The past, present and future of ACS NSQIP-Pediatric: Evolution from a quality registry to a comparative quality performance platform.

Quality and process improvement (QI/PI) in children's surgical care require reliable data across the care continuum. Since 2012, the American College of Surgeons' (ACS) National Surgical Quality Improvement Program-Pediatric (NSQIP-Pediatric) has supported QI/PI by providing participating hospitals with risk-adjusted, comparative data regarding postoperative outcomes for multiple surgical specialties. To advance this goal over the past decade, iterative changes have been introduced to case inclusion and data collection, analysis and reporting. New datasets for specific procedures, such as appendectomy, spinal fusion for scoliosis, vesicoureteral reflux procedures, and tracheostomy in children less than 2 years old, have incorporated additional risk factors and outcomes to enhance the clinical relevance of data, and resource utilization to consider healthcare value. Recently, process measures for urgent surgical diagnoses and surgical antibiotic prophylaxis variables have been developed to promote timely and appropriate care. While a mature program, NSQIP-Pediatric remains dynamic and responsive to meet the needs of the surgical community. Future directions include introduction of variables and analyses to address patient-centered care and healthcare equity.

Procedure-Level Misutilization of Antimicrobial Prophylaxis in Pediatric Surgery: Implications for Improved Stewardship and More Effective Infection Prevention.

BACKGROUND: The objective of this study was to quantify prophylaxis misutilization to identify high-priority procedures for improved stewardship and SSI prevention. METHODS: This was a multicenter analysis including 90 hospitals participating in the NSQIP-Pediatric Antibiotic Prophylaxis Collaborative from 6/2019 to 6/2020. Prophylaxis data were collected from all hospitals and misutilization measures were developed from consensus guidelines. Overutilization included use of overly broad-spectrum agents, continuation of prophylaxis >24 h after incision closure, and use in clean procedures without implants. Underutilization included omission (clean-contaminated cases), use of inappropriately narrow-spectrum agents, and administration post-incision. Procedure-level misutilization burden was estimated by multiplying NSQIP-derived misutilization rates by case volume data obtained from the Pediatric Health Information System database. RESULTS: 9861 patients were included. Overutilization was most commonly associated with overly broad-spectrum agents (14.0%), unindicated utilization (12.6%), and prolonged duration (8.4%). Procedure groups with the greatest overutilization burden included small bowel (27.2%), cholecystectomy (24.4%), and colorectal (10.7%). Underutilization was most commonly associated with post-incision administration (6.2%), inappropriate omission (4.4%), and overly narrow-spectrum agents (4.1%). Procedure groups with the greatest underutilization burden included colorectal (31.2%), gastrostomy (19.2%), and small bowel (11.1%). CONCLUSION: A relatively small number of procedures account for a disproportionate burden of antibiotic misutilization in pediatric surgery. TYPE OF STUDY: Retrospective Cohort. LEVEL OF EVIDENCE: III.

Incidence and Relative Burden of Surgical Site Infections in Children Undergoing Nonemergent Surgery: Implications for Performance Benchmarking and Prioritization of Prevention Efforts.

OBJECTIVE: To establish surgical site infection (SSI) performance benchmarks in pediatric surgery and to develop a prioritization framework for SSI prevention based on procedure-level SSI burden. BACKGROUND: Contemporary epidemiology of SSI rates and event burden in elective pediatric surgery remain poorly characterized. METHODS: Multicenter analysis using sampled SSI data from 90 hospitals participating in NSQIP-Pediatric and procedural volume data from the Pediatric Health Information System (PHIS) database. Procedure-level incisional and organ space SSI (OSI) rates for 17 elective procedure groups were calculated from NSQIP-Pediatric data and estimates of procedure-level SSI burden were extrapolated using procedural volume data. The relative contribution of each procedure to the cumulative sum of SSI events from all procedures was used as a prioritization framework. RESULTS: A total of 11,689 nonemergent procedures were included. The highest incisional SSI rates were associated with gastrostomy closure (4.1%), small bowel procedures (4.0%), and gastrostomy (3.7%), while the highest OSI rates were associated with esophageal atresia/tracheoesophageal fistula repair (8.1%), colorectal procedures (1.8%), and small bowel procedures (1.5%). 66.1% of the cumulative incisional SSI burden from all procedures were attributable to 3 procedure groups (gastrostomy: 27.5%, small bowel: 22.9%, colorectal: 15.7%), and 72.8% of all OSI events were similarly attributable to 3 procedure groups (small bowel: 28.5%, colorectal: 26.0%, esophageal atresia/tracheoesophageal fistula repair: 18.4%). CONCLUSIONS: A small number of procedures account for a disproportionate burden of SSIs in pediatric surgery. The results of this analysis can be used as a prioritization framework for refocusing SSI prevention efforts where they are needed most.

