Faraz A. Khan

All Publications

• Pancreatic masses in children: a single-center experience over two decades. European journal of pediatrics McRae, J. J., Thobani, H., Sacks, M. A., Raymond, S. L., Shah, A., Radulescu, A., Khan, F. A. 2024

  Abstract

  Pancreatic masses are extremely rare in pediatric patients, with limited data available. This lack of data makes the diagnosis and management of these tumors in children extremely challenging. Therefore, we aimed to describe the presentations, clinical course, and outcomes of children with pancreatic tumors at our center. A retrospective analysis was performed of all pediatric patients diagnosed with pancreatic masses between 2003 and 2022 in an academic freestanding children's hospital. Data including demographics, clinical presentation, workup, management, and subsequent morbidity and mortality were collected and aggregated. Furthermore, we reviewed cases of pancreatic tumor resections in the National Surgical Quality Improvement Program - Pediatric (NSQIP-P) database to identify common adverse outcomes and measures for quality improvement. In total, 17 patients were identified at our institution. Diagnoses included solid pseudopapillary (n = 9), gastrinoma (n = 1), rhabdomyosarcoma (n = 2), pancreatoblastoma (n = 2), and insulinoma (n = 1). Two patients did not have a histopathologic diagnosis and were excluded from subsequent analysis. Overall, 12 patients underwent surgical intervention, with the most common procedures being pancreaticoduodenectomy and distal pancreatectomy, and all 12 were known to be alive at last contact. There were 3 deaths, all due to complications related to metastatic disease. Furthermore, 30-day postoperative outcomes in the NSQIP-P dataset for pancreatic surgeries in pediatric patients are excellent, with negligible morbidity and no mortalities after the index surgery.Children with pancreatic tumors amenable to surgical resection appear to have adequate long-term survival. Short-term outcomes at diagnosis are excellent and mainly appear to be influenced by the presence of metastatic disease at initial presentation.• Pancreatic masses are a rare entity in children with limited data on their presentation, management and surgical outcomes. • Solid Pseudopapillary tumors are one of the most common pancreatic tumors in children with a fair prognosis after surgical intervention.• Surgical management of pediatric patients with pancreatic tumors is safe and effective in patients who do not have aggressive tumor types or metastatic disease. • Our case series provides a notable cohort of these pancreatic tumors with insight into the presentation, management and outcomes of five of these tumor types.

  View details for DOI 10.1007/s00431-024-05731-z

  View details for PubMedID 39145888

  View details for PubMedCentralID 10941481

• Establishment of a successful robotic pediatric general surgery practice JOURNAL OF ROBOTIC SURGERY Raymond, S. L., Sharafeddin, F., Sacks, M. A., Srikureja, D., Gomez, N., Moores, D., Radulescu, A., Khan, F. A., Tagge, E. P. 2023

  Abstract

  Robotic-assisted surgery (RAS) has a variety of theoretical advantages, including tremor filtration, optimal visualization, and improvement of surgeon ergonomics. Though it has achieved wide application in pediatric urology, the majority of pediatric general surgeons do not employ RAS. This study reports our institution's experience with RAS on a pediatric general surgery team. Following IRB approval, a retrospective review of all pediatric patients at our academic children's hospital who underwent RAS between 2017 and 2022 for pediatric general surgical conditions was performed. Patient demographics, operation performed, operating time, complications, and recovery were evaluated. A total of 159 children underwent RAS, increasing from 10 patients in 2017 to 59 patients in 2022. The median age and weight were 15.3 years and 76.4 kg, and 121 (76.1%) were female. The application of RAS was successful in all cases. There were no intraoperative complications and no conversions to an open approach. Eleven patients (6.9%) had unplanned presentations to the emergency department within 30 days. Five of these patients (3.1%) required admission to the hospital. This study demonstrates that the application of RAS in an academic pediatric general surgery practice is feasible and safe. The application of RAS to pediatric general surgery should continue to increase as operative teams increase their experience and comfort.Level of evidence Level IV.

  View details for DOI 10.1007/s11701-023-01667-y

  View details for Web of Science ID 001029088400001

  View details for PubMedID 37452975

  View details for PubMedCentralID 6261744

• Assessment and Management of Inguinal Hernias in Children. Pediatrics Khan, F. A., Jancelewicz, T., Kieran, K., Islam, S., COMMITTEE ON FETUS AND NEWBORN, SECTION ON SURGERY, SECTION ON UROLOGY, Eichenwald, E., Guillory, C., Hand, I., Hudak, M., Kaufman, D., Martin, C., Lucke, A., Parker, M., Pramanik, A., Wade, K., Narvey, M., Miller, R., Barfield, W., Grisham, L., Couto, J., Gow, K. W., Beierle, E., Browne, M., Davidoff, A., Downard, C. D., Saunders Walsh, D., Williams, R. F., Thorne, V., Cost, N., Canon, S., Dean, G., Kaefer, M., Kirsch, A., Pope, J. C., Yerkes, E., Gorlewski, J. 2023; 152 (1)

  Abstract

  Inguinal hernia repair is one of the most commonly performed surgical procedures in children. However, a number of controversial issues, such as optimal timing and approach to repair, continue to be debated. This publication reviews the available data pertaining to these controversial issues and identifies best practices in management of inguinal hernias in children.

  View details for DOI 10.1542/peds.2023-062510

  View details for PubMedID 37357733

• Use of Image Guidance During Pediatric Venovenous Extracorporeal Membrane Oxygenation Cannulation: A Survey of the American Pediatric Surgical Association ASAIO JOURNAL Robertson, J. O., Hossain, M., Khan, F. A., Cass, D. L. 2023; 69 (7): 687-694

  Abstract

  This study evaluated practices for image guidance during placement of bicaval dual-lumen (BCDL) venovenous extracorporeal membrane oxygenation (VV-ECMO) cannulas in pediatric and adolescent patients and elucidates reasoning behind surgeon practices. A survey covering VV-ECMO practice and opinions was distributed by the American Pediatric Surgical Association (APSA) to all attending members. A total of 110 pediatric surgeons responded (11.3%). During initial BCDL cannula placement, 67.7% of surgeons reported using bimodal imaging with either fluoroscopy (38.4%) or x-ray (29.3%) plus echocardiography. Although 37.4% of surgeons used serial x-rays during cannula placement, only 5.9% believed it was best practice to do so ( P < 0.0001). Rather, 60.4% believed that fluoroscopy was the standard. Among surgeons not using fluoroscopy, 27.6% (13.3% of respondents) reported fluoroscopy added unnecessary complexity or that they preferred another modality. More frequently, reasons for not using fluoroscopy are related to resource limitations. Echocardiography use to confirm cannula position was considered best practice by 92.1% of surgeons, with 86.9% utilization. Therefore, most pediatric surgeons use multimodal imaging during cannulation and consider it best practice. Fluoroscopy is preferred, but its use is frequently limited by hospital resources. Echocardiography is widely available and used. These data represent increased consensus among surgeons and present opportunities for modernization of hospital resources and standards.

