Social injustice symposium: Urban, rural, and global disparities in access to care.

BACKGROUND: Barriers in access to pediatric surgical care are common in low- and middle-income countries (LMICs), but also exist in high-income countries, particularly in urban and rural areas. METHODS: This article describes "Disparities in Access to Care"-held within the Social Injustice Symposium at the 2020 American Pediatric Surgical Association (APSA) Annual Meeting. RESULTS: This symposium outlined disparities in access to care, illustrated by examples from pediatric trauma and neonatal surgery in U.S. urban, U.S. rural, and non-U.S. global locations (LMICs). Geographic and financial challenges were common to families from the rural U.S. and LMICs. In contrast, families in U.S. urban settings generally do not face geographic barriers, but are often economically and racially diverse and many face complex societal factors leading to poor outcomes. Systemic processes must be changed to improve pediatric surgical health outcomes. CONCLUSION: A comprehensive health system with an equal emphasis on supportive care and surgery is required in all settings. Global collaboration and partnerships can provide an avenue for advocacy and strategic innovation to improve quality of care. LEVEL OF EVIDENCE: Ⅴ.

New anthropometric classification scheme of preoperative nutritional status in children: a retrospective observational cohort study.

OBJECTIVE: WHO uses anthropometric classification scheme of childhood acute and chronic malnutrition based on low body mass index (BMI) ('wasting') and height for age ('stunting'), respectively. The goal of this study was to describe a novel two-axis nutritional classification scheme to (1) characterise nutritional profiles in children undergoing abdominal surgery and (2) characterise relationships between preoperative nutritional status and postoperative morbidity. DESIGN: This was a retrospective observational cohort study. SETTING: The setting was 50 hospitals caring for children in North America that participated in the American College of Surgeons National Surgical Quality Improvement Program Paediatric from 2011 to 2013. PARTICIPANTS: Children >28 days who underwent major abdominal operations were identified. INTERVENTIONS/MAIN PREDICTOR: The cohort of children was divided into five nutritional profile groups based on both BMI and height for age Z-scores: (1) underweight/short, (2) underweight/tall, (3) overweight/short, (4) overweight/tall and (5) non-outliers (controls). MAIN OUTCOME MEASURES: Multiple variable logistic regressions were used to quantify the association between 30-day morbidity and nutritional profile groups while adjusting for procedure case mix, age and American Society of Anaesthesiologists class. RESULTS: A total of 39 520 cases distributed as follows: underweight/short (656, 2.2%); underweight/tall (252, 0.8%); overweight/short (733, 2.4%) and overweight/tall (1534, 5.1%). Regression analyses revealed increased adjusted odds of composite morbidity (35%) and reintervention events (75%) in the underweight/short group, while overweight/short patients had increased adjusted odds of composite morbidity and healthcare-associated infections (43%), and reintervention events (79%) compared with controls. CONCLUSION: Stratification of preoperative nutritional status using a scheme incorporating both BMI and height for age is feasible. Further research is needed to validate this nutritional risk classification scheme for other surgical procedures in children.

Hospital variation in rates of concurrent fundoplication during gastrostomy enteral access procedures.

BACKGROUND: This study aimed to determine whether (1) the propensity for concurrent fundoplication during gastrostomy varies among hospitals, and (2) postoperative morbidity differs among institutions performing fundoplication more or less frequently. METHODS: Children who underwent gastrostomy with or without concurrent fundoplication were identified in the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-P). A hierarchical multivariate regression modeled the excess effects that hospitals exerted over propensity for concurrent fundoplication adjusting for preoperative clinical variables. Hospitals were designated as low outliers (significantly lower-adjusted odds of concurrent fundoplication than the average hospital with similar patient mix), average hospitals, and high outliers based on their risk-adjusted concurrent fundoplication practice. The postoperative morbidity rates were compared among low-outlier, average, and high-outlier hospitals. RESULTS: Between 2011 and 2013, 3775 children underwent gastrostomy at one of 54 ACS-NSQIP-P participating hospitals. The mean hospital concurrent fundoplication rate was 11.7% (range 0-64%). There was no significant difference in unadjusted morbidity rate in children with concurrent fundoplication, 11.0% compared to 9.7% in children without concurrent fundoplication. After controlling for clinical variables, 8 hospitals were identified as low outliers (fundoplication rate of 0.4%) and 16 hospitals were identified as high outliers (fundoplication rate of 34.6%). The average unadjusted morbidity rate among hospitals with low, average, and high odds of concurrent fundoplication were 9.6, 10.6, and 8.4%, respectively. CONCLUSION: Hospitals vary significantly in propensity for concurrent fundoplication during gastrostomy yet postoperative morbidity does not differ significantly among institutions performing fundoplication more or less frequently.