Correlation Between Postoperative Antimicrobial Prophylaxis Use and Surgical Site Infection in Children Undergoing Nonemergent Surgery.

Importance: Use of postoperative antimicrobial prophylaxis is common in pediatric surgery despite consensus guidelines recommending discontinuation following incision closure. The association between postoperative prophylaxis use and surgical site infection (SSI) in children undergoing surgical procedures remains poorly characterized. Objective: To evaluate whether use of postoperative surgical prophylaxis is correlated with SSI rates in children undergoing nonemergent surgery. Design, Setting, and Participants: This is a multicenter cohort study using 30-day postoperative SSI data from the American College of Surgeons' Pediatric National Surgical Quality Improvement Program (ACS NSQIP-Pediatric) augmented with antibiotic-use data obtained through supplemental medical record review from June 2019 to June 2021. This study took place at 93 hospitals participating in the ACS NSQIP-Pediatric Surgical Antibiotic Prophylaxis Stewardship Collaborative. Participants were children (<18 years of age) undergoing nonemergent surgical procedures. Exclusion criteria included antibiotic allergies, conditions associated with impaired immune function, and preexisting infections requiring intravenous antibiotics at time of surgery. Exposures: Continuation of antimicrobial prophylaxis beyond time of incision closure. Main Outcomes and Measures: Thirty-day postoperative rate of incisional or organ space SSI. Hierarchical regression was used to estimate hospital-level odds ratios (ORs) for SSI rates and postoperative prophylaxis use. SSI measures were adjusted for differences in procedure mix, patient characteristics, and comorbidity profiles, while use measures were adjusted for clinically related procedure groups. Pearson correlations were used to examine the associations between hospital-level postoperative prophylaxis use and SSI measures. Results: Forty thousand six hundred eleven patients (47.3% female; median age, 7 years) were included, of which 41.6% received postoperative prophylaxis (hospital range, 0%-71.2%). Odds ratios (ORs) for postoperative prophylaxis use ranged 190-fold across hospitals (OR, 0.10-19.30) and ORs for SSI rates ranged 4-fold (OR, 0.55-1.90). No correlation was found between use of postoperative prophylaxis and SSI rates overall (r = 0.13; P = .20), and when stratified by SSI type (incisional SSI, r = 0.08; P = .43 and organ space SSI, r = 0.13; P = .23), and surgical specialty (general surgery, r = 0.02; P = .83; urology, r = 0.05; P = .64; plastic surgery, r = 0.11; P = .35; otolaryngology, r = -0.13; P = .25; orthopedic surgery, r = 0.05; P = .61; and neurosurgery, r = 0.02; P = .85). Conclusions and Relevance: Use of postoperative surgical antimicrobial prophylaxis was not correlated with SSI rates at the hospital level after adjusting for differences in procedure mix and patient characteristics.

The influence of decreasing variable collection burden on hospital-level risk-adjustment.

BACKGROUND: Risk-adjustment is a key feature of the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-Ped). Risk-adjusted model variables require meticulous collection and periodic assessment. This study presents a method for eliminating superfluous variables using the congenital malformation (CM) predictor variable as an example. METHODS: This retrospective cohort study used NSQIP-Ped data from January 1st to December 31st, 2019 from 141 hospitals to compare six risk-adjusted mortality and morbidity outcome models with and without CM as a predictor. Model performance was compared using C-index and Hosmer-Lemeshow (HL) statistics. Hospital-level performance was assessed by comparing changes in outlier statuses, adjusted quartile ranks, and overall hospital performance statuses between models with and without CM inclusion. Lastly, Pearson correlation analysis was performed on log-transformed ORs between models. RESULTS: Model performance was similar with removal of CM as a predictor. The difference between C-index statistics was minimal (≤ 0.002). Graphical representations of model HL-statistics with and without CM showed considerable overlap and only one model attained significance, indicating minimally decreased performance (P = 0.058 with CM; P = 0.044 without CM). Regarding hospital-level performance, minimal changes in the number and list of hospitals assigned to each outlier status, adjusted quartile rank, and overall hospital performance status were observed when CM was removed. Strong correlation between log-transformed ORs was observed (r ≥ 0.993). CONCLUSIONS: Removal of CM from NSQIP-Ped has minimal effect on risk-adjusted outcome modelling. Similar efforts may help balance optimal data collection burdens without sacrificing highly valued risk-adjustment in the future. LEVEL OF EVIDENCE: Level II prognosis study.