  View details for DOI 10.1097/MAT.0000000000001920

  View details for Web of Science ID 001021552600021

  View details for PubMedID 36947852

• What animal model should I use to study necrotizing enterocolitis? SEMINARS IN PEDIATRIC SURGERY Won, M. M., Mladenov, G. D., Raymond, S. L., Khan, F. A., Radulescu, A. 2023; 32 (3): 151313

  Abstract

  Unfortunately, we are all too familiar with the statement: "Necrotizing enterocolitis remains the leading cause of gastrointestinal surgical emergency in preterm neonates". It's been five decades since the first animal models of necrotizing enterocolitis (NEC) were described. There remains much investigative work to be done on identifying various aspects of NEC, ranging from the underlying mechanisms to treatment modalities. Experimental NEC is mainly focused on a rat, mouse, and piglet models. Our aim is to not only highlight the pros and cons of these three main models, but to also present some of the less-used animal models that have contributed to the body of knowledge about NEC. Choosing an appropriate model is essential to conducting effective research and answering the questions asked. As such, this paper reviews some of the variations that come with each model.

  View details for DOI 10.1016/j.sempedsurg.2023.151313

  View details for Web of Science ID 001016983900001

  View details for PubMedID 37276781

• The Current Pediatric Surgery Job Market: A Perspective of Recent Fellowship Graduates JOURNAL OF PEDIATRIC SURGERY Raymond, S. L., Robertson, J. O., Sacks, M. A., Goodman, L. F., Lobeck, I., Johnson, K., Radulescu, A., Moores, D., Hashmi, A., Islam, S., Stolar, C. J., Tagge, E. P., Khan, F. A. 2023; 58 (6): 1133-1138

  Abstract

  This study describes the job market from the perspective of recent pediatric surgery graduates.An anonymous survey was circulated to the 137 pediatric surgeons who graduated from fellowships 2019-2021.The survey response rate was 49%. The majority of respondents were women (52%), Caucasian (72%), and had a median student debt burden of $225,000. Considering job opportunities, respondents strongly emphasized camaraderie (93%), mentorship (93%), case mix (85%), geography (67%), faculty reputation (62%), spousal employment (57%), compensation (51%), and call frequency (45%). 30% were satisfied with the employment opportunities available, and 21% felt strongly prepared to negotiate for their first job. All respondents were able to secure a job. Most jobs were university-based (70%) or hospital employed (18%) positions where surgeons covered median of two hospitals. 49% wanted protected research time, and 12% of respondents were able to secure substantial, protected research time. The median compensation for university-based jobs was $12,583 below the median AAMC benchmark for assistant professors for the corresponding year of graduation.These data highlight the ongoing need for assessment of the pediatric surgery workforce and for professional societies and training programs to further assist graduating fellows in preparing to negotiate their first job.Survey LEVEL OF EVIDENCE: Level V.

  View details for DOI 10.1016/j.jpedsurg.2023.02.012

  View details for Web of Science ID 001001738800001

  View details for PubMedID 36914464

• Discontinuation of the OriGen (R) Dual-Lumen Right Atrial Cannula Decreased Venovenous ECMO Usage in Neonates and Older Children: A Survey of the American Pediatric Surgical Association JOURNAL OF PEDIATRIC SURGERY Hossain, M., Khan, F. A., Cass, D. L., Robertson, J. O. 2023; 58 (6): 1185-1190

  Abstract

  Dual-lumen cannulas for venovenous (VV)-ECMO are widely used in pediatric patients. The popular OriGen® dual-lumen right atrial cannula was discontinued in 2019 without a comparable replacement.A survey covering VV-ECMO practice and opinions was distributed to attending members of the American Pediatric Surgical Association.137 pediatric surgeons responded (14%). Prior to discontinuation of the OriGen®, 82.5% offered VV-ECMO to neonates, and 79.6% cannulated with the OriGen®. Following its discontinuation, those that offered only venoarterial (VA)-ECMO to neonates increased to 37.6% from 17.5% (p = 0.0002). An additional 33.8% changed their practice to sometimes use VA-ECMO when VV-ECMO was indicated. Reasons for not incorporating dual-lumen bi-caval cannulation into practice included risk of cardiac injury (51.7%), inexperience with bi-caval cannulation in neonates (36.8%), difficulty with placement (31.0%), and recirculation and/or positioning problems (27.6%). For the pediatric/adolescent population, 95.5% of surgeons offered VV-ECMO prior to OriGen® discontinuation. Few switched to exclusive VA-ECMO (1.9%) when the OriGen® was discontinued, but 17.8% of surgeons began to incorporate selective use of VA-ECMO.Discontinuation of the OriGen® cannula drove pediatric surgeons to alter their cannulation practices, dramatically increasing VA-ECMO use for neonatal and pediatric respiratory failure. These data may suggest a need for targeted education accompanying major technological shifts.Level IV.

  View details for DOI 10.1016/j.jpedsurg.2023.02.021

  View details for Web of Science ID 001001641500001

  View details for PubMedID 36914461

• Milky pericardial effusion causing tamponade in a neonate after extracorporeal membrane oxygenation cannulation JOURNAL OF SURGICAL CASE REPORTS Thornhill, R., Fortuna, R., Canteras, K., Raymond, S. L., Khan, F. A., Radulescu, A. 2023; 2023 (5): rjad233

  Abstract

  Cardiac tamponade is a known life-threatening complication of extracorporeal membrane oxygenation (ECMO), often secondary to hemopericardium from major vascular or cardiac perforation. We present the unique case of a neonate with a milky pericardial effusion causing tamponade after ECMO cannulation, managed successfully with pericardial window. Understanding ECMO physiology and its effect on the classic presentation of tamponade is critical and can prevent delays in diagnosis. While hemopericardium is most commonly seen in these cases, findings of a non-bloody, milky effusion should prompt further workup for infection, chylopericardium or total parenteral nutrition-associated pericardial effusion, as the appropriate management can mitigate immediate and potential long-term sequelae.

