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O’Connell AE. Applying the bronchopulmonary dysplasia framework to necrotizing enterocolitis. Front Pediatr 2024; 12:1388392. [PMID: 38813544 PMCID: PMC11135171 DOI: 10.3389/fped.2024.1388392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/01/2024] [Indexed: 05/31/2024] Open
Abstract
Necrotizing enterocolitis (NEC) is a devastating disease of the neonatal intestine, causing widespread intestinal necrosis as well systemic illness that frequently results in death. Because the clinical onset of NEC is sudden and difficult to predict, NEC is considered an acute event. However, NEC does not occur in utero, meaning that postnatal exposures are required, and it does not typically occur right after birth, suggesting that longitudinal changes may be occurring before NEC can develop. In this perspective, the author considers whether NEC should be re-considered as a problem of disordered intestinal epithelial development, with required maladaptation over time prior to the onset of the necrotic event. This framework is similar to how bronchopulmonary dysplasia is currently conceptualized. They also advocate that NEC researchers incorporate this possibility into future studies on NEC susceptibility and pathogenesis.
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Affiliation(s)
- Amy E. O’Connell
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
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2
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Wolfschluckner V, Obermüller B, Horvath A, Rodriguez-Blanco G, Fuchs P, Miekisch W, Mittl B, Flucher C, Till H, Singer G. Metabolomic Alterations of Volatile Organic Compounds and Bile Acids as Biomarkers of Microbial Shifts in a Murine Model of Short Bowel Syndrome. Nutrients 2023; 15:4949. [PMID: 38068807 PMCID: PMC10708115 DOI: 10.3390/nu15234949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 11/24/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023] Open
Abstract
Pediatric short bowel syndrome (SBS) is a rare condition characterized by a massive loss of the small intestine, leading to the inability to meet nutritional requirements without the use of parenteral or enteral supplementation. SBS causes profound alterations in the intestinal microbiome and metabolome. The aim of this study was a detailed assessment of the intestinal microbiome and metabolome in a murine model of SBS. We performed a 60% proximal small bowel resection versus a sham operation in C57BL/6 mice. Four weeks postoperatively, the microbial communities of different intestinal segments (jejunum, ileum, colon) and stool were assessed by 16S rRNA gene sequencing. Bile acids in serum and stool and volatile organic compounds (VOCs) in the fecal headspace were assessed using LC-MS and GC-MS techniques. The α-diversity of the different intestinal segments did not significantly differ between the two groups. β-diversity significantly differed between sham and SBS mice. While in the jejunum, Faecalibaculum was significantly increased in SBS animals, a significant reduction in Lactobacillus and Sporosarcina was detected in the ileum of SBS mice. In the colon of SBS mice, a significant decrease in Ruminococcaceae and a significant increase in Proteobacteria such as Faecalibaculum and Escherichia-Shigella were found. Serum levels of deoxycholic, taurocholic and taurochenodeoxycholic acids were significantly higher in the SBS group. Of the 29 VOCs tested, hexane, isoflurane and pentane were significantly higher in the SBS group, and pyrrole was significantly lower. We were able to show that SBS causes shifts in the murine intestinal microbiome and metabolome including serum BAs and fecal VOCs.
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Affiliation(s)
- Vanessa Wolfschluckner
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, 8036 Graz, Austria; (V.W.); (B.M.); (C.F.); (H.T.); (G.S.)
| | - Beate Obermüller
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, 8036 Graz, Austria; (V.W.); (B.M.); (C.F.); (H.T.); (G.S.)
| | - Angela Horvath
- Division of Gastroenterology and Hepatology, Medical University of Graz, 8036 Graz, Austria;
| | - Giovanny Rodriguez-Blanco
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, 8036 Graz, Austria;
| | - Patricia Fuchs
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Rostock University Medical Center, 18057 Rostock, Germany; (P.F.); (W.M.)
| | - Wolfram Miekisch
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Rostock University Medical Center, 18057 Rostock, Germany; (P.F.); (W.M.)
| | - Barbara Mittl
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, 8036 Graz, Austria; (V.W.); (B.M.); (C.F.); (H.T.); (G.S.)
| | - Christina Flucher
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, 8036 Graz, Austria; (V.W.); (B.M.); (C.F.); (H.T.); (G.S.)
| | - Holger Till
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, 8036 Graz, Austria; (V.W.); (B.M.); (C.F.); (H.T.); (G.S.)
| | - Georg Singer
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, 8036 Graz, Austria; (V.W.); (B.M.); (C.F.); (H.T.); (G.S.)
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3
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Packer CH, Pilliod RA, Caughey AB, Sparks TN. Optimal timing of delivery for growth restricted fetuses with gastroschisis: A decision analysis. Prenat Diagn 2023; 43:1506-1513. [PMID: 37853803 DOI: 10.1002/pd.6452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/21/2023] [Accepted: 09/30/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVE Our objective was to determine the optimal timing of delivery of growth restricted fetuses with gastroschisis in the setting of normal umbilical artery (UA) Dopplers. METHODS We designed a decision analytic model using TreeAge software for a hypothetical cohort of 2000 fetuses with isolated gastroschisis, fetal growth restriction (FGR), and normal UA Dopplers across 34-39 weeks of gestation. This model accounted for costs and quality adjusted life years (QALYs) for the pregnant individual and the neonate. Model outcomes included stillbirth, respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), short gut syndrome (SGS), neonatal sepsis, neonatal death, and neurodevelopmental disability (NDD). RESULTS We found 38 weeks to be the optimal timing of delivery for minimizing overall perinatal mortality and leading to the highest total QALYs. Compared to 37 weeks, delivery at 38 weeks resulted in 367.98 more QALYs, 2.22 more cases of stillbirth, 2.41 fewer cases of RDS, 0.02 fewer cases of NEC, 1.65 fewer cases of IVH, 0.5 fewer cases of SGS, 2.04 fewer cases of sepsis, 11.8 fewer neonatal deaths and 3.37 fewer cases of NDD. However, 39 weeks were the most cost-effective strategy with a savings of $1,053,471 compared to 38 weeks. Monte Carlo analysis demonstrated that 38 weeks was the optimal gestational age for delivery 51.70% of the time, 39 weeks were optimal 47.40% of the time, and 37 weeks was optimal 0.90% of the time. CONCLUSION Taking into consideration a range of adverse perinatal outcomes and cost effectiveness, 38-39 weeks gestation is ideal for the delivery of fetuses with gastroschisis, FGR, and normal UA Dopplers. However, there are unique details to consider for each case, and the timing of delivery should be individualized using shared multidisciplinary decision making.
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Affiliation(s)
- Claire H Packer
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rachel A Pilliod
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
- Department of Maternal Fetal Medicine, Allina Health, Minneapolis, Minnesota, USA
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Teresa N Sparks
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
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Salimi-Jazi F, Thomas AL, Rafeeqi TA, Wood LSY, Portelli K, Dunn JCY. Stem cell activation during distraction enterogenesis in the murine colon. Pediatr Surg Int 2023; 39:172. [PMID: 37031428 DOI: 10.1007/s00383-023-05455-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 04/10/2023]
Abstract
PURPOSE Short bowel syndrome (SBS) is a devastating disease. We have proposed spring-mediated distraction enterogenesis for intestinal lengthening. Colonic lengthening is a potential treatment option for SBS to enhance fluid absorption capacity. We hypothesized that intraluminal spring-mediated colonic lengthening is associated with stem cell proliferation. METHODS C57BL/6 mice underwent placement of a gelatin-encapsulated compressed or uncompressed nitinol spring in a cecal segment. Animals were given clear liquid diet until postoperative day (POD) 7, followed by regular diet until POD 14. Cecal lengths were measured at euthanasia, and tissue was formalin fixed for histological processing. For Lgr5-GFP mice, immunohistochemistry against GFP was performed to localize Lgr5+ cells within crypts. RESULTS Significant cecal lengthening with compressed springs and shortening with uncompressed springs were observed on POD 7 and 14. Mucosa of the compressed spring group was significantly thicker on POD 14. The density of Lgr5+ cells within the crypts in the compressed spring groups was higher than that in the uncompressed spring groups on both POD 7 and 14. CONCLUSION Expandable springs can be used to lengthen the colon in the mouse model. Colonic lengthening was associated with gradual mucosal thickening and correlated with an increased density of stem cells within the crypts.
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Affiliation(s)
- Fereshteh Salimi-Jazi
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, 453 Quarry Road, MC 5733, Palo Alto, CA, 94304, USA
| | - Anne-Laure Thomas
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, 453 Quarry Road, MC 5733, Palo Alto, CA, 94304, USA
| | - Talha A Rafeeqi
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, 453 Quarry Road, MC 5733, Palo Alto, CA, 94304, USA
| | - Lauren S Y Wood
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, 453 Quarry Road, MC 5733, Palo Alto, CA, 94304, USA
| | - Katherine Portelli
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, 453 Quarry Road, MC 5733, Palo Alto, CA, 94304, USA
| | - James C Y Dunn
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, 453 Quarry Road, MC 5733, Palo Alto, CA, 94304, USA.
- Department of Bioengineering, Stanford University, Stanford, CA, USA.
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5
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Long-term safety of intraluminal spring-mediated bowel lengthening. J Pediatr Surg 2023; 58:89-93. [PMID: 36280466 DOI: 10.1016/j.jpedsurg.2022.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/16/2022] [Indexed: 01/12/2023]
Abstract
PURPOSE The purpose of the study is to examine the long-term safety of an endoluminal bowel lengthening device prior to its use in the first human trial. In addition, device performance and natural passage will be evaluated. METHODS Endoluminal lengthening springs were surgically placed into the jejunum of Yucatan minipigs using the Eclipse XL1 device. A matching internal control segment of jejunum was marked at the time of operation. Weekly weights and fluoroscopic studies were obtained to evaluate spring deployment and position until devices passed. Animals were euthanized at 28, 60, 90, and 180 days. At necropsy, length measurements were recorded, and histopathologic analysis was performed. RESULTS There were no bowel obstructions or overt perforations attributable to the device. All surviving animals gained weight and were clinically thriving. All devices passed out of the rectum by 180 days. Bowel lengthening was seen in all experimental segments, and minimal fibrosis was observed by 180 days. CONCLUSION Jejunal lengthening persisted after device had passed through the intestinal tract after 180 days. Early histopathologic changes of the jejunum during distraction enterogenesis normalized over time.
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6
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The effect of spring diameter on porcine ileal distraction enterogenesis. Pediatr Surg Int 2022; 39:19. [PMID: 36449179 DOI: 10.1007/s00383-022-05300-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE Spring-mediated distraction enterogenesis has proven to be successful for intestinal lengthening. We aimed to evaluate the effect of spring diameter mismatch on intestinal adaptation. METHODS Juvenile mini-Yucatan pigs underwent placement of compressed nitinol springs with diameter of 10, 11, or 12 mm into the ileal lumen. Pigs were euthanized on postoperative day 7. The lengths, histology, total area of blood vessels, and enteric ganglia were evaluated. RESULTS All spring groups exhibited significant ileal lengthening. Across the different diameters, spring-expanded segments were similar in terms of ileal lengthening, crypt height, muscular thickness, blood vessels, and enteric ganglia area. CONCLUSION Spring-mediated distraction enterogenesis is successful in the porcine ileum. A smaller diameter spring is as effective as a larger diameter spring in lengthening the ileum. Springs of varying diameters result in comparable structural changes in the ileum.
