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Maiga AW, Snyder RA, Kao LS, Raval MV, Patel MB, Blakely ML. Advancing Randomized Clinical Trials in Surgery: Role of Exception From Informed Consent, Central Institutional Review Board, and Bayesian Approaches. J Surg Res 2024:S0022-4804(24)00167-7. [PMID: 38670847 DOI: 10.1016/j.jss.2024.03.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/16/2024] [Accepted: 03/12/2024] [Indexed: 04/28/2024]
Affiliation(s)
- Amelia W Maiga
- Division of Acute Care Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Critical Illness, Brain dysfunction, and Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Rebecca A Snyder
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lillian S Kao
- Division of Acute Care Surgery, Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mayur B Patel
- Division of Acute Care Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Critical Illness, Brain dysfunction, and Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research Education and Clinical Center, Surgical Services, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Martin L Blakely
- Department of Surgery, Institute for Clinical Research and Learning Health Care, Institute for Implementation Science, University of Texas Health Science Center at Houston, Houston, Texas
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Blakely ML, Krzyzaniak A, Dassinger MS, Pedroza C, Weitkamp JH, Gosain A, Cotten M, Hintz SR, Rice H, Courtney SE, Lally KP, Ambalavanan N, Bendel CM, Bui KCT, Calkins C, Chandler NM, Dasgupta R, Davis JM, Deans K, DeUgarte DA, Gander J, Jackson CCA, Keszler M, Kling K, Fenton SJ, Fisher KA, Hartman T, Huang EY, Islam S, Koch F, Lainwala S, Lesher A, Lopez M, Misra M, Overbey J, Poindexter B, Russell R, Stylianos S, Tamura DY, Yoder BA, Lucas D, Shaul D, Ham PB, Fitzpatrick C, Calkins K, Garrison A, de la Cruz D, Abdessalam S, Kvasnovsky C, Segura BJ, Shilyansky J, Smith LM, Tyson JE. Effect of Early vs Late Inguinal Hernia Repair on Serious Adverse Event Rates in Preterm Infants: A Randomized Clinical Trial. JAMA 2024; 331:1035-1044. [PMID: 38530261 DOI: 10.1001/jama.2024.2302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Importance Inguinal hernia repair in preterm infants is common and is associated with considerable morbidity. Whether the inguinal hernia should be repaired prior to or after discharge from the neonatal intensive care unit is controversial. Objective To evaluate the safety of early vs late surgical repair for preterm infants with an inguinal hernia. Design, Setting, and Participants A multicenter randomized clinical trial including preterm infants with inguinal hernia diagnosed during initial hospitalization was conducted between September 2013 and April 2021 at 39 US hospitals. Follow-up was completed on January 3, 2023. Interventions In the early repair strategy, infants underwent inguinal hernia repair before neonatal intensive care unit discharge. In the late repair strategy, hernia repair was planned after discharge from the neonatal intensive care unit and when the infants were older than 55 weeks' postmenstrual age. Main Outcomes and Measures The primary outcome was occurrence of any prespecified serious adverse event during the 10-month observation period (determined by a blinded adjudication committee). The secondary outcomes included the total number of days in the hospital during the 10-month observation period. Results Among the 338 randomized infants (172 in the early repair group and 166 in the late repair group), 320 underwent operative repair (86% were male; 2% were Asian, 30% were Black, 16% were Hispanic, 59% were White, and race and ethnicity were unknown in 9% and 4%, respectively; the mean gestational age at birth was 26.6 weeks [SD, 2.8 weeks]; the mean postnatal age at enrollment was 12 weeks [SD, 5 weeks]). Among 308 infants (91%) with complete data (159 in the early repair group and 149 in the late repair group), 44 (28%) in the early repair group vs 27 (18%) in the late repair group had at least 1 serious adverse event (risk difference, -7.9% [95% credible interval, -16.9% to 0%]; 97% bayesian posterior probability of benefit with late repair). The median number of days in the hospital during the 10-month observation period was 19.0 days (IQR, 9.8 to 35.0 days) in the early repair group vs 16.0 days (IQR, 7.0 to 38.0 days) in the late repair group (82% posterior probability of benefit with late repair). In the prespecified subgroup analyses, the probability that late repair reduced the number of infants with at least 1 serious adverse event was higher in infants with a gestational age younger than 28 weeks and in those with bronchopulmonary dysplasia (99% probability of benefit in each subgroup). Conclusions and Relevance Among preterm infants with inguinal hernia, the late repair strategy resulted in fewer infants having at least 1 serious adverse event. These findings support delaying inguinal hernia repair until after initial discharge from the neonatal intensive care unit. Trial Registration ClinicalTrials.gov Identifier: NCT01678638.
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Affiliation(s)
- Martin L Blakely
- Department of Surgery, Institute for Clinical Research and Learning Healthcare and Institute for Implementation Science, University of Texas Health Science Center, Houston
| | | | - Melvin S Dassinger
- Division of Pediatric Surgery, University of Arkansas for Medical Sciences, Little Rock
| | - Claudia Pedroza
- Department of Pediatrics, Institute for Clinical Research and Learning Healthcare, University of Texas Health Science Center, Houston
| | | | - Ankush Gosain
- Division of Pediatric Surgery, University of Colorado, Aurora
| | - Michael Cotten
- Division of Neonatology, Duke University, Durham, North Carolina
| | - Susan R Hintz
- Division of Neonatology, Stanford University, Palo Alto, California
| | - Henry Rice
- Division of Pediatric Surgery, Duke University, Durham, North Carolina
| | - Sherry E Courtney
- Division of Neonatology, University of Arkansas for Medical Sciences, Little Rock
| | - Kevin P Lally
- Department of Pediatric Surgery, University of Texas Health Science Center, Houston
| | | | | | - Kim Chi T Bui
- Division of Neonatology, Kaiser Permanente, Los Angeles, California
| | - Casey Calkins
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St Petersburg, Florida
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jonathan M Davis
- Division of Neonatology, Tufts Medical Center, Boston, Massachusetts
| | - Katherine Deans
- Department of Pediatric Surgery, Nemours Children's Hospital, Wilmington, Delaware
| | - Daniel A DeUgarte
- Division of Pediatric Surgery, David Geffen School of Medicine, University of California, Los Angeles
| | - Jeffrey Gander
- Division of Pediatric Surgery, University of Virginia, Charlottesville
| | - Carl-Christian A Jackson
- Division of Pediatric Surgery, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Martin Keszler
- Division of Neonatology, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Karen Kling
- Rady Children's Hospital and Division of Pediatric Surgery, University of California, San Diego
| | - Stephen J Fenton
- Division of Pediatric Surgery, University of Utah, Salt Lake City
| | | | - Tyler Hartman
- Division of Neonatology, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Eunice Y Huang
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Saleem Islam
- Division of Pediatric Surgery, University of Florida, Gainesville
- Department of Surgery, Aga Khan University, Sindh, Pakistan
| | - Frances Koch
- Division of Neonatology, Medical University of South Carolina, Charleston
| | - Shabnam Lainwala
- Division of Neonatology, Connecticut Children's Medical Center, Hartford
| | - Aaron Lesher
- Division of Pediatric Surgery, Medical University of South Carolina, Charleston
| | - Monica Lopez
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Meghna Misra
- Pediatric Surgery, Elliot Hospital, Manchester, New Hampshire
| | - Jamie Overbey
- Division of Neonatology, Naval Medical Center, San Diego, California
| | - Brenda Poindexter
- Division of Neonatology, School of Medicine, Emory University, Atlanta, Georgia
| | - Robert Russell
- Division of Pediatric Surgery, University of Alabama at Birmingham
| | - Steven Stylianos
- Division of Pediatric Surgery, Columbia University Medical Center, Morgan Stanley Children's Hospital, New York, New York
| | - Douglas Y Tamura
- Division of Pediatric Surgery, Valley Children's Hospital, Madera, California
| | | | - Donald Lucas
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Division of Pediatric Surgery, Naval Medical Center, San Diego, California
| | - Donald Shaul
- Division of Pediatric Surgery, Kaiser Permanente, Los Angeles, California
| | - P Ben Ham
- Division of Pediatric Surgery, University at Buffalo, Buffalo, New York
| | - Colleen Fitzpatrick
- Division of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health, New Hyde Park, New York
| | - Kara Calkins
- Division of Neonatology, David Geffen School of Medicine, University of California, Los Angeles
| | - Aaron Garrison
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Diomel de la Cruz
- Division of Neonatology, School of Medicine, University of Florida, Gainesville
| | - Shahab Abdessalam
- Division of Neonatology, University of Nebraska Medical Center, Omaha
| | | | - Bradley J Segura
- Division of Pediatric Surgery, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis
| | - Joel Shilyansky
- Department of Pediatric Surgery, University of Iowa Stead Family Children's Hospital, Iowa City
| | | | - Jon E Tyson
- Department of Pediatrics, Institute for Clinical Research and Learning Healthcare, University of Texas Health Science Center, Houston
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Cramm SL, Graham DA, Blakely ML, Cowles RA, Kunisaki SM, Lipskar AM, Russell RT, Santore MT, DeFazio JR, Griggs CL, Aronowitz DI, Allukian M, Campbell BT, Chandler NM, Collins DT, Commander SJ, Dukleska K, Echols JC, Esparaz JR, Feng C, Gerall C, Hanna DN, Keane OA, McLean SE, Pace E, Scholz S, Sferra SR, Tracy ET, Williams S, Zhang L, He K, Rangel SJ. Utility of a Benchmarking Report for Balancing Infection Prevention and Antimicrobial Stewardship in Children with Complicated Appendicitis. Ann Surg 2024:00000658-990000000-00789. [PMID: 38385252 DOI: 10.1097/sla.0000000000006246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
OBJECTIVE To develop a severity-adjusted, hospital-level benchmarking comparative performance report for postoperative organ space infection and antibiotic utilization in children with complicated appendicitis. BACKGROUND No benchmarking data exist to aid hospitals in identifying and prioritizing opportunities for infection prevention or antimicrobial stewardship in children with complicated appendicitis. METHODS This was a multicenter cohort study using NSQIP-Pediatric data from 16 hospitals participating in a regional research consortium, augmented with antibiotic utilization data obtained through supplemental chart review. Children with complicated appendicitis who underwent appendectomy from 07/01/2015 to 06/30/2020 were included. Thirty-day postoperative OSI rates and cumulative antibiotic utilization were compared between hospitals using observed-to-expected (O/E) ratios after adjusting for disease severity using mixed effects models. Hospitals were considered outliers if the 95% confidence interval for O/E ratios did not include 1.0. RESULTS 1790 patients were included. Overall, the OSI rate was 15.6% (hospital range: 2.6-39.4%) and median cumulative antibiotic utilization was 9.0 days (range: 3.0-13.0). Across hospitals, adjusted O/E ratios ranged 5.7-fold for OSI (0.49-2.80, P=0.03) and 2.4-fold for antibiotic utilization (0.59-1.45, P<0.01). Three (19%) hospitals were outliers for OSI (1 high and 2 low performers), and eight (50%) were outliers for antibiotic utilization (5 high and 3 low utilizers). Ten (63%) hospitals were identified as outliers in one or both measures. CONCLUSIONS A comparative performance benchmarking report may help hospitals identify and prioritize quality improvement opportunities for infection prevention and antimicrobial stewardship, as well as identify exemplar performers for dissemination of best practices.
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Affiliation(s)
- Shannon L Cramm
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Dionne A Graham
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, MA
| | - Martin L Blakely
- Division of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Robert A Cowles
- Department of Pediatric Surgery, Yale New Haven Children's Hospital, Yale School of Medicine, New Haven, CT
| | - Shaun M Kunisaki
- Department of Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Aaron M Lipskar
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - Robert T Russell
- Division of Pediatric Surgery, Children's of Alabama, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Matthew T Santore
- Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Jennifer R DeFazio
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos College of Physcians and Surgeons, New York, NY
| | - Cornelia L Griggs
- Department of Surgery, Division of Pediatric Surgery, Massachusetts General Hospital, Boston, MA
| | - Danielle I Aronowitz
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkin's All Children's Hospital, St. Petersburg, FL
| | - Devon T Collins
- Department of Surgery, Children's National Hospital, Washington, D.C
| | - Sarah J Commander
- Department of Surgery, Duke Children's Hospital and Health Center, Durham, NC
| | - Katerina Dukleska
- Division of Pediatric Surgery, Johns Hopkin's All Children's Hospital, St. Petersburg, FL
| | - Justice C Echols
- Division of Pediatric Surgery, University of North Carolina Health System, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Joseph R Esparaz
- Division of Pediatric Surgery, Children's of Alabama, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Christina Feng
- Department of Surgery, Children's National Hospital, Washington, D.C
| | - Claire Gerall
- Department of Surgery, UT Health San Antonio, San Antonio, TX
| | - David N Hanna
- Division of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Olivia A Keane
- Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Sean E McLean
- Department of Surgery, UT Health San Antonio, San Antonio, TX
| | - Elizabeth Pace
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Stefan Scholz
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Shelby R Sferra
- Department of Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Elisabeth T Tracy
- Department of Surgery, Duke Children's Hospital and Health Center, Duke University School of Medicine, Durham, NC
| | - Sacha Williams
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Lucy Zhang
- Department of Pediatric Surgery, Yale New Haven Children's Hospital, Yale School of Medicine, New Haven, CT
| | - Katherine He
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Cramm SL, Graham DA, Blakely ML, Kunisaki SM, Chandler NM, Cowles RA, Feng C, He K, Russell RT, Allukian M, Campbell BT, Commander SJ, DeFazio JR, Dukleska K, Echols JC, Esparaz JR, Gerall C, Griggs CL, Hanna DN, Keane OA, Lipskar AM, McLean SE, Pace E, Santore MT, Scholz S, Sferra SR, Tracy ET, Zhang L, Rangel SJ. Postoperative Antibiotics, Outcomes, and Resource Use in Children With Gangrenous Appendicitis. JAMA Surg 2024:2814717. [PMID: 38324276 PMCID: PMC10851140 DOI: 10.1001/jamasurg.2023.7754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/04/2023] [Indexed: 02/08/2024]
Abstract
Importance Gangrenous, suppurative, and exudative (GSE) findings have been associated with increased surgical site infection (SSI) risk and resource use in children with nonperforated appendicitis. Establishing the role for postoperative antibiotics may have important implications for infection prevention and antimicrobial stewardship. Objective To compare SSI rates in children with nonperforated appendicitis with GSE findings who did and did not receive postoperative antibiotics. Design, Setting, and Participants This was a retrospective cohort study using American College of Surgeons' National Surgical Quality Improvement Program (NSQIP)-Pediatric Appendectomy Targeted data from 16 hospitals participating in a regional research consortium. NSQIP data were augmented with operative report and antibiotic use data obtained through supplemental medical record review. Children with nonperforated appendicitis with GSE findings who underwent appendectomy between July 1, 2015, and June 30, 2020, were identified using previously validated intraoperative criteria. Data were analyzed from October 2022 to July 2023. Exposure Continuation of antibiotics after appendectomy. Main Outcomes and Measures Rate of 30-day postoperative SSI including both incisional and organ space infections. Complementary hospital and patient-level analyses were conducted to explore the association between postoperative antibiotic use and severity-adjusted outcomes. The hospital-level analysis explored the correlation between postoperative antibiotic use and observed to expected (O/E) SSI rate ratios after adjusting for differences in disease severity (presence of gangrene and postoperative length of stay) among hospital populations. In the patient-level analysis, propensity score matching was used to balance groups on disease severity, and outcomes were compared using mixed-effects logistic regression to adjust for hospital-level clustering. Results A total of 958 children (mean [SD] age, 10.7 [3.7] years; 567 male [59.2%]) were included in the hospital-level analysis, of which 573 (59.8%) received postoperative antibiotics. No correlation was found between hospital-level SSI O/E ratios and postoperative antibiotic use when analyzed by either overall rate of use (hospital median, 53.6%; range, 31.6%-100%; Spearman ρ = -0.10; P = .71) or by postoperative antibiotic duration (hospital median, 1 day; range, 0-7 days; Spearman ρ = -0.07; P = .79). In the propensity-matched patient-level analysis including 404 patients, children who received postoperative antibiotics had similar rates of SSI compared with children who did not receive postoperative antibiotics (3 of 202 [1.5%] vs 4 of 202 [2.0%]; odds ratio, 0.75; 95% CI, 0.16-3.39; P = .70). Conclusions and Relevance Use of postoperative antibiotics did not improve outcomes in children with nonperforated appendicitis with gangrenous, suppurative, or exudative findings.
