An Electronic Health Record-integrated Web Application Augments a QI-directed Morbidity & Mortality Conference and Improves Quality of Care

BACKGROUND

In 2014, we developed a QI-directed Morbidity and Mortality (M&M) Conference, prioritizing discussion of individual and system failures, as well as development of action items to prevent failure recurrence. However, due to a reliance on individual electronic documents to store M&M data, our ability to assess trends in failures and action item implementation was hindered. To address this issue, in 2019, we created a secure electronic health record (EHR)-integrated web application (web app) to store M&M data.

STUDY DESIGN

In this study, we assessed the impact of our web app on efficient review and tracking of M&M data, including system failure occurrence and closure of action items. Additionally, in 2021, it was discovered that a backlog of action items existed. To address this issue, we implemented a QI initiative to reduce the backlog, and used the web app to compare action item closure over time.

RESULTS

Use of the web app dramatically improved review of M&M data. During the study period, there was a 67.0% reduction in the occurrence of the most common system failures. Additionally, our QI initiative resulted in a 97.7% reduction in the duration of time to complete a single action item and a 61.1% increase in the on-time closure rate for action items.

CONCLUSIONS

Integration of a web app into a QI-directed M&M Conference enhanced our ability to track system level failures and action item closure over time. Using this web app, we demonstrated that our M&M Conference achieved its intended goal of improving the quality of patient care.

LEVEL OF EVIDENCE

IV.

Inequities in the Diagnosis of Pediatric Appendicitis in Tertiary Children's Hospitals and the Consequences of Delayed Diagnosis

INTRODUCTION

Missed diagnosis (MD) of acute appendicitis is associated with increased risk of appendiceal perforation. This study aimed to investigate whether racial/ethnic disparities exist in the diagnosis of pediatric appendicitis by comparing rates of MD versus single-encounter diagnosis (SED) between racial/ethnic groups.

METHODS

Patients 0-18 y-old admitted for acute appendicitis from February 2017 to December 2021 were identified in the Pediatric Health Information System (PHIS). International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes for Emergency Department visits within 7 d prior to diagnosis were evaluated to determine whether the encounter represented MD. Generalized mixed models were used to assess the association between MD and patient characteristics. A similar model assessed independent predictors of perforation.

RESULTS

51,164 patients admitted for acute appendicitis were included; 50,239 (98.2%) had SED and 925 (1.8%) had MD. Compared to non-Hispanic White patients, patients of non-Hispanic Black (odds ratio 2.5, 95% confidence interval 2.0-3.1), Hispanic (2.1, 1.8-2.5), and other race/ethnicity (1.6, 1.2-2.1) had higher odds of MD. There was a significant interaction between race/ethnicity and imaging (P < 0.0001). Among patients with imaging, race/ethnicity was not significantly associated with MD. Among patients without imaging, there was an increase in strength of association between race/ethnicity and MD (non-Hispanic Black 3.6, 2.7-4.9; Hispanic 3.3, 2.6-4.1; other 2.0, 1.4-2.8). MD was associated with increased risk of perforation (2.5, 2.2-2.8).

CONCLUSIONS

Minority children were more likely to have MD. Future efforts should aim to mitigate the risk of MD, including implementation of algorithms to standardize the workup of abdominal pain to reduce potential consequences of implicit bias.

Superior performance of biofilm versus planktonic Limosilactobacillus reuteri in protection of the intestines and brain in a piglet model of necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is the leading cause of gastrointestinal-related death in premature infants. Its etiology is multifactorial, with intestinal dysbiosis playing a major role. Probiotics are a logical preventative therapy for NEC, however their benefits have been inconsistent. We previously developed a novel probiotic delivery system in which planktonic (free-living) Limosilactobacillus reuteri (Lr) is incubated with biocompatible dextranomer microspheres (DM) loaded with maltose (Lr-DM-maltose) to induce biofilm formation. Here we have investigated the effects of Lr-DM-maltose in an enteral feed-only piglet model of NEC. We found a significant decrease in the incidence of Definitive NEC (D-NEC), death associated with D-NEC, and activated microglia in the brains of piglets treated with Lr-DM-maltose compared to non-treated piglets. Microbiome analyses using 16S rRNA sequencing of colonic contents revealed a significantly different microbial community composition between piglets treated with Lr-DM-maltose compared to non-treated piglets, with an increase in Lactobacillaceae and a decrease in Clostridiaceae in Lr-DM-maltose-treated piglets. Furthermore, there was a significant decrease in the incidence of D-NEC between piglets treated with Lr-DM-maltose compared to planktonic Lr. These findings validate our previous results in rodents, and support future clinical trials of Lr in its biofilm state for the prevention of NEC in premature neonates.

Probiotics and novel probiotic delivery systems

Necrotizing enterocolitis (NEC) is an infectious and inflammatory intestinal disease that is the most common surgical emergency in the premature patient population. Although the etiology of the disease is multifactorial, intestinal dysbiosis is a hallmark of this disease. Based on this, probiotics may play a therapeutic role in NEC by introducing beneficial bacteria with immunomodulating, antimicrobial, and anti-inflammatory functions into the gastrointestinal tract. Currently, there is no Food and Drug Administration (FDA)-approved probiotic for the prevention and treatment of NEC. All probiotic clinical studies to date have administered the bacteria in their planktonic (free-living) state. This review will discuss established probiotic delivery systems including planktonic probiotics, prebiotics, and synbiotics, as well as novel probiotic delivery systems such as biofilm-based and designer probiotics. We will also shed light on whether or not probiotic efficacy is influenced by administration with breast milk. Finally, we will consider the challenges associated with developing an FDA-approved probiotic for NEC.

Current and future methods of probiotic therapy for necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a complex intestinal disease that primarily affects premature neonates. Given its significant mortality and morbidity, there is an urgent need to develop improved prophylactic measures against the disease. One potential preventative strategy for NEC is the use of probiotics. Although there has been significant interest for decades in probiotics in neonatal care, no clear guidelines exist regarding which probiotic to use or for which patients, and no FDA-approved products exist on the market for NEC. In addition, there is lack of agreement regarding the benefits of probiotics in neonates, as well as some concerns about the safety and efficacy of available products. We discuss currently available probiotics as well as next-generation probiotics and novel delivery strategies which may offer an avenue to capitalize on the benefits of probiotics, while minimizing the risks. Thus, probiotics may still prove to be an effective prevention strategy for NEC, although further product development and research is needed to support use in the preterm population.

Development of a novel definitive scoring system for an enteral feed-only model of necrotizing enterocolitis in piglets

Introduction

Necrotizing enterocolitis (NEC) is a complex inflammatory disorder of the human intestine that most often occurs in premature newborns. Animal models of NEC typically use mice or rats; however, pigs have emerged as a viable alternative given their similar size, intestinal development, and physiology compared to humans. While most piglet NEC models initially administer total parenteral nutrition prior to enteral feeds, here we describe an enteral-feed only piglet model of NEC that recapitulates the microbiome abnormalities present in neonates that develop NEC and introduce a novel multifactorial definitive NEC (D-NEC) scoring system to assess disease severity.

Methods

Premature piglets were delivered via Caesarean section. Piglets in the colostrum-fed group received bovine colostrum feeds only throughout the experiment. Piglets in the formula-fed group received colostrum for the first 24 h of life, followed by Neocate Junior to induce intestinal injury. The presence of at least 3 of the following 4 criteria were required to diagnose D-NEC: (1) gross injury score ≥4 of 6; (2) histologic injury score ≥3 of 5; (3) a newly developed clinical sickness score ≥5 of 8 within the last 12 h of life; and (4) bacterial translocation to ≥2 internal organs. Quantitative reverse transcription polymerase chain reaction was performed to confirm intestinal inflammation in the small intestine and colon. 16S rRNA sequencing was performed to evaluate the intestinal microbiome.