Relative Traffic Tolerance of Warm-Season Grasses and Suitability for Grazing by Equine.

Warm season wear-tolerant turfgrasses, such as those used on golf courses and athletic fields, may be valuable forages on equine operations because of their potential to remain viable during heavy hoof traffic. Crabgrass may also be suitable as it thrives in conditions where other grasses have limited success. The objective of this study was to assess the relative traffic tolerance and nutritional composition of five warm-season (WS) turfgrass cultivars of bermudagrass and zoysiagrass and one WS forage-type crabgrass. All cultivars were established by seed in replicated monoculture plots. Simulated hoof traffic treatments consisted of either none, one, or two passes of a Baldree Traffic Simulator. Traffic was applied weekly for 6 weeks in the summer of 2016 and 2017, with each treatment period followed by a 4-week rest period. Plots were assessed for compaction, biomass, and persistence before and after treatment and rest periods. Nutritional composition was assessed throughout the growing seasons. Soil compaction increased as treatment level increased for all cultivars (P < .0001). There was no effect of treatment on cultivar persistence. Biomass available for grazing was increased in year 1 by the application of LOW traffic treatment (P = .0193). Both bermudagrass and zoysiagrass cultivars showed promise for use in areas of heavy traffic on equine operations, however, zoysiagrass cultivars were more suitable as they were highest ranking in relative traffic tolerance, moderate in yield, and low nonstructural carbohydrates (<12% NSC). Future on-farm studies evaluating bermudagrass and zoysiagrass to determine ideal stocking rate, management methods, and persistence under grazing are warranted.

Antireflux Surgery at National Surgical Quality Improvement Program-Pediatric Hospitals.

PURPOSE: This study aims to examine contemporary practice patterns and compare short-term outcomes for vesicoureteral reflux procedures (ureteral reimplant/endoscopic injection) using National Surgical Quality Improvement Program-Pediatric data. MATERIALS AND METHODS: Procedure-specific variables for antireflux surgery were developed to capture data not typically collected in National Surgical Quality Improvement Program-Pediatric (eg vesicoureteral reflux grade, urine cultures, 31-60-day followup). Descriptive statistics were performed, and logistic regression assessed associations between patient/procedural factors and outcomes (urinary tract infection, readmissions, unplanned procedures). RESULTS: In total, 2,842 patients (median age 4 years; 76% female; 68% open reimplant, 6% minimally invasive reimplant, 25% endoscopic injection) had procedure-specific variables collected from July 2016 through June 2018. Among 88 hospitals, a median of 24.5 procedures/study period were performed (range 1-148); 95% performed ≥1 open reimplant, 30% ≥1 minimally invasive reimplant, and 70% ≥1 endoscopic injection, with variability by hospital. Two-thirds of patients had urine cultures sent preoperatively, and 76% were discharged on antibiotics. Outcomes at 30 days included emergency department visits (10%), readmissions (4%), urinary tract infections (3%), and unplanned procedures (2%). Over half of patients (55%) had optional 31-60-day followup, with additional outcomes (particularly urinary tract infections) noted. Patients undergoing reimplant were younger, had higher reflux grades, and more postoperative occurrences than patients undergoing endoscopic injections. CONCLUSIONS: Contemporary data indicate that open reimplant is still the most common antireflux procedure, but procedure distribution varies by hospital. Emergency department visits are common, but unplanned procedures are rare, particularly for endoscopic injection. These data provide basis for comparing short-term complications and developing standardized perioperative pathways for antireflux surgery.

Relative Traffic Tolerance of Cool-Season Turfgrasses and Suitability for Grazing by Equine.