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7
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Treatment of Food Aversion and Eating Problems in Children with Short Bowel Syndrome: A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9101582. [PMID: 36291518 PMCID: PMC9600729 DOI: 10.3390/children9101582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/10/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
Food Aversion (FA) is a strong refusing behaviour to the oral assumption of food that can affect children with Short Bowel Syndrome (SBS). Management includes behavioural and Messy Play treatments, with few reports on systematic strategies to return the patient to enjoyable eating. We conducted a systematic review to better understand this complex and vital issue. (1) Materials and Methods: We investigated publications using MEDLINE, Embase, and the Web of Science to include articles published up to July 2022. The inclusion criteria were original articles including paediatric patients (aged < 18 years old) affected by SBS and Intestinal Failure (IF) who underwent treatment for FA. (2) Results: A total of 24 patients received treatment—15 (62.5%) patients were male and 9 (37.5%) were female. The age range was from 1 month to 16 years. Treatment of FA was carried out by behavioural therapy in 2 patients and Messy Play Therapy in 12 patients already surgically and pharmacologically managed for SBS. The treatment results showed complete weaning from Parenteral Nutrition in 9/14 cases (64%) using the behavioural treatment and 7/12 cases using Messy Play Therapy. (3) Conclusions: FA is a rare but disabling condition that often affects SBS patients, worsening their overall health and quality of life. This condition should be addressed in an Intestinal Rehabilitation Centre context. Our review sheds light on the literature gap regarding FA, and further studies are required to understand better which treatment options best suit SBS paediatric patients.
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8
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Saayman BD, Millar AJW, van Niekerk E. Nutritional interventions and outcomes of children with short bowel syndrome in a tertiary hospital setting in South Africa. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2022. [DOI: 10.1080/16070658.2022.2114404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- BD Saayman
- Department of Dietetics, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - AJW Millar
- Department of Pediatric Surgery, University of Cape Town and Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - E van Niekerk
- Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
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Portelli KI, Thomas AL, Wood LS, Diyaolu M, Taylor JS, Dunn JCY. Distraction enterogenesis in the murine colon. J Pediatr Surg 2022; 57:1377-1381. [PMID: 34740442 DOI: 10.1016/j.jpedsurg.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 09/26/2021] [Accepted: 10/01/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND/PURPOSE Distraction enterogenesis with intraluminal spring technology has been successfully used to lengthen segments of murine small intestine. We hypothesized that biocompatible springs could also be used to lengthen murine large intestine. METHODS Age and weight matched C57BL/6 mice underwent surgical insertion of nitinol spring-loaded capsules into the cecum. Segment lengths were measured at initial spring placement and at euthanasia after 7 and 14 days. Histologic adaptations were evaluated at scarification. RESULTS Cecal segments loaded with compressed springs lengthened an average of 150%, which was significantly longer than control segments loaded with either empty capsules or uncompressed springs. Muscularis layers tended to be thicker in the compressed spring groups compared to control groups. CONCLUSIONS Insertion of a compressed nitinol spring into the cecum results in significant colonic lengthening in a mouse model. The ability to increase cecum length serves as proof of concept that distraction enterogenesis technology may be feasibly applied to large intestinal models. The use of distraction enterogenesis technology shows promise for application to clinical models in the treatment of pediatric intestinal disease.
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Affiliation(s)
| | - Anne-Laure Thomas
- Department of Surgery, Stanford University, Stanford, CA, United States
| | - Lauren S Wood
- Department of Surgery, Stanford University, Stanford, CA, United States
| | - Modupeola Diyaolu
- Department of Surgery, Stanford University, Stanford, CA, United States
| | - Jordan S Taylor
- Department of Surgery, Stanford University, Stanford, CA, United States
| | - James C Y Dunn
- Department of Surgery, Stanford University, Stanford, CA, United States; Division of Bioengineering, Stanford University, Stanford, CA, United States.
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Gigola F, Cianci MC, Cirocchi R, Ranucci MC, Del Riccio M, Coletta R, Morabito A. Use of Teduglutide in Children With Intestinal Failure: A Systematic Review. Front Nutr 2022; 9:866518. [PMID: 35774551 PMCID: PMC9237607 DOI: 10.3389/fnut.2022.866518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/11/2022] [Indexed: 12/19/2022] Open
Abstract
Background and Objectives Short-bowel syndrome (SBS) results from the loss of a significant portion of the small intestine leading to a state of malabsorption. After an intestinal loss, there is a process of adaptation involving the Glucagon-Like Peptide-2 (GLP-2), an enteroendocrine peptide also involved in nutrient absorption. Teduglutide is a recombinant analog of GLP-2 approved in 2016 to treat selected SBS pediatric patients who are dependent on parenteral support. The present systematic review aims to evaluate the efficacy of Teduglutide in pediatric patients with SBS in reducing the need for parenteral nutrition (PN). Materials and Methods We performed a literature search on MEDLINE and Embase to include articles up to November 2021. We included articles that involved using Teduglutide in the SBS pediatric population to define its efficacy in reducing the need for PN. The key words used were GLP-2, teduglutide, child. Results Fourteen studies completely fulfilled the inclusion criteria. Two hundred 23 patients were treated with Teduglutide, and the median duration of treatment was 45 weeks (IQR: 36–52.5 weeks). One-hundred and fifty-two patients were treated with 0.05 mg/Kg/d of subcutaneous Teduglutide, 38 received 0.025 mg/Kg/d and 8 received either 0.125 mg/Kg/d or 0.20 mg/Kg/d. A total of 36 patients achieved enteral autonomy (EA) after a median of 24 weeks of treatment (IQR: 24–48 weeks) and 149 patients showed a reduction in PN needs in terms of volume, calories, or hours per day. Eleven studies reported complications: gastrointestinal were the most common, with 89 cases reported in treated patients and 11 in non-treated patients. Conclusion Teduglutide appears safe and effective in reducing PN requirements and improving EA in the pediatric population. However, more studies are needed to understand its efficacy in the long term and after discontinuation and possible complications. Systematic Review Registration [https://www.crd.york.ac.uk/prospero/], identifier [CRD42022301593].
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Affiliation(s)
- Francesca Gigola
- Department of Pediatric Surgery, Meyer Children’s Hospital Academic Centre, Florence, Italy
| | - Maria Chiara Cianci
- Department of Pediatric Surgery, Meyer Children’s Hospital Academic Centre, Florence, Italy
| | - Roberto Cirocchi
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Maria Chiara Ranucci
- Department of Digestive and Emergency Surgery, Santa Maria di Terni Hospital, University of Perugia, Perugia, Italy
| | - Marco Del Riccio
- Postgraduate School of Hygiene and Preventive Medicine, Florence, Italy
| | - Riccardo Coletta
- Department of Pediatric Surgery, Meyer Children’s Hospital Academic Centre, Florence, Italy
- School of Health and Society, University of Salford, Salford, United Kingdom
- *Correspondence: Riccardo Coletta,
| | - Antonino Morabito
- Department of Pediatric Surgery, Meyer Children’s Hospital Academic Centre, Florence, Italy
- Meyer Children’s Hospital, Department of Neurofarba, University of Florence, Florence, Italy
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Jones BC, O’Sullivan B, Amin SP, Hill S, Eaton S, De Coppi P. Patient-level costing analysis of paediatric short bowel syndrome care in a specialist tertiary centre. Pediatr Surg Int 2022; 38:533-539. [PMID: 35211770 PMCID: PMC8913464 DOI: 10.1007/s00383-022-05074-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/24/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To undertake a pilot study estimating patient-level costs of care for paediatric short bowel syndrome (SBS) from the healthcare provider perspective. METHODS A pilot group of patients with anatomical SBS was selected at a single specialist tertiary centre in the United Kingdom. The Patient Level Information and Costing System (PLICS) was used to extract costing data for all hospital-based activities related to SBS, from the implementation of PLICS in 2016 to April 2021. Patient-specific and pooled data were reported descriptively in per patient-year terms. RESULTS Five patients had full PLICS data available for the 5-year study period and 2 patients had 4 years of data. The median cost for hospital care of SBS was £52,834 per patient-year (range £1804-£331,489). The key cost drivers were inpatient beds, pharmacy, and staffing costs, which made up > 60% of annual costs. In the first 3 years following index admission (n = 2), there was a steady decline in the annual cost of care to a level comparable with patients with established SBS. CONCLUSION Patient-level cost of care analysis for SBS is feasible using PLICS. Hospital-related costs vary widely between and within individual patients over time. Key drivers of cost are related to complications of SBS.
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Affiliation(s)
- Brendan C. Jones
- Developmental Biology and Cancer Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK ,Specialist Neonatal and Paediatric Surgery Unit, Great Ormond Street Hospital, London, UK
| | - Benjamin O’Sullivan
- Department of Paediatric Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | | | - Susan Hill
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Simon Eaton
- Developmental Biology and Cancer Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Paolo De Coppi
- Developmental Biology and Cancer Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK ,Specialist Neonatal and Paediatric Surgery Unit, Great Ormond Street Hospital, London, UK
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12
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Perez-Guagnelli E, Jones J, D. Damian D. Hyperelastic Membrane Actuators: Analysis of Toroidal and Helical Multifunctional Configurations. CYBORG AND BIONIC SYSTEMS 2022; 2022:9786864. [PMID: 36285311 PMCID: PMC9494722 DOI: 10.34133/2022/9786864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 12/08/2021] [Indexed: 12/15/2022] Open
Abstract
Technologies that provide mechanical assistance are required in the medical field, such as implants that regenerate tissue through elongation and stimulation. One of the challenges is to develop actuators that combine the benefits of high axial extension at low pressures, modularity, multifunction, and load-bearing capabilities into one design while maintaining their shape and softness. Overcoming such a challenge will provide implants with enhanced capacity for mechanical assistance to induce tissue regeneration. We introduce two novel actuators (M2H) built of stacked Hyperelastic Ballooning Membrane Actuators (HBMAs) that can be realized using helical and toroidal configurations. By restraining the HBMA expansion deterministically using a semisoft exoskeleton, the actuators are endowed with axial extension and radial expansion capabilities. These actuators are thus built of modules that can be configured to different therapeutical needs and multifunctionality, to provide anatomically congruent stimulation. We present the design, fabrication, testing, and numerical and experimental validation of the M2H-HBMAs. They can axially extend up to 41% and 32% in their helical and toroidal configurations at input pressures as low as 26 and 24 kPa, respectively. If the axial extension module is used separately, its extension capacity reaches >170%. The M2H-HBMAs can perform independent and simultaneous expansion and extension motions with negligible intraluminal deformation as well as stand at least 1 kg of axial force without collapsing. The M2H-HBMAs overcome the limitations of hyperexpanding machines that show low resistance to load. We envisage M2H-HBMAs as promising tools to perform tissue regeneration procedures.
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Affiliation(s)
| | - Joanna Jones
- Department of Automatic Control and Systems Engineering, University of Sheffield, UK
| | - Dana D. Damian
- Department of Automatic Control and Systems Engineering, University of Sheffield, UK
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13
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Wu H, Guo K, Zhuo Z, Zeng R, Luo Y, Yang Q, Li J, Jiang R, Huang Z, Sha W, Chen H. Current therapy option for necrotizing enterocolitis: Practicalities and challenge. Front Pediatr 2022; 10:954735. [PMID: 35967586 PMCID: PMC9366471 DOI: 10.3389/fped.2022.954735] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 07/07/2022] [Indexed: 02/05/2023] Open
Abstract
Necrotizing enterocolitis (NEC) is one of the most prevalent neonatal gastrointestinal disorders. Despite ongoing breakthroughs in its treatment and prevention, the incidence and mortality associated with NEC remain high. New therapeutic approaches, such as breast milk composition administration, stem cell therapy, immunotherapy, and fecal microbiota transplantation (FMT) have recently evolved the prevention and the treatment of NEC. This study investigated the most recent advances in NEC therapeutic approaches and discussed their applicability to bring new insight to NEC treatment.