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

BACKGROUND: Single visit surgery (SVS) consists of same-day pre-operative assessment and operation with telephone post-operative follow-up. This reduces family time commitment to 1 hospital trip rather than 2-3. We began SVS for ambulatory patients with clear surgical indications in 2013. We sought to determine family satisfaction, cost savings to families, and institutional financial feasibility of SVS. METHODS: SVS patients were compared to age/case matched conventional surgery (CS) patients. Satisfaction was assessed by post-operative telephone survey. Family costs were calculated as the sum of lost revenue (based on median income) and transportation costs ($0.50/mile). RESULTS: Satisfaction was high in both groups (98% for SVS vs. 93% for CS; p=0.27). 40% of CS families indicated that they would have preferred SVS, whereas no SVS families indicated preference for the CS option (p<0.001). Distance from the hospital did not correlate with satisfaction. Estimated cost savings for an SVS family was $188. Reimbursement, hospital and physician charges, and day-of-surgery cancellation rates were similar. CONCLUSIONS: SVS provides substantial cost savings to families while maintaining patient satisfaction and equivalent institutional reimbursement. SVS is an effective approach to low-risk ambulatory surgical procedures that is less disruptive to families, facilitates access to pediatric surgical care, and reduces resource utilization. TYPE OF STUDY: Cost Effectiveness Study. LEVEL OF EVIDENCE: Level II.

Variation in intraoperative and postoperative red blood cell transfusion in pediatric surgery.

BACKGROUND: Intraoperative and postoperative red blood cell (RBC) transfusions are relatively frequent events tracked in the American College of Surgeons' National Surgical Quality Improvement Program-Pediatric (ACS-NSQIP-P). This study sought to quantify variation in RBC transfusion practices among hospitals. STUDY DESIGN AND METHODS: This is an observational study of children older than 28 days who underwent a general, neurologic, urologic, otolaryngologic, plastic, or orthopedic operation at 50 hospitals in participating in the ACS-NSQIP-P during 2011 to 2012. The primary outcome was whether or not a RBC transfusion was administered from incision time to 72 hours postoperatively. Transfusions of fresh-frozen plasma, cryoprecipitate, and platelets were excluded from data abstraction due the rarity of their administration. A multivariate hierarchical risk-adjustment model estimated the risk-adjusted hospital RBC transfusion odds ratio (OR) and designated hospitals by transfusion practice. RESULTS: The mean RBC transfusion rate was 1.5%. Five preoperative variables were associated with greater than threefold increased odds of having an intraoperative or postoperative RBC transfusion; young age; 29 days to 1 year (OR, 5.9; p < 0.001) and 1 to 2 years (OR, 3.4; p < 0.001); American Society of Anesthesiologists Class IV (OR, 3.2; p < 0.001); procedure linear risk (OR, 3.1; p < 0.001); preoperative septic shock (OR, 14.5; p < 0.001); and preoperative cardiopulmonary resuscitation (OR, 8.1; p < 0.001). Twenty-five hospitals had RBC transfusion practices significantly different than risk-adjusted mean (17 higher and eight lower). CONCLUSION: Intraoperative and postoperative RBC transfusion practices vary widely among hospitals after controlling for patient and procedural characteristics.

Estimating Adverse Events After Gastrostomy Tube Placement.