Results

Compared to the colostrum-fed group, the formula-fed group had lower survival, higher clinical sickness scores, and more severe gross and histologic intestinal injury. There was significantly increased bacterial translocation, D-NEC, and expression of IL-1α and IL-10 in the colon of formula-fed compared to colostrum-fed piglets. Intestinal microbiome analysis of piglets with D-NEC demonstrated lower microbial diversity and increased Gammaproteobacteria and Enterobacteriaceae.

Conclusions

We have developed a clinical sickness score and a new multifactorial D-NEC scoring system to accurately evaluate an enteral feed-only piglet model of NEC. Piglets with D-NEC had microbiome changes consistent with those seen in preterm infants with NEC. This model can be used to test future novel therapies to treat and prevent this devastating disease.

Next-Generation Probiotic Therapy to Protect the Intestines From Injury

Probiotics are live microorganisms that, when administered in adequate amounts, provide health benefits to the host. Some strains of the probiotic Lactobacillus reuteri (L. reuteri) have both antimicrobial and anti-inflammatory properties that may be exploited for the treatment and prevention of different gastrointestinal diseases, including necrotizing enterocolitis (NEC) and Clostridioides difficile (C. difficile) infection. Our laboratory has developed a new delivery system for L. reuteri in which the probiotic is incubated with biocompatible, semipermeable, porous dextranomer microspheres (DM) that can be loaded with beneficial and diffusible cargo. L. reuteri can be induced to form a biofilm by incubating the bacteria on the surface of these microspheres, which enhances the efficacy of the probiotic. Loading the DM with sucrose or maltose induces L. reuteri to produce more biofilm, further increasing the efficacy of the probiotic. Using a rat model of NEC, L. reuteri administered in its biofilm state significantly increases animal survival, reduces the incidence of NEC, preserves gut barrier function, and decreases intestinal inflammation. In a murine model of Clostridiodes difficile infection, L. reuteri administered in its biofilm state decreases colitis when administered either before or after C. difficile induction, demonstrating both prophylactic and therapeutic efficacy. There are currently no FDA-approved probiotic preparations for human use. An FDA-approved phase I clinical trial of L. reuteri in its biofilm state in healthy adults is currently underway. The results of this trial will be used to support a phase 1 clinical trial in neonates, with the goal of utilizing L. reuteri in its biofilm state to prevent NEC in premature neonates in the future.

Guidance for Structuring a Pediatric Intermediate Care Unit

The purpose of this policy statement is to update the 2004 American Academy of Pediatrics clinical report and provide enhanced guidance for institutions, administrators, and providers in the development and operation of a pediatric intermediate care unit (IMCU). Since 2004, there have been significant advances in pediatric medical, surgical, and critical care that have resulted in an evolution in the acuity and complexity of children potentially requiring IMCU admission. A group of 9 clinical experts in pediatric critical care, hospital medicine, intermediate care, and surgery developed a consensus on priority topics requiring updates, reviewed the relevant evidence, and, through a series of virtual meetings, developed the document. The intended audience of this policy statement is broad and includes pediatric critical care professionals, pediatric hospitalists, pediatric surgeons, other pediatric medical and surgical subspecialists, general pediatricians, nurses, social workers, care coordinators, hospital administrators, health care funders, and policymakers, primarily in resource-rich settings. Key priority topics were delineation of core principles for an IMCU, clarification of target populations, staffing recommendations, and payment.

Development of an academic RVU (aRVU) system to promote pediatric surgical academic productivity

BACKGROUND/PURPOSE

Improvements in patient care are directly affected by scientific discovery, and surgeons have historically played a vital role in this process. However, increasing clinical demands and incentivization for pure clinical productivity present challenges for promoting academic productivity. The objective of this work was to analyze the effects of adding an academic relative value unit (aRVU) scoring system to an existing work RVU (wRVU)-based incentivization plan on academic productivity in a Department of Pediatric Surgery.

METHODS

Prior to 2012, incentive bonuses in our Department were mainly based on clinical wRVU activities. A weighted scoring system for 30 specific aRVUs was established in 2012. Incentivization for wRVUs vs. aRVUs was based on the clinical full-time equivalent (cFTE) of each faculty member. Academic activities incentivized included grant submissions/funding, peer reviewed publications, national presentations, Study Section participation, education and mentoring activities, receipt of research or teaching awards, initiation of Institutional Review Board (IRB) protocols, new academic society committee memberships/chairpersons, and patents. Academic progress was analyzed from 2012 to 2020.

RESULTS

During the study period, annual external federal funding increased from $750,168 to $5,768,243 (7.7-fold increase); annual peer-reviewed publications increased from 24 to 140 (5.8-fold increase); annual national presentations accepted for oral/poster presentations nearly doubled; and faculty members and their trainees received 41 competitive research awards including 8 American Pediatric Surgical Association Awards, 9 American Academy of Pediatrics Section on Surgery Awards, and 3 American College of Surgeons Awards. During the same study period, wRVUs increased by 8%.

CONCLUSIONS

Incentivization based on the addition of an aRVU system to a pre-existing wRVU system was associated with a significant increase in academic productivity, while still maintaining clinical productivity. Implementing an aRVU program is an important means of increasing academic productivity in Pediatric and other Surgery Departments.

Urine-derived extracellular vesicle miRNAs as possible biomarkers for and mediators of necrotizing enterocolitis: A proof of concept study

BACKGROUND

Early-stage symptomology of necrotizing enterocolitis (NEC) is similar in presentation to non-NEC sepsis, though the treatment plans differ based on antibiotic administration and withholding of feeds. Improved diagnostics for NEC differentiation would allow clinicians to more rapidly set individual patients on a targeted treatment path. Extracellular vesicle-derived miRNAs, have previously demonstrated efficacy as disease biomarkers. To determine if these miRNAs are differentially-expressed in NEC infants, we performed transcriptomic analysis of urine-derived extracellular vesicle-derived miRNAs.

METHODS

Urine was non-invasively obtained from infants in one of four groups (n ≥ 8) (Medical NEC, Surgical NEC, non-NEC sepsis, and healthy age-matched controls). EV-derived miRNAs were isolated and transcriptomic analysis was performed.

RESULTS

Multiple miRNAs, including miR-376a, miR-518a-3p and miR-604, were significantly altered when comparing NEC to non-NEC sepsis and healthy controls, and could potentially be used as specific NEC biomarkers. Additionally, Ingenuity Pathway Analysis demonstrated that miRs differentially-expressed in NEC were associated with inflammatory disease and intestinal disease. Signal transduction molecules associated with NEC including TP53 and RPS15, which were also reduced transcriptionally in a rat model of NEC.

CONCLUSION

These data indicate that there is a pool of potential urine EV-derived miRNAs that may be validated as NEC biomarkers in the differentiation of NEC from non-NEC sepsis and from age-matched controls. Additionally, signal transduction molecules associated with miRNAs differentially-expressed in human NEC are altered in a murine model of NEC, suggesting potential crossover between murine models of the disease and actual human presentation.

LEVEL OF EVIDENCE

Level III Study of Diagnostic Test.

Initial Laparotomy Versus Peritoneal Drainage in Extremely Low Birthweight Infants With Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation: A Multicenter Randomized Clinical Trial

OBJECTIVE

The aim of this study was to determine which initial surgical treatment results in the lowest rate of death or neurodevelopmental impairment (NDI) in premature infants with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP).