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Affiliation(s)
- Huihuan Wu
- Department of Gastroenterology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- School of Medicine, South China University of Technology, Guangzhou, China
| | - Kehang Guo
- Department of Gastroenterology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- School of Medicine, South China University of Technology, Guangzhou, China
| | - Zewei Zhuo
- Department of Gastroenterology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou, China
| | - Ruijie Zeng
- Department of Gastroenterology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Yujun Luo
- Department of Gastroenterology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Qi Yang
- Department of Gastroenterology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jingwei Li
- Department of Gastroenterology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Rui Jiang
- Department of Gastroenterology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- School of Medicine, South China University of Technology, Guangzhou, China
| | - Zena Huang
- Department of General Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Weihong Sha
- Department of Gastroenterology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- School of Medicine, South China University of Technology, Guangzhou, China
- *Correspondence: Weihong Sha,
| | - Hao Chen
- Department of Gastroenterology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- School of Medicine, South China University of Technology, Guangzhou, China
- Hao Chen,
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14
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Generic and Disease-specific Health-related Quality of Life in Pediatric Intestinal Failure. J Pediatr Gastroenterol Nutr 2021; 73:338-344. [PMID: 33633085 DOI: 10.1097/mpg.0000000000003102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The aim of the study was to assess overall and disease-specific health-related quality of life (hrQOL) in patients with pediatric intestinal failure (PIF) and caregivers and elucidate differences from healthy and chronic gastrointestinal (GI) illness cohorts. METHODS Cross-sectional study of patients with PIF and their caregivers managed at a multidisciplinary intestinal rehabilitation program using the PedsQL Generic Core and the Gastrointestinal Symptoms Module to assess generic and disease-specific hrQOL, respectively. These data were compared to established healthy and chronic GI disease controls. RESULTS A total of 53 patients (mean age 6.2 ± 3.9 years) and their caregivers were studied. Patients reported lower generic hrQOL than healthy children (73.0 vs 83.84, P < 0.001), but no difference from patients with chronic GI disease (73.0 vs 77.79). In contrast, PIF caregivers perceived similar generic hrQOL compared to a healthy cohort (78.9 vs 82.70), but higher when compared to the GI disease cohort (78.9 vs 72.74, P < 0.01). Patients with PIF and caregivers reported lower psychosocial health scores than healthy controls. Patients and caregivers reported similar disease-specific hrQOL to a cohort with chronic GI disease but significantly lower disease-specific hrQOL than a healthy cohort (P < 0.001 both groups). CONCLUSIONS Patients with PIF and their caregivers have disparate perceptions of generic hrQOL when compared to healthy and chronic GI disease controls. Both patients and caregivers, however, had significantly lower scores in psychosocial health than healthy controls. In addition, disease-specific hrQOL was substantially lower than healthy controls for PIF patients and caregivers. Further investigation to expand on these findings and identify modifiable variables to improve the psychosocial health score and disease-specific factors would be of high value.
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Siu AHY, Carey S, Jones L, Morton RL, Koh CE. Detailed analysis of in-hospital costs for adult patients with type III intestinal failure: A single-center study with global implications. JPEN J Parenter Enteral Nutr 2021; 46:685-692. [PMID: 33929048 DOI: 10.1002/jpen.2136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Home parenteral nutrition (HPN) is the recommended treatment for patients with type III intestinal failure (IF). However, owing to IF's rarity, the economic cost of managing these patients is not well understood. These patients often develop complications resulting in readmissions, which in turn contribute to ongoing costs. This study aims to document the costs of type III IF within the hospital, from initial admission, including readmissions, and to compare incurred costs with current government reimbursement. METHODS A retrospective study design reviewed costs and reimbursement for 25 consecutive patients commencing HPN at a quaternary hospital (October 2011 to September 2017). Hospital admissions were separated into the initial admission and readmission(s) period. Healthcare use and cost data were collected using electronic medical records. Hospital reimbursement costs were retrieved from Sydney Local Health District's Targeted Activity and Reporting Systems. Patient demographics were tabulated, and healthcare use and cost data were compared using Wilcoxon signed rank tests. RESULTS The median cost of the initial hospital admission was substantially higher than the median reimbursement ($36,675; interquartile range [IQR], $23,196-$67,439 vs $19,247; IQR, $7485-$41,090; P < .001). Similar results were observed in the readmissions period, with median incurred costs of $13,898; (IQR, $11,151-$32,130) vs reimbursement of $8469 (IQR, $5625-$13,078) (P = .001). CONCLUSION Results indicate that type III IF patients have high inpatient costs, which substantially outweigh current reimbursement. Improved funding models are needed to ensure hospitals that accept the management challenge of type III IF patients are not unduly penalized.
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Affiliation(s)
- Adrian H Y Siu
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia.,Graduate School of Medicine, University of Wollongong, NSW, Australia
| | - Sharon Carey
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia.,Department of Dietetics and Nutrition, Royal Prince Alfred Hospital, Sydney, Australia.,School of Life and Environmental Sciences, University of Sydney, Sydney, Australia.,Intestinal Failure and Home Parenteral Nutrition Service, Royal Prince Alfred Hospital, Sydney, Australia
| | - Lynn Jones
- Intestinal Failure and Home Parenteral Nutrition Service, Royal Prince Alfred Hospital, Sydney, Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Cherry E Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia.,Intestinal Failure and Home Parenteral Nutrition Service, Royal Prince Alfred Hospital, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Discipline of Surgery, Central Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
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16
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Portelli KI, Park JB, Taylor JS, Thomas AL, Stelzner M, Martin MG, Dunn JC. Intestinal adaptation following spring insertion into a roux limb in mice. J Pediatr Surg 2021; 56:346-351. [PMID: 32709529 PMCID: PMC7772252 DOI: 10.1016/j.jpedsurg.2020.06.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/03/2020] [Accepted: 06/23/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND/PURPOSE Intraluminal springs have recently been shown to lengthen segments of intestine in a process known as distraction enterogenesis. We hypothesized that biocompatible springs could be used to lengthen defunctionalized murine small intestine and would lead to identifiable intestinal adaptations at the molecular level. METHODS Age and weight matched C57BL/6 mice underwent surgical insertion of nitinol spring-loaded capsules into a Roux limb of jejunum. Segment lengths were measured at initial spring placement and at euthanasia after 14 and 21 days. Histology and gene expression of the Roux limb were evaluated at scarification and compared to untreated control segments. RESULTS Intestinal segments loaded with compressed springs lengthened an average of 240%, which was significantly longer than control segments loaded with either empty capsules or uncompressed springs. Muscularis thickening was greater in spring-treated mice compared to controls without springs. Crypt depth and Lgr5+ expression was greater in mice that received compressed spring treatments when compared to control groups. CONCLUSIONS Insertion of a compressed nitinol spring into a Roux limb results in significant intestinal lengthening, smooth muscle thickening, and Lgr5+ expression in a mouse model. The ability to increase small bowel length in a defunctionalized murine model may be used to understand the mechanism of distraction enterogenesis.
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Affiliation(s)
| | - Jun-Beom Park
- Department of Surgery, Stanford University, Stanford, CA
| | | | | | | | - Martin G. Martin
- Department of Pediatrics, University of California, Los Angeles, CA
| | - James C.Y. Dunn
- Department of Surgery, Stanford University, Stanford, CA,Division of Bioengineering, Stanford University, Stanford, CA,Correspondence to: James Dunn, Division of Pediatric Surgery, Stanford University, 300 Pasteur Drive, Alway Building M116, Stanford, CA 94305; Telephone: (650) 723-6439; Fax (650) 725-5577;
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17
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The economic costs of home parenteral nutrition: Systematic review of partial and full economic evaluations. Clin Nutr 2021; 40:339-349. [DOI: 10.1016/j.clnu.2020.06.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/07/2020] [Accepted: 06/09/2020] [Indexed: 02/08/2023]
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18
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Coletta R, Mussi E, Uccheddu F, Volpe Y, Morabito A. Preoperative Planning of Spiral Intestinal Lengthening and Tailoring: A Geometrical Approach. Bioengineering (Basel) 2021; 8:bioengineering8020020. [PMID: 33572644 PMCID: PMC7911342 DOI: 10.3390/bioengineering8020020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 12/03/2022] Open
Abstract
Short bowel syndrome is a pathological condition resulting from extensive resection of the intestine, generally performed due to congenital abnormalities, Crohn’s disease, mesenteric ischemia, or neoplasms. The main consequence of this syndrome is a reduction of intestinal absorption, which causes malnutrition and dehydration. In the most severe cases, specific and complex surgical procedures are requested to manage the syndrome. Such procedures consist of the intestinal lengthening, with lead to an increase of absorptive mucosal surface and intestinal transit time and an overall enhancement of intestinal absorption. One of the most promising surgical procedures is spiral intestinal lengthening and tailoring, which consists of a spiral incision of the intestinal wall and in the elongation longitudinally of the intestine by sliding one flap over the other. The final intestinal lengthening is strictly dependent on a series of parameters, some of which are defined by the surgeon. The present paper proposes a mathematical model, based on patient specific anatomical data, which aims to help the surgeon in defining the optimal parameters for the intervention and in foreseeing its outcomes from the preoperative planning phase. Such a tool can assist the physician in the surgery room by improving the procedure and reducing surgical times.
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Affiliation(s)
- Riccardo Coletta
- Department of Pediatric Surgery, Meyer Children’s Hospital, Viale Pieraccini 24, 50141 Florence, Italy; (R.C.); (A.M.)
| | - Elisa Mussi
- Department of Industrial Engineering, University of Florence, Via Santa Marta 3, 50139 Florence, Italy; (F.U.); (Y.V.)
- Correspondence: ; Tel.: +39-055-0552758741
| | - Francesca Uccheddu
- Department of Industrial Engineering, University of Florence, Via Santa Marta 3, 50139 Florence, Italy; (F.U.); (Y.V.)
| | - Yary Volpe
- Department of Industrial Engineering, University of Florence, Via Santa Marta 3, 50139 Florence, Italy; (F.U.); (Y.V.)
| | - Antonino Morabito
- Department of Pediatric Surgery, Meyer Children’s Hospital, Viale Pieraccini 24, 50141 Florence, Italy; (R.C.); (A.M.)
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19
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Diyaolu M, Thomas AL, Wood LS, Taylor J, Dunn JC. Mesenteric neovascularization during spring-mediated intestinal lengthening. J Pediatr Surg 2021; 56:5-10. [PMID: 33143878 DOI: 10.1016/j.jpedsurg.2020.09.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/22/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Short gut syndrome, a condition characterized by inadequate absorption of nutrients owing to decreased bowel length, has minimal avenues for treatment. We have proposed spring-mediated distraction enterogenesis to lengthen bowel in porcine jejunum as a treatment for short gut. We aim to evaluate the extent of mesenteric neovascularization in segments of lengthened bowel via spring-mediated enterogenesis. METHODS Female juvenile Yucatan pigs underwent laparotomy and insertion of gelatin-encapsulated compressed nitinol springs, held in place with plication sutures, into the jejunum. At surgery and sacrifice, macroscopic mesenteric blood vessels were counted between the plication sites. Histologic samples of the mesentery were obtained to evaluate microscopic vasculature. RESULTS A statistically significant increase in macroscopic mesenteric blood vessels was seen after intestinal lengthening (before: 1.9 ± 0.7 vessels, after: 4.7 ± 1.2 vessels, p = 0.001). A statistical significance is also seen in the density of arterioles (control: 3.0 ± 3.0 vessels/mm, spring: 7.0 ± 9.0 vessels/mm, p = 0.01) and venules (control: 4.0 ± 3.0 vessels/mm, spring: 8.0 ± 8.0 vessels/mm, p = 0.003). CONCLUSION Intestinal segments lengthened by intraluminal springs demonstrated total greater number of macroscopic vessels and microscopic blood vessels per length of mesentery as compared to control. This suggests local changes within the mesentery to recruit blood supply to growing intestine. LEVEL OF EVIDENCE N/A TYPE OF STUDY: Treatment study.
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Affiliation(s)
- Modupeola Diyaolu
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Anne-Laure Thomas
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Lauren Sy Wood
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Jordan Taylor
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - James Cy Dunn
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA, USA.