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Affiliation(s)
- Shannon L. Cramm
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dionne A. Graham
- Program for Patient Safety and Quality, Boston Children’s Hospital, Boston, Massachusetts
| | - Martin L. Blakely
- Division of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shaun M. Kunisaki
- Department of Surgery, Johns Hopkins Children’s Center, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nicole M. Chandler
- Division of Pediatric Surgery, Johns Hopkin’s All Children’s Hospital, St. Petersburg, Florida
| | - Robert A. Cowles
- Department of Pediatric Surgery, Yale New Haven Children’s Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Christina Feng
- Department of Surgery, Children’s National Hospital, Washington, D.C
| | - Katherine He
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert T. Russell
- Division of Pediatric Surgery, Children’s of Alabama; Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children’s Hospital of Philadelphia, Perelman Medical School at the University of Pennsylvania, Philadelphia
| | - Brendan T. Campbell
- Department of Surgery, Connecticut Children’s Hospital, Hartford, Connecticut
| | - Sarah J. Commander
- Department of Surgery, Duke Children’s Hospital and Health Center, Durham, North Carolina
| | - Jennifer R. DeFazio
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children’s Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York
| | - Katerina Dukleska
- Department of Surgery, Connecticut Children’s Hospital, Hartford, Connecticut
| | - Justice C. Echols
- Department of Surgery, University of North Carolina Health System, University of North Carolina School of Medicine, Chapel Hill
| | - Joseph R. Esparaz
- Division of Pediatric Surgery, Children’s of Alabama; Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Claire Gerall
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
| | - Cornelia L. Griggs
- Department of Surgery, Division of Pediatric Surgery, Massachusetts General Hospital, Boston
| | - David N. Hanna
- Division of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Olivia A. Keane
- Department of Surgery, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Aaron M. Lipskar
- Division of Pediatric Surgery, Cohen Children’s Medical Center, Zucker School of Medicine at Hoftsra/Northwell, New Hyde Park, New York
| | - Sean E. McLean
- Division of Pediatric Surgery, University of North Carolina Health System, University of North Carolina School of Medicine, Chapel Hill
| | - Elizabeth Pace
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew T. Santore
- Department of Surgery, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Stefan Scholz
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Shelby R. Sferra
- Department of Surgery, Johns Hopkins Children’s Center, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Elisabeth T. Tracy
- Department of Surgery, Duke Children’s Hospital and Health Center, Durham, North Carolina
| | - Lucy Zhang
- Department of Pediatric Surgery, Yale New Haven Children’s Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Shawn J. Rangel
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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5
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Cramm SL, Graham DA, Feng C, Allukian M, Blakely ML, Chandler NM, Cowles RA, Kunisaki SM, Lipskar AM, Russell RT, Santore MT, Campbell BT, Commander SJ, DeFazio JR, Dukleska K, Echols JC, Esparaz JR, Gerall C, Griggs CL, Hanna DN, He K, Keane OA, McLean SE, Pace E, Scholz S, Sferra SR, Tracy ET, Zhang L, Rangel SJ. Use of Antipseudomonal Antibiotics is not Associated with Lower Rates of Postoperative Drainage Procedures or More Favorable Culture Profiles in Children with Complicated Appendicitis: Results from a Multicenter Regional Research Consortium. Ann Surg 2023:00000658-990000000-00697. [PMID: 37970676 DOI: 10.1097/sla.0000000000006152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
OBJECTIVE To compare rates of postoperative drainage and culture profiles in children with complicated appendicitis treated with the two most common antibiotic regimens with and without antipseudomonal activity (piperacillin-tazobactam [PT] and ceftriaxone with metronidazole [CM]). SUMMARY OF BACKGROUND DATA Variation in use of antipseudomonal antibiotics has been driven by a paucity of multicenter data reporting clinically relevant, culture-based outcomes. METHODS Retrospective cohort study of patients with complicated appendicitis (7/2015-6/2020) using NSQIP-Pediatric data from 15 hospitals participating in a regional research consortium. Operative report details, antibiotic utilization, and culture data were obtained through supplemental chart review. Rates of 30-day postoperative drainage and organism-specific culture positivity were compared between groups using mixed effects regression to adjust for clustering after propensity matching on measures of disease severity. RESULTS 1002 children met criteria for matching (58.9% received CM and 41.1% received PT). In the matched sample of 778 patients, children treated with PT had similar rates of drainage overall (PT: 11.8%, CM: 12.1%; OR 1.44 [OR:0.71-2.94]) and higher rates of drainage associated with growth of any organism (PT: 7.7%, CM: 4.6%; OR 2.41 [95%CI:1.08-5.39]) and Escherichia coli (PT: 4.6%, CM: 1.8%; OR 3.42 [95%CI:1.07-10.92]) compared to treatment with CM. Rates were similar between groups for drainage associated with multiple organisms (PT: 2.6%, CM: 1.5%; OR 3.81 [95%CI:0.96-15.08]) and Pseudomonas (PT: 1.0%, CM: 1.3%; OR 3.42 [95%CI:0.55-21.28]). CONCLUSIONS AND RELEVANCE Use of antipseudomonal antibiotics is not associated with lower rates of postoperative drainage procedures or more favorable culture profiles in children with complicated appendicitis.
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Affiliation(s)
- Shannon L Cramm
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Dionne A Graham
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, MA
| | - Christina Feng
- Department of Surgery, Children's National Hospital, Washington, D.C
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman Medical School at the University of Pennsylvania, Philadelphia, PA
| | - Martin L Blakely
- Division of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkin's All Children's Hospital, St. Petersburg, FL
| | - Robert A Cowles
- Department of Pediatric Surgery, Yale New Haven Children's Hospital, Yale School of Medicine, New Haven, CT
| | - Shaun M Kunisaki
- Department of Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Aaron M Lipskar
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hoftsra/Northwell, New Hyde Park, NY
| | - Robert T Russell
- Division of Pediatric Surgery, Children's of Alabama; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Matthew T Santore
- Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | | | - Sarah J Commander
- Department of Surgery, Duke Children's Hospital and Health Center, Durham, NC
| | - Jennifer R DeFazio
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos College of Physcians and Surgeons, New York, NY
| | - Katerina Dukleska
- Department of Surgery, Connecticut Children's Hospital, Hartford, CT
| | - Justice C Echols
- Department of Surgery, University of North Carolina Health System, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Joseph R Esparaz
- Division of Pediatric Surgery, Children's of Alabama; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Claire Gerall
- Department of Surgery, UT Health San Antonio, San Antonio, TX
| | - Cornelia L Griggs
- Department of Surgery, Division of Pediatric Surgery, Massachusetts General Hospital, Boston, MA
| | - David N Hanna
- Division of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Katherine He
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Olivia A Keane
- Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Sean E McLean
- Division of Pediatric Surgery, University of North Carolina Health System, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Elizabeth Pace
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Stefan Scholz
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Shelby R Sferra
- Department of Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Elisabeth T Tracy
- Department of Surgery, Duke Children's Hospital and Health Center, Duke University School of Medicine, Durham, NC
| | - Lucy Zhang
- Department of Pediatric Surgery, Yale New Haven Children's Hospital, Yale School of Medicine, New Haven, CT
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Rysavy MA, Eggleston B, Dahabreh IJ, Tyson JE, Patel RM, Watterberg KL, Greenberg RG, Pedroza C, Trotta M, Stevenson DK, Stoll BJ, Lally KP, Das A, Blakely ML. Generalizability of the Necrotizing Enterocolitis Surgery Trial to the Target Population of Eligible Infants. J Pediatr 2023; 262:113453. [PMID: 37169336 PMCID: PMC10632546 DOI: 10.1016/j.jpeds.2023.113453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/25/2023] [Accepted: 04/21/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate whether infants randomized in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network Necrotizing Enterocolitis Surgery Trial differed from eligible infants and whether differences affected the generalizability of trial results. STUDY DESIGN Secondary analysis of infants enrolled in Necrotizing Enterocolitis Surgery Trial (born 2010-2017, with follow-up through 2019) at 20 US academic medical centers and an observational data set of eligible infants through 2013. Infants born ≤1000 g and diagnosed with necrotizing enterocolitis or spontaneous intestinal perforation requiring surgical intervention at ≤8 weeks were eligible. The target population included trial-eligible infants (randomized and nonrandomized) born during the first half of the study with available detailed preoperative data. Using model-based weighting methods, we estimated the effect of initial laparotomy vs peritoneal drain had the target population been randomized. RESULTS The trial included 308 randomized infants. The target population included 382 (156 randomized and 226 eligible, non-randomized) infants. Compared with the target population, fewer randomized infants had necrotizing enterocolitis (31% vs 47%) or died before discharge (27% vs 41%). However, incidence of the primary composite outcome, death or neurodevelopmental impairment, was similar (69% vs 72%). Effect estimates for initial laparotomy vs drain weighted to the target population were largely unchanged from the original trial after accounting for preoperative diagnosis of necrotizing enterocolitis (adjusted relative risk [95% CI]: 0.85 [0.71-1.03] in target population vs 0.81 [0.64-1.04] in trial) or spontaneous intestinal perforation (1.02 [0.79-1.30] vs 1.11 [0.95-1.31]). CONCLUSION Despite differences between randomized and eligible infants, estimated treatment effects in the trial and target population were similar, supporting the generalizability of trial results. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT01029353.
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Affiliation(s)
- Matthew A Rysavy
- McGovern Medical School at McGovern Medical School at UTHealth Houston, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX.
| | | | - Issa J Dahabreh
- CAUSALab, Department of Epidemiology and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Jon E Tyson
- McGovern Medical School at McGovern Medical School at UTHealth Houston, Houston, TX
| | - Ravi M Patel
- Emory University School of Medicine, Atlanta, GA
| | | | | | - Claudia Pedroza
- McGovern Medical School at McGovern Medical School at UTHealth Houston, Houston, TX
| | | | | | - Barbara J Stoll
- McGovern Medical School at McGovern Medical School at UTHealth Houston, Houston, TX; Emory University School of Medicine, Atlanta, GA
| | - Kevin P Lally
- McGovern Medical School at McGovern Medical School at UTHealth Houston, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX
| | | | - Martin L Blakely
- McGovern Medical School at McGovern Medical School at UTHealth Houston, Houston, TX; Vanderbilt University Medical Center, Nashville, TN
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7
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Papastefan ST, Zeineddin S, Blakely ML, Lovvorn HN, Huang LW, Raval MV, Lautz TB. Association of Prophylactic Antibiotics With Early Infectious Complications in Children With Cancer Undergoing Central Venous Access Device Placement. Ann Surg 2023:00000658-990000000-00686. [PMID: 37870252 DOI: 10.1097/sla.0000000000006140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
OBJECTIVE To evaluate the impact of prophylactic antibiotics on early infectious complications after central venous access device (VAD) placement in children with cancer. SUMMARY OF BACKGROUND DATA Despite the frequency of VAD procedures in children, the effectiveness of prophylactic antibiotics for reducing infectious complications is unknown. METHODS This was a retrospective cohort study of children with cancer undergoing central VAD placement identified in the Pediatric Health Information System database between 2017-2021. The primary outcome was the rate of early infectious complications (composite surgical site infections, central line-associated bloodstream infections, and bacteremia). Multivariable logistic regression was used to evaluate factors associated with early infection, and heterogeneity of treatment effect of prophylactic antibiotics was compared across subgroups. RESULTS 9,216 patients were included (6,058 ports and 3,158 tunneled lines). Prophylactic antibiotics were associated with lower early infectious complications overall (1.3% vs. 2.4%; OR 0.55 [95% C.I. 0.39-0.79], P<0.001), an effect demonstrated for tunneled lines (OR 0.59, 95% C.I.: 0.41-0.84) but not ports (OR 3.01, 95% C.I.: 0.66-13.78). On multivariate analysis, prophylactic antibiotics (OR 0.67, 95% C.I.: 0.45-0.97) and solid tumors (OR 0.38, 95% C.I.: 0.22-0.64) were associated with reduced odds of early infections, while tunneled lines (OR 20.78, 95% C.I.: 9.83-43.93) and acute myelogenous leukemia (OR 2.37, 95% C.I.: 1.58-3.57) had increased odds. CONCLUSIONS Prophylactic antibiotics are associated with reduced early infectious complications after central VAD placement overall. Despite recommendations from multiple national organizations against prophylactic antibiotics, these findings suggest a benefit in children with malignancy undergoing tunneled line placement.
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Affiliation(s)
- Steven T Papastefan
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Martin L Blakely
- Department of Surgery, Center for Clinical Research and Evidence Based Medicine, Institute for Implementation Science, University of Texas Health Science Center at Houston, Houston, TX
| | - Harold N Lovvorn
- Department of Surgery, Center for Clinical Research and Evidence Based Medicine, Institute for Implementation Science, University of Texas Health Science Center at Houston, Houston, TX
| | - Lynn Wei Huang
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Timothy B Lautz
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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8
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Cramm SL, Chandler NM, Graham DA, Kunisaki SM, Russell RT, Blakely ML, Lipskar AM, Allukian M, Aronowitz DI, Campbell BT, Collins DT, Commander SJ, Cowles RA, DeFazio JR, Esparaz JR, Feng C, Griggs CL, Guyer RA, Hanna DN, Kahan AM, Keane OA, Lamoshi A, Lopez CM, Pace E, Regan MD, Santore MT, Scholz S, Tracy ET, Williams SA, Zhang L, Rangel SJ. Association Between Antibiotic Redosing Before Incision and Risk of Incisional Site Infection in Children With Appendicitis. Ann Surg 2023; 278:e863-e869. [PMID: 36317528 DOI: 10.1097/sla.0000000000005747] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To evaluate whether redosing antibiotics within an hour of incision is associated with a reduction in incisional surgical site infection (iSSI) in children with appendicitis. BACKGROUND Existing data remain conflicting as to whether children with appendicitis receiving antibiotics at diagnosis benefit from antibiotic redosing before incision. METHODS This was a multicenter retrospective cohort study using data from the Pediatric National Surgical Quality Improvement Program augmented with antibiotic utilization and operative report data obtained though supplemental chart review. Children undergoing appendectomy at 14 hospitals participating in the Eastern Pediatric Surgery Network from July 2016 to June 2020 who received antibiotics upon diagnosis of appendicitis between 1 and 6 hours before incision were included. Multivariable logistic regression was used to compare odds of iSSI in those who were and were not redosed with antibiotics within 1 hour of incision, adjusting for patient demographics, disease severity, antibiotic agents, and hospital-level clustering of events. RESULTS A total of 3533 children from 14 hospitals were included. Overall, 46.5% were redosed (hospital range: 1.8%-94.4%, P <0.001) and iSSI rates were similar between groups [redosed: 1.2% vs non-redosed: 1.3%; odds ratio (OR) 0.84, (95%,CI, 0.39-1.83)]. In subgroup analyses, redosing was associated with lower iSSI rates when cefoxitin was used as the initial antibiotic (redosed: 1.0% vs nonredosed: 2.5%; OR: 0.38, (95% CI, 0.17-0.84)], but no benefit was found with other antibiotic regimens, longer periods between initial antibiotic administration and incision, or with increased disease severity. CONCLUSIONS Redosing of antibiotics within 1 hour of incision in children who received their initial dose within 6 hours of incision was not associated with reduction in risk of incisional site infection unless cefoxitin was used as the initial antibiotic.