SUMMARY BACKGROUND DATA

The impact of initial laparotomy versus peritoneal drainage for NEC or IP on the rate of death or NDI in extremely low birth weight infants is unknown.

METHODS

We conducted the largest feasible randomized trial in 20 US centers, comparing initial laparotomy versus peritoneal drainage. The primary outcome was a composite of death or NDI at 18 to 22 months corrected age, analyzed using prespecified frequentist and Bayesian approaches.

RESULTS

Of 992 eligible infants, 310 were randomized and 96% had primary outcome assessed. Death or NDI occurred in 69% of infants in the laparotomy group versus 70% with drainage [adjusted relative risk (aRR) 1.0; 95% confidence interval (CI): 0.87-1.14]. A preplanned analysis identified an interaction between preoperative diagnosis and treatment group (P = 0.03). With a preoperative diagnosis of NEC, death or NDI occurred in 69% after laparotomy versus 85% with drainage (aRR 0.81; 95% CI: 0.64-1.04). The Bayesian posterior probability that laparotomy was beneficial (risk difference <0) for a preoperative diagnosis of NEC was 97%. For preoperative diagnosis of IP, death or NDI occurred in 69% after laparotomy versus 63% with drainage (aRR, 1.11; 95% CI: 0.95-1.31); Bayesian probability of benefit with laparotomy = 18%.

CONCLUSIONS

There was no overall difference in death or NDI rates at 18 to 22 months corrected age between initial laparotomy versus drainage. However, the preoperative diagnosis of NEC or IP modified the impact of initial treatment.

Lactobacillus reuteri in its biofilm state promotes neurodevelopment after experimental necrotizing enterocolitis in rats

Necrotizing enterocolitis (NEC) is a devastating disease affecting premature newborns with no known cure. Up to half of survivors subsequently exhibit cognitive impairment and neurodevelopmental defects. We created a novel probiotics delivery system in which the probiotic Lactobacillus reuteri (Lr) was induced to form a biofilm [Lr (biofilm)] by incubation with dextranomer microspheres loaded with maltose (Lr-DM-maltose). We have previously demonstrated that a single dose of the probiotic Lr administered in its biofilm state significantly reduces the incidence of NEC and decreases inflammatory cytokine production in an animal model of the disease. The aim of our current study was to determine whether a single dose of the probiotic Lr administered in its biofilm state protects the brain after experimental NEC. We found that rat pups exposed to NEC reached developmental milestones significantly slower than breast fed pups, with mild improvement with Lr (biofilm) treatment. Exposure to NEC had a negative effect on cognitive behavior, which was prevented by Lr (biofilm) treatment. Lr administration also reduced anxiety-like behavior in NEC-exposed rats. The behavioral effects of NEC were associated with increased numbers of activated microglia, decreased myelin basic protein (MBP), and decreased neurotrophic gene expression, which were prevented by administration of Lr (biofilm). Our data indicate early enteral treatment with Lr in its biofilm state prevented the deleterious effects of NEC on developmental impairments.

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Early treatment with Lr in its biofilm state improves cognitive function in pups that survive experimental NEC.

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Lr in its biofilm state reduces microglia activation and MBP loss, and maintains memory and learning-related gene expression.

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Administration of Lr in its biofilm state protects the brain, as well as intestines, during experimental NEC.

Lactobacillus reuteri in Its Biofilm State Improves Protection from Experimental Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a devastating disease predominately found in premature infants that is associated with significant morbidity and mortality. Despite decades of research, medical management with broad spectrum antibiotics and bowel rest has remained relatively unchanged, with no significant improvement in patient outcomes. The etiology of NEC is multi-factorial; however, gastrointestinal dysbiosis plays a prominent role in a neonate's vulnerability to and development of NEC. Probiotics have recently emerged as a new avenue for NEC therapy. However, current delivery methods are associated with potential limitations, including the need for at least daily administration in order to obtain any improvement in outcomes. We present a novel formulation of enterally delivered probiotics that addresses the current limitations. A single enteral dose of Lactobacillus reuteri delivered in a biofilm formulation increases probiotic survival in acidic gastric conditions, increases probiotic adherence to gastrointestinal epithelial cells, and reduces the incidence, severity, and neurocognitive sequelae of NEC in experimental models.

Intestinal proinflammatory macrophages induce a phenotypic switch in interstitial cells of Cajal

Interstitial cells of Cajal (ICCs) are pacemaker cells in the intestine, and their function can be compromised by loss of C-KIT expression. Macrophage activation has been identified in intestine affected by Hirschsprung disease-associated enterocolitis (HAEC). In this study, we examined proinflammatory macrophage activation and explored the mechanisms by which it downregulates C-KIT expression in ICCs in colon affected by HAEC. We found that macrophage activation and TNF-α production were dramatically increased in the proximal dilated colon of HAEC patients and 3-week-old Ednrb-/- mice. Moreover, ICCs lost their C-KIT+ phenotype in the dilated colon, resulting in damaged pacemaker function and intestinal dysmotility. However, macrophage depletion or TNF-α neutralization led to recovery of ICC phenotype and restored their pacemaker function. In isolated ICCs, TNF-α-mediated phosphorylation of p65 induced overexpression of microRNA-221 (miR-221), resulting in suppression of C-KIT expression and pacemaker currents. We also identified a TNF-α/NF-κB/miR-221 pathway that downregulated C-KIT expression in ICCs in the colon affected by HAEC. These findings suggest the important roles of proinflammatory macrophage activation in a phenotypic switch of ICCs, representing a promising therapeutic target for HAEC.

A novel probiotic therapeutic in a murine model of Clostridioides difficile colitis

For prophylactic therapy, mice received an oral antibiotic cocktail followed by clindamycin injection, followed by probiotic administration (planktonic vs. biofilm state), followed by C. difficile oral gavage. For treatment therapy, mice received antibiotics and C. difficile first, followed by probiotic administration. Clinical sickness scores (CSS) and intestinal histologic injury scores (HIS) were assigned. In the Prophylactic Therapy model, CSS: 67% of untreated mice exposed to C. difficile demonstrated CSS ≥ 6, which is consistent with C. difficile infection (p< .001 compared to unexposed mice). In mice treated with planktonic Lr, 55% had a CSS ≥ 6, but only 19% of mice treated with Lr in its biofilm state had CSS ≥ 6 (p< .001). Mice receiving Lr + DM-Maltose lost the least amount of weight compared to mice receiving saline (p = .004676) or to mice receiving Lr (p= .003185). HIS: 77% of untreated mice exposed to C. difficile had HIS scores ≥4, which is consistent with C. difficile infection. In mice treated with planktonic Lr, 62% had HIS ≥4, but only 19% of mice treated with Lr in its biofilm state had HIS ≥4. (p< .001). Additionally, mice treated with Lr in its biofilm state had better survival compared to untreated mice and to mice treated with planktonic Lr (p ≤ 0.05). Similar findings for weight loss, CSS, HIS and survival were obtained for Treatment Therapy. A single dose of Lactobacillus reuteri in its biofilm state reduces the severity and incidence of experimental C. difficile infection when administered as both prophylactic and treatment therapy.

Prenatal low-dose endotoxin exposure prolongs intestinal epithelial activation after birth and contributes to necrotizing enterocolitis

PURPOSE

To investigate the effects of low dose endotoxin on transcriptional activity in intestinal epithelium, and its role in necrotizing enterocolitis (NEC).