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20
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Hinchliffe T, Pauline ML, Wizzard PR, Nation PN, Brubaker P, Campbell JR, Kim Y, Dimitriadou V, Wales PW, Turner JM. Durability of Linear Small-Intestinal Growth Following Treatment Discontinuation of Long-Acting Glucagon-Like Peptide 2 (GLP-2) Analogues. JPEN J Parenter Enteral Nutr 2020; 45:1466-1474. [PMID: 33241564 DOI: 10.1002/jpen.2053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 10/23/2020] [Accepted: 11/17/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Short-bowel syndrome is the leading cause of pediatric intestinal failure, resulting in dependency on long-term parenteral nutrition (PN). To promote enteral autonomy in neonates, a key outcome may be intestinal growth in length. The purpose of this study was to determine if intestinal lengthening persists following discontinuation of treatment with 1 of 2 GLP-2 analogues with different pharmacokinetic profiles. METHODS Neonatal short-bowel piglets were assigned to saline control (S), 7-day treatment with teduglutide (T) (0.05 mg/kg twice daily), or 7-day treatment with apraglutide (A) (5 mg/kg twice weekly). Comparisons were made between day 7 and day 14 endpoints using analysis of variance. Data included small-intestine length, weight, histology, and quantitative polymerase chain reaction analysis of mucosal transcripts for peptide growth factors and their receptors, nutrient transporters, and tight-junction proteins. RESULTS Compared with control, 7 days of GLP-2 analogue treatment induced mucosal adaptation based on villus hyperplasia (P = .003), which was not durable 7 days after treatment cessation (day 14; P = .081). Treatment increased intestinal growth in length by day 7 (P = .005), which was maintained (by T) or further increased (by A) at day 14 (P < .001). No significant differences in mucosal transcripts were detected. CONCLUSION Unlike mucosal adaptation, intestinal growth appears to be a lasting outcome of treatment with long-acting GLP-2 analogues in a neonatal piglet short-bowel model. This has significant clinical implications for neonates, given their potential for intestinal growth. Intestinal lengthening varies between analogues with different half-lives; however, molecular mechanisms require further elucidation.
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Affiliation(s)
- Tierah Hinchliffe
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Mirielle L Pauline
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela R Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Patrick N Nation
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Patricia Brubaker
- Departments of Physiology and Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jhenielle R Campbell
- Departments of Physiology and Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yunji Kim
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Paul W Wales
- Department of Surgery, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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21
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Boyle MA, Sequeira DJ, McNeill EP, Criss ZK, Shroyer NF, Speer AL. In Vivo Transplantation of Human Intestinal Organoids Enhances Select Tight Junction Gene Expression. J Surg Res 2020; 259:500-508. [PMID: 33168233 DOI: 10.1016/j.jss.2020.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 09/23/2020] [Accepted: 10/02/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Short bowel syndrome is a potentially fatal condition with inadequate management options. Tissue-engineered small intestine (TESI) is a promising solution, but confirmation of TESI function will be crucial before human application. We sought to define intestinal epithelial barrier function in human intestinal organoid (HIO)-derived TESI. MATERIALS AND METHODS HIOs were generated in vitro from human embryonic stem cells. After 1 mo, HIOs were collected for analysis or transplanted into the kidney capsule of immunocompromised mice. Transplanted HIOs (tHIOs) were harvested for analysis at 4 or 8 wk. Reverse transcription quantitative polymerase chain reaction and immunofluorescent staining were performed for tight junction components: claudin 3 (CLDN3), claudin 15 (CLDN15), occludin (OCLN), and zonula occludens-1, or tight junction protein-1 (TJP1/ZO-1). RESULTS Four-week-old tHIOs demonstrated significantly (P < 0.05) higher levels of CLDN15 (6x), OCLN (4x), and TJP1/ZO-1 (3x) normalized to GAPDH than in vitro HIOs. Eight-week-old tHIOs demonstrated significantly (P < 0.05) higher expression levels of CLDN3 (26x), CLDN15 (29x), OCLN (4x), and TJP1/ZO-1 (5x) than in vitro HIOs. There was no significant difference in expression of these tight junction components between 4- and 8-week-old tHIOs. Immunofluorescent staining revealed the presence of claudin 3, claudin 15, occludin, and zonula occludens-1 in both in vitro HIOs and tHIOs; however, the morphology appeared more mature in tHIOs. CONCLUSIONS In vitro HIOs have lower levels of tight junction mRNA, and tight junction proteins appear morphologically immature. Transplantation facilitates maturation of the HIOs and enhances select tight junction gene expression.
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Affiliation(s)
- Mariaelena A Boyle
- Department of Pediatric Surgery, McGovern Medical School at UTHealth, Houston, Texas
| | - David J Sequeira
- Department of Pediatric Surgery, McGovern Medical School at UTHealth, Houston, Texas
| | - Eoin P McNeill
- Department of Pediatric Surgery, McGovern Medical School at UTHealth, Houston, Texas
| | - Zachary K Criss
- Department of Medicine Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
| | - Noah F Shroyer
- Department of Medicine Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
| | - Allison L Speer
- Department of Pediatric Surgery, McGovern Medical School at UTHealth, Houston, Texas.
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22
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Seliga-Siwecka J, Rutkowski J, Margas W, Puskarz-Gąsowska J, Bokiniec R. Sensitivity and specificity of different imaging modalities in diagnosing necrotising enterocolitis in a Polish population of preterm infants: a diagnostic test accuracy study protocol. BMJ Open 2020; 10:e033519. [PMID: 32690727 PMCID: PMC7375631 DOI: 10.1136/bmjopen-2019-033519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 03/09/2020] [Accepted: 05/12/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Necrotising enterocolitis (NEC) is one of the most serious conditions in newborn infants, affecting up to 10% of very low birth weight (VLBW) infants. Mortality rates can rise as high as 60%.The suspected diagnosis is confirmed with typical findings on abdominal radiography (AR) such as pneumatosis intestinalis (PI), portal vein gas (PVG) and in extreme cases pneumoperitoneum. Abdominal ultrasound (AUS) can depict PI, PVG and pnuemoperitoneum (in some cases ahead of AR), but it also provides other crucial information such as bowel wall viability (thickness or thinning) and free abdominal fluid. These additional findings are helpful in diagnosing and managing NEC. METHODS AND ANALYSIS The hypothesis being tested is that preforming an AR in patients with clinical symptoms of NEC, but inconclusive/normal AR will enhance detection rates, and expedite treatment in infants born at <32 weeks. Additionally, the time needed to initiate treatment, according to decision made based on AR or AR and AUS will also be compared. The use of AUS together with AR as an add-on test may increase the accuracy of diagnosing NEC and expedite life-saving treatment. We plan to recruit 200 VLBW infants, who are most prone to NEC. It will also be the first multicentre study evaluating the use of AUS as an add-on test, enabling us to recruit a significantly higher number of patients compared with published studies. ETHICS AND DISSEMINATION The Bioethical Committee of the Medical University of Warsaw has approved the study (KB 130/2017). We plan to submit our findings to international peer-reviewed journals. Abstract will be submitted to local and international conferences. TRIAL REGISTRATION NUMBER NCT03188380; Protocol version: V.2.08.2019; Pre-results.
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Affiliation(s)
- Joanna Seliga-Siwecka
- Neonatal and Intensive Care Department, Medical University of Warsaw, Warsaw, Poland
| | | | | | | | - Renata Bokiniec
- Neonatal and Intensive Care Department, Medical University of Warsaw, Warsaw, Poland
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Capriati T, Mosca A, Alterio T, Spagnuolo MI, Gandullia P, Lezo A, Lionetti P, D’Antiga L, Fusaro F, Diamanti A. To Wean or Not to Wean: The Role of Autologous Reconstructive Surgery in the Natural History of Pediatric Short Bowel Syndrome on Behalf of Italian Society for Gastroenterology, Hepatology and Nutrition (SIGENP). Nutrients 2020; 12:E2136. [PMID: 32708377 PMCID: PMC7400841 DOI: 10.3390/nu12072136] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/13/2020] [Indexed: 12/15/2022] Open
Abstract
Pediatric Short Bowel Syndrome (SBS) can require prolonged parenteral nutrition (PN). Over the years, SBS management has been implemented by autologous gastrointestinal reconstructive surgery (AGIR). The primary objective of the present review was to assess the effect of AGIR on weaning off PN. We also evaluated how AGIR impacts survival, the need for transplantation (Tx) and the development of liver disease (LD). We conducted a systematic literature search to identify studies published from January 1999 to the present and 947 patients were identified. PN alone was weakly associated with higher probability of weaning from PN (OR = 1.1, p = 0.03) and of surviving (OR = 1.05, p = 0.01). Adjusting for age, the probability of weaning off PN but of not surviving remained significantly associated with PN alone (OR = 1.08, p = 0.03). Finally, adjusting for age and primary diagnosis (gastroschisis), any association was lost. The prevalence of TX and LD did not differ by groups. In conclusion, in view of the low benefit in terms of intestinal adaptation and of the not negligible rate of complications (20%), a careful selection of candidates for AGIR should be required. Bowel dilation associated with failure of advancing EN and poor growth, should be criteria to refer for AGIR.
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Affiliation(s)
- Teresa Capriati
- Artificial Nutrition Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy;
| | - Antonella Mosca
- Hepatology Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Tommaso Alterio
- Hepatology Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Maria Immacolata Spagnuolo
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, 80138 Naples, Italy;
| | - Paolo Gandullia
- Gastroenterology Unit, G.Gaslini Institute for Maternal and Child Health, IRCCS, 16145 Genova, Italy;
| | - Antonella Lezo
- Division of Nutrition, Regina Margherita Children’s Hospital, 10126 Turin, Italy;
| | - Paolo Lionetti
- Department of Neuroscience, Psychology, Pharmacology and Child’s Health, University of Florence, Meyer Hospital, 50139 Florence, Italy;
| | - Lorenzo D’Antiga
- Paediatric, Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Fabio Fusaro
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, 00165 Rome, Italy;
| | - Antonella Diamanti
- Artificial Nutrition Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy;
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Onufer EJ, Han YH, Czepielewski RS, Courtney CM, Sutton S, Randolph GJ, Warner BW. Effects of high-fat diet on liver injury after small bowel resection. J Pediatr Surg 2020; 55:1099-1106. [PMID: 32164985 PMCID: PMC7299751 DOI: 10.1016/j.jpedsurg.2020.02.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal regimen for enteral nutritional support in the management of children with short bowel syndrome (SBS) is not well characterized. A high fat, enteral diet is theoretically beneficial due to increased caloric density and enhanced structural adaptation. We therefore sought to determine the long-term effects of a high fat diet (HFD) on liver injury, a common complication of SBS, compared to a standard chow (SC) diet. METHODS Using a parenteral nutrition-independent model of resection-associated liver injury, C57BL/6 mice underwent a sham operation or a 50% or 75% proximal small bowel resection (SBR). Mice in each group were then fed either a HFD (35% kcal fat) or SC (13% kcal fat). At post-operative week 15, markers of liver injury were quantified. RESULTS Liver triglyceride levels were increased from 7- to 19-fold in mice on the HFD compared to mice fed SC in the sham, 50%, and 75% resection groups. Serum ALT (2.2-fold increase in 75% resected mice compared to sham controls) and AST (2.0- and 2.7-fold increases in 50% and 75% resected mice, respectively) levels as well as fibrotic liver staining were elevated only in resected mice fed a HFD. CONCLUSION Long-term enteral feeding of HFD in our murine SBS model is associated with hepatic steatosis and liver injury. Our observation that liver steatosis and injury occur independent of parenteral nutrition suggests that enteral feeding composition and magnitude of intestinal loss may make a significant contribution to intestinal failure-associated liver disease.