OBJECTIVE: Gastrostomy feeding tube placement in children is associated with a high frequency of adverse events. This study sought to preoperatively estimate postoperative adverse events in children undergoing gastrostomy feeding tube placement. METHODS: This was an observational study of children who underwent gastrostomy with or without fundoplication at 1 of 50 participating hospitals, using 2011-2013 data from the American College of Surgeons' National Surgical Quality Improvement Program Pediatric. The outcome was the occurrence of any postoperative complications or mortality at 30 days after gastrostomy tube placement. The preoperative clinical characteristics significantly associated with occurrence of adverse events were included in a multivariate logistic model. The area under the receiver operating characteristic curve was computed to assess model performance and split-set validated. RESULTS: A total of 2817 children were identified as having undergone gastrostomy tube placement. The unadjusted rate of adverse events within 30 days after gastrostomy tube placement was 11%. Thirteen predictor variables were identified. Notable preoperative variables associated with a greater than 75% increase in adverse event rate were preoperative sepsis/septic shock (odds ratio [OR], 10.76, 95% confidence interval [CI], 3.84-30.17), central nervous system tumor (OR, 3.36; 95% CI, 1.42-7.95), the primary procedure as indicated by the current procedural terminology (CPT) linear risk variable (OR, 1.93; 95% CI, 1.50-2.49), severe cardiac risk factors (OR, 1.88; 95% CI, 1.17-3.03), and preoperative seizure history (OR, 1.90; 95% CI, 1.38-2.62). The area under the receiver operating characteristic curve was 0.71 with the derivation data set and 0.71 upon split-set validation. CONCLUSIONS: Preoperatively estimating postoperative adverse events in children undergoing gastrostomy tube placement is feasible.

Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis.

IMPORTANCE: Current evidence suggests that nonoperative management of uncomplicated appendicitis is safe, but overall effectiveness is determined by combining medical outcomes with the patient's and family's perspective, goals, and expectations. OBJECTIVE: To determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children. DESIGN, SETTING, AND PARTICIPANTS: Prospective patient choice cohort study in patients aged 7 to 17 years with acute uncomplicated appendicitis presenting at a single pediatric tertiary acute care hospital from October 1, 2012, through March 6, 2013. Participating patients and families gave informed consent and chose between nonoperative management and urgent appendectomy. INTERVENTIONS: Urgent appendectomy or nonoperative management entailing at least 24 hours of inpatient observation while receiving intravenous antibiotics and, on demonstrating improvement of symptoms, completion of 10 days of treatment with oral antibiotics. MAIN OUTCOMES AND MEASURES: The primary outcome was the 1-year success rate of nonoperative management. Successful nonoperative management was defined as not undergoing an appendectomy. Secondary outcomes included comparisons of the rates of complicated appendicitis, disability days, and health care costs between nonoperative management and surgery. RESULTS: A total of 102 patients were enrolled; 65 patients/families chose appendectomy (median age, 12 years; interquartile range [IQR], 9-13 years; 45 male [69.2%]) and 37 patients/families chose nonoperative management (median age, 11 years; IQR, 10-14 years; 24 male [64.9%]). Baseline characteristics were similar between the groups. The success rate of nonoperative management was 89.2% (95% CI, 74.6%-97.0%) at 30 days (33 of 37 children) and 75.7% (95% CI, 58.9%-88.2%) at 1 year (28 of 37 children). The incidence of complicated appendicitis was 2.7% in the nonoperative group (1 of 37 children) and 12.3% in the surgery group (8 of 65 children) (P = .15). After 1 year, children managed nonoperatively compared with the surgery group had fewer disability days (median [IQR], 8 [5-18] vs 21 [15-25] days, respectively; P < .001) and lower appendicitis-related health care costs (median [IQR], $4219 [$2514-$7795] vs $5029 [$4596-$5482], respectively; P = .01). CONCLUSIONS AND RELEVANCE: When chosen by the family, nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis, incurring less morbidity and lower costs than surgery. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01718275.

Improving Quality and Efficiency for Intussusception Management After Successful Enema Reduction.