METHODS

Lipopolysaccharides (LPS) were injected into the amniotic cavity of pregnant mice under ultrasound guidance. The effects of LPS on fetal and neonatal intestines were determined. Mouse pups were exposed to low dose LPS (0.01 μg per fetus) prenatally and subjected to experimental NEC after birth. The incidence and severity of NEC, as well as intestinal permeability, NF-κB activation, and IL-6 expression were studied. The signaling pathways in the intestinal epithelial cells (IECs) that were activated by LPS were also investigated.

RESULTS

Low dose LPS did not increase apoptosis, myeloperoxidase activity, histological injury or NF-κB activity in fetal intestines. However, prenatal low dose LPS exposure disturbed the transient and self-limited activation of NF-κB in neonatal intestines after birth. Importantly, it increased the incidence and severity of experimental NEC in neonatal mice. In primary IECs, low dose LPS induced IRAK-1 expression via activation of GSK3β. Elevated IRAK-1 levels prolonged the activation of IECs upon stimulation by high dose LPS.

CONCLUSION

Prenatal low dose endotoxin exposure disturbs self-limited postnatal epithelial cell activation and predisposes the neonatal intestine to NEC.

LEVEL OF EVIDENCE

Not applicable (experimental animal study).

Subspecialization in pediatric surgery: Results of a survey to the American Pediatric Surgical Association

BACKGROUND

Current practice patterns and opinions regarding subspecialization within pediatric surgery are not well known. We aimed to characterize the prevalence of and attitudes surrounding subspecialization within pediatric surgery.

METHODS

An anonymous survey regarding subspecialization was distributed to all nonresident members of the American Pediatric Surgical Association.

RESULTS

Of 1118 surveys, we received 458 responses (41%). A majority of respondents labeled themselves 'general pediatric surgeons' (63%), while 34% considered themselves general surgeons with a specific clinical focus, and 3% reported practicing solely within a specific niche. Subspecialists commonly serve as consultants for relevant cases (52%). Common niches included oncology (10%) and anorectal malformations (9%). Subspecialists felt to be necessary included transplant (79%) and fetal (78%) surgeons. Opinions about subspecialization were variable: 41% felt subspecialization improves patient care while 39% believe it is detrimental to surgeon well-roundedness. Only 10% felt subspecialists should practice solely within their subspecialty. Practicing at an academic hospital or fellowship program correlated with subspecialization, while length of time in practice did not.

CONCLUSION

While pediatric surgeons report that subspecialization may benefit patient care, concerns exist regarding the unfavorable effect it may have on the individual surgeon. A better understanding of how subspecialization affects quality and outcomes would help clarify its utility.

TYPE OF STUDY

Review article.

LEVEL OF EVIDENCE

Level V.

Hope on the horizon: promising novel therapies for necrotizing enterocolitis

Necrotizing enterocolitis (NEC) remains among the most common and devastating diseases in neonates. Despite advances in neonatal clinical care, specific treatment strategies and diagnostic modalities remain lacking. As a result, morbidity and mortality remain high. Improved understanding of the pathogenesis of NEC has the potential for improved therapeutics. Some of the areas of research leading to promising discoveries include inhibition of Toll-like receptor signaling, modulation of vascular endothelial growth factor signal pathways, defining metabolomic alterations in NEC to discover potential biomarkers, probing for genetic predispositions to NEC susceptibility, determining mechanistic relations between anemia and NEC, and microflora modulation through the use of probiotics. All of these areas may represent novel promising approaches to the prevention and treatment of NEC. This review will focus on these current and possible therapeutic perspectives.

The Therapeutic Potential of Breast Milk-Derived Extracellular Vesicles

In the past few decades, interest in the therapeutic benefits of exosomes and extracellular vesicles (EVs) has grown exponentially. Exosomes/EVs are small particles which are produced and exocytosed by cells throughout the body. They are loaded with active regulatory and stimulatory molecules from the parent cell including miRNAs and enzymes, making them prime targets in therapeutics and diagnostics. Breast milk, known for years to have beneficial health effects, contains a population of EVs which may mediate its therapeutic effects. This review offers an update on the therapeutic potential of exosomes/EVs in disease, with a focus on EVs present in human breast milk and their remedial effect in the gastrointestinal disease necrotizing enterocolitis. Additionally, the relationship between EV miRNAs, health, and disease will be examined, along with the potential for EVs and their miRNAs to be engineered for targeted treatments.

Stem cell therapy for preventing neonatal diseases in the 21st century: Current understanding and challenges

Diseases of the preterm newborn such as bronchopulmonary dysplasia, necrotizing enterocolitis, cerebral palsy, and hypoxic-ischemic encephalopathy continue to be major causes of infant mortality and long-term morbidity. Effective therapies for the prevention or treatment for these conditions are still lacking as recent clinical trials have shown modest or no benefit. Stem cell therapy is rapidly emerging as a novel therapeutic tool for several neonatal diseases with encouraging pre-clinical results that hold promise for clinical translation. However, there are a number of unanswered questions and facets to the development of stem cell therapy as a clinical intervention. There is much work to be done to fully elucidate the mechanisms by which stem cell therapy is effective (e.g., anti-inflammatory versus pro-angiogenic), identifying important paracrine mediators, and determining the timing and type of therapy (e.g., cellular versus secretomes), as well as patient characteristics that are ideal. Importantly, the interaction between stem cell therapy and current, standard-of-care interventions is nearly completely unknown. In this review, we will focus predominantly on the use of mesenchymal stromal cells for neonatal diseases, highlighting the promises and challenges in clinical translation towards preventing neonatal diseases in the 21st century.

Human Breast Milk-Derived Extracellular Vesicles in the Protection Against Experimental Necrotizing Enterocolitis

PURPOSE

Necrotizing enterocolitis (NEC) is a leading cause of death in premature infants. Breast feeding decreases the incidence of NEC but, even with aggressive promotion of nursing in Neonatal Intensive Care Units, morbidity and mortality remain high. Previous studies from our laboratory have demonstrated that extracellular vesicles (EVs) purified from mouse and rat stem cells can protect the intestines from NEC. The aim of this study was to determine whether human breast milk (BM)-derived EVs could prevent NEC.

METHODS

EVs were purified from human donor breast milk. NEC was induced in premature rat pups by exposure to asphyxia/hypothermia/hypercaloric feeds. Pups were randomized to: (1) breast fed, no injury, (2) NEC, (3) NEC + BM-derived EVs once intraperitoneally (IP), (4) NEC + BM-derived EVs enterally (PO) with each feed. Intestinal tracts were examined for histologic damage. Additionally, the effect of BM-derived EVs on intestinal epithelial cells (IEC) subjected to hypoxia/reoxygenation injury in vitro was examined.

RESULTS

NEC incidence was 0% in breast-fed pups and 62% in pups subjected to NEC. IP administration of BM-derived EVs decreased NEC incidence to 29% and enteral administration further decreased NEC incidence to 11.9%. (p < 0.05). BM-derived EVs significantly increased cell proliferation and decreased apoptosis in IEC in vitro.

CONCLUSION

Breast milk-derived EVs delivered either IP or enterally significantly decrease the incidence and severity of experimental NEC, protect IEC from injury in vitro, and may represent an innovative therapeutic option for NEC in the future.

TYPE OF STUDY

Basic science study.

LEVEL OF EVIDENCE

N/A.