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Affiliation(s)
- Emily J. Onufer
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Yong-Hyun Han
- Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, MO
| | - Rafael S. Czepielewski
- Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, MO
| | - Cathleen M. Courtney
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Stephanie Sutton
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Gwendalyn J. Randolph
- Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, MO
| | - Brad W. Warner
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO
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Samuelsson M, Wennick A. An Exploratory Study of the Everyday Life of Swedish Children on Home Parenteral Nutrition and Their Families. J Pediatr Nurs 2020; 52:e84-e89. [PMID: 32044196 DOI: 10.1016/j.pedn.2020.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/24/2020] [Accepted: 01/25/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Improved survival rates of preterm infants and critically ill children has resulted in an increasing number of children growing up on HPN. However, how the child and the child's family experience HPN is sparsely studied. PURPOSE Thus, this study aims to elucidate the everyday life experiences of children with intestinal failure on HPN from the perspective of the child and the child's family. DESIGN AND METHODS We used a qualitative inductive study that included semi-structured interviews from 13 family members in six families, and we analyzed them using content analysis. RESULTS The family members' experiences had an overall theme, having to take on a full-time (nursing) responsibility, and fell into three categories: family restrictions, family adjustments, and family uncertainty. CONCLUSION Families on HPN had to shoulder an in-home round-the-clock (nursing) responsibility that came with a daily logistical challenge. The complexity of HPN complicates the possibility of external support, so the families choose to keep the burden within the family; consequently single-parent households have limited possibilities for relief and recovery. PRACTICE IMPLICATIONS To minimize the intrusion of the treatment in family's everyday life and, thereby, support the families, health care professionals might find it beneficial to obtain an inventory of the everyday life needs of each specific family when first introducing HPN. Further, by encouraging close kin to participate in the HPN education these families may be unburdened some more. In addition, it is essential that professionals follow the families protocol for management and not the other way around.
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Affiliation(s)
- Maria Samuelsson
- Skåne University Hospital, Malmö, Sweden; Department of Pediatrics, Malmö, Sweden; Malmö University, Faculty of Health and Society, Department of Care Science, Malmö, Sweden.
| | - Anne Wennick
- Malmö University, Faculty of Health and Society, Department of Care Science, Malmö, Sweden
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Lock JY, Carlson TL, Yu Y, Lu J, Claud EC, Carrier RL. Impact of Developmental Age, Necrotizing Enterocolitis Associated Stress, and Oral Therapeutic Intervention on Mucus Barrier Properties. Sci Rep 2020; 10:6692. [PMID: 32317678 PMCID: PMC7174379 DOI: 10.1038/s41598-020-63593-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 02/24/2020] [Indexed: 12/12/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease of incompletely understood pathophysiology predominantly affecting premature infants. While NEC is associated with microbial invasion of intestinal tissues, and mucus modulates interactions between microbes and underlying tissues, variations in mucus barrier properties with NEC-associated risk factors have not been investigated. This study explored differences in mucus composition (total protein, DNA, mucin content, sialic acid, and immunoregulatory proteins), as well as structural and transport properties, assessed by tracking of particles and bacteria (E. coli and E. cloacae) with developmental age and exposure to NEC stressors in Sprague Dawley rats. Early developmental age (5 day old) was characterized by a more permeable mucus layer relative to 21 day old pups, suggesting immaturity may contribute to exposure of the epithelium to microbes. Exposure to NEC stressors was associated with reduced mucus permeability, which may aid in survival. Feeding with breastmilk as opposed to formula reduces incidence of NEC. Thus, NEC-stressed (N-S) rat pups were orally dosed with breastmilk components lysozyme (N-S-LYS) or docosahexaenoic acid (N-S-DHA). N-S-LYS and N-S-DHA pups had a less permeable mucus barrier relative to N-S pups, which suggests the potential of these factors to strengthen the mucus barrier and thus protect against disease.
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Affiliation(s)
- Jaclyn Y Lock
- Department of Bioengineering, Northeastern University, Boston, Massachusetts, USA
| | - Taylor L Carlson
- Department of Chemical Engineering, Northeastern University, Boston, Massachusetts, USA
| | - Yueyue Yu
- Department of Pediatrics, Section of Neonatology, University of Chicago, Chicago, Illinois, USA
| | - Jing Lu
- Department of Pediatrics, Section of Neonatology, University of Chicago, Chicago, Illinois, USA
| | - Erika C Claud
- Department of Pediatrics, Section of Neonatology, University of Chicago, Chicago, Illinois, USA
- Department of Medicine, Section of Gastroenterology, University of Chicago, Chicago, Illinois, USA
| | - Rebecca L Carrier
- Department of Chemical Engineering, Northeastern University, Boston, Massachusetts, USA.
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Abstract
Congenital diseases requiring reconstruction of parts of the gastrointestinal tract, skin, or bone are a challenge to alleviate especially in rapidly growing children. Novel technologies may be the answer. This article presents the state-of-art in regenerative robotic technologies, which are technologies that assist tissues and organs to regenerate using sensing and mechanotherapeutical capabilities. It addresses the challenges in the development of such technologies, among which are autonomy and fault-tolerance for long-term therapy as well as morphological conformations and compliance of such devices to adapt to gradual changes of the tissues in vivo. The potential as medical devices for delivering therapies for tissue growth and as tools for scientific exploration of regenerative mechanisms is also discussed.
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Affiliation(s)
- Dana D. Damian
- Department of Automatic Control and Systems EngineeringUniversity of SheffieldSheffieldUnited Kingdom
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Antibiotic Susceptibility and Therapy in Central Line Infections in Pediatric Home Parenteral Nutrition Patients. J Pediatr Gastroenterol Nutr 2020; 70:59-63. [PMID: 31567890 DOI: 10.1097/mpg.0000000000002506] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients receiving home parenteral nutrition (HPN) are at high-risk for central line-associated bloodstream infections (CLABSI). There are no published management guidelines, however, for the antibiotic treatment of suspected CLABSI in this population. Historical microbiology data may help inform empiric antimicrobial regimens in this population. OBJECTIVE The aim of the study was to describe antimicrobial resistance patterns and determine the most appropriate empiric antibiotic therapy in HPN-dependent children experiencing a community-acquired CLABSI. METHODS Single-center retrospective cohort study evaluating potential coverage of empiric antibiotic regimens in children on HPN who developed a community-acquired CLABSI. RESULTS From October 1, 2011 to September 30, 2017, there were 309 CLABSI episodes among 90 HPN-dependent children with median age 3.8 years old.Fifty-nine percent of patients carried the diagnosis of surgical short bowel syndrome. Organisms isolated during these infections included 60% Gram-positive bacteria, 34% Gram-negative bacteria, and 6% fungi. Among all staphylococcal isolates, 51% were methicillin sensitive. Among enteric Gram-negative organisms, sensitivities were piperacillin-tazobactam 71%, cefepime 97%, and meropenem 99%. Organisms were sensitive to current institutional standard therapy with vancomycin and piperacillin-tazobactam in 69% of cases compared with vancomycin and cefepime or vancomycin an meropenem in 85% and 96% of cases (both P < 0.01). CONCLUSIONS Empiric antimicrobial therapy for suspected CLABSI in HPN-dependent children should include therapy for methicillin-resistant staphylococci as well as enteric Gram-negative organisms. Future studies are needed to evaluate clinical outcomes based upon evidence-based antimicrobial regimens.
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Han SM, Knell J, Henry O, Hong CR, Han GY, Staffa SJ, Modi BP, Jaksic T. Long-Term Outcomes and Disease Burden of Neonatal Onset Short Bowel Syndrome. J Pediatr Surg 2020; 55:164-168. [PMID: 31679769 DOI: 10.1016/j.jpedsurg.2019.09.071] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 09/29/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE The study aims to describe long-term outcomes and disease burden of neonatal onset short bowel syndrome (SBS). METHODS Utilizing the WHO criteria for adolescence, patients 10-19 years of age with neonatal onset SBS requiring parenteral nutrition (PN) for >90 days and followed by our multidisciplinary intestinal rehabilitation center between 2009 and 2018 were included for analysis. RESULTS Seventy adolescents with SBS were studied. Median (IQR) age at last follow up in our center was 15 (11, 17) years. There was 0% mortality in the cohort, and 94% remained transplant free. Fifty-three patients (76%) achieved enteral autonomy. Three patients were weaned from PN without transplantation after six years of follow-up and another four after ten years of care at our multidisciplinary center. Disease burden remained higher in adolescents receiving PN, including inpatient hospitalizations (p < 0.01), procedures (p = 0.01), clinic visits (p < 0.01), and number of prescribed medications (p < 0.01). CONCLUSION Survival for adolescents with neonatal onset SBS is excellent. Of the cohort studied, there was no mortality, and more than 75% achieved enteral autonomy. Disease burden remains high for adolescents who remain dependent on PN. However, achievement of enteral autonomy is feasible with long-term multidisciplinary rehabilitation. TYPE OF STUDY Prognosis study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Sam M Han
- Center for Advanced Intestinal Rehabilitation and Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Jamie Knell
- Center for Advanced Intestinal Rehabilitation and Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Owen Henry
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Charles R Hong
- Center for Advanced Intestinal Rehabilitation and Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Grace Y Han
- Center for Advanced Intestinal Rehabilitation and Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Steven J Staffa
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Biren P Modi
- Center for Advanced Intestinal Rehabilitation and Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation and Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA.
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Meister AL, Doheny KK, Travagli RA. Necrotizing enterocolitis: It's not all in the gut. Exp Biol Med (Maywood) 2019; 245:85-95. [PMID: 31810384 DOI: 10.1177/1535370219891971] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Necrotizing enterocolitis is the leading cause of death due to gastrointestinal disease in preterm neonates, affecting 5–12% of neonates born at a very-low birth weight. Necrotizing enterocolitis can present with a slow and insidious onset, with some neonates displaying early symptoms such as feeding intolerance. Treatment during the early stages includes bowel rest and careful use of antibiotics, but surgery is required if pneumoperitoneum and intestinal perforation occur. Mortality rates among neonates requiring surgery are estimated to be 20–30%, mandating the development of non-invasive and reliable biomarkers to predict necrotizing enterocolitis before the onset of clinical signs. Such biomarkers would allow at-risk neonates to receive maximal preventative therapies such as careful nutritional consideration, probiotics, and increased skin-to-skin care.Impact statementNecrotizing enterocolitis (NEC) is a devastating gastrointestinal disease; its high mortality rate mandates the development of non-invasive biomarkers to predict NEC before its onset. This review summarizes the pathogenesis, prevention, unresolved issues, and long-term outcomes of NEC.
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Affiliation(s)
- Alissa L Meister
- Department of Neural and Behavioral Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Kim K Doheny
- Department of Neural and Behavioral Sciences, Penn State College of Medicine, Hershey, PA, USA.,Neonatal-Perinatal Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - R Alberto Travagli
- Department of Neural and Behavioral Sciences, Penn State College of Medicine, Hershey, PA, USA
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Mezoff EA, Cole CR, Cohran VC. Etiology and Medical Management of Pediatric Intestinal Failure. Gastroenterol Clin North Am 2019; 48:483-498. [PMID: 31668178 DOI: 10.1016/j.gtc.2019.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pediatric intestinal failure occurs when gut function is insufficient to meet the growing child's hydration and nutrition needs. After massive bowel resection, the remnant bowel adapts to lost absorptive and digestive capacity through incompletely defined mechanisms newly targeted for pharmacologic augmentation. Management seeks to achieve enteral autonomy and mitigate the development of comorbid disease. Care has improved, most notably related to reductions in blood stream infection and liver disease. The future likely holds expansion of pharmacologic adaptation augmentation, refinement of intestinal tissue engineering techniques, and the development of a learning health network for efficient multicenter study and care improvement.