  View details for DOI 10.1093/jscr/rjad233

  View details for Web of Science ID 000988447500004

  View details for PubMedID 37192875

  View details for PubMedCentralID PMC10182393

• Multiple Perianal Epidermal Cysts Found in a Case of Lowe Syndrome: A Case Report and Review of the Literature AMERICAN JOURNAL OF CASE REPORTS Goodman, C. P., Park, H., Mladenov, G. D., Raymond, S. L., Sundin, A., Radulescu, A., Khan, F. A. 2023; 24: e938248

  Abstract

  BACKGROUND Lowe syndrome, also known as oculocerebrorenal syndrome, is a rare genetic condition caused by an X-linked mutation of the OCRL1 gene, with an estimated prevalence in the general population of approximately 1 in 500 000. It is a multisystem disorder most commonly affecting the eyes, central nervous system, and kidneys. These commonly manifest as congenital cataracts, intellectual disability, and proximal renal dysfunction (Fanconi-type). Epidermal lesions are an uncommon manifestation of this condition, and the association is not completely understood. CASE REPORT Here we present a case of a 9-year-old boy with Lowe syndrome who presented with multiple cystic masses found in the perianal region. An excision was then performed to remove the masses and found that the lesions were epidermal cysts, which are infrequently found in Lowe syndrome. After excision, the patient recovered uneventfully without complications. CONCLUSIONS While epidermal cysts are an uncommon manifestation that have been documented, our case remains unique given the location and associated symptoms of the lesions. At presentation, the constellation of pain and perianal masses was concerning for a malignant etiology. However, after diagnostic imaging was performed, these lesions were found to be epidermal cysts, an infrequent manifestation of Lowe syndrome. Few previous case reports described cystic lesions in association with Lowe syndrome, and none, to our knowledge, have described multiple symptomatic perianal lesions. This case is important to consider because epidermal cystic lesions can be found with this presentation and should be considered on differential diagnoses for dermatologic findings in Lowe syndrome patients.

  View details for DOI 10.12659/AJCR.938248

  View details for Web of Science ID 000959234900001

  View details for PubMedID 36959724

  View details for PubMedCentralID PMC10042271

• Short-term outcomes of thoracoscopic versus open lobectomy for congenital lung malformations PEDIATRIC SURGERY INTERNATIONAL Raymond, S. L., Sacks, M. A., Hashmi, A., Robertson, J. O., Moores, D., Tagge, E. P., Radulescu, A., Islam, S., Khan, F. A. 2023; 39 (1)

  View details for DOI 10.1007/s00383-023-05445-7

  View details for Web of Science ID 000954578700001

• A 12-Year-Old Girl with Juvenile Granulosa Cell Tumor of the Ovary, Presenting with Adolescent Hyperprolactinemia, Galactorrhea, and Amenorrhea AMERICAN JOURNAL OF CASE REPORTS Park, H., Goodman, C. P., Raymond, S. L., Sundin, A., Khan, F. A., Radulescu, A. 2023; 24: e938249

  Abstract

  BACKGROUND Juvenile-type granulosa cell tumors (JGCTs) are a rare subtype of sex cord stromal tumor with a characteristic histology that is commonly found in the first 3 decades of life. It most commonly presents with symptoms of hyperestrogenism, which may present as precocious pseudopuberty or as menstruation-related symptoms, allowing for early detection of the tumor. CASE REPORT We present the case of a 12-year-old girl who presented to her primary care provider (PCP) with secondary amenorrhea with intermittent abdominal pain, who underwent an ultrasound for further evaluation, which revealed a large incidental pelvic mass. She was admitted to the Emergency Department (ED) and had findings of galactorrhea and hyperprolactinemia on examination. Imaging studies demonstrated a large ovarian mass measuring 15.0×9.0×18.8 cm that was resected, and subsequent pathology results showed JGCT stage 1A. CONCLUSIONS Prognosis of granulosa cell tumors (GCT) largely depends on its initial size, stage at diagnosis, residual tumors after surgery, and the subtype of GCT. If the patient is of reproductive age, fertility-sparing surgical options must be considered and patients must be regularly monitored for recurrence. JGCTs can present with minimal to no symptoms of precocious puberty in young girls but may present with amenorrhea, which may be considered normal for their developmental age. Although JGCTs are rare, they are important to include in differential diagnoses of younger female patients with abdominal pain, especially if accompanied by hormonal irregularities.

  View details for DOI 10.12659/AJCR.938249

  View details for Web of Science ID 000963199200001

  View details for PubMedID 36647328

  View details for PubMedCentralID PMC9867898

• Are pediatric surgery fellowship websites ready for the changing paradigms in the virtual interview era? Global surgical education : journal of the Association for Surgical Education Sacks, M. A., Do Jeong, Y., Mendez, Y. S., Hashmi, A., Radulescu, A., Tagge, E. P., Robertson, J. O., Khan, F. A. 2023; 2 (1): 27

  Abstract

  Purpose: With the COVID-19 pandemic, in-person fellowship interviews were curtailed, leading candidates to seek information from other resources. Our main purposes were (1) to determine what information recent participants in the match needed to evaluate programs and (2) to assess which of these were available online.Methods: A focus group of ten recent graduates/applicants identified information that was important in choosing a fellowship program. In August 2020 and December 2021, websites belonging to the American Pediatric Surgical Association (APSA) and individual programs were assessed.Results: Recent applicants identified 55 pieces of information considered important to their decision making. Of 57 pediatric surgery fellowships, 98% were listed on APSA's website. Program descriptions on APSA's website listed on average 60% of program information desired by applicants. All listed fellowship director, accreditation status, faculty list, and current fellow(s). Other descriptors frequently noted were alumni (95%), graduate's board performance (83%), ECMO exposure (77%), and curriculum (70%). Information desired but less frequently available were fellow case logs (63%), trauma center designation (53%), burn center designation (40%), research opportunities (30%), candidate interview assistance (25%), and supplemental fellowships (12%). There were 7% of program descriptions that were not updated for at least a year.Conclusions: APSA and individual program websites were complimentary. Websites often lacked data that applicants sought to inform their rank list. To best adapt to the evolving virtual interview paradigm, we suggest reporting key information on a central APSA website with more nuanced information available via links to program specific websites.Supplementary Information: The online version contains supplementary material available at 10.1007/s44186-023-00104-w.