OBJECTIVES: The purpose of this project was to implement a protocol facilitating discharge from the emergency department (ED) after successful radiologic ileocolic intussusception reduction in a pediatric referral center. METHODS: A multidisciplinary team identified drivers for successful quality improvement including educational brochures, a standardized radiologic report, an observation period in the ER with oral hydration challenges, and follow-up phone calls the day after discharge. Patient outcomes were tracked, and quarterly feedback was provided. RESULTS: Of 80 patients identified over a 24-month period, 34 (42.5%) did not qualify for discharge home due to need for surgical intervention (n = 9), specific radiologic findings (n = 11), need for additional intravenous hydration (n = 4), or other reasons (n = 7). Of 46 patients who qualified for discharge, 30 (65.2%) were successfully sent home from the ED. One patient returned with recurrent symptoms that required repeat enema reduction. Sixteen patients were observed and discharged within 23 hours. Adherence with discharge from the ED improved over time. Discharge from the ED was associated with cost savings and improved net margins at the hospital level for each encounter. CONCLUSIONS: A sustainable multidisciplinary quality improvement project to discharge intussusception patients from the ED after air-contrast enema reduction was successfully integrated in a high-volume referral center through education, standardized radiologic reporting, and protocoled follow-up.

Impaired Activity of Blood Coagulant Factor XIII in Patients with Necrotizing Enterocolitis.

Necrotizing enterocolitis (NEC) is the most common gastrointestinal (GI) medical/surgical emergency of the newborn and a leading cause of preterm neonate morbidity and mortality. NEC is a challenge to diagnose since it often shares similar clinical features with neonatal sepsis. In the present study, plasma protein profiling was compared among NEC, sepsis and control cohorts using gel electrophoresis, immunoblot and mass spectrometry. We observed significant impairment in the formation of fibrinogen-γ dimers (FGG-dimer) in the plasma of newborns with NEC that could efficiently differentiate NEC and sepsis with a high level of sensitivity and specificity. Interestingly, the impaired FGG-dimer formation could be restored in NEC plasma by the addition of exogenous active factor XIII (FXIII). Enzymatic activity of FXIII was determined to be significantly lower in NEC subject plasma for crosslinking FGG when compared to sepsis. These findings demonstrate a potential novel biomarker and related biologic mechanism for diagnosing NEC, as well as suggest a possible therapeutic strategy.

A risk calculator predicting postoperative adverse events in neonates undergoing major abdominal or thoracic surgery.

PURPOSE: This study sought to demonstrate the feasibility of a risk calculator for neonates undergoing major abdominal or thoracic surgery with good discriminative ability. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-P) 2011-12 data were queried for neonates who underwent major abdominal or thoracic surgery. The outcome of interest was the occurrence of any adverse event, including mortality, within 30-days postoperatively. The preoperative clinical characteristics significantly associated with any adverse event were used to build a multivariate model. The model's discriminative ability was assessed with the area under the receiver operating characteristic curve (AUROC). The model was split-set validated with 2013 data. RESULTS: A total of 2967 neonates undergoing major abdominal or thoracic surgery were identified. The overall rate of adverse events was 23.3%. Sixteen variables were found to be associated with adverse events. Four variables increased the odds of adverse events at least two-fold: dirty or infected wound class [odds ratio (OR)=2.1] dialysis (OR=3.8), hepatobiliary disease (OR=2.1), and inotropic agent use (OR=2.6). The AUROC=0.79 for development data and 0.77 on split-set validation. CONCLUSION: Preoperatively estimating the probability of postoperative adverse events in neonates undergoing major abdominal or thoracic surgery with good discrimination is feasible.

Urine biomarkers for necrotizing enterocolitis.

Necrotizing enterocolitis (NEC) remains a significant cause of morbidity and mortality in premature neonates. Despite decades of investigation, treating clinicians are still not able to determine which premature infants are at greatest risk of developing NEC and which of the affected infants will develop severe NEC requiring operation. A biomarker is a specific molecular indicator that can be used to identify or measure the progress of a disease. Many potential biomarkers have been studied for their potential relevance to NEC. Those showing promise include C-reactive protein, intestinal fatty acid-binding protein, platelet-activating factor and many others. None to date have achieved sufficient predictive value to be clinically useful. Distinguishing between the specific changes in NEC and the non-specific inflammation of sepsis has proven challenging. Urine is a particularly attractive site for potential biomarkers. It can be collected readily and non-invasively, and it is a rich source of both proteins and peptides. Preliminary work has revealed some promising biomarkers of NEC in urine. Combined with clinical data, they have been shown to be highly predictive in small series of patients. Advances in high-throughput molecular analysis have opened the door to finding biomarkers that may meaningfully improve the outcome of infants at risk for NEC.

