged 17 and below, with high-grade BHI (AAST Grades III–V, defined by AIS) in the ACS Trauma Quality Improvement Program database from 2017 to 2022. Univariate analyses compared demographics, injury characteristics, management strategies, and outcomes between ATCs, HTCs, and PTCs. Backward stepwise regression evaluated predictors of hemorrhage control laparotomy, angioembolization, and mortality. RESULTS: In total, 5,498 children were included. Children presenting to an ATC were older ( p p =0.50). On univariate analyses, PTC-presentation was associated with lower injury severity score, higher rates of isolated injury, lower rates of positive shock index, and lower rates of early blood transfusion ( p p p p <0.01). However, on regression analysis, trauma center verification status did not independently predict angioembolization, hemorrhage control laparotomy, or mortality. CONCLUSIONS: Contrary to prior data in smaller populations, in this national analysis of high-grade pediatric blunt hepatic trauma, hospital verification status did not independently influence the likelihood of hepatic angioembolization, hemorrhage control laparotomy, or mortality. LEVEL OF EVIDENCE: Cohort Study; Level III.

BACKGROUND Liver injury is common in children with blunt or penetrating injury. In rare cases with devastating biliary or vascular injury, or posttraumatic acute hepatic failure, liver transplantation may be warranted. Outcomes of liver transplant after traumatic hepatic injury in children are not known. We hypothesized that pediatric patients who underwent liver transplantation after traumatic liver injury would have a decreased graft survival and similar patient survival, compared with children who underwent liver transplantation for other nontrauma indications. METHODS We retrospectively reviewed all pediatric (age 0–18 years) liver transplants in the Scientific Registry of Transplant Recipients database. Children with a liver transplant after traumatic liver injury were compared with children requiring transplant for other, nontrauma, indications. Propensity score matching was performed in a 5:1 ratio (nontrauma to trauma groups), with sex, race, age at transplant, and cold ischemia time used for matching variables. Metrics of graft and long-term survival were evaluated between the matched groups. RESULTS In total, 18,296 records were analyzed, with 12 patients receiving a liver transplant after trauma. Trauma patients were older and more likely to require pretransplant life support, compared with nontrauma patients. There were no significant differences in graft or long-term survival between the trauma and nontrauma patients, in either the propensity matched or unmatched analyses. CONCLUSION Liver transplant may be deemed necessary in rare cases of devastating hepatic injury in children. These data show no association between patients' graft- or long-term survival, and indication for liver transplant, between children transplanted after trauma and those after other indications. These data support consideration of liver transplant in devastating pediatric liver injury. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III. Export

Background: Traumatic injury is associated with significant mental health morbidity. To evaluate the need for implementation of active-post injury mental health screening at a Level 1 Pediatric Trauma center, we aimed to characterize all new mental health diagnoses after injury and evaluated for patient or injury factors that may aid in targeting of future screening. Methods: A single-center retrospective analysis of trauma patients aged 6-18 years presenting in 2022 was performed. Our primary outcome was a new DSM-5 mental health diagnosis documented after traumatic injury. Patients with and without a new mental health diagnosis were compared by age, sex, race, ethnicity, injury type/mechanism, injury severity score (ISS), intensive care unit (ICU) admission, and length of stay (LOS). Results: 492 patients were included. Their median (IQR) age was 13.5 (10.4, 15.4) years. The median (IQR) follow-up interval was 157 (9, 429) days. There were 24 (4.9%) children with a new mental health diagnosis: 12 (50%) with trauma-related stress disorders, with the remaining having diagnoses such as depressive or anxiety disorders. Patients with a new mental health diagnosis had longer LOS (3.0 [1.8, 7.5] vs 2.0 [1.0, 3.3] days, P = 0.02) and were more likely to have sustained penetrating injury ( P = 0.01). There were no differences in demographics, rates of preexisting mental health diagnosis or area deprivation index ( P > 0.05). Discussion: There were fewer new mental health diagnoses in our cohort than expected, likely underestimating the acute need. Comprehensive post-injury screening is imperative to sufficiently identify and intervene upon mental health morbidity after pediatric trauma.