  View details for DOI 10.1007/s44186-023-00104-w

  View details for PubMedID 38013871

• Optimal Timing of Inguinal Hernia Repair in Premature Infants: An NSQIP-P Study JOURNAL OF SURGICAL RESEARCH Sacks, M. A., Neal, D., Pairawan, S., Tagge, E. P., Hashmi, A., Islam, S., Khan, F. A. 2023; 283: 690-698

  Abstract

  Among premature infants, the incidence of inguinal hernias is reported to be as high as 30%. Despite being one of the most commonly performed procedures, the optimal setting of inguinal hernia repair (IHR) that is inpatient versus outpatient remains debatable. We sought to compare the 30-day outcomes of each approach by querying the National Surgical Quality Improvement Program-Pediatric database.A retrospective cohort study comparing inpatient versus outpatient IHR using the National Surgical Quality Improvement Program-Pediatric database from 2013 to 2019 was performed. Demographic and clinical data were initially compared using univariate analysis. Continuous variables are presented as median and interquartile range and categorical variables are presented as n (%). Subsequently, cohorts were propensity matched using clinically and statistically significant patient characteristics.928 patients underwent IHR, 634 (68.3%) while inpatient, 294 (31.7%) following hospital discharge. Inpatient IHR was associated with lower age at the time of surgery (120 versus 147 d; P < 0.0001), younger gestational age (27 versus 33 wk; P < 0.0001), decreased probability of repair in elective setting (87.2% versus 97.3%; P < 0.0001), and increased preoperative supplemental oxygen need (42% versus 4.4%; P < 0.0001). Comparison of propensity matched cohorts revealed that inpatient IHR was associated with increased procedure time (82 versus 51 min; P < 0.0001) and anesthetic duration (146 versus 102 min; P < 0.0001), wound infection rates (3.8% versus 0%; P = 0.007), blood transfusions (4.2% versus 0.5%; P = 0.036), unplanned intubations (2.8% versus 0%; P = 0.03), ventilator days (0 versus 0; range [0,30 versus 0,2]; P = 0.002), reoperation rate (5.6% versus 0%; P < 0.001), postoperative hospital length of stay (4 versus 1 d; P < 0.0001), and unplanned readmissions (8.9% versus 0.9%; P = 0.002).Inpatient IHR in premature neonates were associated with different postoperative outcomes than outpatient IHR. At least in the elective setting among premature infants, outpatient IHR can be considered safe in select patients while we await higher quality prospective data.

  View details for DOI 10.1016/j.jss.2022.11.011

  View details for Web of Science ID 000893019800036

  View details for PubMedID 36459862

• Anatomy and embryology of abdominal wall defects SEMINARS IN PEDIATRIC SURGERY Khan, F. A., Raymond, S. L., Hashmi, A., Islam, S. 2022; 31 (6): 151230

  Abstract

  Abdominal wall defects are one of the most frequently encountered human congenital anomalies. They are seen in as many as 1 in 2,000 live births with evidence to suggest that their incidence is increasing. While often discussed together abdominal wall defects consist mainly of two entities namely gastroschisis and omphalocele. There are marked differences in their theories of embryo-pathogenesis, clinical presentation/anatomy and overall outcomes. There is no clear consensus explaining the precise embryological mechanisms leading to the development of abdominal wall defects. Many clinicians and embryologists have attempted to explain the genesis of congenital abdominal wall defects because of failure of progression of various phases of normal embryonic development. This review summarizes the mechanisms involved in normal and abnormal development of the ventral abdominal wall leading to the development of gastroschisis and omphalocele.

  View details for DOI 10.1016/j.sempedsurg.2022.151230

  View details for Web of Science ID 000914440200010

  View details for PubMedID 36446303

• Trisomy 18 and necrotizing enterocolitis JOURNAL OF PEDIATRIC SURGERY CASE REPORTS Maidan, A., Sacks, M. A., Raymond, S. L., Mladenov, G. D., Khan, F. A., Radulescu, A. 2022; 85

  View details for DOI 10.1016/j.epsc.2022.102411

  View details for Web of Science ID 000860443600001

• Objective Personality Determination: A Useful Addition to the Traditional Process of Pediatric Surgical Fellow Selection AMERICAN SURGEON Sacks, M. A., Khan, F. A., Hazboun, R., Radulescu, A., Tagge, E. P. 2022; 88 (10): 2531-2537

  Abstract

  Selection of pediatric surgical trainees is a multifaceted process heavily influenced by in-person interviews to determine personality makeup and institutional compatibility. We present our experience in utilizing a validated personality inventory in the selection of our candidates.All applicants selected for an in-person interview for the 2020 Pediatric Surgery Match were offered the Big Five Inventory (BFI) questionnaire. An initial rank order list (ROL) was formulated employing application information and in-person interview score. A reformulated ROL was created after incorporating BFI data. Correlation of specific personality characteristics vs position on the ROL was assessed for both the initial ROL and the reformulated ROL.Thirty-four applicants were interviewed and 24 (70.6%) were ranked. Linear regression analysis identified a lower neuroticism score directly related to a higher position on the initial ROL {R = .4626, P = .023}. The reformulated ROL identified a higher conscientiousness score {R = .5331; P = .007} and a lower neuroticism score {R = -.4383; P = .032} correlated with ascending the final ROL.The self-administered BFI adds objectivity to personality determination gleamed from the standard face-to-face interview. Conscientiousness and neuroticism had a significant impact on the final ROL position. Adding objective personality data appears to provide additional aid in this difficult process.

  View details for DOI 10.1177/00031348221103646

  View details for Web of Science ID 000802793200001

  View details for PubMedID 35619551

• Recidivism following childhood maltreatment necessitating inpatient care in the United States AMERICAN JOURNAL OF SURGERY Shah, A. A., Nizam, W., Sandler, A., Khan, F., Kane, T., Petrosyan, M. 2022; 223 (4): 774-779

  Abstract

  Non-accidental trauma (NAT) is one of the common causes of injury in children in the United States (US). Abuse and maltreatment affect 2 per 100,000 children annually and may go unrecognized. The aim of this study to quantify the recidivistic nature of NAT in the US pediatric population.The National Readmissions Database (2007-2015) was queried for pediatric (≤18y) trauma patients. Children presenting for non-accidental trauma were further identified. Data was obtained on demographic, clinical, and hospital-level characteristics. Body regions with an Abbreviated Injury Scale (AIS) greater than three were further identified. Multivariable logistic regression analysis (adjusting for age, gender, insurance status, year, Injury Severity Score [ISS], hospital region, and mechanism of injury) was utilized to determine factors influencing unintentional and intentional (assault) non-accidental traumatic injuries.NAT represents 1.6% (n = 4,634/286,508) of all pediatric trauma. The median age of presentation was <1y [IQR:0-3] with a male predominance (56.2%). Median ISS was 9 [IQR:2-16]. 87.5% of incidents represented assault (intentional). The most commonly affected body region was the head and neck (32.8%), followed by the extremities (11.4%) and soft tissue trauma or burns (6.3%). Penetrating trauma accounted for 18% of these injuries. 3.2% were readmitted to the hospital for a recurrent episode. 85.5% presented to the hospital for their initial evaluation. Mortality rates were 3.8% for those re-admitted to the hospital. The most common perpetrators were other specified persons known to the family, followed by fathers and mothers.Although uncommon, recidivism, after an initial episode of NAT, can have devastating consequences. The majority of the perpetrators of abuse are individuals known to the patient or family. Health policy aimed towards developing preventative strategies is needed to facilitate early recognition and tackle abuse in children.III.Case Control Study.