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Affiliation(s)
- Shannon L Cramm
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Dionne A Graham
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, MA
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Robert T Russell
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
| | - Aaron M Lipskar
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Danielle I Aronowitz
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Devon T Collins
- Department of Surgery, Children's National Hospital, Washington, DC
| | - Sarah J Commander
- Department of Surgery, Duke Children's Hospital and Health Center, Duke University School of Medicine, Durham, NC
| | - Robert A Cowles
- Division of Pediatric Surgery, Yale New Haven Children's Hospital and Yale School of Medicine, New Haven, CT
| | - Jennifer R DeFazio
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos Colleges of Physicians and Surgeons, New York, NY
| | - Joseph R Esparaz
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL
| | - Christina Feng
- Department of Surgery, Children's National Hospital, Washington, DC
| | - Cornelia L Griggs
- Division of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Richard A Guyer
- Division of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David N Hanna
- Department of Surgery, Vanderbilt Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
| | - Anastasia M Kahan
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos Colleges of Physicians and Surgeons, New York, NY
- Department of Surgery, Mount Sinai Health System, New York, NY
| | - Olivia A Keane
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Abdulraouf Lamoshi
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - Carla M Lopez
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Elizabeth Pace
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Maia D Regan
- Department of Surgery, Connecticut Children's Hospital, Hartford, CT
| | - Matthew T Santore
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Stefan Scholz
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Elisabeth T Tracy
- Department of Surgery, Duke Children's Hospital and Health Center, Duke University School of Medicine, Durham, NC
| | - Sacha A Williams
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Lucy Zhang
- Division of Pediatric Surgery, Yale New Haven Children's Hospital and Yale School of Medicine, New Haven, CT
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
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9
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Evans PT, Blakely ML, Mixon AS, Canvasser J, Rysavy MA, Fernandez ME, Pedroza C, Tyson JE. The evidence base for surgical treatment of infants with necrotizing enterocolitis or spontaneous intestinal perforation: Impact of trial design and questions regarding implementation of trial recommendations. Semin Pediatr Surg 2023; 32:151304. [PMID: 37276785 DOI: 10.1016/j.sempedsurg.2023.151304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Parker T Evans
- Vanderbilt University Medical Center, Department of Surgery
| | - Martin L Blakely
- University of Texas Health Science Center at Houston, Center for Clinical Research and Evidence-Based Medicine; University of Texas Health Science Center at Houston, Department of Surgery; Vanderbilt University Medical Center, Department of Pediatric Surgery; University of Texas Health Science Center at Houston, Institute for Implementation Science.
| | - Amanda S Mixon
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research
| | | | - Matthew A Rysavy
- University of Texas Health Science Center at Houston, Center for Clinical Research and Evidence-Based Medicine; University of Texas Health Science Center at Houston, Department of Pediatrics
| | - Maria E Fernandez
- University of Texas Health Science Center at Houston, Institute for Implementation Science
| | - Claudia Pedroza
- University of Texas Health Science Center at Houston, Center for Clinical Research and Evidence-Based Medicine; University of Texas Health Science Center at Houston, Department of Pediatrics
| | - Jon E Tyson
- University of Texas Health Science Center at Houston, Center for Clinical Research and Evidence-Based Medicine; University of Texas Health Science Center at Houston, Department of Pediatrics
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10
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Cramm SL, Graham DA, Allukian M, Blakely ML, Chandler NM, Cowles RA, Feng C, Kunisaki SM, Russell RT, Rangel SJ. Predictive Value of Routine WBC Count Obtained Before Discharge for Organ Space Infection in Children with Complicated Appendicitis: Results from the Eastern Pediatric Surgery Network. J Am Coll Surg 2023; 236:1181-1187. [PMID: 36503868 DOI: 10.1097/xcs.0000000000000520] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the clinical utility of a routine predischarge WBC count (RPD-WBC) for predicting postdischarge organ space infection (OSI) in children with complicated appendicitis. STUDY DESIGN This was a multicenter study using NSQIP-Pediatric data from 14 hospitals augmented with RPD-WBC data obtained through supplemental chart review. Children with fever or surgical site infection diagnosed during the index admission were excluded. The positive predictive value (PPV) for postdischarge OSI was calculated for RPD-WBC values of persistent leukocytosis (≥9.0 × 10 3 cells/μL), increasing leukocytosis (RPD-WBC > preoperative WBC), quartiles of absolute RPD-WBC, and quartiles of relative proportional change from preoperative WBC. Logistic regression was used to calculate predictive values adjusted for patient age, appendicitis severity, and use of postdischarge antibiotics. RESULTS A total of 1,264 children were included, of which 348 (27.5%) had a RPD-WBC obtained (hospital range: 0.8 to 100%, p < 0.01). The median RPD-WBC was similar between children who did and did not develop a postdischarge OSI (9.0 vs 8.9; p = 0.57), and leukocytosis was absent in 50% of children who developed a postdischarge OSI. The PPV of RPD-WBC was poor for both persistent and increasing leukocytosis (3.9% and 9.8%, respectively) and for thresholds based on the quartiles of highest RPD-WBC values (>11.1, PPV: 6.4%) and greatest proportional change (<32% decrease from preoperative WBC; PPV: 7.8%). CONCLUSIONS Routine predischarge WBC data have poor predictive value for identifying children at risk for postdischarge OSI after appendectomy for complicated appendicitis.
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Affiliation(s)
- Shannon L Cramm
- From the Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA (Cramm, Graham, Rangel)
| | - Dionne A Graham
- From the Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA (Cramm, Graham, Rangel)
| | - Myron Allukian
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA (Allukian)
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt Children's Hospital, Nashville, TN (Blakely)
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL (Chandler)
| | - Robert A Cowles
- Division of Pediatric Surgery, Yale New Haven Children's Hospital/Yale School of Medicine, New Haven, CT (Cowles)
| | - Christina Feng
- Department of Surgery, Children's National Hospital, Washington, DC (Feng)
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center/Johns Hopkins School of Medicine, Baltimore, MD (Kunisaki)
| | - Robert T Russell
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL (Russell)
| | - Shawn J Rangel
- From the Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA (Cramm, Graham, Rangel)
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11
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Cramm SL, Graham DA, Blakely ML, Chandler NM, Cowles RA, Kunisaki SM, Russell RT, Allukian M, DeFazio JR, Griggs CL, Santore MT, Scholz S, Aronowitz DI, Campbell BT, Collins DT, Commander SJ, Engwall-Gill A, Esparaz JR, Feng C, Gerall C, Hanna DN, Keane OA, Lamoshi A, Lipskar AM, Orlas Bolanos CP, Pace E, Regan MD, Tracy ET, Williams S, Zhang L, Rangel SJ. Outcomes and resource utilization associated with use of routine pre-discharge white blood cell count for clinical decision-making in children with complicated appendicitis: A multi-center hospital-level analysis. J Pediatr Surg 2023; 58:1178-1184. [PMID: 37030979 DOI: 10.1016/j.jpedsurg.2023.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 02/10/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND The objective was to explore the hospital-level relationship between routine pre-discharge WBC utilization (RPD-WBC) and outcomes in children with complicated appendicitis. METHODS Multicenter analysis of NSQIP-Pediatric data from 14 consortium hospitals augmented with RPD-WBC data. WBC were considered routine if obtained within one day of discharge in children who did not develop an organ space infection (OSI) or fever during the index admission. Hospital-level observed-to-expected ratios (O/E) for 30-day outcomes (antibiotic days, imaging utilization, healthcare days, and OSI) were calculated after adjusting for appendicitis severity and patient characteristics. Spearman correlation was used to explore the relationship between hospital-level RPD-WBC utilization and O/E's for each outcome. RESULTS 1528 children were included. Significant variation was found across hospitals in RPD-WBC use (range: 0.7-100%; p < 0.01) and all outcomes (mean antibiotic days: 9.9 [O/E range: 0.56-1.44, p < 0.01]; imaging: 21.9% [O/E range: 0.40-2.75, p < 0.01]; mean healthcare visit days: 5.7 [O/E 0.74-1.27, p < 0.01]); OSI: 14.1% [O/E range: 0.43-3.64, p < 0.01]). No correlation was found between RPD-WBC use and antibiotic days (r = +0.14, p = 0.64), imaging (r = -0.07, p = 0.82), healthcare days (r = +0.35, p = 0.23) or OSI (r = -0.13, p = 0.65). CONCLUSIONS Increased RPD-WBC utilization in pediatric complicated appendicitis did not correlate with improved outcomes or resource utilization at the hospital level. LEVEL OF EVIDENCE III. TYPE OF STUDY Clinical Research.
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Affiliation(s)
- Shannon L Cramm
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Dionne A Graham
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, MA, USA
| | - Martin L Blakely
- Department of Surgery, Vanderbilt Children's Hospital, Vanderbilt School of Medicine, Nashville, TN, USA
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkin's All Children's Hospital, St. Petersburg, FL, USA
| | - Robert A Cowles
- Department of Pediatric Surgery, Yale New Haven Children's Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Robert T Russell
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children's of Alabama
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer R DeFazio
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos Colleges of Physicians and Surgeons, New York, NY, USA
| | - Cornelia L Griggs
- Department of Surgery, Division of Pediatric Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Matthew T Santore
- Department of Surgery, Division of Pediatric Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Stefan Scholz
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Danielle I Aronowitz
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brendan T Campbell
- Department of Surgery, Connecticut Children's Hospital, Hartford, CT, USA
| | - Devon T Collins
- Department of Surgery, Children's National Hospital, Washington, D.C, USA
| | - Sarah J Commander
- Department of Surgery, Duke Children's Hospital and Health Center, Durham, NC, USA
| | - Abigail Engwall-Gill
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Joseph R Esparaz
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - Christina Feng
- Department of Surgery, Duke Children's Hospital and Health Center, Durham, NC, USA
| | - Claire Gerall
- Department of Surgery, UT Health San Antonio, San Antonio, TX, USA
| | - David N Hanna
- Department of Surgery, Vanderbilt Children's Hospital, Nashville, TN, USA
| | - Olivia A Keane
- Department of Surgery, Division of Pediatric Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Abdulraouf Lamoshi
- Division of Pediatric Surgery, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Aaron M Lipskar
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Claudia P Orlas Bolanos
- Department of Surgery, Division of Pediatric Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth Pace
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Maia D Regan
- Department of Surgery, Children's National Hospital, Washington, D.C, USA
| | - Elisabeth T Tracy
- Department of Surgery, Duke Children's Hospital and Health Center, Duke University School of Medicine, Durham, NC, USA
| | - Sacha Williams
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Lucy Zhang
- Department of Pediatric Surgery, Yale New Haven Children's Hospital, New Haven, CT, USA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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12
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Rausch LA, Hanna DN, Patel A, Blakely ML. Review of Necrotizing Enterocolitis and Spontaneous Intestinal Perforation Clinical Presentation, Treatment, and Outcomes. Clin Perinatol 2022; 49:955-964. [PMID: 36328610 DOI: 10.1016/j.clp.2022.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The Necrotizing Enterocolitis Surgery Trial (NEST) highlights the importance of distinguishing necrotizing enterocolitis (NEC) from spontaneous intestinal perforation (SIP) when developing surgical treatment plans. Further research is needed to increase the accuracy of this distinction, but even with our current abilities to do this initial laparotomy appears to be optimal for infants with presumed NEC. The preferred initial operation for those with SIP is more equivocal. Rates of NEC are likely decreasing slowly, whereas those with SIP are not. New imaging modalities, especially ultrasound, are becoming more useful but require more detailed investigation. Understanding the mechanisms causing these two conditions remains of paramount importance.
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Affiliation(s)
- Laura A Rausch
- Vanderbilt University Medical Center, 2200 Children's Way, Suite 7100, Nashville, TN 37232, USA; Vanderbilt University Master of Public Health School, 2200 Children's Way, Suite 7100, Nashville, TN 37232, USA; Geriatric Research Education and Clinical Center, 2200 Children's Way, Suite 7100, Nashville, TN 37232, USA
| | - David N Hanna
- Vanderbilt University Medical Center, 2200 Children's Way, Suite 7100, Nashville, TN 37232, USA
| | - Anuradha Patel
- Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Suite 7100, Nashville, TN 37232, USA
| | - Martin L Blakely
- Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Suite 7100, Nashville, TN 37232, USA.
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13
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Blakely ML, Rysavy MA, Lally KP, Eggleston B, Pedroza C, Tyson JE. Special considerations in randomized trials investigating neonatal surgical treatments. Semin Perinatol 2022; 46:151640. [PMID: 35811154 PMCID: PMC9529875 DOI: 10.1016/j.semperi.2022.151640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Randomized controlled trials (RCTs) are challenging, but are the studies most likely to change practice and benefit patients. RCTs investigating neonatal surgical therapies are rare. The Necrotizing Enterocolitis Surgery Trial (NEST) was the first surgical RCT conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network (NRN), and multiple lessons were learned. NEST was conducted over a 7.25-year enrollment period and the primary outcome was death or neurodevelopmental impairment (NDI) at 18-22 months corrected age. Surgical investigators designing clinical trials involving neonatal surgical treatments have many considerations to include, including how to study eligible but non-randomized patients, heterogeneity of treatment effect, use of frequentist and Bayesian analyses, assessment of generalizability, and anticipating criticisms during peer review. Surgeons are encouraged to embrace these challenges and seek innovative methods to acquire evidence that will be used to improve patient outcomes.
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Affiliation(s)
- Martin L Blakely
- Vanderbilt University Medical Center, Department of Pediatric Surgery, Nashville, TN, USA; McGovern Medical School at the University of Texas Health Science Center at Houston, Division of Neonatology, Department of Pediatrics, and Center for Clinical Research and Evidence-Based Medicine, Houston, TX, USA.
| | - Matthew A Rysavy
- McGovern Medical School at the University of Texas Health Science Center at Houston, Division of Neonatology, Department of Pediatrics, and Center for Clinical Research and Evidence-Based Medicine, Houston, TX, USA
| | - Kevin P Lally
- McGovern Medical School at the University of Texas Health Science Center at Houston, Department of Pediatric Surgery, Houston, TX, USA
| | - Barry Eggleston
- RTI International, Social, Statistical and Environmental Sciences Unit, Research Triangle Park, NC, USA
| | - Claudia Pedroza
- McGovern Medical School at the University of Texas Health Science Center at Houston, Division of Neonatology, Department of Pediatrics, and Center for Clinical Research and Evidence-Based Medicine, Houston, TX, USA
| | - Jon E Tyson
- McGovern Medical School at the University of Texas Health Science Center at Houston, Division of Neonatology, Department of Pediatrics, and Center for Clinical Research and Evidence-Based Medicine, Houston, TX, USA
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14
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Cramm SL, Lipskar AM, Graham DA, Kunisaki SM, Griggs CL, Allukian M, Russell RT, Chandler NM, Santore MT, Aronowitz DI, Blakely ML, Campbell B, Collins DT, Commander SJ, Cowles RA, DeFazio JR, Echols JC, Esparaz JR, Feng C, Guyer RA, Hanna DN, He K, Kahan AM, Keane OA, Lamoshi A, Lopez CM, McLean SE, Pace E, Regan MD, Scholz S, Tracy ET, Williams SA, Zhang L, Rangel SJ. Association of Gangrenous, Suppurative, and Exudative Findings With Outcomes and Resource Utilization in Children With Nonperforated Appendicitis. JAMA Surg 2022; 157:685-692. [PMID: 35648410 PMCID: PMC9161124 DOI: 10.1001/jamasurg.2022.1928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance The clinical significance of gangrenous, suppurative, or exudative (GSE) findings is poorly characterized in children with nonperforated appendicitis. Objective To evaluate whether GSE findings in children with nonperforated appendicitis are associated with increased risk of surgical site infections and resource utilization. Design, Setting, and Participants This multicenter cohort study used data from the Appendectomy Targeted Database of the American College of Surgeons Pediatric National Surgical Quality Improvement Program, which were augmented with operative report data obtained by supplemental medical record review. Data were obtained from 15 hospitals participating in the Eastern Pediatric Surgery Network (EPSN) research consortium. The study cohort comprised children (aged ≤18 years) with nonperforated appendicitis who underwent appendectomy from July 1, 2015, to June 30, 2020. Exposures The presence of GSE findings was established through standardized, keyword-based audits of operative reports by EPSN surgeons. Interrater agreement for the presence or absence of GSE findings was evaluated in a random sample of 900 operative reports. Main Outcomes and Measures The primary outcome was 30-day postoperative surgical site infections (incisional and organ space infections). Secondary outcomes included rates of hospital revisits, postoperative abdominal imaging, and postoperative length of stay. Multivariable mixed-effects regression was used to adjust measures of association for patient characteristics and clustering within hospitals. Results Among 6133 children with nonperforated appendicitis, 867 (14.1%) had GSE findings identified from operative report review (hospital range, 4.2%-30.2%; P < .001). Reviewers agreed on presence or absence of GSE findings in 93.3% of cases (weighted κ, 0.89; 95% CI, 0.86-0.92). In multivariable analysis, GSE findings were associated with increased odds of any surgical site infection (4.3% vs 2.2%; odds ratio [OR], 1.91; 95% CI, 1.35-2.71; P < .001), organ space infection (2.8% vs 1.1%; OR, 2.18; 95% CI, 1.30-3.67; P = .003), postoperative imaging (5.8% vs 3.7%; OR, 1.70; 95% CI, 1.23-2.36; P = .002), and prolonged mean postoperative length of stay (1.6 vs 0.9 days; rate ratio, 1.43; 95% CI, 1.32-1.54; P < .001). Conclusions and Relevance In children with nonperforated appendicitis, findings of gangrene, suppuration, or exudate are associated with increased surgical site infections and resource utilization. Further investigation is needed to establish the role and duration of postoperative antibiotics and inpatient management to optimize outcomes in this cohort of children.