Unlike traditional forage grasses, turfgrasses, which were developed to be tolerant of foot traffic and close mowing, may be suitable as alternative ground cover in areas of high hoof traffic such as dry lots. The objective of this study was to evaluate the potential of eight cool-season turfgrasses as alternative ground cover in heavy use areas. Cultivars were established via seeding in four replicated plots. To simulate horse traffic at a trot, a Baldree traffic simulator was driven over a section of the plot, either 0 (CON), 1 (LOW), or 2 (HIGH) times per week for 6 weeks followed by 4 weeks of rest in the spring, summer, and fall over a 2-year period. Variables assessed include compaction, biomass available for grazing, vegetative cover (persistence), and nutrient composition. Soil compaction increased with the application of traffic treatments (P < .0001). Traffic treatment reduced persistence following traffic by 19%-36% across all trials in both years (P = .0003). For most trials, biomass available for grazing was reduced after traffic treatment by 19% and 43% (P = .02). Overall, tall fescue cultivars were most traffic tolerant followed by hard fescue. Cultivars considered "low" in nonstructural carbohydrate (<15%) included creeping bentgrass in Year 1 and hard fescue and chewings fescue in Year 2. In Year 2, the Ca:P ratio declined beyond what is recommended for horses. Tall fescue, hard fescue, and creeping bentgrass cultivars are recommended for further evaluation as suitable ground cover in areas of heavy use on equine operations.

Dietary tributyrin, an HDAC inhibitor, promotes muscle growth through enhanced terminal differentiation of satellite cells.

Muscle growth and repair rely on two main mechanisms - myonuclear accretion and subsequent protein accumulation. Altering the ability of muscle resident stem cells (satellite cells) to progress through their myogenic lineage can have a profound effect on lifetime muscle growth and repair. The use of the histone deacetylase (HDAC) inhibitor, butyrate, has had positive outcomes on the in vitro promotion of satellite cell myogenesis. In animal models, the use of butyrate has had promising results in treating myopathic conditions as well as improving growth efficiency, but the impact of dietary butyrate on satellite cells and muscle growth has not been elucidated. We investigated the impact of tributyrin, a butyrate prodrug, on satellite cell activity and muscle growth in a piglet model. Satellite cells from tributyrin-treated piglets had altered myogenic potential, and piglets receiving tributyrin had a ~40% increase in DNA:protein ratio after 21 days, indicating the potential for enhanced muscle growth. To assess muscle growth potential, piglets were supplemented tributyrin (0.5%) during either the neonatal phase (d1-d21) and/or the nursery phase (d21-d58) in a 2 × 2 factorial design. Piglets who received tributyrin during the neonatal phase had improved growth performance at the end of the study and had a ~10% larger loin eye area and muscle fiber cross-sectional area. Tributyrin treatment in the nursery phase alone did not have a significant effect on muscle growth or feed efficiency. These findings suggest that tributyrin is a potent promoter of muscle growth via altered satellite cell myogenesis.

Characterization of the Prevalence and Management of Over-Conditioned Ponies and Horses in Maryland.

It has been estimated in the United States and abroad that 20%-51% of the equine population suffers from over-conditioning or obesity. The objective of this study was to evaluate the prevalence of over-conditioning in the equine population in Maryland, to characterize weight control measures used, and to ascertain how control measures impact the operation. Over-conditioning was defined as a body condition score of 4 or 5 on a 5-point scale. All licensed horse operators in Maryland were invited to participate in an online survey. A total of 93 farm operators completed the survey with 238 ponies and 1,290 horses represented. Nearly, all operators (96%) indicated that they managed at least one obese pony or horse and that 41% of their ponies (n = 97) and 40% of their horses (n = 512) were over-conditioned. Over-conditioned ponies had a higher incidence of laminitis and were more heavily managed. Dry lots were the most common management practice used for ponies even though they were reported to be more time consuming and required more maintenance than pasturing horses. Participants were most satisfied with using exercise for weight control followed by dry lots and least satisfied with using grazing muzzles and administering medication. Operators spent an average of $434.18 ± $15.19 more each year to manage their over-conditioned equids. In conclusion, a significant portion of Maryland's horses and ponies is over-conditioned with laminitis occurring more frequently in over-conditioned ponies. Additional or alternative measures to prevent over-conditioning are needed to reduce labor and maintenance costs as well as improve welfare practices.

Influence of maternal nutrition and heat stress on bovine oocyte and embryo development.

The global population is expected to increase from 7.6 to 9.6 billion people from 2017 to 2050. Increased demand for livestock production and rising global temperatures have made heat stress (HS) a major challenge for the dairy industry. HS been shown to have negative effects on production parameters such as dry matter intake, milk yield, and feed efficiency. In addition to affecting production parameters, HS has also been shown to have negative effects on the reproductive functions of dairy cows. Mitigation of HS effects on dairy cow productivity and fertility necessitate the strategic planning of nutrition, and environmental conditions. The current review will discuss the potential nutriepigenomic strategies to mitigate the effect of HS on bovine embryo.