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Affiliation(s)
- Ethan A Mezoff
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University College of Medicine, Center for Intestinal Rehabilitation and Nutrition Support, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Conrad R Cole
- Division of Gastroenterology, Hepatology and Nutrition, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Valeria C Cohran
- Division of Gastroenterology, Hepatology and Nutrition, Feinberg School of Medicine, Northwestern University, The Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Box 65, Chicago, IL 60611, USA
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Mezoff EA, Minneci PC, Hoyt RR, Hoffman JM. Toward an Electronic Health Record Leveraged to Learn from Every Complex Patient Encounter: Health Informatics Considerations with Pediatric Intestinal Rehabilitation as a Model. J Pediatr 2019; 215:257-263. [PMID: 31570156 DOI: 10.1016/j.jpeds.2019.07.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/12/2019] [Accepted: 07/22/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Ethan A Mezoff
- Nationwide Children's Hospital, College of Medicine; Ohio State University College of Medicine; Center for Intestinal Rehabilitation and Nutrition Support, Division of Pediatric Gastroenterology, Hepatology, and Nutrition.
| | - Peter C Minneci
- Nationwide Children's Hospital, College of Medicine; Ohio State University College of Medicine; Center for Surgical Outcomes Research, The Research Institute and Department of Surgery
| | - Richard R Hoyt
- Nationwide Children's Hospital, College of Medicine; Research Information Solutions and Innovation - R&D
| | - Jeffrey M Hoffman
- Nationwide Children's Hospital, College of Medicine; Ohio State University College of Medicine; Chief Medical Information Officer, Nationwide Children's Hospital, Columbus, OH
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Raphael BP, Takvorian-Bené M, Gallotto M, Tascione C, McClelland J, Rosa C, Dinan J, O'Connell B, Weinstock P. Learning Gaps and Family Experience, Nurse-Facilitated Home Parenteral Nutrition Simulation-Based Discharge Training: Proof-of-Concept Study. Nutr Clin Pract 2019; 36:489-496. [PMID: 31589007 DOI: 10.1002/ncp.10421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Home parenteral nutrition (HPN) is a life-sustaining therapy for children and adults suffering with severe digestive diseases, yet complications are commonplace, and predischarge trainings are variable. High-fidelity simulation training provides participants with an immersive experience using realistic equipment, supplies, and scenarios. Simulation training is rapidly becoming a potential gold standard for healthcare but is currently underutilized for families and caregivers. METHODS We prospectively collected data on pediatric patients managed at a single HPN program from September 1, 2016, to September 30, 2018. Participants in a pilot simulation-based training program (orientation, high-fidelity mannequin, realistic homelike space, standardized clinical scenarios, and structured debriefing) were compared with historical controls. We excluded patients with short-term HPN use and strictly palliative goals of care. RESULTS Nineteen (90%) families participated in the pilot initiative with a median (interquartile range) age of 0.9 (3.7) years and diagnosis of short-bowel syndrome in 14 (74%). During teaching scenarios, learning gaps were identified for aseptic needleless changes (53%), HPN equipment setup (84%) with specific difficulty adding multivitamin (32%), and dressing changes (63%). Thirty-day readmission rates in simulation-based training group vs historical cases were 42% vs 63% (P = not significant). There was no difference in length of stay between groups. All (100%) simulation-based training group participants would recommend this learning experience to others. CONCLUSION HPN discharge training is a novel use for high-fidelity simulation to address family/caregiver satisfaction and to identify learning gaps. Further studies are needed to refine predischarge training materials and examine the impact on postdischarge outcomes.
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Affiliation(s)
- Bram P Raphael
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Melissa Takvorian-Bené
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mary Gallotto
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christina Tascione
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jennifer McClelland
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Carolyn Rosa
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jessica Dinan
- Boston Children's Hospital Simulator Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Brianna O'Connell
- Boston Children's Hospital Simulator Program, Boston Children's Hospital, Boston, Massachusetts, USA.,Child Life Services, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Peter Weinstock
- Harvard Medical School, Boston, Massachusetts, USA.,Boston Children's Hospital Simulator Program, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, USA
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Ladd MR, Costello CM, Gosztyla C, Werts AD, Johnson B, Fulton WB, Martin LY, Redfield EJ, Crawford B, Panaparambil R, Sodhi CP, March JC, Hackam DJ. Development of Intestinal Scaffolds that Mimic Native Mammalian Intestinal Tissue. Tissue Eng Part A 2019; 25:1225-1241. [PMID: 30652526 PMCID: PMC6760185 DOI: 10.1089/ten.tea.2018.0239] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/05/2018] [Indexed: 12/27/2022] Open
Abstract
IMPACT STATEMENT This study is significant because it demonstrates an attempt to design a scaffold specifically for small intestine using a novel fabrication method, resulting in an architecture that resembles intestinal villi. In addition, we use the versatile polymer poly(glycerol sebacate) (PGS) for artificial intestine, which has tunable mechanical and degradation properties that can be harnessed for further fine-tuning of scaffold design. Moreover, the utilization of PGS allows for future development of growth factor and drug delivery from the scaffolds to promote artificial intestine formation.
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Affiliation(s)
- Mitchell R. Ladd
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Cait M. Costello
- Department of Biological and Environmental Engineering, Cornell University, Ithaca, New York
| | - Carolyn Gosztyla
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Adam D. Werts
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Blake Johnson
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - William B. Fulton
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Laura Y. Martin
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Elizabeth J. Redfield
- Department of Biological and Environmental Engineering, Cornell University, Ithaca, New York
| | - Bryan Crawford
- Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Rohan Panaparambil
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Chhinder P. Sodhi
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - John C. March
- Department of Biological and Environmental Engineering, Cornell University, Ithaca, New York
| | - David J. Hackam
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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Analysis of Healthcare Institutional Costs of Pediatric Home Parenteral Nutrition Central Line Infections. J Pediatr Gastroenterol Nutr 2018; 67:e77-e81. [PMID: 29912033 DOI: 10.1097/mpg.0000000000002058] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although previous literature suggests home parenteral nutrition (HPN)-dependent children experience frequent complications like community-acquired central line-associated bloodstream infections (CLABSI), few studies have characterized the cost. OBJECTIVE The aim of this study was to evaluate institutional cost of community-acquired CLABSI in pediatric patients with HPN. METHODS This is a single-center retrospective review of institutional costs for patients with HPN with community-acquired CLABSI at a tertiary care children's hospital. Inclusion was age 18 years or less between October 2011 and April 2016. Exclusions were death during hospitalization and readmission within 2 days of discharge. Patient-level factors were compared between high-cost group and all others using Welch 2-sample t test and analysis of variance. Multivariable logistic regression was used to determine predictors of higher cost. RESULTS There were 176 CLABSI admissions among 68 patients during the study period (median 2 hospitalizations per patients). The mean cost and length of stay per hospital admission are $28,375 (2015 US dollars) and 8 days, and both were associated with intensive care unit admission (ICU), central venous catheter removal, private insurance, and age <2 years at admission. Nine percent of patients were classified as "super-utilizers" whose 54 hospitalizations accounted for 28% of total institutional costs. CONCLUSIONS Among pediatric patients with HPN, community-acquired CLABSI is associated with significant cost and length of stay. Healthcare utilization is disproportionately concentrated in a small number of patients. These study findings may help inform cost analysis for future CLABSI prevention strategies.
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Double plication for spring-mediated in-continuity intestinal lengthening in a porcine model. Surgery 2018; 165:389-392. [PMID: 30217395 DOI: 10.1016/j.surg.2018.07.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 07/19/2018] [Accepted: 07/23/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Short bowel syndrome is a condition with substantial morbidity and mortality, yet definitive therapies are lacking. Distraction enterogenesis uses mechanical force to "grow" new intestine. In this study, we examined whether intestinal plication can be used to safely achieve spring-mediated intestinal lengthening in a functioning segment of jejunum in its native position. METHODS A total of 12 juvenile, miniature Yucatan pigs underwent laparotomy to place either compressed springs or expanded springs within a segment of jejunum (n = 6 per group). The springs were secured within the jejunum by performing intestinal plication to narrow the intestinal lumen around the spring. After 3 weeks, the jejunum was retrieved and examined for lengthening and for histologic changes. RESULTS There were no intraoperative or postoperative complications, and the pigs tolerated their diets and gained weight. Segments of jejunum containing expanded springs showed no significant change in length over the 3 weeks. In contrast, jejunum containing compressed springs showed nearly a 3-fold increase in length (P < .001). Histology of the retrieved jejunum showed a significant increase in thickness of the muscularis propria and in crypt depth relative to normal jejunum. CONCLUSION Intestinal plication is effective in securing endoluminal springs to lengthen the jejunum. This approach is a clinically relevant model because it allows for normal GI function and growth of animals during intestinal lengthening, which may be useful in lengthening intestine in patients with short bowel syndrome.
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Abstract
Pediatric intestinal failure is a complex and devastating condition defined as the inability of the intestine to absorb an adequate amount of fluid and nutrients to sustain life. The primary goal of intestinal failure treatment is to achieve enteral autonomy with a customized treatment plan. Although recent improvements in intestinal failure patient care have led to significant improvements in the morbidity and mortality rate, children with intestinal failure are at risk for multiple complications such as intestinal failure associated liver disease, recurrent septic episodes, central line complications, metabolic bone disease, impaired kidney function, and failure to thrive. In this article, we review the current literature on the etiology and factors affecting prognosis of pediatric IF.
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Affiliation(s)
- Annika Mutanen
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
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Huynh N, Dubrovsky G, Rouch JD, Scott A, Chiang E, Nguyen T, Wu BM, Shekherdimian S, Krummel TM, Dunn JCY. Three-dimensionally printed surface features to anchor endoluminal spring for distraction enterogenesis. PLoS One 2018; 13:e0200529. [PMID: 30001433 PMCID: PMC6042758 DOI: 10.1371/journal.pone.0200529] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 06/28/2018] [Indexed: 12/16/2022] Open
Abstract
Spring-mediated distraction enterogenesis has been studied as a novel treatment for short bowel syndrome (SBS). Previous approaches are limited by multiple surgeries to restore intestinal continuity. Purely endoluminal devices require a period of intestinal attachment for enterogenesis. The purpose of this study is to modify the device to prevent premature spring migration in a porcine model. Two models were created in juvenile mini-Yucatan pigs for the placement of three-dimensionally printed springs. (1) Two Roux-en-y jejunojenostomies with two Roux limbs were made. A spring with bidirectional hooked surface features was placed in one Roux limb and a spring with smooth surface was placed in the other Roux limb. (2) The in-continuity model had both hooked and smooth surface springs placed directly in intestinal continuity. Spring location was evaluated by weekly radiographs, and the intestine was retrieved after 2 to 4 weeks. Springs with smooth surfaces migrated between 1 to 3 weeks after placement in both porcine models. Springs with bidirectional hooked surface features were anchored to the intestine for up to 4 weeks without migration. Histologically, the jejunal architecture showed significantly increased crypt depth and muscularis thickness compared to normal jejunum. Bidirectional features printed on springs prevented the premature migration of endoluminal springs. These novel spring anchors allowed for their endoluminal placement without any sutures. This approach may lead to the endoscopic placement of the device for patients with SBS.
