Akemi L. Kawaguchi

Characterization of bacterial and fungal microbiome in children with Hirschsprung disease with and without a history of enterocolitis: A multicenter study

Development of potentially life-threatening enterocolitis is the most frequent complication in children with Hirschsprung disease (HSCR), even after definitive corrective surgery. Intestinal microbiota likely contribute to the etiology of enterocolitis, so the aim of this study was to compare the fecal bacterial and fungal communities of children who developed Hirschsprung-associated enterocolitis (HAEC) with HSCR patients who had never had enterocolitis. Eighteen Hirschsprung patients who had completed definitive surgery were enrolled: 9 had a history of HAEC and 9 did not. Fecal DNA was isolated and 16S and ITS-1 regions sequenced using Next Generation Sequencing and data analysis for species identification. The HAEC group bacterial composition showed a modest reduction in Firmicutes and Verrucomicrobia with increased Bacteroidetes and Proteobacteria compared with the HSCR group. In contrast, the fecal fungi composition of the HAEC group showed marked reduction in diversity with increased Candida sp., and reduced Malassezia and Saccharomyces sp. compared with the HSCR group. The most striking finding within the HAEC group is that the Candida genus segregated into “high burden” patients with 97.8% C. albicans and 2.2% C. tropicalis compared with “low burden” patients 26.8% C. albicans and 73% C. tropicalis. Interestingly even the low burden HAEC group had altered Candida community structure with just two species compared to more diverse Candida populations in the HSCR patients. This is the first study to identify Candida sp. as potentially playing a role in HAEC either as expanded commensal species as a consequence of enterocolitis (or treatment), or possibly as pathobioants contributing to the pathogenesis of HAEC. These findings suggest a dysbiosis in the gut microbial ecosystem of HAEC patients, such that there may be dominance of fungi and bacteria predisposing patients to development of HAEC.

Surgical wound misclassification: A multicenter evaluation

BACKGROUNDnSurgical wound classification (SWC) is used by hospitals, quality collaboratives, and Centers for Medicare and Medicaid to stratify patients for their risk for surgical site infection. Although these data can be used to compare centers, the validity and reliability of SWC as currently practiced has not been well studied. Our objective was to assess the reliability of SWC in a multicenter fashion. We hypothesized that the concordance rates between SWC in the electronic medical record and SWC determined from the operative note review is low and varies by institution and operation.nnnSTUDY DESIGNnSurgical wound classification concordance was assessed at 11 participating institutions between SWC from the electronic medical record and SWC from operative note review for 8 common pediatric surgical operations. Cases with concurrent procedures were excluded. A maximum of 25 consecutive cases were selected per operation from each institution. A designated surgeon reviewed the included operative notes from his/her own institution to determine SWC based on a predetermined algorithm.nnnRESULTSnIn all, 2,034 cases were reviewed. Overall SWC concordance was 56%, ranging from 47% to 66% across institutions. Inguinal hernia repair had the highest overall median concordance (92%) and appendectomy had the lowest (12%). Electronic medical records and reviewer SWC differed by up to 3 classes for certain cases.nnnCONCLUSIONSnSurgical site infection risk stratification by SWC, as currently practiced, is an unreliable methodology to compare patients and institutions. Surgical wound classification should not be used for quality benchmarking. If SWC continues to be used, individual institutions should evaluate their process of assigning SWC to ensure its accuracy and reliability.

Altered fecal short chain fatty acid composition in children with a history of Hirschsprung-associated enterocolitis

PURPOSEnChildren with Hirschsprung disease (HD) who have a history of enterocolitis (HAEC) have a shift in colonic microbiota, many of which are necessary for short chain fatty acid (SCFA) production. As SCFAs play a critical role in colonic mucosal preservation, we hypothesized that fecal SCFA composition is altered in children with HAEC.nnnMETHODSnA multicenter study enrolled 18 HD children, abstracting for history of feeding, antibiotic/probiotic use, and enterocolitis symptoms. HAEC status was determined per Pastor et al. criteria (12). Fresh feces were collected for microbial community analysis via 16S sequencing as well as SCFA analysis by gas chromatography-mass spectrometry.nnnRESULTSnNine patients had a history of HAEC, and nine had never had HAEC. Fecal samples from HAEC children showed a 4-fold decline in total SCFA concentration vs. non-HAEC HD patients. We then compared the relative composition of individual SCFAs and found reduced acetate and increased butyrate in HAEC children. Finally, we measured relative abundance of SCFA-producing fecal microbiota. Interestingly, 10 of 12 butyrate-producing genera as well as 3 of 4 acetate-producing genera demonstrated multi-fold expansion.nnnCONCLUSIONnChildren with HAEC history have reduced fecal SCFAs and altered SCFA profile. These findings suggest a complex interplay between the colonic metabolome and changes in microbiota, which may influence the pathogenesis of HAEC.

Inguinal hernias can be accurately diagnosed using the parent's digital photographs when the physical examination is nondiagnostic

PURPOSEnInguinal hernias in infants and children may not be evident during visits to the pediatric surgeons office. Preoperative photographic confirmation of the hernia may be helpful and accurate. This study retrospectively assesses the preoperative examination, photographic evidence, operative findings, and complications of these patients.nnnMETHODSnFor a 30-month period, children with a history of a possible inguinal bulge were assessed by clinical examination. If no bulge was detected, the parents were given the option of sending a photograph to the surgeon. Patients underwent surgery based solely upon the history and definitive image.nnnRESULTSnFor 30 months, 25 children were evaluated for inguinal pathology but had no hernia on clinical examination. Based solely upon the history and the digital image, 23 of these patients underwent surgery. All of the patients who were diagnosed with a hernia by history and imaging alone had an operatively confirmed hernia. The remaining 2 patients have not developed a hernia with continued observation.nnnCONCLUSIONnPhotographic images are a reliable way to document the presence and laterality of inguinal hernias. Reliance upon digital transmission of images avoids the need for repeat office visits, saving considerable physician and parental time and expense.