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Affiliation(s)
- Shannon L. Cramm
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aaron M. Lipskar
- Division of Pediatric Surgery, Cohen Children’s Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Dionne A. Graham
- Program for Patient Safety and Quality, Boston Children’s Hospital, Boston, Massachusetts
| | - Shaun M. Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children’s Center, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Cornelia L. Griggs
- Division of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert T. Russell
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children’s of Alabama, Birmingham
| | - Nicole M. Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
| | - Matthew T. Santore
- Division of Pediatric Surgery, Department of Surgery, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Danielle I. Aronowitz
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Martin L. Blakely
- Department of Surgery, Vanderbilt Children’s Hospital, Vanderbilt School of Medicine, Nashville, Tennessee
| | - Brendan Campbell
- Department of Surgery, Connecticut Children’s Hospital, Hartford
| | - Devon T. Collins
- Department of Surgery, Children’s National Hospital, Washington, DC
| | - Sarah J. Commander
- Department of Surgery, Duke Children’s Hospital and Health Center, Duke University School of Medicine, Durham, North Carolina
| | - Robert A. Cowles
- Department of Pediatric Surgery, Yale New Haven Children’s Hospital Yale School of Medicine, New Haven, Connecticut
| | - Jennifer R. DeFazio
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children’s Hospital, Columbia University Vagelos Colleges of Physicians and Surgeons, New York
| | - Justice C. Echols
- Division of Pediatric Surgery, University of North Carolina Health System, University of North Carolina School of Medicine, Chapel Hill
| | - Joseph R. Esparaz
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children’s of Alabama, Birmingham
| | - Christina Feng
- Department of Surgery, Children’s National Hospital, Washington, DC
| | - Richard A. Guyer
- Division of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David N. Hanna
- Department of Surgery, Vanderbilt Children’s Hospital, Vanderbilt School of Medicine, Nashville, Tennessee
| | - Katherine He
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anastasia M. Kahan
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children’s Hospital, Columbia University Vagelos Colleges of Physicians and Surgeons, New York
- Department of Surgery, Mount Sinai Health System, New York, New York
| | - Olivia A. Keane
- Division of Pediatric Surgery, Department of Surgery, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Abdulraouf Lamoshi
- Division of Pediatric Surgery, Cohen Children’s Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Carla M. Lopez
- Division of General Pediatric Surgery, Johns Hopkins Children’s Center, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sean E. McLean
- Division of Pediatric Surgery, University of North Carolina Health System, University of North Carolina School of Medicine, Chapel Hill
| | - Elizabeth Pace
- Division of Pediatric Surgery, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Maia D. Regan
- Department of Surgery, Connecticut Children’s Hospital, Hartford
| | - Stefan Scholz
- Division of Pediatric Surgery, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Elisabeth T. Tracy
- Department of Surgery, Duke Children’s Hospital and Health Center, Duke University School of Medicine, Durham, North Carolina
| | - Sasha A. Williams
- Division of Pediatric Surgery, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
| | - Lucy Zhang
- Department of Pediatric Surgery, Yale New Haven Children’s Hospital Yale School of Medicine, New Haven, Connecticut
| | - Shawn J. Rangel
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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15
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France DJ, Schremp E, Rhodes EB, Slagle J, Moroz S, Grubb PH, Hatch LD, Shotwell M, Lorinc A, Robinson J, Crankshaw M, Newman T, Weinger MB, Blakely ML. A pilot study to determine the incidence, type, and severity of non-routine events in neonates undergoing gastrostomy tube placement. J Pediatr Surg 2022; 57:1342-1348. [PMID: 34839947 PMCID: PMC9050962 DOI: 10.1016/j.jpedsurg.2021.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/13/2021] [Accepted: 10/20/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Non-routine events (NRE) are defined as any suboptimal occurrences in a process being measured in the opinion of the reporter and comes from the field of human factors engineering. These typically occur well up-stream of an adverse event and NRE measurement has not been applied to the complex context of neonatal surgery. We sought to apply this novel safety event measurement methodology to neonates in the NICU undergoing gastrostomy tube placement. METHODS A prospective pilot study was conducted between November 2016 and August 2020 in the Level IV NICU and the pediatric operating rooms of an urban academic children's hospital to determine the incidence, severity, impact, and contributory factors of clinician-reported non-routine events (NREs, i.e., deviations from optimal care) and 30-day NSQIP occurrences in neonates receiving a G-tube. RESULTS Clinicians reported at least one NRE in 32 of 36 (89%) G-tube cases, averaging 3.0 (Standard deviation: 2.5) NRE reports per case. NSQIP-P review identified 7 cases (19%) with NSQIP-P occurrences and each of these cases had multiple reported NREs. One case in which NREs were not reported was without NSQIP-P occurrences. The odds ratio of having a NSQIP-P occurrence with the presence of an NRE was 0.695 (95% CI 0.06-17.04). CONCLUSION Despite being considered a "simple" operation, >80% of neonatal G-tube placement operations had at least one reported NRE by an operative team member. In this pilot study, NRE occurrence was not significantly associated with the subsequent reporting of an NSQIP-P occurrence. Understanding contributory factors of NREs that occur in neonatal surgery may promote surgical safety efforts and should be evaluated in larger and more diverse populations. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Daniel J. France
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Emma Schremp
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Evan B. Rhodes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason Slagle
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sarah Moroz
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter H. Grubb
- Department of Pediatrics, Division of Neonatology, University of Utah, Salt Lake City,UT,USA
| | - Leon D. Hatch
- Department of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda Lorinc
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jamie Robinson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA,Department of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt, TN, USA
| | - Marlee Crankshaw
- Neonatal Intensive Care Unit, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
| | - Timothy Newman
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew B. Weinger
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Martin L. Blakely
- Department of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt, TN, USA
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16
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Mehl SC, Cunningham ME, Streck CJ, Pettit R, Huang EY, Santore MT, Tsao K, Falcone RA, Dassinger MS, Haynes JH, Russell RT, Naik-Mathuria BJ, St Peter SD, Mooney D, Upperman J, Blakely ML, Vogel AM. Characteristics and predictors of intensive care unit admission in pediatric blunt abdominal trauma. Pediatr Surg Int 2022; 38:589-597. [PMID: 35124723 PMCID: PMC9087985 DOI: 10.1007/s00383-022-05067-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pediatric trauma patients sustaining blunt abdominal trauma (BAT) with intra-abdominal injury (IAI) are frequently admitted to the intensive care unit (ICU). This study was performed to identify predictors for ICU admission following BAT. METHODS Prospective study of children (< 16 years) who presented to 14 Level-One Pediatric Trauma Centers following BAT over a 1-year period. Patients were categorized as ICU or non-ICU patients. Data collected included vitals, physical exam findings, laboratory results, imaging, and traumatic injuries. A multivariable hierarchical logistic regression model was used to identify predictors of ICU admission. Predictive ability of the model was assessed via tenfold cross-validated area under the receiver operating characteristic curves (cvAUC). RESULTS Included were 2,182 children with 21% (n = 463) admitted to the ICU. On univariate analysis, ICU patients were associated with abnormal age-adjusted shock index, increased injury severity scores (ISS), lower Glasgow coma scores (GCS), traumatic brain injury (TBI), and severe solid organ injury (SOI). With multivariable logistic regression, factors associated with ICU admission were severe trauma (ISS > 15), anemia (hematocrit < 30), severe TBI (GCS < 8), cervical spine injury, skull fracture, and severe solid organ injury. The cvAUC for the multivariable model was 0.91 (95% CI 0.88-0.92). CONCLUSION Severe solid organ injury and traumatic brain injury, in association with multisystem trauma, appear to drive ICU admission in pediatric patients with BAT. These results may inform the design of a trauma bay prediction rule to assist in optimizing ICU resource utilization after BAT. STUDY DESIGN Prognosis study. LEVEL OF EVIDENCE: 1
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Affiliation(s)
- Steven C Mehl
- Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street #1210, Houston, TX, 77030, USA
| | - Megan E Cunningham
- Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street #1210, Houston, TX, 77030, USA
| | - Christian J Streck
- Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Rowland Pettit
- Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street #1210, Houston, TX, 77030, USA
| | | | | | - Kuojen Tsao
- Children's Memorial Hermann Hospital, Houston, TX, USA
| | | | | | - Jeffrey H Haynes
- Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA
| | | | - Bindi J Naik-Mathuria
- Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street #1210, Houston, TX, 77030, USA
| | | | | | | | | | - Adam M Vogel
- Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street #1210, Houston, TX, 77030, USA.
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17
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France DJ, Slagle J, Schremp E, Moroz S, Hatch LD, Grubb P, Vogus TJ, Shotwell MS, Lorinc A, Lehmann CU, Robinson J, Crankshaw M, Sullivan M, Newman TA, Wallace T, Weinger MB, Blakely ML. Defining the Epidemiology of Safety Risks in Neonatal Intensive Care Unit Patients Requiring Surgery. J Patient Saf 2021; 17:e694-e700. [PMID: 32168276 PMCID: PMC8590832 DOI: 10.1097/pts.0000000000000680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The aim of the study was to determine the incidence, type, severity, preventability, and contributing factors of nonroutine events (NREs)-events perceived by care providers or skilled observers as a deviations from optimal care based on the clinical situation-in the perioperative (i.e., preoperative, operative, and postoperative) care of surgical neonates in the neonatal intensive care unit and operating room. METHODS A prospective observational study of noncardiac surgical neonates, who received preoperative and postoperative neonatal intensive care unit care, was conducted at an urban academic children's hospital between November 1, 2016, and March 31, 2018. One hundred twenty-nine surgical cases in 109 neonates were observed. The incidence and description of NREs were collected via structured researcher-administered survey tool of involved clinicians. Primary measurements included clinicians' ratings of NRE severity and contributory factors and trained research assistants' ratings of preventability. RESULTS One or more NREs were reported in 101 (78%) of 129 observed cases for 247 total NREs. Clinicians reported 2 (2) (median, interquartile range) NREs per NRE case with a maximum severity of 3 (1) (possible range = 1-5). Trained research assistants rated 47% of NREs as preventable and 11% as severe and preventable. The relative risks for National Surgical Quality Improvement Program - pediatric major morbidity and 30-day mortality were 1.17 (95% confidence interval = 0.92-1.48) and 1.04 (95% confidence interval = 1.00-1.08) in NRE cases versus non-NRE cases. CONCLUSIONS The incidence of NREs in neonatal perioperative care at an academic children's hospital was high and of variable severity with a myriad of contributory factors.
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Affiliation(s)
- Daniel J. France
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jason Slagle
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emma Schremp
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah Moroz
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
| | - L. Dupree Hatch
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pediatrics, Division of Neonatology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Peter Grubb
- Department of Pediatrics, Division of Neonatology, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah
| | - Timothy J. Vogus
- Owen Graduate School of Management, Vanderbilt University, Nashville, Tennessee
| | - Matthew S. Shotwell
- Department of Biostatistics and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amanda Lorinc
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christoph U. Lehmann
- Department of Pediatrics, Division of Neonatology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jamie Robinson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Marlee Crankshaw
- Department of Neonatal Intensive Care Unit, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Maria Sullivan
- Perioperative Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Timothy A. Newman
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tamara Wallace
- Neonatal Intensive Care Unit, Nationwide Children’s Hospital, Columbus, Ohio
| | - Matthew B. Weinger
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Martin L. Blakely
- Department of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
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18
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Blakely ML, Tyson JE, Lally KP, Hintz SR, Eggleston B, Stevenson DK, Besner GE, Das A, Ohls RK, Truog WE, Nelin LD, Poindexter BB, Pedroza C, Walsh MC, Stoll BJ, Geller R, Kennedy KA, Dimmitt RA, Carlo WA, Cotten CM, Laptook AR, Van Meurs KP, Calkins KL, Sokol GM, Sanchez PJ, Wyckoff MH, Patel RM, Frantz ID, Shankaran S, D’Angio CT, Yoder BA, Bell EF, Watterberg KL, Martin CA, Harmon CM, Rice H, Kurkchubasche AG, Sylvester K, Dunn JCY, Markel TA, Diesen DL, Bhatia AM, Flake A, Chwals WJ, Brown R, Bass KD, St. Peter SD, Shanti CM, Pegoli W, Skarda D, Shilyansky J, Lemon DG, Mosquera RA, Peralta-Carcelen M, Goldstein RF, Vohr BR, Purdy IB, Hines AC, Maitre NL, Heyne RJ, DeMauro SB, McGowan EC, Yolton K, Kilbride HW, Natarajan G, Yost K, Winter S, Colaizy TT, Laughon MM, Lakshminrusimha S, Higgins RD. Initial Laparotomy Versus Peritoneal Drainage in Extremely Low Birthweight Infants With Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation: A Multicenter Randomized Clinical Trial. Ann Surg 2021; 274:e370-e380. [PMID: 34506326 PMCID: PMC8439547 DOI: 10.1097/sla.0000000000005099] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
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.