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Affiliation(s)
- Nhan Huynh
- Department of Surgery, Division of Pediatric Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, United States of America
- Department of Surgery, Division of Pediatric Surgery, School of Medicine, Stanford University, Stanford, California, United States of America
| | - Genia Dubrovsky
- Department of Surgery, Division of Pediatric Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Joshua D. Rouch
- Department of Surgery, Division of Pediatric Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Andrew Scott
- Department of Surgery, Division of Pediatric Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Elvin Chiang
- Department of Surgery, Division of Pediatric Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Tommy Nguyen
- School of Engineering, Department of Bioengineering, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Benjamin M. Wu
- School of Engineering, Department of Bioengineering, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Shant Shekherdimian
- Department of Surgery, Division of Pediatric Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Thomas M. Krummel
- Department of Surgery, Division of Pediatric Surgery, School of Medicine, Stanford University, Stanford, California, United States of America
- Department of Bioengineering, School of Medicine, Stanford University, Stanford, California, United States of America
| | - James C. Y. Dunn
- Department of Surgery, Division of Pediatric Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, United States of America
- Department of Surgery, Division of Pediatric Surgery, School of Medicine, Stanford University, Stanford, California, United States of America
- School of Engineering, Department of Bioengineering, University of California, Los Angeles, Los Angeles, California, United States of America
- Department of Bioengineering, School of Medicine, Stanford University, Stanford, California, United States of America
- * E-mail:
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Drucker NA, Jensen AR, Te Winkel JP, Ferkowicz MJ, Markel TA. Loss of endothelial nitric oxide synthase exacerbates intestinal and lung injury in experimental necrotizing enterocolitis. J Pediatr Surg 2018; 53:1208-1214. [PMID: 29618412 PMCID: PMC5994357 DOI: 10.1016/j.jpedsurg.2018.02.087] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 02/27/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) continues to be a devastating condition among preterm infants. Nitric oxide, which is synthesized in the intestine by endothelial nitric oxide synthase (eNOS), acts as a potent vasodilator and antioxidant within the mesentery and may play a role in prevention of NEC. We hypothesized that loss of endothelial nitric oxide would worsen both intestinal and associated lung injury and increase local and systemic inflammation during experimental NEC. METHODS NEC was induced in five-day-old wild type (WT) and eNOS-knockout (eNOSKO) mouse pups. Experimental groups (n=10) were formula fed and subjected to intermittent hypoxic and hypothermic stress, while control groups (n=10) remained with their mother to breastfeed. Pups were monitored by daily clinical assessment. After sacrifice on day nine, intestine and lung were assessed for injury, and cytokines were measured in tissue homogenates by ELISA. Data were compared with Mann-Whitney, and p<0.05 was significant. RESULTS Each NEC group was compared to its respective strain's breastfed control to facilitate comparisons between the groups. Both NEC groups were significantly sicker than their breastfed controls. eNOSKO NEC animals had a median clinical assessment score of 3 (IQR=1-5), and the WT NEC animal's median score was 3 (IQR=2-5). Despite similar clinical scores, intestinal injury was significantly worse in the eNOSKO NEC groups compared to WT NEC groups (median injury scores of 3.25 (IQR=2.25-3.625) and 2 (IQR=1-3), respectively (p=0.0474). Associated lung injury was significantly worse in the eNOSKO NEC group as compared to the WT NEC group (median scores of 8.5 (IQR=6.75-11.25) and 6.5 (IQR=5-7.5), respectively, p=0.0391). Interestingly, cytokines in both tissues were very different between the two groups, with varying effects noted for each cytokine (IL-6, IL-1β, VEGF, and IL-12) in both tissues. CONCLUSION Nitric oxide from eNOS plays a key role in preventing the development of NEC. Without eNOS function, both intestinal and lung injuries are more severe, and the inflammatory cascade is significantly altered. Further studies are needed to determine how eNOS-derived nitric oxide facilitates these beneficial effects.
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MESH Headings
- Animals
- Animals, Newborn
- Cytokines/metabolism
- Disease Models, Animal
- Enterocolitis, Necrotizing/enzymology
- Enterocolitis, Necrotizing/pathology
- Enterocolitis, Necrotizing/prevention & control
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/enzymology
- Infant, Premature, Diseases/pathology
- Infant, Premature, Diseases/prevention & control
- Intestinal Mucosa/metabolism
- Intestines/pathology
- Lung Injury/pathology
- Mesentery/metabolism
- Mice
- Nitric Oxide Synthase Type III/metabolism
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Affiliation(s)
- Natalie A Drucker
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, IN; The Indiana University School of Medicine, Indianapolis, IN
| | - Amanda R Jensen
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, IN; The Indiana University School of Medicine, Indianapolis, IN
| | - Jan P Te Winkel
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, IN; The Indiana University School of Medicine, Indianapolis, IN
| | - Michael J Ferkowicz
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, IN; The Indiana University School of Medicine, Indianapolis, IN
| | - Troy A Markel
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, IN; Riley Hospital for Children at Indiana University Health, Indianapolis, IN; The Indiana University School of Medicine, Indianapolis, IN.
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Raphael BP, Schumann C, Garrity-Gentille S, McClelland J, Rosa C, Tascione C, Gallotto M, Takvorian-Bené M, Carey AN, McCarthy P, Duggan C, Ozonoff A. Virtual Telemedicine Visits in Pediatric Home Parenteral Nutrition Patients: A Quality Improvement Initiative. Telemed J E Health 2018; 25:60-65. [PMID: 29727261 DOI: 10.1089/tmj.2017.0298] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Despite being less costly than prolonged hospitalization, home parenteral nutrition (HPN) is associated with high rates of post-discharge complications, including frequent readmissions and central line-associated bloodstream infections (CLABSIs). Telemedicine has been associated with improved outcomes and reduced healthcare utilization in other high-risk populations, but no studies to date have supported effectiveness of telemedicine in pediatric HPN. METHODS We prospectively collected data on pediatric patients managed at a single HPN program who participated in postdischarge telemedicine visits from March 1, 2014 to March 30, 2016. We excluded patients with a history of HPN and strictly palliative care goals. Univariate analysis was performed for primary outcomes: Community-acquired CLABSI and 30-day readmission rate. RESULTS Twenty-six families participated in the pilot initiative with median (interquartile range) patient age 1.5 (5.7) years old, diagnosis of short bowel syndrome in 16 (62%), and in-state residence in 17 (55%). Ishikawa (fishbone) diagram identified causes of post-discharge HPN complications. Areas of focus during telemedicine visit included central venous catheter care methods, materials, clinical concerns, and equipment. Compared to historical comparison group, the telemedicine group experienced CLABSI rates of 1.0 versus 2.7 per 1,000 line days and readmission rates of 38% versus 17% (p = 0.03, 0.02, respectively). CONCLUSIONS Telemedicine visits identified opportunities for improvement for families newly discharged on HPN. In a small cohort of patients who experienced telemedicine visits, we found lower CLABSI rates alongside higher readmission rates compared with a historical comparison group. Further studies are needed to optimize telemedicine in delivering care to this high-risk population.
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Affiliation(s)
- Bram P Raphael
- 1 Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts.,2 Home Parenteral Nutrition Program, Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - Caitlin Schumann
- 3 Innovation and Digital Health Accelerator, Boston Children's Hospital, Boston, Massachusetts
| | - Sara Garrity-Gentille
- 3 Innovation and Digital Health Accelerator, Boston Children's Hospital, Boston, Massachusetts
| | - Jennifer McClelland
- 1 Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts.,2 Home Parenteral Nutrition Program, Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - Carolyn Rosa
- 1 Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts.,2 Home Parenteral Nutrition Program, Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - Christina Tascione
- 1 Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts.,2 Home Parenteral Nutrition Program, Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - Mary Gallotto
- 1 Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts.,2 Home Parenteral Nutrition Program, Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - Melissa Takvorian-Bené
- 1 Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts.,2 Home Parenteral Nutrition Program, Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - Alexandra N Carey
- 1 Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts.,2 Home Parenteral Nutrition Program, Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - Patrick McCarthy
- 3 Innovation and Digital Health Accelerator, Boston Children's Hospital, Boston, Massachusetts
| | - Christopher Duggan
- 1 Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Al Ozonoff
- 4 Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, Massachusetts.,5 Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Bode L. Human Milk Oligosaccharides in the Prevention of Necrotizing Enterocolitis: A Journey From in vitro and in vivo Models to Mother-Infant Cohort Studies. Front Pediatr 2018; 6:385. [PMID: 30564564 PMCID: PMC6288465 DOI: 10.3389/fped.2018.00385] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/21/2018] [Indexed: 11/15/2022] Open
Abstract
Preterm infants who receive human milk instead of formula are 6- to 10-times less likely to develop necrotizing enterocolitis (NEC), one of the most common and devastating intestinal disorders that affects 5-10% of all very-low-birth-weight infants. Combined data from in vitro tissue culture models, in vivo preclinical studies in animal models, as well human mother-infant cohort studies support the hypothesis that human milk oligosaccharides (HMOs), complex sugars that are highly abundant in human milk but not in infant formula, contribute to the beneficial effects of human milk feeding in reducing NEC. The almost 20-year long journey of testing this hypothesis took an interesting turn during HMO in vivo efficacy testing and structure elucidation, suggesting that the original hypothesis may indeed be correct and specific HMO reduce NEC risk, however, the underlying mechanisms are likely different than originally postulated.
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Affiliation(s)
- Lars Bode
- Department of Pediatrics and Larsson-Rosenquist Foundation Mother-Milk-Infant Center of Research Excellence (LRF MOMI CORE), University of California, San Diego, La Jolla, CA, United States
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Intestinal Rehabilitation Programs in the Management of Pediatric Intestinal Failure and Short Bowel Syndrome. J Pediatr Gastroenterol Nutr 2017; 65:588-596. [PMID: 28837507 DOI: 10.1097/mpg.0000000000001722] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intestinal failure is a rare, debilitating condition that presents both acute and chronic medical management challenges. The condition is incompatible with life in the absence of the safe application of specialized and individualized medical therapy that includes surgery, medical equipment, nutritional products, and standard nursing care. Intestinal rehabilitation programs are best suited to provide such complex care with the goal of achieving enteral autonomy and oral feeding with or without intestinal transplantation. These programs almost all include pediatric surgeons, pediatric gastroenterologists, specialized nurses, and dietitians; many also include a variety of other medical and allied medical specialists. Intestinal rehabilitation programs provide integrated interdisciplinary care, more discussion of patient management by involved specialists, continuity of care through various treatment interventions, close follow-up of outpatients, improved patient and family education, earlier treatment of complications, and learning from the accumulated patient databases. Quality assurance and research collaboration among centers are also goals of many of these programs. The combined and coordinated talents and skills of multiple types of health care practitioners have the potential to ameliorate the impact of intestinal failure and improve health outcomes and quality of life.
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Stýblová J, Kalousová J, Adamcová M, Bajerová K, Bronský J, Fencl F, Karásková E, Keslová P, Melek J, Pozler O, Sebroň V, Šuláková A, Tejnická J, Tláskal P, Tomášek L, Vlková B, Szitányi P. Paediatric Home Parenteral Nutrition in the Czech Republic and Its Development: Multicentre Retrospective Study 1995-2011. ANNALS OF NUTRITION AND METABOLISM 2017; 71:99-106. [DOI: 10.1159/000479339] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 07/09/2017] [Indexed: 01/24/2023]
Abstract
Background: Treatment quality and outcomes of paediatric home parenteral nutrition (HPN) program during its development in the Czech Republic. Methods: A retrospective study of patients receiving HPN from May 1995 till June 2011. Results: Sixty-six patients were treated in 8 centres. In 48 patients, long-term PN began in the first year of life and in 35 of them in the first month. Sixty children had gastrointestinal and 6 had non-gastrointestinal disease. In a majority of the patients, the Broviac catheter was used. Thirty-two (48.5%) patients were weaned from PN after 1-117 months, 21 (32.8%) continued on HPN after 7-183 months, and 13 (19.7%) patients died, all on PN. The mortality in patients with primary gastrointestinal disease was significantly lower than in patients with non-gastrointestinal disease. Thirty-one paediatric patients were receiving HPN for 14,480 catheter days in 2009-2010. Fourteen patients had 23 Catheter Related Blood Stream Infections (CRBSI) episodes. The incidence of CRBSI in 2009-2010 was 1.58/1,000 catheter days. Conclusion: Submitted data showed that even in the absence of expert centres, patient care may achieve results comparable to countries with well-developed HPN program. A majority of Czech HPN patients are at present treated in specialized centres, following the most desirable pattern of care.