Volume of Irrigation Does Not Affect Rate of Abscess in Perforated Appendicitis

Background: Although previous studies have evaluated whether use of irrigation decreases postoperative intraabdominal abscess (PO-IAA) formation, these studies treated irrigation as a dichotomous variable and concluded that no irrigation resulted in a decreased incidence of PO-IAA formation. However, a recent study found decreased incidence with small aliquots to a total volume of 6 L. We hypothesized that higher volumes of irrigation would result in a lower incidence of PO-IAA. Materials and Methods: A postoperative template was developed as a quality improvement initiative and included descriptors for complex appendicitis and volume of irrigation. Data were prospectively collected from February 2016 to December 2018. Patients with complex appendicitis (fibropurulent exudate, extraluminal fecalith, well-formed abscess, visible hole in the appendix) were identified and analyzed by using standard statistical analysis. Volume of irrigation was categorized for analysis. Results: Two thousand three hundred six appendicitis patients were identified; 408 had complex appendicitis (17.7%). Three hundred eighty-four patients with complex appendicitis had documented irrigation volumes. The overall incidence of PO-IAA was 13.8%. Irrigation was commonly used (92.7%). The median amount of irrigation was 1000 mL (500 mL, 2500 mL), but it ranged from none to 9000 mL. There was no overall difference in the volume of irrigation used between those who developed a PO-IAA and those who did not (P = .34). No specific intraoperative finding was associated with the development of PO-IAA. Increasing volume of irrigation did not lower PO-IAA incidence (P = .24). Conclusions: The volume of irrigation did not appear to affect the rate of PO-IAA formation. The use of irrigation should be left to the discretion of the operating surgeon.

Gangrenous appendicitis: No longer complicated

BACKGROUND

Appendicitis presents on a spectrum ranging from inflammation to gangrene to perforation. Studies suggest that gangrenous appendicitis has lower postoperative infection rates relative to perforated cases. We hypothesized that gangrenous appendicitis could be successfully treated as simple appendicitis, reducing length of stay (LOS) and antibiotic usage without increasing postoperative infections.

METHODS

In February 2016, we strictly defined complex appendicitis as a hole in the appendix, extraluminal fecalith, diffuse pus or a well-formed abscess. We switched gangrenous appendicitis to a simple pathway and reviewed all patients undergoing laparoscopic appendectomy for 12 months before (Group 1) and 12 months after (Group 2) the protocol change. Data collected included demographics, appendicitis classification, LOS, presence of a postoperative infection, and 30-day readmissions.

RESULTS

Patients in Group 1 and Group 2 were similar, but more cases of simple appendicitis occurred in Group 2. Average LOS for gangrenous appendicitis patients decreased from 2.5 to 1.4 days (p < 0.001) and antibiotic doses decreased from 5.2 to 1.3 (p < 0.001). Only one gangrenous appendicitis patient required readmission, and one patient in each group developed a superficial infection; there were no postoperative abscesses.

CONCLUSIONS

Gangrenous appendicitis can be safely treated as simple appendicitis without increasing postoperative infections or readmissions.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

Level II.

Development of a Standardized Scoring System to Assess a Murine Model of Clostridium difficile Colitis

Background: Clostridium difficile infection is the most common cause of antimicrobial-associated diarrhea. Our aim was to introduce a novel and efficient clinical sickness score (CSS), and to define a detailed histologic injury score (HIS) in a murine model of C. difficile colitis. Methods: Mice received an antibiotic cocktail (kanamycin, gentamicin, colistin, metronidazole, and vancomycin) for 96 h. After 48 h, mice received an intraperitoneal injection of clindamycin, followed by oral C. difficile (1.5 × 10⁷ CFU). Signs of sickness were scored using a novel CSS (range 0-12) with scores ≥6 consistent with C. difficile colitis. Intestinal tissue was analyzed utilizing an adapted HIS (range 0-9) with scores ≥4 consistent with C. difficile colitis. Stool was analyzed for C. difficile, and survival evaluated. Results: No control mice showed signs of sickness, whereas 23% of mice receiving antibiotics alone and 65% of mice exposed to antibiotics and subsequently C. difficile demonstrated signs of sickness (p = 0.0134). No control mice had histologic injury, whereas 8% of mice receiving antibiotics alone and 75% of mice exposed to antibiotics followed by C. difficile had evidence of histologic injury (p = 0.0001). Mice exposed to C. difficile lost more weight, although not significant (p = 0.070). Mice that received C. difficile had decreased survival compared to control mice and mice receiving antibiotics only (p = 0.03). Conclusions: We have developed a novel clinical scoring system, and detailed histological grading system, that enables the objective evaluation of a murine C. difficile colitis model. This model allows the study of this disease in a host that demonstrates clinical and histologic signs comparable to human C. difficile infection. This will allow for improved study of therapeutics for this disease in the future.

Influence of Growth Factors on the Development of Necrotizing Enterocolitis

Growth factors have important roles in gastrointestinal tract development, maintenance, and response to injury. Various experiments have been used to demonstrate growth factor influence in multiple disease processes. These studies demonstrated enhancement of mucosal proliferation, intestinal motility, immune modulation, and many other beneficial effects. Select growth factors, including epidermal growth factor and heparin-binding epidermal growth factor like growth factor, demonstrate some beneficial effects in experimental and clinical intestinal injury demonstrated in necrotizing enterocolitis. The roles of glucagon-like peptide 2, insulin-like growth factor 1, erythropoietin, growth hormone, and hepatocyte growth factor in necrotizing enterocolitis are summarized in this article.

Potential role of stem cells in disease prevention based on a murine model of experimental necrotizing enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is a devastating disease of newborns, and despite years of research, there is no known cure. The mortality rate of infants with NEC remains as high as 20%-30%. Babies who survive NEC frequently have long term complications including short gut syndrome, developmental delays and neurological sequelae. Unfortunately, despite much research over the past years, the precise pathogenesis of the disease is still not completely understood.

METHODS

Our laboratory has focused on identifying novel therapies to prevent the disease, including the use of stem cells (SC), heparin-binding epidermal growth factor-like growth factor (HB-EGF) and recently, stem cell derived-exosomes, a type of nanovesicle, to combat this illness.

RESULTS

We have outlined the major SC lines and data suggesting potential benefit as a curative or preventive approach for NEC as well as describing several new therapeutic strategies, including stem cell derived- exosomes and HB-EGF for decreasing the incidence and severity of this disease in rat models in our lab.

CONCLUSION

Overall, our lab has demonstrated that these different types of SC equivalently reduce the incidence and severity of NEC and equally preserve intestinal barrier function during NEC. We have previously demonstrated that AF-MSC can protect the intestines from intestinal injury and may therefore hold strong therapeutic potential for the prevention of NEC. Most recently, our work with stem cell derived-exosomes has shown them to be equivalent to their derived SC lines in decreasing the incidence of this disease.

Production of Tissue-Engineered Small Intestine in Rats with Different Ages of Cell Donors

IMPACT STATEMENT

This study compared side-by-side the impact of donor age on the production of tissue-engineered small intestine (TESI). Each age represents a specific period of life: E18 for fetuses, 5-day-old pups for neonates, 21-day-old rats for weanlings, and 6-week-old rats for adults. The TESI produced was compared macroscopically and microscopically. The mechanism(s) contributing to the differences observed was explored by detecting proliferating cells in the TESI and by analyzing intestinal stem cell gene expression in donor cells. These data may provide valuable information for future application of TESI clinically.