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MESH Headings
- Drainage
- Enterocolitis, Necrotizing/mortality
- Enterocolitis, Necrotizing/psychology
- Enterocolitis, Necrotizing/surgery
- Feasibility Studies
- Female
- Humans
- Infant, Extremely Low Birth Weight
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/mortality
- Infant, Premature, Diseases/psychology
- Infant, Premature, Diseases/surgery
- Intestinal Perforation/mortality
- Intestinal Perforation/psychology
- Intestinal Perforation/surgery
- Laparotomy
- Male
- Neurodevelopmental Disorders/diagnosis
- Neurodevelopmental Disorders/epidemiology
- Survival Rate
- Treatment Outcome
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Affiliation(s)
- Martin L. Blakely
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Jon E. Tyson
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Kevin P. Lally
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Susan R. Hintz
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Barry Eggleston
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - David K. Stevenson
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Gail E. Besner
- Department of Pediatric Surgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Rockville, MD
| | - Robin K. Ohls
- University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Pediatrics, Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT
| | - William E. Truog
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO
| | - Leif D. Nelin
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Brenda B. Poindexter
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Claudia Pedroza
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Barbara J. Stoll
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Rachel Geller
- Department of Pediatrics, University of California, Los Angeles, CA
| | - Kathleen A. Kennedy
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Reed A. Dimmitt
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Abbot R. Laptook
- Department of Pediatrics, Women’s & Infants Hospital, Brown University, Providence, RI
| | - Krisa P. Van Meurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Kara L. Calkins
- Department of Pediatrics, University of California, Los Angeles, CA
| | - Gregory M. Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Pablo J. Sanchez
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Myra H. Wyckoff
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ravi M. Patel
- Emory University School of Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Ivan D. Frantz
- Department of Pediatrics, Division of Newborn Medicine, Floating Hospital for Children, Tufts Medical Center, Boston, MA
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Carl T. D’Angio
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Bradley A. Yoder
- Department of Pediatrics, Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | | | - Colin A. Martin
- Division of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Carroll M. Harmon
- Division of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, AL
- Division of Pediatric Surgery, University of Buffalo, John R. Oishei Children’s Hospital, Buffalo, NY
| | - Henry Rice
- Division of Pediatric General Surgery, Duke University, Durham, NC
| | - Arlet G. Kurkchubasche
- Department of Pediatric Surgery, Hasbro Children’s Hospital, Brown University, Providence, RI
| | - Karl Sylvester
- Department of Pediatric Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - James C. Y. Dunn
- Department of Pediatric Surgery, Stanford University School of Medicine, Palo Alto, CA
- Department of Pediatric Surgery, University of California, Los Angeles, CA
| | - Troy A. Markel
- Department of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Diana L. Diesen
- Department of Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Amina M. Bhatia
- Department of Pediatric Surgery, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Alan Flake
- Department of Pediatric Surgery, University of Pennsylvania, Philadelphia, PA
| | - Walter J. Chwals
- Department of Pediatric Surgery, Floating Hospital for Children, Tufts Medical Center, Boston, MA
| | - Rebeccah Brown
- Department of Pediatric Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kathryn D. Bass
- Division of Pediatric Surgery, University of Buffalo, John R. Oishei Children’s Hospital, Buffalo, NY
| | - Shawn D. St. Peter
- Department of Pediatric Surgery, Children’s Mercy Hospital, Kansas City, MO
| | | | - Walter Pegoli
- Department of Pediatric Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - David Skarda
- Department of Pediatric Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | | | - David G. Lemon
- Department of Pediatric Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Ricardo A. Mosquera
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | | | | | - Betty R. Vohr
- Department of Pediatrics, Women’s & Infants Hospital, Brown University, Providence, RI
| | - Isabell B. Purdy
- Department of Pediatrics, University of California, Los Angeles, CA
| | - Abbey C. Hines
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Nathalie L. Maitre
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Roy J. Heyne
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Sara B. DeMauro
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA
| | - Elisabeth C. McGowan
- Department of Pediatrics, Women’s & Infants Hospital, Brown University, Providence, RI
- Department of Pediatrics, Division of Newborn Medicine, Floating Hospital for Children, Tufts Medical Center, Boston, MA
| | - Kimberly Yolton
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | | | | | - Kelley Yost
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Sarah Winter
- Department of Pediatrics, Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT
| | | | - Matthew M. Laughon
- Division of Neonatal/Perinatal Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | | | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
- College of Health and Human Services, George Mason University, Fairfax, VA
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19
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Vogel AM, Zhang J, Mauldin PD, Williams RF, Huang EY, Santore MT, Tsao K, Falcone RA, Dassinger MS, Haynes JH, Blakely ML, Russell RT, Naik-Mathuria BJ, St Peter SD, Mooney D, Upperman JS, Streck CJ. Variability in the evalution of pediatric blunt abdominal trauma. Pediatr Surg Int 2019; 35:479-485. [PMID: 30426222 DOI: 10.1007/s00383-018-4417-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe the practice pattern for routine laboratory and imaging assessment of children following blunt abdominal trauma (BAT). METHODS Children (age < 16 years) presenting to 14 pediatric trauma centers following BAT over a 1-year period were prospectively identified. Injury, demographic, routine laboratory and imaging utilization data were collected. Descriptive, comparative, and correlation analysis was performed. RESULTS 2188 children with a median age of 8 (4,12) years were included and the median injury severity score was 5 (1,10). There were significant differences in activation status, injury severity, and mechanism across centers; however, there was no correlation of level of activation, injury severity, or severe mechanism with test utilization. Routine laboratory and imaging utilization for hematocrit, hepatic enzymes, pancreatic enzymes, base deficit urine microscopy, chest and pelvis X-ray, and abdominal computed tomography (CT) varied significantly among centers. Only obtaining a hematocrit had a moderate correlation with CT use. There was no correlation between centers that were high or low frequency laboratory utilizers with CT use. CONCLUSIONS Wide variability exists in the routine initial laboratory and imaging assessment in children following BAT. This represents an opportunity for quality improvement in pediatric trauma. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Adam M Vogel
- Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX, 77030, USA.
| | - Jingwen Zhang
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Regan F Williams
- University of Tennessee Health Science Center at Memphis, Memphis, TN, USA
| | - Eunice Y Huang
- University of Tennessee Health Science Center at Memphis, Memphis, TN, USA
| | | | - Kuojen Tsao
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | | | | | | | - Robert T Russell
- University of Alabama Birmingham School of Medicine, Birmingham, AL, USA
| | - Bindi J Naik-Mathuria
- Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX, 77030, USA
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20
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Gulack BC, Greenberg R, Clark RH, Miranda ML, Blakely ML, Rice HE, Adibe OO, Tracy ET, Smith PB. A multi-institution analysis of predictors of timing of inguinal hernia repair among premature infants. J Pediatr Surg 2018; 53:784-788. [PMID: 29055488 PMCID: PMC7538232 DOI: 10.1016/j.jpedsurg.2017.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 08/17/2017] [Accepted: 09/17/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE Inguinal hernias are common in premature infants, but there is substantial variation with regards to timing of repair. We sought to quantify and explain this variation. METHODS Cohort study of infants <34weeks gestation diagnosed with an inguinal hernia and discharged from one of 329 neonatal intensive units between 1998 and 2012. Multivariable logistic regression clustered by site was used to evaluate demographic, clinical, maternal, and socioeconomic variables associated with pre-discharge repair. RESULTS A total of 8037 infants met study criteria, and 3230 (40%) received a pre-discharge repair. The frequency of pre-discharge repair varied by site from 9% to 84%, and increased over the study period from 20% in 1998 to 45% in 2012. Concurrent gastrostomy or fundoplication and lower socioeconomic status were associated with an increased odds of receiving a pre-discharge repair. CONCLUSION There is substantial variation with regards to the timing of repair of inguinal hernias in premature infants, with an increasing number of infants receiving repair prior to hospital discharge over time. Concurrent gastrostomy or fundoplication and socioeconomic status are associated with timing of repair. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Brian C Gulack
- Department of Surgery, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC.
| | - Rachel Greenberg
- Department of Pediatrics, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | - Marie Lynn Miranda
- Department of Pediatrics, Duke University Medical Center, Durham, NC; Department of Statistics, Rice University, Houston, TX
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Henry E Rice
- Department of Surgery, Duke University Medical Center, Durham, NC; Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Obinna O Adibe
- Department of Surgery, Duke University Medical Center, Durham, NC; Department of Pediatrics, Duke University Medical Center, Durham, NC
| | | | - P Brian Smith
- Department of Pediatrics, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC
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21
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Cameron DB, Williams R, Geng Y, Gosain A, Arnold MA, Guner YS, Blakely ML, Downard CD, Goldin AB, Grabowski J, Lal DR, Dasgupta R, Baird R, Gates RL, Shelton J, Jancelewicz T, Rangel SJ, Austin MT. Time to appendectomy for acute appendicitis: A systematic review. J Pediatr Surg 2018; 53:396-405. [PMID: 29241958 DOI: 10.1016/j.jpedsurg.2017.11.042] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 10/21/2017] [Accepted: 11/09/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to develop recommendations regarding time to appendectomy for acute appendicitis in children within the context of preventing adverse events, reducing cost, and optimizing patient/parent satisfaction. METHODS The committee selected three questions that were addressed by searching MEDLINE, Embase, and the Cochrane Library databases for English language articles published between January 1, 1970 and November 3, 2016. Consensus recommendations for each question were made based on the best available evidence for both children and adults. RESULTS Based on level 3-4 evidence, appendectomy performed within 24h of admission in patients with acute appendicitis does not appear to be associated with increased perforation rates or other adverse events. Based on level 4 evidence, time from admission to appendectomy within 24h does not increase hospital cost or length of stay (LOS). Data are currently limited to determine an association between the timing of appendectomy and parent/patient satisfaction. CONCLUSIONS There is a paucity of high-quality evidence in the literature regarding timing of appendectomy for patients with acute appendicitis and its association with adverse events or resource utilization. Based on available evidence, appendectomy performed within the first 24h from presentation is not associated with an increased risk of perforation or adverse outcomes. TYPE OF STUDY Systematic Review of Level 1-4 studies.
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Affiliation(s)
| | - Regan Williams
- Department of Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN.
| | - Yimin Geng
- University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Ankush Gosain
- Department of Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Meghan A Arnold
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, CS Mott Children's Hospital, Ann Arbor, MI
| | - Yigit S Guner
- Department of Surgery, University of California Irvine and Division of Pediatric Surgery Children's Hospital of Orange County
| | - Martin L Blakely
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Cynthia D Downard
- Division of Pediatric Surgery, Department of Surgery, University of Louisville, Louisville, KY
| | - Adam B Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA
| | - Julia Grabowski
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital, Northwestern University, Chicago, IL
| | - Dave R Lal
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital
| | - Robert Baird
- Division of Pediatric General and Thoracic Surgery, Montreal Children's Hospital, QC, Canada
| | - Robert L Gates
- Division of Pediatric Surgery, Greenville Health System, Greenville, SC
| | - Julia Shelton
- Division of Pediatric Surgery, University of Iowa Stead Family Children's Hospital, Iowa City, IA
| | - Tim Jancelewicz
- Department of Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Mary T Austin
- Division of Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, TX
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22
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Abstract
The majority of surviving infants with surgical necrotizing enterocolitis (NEC) will have some degree of neurodevelopmental impairment. The impact of specific medial and surgical treatments for infants with severe NEC remains largely unknown but is being actively investigated. It is incumbent upon all providers caring for these infants to continue to focus on long term neurodevelopmental outcomes and to develop more widespread methods of neurodevelopmental assessment.
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Affiliation(s)
- Jamie R Robinson
- Department of Pediatric Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Doctors Office Tower, Suite 7100, Nashville, Tennessee 37232
| | | | - Kyle J van Arendonk
- Department of Pediatric Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Doctors Office Tower, Suite 7100, Nashville, Tennessee 37232
| | - Alyssa Green
- Meharry Medical College School of Medicine, Nashville, Tennessee
| | - Camilia R Martin
- Department of Neonatology and Division of Translational Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Doctors Office Tower, Suite 7100, Nashville, Tennessee 37232.
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23
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Moya FR, Lally KP, Moyer VA, Blakely ML. Surfactant for newborn infants with congenital diaphragmatic hernia. Hippokratia 2017. [DOI: 10.1002/14651858.cd004209.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Fernando R Moya
- New Hanover Regional Medical Center; PLLC Director of Neonatology; Wilmington NC USA 28401
| | - Kevin P Lally
- University of Texas Health Science Center at Houston; Department of Pediatric Surgery; PO Box 20708 Houston Texas USA TX 77225-0708
| | - Virginia A Moyer
- The American Board of Pediatrics; 111 Silver Cedar Court Chapel Hill North Carolina USA 27514
| | - Martin L Blakely
- University of Texas, Houston; Pediatric Surgery; 6431 Fannin MSB 5.254 Houston TX USA 77584
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24
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Streck CJ, Vogel AM, Zhang J, Huang EY, Santore MT, Tsao K, Falcone RA, Dassinger MS, Russell RT, Blakely ML, Mauldin PD, Calder BW, Savoie KB, Haynes JH, Naik-Mathuria BJ, St Peter SD, Mooney DP, Onwubiko C, Upperman JS. Identifying Children at Very Low Risk for Blunt Intra-Abdominal Injury in Whom CT of the Abdomen Can Be Avoided Safely. J Am Coll Surg 2017; 224:449-458.e3. [DOI: 10.1016/j.jamcollsurg.2016.12.041] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 12/19/2016] [Indexed: 11/29/2022]
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25
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Putnam LR, Tsao K, Lally KP, Blakely ML, Jancelewicz T, Lally PA, Harting MT. Minimally Invasive vs Open Congenital Diaphragmatic Hernia Repair: Is There a Superior Approach? J Am Coll Surg 2017; 224:416-422. [DOI: 10.1016/j.jamcollsurg.2016.12.050] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 12/20/2016] [Indexed: 10/20/2022]
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26
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Abstract
Although currently available data are variable, it appears that the incidence of surgical necrotizing enterocolitis (NEC) has not decreased significantly over the past decade. Pneumoperitoneum and clinical deterioration despite maximal medical therapy remain the most common indications for operative treatment. Robust studies linking outcomes with specific indications for operation are lacking. Promising biomarkers for severe NEC include fecal calprotectin and S100A12; serum fatty acid-binding protein; and urine biomarkers. Recent advances in ultrasonography make this imaging modality more useful in identifying surgical NEC and near-infrared spectroscopy (NIRS) is being actively studied. Another fairly recent finding is that regionalization of care for infants with NEC likely improves outcomes. The neurodevelopmental outcomes after surgical treatment are known to be poor. A randomized trial near completion will provide robust data regarding neurodevelopmental outcomes after laparotomy versus drainage as the initial operative treatment for severe NEC.
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Affiliation(s)
- Jamie R. Robinson
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Eric J. Rellinger
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - L. Dupree Hatch
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Joern-Hendrik Weitkamp
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - K. Elizabeth Speck
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Melissa Danko
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Martin L. Blakely
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN,Correspondence to: Department of Pediatric Surgery, Vanderbilt University Medical Center, 2200 Children’s Way, Suite 7100, Nashville, TN 37232-2730. (M.L. Blakely)
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27
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Bucher BT, Duggan EM, Grubb PH, France DJ, Lally KP, Blakely ML. Does the American College of Surgeons National Surgical Quality Improvement Program pediatric provide actionable quality improvement data for surgical neonates? J Pediatr Surg 2016; 51:1440-4. [PMID: 27046303 DOI: 10.1016/j.jpedsurg.2016.02.084] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 02/23/2016] [Accepted: 02/24/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this project was to examine the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACSNSQIP-P) Participant Use File (PUF) to compare risk-adjusted outcomes of neonates versus other pediatric surgical patients. METHODS In the ACS-NSQIP-P 2012-2013 PUF, patients were classified as preterm neonate, term neonate, or nonneonate at the time of surgery. The primary outcomes were 30-day mortality and composite morbidity. Patient characteristics significantly associated with the primary outcomes were used to build a multivariate logistic regression model. RESULTS The overall 30-day mortality rate for preterm neonates, term neonate, and nonneonates was 4.9%, 2.0%, 0.1%, respectively (p<0.0001). The overall 30-day morbidity rate for preterm neonates, term neonates, and nonneonates was 27.0%, 17.4%, 6.4%, respectively (p<0.0001). After adjustment for preoperative and operative risk factors, both preterm (adjusted odds ratio, 95% CI: 2.0, 1.4-3.0) and term neonates (aOR, 95% CI: 1.9, 1.2-3.1) had a significantly increased odds of 30-day mortality compared to nonneonates. CONCLUSION Surgical neonates are a cohort who are particularity susceptible to postoperative morbidity and mortality after adjusting for preoperative and operative risk factors. Collaborative efforts focusing on surgical neonates are needed to understand the unique characteristics of this cohort and identify the areas where the morbidity and mortality can be improved.