  View details for DOI 10.1016/j.amjsurg.2021.07.039

  View details for Web of Science ID 000795155400029

  View details for PubMedID 34325911

• To Wrap or Not? Utility of Anti-reflux Procedure in Infants Needing Gastrostomy Tubes FRONTIERS IN PEDIATRICS Khan, F. A., Nestor, K., Hashmi, A., Islam, S. 2022; 10: 855156

  Abstract

  Gastrostomy tube (GT) insertion is commonly performed in children with failure to thrive. Pediatric patients' frequently have gastroesophageal reflux (GER) and discerning pathological GER can be challenging. Moreover, there is some evidence that GT insertion may lead to worsening GER and to avoid a subsequent anti-reflux procedure (ARP), though controversial some surgeons advocate considering an ARP concomitantly. The purpose of this report is to assess outcomes in infants who underwent a GT vs. GT with ARP.Retrospective review of all infants who had a GT placed at a single institution from 2009-2014. The patients were then divided into two cohorts based on the index operation i.e., GT vs GT with ARP and outcomes compared.226 operations (104 GT, 122 GT with ARP) were performed. The cohorts were similar in gender, gestational age, race, weight, median age, LOS, and proportion of neurologically impaired patients. Preoperative GER was significantly higher in the GT with ARP cohort (91 vs. 18%). No difference in the rate of immediate complications was noted between the two groups. Postoperative increase in anti-reflux medications was significantly higher in the GT cohort (p = 0.01). Post-op GER needing a secondary procedure (ARP or GJ tube) was noted in 21/104 (20%) patients. Those needing an additional procedure vs. those with GT alone were similar in the proportion of patients with pre-op GER, neurologic impairment, type of feeds, and age.Identifying patients who would benefit from a concomitant ARP remains challenging. A fifth of GT patients needed a subsequent procedure despite most high-risk patients having already undergone an ARP. Since the overall rate of complications remained similar, initial GT approach can be considered reasonable.

  View details for DOI 10.3389/fped.2022.855156

  View details for Web of Science ID 000773605500001

  View details for PubMedID 35321013

  View details for PubMedCentralID PMC8936420

• The impact of regionality and hospital status on mortality associated with non-accidental trauma AMERICAN JOURNAL OF SURGERY Shah, A. A., Nizam, W., Sandler, A., Zuberi, M., Khan, F. A., Manicone, P., Kane, T., Petrosyan, M. 2022; 223 (2): 238-242

  Abstract

  Non-accidental trauma (NAT) affects 2 per 100,000 children annually in the US and may go unrecognized. The aim of this study to quantify the burden of NAT and to evaluate regional variations in mortality.The Kids Inpatient Database (2000-2012) was queried for pediatric patients presenting with a diagnosis of NAT. Data was obtained on demographic, clinical and hospital-level characteristics. Primary outcome measure was mortality. Multivariable logistic regression models for age, sex, race/ethnicity, insurance status, income quartile, hospital volume, region (Northeast, South, West and Midwest), teaching status, and injury severity scores.NAT represented 1.92% (n = 15,999) of all trauma patients. Mortality rates were 3.98% for patients presenting with NAT. African American children had a higher likelihood of mortality compared to White children (OR[95%CI]:1.35[1.03-1.79]), however, this effect was not statistically significant for patients being treated at designated children's hospitals (OR[95%CI]:1.23(0.78-1.95) and urban facilities (OR[95%CI]:1.30[0.99-1.72]). Statistically significant regional variations in mortality, lost significance for patients treated at designated children's hospitals (p > 0.05).NAT has devastating consequences and is associated with a high mortality rate. Treatment at designated children's hospitals results in the loss of variation in mortality, resulting in diminished disparities and improved outcomes. These findings align with current trends towards the "regionalization of pediatric health care" and reflects the value of regional transfer centers that are.

  View details for DOI 10.1016/j.amjsurg.2021.06.014

  View details for Web of Science ID 000755082100007

  View details for PubMedID 34274104

• Prenatal administration of heparin-binding epidermal growth factor-like growth factor in an experimental model of necrotizing enterocolitis decreased both incidence and severity of the disease WORLD JOURNAL OF PEDIATRIC SURGERY Sacks, M., Mendez, Y., Khan, F. A., Propst, R., Zuppan, C. W., Wilson, C. G., Radulescu, A. 2022; 5 (1): e000345

  Abstract

  Necrotizing enterocolitis (NEC) is the leading gastrointestinal cause of death in premature infants and causes long-term disabilities. Previously, enteral heparin-binding epidermal growth factor-like growth factor (HB-EGF) administered after birth demonstrated decreased incidence and severity of NEC in a neonatal animal model of NEC. We investigated the potential prophylactic strategy of preventing NEC using prenatally administered HB-EGF.An HB-EGF (800 µg/kg/dose) dose was injected into pregnant rats via tail vein or intraperitoneal route 2 hours prior to delivery. After cesarean section (C-section) at 21 days' gestation, the rat pups were subjected to the NEC protocol by inducing stressors: hypoxia, hypothermia, hypertonic feeds, and orogastric gavage of lipopolysaccharide (2 mg/kg). Postnatally, pups were monitored for 96 hours and assessed for the development of clinical and postmortem histological NEC.The experimental NEC incidence in untreated, stressed rat pups was 66%. Compared with untreated pups, the maternal administration of HB-EGF correlated with a significant NEC incidence and severity decrease in rat pups. The strongest decrease was seen when HB-EGF was administered via the intraperitoneal route 2 hours prior to C-section (66% vs 31%, *p<0.05). Prenatal HB-EGF administration significantly increased pups' survival after NEC protocol exposure, with the greatest benefit observed in the group that received HB-EGF intraperitoneally 2 hours before delivery.Prenatal administration of HB-EGF decreases the incidence and severity of NEC, preserves gut barrier function and increases survival. This may represent a novel prophylactic clinical strategy for NEC offered to mothers at risk of delivering a premature infant.