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Predicting time to full enteral nutrition in children after significant bowel resection. J Pediatr Surg 2017; 52:764-767. [PMID: 28168985 DOI: 10.1016/j.jpedsurg.2017.01.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 01/23/2017] [Indexed: 01/02/2023]
Abstract
PURPOSE Parenteral nutrition (PN) contributes to considerable morbidity in children after significant bowel resection. This study evaluates the utility of clinical variables in predicting time to independence from PN. METHODS After IRB approval, a retrospective review (1999-2012) of 71 children who were on PN for >6weeks after intestinal resection and successfully weaned was performed. Clinical characteristics were evaluated to determine the relationship to time to full enteral nutrition. P-values<0.05 were significant. RESULTS Most children had necrotizing enterocolitis (56%), intestinal atresia (20%), or gastroschisis (11%) with a median small bowel length of 55cm (IQR, 35-92cm). The duration of PN was independent of the etiology of intestinal loss, presence of the ileocecal valve or colon, or location of anastomosis, but was strongly associated with small bowel length (<0.01) and percent of expected small bowel based on gestational age (GA) (median 50%, <0.01). In general, children who had 25-50% of their small bowel were dependent on PN for at least 2years compared to approximately 1year for those with 51-75%. CONCLUSION The duration of PN dependence in children after major bowel resection is best predicted by remaining small bowel length and can be estimated using a linear regression model. LEVEL OF EVIDENCE 2b.
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Cohran VC, Prozialeck JD, Cole CR. Redefining short bowel syndrome in the 21st century. Pediatr Res 2017; 81:540-549. [PMID: 27997531 DOI: 10.1038/pr.2016.265] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 10/30/2016] [Indexed: 12/12/2022]
Abstract
In 1968, Wilmore and Dudrick reported an infant sustained by parenteral nutrition (PN) providing a potential for survival for children with significant intestinal resections. Increasing usage of TPN over time led to some patients developing Intestinal Failure Associated Liver Disease (IFALD), a leading cause of death and indication for liver/intestinal transplant. Over time, multidisciplinary teams called Intestinal Rehabilitation Programs (IRPs) began providing meticulous and innovative management. Usage of alternative lipid emulsions and lipid minimization strategies have resulted in the decline of IFALD and an increase in long-term and transplant-free survival, even in the setting of ultrashort bowel (< 20 cm). Autologous bowel reconstructive surgeries, such as the serial tapering enteroplasty procedure, have increased the likelihood of achieving enteral autonomy. Since 2007, the number of pediatric intestinal transplants performed has sharply declined and likely attributed to the newer innovations healthcare. Recent data support the need for changes in the listing criteria for intestinal transplantation given the overall improvement in outcomes. Over the last 50 y, the diagnosis of short bowel syndrome has changed from a death sentence to one of hope with a vast improvement of quality of life and survival.
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Affiliation(s)
- Valeria C Cohran
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Joshua D Prozialeck
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Conrad R Cole
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Abstract
PURPOSE OF REVIEW This review summarizes recent innovations in the treatment of patients with short bowel syndrome. RECENT FINDINGS The use of surgical procedures, growth factor stimulation, and bioengineering approaches to increase absorptive surface area of the intestine is examined. While the morphology of the intestine is clearly altered by these interventions, it is less clear that the overall function of the intestine is improved. SUMMARY Continued innovations will likely bring about new therapeutic options for patients with short bowel syndrome. Careful evaluations of the impact of these interventions await controlled clinical trials.
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Groen H, Neelis EG, Poley MJ, Olieman JF, Scheenstra R, Krabbe PF, Dijkstra G, Rings EH. Intestinal rehabilitation for children with intestinal failure is cost-effective: a simulation study. Am J Clin Nutr 2017; 105:417-425. [PMID: 28052886 DOI: 10.3945/ajcn.116.135160] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 11/29/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Children with intestinal failure (IF) depend on parenteral nutrition (PN). The goal in the treatment of IF is to wean children off PN through intestinal rehabilitation (IR). Although the healthcare burden of IF is enormous, to our knowledge there has been no previous cost-effectiveness analysis in pediatric IF including IR. OBJECTIVE We sought to determine the cost-effectiveness of IR in terms of costs and life-years. DESIGN We simulated the treatment of IF in children in a discrete-event model. Data for this model were derived from patient records, the Dutch Registry of Intestinal Failure and Transplantation, the Intestinal Transplant Registry, and the literature. The time horizon of the model was 40 y. Simulated patients were enrolled at a rate of 40 patients/mo for 10 y. Actual costs were calculated for hospital admissions, surgical interventions, endoscopies, PN, and immunosuppressive medication. We evaluated the cost-effectiveness of IR by comparing 1 scenario with IR with 1 scenario without IR. In the scenario with IR, a proportion of patients who represented those with the ability to wean off PN were assigned to IR. In the scenario without IR, all patients progressed to home PN (HPN). In both scenarios, a proportion of patients receiving HPN were eventually eligible for an intestinal transplantation. RESULTS IR prolonged survival; the mean number of life-years per patient was 19.4 in the scenario with IR compared with 18.2 in the scenario without IR. Average total costs per patient were €819,292 in the scenario with IR compared with €1,176,830 in the scenario without IR (equivalent to 1,129,230 US$ and 1,622,025 US$, respectively, in January 2014); costs mainly included hospital admissions and PN. CONCLUSIONS On the basis of our simulations, we concluded that IR improved the survival of children with IF and was associated with cost savings. Therefore, we consider IR to be a cost-effective treatment for children with IF.
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Affiliation(s)
| | | | - Marten J Poley
- Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands.,Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Joanne F Olieman
- Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Dietetics, Erasmus Medical Center, Rotterdam, Netherlands
| | - René Scheenstra
- Department of Pediatric Gastroenterology, University of Groningen, University Medical Center Groningen-Beatrix Children's Hospital, Groningen, Netherlands; and
| | | | - Gerard Dijkstra
- Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Edmond Hhm Rings
- Departments of Pediatric Gastroenterology and.,Department of Pediatrics, Leiden University Medical Center-Willem Alexander Children's Hospital, Leiden, Netherlands
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Barrett M, Demehri FR, Ives GC, Schaedig K, Arnold MA, Teitelbaum DH. Taking a STEP back: Assessing the outcomes of multiple STEP procedures. J Pediatr Surg 2017; 52:69-73. [PMID: 27865472 DOI: 10.1016/j.jpedsurg.2016.10.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 10/20/2016] [Indexed: 12/12/2022]
Abstract
PURPOSE Short bowel syndrome (SBS) is a highly morbid condition primarily because of parenteral nutrition (PN)-associated complications. Bowel lengthening via serial transverse enteroplasty (STEP) has become standard of care. While initial STEPs have resulted in weaning from PN, outcomes of repeated STEPs (ReSTEPs) are not well described. We investigated outcomes of initial STEP compared to ReSTEP procedures. METHODS This retrospective review of STEPs included 17 children and a total of 24 procedures. Demographics, complications, hospital readmission rates, postoperative costs, and PN weaning were analyzed. RESULTS Neither patient-specific data nor the etiology of SBS was predictive of requiring a ReSTEP. PN weaning was more likely in the year following a first STEP (18% wean rate vs. 0% for ReSTEP, p>.05). No ReSTEP patients reached enteral autonomy. Enteral nutrition (%EN) increases were greater after first STEP compared to ReSTEP (26.0% vs. 4.7%, p=0.03). This trend was true for bowel length as well, where first STEPs resulted in a 51% increase in bowel length compared to a 20% increase after in ReSTEP (p=0.02). CONCLUSIONS ReSTEPs failed to result in significant PN weaning, with no ReSTEP patients achieving enteral autonomy during follow-up. Given its higher costs, smaller bowel length gains, and limited ability to produce enteral autonomy, surgeons should carefully consider performing ReSTEP procedures. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Meredith Barrett
- Division of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan; Ann Arbor, MI.
| | - Farokh R Demehri
- Division of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan; Ann Arbor, MI
| | - Graham C Ives
- Division of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan; Ann Arbor, MI
| | - Kristen Schaedig
- University of Michigan Clinical Financial Planning and Analysis Center, University of Michigan Health System; Ann Arbor, MI
| | - Meghan A Arnold
- Division of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan; Ann Arbor, MI
| | - Daniel H Teitelbaum
- Division of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan; Ann Arbor, MI
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Rouch JD, Huynh N, Scott A, Chiang E, Wu BM, Shekherdimian S, Dunn JCY. Scalability of an endoluminal spring for distraction enterogenesis. J Pediatr Surg 2016; 51:1988-1992. [PMID: 27665493 DOI: 10.1016/j.jpedsurg.2016.09.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 09/12/2016] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Techniques of distraction enterogenesis have been explored to provide increased intestinal length to treat short bowel syndrome (SBS). Self-expanding, polycaprolactone (PCL) springs have been shown to lengthen bowel in small animal models. Their feasibility in larger animal models is a critical step before clinical use. METHODS Juvenile mini-Yucatan pigs underwent jejunal isolation or blind ending Roux-en-y jejunojejunostomy with insertion of either a PCL spring or a sham PCL tube. Extrapolated from our spring characteristics in rodents, proportional increases in spring constant and size were made for porcine intestine. RESULTS Jejunal segments with 7mm springs with k between 9 and 15N/m demonstrated significantly increased lengthening in isolated segment and Roux-en-y models. Complications were noted in only two animals, both using high spring constant k>17N/m. Histologically, lengthened segments in the isolated and Roux models demonstrated significantly increased muscularis thickness and crypt depth. Restoration of lengthened, isolated segments back into continuity was technically feasible after 6weeks. CONCLUSION Self-expanding, endoluminal PCL springs, which exert up to 0.6N force, safely achieve significant intestinal lengthening in a translatable, large-animal model. These spring characteristics may provide a scalable model for the treatment of SBS in children.
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Affiliation(s)
- Joshua D Rouch
- Department of Surgery, Division of Pediatric Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Nhan Huynh
- Department of Surgery, Division of Pediatric Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Andrew Scott
- Department of Surgery, Division of Pediatric Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Elvin Chiang
- Department of Surgery, Division of Pediatric Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Benjamin M Wu
- School of Engineering, Department of Bioengineering, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Shant Shekherdimian
- Department of Surgery, Division of Pediatric Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - James C Y Dunn
- Department of Surgery, Division of Pediatric Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA; School of Engineering, Department of Bioengineering, University of California, Los Angeles, Los Angeles, CA, 90095, USA.
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50
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Walthers CM, Lyall CJ, Nazemi AK, Rana PV, Dunn JCY. Collagen and heparan sulfate coatings differentially alter cell proliferation and attachment in vitro and in vivo. TECHNOLOGY 2016; 4:159-169. [PMID: 28713850 PMCID: PMC5507618 DOI: 10.1142/s2339547816400033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Tissue engineering is an innovative field of research applied to treat intestinal diseases. Engineered smooth muscle requires dense smooth muscle tissue and robust vascularization to support contraction. The purpose of this study was to use heparan sulfate (HS) and collagen coatings to increase the attachment of smooth muscle cells (SMCs) to scaffolds and improve their survival after implantation. SMCs grown on biologically coated scaffolds were evaluated for maturity and cell numbers after 2, 4 and 6 weeks in vitro and both 2 and 6 weeks in vivo. Implants were also assessed for vascularization. Collagen-coated scaffolds increased attachment, growth and maturity of SMCs in culture. HS-coated implants increased angiogenesis after 2 weeks, contributing to an increase in SMC survival and growth compared to HS-coated scaffolds grown in vitro. The angiogenic effects of HS may be useful for engineering intestinal smooth muscle.
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Affiliation(s)
- Christopher M Walthers
- Department of Bioengineering and Department of Surgery, University of California, Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Chase J Lyall
- Department of Bioengineering and Department of Surgery, University of California, Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Alireza K Nazemi
- Department of Bioengineering and Department of Surgery, University of California, Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Puneet V Rana
- Department of Bioengineering and Department of Surgery, University of California, Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - James C Y Dunn
- Department of Bioengineering and Department of Surgery, University of California, Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
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