Comparison of polyglycolic acid, polycaprolactone, and collagen as scaffolds for the production of tissue engineered intestine

Cell-seeded scaffolds play critical roles in the production of tissue engineered intestine (TEI), a potential strategy for the treatment of short bowel syndrome. The current study compares polyglycolic acid (PGA), polycaprolactone (PCL), and collagen as scaffolds for TEI production. Tubular PGA scaffolds were prepared from nonwoven BIOFELT^® . Tubular PCL scaffolds were fabricated by electrospinning. Tubular collagen scaffolds were prepared using CollaTape, a wound dressing material. Both PGA and collagen were coated with poly-l-lactic acid (PLLA) to improve scaffold mechanical properties. Pore size, porosity, microstructure, mechanical properties (suture retention strength and ultimate compressive force) were determined. The scaffolds were first seeded with crypt stem cells isolated from 1 to 3 day old rat pups and then implanted into the peritoneal cavity of nude rats. After 4 weeks of in vivo incubation, these cell-seeded scaffolds were harvested for assessment of the TEI produced. Of the three materials compared, PLLA coated tubular PGA scaffolds had the appropriate pore size, mechanical properties and degradation rate leading to the production of TEI with an architecture similar to that of native rat intestine. © 2018 Wiley Periodicals, Inc. J. Biomed. Mater. Res. Part B, 2018. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 750-760, 2019.

An enhanced Lactobacillus reuteri biofilm formulation that increases protection against experimental necrotizing enterocolitis

One significant drawback of current probiotic therapy for the prevention of necrotizing enterocolitis (NEC) is the need for at least daily administration because of poor probiotic persistence after enteral administration, increasing the risk of the probiotic bacteria causing bacteremia or sepsis if the intestines are already compromised. We previously showed that the effectiveness of Lactobacillus reuteri ( Lr) in preventing NEC is enhanced when Lr is grown as a biofilm on the surface of dextranomer microspheres (DM). Here we sought to test the efficacy of Lr administration by manipulating the Lr biofilm state with the addition of biofilm-promoting substances (sucrose and maltose) to DM or by mutating the Lr gtfW gene (encoding an enzyme central to biofilm production). Using an animal model of NEC, we determined that Lr adhered to sucrose- or maltose-loaded DM significantly reduced histologic injury, improved host survival, decreased intestinal permeability, reduced intestinal inflammation, and altered the gut microbiome compared with Lr adhered to unloaded DM. These effects were abolished when DM or GtfW were absent from the Lr inoculum. This demonstrates that a single dose of Lr in its biofilm state decreases NEC incidence. Importantly, preloading DM with sucrose or maltose further enhances Lr protection against NEC in a GtfW-dependent fashion, demonstrating the tunability of the approach and the potential to use other cargos to enhance future probiotic formulations. NEW & NOTEWORTHY Previous clinical trials of probiotics to prevent necrotizing enterocolitis have had variable results. In these studies, probiotics were delivered in their planktonic, free-living form. We have developed a novel probiotic delivery system in which Lactobacillus reuteri (Lr) is delivered in its biofilm state. In a model of experimental necrotizing enterocolitis, this formulation significantly reduces intestinal inflammation and permeability, improves survival, and preserves the natural gut microflora compared with the administration of Lr in its free-living form.

Treatment of experimental necrotizing enterocolitis with stem cell-derived exosomes

PURPOSE

Necrotizing enterocolitis (NEC) remains a devastating disease in premature infants. We previously showed that four stem cell (SC) types equivalently improve experimental NEC. Exosomes are intercellular nanovesicles containing RNA, miRNA, DNA, and protein. Because SC therapy faces challenges, our aim was to determine if the beneficial effects of SC are achievable with cell-free exosomes.

METHODS

Exosomes from four SC types were compared: (1) amniotic fluid-derived mesenchymal SC (AF-MSC); (2) bone marrow-derived MSC (BM-MSC); (3) amniotic fluid-derived neural SC (AF-NSC); and (4) neonatal enteric NSC (E-NSC). Rat pups exposed to NEC received a varying concentration of a single type of exosome with control pups receiving PBS only. Intestinal damage was graded histologically.

RESULTS

The incidence of NEC was 0% in unstressed pups and 60.7% in control pups subjected to NEC. Exosomes (4.0×10⁸) reduced NEC incidence to: AF-MSC 25.0%; BM-MSC 23.1%; AF-NSC 11.1%; E-NSC 27.3%. When administered at a concentration of at least 4.0×10⁸, all groups demonstrated a significant reduction in NEC compared to untreated pups. At this minimum concentration, there was no difference in treatment efficacy between exosomes and the SC from which they were derived.

CONCLUSION

Stem cell-derived exosomes reduce the incidence and severity of experimental NEC as effectively as the stem cells from which they are derived, supporting the potential for novel cell-free exosome therapy for NEC.

TYPE OF STUDY

Basic science.

Comparison of Different In Vivo Incubation Sites to Produce Tissue-Engineered Small Intestine

OBJECTIVE

The objective of this study was to compare the impact of different in vivo incubation sites on the production of tissue-engineered small intestine (TESI).

MATERIALS AND METHODS

Green fluorescent protein transgenic rat pups (3-5 days) were used as donors of intestinal organoids. Harvested intestine was exposed to enzymatic digestion to release intestinal stem cell-containing organoids. Organoids were purified, concentrated, and seeded onto tubular polyglycolic acid scaffolds. Seeded scaffolds were implanted in each of five locations in recipient female nude rats: wrapped with omentum, wrapped with intestinal mesentery, wrapped with uterine horn membrane, attached to the abdominal wall, and inserted into the subcutaneous space. After 4 weeks of in vivo incubation, specimens from each site were explanted for evaluation.

RESULTS

Wrapping seeded scaffolds with vascularized membranes produced TESI with variable lengths of vascularized pedicles, with the longest pedicle length from uterine horn membrane, the shortest pedicle length from intestinal mesentery, and intermediate length from omentum. The quantity of TESI, as expressed by volume and neomucosal length, was identical in TESI produced by wrapping with any of the three membranes. The smallest quantity of TESI was found in TESI produced from insertion into the subcutaneous space, with an intermediate quantity of TESI produced from attachment to the abdominal wall. Periodic acid-Schiff and immunofluorescence (IF) staining confirmed the presence of all intestinal epithelial cell lineages in TESI produced at all incubation sites. Additional IF staining demonstrated the presence of enteric nervous system components and blood vessels. Wrapping of seeded scaffolds with vascularized membranes significantly increased the density of blood vessels in the TESI produced.

CONCLUSION

Wrapping of seeded scaffolds in vascularized membranes produced the largest quantity and highest quality of TESI. Attaching seeded scaffolds to the abdominal wall produced an intermediate quantity of TESI, but the quality was still comparable to TESI produced in vascularized membranes. Insertion of seeded scaffolds into the subcutaneous space produced the smallest quantity and lowest quality of TESI. In summary, wrapping seeded scaffolds with vascularized membranes is favorable for the production of TESI, and wrapping with omentum may produce TESI that is most easily anastomosed with host intestine.

Critical intestinal cells originate from the host in enteroid-derived tissue-engineered intestine

BACKGROUND

Enteroid-derived tissue-engineered intestine (TEI) contains intestinal subepithelial myofibroblasts (ISEMFs) and smooth muscle cells (SMCs). However, these cell types are not present in the donor enteroids. We sought to determine the origin of these cell types and to quantify their importance in TEI development.

MATERIALS AND METHODS

Crypts from pan-EGFP or LGR5-EGFP mice were used for enteroid culture and subsequent implantation for the production of TEI. TEI from pan-EGFP enteroids was labeled for smooth muscle alpha actin (SMA) to identify ISEMFs and SMCs and green fluorescent protein (GFP) to identify cells from pan-EGFP enteroids. Fluorescence in situ hybridization (FISH) for the Y chromosome was applied to TEI from male LGR5-EGFP enteroids implanted into female nonobese diabetic/severe combined immunodeficiency mice. To identify chemotactic effects of intestinal epithelium on ISEMFs, a Boyden chamber assay was performed.