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Affiliation(s)
- Brian T Bucher
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100 North Mario Capecchi Drive, Suite #3800, Salt Lake City, UT 84113-1103, USA.
| | - Eileen M Duggan
- Department of Pediatric Surgery, Section of Surgical Sciences, Vanderbilt University School of Medicine, 7100 Doctors' Office Tower, 2200 Children's Way, Nashville, TN 37232, USA
| | - Peter H Grubb
- Division of Neonatology, Department of Pediatrics, Vanderbilt University School of Medicine, 11111 Doctors' Office Tower, 2200 Children's Way, Nashville, TN 37232, USA
| | - Daniel J France
- Center for Research and Innovation in Systems Safety, Department of Anesthesiology, Vanderbilt University School of Medicine, 2301 Vanderbilt University Hospital, 1211 Medical Center Drive, Nashville, TN 37232, USA
| | - Kevin P Lally
- Department of Pediatric Surgery, UT Health Medical School and Children's Memorial Hermann Hospital, 6431 Fannin Street, Suite 5.258, Houston, TX 77030, USA
| | - Martin L Blakely
- Department of Pediatric Surgery, Section of Surgical Sciences, Vanderbilt University School of Medicine, 7100 Doctors' Office Tower, 2200 Children's Way, Nashville, TN 37232, USA
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28
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Duggan EM, Marshall AP, Weaver KL, St Peter SD, Tice J, Wang L, Choi L, Blakely ML. A systematic review and individual patient data meta-analysis of published randomized clinical trials comparing early versus interval appendectomy for children with perforated appendicitis. Pediatr Surg Int 2016; 32:649-55. [PMID: 27161128 DOI: 10.1007/s00383-016-3897-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2016] [Indexed: 12/31/2022]
Abstract
PURPOSE Our objective was to perform a meta-analysis on RCTs that compared outcomes in children with perforated appendicitis (PA) who underwent either early appendectomy (EA) or interval appendectomy (IA). We also sought to determine if the presence of an intra-abdominal abscess (IAA) at admission impacted treatment strategy and outcomes. METHODS We identified two RCTs comparing EA versus IA in children with PA. A meta-analysis was performed using regression models and the overall adverse event rate was analyzed. The treatment effect variation depending on the presence of IAA at admission was also evaluated. RESULTS EA significantly reduced the odds of an adverse event (OR 0.28, 95 % CI 0.1-0.77) and an unplanned readmission (OR 0.08, 95 % CI 0.01-0.67), as well as the total charges (79 % of the IA, 95 % CI 63-100) for those who did not have an IAA at admission. In children with an IAA, there was no difference between EA and IA. However, heterogeneity of treatment effect was present regarding IAA at presentation. CONCLUSIONS While EA appears to improve outcomes in patients without an abscess, the published data support no significant difference in outcomes between EA and IA in patients with an abscess.
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Affiliation(s)
- Eileen M Duggan
- Department of Pediatric Surgery, Vanderbilt University Medical Center, 2200 Childrens Way, DOT 7100, Nashville, TN, 37232, USA
| | - Andre P Marshall
- Department of Pediatric Surgery, Vanderbilt University Medical Center, 2200 Childrens Way, DOT 7100, Nashville, TN, 37232, USA
| | - Katrina L Weaver
- Department of Pediatric Surgery, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO, 64108, USA
| | - Shawn D St Peter
- Department of Pediatric Surgery, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO, 64108, USA.
| | - Jamie Tice
- Department of Pediatric Surgery, Vanderbilt University Medical Center, 2200 Childrens Way, DOT 7100, Nashville, TN, 37232, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt University Medical Center, 2200 Childrens Way, DOT 7100, Nashville, TN, 37232, USA.
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29
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Goldin AB, Heiss KF, Hall M, Rothstein DH, Minneci PC, Blakely ML, Browne M, Raval MV, Shah SS, Rangel SJ, Snyder CL, Vinocur CD, Berman L, Cooper JN, Arca MJ. Emergency Department Visits and Readmissions among Children after Gastrostomy Tube Placement. J Pediatr 2016; 174:139-145.e2. [PMID: 27079966 DOI: 10.1016/j.jpeds.2016.03.032] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/25/2016] [Accepted: 03/10/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To define the incidence of 30-day postdischarge emergency department (ED) visits and hospital readmissions following pediatric gastrostomy tube (GT) placement across all procedural services (Surgery, Interventional-Radiology, Gastroenterology) in 38 freestanding Children's Hospitals. STUDY DESIGN This retrospective cohort study evaluated patients <18 years of age discharged between 2010 and 2012 after GT placement. Factors significantly associated with ED revisits and hospital readmissions within 30 days of hospital discharge were identified using multivariable logistic regression. A subgroup analysis was performed comparing patients having the GT placed on the date of admission or later in the hospital course. RESULTS Of 15 642 identified patients, 8.6% had an ED visit within 30 days of hospital discharge, and 3.9% were readmitted through the ED with a GT-related issue. GT-related events associated with these visits included infection (27%), mechanical complication (22%), and replacement (19%). In multivariable analysis, Hispanic ethnicity, non-Hispanic black race, and the presence of ≥3 chronic conditions were independently associated with ED revisits; gastroesophageal reflux and not having a concomitant fundoplication at time of GT placement were independently associated with hospital readmission. Timing of GT placement (scheduled vs late) was not associated with either ED revisits or hospital readmission. CONCLUSIONS GT placement is associated with high rates of ED revisits and hospital readmissions in the first 30 days after hospital discharge. The association of nonmodifiable risk factors such as race/ethnicity and medical complexity is an initial step toward understanding this population so that interventions can be developed to decrease these potentially preventable occurrences given their importance among accountable care organizations.
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Affiliation(s)
- Adam B Goldin
- Department of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA.
| | - Kurt F Heiss
- Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Matt Hall
- Children's Hospital Association, Overland Park, KS
| | | | - Peter C Minneci
- The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | | | - Marybeth Browne
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Mehul V Raval
- Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Shawn J Rangel
- Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | - Loren Berman
- Nemours-Alfred I. DuPont Hospital for Children, Wilmington, DE
| | - Jennifer N Cooper
- The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Marjorie J Arca
- Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, WI
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30
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Willis ZI, Duggan EM, Bucher BT, Pietsch JB, Milovancev M, Wharton W, Gillon J, Lovvorn HN, O'Neill JA, Di Pentima MC, Blakely ML. Effect of a Clinical Practice Guideline for Pediatric Complicated Appendicitis. JAMA Surg 2016; 151:e160194. [PMID: 27027263 DOI: 10.1001/jamasurg.2016.0194] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Complicated appendicitis is a common condition in children that causes substantial morbidity. Significant variation in practice exists within and between centers. We observed highly variable practices within our hospital and hypothesized that a clinical practice guideline (CPG) would standardize care and be associated with improved patient outcomes. OBJECTIVE To determine whether a CPG for complicated appendicitis could be associated with improved clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS A comprehensive CPG was developed for all children with complicated appendicitis at Monroe Carell Jr Children's Hospital at Vanderbilt, a freestanding children's hospital in Nashville, Tennessee, and was implemented in July 2013. All patients with complicated appendicitis who were treated with early appendectomy during the study period were included in the study. Patients were divided into 2 cohorts, based on whether they were treated before or after CPG implementation. Clinical characteristics and outcomes were recorded for 30 months prior to and 16 months following CPG implementation. EXPOSURE Clinical practice guideline developed for all children with complicated appendicitis at Monroe Carell Jr Children's Hospital at Vanderbilt. MAIN OUTCOMES AND MEASURES The primary outcome measure was the occurrence of any adverse event such as readmission or surgical site infection. In addition, resource use, practice variation, and CPG adherence were assessed. RESULTS Of the 313 patients included in the study, 183 were boys (58.5%) and 234 were white (74.8%). Complete CPG adherence occurred in 78.7% of cases (n = 96). The pre-CPG group included 191 patients with a mean (SD) age of 8.8 (4.0) years, and the post-CPG group included 122 patients with a mean (SD) age of 8.7 (4.1) years. Compared with the pre-CPG group, patients in the post-CPG group were less likely to receive a peripherally inserted central catheter (2.5%, n = 3 vs 30.4%, n = 58; P < .001) or require a postoperative computed tomographic scan (13.1%, n = 16 vs 29.3%, n = 56; P = .001), and length of hospital stay was significantly reduced (4.6 days post-CPG vs 5.1 days pre-CPG, P < .05). Patients in the post-CPG group were less likely to have a surgical site infection (relative risk [RR], 0.41; 95% CI, 0.27-0.74) or require a second operation (RR, 0.35; 95% CI, 0.12-1.00). In the pre-CPG group, 30.9% of patients (n = 59) experienced any adverse event, while 22.1% of post-CPG patients (n = 27) experienced any adverse event (RR, 0.72; 95% CI, 0.48-1.06). CONCLUSIONS AND RELEVANCE Significant practice variation exists among surgeons in the management of pediatric complicated appendicitis. In our institution, a CPG that standardized practice patterns was associated with reduced resource use and improved patient outcomes. Most surgeons had very high compliance with the CPG.
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Affiliation(s)
- Zachary I Willis
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eileen M Duggan
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Brian T Bucher
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee3Division of Pediatric Surgery, University of Utah, Salt Lake City
| | - John B Pietsch
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Monica Milovancev
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Whitney Wharton
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jessica Gillon
- Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - James A O'Neill
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - M Cecilia Di Pentima
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
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Shinnick JK, Short HL, Heiss KF, Santore MT, Blakely ML, Raval MV. Enhancing recovery in pediatric surgery: a review of the literature. J Surg Res 2016; 202:165-76. [DOI: 10.1016/j.jss.2015.12.051] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 12/28/2015] [Accepted: 12/31/2015] [Indexed: 12/20/2022]
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Putnam LR, Levy SM, Blakely ML, Lally KP, Wyrick DL, Dassinger MS, Russell RT, Huang EY, Vogel AM, Streck CJ, Kawaguchi AL, Calkins CM, St Peter SD, Abbas PI, Lopez ME, Tsao K. A multicenter, pediatric quality improvement initiative improves surgical wound class assignment, but is it enough? J Pediatr Surg 2016; 51:639-44. [PMID: 26590473 DOI: 10.1016/j.jpedsurg.2015.10.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 08/21/2015] [Accepted: 10/10/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE Surgical wound classification (SWC) is widely utilized for surgical site infection (SSI) risk stratification and hospital comparisons. We previously demonstrated that nearly half of common pediatric operations are incorrectly classified in eleven hospitals. We aimed to improve multicenter, intraoperative SWC assignment through targeted quality improvement (QI) interventions. METHODS A before-and-after study from 2011-2014 at eleven children's hospitals was conducted. The SWC recorded in the hospital's intraoperative record (hospital-based SWC) was compared to the SWC assigned by a surgeon reviewer utilizing a standardized algorithm. Study centers independently performed QI interventions. Agreement between the hospital-based and surgeon SWC was analyzed with Cohen's weighted kappa and chi square. RESULTS Surgeons reviewed 2034 cases from 2011 (Period 1) and 1998 cases from 2013 (Period 2). Overall SWC agreement improved from 56% to 76% (p<0.01) and weighted kappa from 0.45 (95% CI 0.42-0.48) to 0.73 (95% CI 0.70-0.75). Median (range) improvement per institution was 23% (7-35%). A dose-response-like pattern was found between the number of interventions implemented and the amount of improvement in SWC agreement at each institution. CONCLUSIONS Intraoperative SWC assignment significantly improved after resource-intensive, multifaceted interventions. However, inaccurate wound classification still commonly occurred. SWC used in SSI risk-stratification models for hospital comparisons should be carefully evaluated.
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Affiliation(s)
- Luke R Putnam
- Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA
| | - Shauna M Levy
- Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA
| | - Martin L Blakely
- Vanderbilt Children's Hospital, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kevin P Lally
- Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA
| | - Deidre L Wyrick
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Melvin S Dassinger
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Robert T Russell
- Children's of Alabama, University of Alabama Birmingham School of Medicine, Birmingham, AL, USA
| | - Eunice Y Huang
- Le Bonheur Children's Hospital, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Adam M Vogel
- St. Louis Children's Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Christian J Streck
- MUSC Children's Hospital, Medical University of South Carolina, Charleston, SC, USA
| | - Akemi L Kawaguchi
- Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA; Children's Hospital Los Angeles, Keck Medical Center of USC, Los Angeles, CA, USA
| | - Casey M Calkins
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Shawn D St Peter
- Children's Mercy Hospital, University of Missouri - Kansas City School of Medicine, Kansas City, MO, USA
| | - Paulette I Abbas
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Monica E Lopez
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - KuoJen Tsao
- Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA.
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Englum BR, Rothman J, Leonard S, Reiter A, Thornburg C, Brindle M, Wright N, Heeney MM, Smithers CJ, Brown RL, Kalfa T, Langer JC, Cada M, Oldham KT, Scott JP, St Peter SD, Sharma M, Davidoff AM, Nottage K, Bernabe K, Wilson DB, Dutta S, Glader B, Crary SE, Dassinger MS, Dunbar L, Islam S, Kumar M, Rescorla F, Bruch S, Campbell A, Austin M, Sidonio R, Blakely ML, Rice HE. Hematologic outcomes after total splenectomy and partial splenectomy for congenital hemolytic anemia. J Pediatr Surg 2016; 51:122-7. [PMID: 26613837 PMCID: PMC5083068 DOI: 10.1016/j.jpedsurg.2015.10.028] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 10/07/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to define the hematologic response to total splenectomy (TS) or partial splenectomy (PS) in children with hereditary spherocytosis (HS) or sickle cell disease (SCD). METHODS The Splenectomy in Congenital Hemolytic Anemia (SICHA) consortium registry collected hematologic outcomes of children with CHA undergoing TS or PS to 1 year after surgery. Using random effects mixed modeling, we evaluated the association of operative type with change in hemoglobin, reticulocyte counts, and bilirubin. We also compared laparoscopic to open splenectomy. RESULTS The analysis included 130 children, with 62.3% (n=81) undergoing TS. For children with HS, all hematologic measures improved after TS, including a 4.1g/dl increase in hemoglobin. Hematologic parameters also improved after PS, although the response was less robust (hemoglobin increase 2.4 g/dl, p<0.001). For children with SCD, there was no change in hemoglobin. Laparoscopy was not associated with differences in hematologic outcomes compared to open. TS and laparoscopy were associated with shorter length of stay. CONCLUSION Children with HS have an excellent hematologic response after TS or PS, although the hematologic response is more robust following TS. Children with SCD have smaller changes in their hematologic parameters. These data offer guidance to families and clinicians considering TS or PS.
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Affiliation(s)
- Brian R. Englum
- Duke University Medical Center, Durham, NC, United States,Corresponding author at: Duke University Medical Center, DUMC, Box #3443, Durham, NC 27710-0001, United States. Tel.: +1 317 213 2360
| | | | - Sarah Leonard
- Duke University Medical Center, Durham, NC, United States
| | - Audra Reiter
- Duke University Medical Center, Durham, NC, United States
| | | | - Mary Brindle
- Calgary Children’s Hospital, Calgary, AB, Canada
| | | | | | | | | | - Theodosia Kalfa
- Cincinnati Children’s Medical Center, Cincinnati, OH, United States
| | | | | | | | - J. Paul Scott
- Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - Mukta Sharma
- Children’s Mercy Hospital, Kansas City, MO, United States
| | | | - Kerri Nottage
- St. Jude Children’s Research Hospital, Memphis, TN, United States
| | | | | | | | | | | | | | - Levette Dunbar
- University of Arkansas, Little Rock, AR, United States,University of Florida, Gainesville, FL, United States
| | - Saleem Islam
- University of Florida, Gainesville, FL, United States
| | | | - Fred Rescorla
- University of Indiana, Indianapolis, IN, United States
| | - Steve Bruch
- University of Michigan, Ann Arbor, MI, United States
| | | | - Mary Austin
- University of Texas/MD Anderson Cancer Center, Houston, TX, United States
| | | | | | - Henry E. Rice
- Duke University Medical Center, Durham, NC, United States
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Duggan EM, Patel VP, Blakely ML. Inguinal hernia repair in premature infants: more questions than answers. Arch Dis Child Fetal Neonatal Ed 2015; 100:F286-8. [PMID: 25710179 DOI: 10.1136/archdischild-2012-302964] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 01/28/2015] [Indexed: 11/03/2022]
Abstract
This review shows that there are many single institution studies reviewing outcomes of premature infants with IH. However, the numbers of patients in these studies are often small and most studies were retrospective, therefore, these studies were subject to the limitations inherent to observational studies for identifying best treatment methods. Nevertheless, the studies show that risks are high in this population and that outcomes may vary with the timing of repair. There have been calls for multicentre randomised trials comparing early versus later IH repair from all over the world and for a very long time. Yet, despite the frequency of IH repair in premature infants, this issue remains unstudied in a high-quality manner. A large, multicentre randomised trial is currently underway to address the effect of timing on the short-term and long-term safety and efficacy of IH repair in this population so that we may be able to deliver safe surgical care to this vulnerable population.