Feasibility of a nonoperative management strategy for uncomplicated acute appendicitis in children.

BACKGROUND: For decades, urgent operation has been considered the only appropriate management of acute appendicitis in children. The purpose of this study was to investigate the feasibility of nonoperative management of uncomplicated acute appendicitis in children. STUDY DESIGN: A prospective nonrandomized clinical trial of children with uncomplicated acute appendicitis comparing nonoperative management with urgent appendectomy was performed. The primary result was 30-day success rate of nonoperative management. Secondary outcomes included comparisons of disability days, missed school days, hospital length of stay, and measures of quality of life and health care satisfaction. RESULTS: Seventy-seven patients were enrolled during October 2012 to October 2013; 30 chose nonoperative management and 47 chose surgery. There were no significant differences in demographic or clinical characteristics. The immediate and 30-day success rates of nonoperative management were 93% (28 of 30) and 90% (27 of 30). There was no evidence of progression of appendicitis to rupture at the time of surgery in the 3 patients for whom nonoperative management failed. Compared with the surgery group, the nonoperative group had fewer disability days (3 vs 17 days; p < 0.0001), returned to school more quickly (3 vs 5 days; p = 0.008), and exhibited higher quality of life scores in both the child (93 vs 88; p = 0.01) and the parent (96 vs 90; p = 0.03), but incurred a longer length of stay (38 vs 20 hours; p < 0.0001). CONCLUSIONS: Nonoperative management of uncomplicated acute appendicitis in children is feasible, with a high 30-day success rate and short-term benefits that include quicker recovery and improved quality of life scores. Additional follow-up will allow for determination of longer-term success rate, safety, and cost effectiveness.

The importance of extreme weight percentile in postoperative morbidity in children.

BACKGROUND: Anthropometric data are important indicators of child health. This study sought to determine whether anthropometric data of extreme weight were significant predictors of perioperative morbidity in pediatric surgery. STUDY DESIGN: This was a cohort study of children 29 days up to 18 years of age undergoing surgical procedures at participating American College of Surgeons' NSQIP Pediatric hospitals in 2011 and 2012. The primary outcomes were composite morbidity and surgical site infection. The primary predictor of interest was weight percentile, which was divided into the following categories: ≤5(th) percentile, 6(th) to 94(th), or ≥95(th) percentile. A hierarchical multivariate logistic model, adjusting for procedure case mix, demographic, and clinical patient characteristic variables, was used to quantify the relationship between weight percentile category and outcomes. RESULTS: Children in the ≤5th weight percentile had 1.19-fold higher odds of overall postoperative morbidity developing than children in the nonextreme range (95% CI, 1.10-1.30) when controlling for clinical variables. Yet these children did not have higher odds of surgical site infection developing. Children in the ≥95(th) weight percentile did not have a significant increase in overall postoperative morbidity. However, they were at 1.35-fold increased odds of surgical site infection compared with those in the nonextreme range when controlling for clinical variables (95% CI, 1.16-1.57). CONCLUSIONS: Both extremely high and extremely low weight percentile scores can be associated with increased postoperative complications after controlling for clinical variables.

A data-driven algorithm integrating clinical and laboratory features for the diagnosis and prognosis of necrotizing enterocolitis.