RESULTS

Immunofluorescence of TEI from pan-EGFP enteroids revealed GFP-positive epithelium with surrounding SMA positivity and no colocalization of the two. FISH of TEI from male LGR5-EGFP enteroids implanted into female nonobese diabetic/severe combined immunodeficiency mice revealed that only the epithelium was Y chromosome positive. Chemotactic assays demonstrated increased ISEMF migration in the presence of enteroids (983 ± 133) compared to that in the presence of either Matrigel alone (357 ± 36) or media alone (339 ± 24; P ≤ 0.05).

CONCLUSIONS

Lack of GFP/SMA colocalization suggests that ISEMFs and SMCs are derived from host animals. This was confirmed by FISH which identified only epithelial cells as being male. All other cell types originated from host animals. The mechanism by which these cells are recruited is unknown; however, Boyden chamber assays indicate a direct chemotactic effect of intestinal epithelium on ISEMFs.

Stem cell therapy in necrotizing enterocolitis: Current state and future directions

Stem cell therapy is a promising treatment modality for necrotizing enterocolitis. Among the many promising stem cells identified to date, it is likely that mesenchymal stem cells will be the most useful and practical cell-based therapies for this condition. Using acellular components such as exosomes or other paracrine mediators are promising as well. Multiple mechanisms are likely at play in the positive effects provided by these cells, and further research is underway to further elucidate these effects.

Single visit surgery for pediatric ambulatory surgical procedures: a satisfaction and cost analysis

BACKGROUND

Single visit surgery (SVS) consists of same-day pre-operative assessment and operation with telephone post-operative follow-up. This reduces family time commitment to 1 hospital trip rather than 2-3. We began SVS for ambulatory patients with clear surgical indications in 2013. We sought to determine family satisfaction, cost savings to families, and institutional financial feasibility of SVS.

METHODS

SVS patients were compared to age/case matched conventional surgery (CS) patients. Satisfaction was assessed by post-operative telephone survey. Family costs were calculated as the sum of lost revenue (based on median income) and transportation costs ($0.50/mile).

RESULTS

Satisfaction was high in both groups (98% for SVS vs. 93% for CS; p=0.27). 40% of CS families indicated that they would have preferred SVS, whereas no SVS families indicated preference for the CS option (p<0.001). Distance from the hospital did not correlate with satisfaction. Estimated cost savings for an SVS family was $188. Reimbursement, hospital and physician charges, and day-of-surgery cancellation rates were similar.

CONCLUSIONS

SVS provides substantial cost savings to families while maintaining patient satisfaction and equivalent institutional reimbursement. SVS is an effective approach to low-risk ambulatory surgical procedures that is less disruptive to families, facilitates access to pediatric surgical care, and reduces resource utilization.

TYPE OF STUDY

Cost Effectiveness Study.

LEVEL OF EVIDENCE

Level II.

Using quality improvement methodology to improve ovarian salvage for benign ovarian masses

PURPOSE

Most ovarian masses in children are benign and potentially amenable to ovarian salvage surgery (OSS). Despite the common use of OSS among pediatric and adolescent gynecologists (PAG) in recognition of reproductive and hormonal health advantages, this technique is not commonly performed by pediatric surgeons. The aim of this quality improvement (QI) initiative was to improve our institutional rate of OSS for benign ovarian masses.

METHODS

Baseline data were obtained retrospectively from surgical procedures performed for benign ovarian masses between January 2012 and February 2016. Designed interventions to improve the rate of OSS included the development of an ovarian mass algorithm, standardization of radiologic templates, multidisciplinary analyses of ovarian procedures, and implementation of a training model for performing OSS. Procedures performed for benign ovarian masses from March 2016 to February 2017 comprised the process stage.

RESULTS

Our institutional baseline OSS rate was 28.8%. After implementation of the institutional algorithm, a single oophorectomy was performed for a benign mass, increasing the OSS rate to 96%. There have been no missed ovarian malignancies.

CONCLUSIONS

Utilizing preoperative risk assessment, QI methodology and multidisciplinary collaboration resulted in improved OSS rates for benign ovarian masses with no evidence of missed ovarian malignancies.

LEVEL OF EVIDENCE

Level II. This is a prospective comparative study, with comparison to a retrospective cohort. This is a quality improvement initiative without randomization.

Effective methods to decrease surgical site infections in pediatric gastrointestinal surgery

BACKGROUND

Gastrointestinal (GI) surgeries represent a significant proportion of the surgical site infection (SSI) burden in pediatric patients, resulting in significant morbidity. Previous studies have shown that perioperative bundles reduce SSIs, but few have focused on pediatric GI operations. We hypothesized that a GI bundle would decrease SSI rates, length of stay (LOS), and hospital charges.

METHODS

After establishing baseline SSI rates, a GI bundle was created and implemented in November 2014. We prospectively collected data including demographics, procedure type, LOS, inpatient charges, bundle compliance, and SSI development. We analyzed SSI rates, LOS, and charges using process control charts.

RESULTS

The baseline SSI rate for all GI operations was 3.4%, which increased to 7.1%, then decreased to 4.7%. Midgut/hindgut and stoma closure SSI rates decreased from 11.3% to 8.0% (p<0.05) and 21.4% to 7.9%, respectively (p<0.05). Although overall LOS and charges were unchanged, average LOS for midgut/hindgut surgeries and stoma closures decreased from 20.3 to 13.6days (p=0.015) and 12.6 to 7.9days (p=0.04), respectively. Stoma closure charges decreased from $94,262 to $50,088 (p=0.01).

CONCLUSIONS

Our perioperative GI bundle decreased SSI rates, primarily among midgut/hindgut operations. Bundle usage decreased LOS and charges most effectively in stoma closures.

TYPE OF STUDY

Prognosis Study.

LEVEL OF EVIDENCE

Level 2.

Stem cells and necrotizing enterocolitis: A direct comparison of the efficacy of multiple types of stem cells

PURPOSE

Necrotizing enterocolitis (NEC) is a leading cause of gastrointestinal morbidity and mortality in premature infants. While studies have shown potential for stem cell (SC) therapy in experimental NEC, no study has compared different SC side-by-side. Our purpose was to determine whether one type of SC may more effectively treat NEC than others.

METHODS

Four SC were compared: (1) amniotic fluid-derived mesenchymal SC (AF-MSC); (2) amniotic fluid-derived neural SC (AF-NSC); (3) bone marrow-derived mesenchymal SC (BM-MSC); and (4) neonatal enteric neural SC (E-NSC). Using an established rat model of NEC, pups delivered prematurely received an intraperitoneal injection of SC. Control pups were injected with PBS. Additional controls were breast-fed by surrogates and not subjected to experimental NEC. Intestinal tissue was graded histologically.

RESULTS

NEC incidence was: PBS, 61.3%; breast-fed unstressed, 0%; AF-MSC, 19.1%; BM-MSC, 22.9%; AF-NSC, 18.9%; E-NSC 22.2%. All groups demonstrated statistical significance (p<0.05) compared to controls, and there was no difference between SC groups.

CONCLUSION

All four SC groups reduced the incidence and severity of experimental NEC equivalently. AF-MSC may be preferable because of availability of AF at delivery and ease of expansion, increasing potential for clinical translation.

LEVEL OF EVIDENCE

V (Animal study).