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Affiliation(s)
- Eileen M Duggan
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Vikram P Patel
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Dassinger MS, Renaud EJ, Goldin A, Huang EY, Russell RT, Streck CJ, Tang X, Blakely ML. Use of real-time ultrasound during central venous catheter placement: Results of an APSA survey. J Pediatr Surg 2015; 50:1162-7. [PMID: 25783346 DOI: 10.1016/j.jpedsurg.2015.03.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 02/23/2015] [Accepted: 03/06/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to document the attitudes and practice patterns of pediatric surgeons regarding use of RTUS with CVC placement. METHODS An analytic survey composed of 20 questions was sent via APSA headquarters to all practicing members. Answers were summarized as frequency and percentage. Distributions of answers were compared using the chi-square tests. P-values ≤0.05 were considered statistically significant. RESULTS 361 of 1072 members chose to participate for a response rate of 34%. Most placed CVCs into the subclavian veins (SCV) of patients without coagulopathy, with the left SCV chosen approximately four times more often than the right. Conversely, RTUS use at the internal jugular vein (IJV) was significantly greater than that for the SCV (p<0.001). Coagulopathy, multiple previous catheters, and morbid obesity were identified as patient characteristics that would encourage RTUS use. The most commonly cited potential barriers to RTUS use were lack of formal ultrasound training and the belief that ultrasound is not necessary. CONCLUSIONS Variability exists among pediatric surgeons regarding use of RTUS during CVC placement. Additional studies are needed to document actual frequency of use, how RTUS is implemented, and its efficacy of preventing adverse events in children.
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Affiliation(s)
- Melvin S Dassinger
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR.
| | | | - Adam Goldin
- Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Eunice Y Huang
- University of Tennessee Health Sciences Center, Memphis, TN
| | - Robert T Russell
- Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, AL
| | | | - Xinyu Tang
- Biostatistics Program, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Martin L Blakely
- Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
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Rice HE, Englum BR, Rothman J, Leonard S, Reiter A, Thornburg C, Brindle M, Wright N, Heeney MM, Smithers C, Brown RL, Kalfa T, Langer JC, Cada M, Oldham KT, Scott JP, St. Peter S, Sharma M, Davidoff AM, Nottage K, Bernabe K, Wilson DB, Dutta S, Glader B, Crary SE, Dassinger MS, Dunbar L, Islam S, Kumar M, Rescorla F, Bruch S, Campbell A, Austin M, Sidonio R, Blakely ML. Clinical outcomes of splenectomy in children: report of the splenectomy in congenital hemolytic anemia registry. Am J Hematol 2015; 90:187-92. [PMID: 25382665 DOI: 10.1002/ajh.23888] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 10/29/2014] [Indexed: 11/10/2022]
Abstract
The outcomes of children with congenital hemolytic anemia (CHA) undergoing total splenectomy (TS) or partial splenectomy (PS) remain unclear. In this study, we collected data from 100 children with CHA who underwent TS or PS from 2005 to 2013 at 16 sites in the Splenectomy in Congenital Hemolytic Anemia (SICHA) consortium using a patient registry. We analyzed demographics and baseline clinical status, operative details, and outcomes at 4, 24, and 52 weeks after surgery. Results were summarized as hematologic outcomes, short-term adverse events (AEs) (≤30 days after surgery), and long-term AEs (31-365 days after surgery). For children with hereditary spherocytosis, after surgery there was an increase in hemoglobin (baseline 10.1 ± 1.8 g/dl, 52 week 12.8 ± 1.6 g/dl; mean ± SD), decrease in reticulocyte and bilirubin as well as control of symptoms. Children with sickle cell disease had control of clinical symptoms after surgery, but had no change in hematologic parameters. There was an 11% rate of short-term AEs and 11% rate of long-term AEs. As we accumulate more subjects and longer follow-up, use of a patient registry should enhance our capacity for clinical trials and engage all stakeholders in the decision-making process.
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Affiliation(s)
- Henry E. Rice
- Duke University Medical Center; Durham North Carolina
| | | | | | - Sarah Leonard
- Duke University Medical Center; Durham North Carolina
| | - Audra Reiter
- Duke University Medical Center; Durham North Carolina
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Kerri Nottage
- St. Jude Children's Research Hospital; Memphis Tennessee
| | | | | | | | | | | | | | | | | | | | | | | | | | - Mary Austin
- University of Texas/MD Anderson Cancer Center; Houston Texas
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Levy SM, Lally KP, Blakely ML, Calkins CM, Dassinger MS, Duggan E, Huang EY, Kawaguchi AL, Lopez ME, Russell RT, St Peter SD, Streck CJ, Vogel AM, Tsao K. Surgical Wound Misclassification: A Multicenter Evaluation. J Am Coll Surg 2015; 220:323-9. [DOI: 10.1016/j.jamcollsurg.2014.11.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Revised: 11/16/2014] [Accepted: 11/17/2014] [Indexed: 11/28/2022]
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Sulkowski JP, Cooper JN, Duggan EM, Balci O, Anandalwar SP, Blakely ML, Heiss K, Rangel S, Minneci PC, Deans KJ. Does timing of neonatal inguinal hernia repair affect outcomes? J Pediatr Surg 2015; 50:171-6. [PMID: 25598118 PMCID: PMC4298703 DOI: 10.1016/j.jpedsurg.2014.10.035] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to examine practice variability and compare outcomes between early and delayed neonatal inguinal hernia repair (IHR). METHODS Patients admitted to neonatal intensive care units with a diagnosis of IH who underwent IHR by age 1 year in the Pediatric Health Information System from 1999 to 2011 were included. IHR after the index hospitalization was considered delayed. Inter-hospital variability in the proportion of delayed repairs and differences in outcomes for each group were compared. A propensity score matched analysis was performed to account for baseline differences between treatment groups. RESULTS Of the 2030 patients identified, 32.9% underwent delayed IHR with significant variability in the proportion of patients having delayed repair across hospitals (p<0.0001). More patients in the delayed group had a congenital anomaly or received life supportive measures prior to IHR (all p<0.01), and 8.2% of patients undergoing delayed repair had a diagnosis of incarceration at repair. More patients in the early group underwent reoperation for hernia within 1 year (5.9% vs. 3.7%, p=0.02). Results were similar after performing a propensity score matched analysis. CONCLUSIONS Significant variability in practice exists between children's hospitals in the timing of IHR, with delayed repair associated with incarceration and early repair with a higher rate of reoperation.
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Affiliation(s)
- Jason P Sulkowski
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Eileen M Duggan
- Department of Pediatric Surgery, Monroe Carell Jr Children's Hospital, Nashville, TN
| | - Ozlem Balci
- Department of Pediatric Surgery, Children's Hospital of Atlanta, Atlanta, GA
| | | | - Martin L Blakely
- Department of Pediatric Surgery, Monroe Carell Jr Children's Hospital, Nashville, TN
| | - Kurt Heiss
- Department of Pediatric Surgery, Children's Hospital of Atlanta, Atlanta, GA
| | - Shawn Rangel
- Department of Pediatric Surgery, Children's Hospital Boston, Boston, MA
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH.
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Sulkowski JP, Cooper JN, Duggan EM, Balci O, Anandalwar S, Blakely ML, Heiss K, Rangel SJ, Minneci PC, Deans KJ. Early versus delayed surgical correction of malrotation in children with critical congenital heart disease. J Pediatr Surg 2015; 50:86-91. [PMID: 25598100 PMCID: PMC4298705 DOI: 10.1016/j.jpedsurg.2014.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to compare outcomes between early and delayed surgical correction of malrotation in children with critical congenital heart disease (CHD). METHODS Patients with CHD who underwent cardiac surgery by 1 year of age and had malrotation diagnosed during their initial admission at 34 hospitals contributing to the Pediatric Health Information System in 2004-2009 were included. Ladd's procedures performed during the first admission were considered early correction, and those at a subsequent admission were considered delayed. Interhospital variability in the proportion of patients undergoing delayed correction was assessed, and outcomes were compared between the groups. RESULTS Of the 324 patients identified, 85.2% underwent early correction. Significant variability existed in the proportion of patients undergoing delayed correction across hospitals (p<0.0001). Baseline characteristics, including severity of CHD, were similar between the groups. In the delayed group, 27% of patients underwent a Ladd's procedure during an urgent or emergent admission, but none had volvulus or underwent intestinal resection. Rates of mortality and readmission within 1 year of malrotation diagnosis were similar in both groups. Chart validation confirmed 100% accuracy of diagnosis and treatment group assignment. CONCLUSIONS In patients with critical CHD, delayed operative intervention for malrotation without volvulus may be a reasonable alternative.
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Affiliation(s)
- Jason P Sulkowski
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Eileen M Duggan
- Department of Pediatric Surgery, Monroe Carell Jr Children's Hospital, Nashville, TN
| | - Ozlem Balci
- Department of Pediatric Surgery, Children's Hospital of Atlanta, Atlanta, GA
| | - Seema Anandalwar
- Department of Pediatric Surgery, Children's Hospital Boston, Boston, MA
| | - Martin L Blakely
- Department of Pediatric Surgery, Monroe Carell Jr Children's Hospital, Nashville, TN
| | - Kurt Heiss
- Department of Pediatric Surgery, Children's Hospital of Atlanta, Atlanta, GA
| | - Shawn J Rangel
- Department of Pediatric Surgery, Children's Hospital Boston, Boston, MA
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH, USA.
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Rangel SJ, Islam S, St Peter SD, Goldin AB, Abdullah F, Downard CD, Saito JM, Blakely ML, Puligandla PS, Dasgupta R, Austin M, Chen LE, Renaud E, Arca MJ, Calkins CM. Prevention of infectious complications after elective colorectal surgery in children: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee comprehensive review. J Pediatr Surg 2015; 50:192-200. [PMID: 25598122 DOI: 10.1016/j.jpedsurg.2014.11.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 11/03/2014] [Accepted: 11/03/2014] [Indexed: 12/13/2022]
Abstract
OBJECTIVE This goal of this review was to examine the clinical evidence in support of commonly utilized measures intended to reduce complications following elective colorectal surgery. DATA SOURCE Literature searches were performed to identify relevant studies from Medline, PubMed, and Cochrane databases. STUDY SELECTION The American Pediatric Surgery Association Outcomes and Clinical Trials Committee selected eight questions to address this topic systematically in the context of three management areas: 1) appropriate utilization of systemic antibiotics for colorectal procedures, 2) reduction of stool burden through mechanical bowel preparation, and 3) intraluminal gut decontamination through use of enteral nonabsorbable antibiotics. Primary outcomes of interest included the occurrence of infectious and mechanical complications related to stool burden and intraluminal bacterial concentration (incisional surgical site infection, anastomotic leakage, and intraabdominal abscess). RESULTS The evidence in support of each management category was systematically reviewed, graded, and summarized in the context of the review's primary outcomes. Practice recommendations were made as deemed appropriate by the committee. CONCLUSIONS Clinical evidence in support of interventions to reduce infectious complications following colorectal surgery is derived almost exclusively from the adult literature. High-quality evidence to guide clinical practice in children is sorely needed, as the available data may have only limited relevance to pediatric colorectal diseases.
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Affiliation(s)
- Shawn J Rangel
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Saleem Islam
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Shawn D St Peter
- Children's Mercy Hospital, University of Missouri, Kansas City, MO, USA
| | - Adam B Goldin
- Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | | | | | - Jacqueline M Saito
- St. Louis Children's Hospital, Washington University, St. Louis, MO, USA
| | | | | | - Roshni Dasgupta
- Cincinnati Children's Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Mary Austin
- Children's Memorial Hermann Hospital, University of Texas, Houston, TX, USA
| | - Li Ern Chen
- Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Marjorie J Arca
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Casey M Calkins
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
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Savoie KB, Huang EY, Aziz SK, Blakely ML, Dassinger S, Dorale AR, Duggan EM, Harting MT, Markel TA, Moore-Olufemi SD, Shah SR, St Peter SD, Tsao K, Wyrick DL, Williams RF. Improving gastroschisis outcomes: does birth place matter? J Pediatr Surg 2014; 49:1771-5. [PMID: 25487481 DOI: 10.1016/j.jpedsurg.2014.09.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 09/05/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Babies born in the hospital where they obtain definitive surgical care do not require transportation between institutions and may have shorter time to surgical intervention. Whether these differences result in meaningful improvement in outcomes has been debated. A multi-institutional retrospective study was performed comparing outcomes based on birthplace. METHODS Six institutions within the PedSRC reviewed infants born with gastroschisis from 2008 to 2013. Birthplace, perinatal, and postoperative data were collected. Based on the P-NSQIP definition, inborn was defined as birth at the pediatric hospital where repair occurred. The primary outcome was days to full enteral nutrition (FEN; 120kcal/kg/day). RESULTS 528 patients with gastroschisis were identified: 286 inborn, 242 outborn. Days to FEN, time to bowel coverage and abdominal wall closure, primary closure rate, and length of stay significantly favored inborn patients. In multivariable analysis, birthplace was not a significant predictor of time to FEN. Gestational age, presence of atresia or necrosis, primary closure rate, and time to abdominal wall closure were significant predictors. CONCLUSIONS Inborn patients had bowel coverage and definitive closure sooner with fewer days to full feeds and shorter length of stay. Birthplace appears to be important and should be considered in efforts to improve outcomes in patients with gastroschisis.
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Affiliation(s)
- Kate B Savoie
- University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Eunice Y Huang
- University of Tennessee Health Science Center, Memphis, Tennessee.
| | | | | | | | - Amanda R Dorale
- Indiana University School of Medicine, Indianapolis, Indiana.
| | | | | | - Troy A Markel
- Indiana University School of Medicine, Indianapolis, Indiana.
| | | | - Sohail R Shah
- University of Missouri-Kansas City, Kansas City, Missouri.
| | | | - Koujen Tsao
- University of Texas at Houston, Houston, Texas.
| | | | - Regan F Williams
- University of Tennessee Health Science Center, Memphis, Tennessee.
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Sulkowski JP, Cooper JN, Congeni A, Pearson EG, Nwomeh BC, Doolin EJ, Blakely ML, Minneci PC, Deans KJ. Single-stage versus multi-stage pull-through for Hirschsprung's disease: practice trends and outcomes in infants. J Pediatr Surg 2014; 49:1619-25. [PMID: 25475806 PMCID: PMC4257999 DOI: 10.1016/j.jpedsurg.2014.06.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 04/22/2014] [Accepted: 06/03/2014] [Indexed: 11/15/2022]
Abstract
PURPOSE The aim of this study was to evaluate surgical treatments and outcomes in a multi-institutional cohort of neonates with Hirschsprung's disease (HD). METHODS Using the Pediatric Health Information System (PHIS) from 1999 to 2009, neonates diagnosed with HD were identified and classified as having a single stage pull-through (SSPT) or multi-stage pull-through (MSPT). Diagnosis and classification algorithms and clinical variables and outcomes were validated by multi-institutional chart review. Groups were compared using logistic regression modeling and propensity-score matched analysis to account for baseline differences between groups. RESULTS 1555 neonates with HD were identified; 77.2% underwent SSPT and 22.8% underwent MSPT. Misclassification of disease or surgical treatment was <2%. Rates of SSPT increased over time (p=0.03). Compared to SSPT, patients undergoing MSPT had significantly lower birth weights and higher rates of prematurity, non-HD gastrointestinal anomalies, enterocolitis, and preoperative mechanical ventilation. Patients undergoing MSPT had significantly higher rates of readmissions (58.5 vs. 37.9%) and additional operations (38.7 vs. 26%). Results were consistent in the propensity-score matched analysis. CONCLUSION Most neonates with HD undergo SSPT. In patients with similar observed baseline characteristics, MSPT was associated with worse outcomes suggesting that some infants currently selected to undergo MSPT may have better outcomes with SSPT. However, there remains a subgroup of MSPT patients who were too ill to be adequately compared to SSPT patients; for this subgroup of severely ill infants with HD, MSPT may be the best option.