  View details for DOI 10.1136/wjps-2021-000345

  View details for Web of Science ID 000740755100009

  View details for PubMedID 36474622

  View details for PubMedCentralID PMC9716957

• Pain versus Gain: Multiport versus single-port thoracoscopic surgery for pediatric pneumothorax a case series INTERNATIONAL JOURNAL OF SURGERY OPEN Sacks, M. A., Goodman, L. F., Mendez, Y. S., Khan, F. A., Radulescu, A. 2021; 37

  View details for DOI 10.1016/j.ijso.2021.100428

  View details for Web of Science ID 000720545300001

• Prehospital personnel discretion pediatric trauma team activations: Too much of a good thing? JOURNAL OF PEDIATRIC SURGERY Khan, F. A., Apple, C., Caldwell, K. J., Larson, S. D., Islam, S. 2021; 56 (11): 2052-2057

  Abstract

  Trauma team activation is essential to provide rapid assessment of injured patients, however excessive utilization can overburden systems. We aimed to identify predictors of over triage and evaluate impact of prehospital personal discretion trauma activations on the over triage rate.Retrospective comparative study of pediatric trauma patients (<18 years) evaluated after activation of the trauma team to those evaluated as a trauma consult treated between 2010 and 2013. Cohort matching of trauma activated and consult patients was done on the basis of patients' age and ISS.1363 patients including 359 trauma team activations were evaluated. Median age was 6 years, Injury Severity Score (ISS) 4, 116 (8.5%) required operative intervention and 20 (1.4%) died. Matched analysis using age and ISS showed trauma activated patients were more likely to have penetrating MOI (4.7% vs.1.7%; p = 0.03) and need ICU admission(32.9% vs.16.7%; p = 0.0001). State of Florida discrete criteria based trauma activated patients when compared to paramedic discretion activations had a higher ISS (9 vs.5; p = 0.014), need for ICU admission (36.5% vs.20.4%; p = 0.004), ICU LOS(2 vs.0 days; p = 0.02), hospital LOS(2 vs.2 days; p = 0.014) and higher likelihood of death(4.9% vs.0%;p = 0.0001). Moreover, paramedic discretion trauma activated patients were similar to trauma consult patients in terms of ISS score(p = 0.86), need for ICU admission(p = 0.86), operative intervention(p = 0.86), death(p = 0.86) and hospital LOS(p = 0.86), with a considerably higher cost of care(p = 0.0002).Discrete criteria-based trauma team activations appear to more reliably identify patients likely to benefit from initial multidisciplinary management.

  View details for DOI 10.1016/j.jpedsurg.2021.03.002

  View details for Web of Science ID 000711604100025

  View details for PubMedID 33814181

• Newborn with annular pancreas and H-Type tracheoesophageal fistula JOURNAL OF PEDIATRIC SURGERY CASE REPORTS Thornhill, R., Sacks, M. A., Goodman, L. F., Khan, F. A., Radulescu, A. 2021; 75

  View details for DOI 10.1016/j.epsc.2021.102068

  View details for Web of Science ID 000729961700014

• Safe Zone for Dissection in Frontotemporal Region to Avoid Injury to the Temporal Branch of Facial Nerve JOURNAL OF CRANIOFACIAL SURGERY Hashmi, A., Zahed, A., Hamamdjian, C., McGee, C., Barry, M., Asali, D., Khan, F., Al-Mufarrej, F. 2021; 32 (7): 2322-2325

  Abstract

  The objective of this study is to provide a reliable roadmap for temporal branch of the facial nerve, in order to minimize, the risk of injury to the nerve during surgical dissections. A literature search was conducted on temporal branch of facial nerve. The date search range was 1950 to 2017. Databases searched included Medline, Web of science, Biosis, SciELO, Data Citation, and Zoologic Records. Data were collected on, author specialty, date of publication, and the relationship of the temporal branch of facial nerve to various landmarks in the frontotemporal region reported in human anatomic studies. Among the 48 studies reviewed, a total of 3477 anatomic dissections were performed in the craniofacial region. Temporal branch of facial nerve was located between 2.5 and 3 cm from lateral orbital rim. In relation to the zygomatic arch, it was found anywhere from the midpoint of the arch to 1 finger breath posterior to the arch. For the plane, it was most commonly described as being under the superficial temporal fascia (STF) or within the loose areolar tissue. Most anatomic dissections found 2 to 4 twigs of the temporal branch of facial nerve. In relation to the lateral canthus, it was found to be 2.85 +/- 0.69 cm superior and 2.54 +/- 0.43 cm lateral to the lateral canthus. Our study suggests consolidated data on surgical landmarks in order to ensure safe dissection in temporal region and prevent injury to the temporal branch of facial nerve.

  View details for DOI 10.1097/SCS.0000000000007668

  View details for Web of Science ID 000708552800054

  View details for PubMedID 34705381

• Thoracoscopic segmentectomy for a large previously undiagnosed CPAM presenting as a spontaneous pneumothorax: A case report INTERNATIONAL JOURNAL OF SURGERY CASE REPORTS Pairawan, S. S., Tagge, E. P., Sacks, M. A., Hashmi, A., Radulescu, A., Khan, F. A. 2021; 87: 106412

  Abstract

  Incidentally found congenital pulmonary airway malformations (CPAM) in older children are extremely rare and have traditionally been managed with minimally invasive versus open lobectomy of the affected lobe.In this report, we present a 11-year-old male who presented with a recurrent spontaneous pneumothorax and was found to have a large symptomatic CPAM confined to a single segment of the right lower lobe. The patient was successfully treated with thoracoscopic segmentectomy without any residual disease seen on follow up imaging.Minimally invasive thoracoscopic approach has many advantages over open approach including better pain control, reduced hospital length of stay, and decreased intraoperative blood loss. With increasing use of minimally invasive approaches, lung-sparing surgery has demonstrated to be a viable and an attractive option for definitive resection of CPAM, without compromising resection margins and/or future lung function.This report demonstrates that minimally invasive lung-sparing surgical treatment of a large CPAM is feasible in older children.

  View details for DOI 10.1016/j.ijscr.2021.106412

  View details for Web of Science ID 000704985300005

  View details for PubMedID 34560589

  View details for PubMedCentralID PMC8473762

• The Utility of Gallbladder Absence on Ultrasound for Children With Biliary Atresia FRONTIERS IN PEDIATRICS Ho, A., Sacks, M. A., Sapra, A., Khan, F. A. 2021; 9: 685268

  Abstract

  Background: Biliary Atresia (BA) is congenital condition, where infant intra- and extrahepatic bile ducts become obliterated, leading to cholestasis, and cirrhosis if untreated. This study aims to assess the predictive measure of absent gallbladder on ultrasounds (US) performed in infants with cholestasis for diagnosing BA. Method: After Institutional Review Board approval, retrospective chart reviews of 61 infants with cholestasis found 43 (70.5%) were diagnosed with BA. A pediatric radiologist provided interpretations of all ultrasounds in a blinded fashion. Statistical analysis was used to assess the utility of absence of gallbladder on US in predicting BA, confirmed intraoperatively. Results: Absent gallbladder on US predicts absent gallbladder with 77% accuracy, 92% sensitivity, 73% specificity, PPV 43%, and NPV 97% (P < 0.001, Fisher exact test). To diagnose BA, absent gallbladder on US has 66% accuracy, 53% sensitivity, 94% specificity, 96% PPV, and 46% NPV (P < 0.001, Fisher exact test). Conclusion: Sonographic gallbladder absence has high specificity and PPV, indicating utility for BA diagnosis; however, it is not useful for ruling out BA given its low sensitivity.