BACKGROUND: Necrotizing enterocolitis (NEC) is a major source of neonatal morbidity and mortality. Since there is no specific diagnostic test or risk of progression model available for NEC, the diagnosis and outcome prediction of NEC is made on clinical grounds. The objective in this study was to develop and validate new NEC scoring systems for automated staging and prognostic forecasting. STUDY DESIGN: A six-center consortium of university based pediatric teaching hospitals prospectively collected data on infants under suspicion of having NEC over a 7-year period. A database comprised of 520 infants was utilized to develop the NEC diagnostic and prognostic models by dividing the entire dataset into training and testing cohorts of demographically matched subjects. Developed on the training cohort and validated on the blind testing cohort, our multivariate analyses led to NEC scoring metrics integrating clinical data. RESULTS: Machine learning using clinical and laboratory results at the time of clinical presentation led to two nec models: (1) an automated diagnostic classification scheme; (2) a dynamic prognostic method for risk-stratifying patients into low, intermediate and high NEC scores to determine the risk for disease progression. We submit that dynamic risk stratification of infants with NEC will assist clinicians in determining the need for additional diagnostic testing and guide potential therapies in a dynamic manner. ALGORITHM AVAILABILITY: http://translationalmedicine.stanford.edu/cgi-bin/NEC/index.pl and smartphone application upon request.

Enhancing NSQIP-Pediatric through integration with the Pediatric Health Information System.

PURPOSE: We implemented and validated a linkage algorithm for cases in both the National Surgical Quality Improvement Program-Pediatric (NSQIP-Peds) and the Pediatric Health Information System (PHIS) to investigate healthcare utilization during the first post-operative year. METHODS: NSQIP-Peds and PHIS cases from our institution who were operated on between January 2010 and September 2011 were matched on gender and dates of birth, admission, and discharge. Rates of true matches were validated using medical records. We examined rates of emergency department (ED) visits, hospital readmissions, potentially preventable readmissions (PPR), and hospital charges within one year of the NSQIP-Peds encounter. RESULTS: Of the 2,409 NSQIP-Peds and 61,147 PHIS records, 93.6% met match criteria with 92.5% being true matches. Post-operative ED visit rates were 7.8% within 30days, 17.2% between 31-180days, and 18.1% between 181-365days. Readmission rates were 5.5% within 30days, 9.3% between 31-180days, and 8.4% between 181-365days. In patients undergoing inpatient procedures, 10.6% had readmissions within 30days, and 23.7% had readmissions within 365days that were potentially preventable. CONCLUSIONS: Using indirect identifiers, a linked NSQIP-Peds-PHIS dataset demonstrated high rates of ED visits, readmissions, and PPR in the first post-operative year. This dataset may provide a more comprehensive way to study health care utilization and clinical outcomes.

Urine protein biomarkers for the diagnosis and prognosis of necrotizing enterocolitis in infants.

OBJECTIVES: To test the hypothesis that an exploratory proteomics analysis of urine proteins with subsequent development of validated urine biomarker panels would produce molecular classifiers for both the diagnosis and prognosis of infants with necrotizing enterocolitis (NEC). STUDY DESIGN: Urine samples were collected from 119 premature infants (85 NEC, 17 sepsis, 17 control) at the time of initial clinical concern for disease. The urine from 59 infants was used for candidate biomarker discovery by liquid chromatography/mass spectrometry. The remaining 60 samples were subject to enzyme-linked immunosorbent assay for quantitative biomarker validation. RESULTS: A panel of 7 biomarkers (alpha-2-macroglobulin-like protein 1, cluster of differentiation protein 14, cystatin 3, fibrinogen alpha chain, pigment epithelium-derived factor, retinol binding protein 4, and vasolin) was identified by liquid chromatography/mass spectrometry and subsequently validated by enzyme-linked immunosorbent assay. These proteins were consistently found to be either up- or down-regulated depending on the presence, absence, or severity of disease. Biomarker panel validation resulted in a receiver-operator characteristic area under the curve of 98.2% for NEC vs sepsis and an area under the curve of 98.4% for medical NEC vs surgical NEC. CONCLUSIONS: We identified 7 urine proteins capable of providing highly accurate diagnostic and prognostic information for infants with suspected NEC. This work represents a novel approach to improving the efficiency with which we diagnose early NEC and identify those at risk for developing severe, or surgical, disease.

A novel urine peptide biomarker-based algorithm for the prognosis of necrotising enterocolitis in human infants.