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Affiliation(s)
- Jason P. Sulkowski
- Center for Surgical Outcomes Research and Department of Surgery, Nationwide Children’s Hospital, Columbus, OH
| | - Jennifer N. Cooper
- Center for Surgical Outcomes Research and Department of Surgery, Nationwide Children’s Hospital, Columbus, OH
| | - Anthony Congeni
- Center for Surgical Outcomes Research and Department of Surgery, Nationwide Children’s Hospital, Columbus, OH
| | - Erik G. Pearson
- Department of Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Benedict C. Nwomeh
- Center for Surgical Outcomes Research and Department of Surgery, Nationwide Children’s Hospital, Columbus, OH
| | - Edward J. Doolin
- Department of Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Martin L. Blakely
- Department of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital, Nashville, TN
| | - Peter C. Minneci
- Center for Surgical Outcomes Research and Department of Surgery, Nationwide Children’s Hospital, Columbus, OH
| | - Katherine J. Deans
- Center for Surgical Outcomes Research and Department of Surgery, Nationwide Children’s Hospital, Columbus, OH
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Duggan EM, Gates DW, Slayton JM, Blakely ML. Is NSQIP Pediatric review representative of total institutional experience for children undergoing appendectomy? J Pediatr Surg 2014; 49:1292-4. [PMID: 25092092 DOI: 10.1016/j.jpedsurg.2013.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 10/07/2013] [Accepted: 10/08/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND/PURPOSE NSQIP Pediatric (NSQIP-P) is a robust quality improvement effort. A limitation of the NSQIP process lies in capturing a small proportion of the total case volume. This study examines whether appendectomies captured by NSQIP-P are concordant with all appendectomies, the most commonly captured procedure in 2011. METHODS We compared case mix and 30-day outcomes between children undergoing an appendectomy who were included in NSQIP (n=80) and children not captured by NSQIP (n=276) during 2011 at a tertiary referral children's hospital. A single surgical case reviewer reviewed all cases using NSQIP-P methodology. RESULTS NSQIP-P captured 80 of a total of 356 appendectomies (22%). The case mix was similar between NSQIP and non-NSQIP groups (e.g., 31% of each group had complicated appendicitis). Outcomes were also similar; post-operative occurrences, readmissions and return to the operation room occurred at rates of 7.5% vs. 7.6%, 5% vs. 4.7%, and 3.8% vs. 4.3% respectively. CONCLUSION Although NSQIP-P captured a minority of the total patient population that had an appendectomy, the case mix and outcomes were similar. Our results offer reassurance that NSQIP-P data are representative of the larger population for this procedure. Whether this concordance exists for procedures less commonly performed is unknown and a focus of ongoing work.
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Affiliation(s)
- Eileen M Duggan
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN 37232-2730, USA.
| | - Dan W Gates
- Department of Performance Management and Improvement, Monroe Carrell, Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, TN 37232-2730, USA
| | - Jenny M Slayton
- Department of Performance Management and Improvement, Monroe Carrell, Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, TN 37232-2730, USA
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN 37232-2730, USA
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Williams RF, Interiano RB, Paton E, Eubanks JW, Huang EY, Langham MR, Blakely ML. Impact of a randomized clinical trial on children with perforated appendicitis. Surgery 2014; 156:462-6. [PMID: 24878457 DOI: 10.1016/j.surg.2014.03.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 03/20/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND We previously conducted a randomized, clinical trial comparing early appendectomy with interval appendectomy for perforated appendicitis. The purpose of the present study was to evaluate the effect this clinical trial had on subsequent practice patterns and outcomes for patients with perforated appendicitis at the free-standing children's hospital conducting the trial. METHODS A retrospective study was conducted comparing children with perforated appendicitis treated before the trial (2005-2006) and after the trial (2009-2011). Early appendectomy was performed within 24 hours of diagnosis; interval appendectomy occurred 4-6 weeks after initial treatment with antibiotics. Patient characteristics, treatment variables, and outcomes were collected and compared. RESULTS The pretrial group consisted of 92 patients-62 (67%) underwent early appendectomy, and 30 (33%) patients had interval appendectomy. The posttrial group was composed of 103 patients, with 87 (84%) undergoing early appendectomy and 16 (16%) interval appendectomy (P = .005). The groups were similar in patient and admission characteristics, although the posttrial group had a lower percentage of self-pay patients and fewer computed tomography scans; health care use was similar between groups. Overall, the posttrial group had fewer adverse events (18% vs 34%, P = .02), specifically fewer wound infections (2% vs 14%, P = .001) and fewer unplanned readmissions (7% vs 16%, P = .04) than the pretrial group. In the posttrial group, those patients selected for interval appendectomy were more likely to complete the planned course of therapy than in the pretrial group. CONCLUSION A clinical trial conducted at our institution to evaluate currently available treatment options for perforated appendicitis did change practice patterns at our hospital. After the trial, there was an increase in the use of early appendectomy, a decrease in the number of computed tomography scans performed per patient, and a reduction in the overall adverse event rate.
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Affiliation(s)
- Regan F Williams
- LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN.
| | - Rodrigo B Interiano
- LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Elizabeth Paton
- LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - James W Eubanks
- LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Eunice Y Huang
- LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Max R Langham
- LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Martin L Blakely
- Surgery Department, Vanderbilt University Medical Center, Nashville, TN
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Goldin AB, Dasgupta R, Chen LE, Blakely ML, Islam S, Downard CD, Rangel SJ, St Peter SD, Calkins CM, Arca MJ, Barnhart DC, Saito JM, Oldham KT, Abdullah F. Optimizing resources for the surgical care of children: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee consensus statement. J Pediatr Surg 2014; 49:818-22. [PMID: 24851778 DOI: 10.1016/j.jpedsurg.2014.02.085] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 02/16/2014] [Accepted: 02/17/2014] [Indexed: 10/25/2022]
Abstract
The United States' healthcare system is facing unprecedented pressures: the healthcare cost curve is not sustainable while the bar of standards and expectations for the quality of care continues to rise. Systems committed to the surgical treatment of children will likely require changes and reorganization. Regardless of these mounting pressures, hospitals must remain focused on providing the best possible care to each child at every encounter. Available clinical expertise and hospital resources should be optimized to match the complexity of the treated condition. Although precise criteria are lacking, there is a growing consensus that the optimal combination of clinical experience and hospital resources must be defined, and efforts toward this goal have been supported by the Regents of the American College of Surgeons, the members of the American Pediatric Surgical Association, and the Society for Pediatric Anesthesia (SPA) Board of Directors. The topic of optimizing outcomes and the discussion of the concepts involved have unfortunately become divisive. Our goals, therefore, are 1) to provide a review of the literature that can provide context for the discussion of regionalization, volume, and optimal resources and promote mutual understanding of these important terms, 2) to review the evidence that has been published to date in pediatric surgery associated with regionalization, volume, and resource, 3) to focus on a specific resource (anesthesia), and the association that this may have with outcomes, and 4) to provide a framework for future research and policy efforts.
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Affiliation(s)
- Adam B Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA 98105.
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH 45229-3039
| | - Li Ern Chen
- Division of Pediatric Surgery, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, TX 75235
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN 37232
| | - Saleem Islam
- Division of Pediatric Surgery, University of Florida College of Medicine, Gainesville, FL 32610
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr. M.D. Department of Surgery, University of Louisville, Louisville, KY 40202
| | - Shawn J Rangel
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108
| | - Casey M Calkins
- Department of Pediatric Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI 53226
| | - Marjorie J Arca
- Department of Pediatric Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI 53226
| | - Douglas C Barnhart
- Division of Pediatric Surgery, University of Utah, Salt Lake City, UT 84113
| | - Jacqueline M Saito
- Division of Pediatric Surgery, Washington University, St. Louis, MO 63110
| | - Keith T Oldham
- Department of Pediatric Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI 53226
| | - Fizan Abdullah
- Division of Pediatric Surgery, Johns Hopkins University, Baltimore, MD 21287
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Wadhawan R, Oh W, Hintz SR, Blakely ML, Das A, Bell EF, Saha S, Laptook AR, Shankaran S, Stoll BJ, Walsh MC, Higgins RD. Neurodevelopmental outcomes of extremely low birth weight infants with spontaneous intestinal perforation or surgical necrotizing enterocolitis. J Perinatol 2014; 34:64-70. [PMID: 24135709 PMCID: PMC3877158 DOI: 10.1038/jp.2013.128] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 08/04/2013] [Accepted: 08/26/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine if extremely low birth weight infants with surgical necrotizing enterocolitis have a higher risk of death or neurodevelopmental impairment and neurodevelopmental impairment among survivors (secondary outcome) at 18-22 months corrected age compared with infants with spontaneous intestinal perforation and infants without necrotizing enterocolitis or spontaneous intestinal perforation. STUDY DESIGN Retrospective analysis of the Neonatal Research Network very low birth weight registry, evaluating extremely low birth weight infants born between 2000 and 2005. The study infants were designated into three groups: (1) spontaneous intestinal perforation without necrotizing enterocolitis; (2) surgical necrotizing enterocolitis (Bell's stage III); and (3) neither spontaneous intestinal perforation nor necrotizing enterocolitis. Multivariate logistic regression analysis was performed to evaluate the association between the clinical group and death or neurodevelopmental impairment, controlling for multiple confounding factors including center. RESULT Infants with surgical necrotizing enterocolitis had the highest rate of death before hospital discharge (53.5%) and death or neurodevelopmental impairment (82.3%) compared with infants in the spontaneous intestinal perforation group (39.1 and 79.3%) and no necrotizing enterocolitis/no spontaneous intestinal perforation group (22.1 and 53.3%; P<0.001). Similar results were observed for neurodevelopmental impairment among survivors. On logistic regression analysis, both spontaneous intestinal perforation and surgical necrotizing enterocolitis were associated with increased risk of death or neurodevelopmental impairment (adjusted odds ratio 2.21, 95% confidence interval (CI): 1.5, 3.2 and adjusted OR 2.11, 95% CI: 1.5, 2.9, respectively) and neurodevelopmental impairment among survivors (adjusted OR 2.17, 95% CI: 1.4, 3.2 and adjusted OR 1.70, 95% CI: 1.2, 2.4, respectively). CONCLUSION Spontaneous intestinal perforation and surgical necrotizing enterocolitis are associated with a similar increase in the risk of death or neurodevelopmental impairment and neurodevelopmental impairment among extremely low birth weight survivors at 18-22 months corrected age.
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Affiliation(s)
- Rajan Wadhawan
- Department of Pediatrics, Women & Infants Hospital, Providence, RI, USA
| | - William Oh
- Department of Pediatrics, Women & Infants Hospital, Providence, RI, USA
| | - Susan R Hintz
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt University, Nashville, TN, USA
| | - Abhik Das
- Statistics and Epidemiology Unit, RTI International, Rockville, MD, USA
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Shampa Saha
- Statistics and Epidemiology Unit, RTI International, Research Triangle Park, NC, USA
| | - Abbot R. Laptook
- Department of Pediatrics, Women & Infants Hospital, Providence, RI, USA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
| | - Barbara J. Stoll
- Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
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Snyder RA, Johnson L, Tice J, Wingo T, Williams D, Wang L, Blakely ML. Wound classification in pediatric general surgery: significant variation exists among providers. J Am Coll Surg 2013; 217:819-26. [PMID: 24012296 DOI: 10.1016/j.jamcollsurg.2013.05.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 05/21/2013] [Accepted: 05/21/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Risk-adjusted rates of surgical site infections (SSI) are used as a quality metric to facilitate improvement within a hospital system and allow comparison across institutions. The NSQIP-Pediatric, among others, uses surgical wound classification as a variable in models designed to predict risk-adjusted postoperative morbidity, including SSI rates. The purpose of this study was to measure the level of agreement in wound classification assignment among 3 providers: surgeons, operating room (OR) nurses, and NSQIP surgical clinical reviewers (SCR). STUDY DESIGN An analysis was performed of pediatric general surgery operations from 2010 to 2011. Wound classification was assigned at the time of operation by the OR nurse and surgeon, and by the NSQIP SCR postoperatively, according to NSQIP methodology. Disagreement was defined as any discrepancy in classification among the 3 providers, and the level of agreement was determined using the kappa statistic. RESULTS For the 374 procedures reviewed, there was an overall disagreement of 48% among all providers, kappa 0.48 (95% CI 0.43 to 0.53). When comparing wound classification by surgeon and NSQIP SCR, 23% of cases were in disagreement, kappa 0.74 (95% CI 0.68 to 0.78). Disagreement between OR nurse and either surgeon or NSQIP SCR was higher: 38%, kappa 0.45 (95% CI 0.38 to 0.53) and 40%, kappa 0.44 (95% CI 0.37 to 0.51). Fundoplication, appendectomy, and cholecystectomy demonstrated the highest overall disagreement (73%, 71%, and 60%, respectively). CONCLUSIONS There is significant variation in assigning surgical wound classification among health care providers. For future SSI comparative analyses, it will be critical to improve uniformity and understanding of wound class assignment among providers and institutions.
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Affiliation(s)
- Rebecca A Snyder
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN; Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN
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Marshall AP, Issar NM, Blakely ML. Appendiceal duplication in children presenting as an appendiceal tumor and as recurrent intussusception. J Pediatr Surg 2013; 48:e9-e12. [PMID: 23583164 DOI: 10.1016/j.jpedsurg.2013.01.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 01/18/2013] [Accepted: 01/19/2013] [Indexed: 02/06/2023]
Abstract
Duplication of the appendix is a rare condition and is usually an incidental finding during an appendectomy. There have been several cases reported in the literature. Although not usually associated with any discrete pathology, the presenting symptoms can vary but are usually associated with acute appendicitis. We present two cases of appendiceal duplication in young children, one presenting with the usual signs and symptoms of acute appendicitis and the other with intussusception. The purpose of this report is to present two distinct modes of presentation of this rare condition so that pediatric general surgeons are aware of this as a possible entity.
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Affiliation(s)
- Andre P Marshall
- Department of Surgery, Vanderbilt University Medical Center, D-4314 MCN 2730, Nashville, TN 37232, USA.
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50
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Downard CD, Renaud E, St Peter SD, Abdullah F, Islam S, Saito JM, Blakely ML, Huang EY, Arca MJ, Cassidy L, Aspelund G. Treatment of necrotizing enterocolitis: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J Pediatr Surg 2012; 47:2111-22. [PMID: 23164007 DOI: 10.1016/j.jpedsurg.2012.08.011] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 08/12/2012] [Accepted: 08/13/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The optimal treatment of necrotizing enterocolitis (NEC) is a common challenge for pediatric surgeons. Although many studies have evaluated prevention and medical therapy for NEC, few guidelines for surgical care exist. The aim of this systematic review is to review and evaluate the currently available evidence for the surgical care of patients with NEC. METHODS Data were compiled from a search of PubMed, OVID, the Cochrane Library database, and Web of Science from January 1985 until December 2011. Publications were screened, and their references were hand-searched to identify additional studies. Clinicaltrials.gov was also searched to identify ongoing or unpublished trials. The American Pediatric Surgical Association Outcomes and Clinical Trials Committee proposed six questions deemed pertinent to the surgical treatment of NEC. Recent Cochrane Reviews examined three of these topics; a literature review was performed to address the additional three specific questions. RESULTS The Cochrane Reviews support the use of prophylactic probiotics in preterm infants less than 2500 grams to reduce the incidence of NEC, as well as the use of human breast milk rather than formula when possible. There is no clear evidence to support delayed initiation or slow advancement of feeds. For surgical treatment of NEC with perforation, there is no clear support of peritoneal drainage versus laparotomy. Similarly, there is a lack of evidence comparing enterostomy versus primary anastomosis after resection at laparotomy. There are little data to determine the length of treatment with antibiotics to prevent recurrence of NEC. CONCLUSION Based on available evidence, probiotics are advised to decrease the incidence of NEC, and human milk should be used when possible. The other reviewed questions are clinically relevant, but there is a lack of evidence-based data to support definitive recommendations. These areas of NEC treatment would benefit from future investigation.
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Affiliation(s)
- Cynthia D Downard
- Kosair Children's Hospital, University of Louisville, Louisville, KY, USA.
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