  View details for DOI 10.3389/fped.2021.685268

  View details for Web of Science ID 000672149900001

  View details for PubMedID 34268279

  View details for PubMedCentralID PMC8275825

• Unusual cause of appendicitis: Orthodontic wire JOURNAL OF PEDIATRIC SURGERY CASE REPORTS Sacks, M. A., Goodman, L. F., Khan, F. A., Radulescu, A. 2021; 71

  View details for DOI 10.1016/j.epsc.2021.101909

  View details for Web of Science ID 000665551400006

• Rare case report of anorectal malformation and intestinal atresia INTERNATIONAL JOURNAL OF SURGERY CASE REPORTS Gunderson, E. J., Sacks, M. A., Goodman, L. F., Hashmi, A., Radulescu, A., Khan, F. A. 2021; 82: 105945

  Abstract

  Intestinal malformations, such as intestinal atresia, malrotation, and anorectal malformation, are rare events, but concurrent intestinal atresia and anorectal malformation are rare in combination. These anomalies have similar in utero and perinatal symptoms, which can make the diagnosis of both defects prenatally challenging.We present a case of a male infant with a prenatal diagnosis of truncus arteriosus who on a 32-week routine prenatal ultrasound was suspected to have an intestinal malformation. On day of life one, the patient was taken to the operating room and found to have both type IIIa ileal atresia and anorectal malformation with normal bowel in between. A complete work up for vertebral defects, anorectal malformation, cardiac septal defects, esophageal atresia, renal anomalies, and radial limb defects (VACTERL) anomalies did not reveal additional anomalies.In this case, prenatal information supported intestinal obstruction, and the rare combination of both intestinal atresia and anorectal malformation proved surprising and interesting.We suggest providers be aware of the potential of multiple alimentary tract malformations to improve operative preparation and reduce the morbidity or mortality risk from repeat procedures when possible.

  View details for DOI 10.1016/j.ijscr.2021.105945

  View details for Web of Science ID 000670025300021

  View details for PubMedID 33964718

  View details for PubMedCentralID PMC8114125

• Single site versus conventional laparoscopic appendectomy: some pain for no gain? JOURNAL OF SURGICAL RESEARCH Goodman, L. F., Lin, A. C., Sacks, M. A., McRae, J. H., Radulescu, A., Khan, F. A. 2021; 264: 321-326

  Abstract

  The optimal laparoscopic appendectomy approach is not clear, comparing single site laparoscopic appendectomy (SILA) to conventional 3-port appendectomy (CLA). We investigated outcomes in pediatric patients comparing SILA to CLA: length of operation, length of stay, time to resumption of regular diet, follow up, rehospitalization, and cost.Data was collected from children 1 to 18 years with appendectomy at Loma Linda University from 2018 to 2020, operated by two surgeons. Analysis utilized two-sample T, chi-squared, and Fisher's exact tests.Of 173 patients, 77 underwent SILA and 96 had CLA. There was no gender, age, or race difference between groups. Mean WBC was 17.5 × 103/mL in SILA group, compared to 15.3 × 103/mL in CLA group (P = 0.004). Operative time was 47.0 SILA compared to 49.5 minutes CLA (P = 0.269). Of SILA cases, 55.8% were simple appendicitis, while 53.3% of the CLA cases were simple (P = 0.857). Regular diet was resumed after 1.7 days in the SILA group, 1.1 days in CLA (P = 0.018). Length of stay was 2.9 days for SILA, 2.4 days for CLA (P = 0.144). Seven children required hospital readmission, 5 SILA and 2 CLA (P = 0.244). Five of the children who returned had intra-abdominal abscesses, of whom 4 had SILA. There was no difference in cost.The operative techniques had similar outcomes and operative times. There was a trend toward more intra-abdominal abscesses in the SILA group. Further study and longer follow up is needed to determine if there is an advantage to one laparoscopic approach over another.

  View details for DOI 10.1016/j.jss.2021.03.010

  View details for Web of Science ID 000664031200043

  View details for PubMedID 33848830

• Lipoblastomas and liposarcomas in paediatric patients: A case series JOURNAL OF INTERNATIONAL MEDICAL RESEARCH McRae, J. H., Hashmi, A., Radulescu, A., Carter, C. S., Khan, F. A. 2021; 49 (3): 300060520981362

  Abstract

  Lipoblastomas and liposarcomas are rare causes of soft tissue masses in paediatric patients. In this retrospective clinical case series we identified 11 patients from our paediatric database (10 with a lipoblastoma and one with a liposarcoma) who had attended our hospital between 1998 and 2019. The median age of patients with lipoblastoma was 29 months. All lipoblastoma cases were managed with surgical excision and histological examination. The 18-year old patient with liposarcoma presented with a metastatic and unresectable tumour that was unresponsive to chemotherapy and radiation. Our experience demonstrates the importance of differentiating the type of soft tissue mass in children.

  View details for DOI 10.1177/0300060520981362

  View details for Web of Science ID 000631129500001

  View details for PubMedID 33730887

  View details for PubMedCentralID PMC8166409

• Paraspinal plexiform schwannoma of unknown nerve origin: A case report INTERNATIONAL JOURNAL OF SURGERY CASE REPORTS Pace, S., Sacks, M. A., Minasian, T., Hashmi, A., Khan, F. A. 2021; 79: 267-270

  Abstract

  Schwannomas are benign, slow-growing nerve sheath tumors of neoplastic Schwann cells. They are the most common peripheral nerve tumors in adults and are typically discovered incidentally due to their asymptomatic presentation. Despite the fact that most schwannomas are unassociated with a syndrome, their etiology is thought to be related to alterations or loss of the neurofibromatosis type two tumor suppressor gene.We present the case of a fifteen-year-old female who presented with a recurrent lower back/upper buttocks 9 cm mass with imaging suspicious for schwannoma. Needle biopsy revealed an S100 positive cellular schwannoma with patchy Ki-67. During surgical dissection down to the sacrum, no nerve of origin was identified.Schwannomas have no pathognomonic findings on MRI and may occur at any location that Schwann cells are present; therefore, confirming a diagnosis relies on histopathology. Plexiform schwannomas are defined by a "network-like" intraneural growth pattern and are exceedingly rare in paediatric populations. A location distinct from the spinal canal is also very rare as schwannomas typically originate from the head and neck region.Paediatric plexiform schwannomas have been rarely reported. Surgical planning relies on multiple factors such as tumor size, tumor location, pathologic features and symptomatic burden. The distinctive features of this case including an unknown nerve origin and a location outside the spinal canal provide a unique opportunity to discuss the diagnosis and management of paraspinal schwannomas and the impact on operative planning when a nerve of origin is not identified.