OBJECTIVE: Necrotising enterocolitis (NEC) is a major source of neonatal morbidity and mortality. The management of infants with NEC is currently complicated by our inability to accurately identify those at risk for progression of disease prior to the development of irreversible intestinal necrosis. We hypothesised that integrated analysis of clinical parameters in combination with urine peptide biomarkers would lead to improved prognostic accuracy in the NEC population. DESIGN: Infants under suspicion of having NEC (n=550) were prospectively enrolled from a consortium consisting of eight university-based paediatric teaching hospitals. Twenty-seven clinical parameters were used to construct a multivariate predictor of NEC progression. Liquid chromatography/mass spectrometry was used to profile the urine peptidomes from a subset of this population (n=65) to discover novel biomarkers of NEC progression. An ensemble model for the prediction of disease progression was then created using clinical and biomarker data. RESULTS: The use of clinical parameters alone resulted in a receiver-operator characteristic curve with an area under the curve of 0.817 and left 40.1% of all patients in an 'indeterminate' risk group. Three validated urine peptide biomarkers (fibrinogen peptides: FGA1826, FGA1883 and FGA2659) produced a receiver-operator characteristic area under the curve of 0.856. The integration of clinical parameters with urine biomarkers in an ensemble model resulted in the correct prediction of NEC outcomes in all cases tested. CONCLUSIONS: Ensemble modelling combining clinical parameters with biomarker analysis dramatically improves our ability to identify the population at risk for developing progressive NEC.

Current concepts in the surgical approach to necrotizing enterocolitis.

Necrotizing enterocolitis (NEC) is the most common surgical emergency occurring in neonatal intensive care unit (NICU) patients. Among patients with NEC, those that require surgery experience the poorest outcomes and highest mortality. Surgical intervention, while attempting to address the intestinal injury and ongoing mulitfactorial physiologic insults in NEC is associated with its own stresses that may compound the ongoing physiologic derangement. Surgery is thus reserved for those patients with clear indication for intervention such as pneumoperitoneum, confirmed stool or pus in the peritoneal cavity, or worsening clinical status. The purpose of this review is to briefly describe the physiologic stress induced by surgical intervention in the preterm, low birth weight patient with NEC and to provide a contemporary overview of available surgical management options for NEC. The optimal surgical plan employed is strongly influenced by clinical judgment and theoretical benefits in terms of minimizing physiologic stressors while providing temporary and/or definitive treatment in a timely fashion. While the choice of operation has not been shown to have a significant effect on any clinically important outcomes, ongoing investigations continue to study both short and long-term outcomes in patients with NEC.

Multicenter study of pectus excavatum, final report: complications, static/exercise pulmonary function, and anatomic outcomes.

BACKGROUND: A multicenter study of pectus excavatum was described previously. This report presents our final results. STUDY DESIGN: Patients treated surgically at 11 centers were followed prospectively. Each underwent a preoperative evaluation with CT scan, pulmonary function tests, and body image survey. Data were collected about associated conditions, complications, and perioperative pain. One year after treatment, patients underwent repeat chest CT scan, pulmonary function tests, and body image survey. A subset of 50 underwent exercise pulmonary function testing. RESULTS: Of 327 patients, 284 underwent Nuss procedure and 43 underwent open procedure without mortality. Of 182 patients with complete follow-up (56%), 18% had late complications, similarly distributed, including substernal bar displacement in 7% and wound infection in 2%. Mean initial CT scan index of 4.4 improved to 3.0 post operation (severe >3.2, normal = 2.5). Computed tomography index improved at the deepest point (xiphoid) and also upper and middle sternum. Pulmonary function tests improved (forced vital capacity from 88% to 93%, forced expiratory volume in 1 second from 87% to 90%, and total lung capacity from 94% to 100% of predicted (p < 0.001 for each). VO2 max during peak exercise increased by 10.1% (p = 0.015) and O2 pulse by 19% (p = 0.007) in 20 subjects who completed both pre- and postoperative exercise tests. CONCLUSIONS: There is significant improvement in lung function at rest and in VO2 max and O2 pulse after surgical correction of pectus excavatum, with CT index >3.2. Operative correction significantly reduces CT index and markedly improves the shape of the entire chest, and can be performed safely in a variety of centers.