A multicenter, pediatric quality improvement initiative improves surgical wound class assignment, but is it enough? ☆ ☆☆ ★

BACKGROUND/PURPOSEnSurgical 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.nnnMETHODSnA before-and-after study from 2011-2014 at eleven childrens hospitals was conducted. The SWC recorded in the hospitals 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 Cohens weighted kappa and chi square.nnnRESULTSnSurgeons 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.nnnCONCLUSIONSnIntraoperative 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.

The impact of cardiac risk factors on short-term outcomes for children undergoing a Ladd procedure

BACKGROUND/PURPOSEnThe purpose of this study was to describe the outcomes of children with and without congenital heart disease who undergo a Ladd procedure.nnnMETHODSnThe 2012-2014 National Surgical Quality Improvement Program Pediatric (NSQIP-P) data were queried for patients undergoing a Ladd procedure. Utilizing NSQIP-P definitions, patients were categorized into four cardiac risk groups (none, minor, major, severe) based on severity of cardiac anomalies, previous cardiac procedure(s), and ongoing cardiac dysfunction. Ladd procedures were elective/non-elective. Outcomes included length of stay, adverse events, and mortality.nnnRESULTSn878 patients underwent Ladd procedures. 633 (72%) patients had no cardiac risk factors and 84 (10%), 109 (12%), and 52 (6%) had minor, major, and severe cardiac risk factors, respectively. Children with congenital heart disease experienced increased morbidity and mortality and longer hospital stays (all p<0.05). Elective Ladd procedures were associated with similar morbidity but shorter length of stay and lower mortality than non-elective procedures. Older age at time of operation was associated with fewer adverse events.nnnCONCLUSIONSnAlthough overall mortality remains low, children with higher risk cardiac disease experience increased morbidity and mortality when undergoing a Ladd procedure. Older age at the time of the Ladd procedure was associated with improved outcomes in children.

Management of rectal pyogenic granuloma with transanal mucosal sleeve resection.

In children, pyogenic granulomas are most commonly cutaneous benign vascular lesions but can also present in the gastrointestinal tract. When they occur in the intestine, they can cause acute or chronic gastrointestinal bleeding. We present an unusual case of rectal pyogenic granuloma and our management strategy.

Let the right one in: High admission rate for low-acuity pediatric burns

Background: The purpose of this study was to characterize emergency pediatric burn care triage at a tertiary childrens hospital to identify targets for quality improvement. Methods: A retrospective review of patients <18 years with primary burn injuries who presented to a childrens emergency department in 2016 was conducted. Demographic and injury characteristics were recorded. Low acuity was defined by size (<5% total body surface area burn), depth (not third degree), and no need for conscious sedation for debridement. Multiple logistic regression was used for analysis. Results: A total of 309 pediatric burn patients were triaged in the emergency department. Patients were typically young (median 3.3 years), male (59%), Hispanic (47%), publically insured (77%), and transferred in (65%). Scalding was the most common mechanism (59%). Though most burns were small (median 2% total body surface area), not deep (<third degree: 91%), and debrided without sedation (70%), most patients were admitted (80%). On regression, larger total body surface area, child protective services involvement, and in‐transfer, but not mechanism, location of injury, or time of day, were associated with observation admission (<24 hours) versus emergency department discharge. Conclusion: Though burns were low acuity, most children were admitted. Social factors may play an important role in triage decisions but there may be an opportunity for improved resource utilization.

Too much of a bad thing: Discharge opioid prescriptions in pediatric appendectomy patients

BACKGROUNDnOpioid misuse is a public health crisis in the United States. This study aimed to evaluate the discharge opioid prescription practices for pediatric simple appendectomy patients.nnnMETHODSnA retrospective review of pediatric appendectomy patients at a tertiary childrens hospital was conducted from October 2016 to January 2018. Only patients with simple appendicitis were included. Written opioid prescriptions were found in the electronic medical record (EMR) or through a statewide prescription monitoring database. All dosing data were converted to oral morphine equivalents (OMEs). Analysis of variance and logistic regression were used.nnnRESULTSnDuring the study, 590 patients underwent appendectomy, of which 371 (62.9%) were diagnosed as having simple acute appendicitis. The majority of patients were prescribed an opioid analgesic (62.5%). Demographics were similar between those who received opioids and those who did not. The OME prescribed per day (range 0.2 to 3.4u202fmg/kg/day) was highly variable as was duration of prescription (1 to 30u202fdays). Odds of emergency department visit were 3.3 times higher (95% CI 1.3-8.2) in those who received opioids.nnnCONCLUSIONnPostdischarge prescription practices for pediatric appendectomy are highly variable. Two-thirds of patients who received narcotics had a higher rate of complications. Greater scrutiny is required to optimize opioid stewardship.nnnTYPE OF STUDYnRetrospective comparative study.nnnLEVEL OF EVIDENCEnLevel III.