Inter-facility transfer of pediatric burn patients from U.S. Emergency Departments

PURPOSE

To describe the epidemiology of pediatric burn patients seen in U.S. emergency departments (EDs) and to determine factors associated with inter-facility transfer.

METHODS

We analyzed data from the 2012 Nationwide Emergency Department Sample. Current American Burn Association (ABA) Guidelines were used to identify children <18 who met criteria for referral to burn centers. Burn patient admission volume was used as a proxy for burn expertise. Logistic models were fitted to examine the odds of transfer from low volume hospitals.

RESULTS

In 2012, there were an estimated 126,742 (95% CI: 116,104-137,380) pediatric burn ED visits in the U.S. Of the 69,003 (54.4%) meeting referral criteria, 83.2% were in low volume hospitals. Only 8.2% of patients meeting criteria were transferred from low volume hospitals. Of the 52,604 (95% CI: 48,433-56,775) not transferred, 98.3% were treated and released and 1.7% were admitted without transfer; 54.7% of burns involved hands.

CONCLUSIONS

Over 90% of pediatric burn ED patients meet ABA burn referral criteria but are not transferred from low volume hospitals. Perhaps a portion of the 92% of patients currently receiving definitive care in low volume hospitals are under-referred and would have improved clinical outcomes if transferred at the time of presentation.

Exosomes secreted from bone marrow-derived mesenchymal stem cells protect the intestines from experimental necrotizing enterocolitis

PURPOSE

Treatment options for necrotizing enterocolitis (NEC) remain inadequate. Bone marrow-derived mesenchymal stem cells (BM-MSCs) can protect the intestines from NEC. Exosomes are nanoparticle-sized vesicles with important cell signaling capabilities. The objective of this study was to determine whether BM-MSC-derived exosomes can prevent NEC.

METHODS

Rat pups were either breast fed (Group 1) or subjected to experimental NEC and randomized to receive either no treatment (Group 2) or an intraperitoneal (IP) injection of PBS (Group 3), BM-MSC (Group 4), or BM-MSC-derived exosomes (Group 5). Histologic injury grade and intestinal permeability were determined. The effect of BM-MSC-derived exosomes on IEC-6 intestinal epithelial cells in an in vitro scrape model of wound healing was also determined.

RESULTS

Animals exposed to NEC that were either untreated or received PBS alone had an NEC incidence of 46% and 41%, respectively (p=0.61). Compared to untreated pups, the incidence of NEC was significantly lower in pups treated with either BM-MSC (9%, p=0.0003) or MB-MSC-derived exosomes (13%, p=0.0008). Similar results were found for intestinal permeability. Wound healing in IEC-6 cells was significantly increased by BM-MSC-derived exosomes.

CONCLUSION

BM-MSC-derived exosomes protect the intestines from NEC and may represent a novel, cell-free, preventative therapy for NEC in the future.

Harvesting the benefits of biofilms: A novel probiotic delivery system for the prevention of necrotizing enterocolitis

BACKGROUND/PURPOSE

Probiotics reduce the incidence of necrotizing enterocolitis (NEC) albeit only when administered at high frequency (at least daily). We have developed a novel probiotic delivery system in which probiotics are grown as a biofilm on microspheres, allowing enhanced efficacy with only a single treatment.

METHODS

Neonatal rats were subjected to experimental NEC. Pups received a single enteral dose of: (1) vehicle only, (2) unloaded microspheres, (3) MRS (broth)-loaded microspheres, (4) Lactobacillus reuteri, (5) L. reuteri grown on unloaded microspheres, or (6) L. reuteri grown on MRS-loaded microspheres. Intestinal injury was graded histologically and intestinal permeability determined by serum levels of enterally administered fluorescein isothiocyanate-labeled dextran.

RESULTS

69% of untreated pups developed NEC, whereas 32% of pups treated with L. reuteri grown as a biofilm on unloaded microspheres (p=0.009) and 33% of pups treated with L. reuteri grown as a biofilm on MRS-loaded microspheres (p=0.005) developed NEC. No other group had a significant reduction in NEC. Furthermore, pups treated with L. reuteri grown as a biofilm had significantly reduced intestinal permeability.

CONCLUSIONS

A single dose of Lactobacillus biofilm grown on biocompatible microspheres significantly reduces NEC incidence and severity. This novel probiotic delivery system may be beneficial in the prevention of NEC in the future.

Production of tissue-engineered intestine from expanded enteroids

BACKGROUND

Short bowel syndrome is a life-threatening condition with few solutions. Tissue-engineered intestine (TEI) is a potential treatment, but donor intestine is a limiting factor. Expanded epithelial surrogates termed enteroids may serve as a potential donor source.

MATERIALS AND METHODS

To produce TEI from enteroids, crypts were harvested from mice and enteroid cultures established. Enteroids were seeded onto polymer scaffolds using Matrigel or culture medium and implanted in immunosuppressed mice for 4 wk. Histology was analyzed using Periodic acid-Schiff staining and immunofluorescence. Neomucosa was quantified using ImageJ software. To determine whether TEI could be produced from enteroids established from small intestinal biopsies, 2 × 2-mm pieces of jejunum were processed for enteroid culture, enteroids were expanded and seeded onto scaffolds, and scaffolds implanted for 4 wk.

RESULTS

Enteroids in Matrigel produced TEI in 15 of 15 scaffolds, whereas enteroids in medium produced TEI in 9 of 15 scaffolds. Use of Matrigel led to more neomucosal surface area compared to media (10,520 ± 2905 μm versus 450 ± 127 μm, P < 0.05). Histologic examination confirmed the presence of crypts and blunted villi, normal intestinal epithelial lineages, intestinal subepithelial myofibroblasts, and smooth muscle cells. Crypts obtained from biopsies produced an average of 192 ± 71 enteroids. A single passage produced 685 ± 58 enteroids, which was adequate for scaffold seeding. TEI was produced in 8 of 9 scaffolds seeded with expanded enteroids.

CONCLUSIONS

Enteroids can be obtained from minimal starting material, expanded ex vivo, and implanted to produce TEI. This method shows promise as a solution to the limited donor intestine available for TEI production in patients with short bowel syndrome.

Implementation of a pediatric surgical quality improvement (QI)-driven M&M conference

BACKGROUND/PURPOSE

The M&M conference at Nationwide Children's Hospital (NCH) categorized failures as technical error or patient disease, but failure modes were never captured, action items rarely assigned, and follow-up rarely completed. In 2013 a QI-driven M&M conference was developed, supporting implementation of directed actions to improve quality of care.

METHODS

A classification was developed to enhance analysis of complications. Each complication was analyzed for identification of failure modes with subcategorization of root cause, a level of preventability assigned, and action items designated. Failure determinations from 11/2013-10/2014 were reviewed to evaluate the distribution of failure modes and action items.

RESULTS

Two-hundred thirty-seven patients with complications were reviewed. One-hundred thirty patients had complications attributed to patient disease with no individual or system failure identified, whereas 107 patients had identifiable failures. Eighty-five patients had one failure identified, and 22 patients had multiple failures identified. Of the 142 failures identified in 107 patients, 112 (78.9%) were individual failures, and 30 (21.1%) were system failures. One-hundred forty-seven action items were implemented including education initiatives, establishing criteria for interdisciplinary consultation, resolving equipment inadequacies, removing high risk medications from formulary, restructuring physician handoffs, and individual practitioner counseling/training.

CONCLUSIONS

Development of a QI-driven M&M conference allowed us to categorize complications beyond surgical or patient disease categories, ensuring added focus on system solutions and a reliable accountability structure to ensure implementation of assigned interventions intended to address failures. This may lead to improvement in the processes of patient care.