  View details for DOI 10.1016/j.ijscr.2021.01.022

  View details for Web of Science ID 000626814300060

  View details for PubMedID 33486308

  View details for PubMedCentralID PMC7829105

• What is the role of the cholecystokinin stimulated HIDA scan in evaluating abdominal pain in children? JOURNAL OF PEDIATRIC SURGERY Khan, F. A., Markwith, N., Islam, S. 2020; 55 (12): 2653-2656

  Abstract

  Cholecystokinin stimulated HIDA (CCK-HIDA) has been used to identify patients with biliary dyskinesia and select patients likely to benefit from cholecystectomy. The appropriate use of this study in children remains controversial and this study aims to better understand the utility of this test.Children who underwent a CCK-HIDA for evaluation of abdominal pain over a 15-year period were included, after excluding infants and patient's s/p liver transplant. Relevant clinical and outcomes data were abstracted and analyzed.124 patients met inclusion criteria. Mean age was 14.5 ± 2.6 years, Mean BMI was 27.9 ± 9.9 and 96 (77.4%) presented with right upper quadrant or epigastric pain. The mean ejection fraction (EF) was 58.5 ± 31.8%, with 37 (29.8%) < 35% EF. Using receiver operating curve analysis no specific EF threshold value predictive of resolution of symptoms was identified (AUC 0.510; p = 0.94). Using EF <35% and >35% and <20% and >20%, no association was noted with partial/complete resolution of symptoms. On multivariate regression analysis neither EF nor pain reproduction with CCK administration were independently associated with resolution of symptoms.These data suggest that the CCK-HIDA scan is a poor predictor of benefit from cholecystectomy. Prospective large studies would help in identifying better criterion for patient selection, especially with the trend of increasing surgery for functional gallbladder disorders.Case cohort.IV.

  View details for DOI 10.1016/j.jpedsurg.2020.03.020

  View details for Web of Science ID 000598960000019

  View details for PubMedID 32482410

• Single site video assisted thoracoscopic wedge resection for spontaneous pneumothorax in a pediatric patient JOURNAL OF PEDIATRIC SURGERY CASE REPORTS Won, T. M., Munoz, A., Sacks, M. A., Mendez, Y. S., Goodman, L., Khan, F. A., Radulescu, A. 2020; 61

  View details for DOI 10.1016/j.epsc.2020.101614

  View details for Web of Science ID 000571895100005

• Pediatric adrenal incidentaloma JOURNAL OF PEDIATRIC SURGERY CASE REPORTS McRae, J. H., Radulescu, A., Khan, F. A. 2020; 60

  View details for DOI 10.1016/j.epsc.2020.101573

  View details for Web of Science ID 000561628700010

• Pediatric earlobe keloids: Outcomes and patterns of recurrence JOURNAL OF PEDIATRIC SURGERY Khan, F. A., Drucker, N. A., Larson, S. D., Taylor, J. A., Islam, S. 2020; 55 (3): 461-464

  Abstract

  Keloids occur as a result of abnormal wound healing and as many as 70% of keloids and hypertrophic scars affect the pediatric population. Earlobe keloids, similar to lesions elsewhere in the body, remain a challenging problem given the high rates of recurrence and lack of consensus regarding treatment strategy. This study aims to evaluate the outcomes and patterns of recurrences following treatment of earlobe keloids in a large cohort of pediatric patients to facilitate identification of the optimal treatment strategy.All pediatric patients who underwent surgical therapy for earlobe keloids over a 10-year period (2004-2015) were identified and demographic, clinical and outcomes data were collected. A follow-up phone survey was administered to assess rates of long-term recurrence and overall satisfaction with the treatment strategy. Data analysis was performed using Student's t-test and Fisher's exact as appropriate.A total of 94 patients with 135 keloids were identified. Mean age was 14 years with slight preponderance of females (52%) and a majority (75%) of the patients were African American (AA). Mean keloid size was 2.4 cm (0.25-11 cm) with ear piercing being the most common inciting etiology. Excision with steroid injection (59%) was the most frequent treatment approach followed by excision alone (25%). During a median follow up of 2 years, keloid recurrence occurred in 27 (28.7%) patients, 19 (70.4%) underwent additional therapy with 10 (52.6%) re-recurrences noted. Median time to recurrence was 23 months, with a slightly higher recurrence rate in AA patients (32%; p = 0.26) and in those age < 10 years (50%; p = 0.11).This represents the largest series of earlobe keloids treatment in children. Our data suggest that recurrence rates are unaffected by the age at excision and race of the patient. Moreover, adjuncts to excisional therapy such as steroid injection, compression therapy and radiation also did not appear to influence recurrence. Given the pattern of recurrences studies with longer term follow-up are needed to assess the efficacy of treatment strategies.Case series.IV.

  View details for DOI 10.1016/j.jpedsurg.2019.07.006

  View details for Web of Science ID 000522662800019

  View details for PubMedID 31383580

• Animal models of necrotizing enterocolitis. World journal of pediatric surgery Mendez, Y. S., Khan, F. A., Perrier, G. V., Radulescu, A. 2020; 3 (1): e000109

  Abstract

  Background: Necrotizing enterocolitis (NEC) is one of the leading causes of death in premature infants. To determine the factors present in the disease that lead to increased morbidity and mortality, manipulation of variables that are shown to have a positive response has been tested using various animal models. Testing and manipulation of these variables are unwarranted in humans due to regulatory health standards.Methods: The purpose of this review is to provide an update to previous summaries that determine the significance of animal models in studying the mechanisms of NEC. A large variety of animal models including rats, mice, rabbits, piglets, nonhuman primates, and quails have been described in literature. We reviewed the reported animal models of NEC and examined the pros and cons of the various models as well as the scientific question addressed.Results: The animals used in these experiments were subject to gavage feeding, hypoxia, hypothermia, oxygen perfusion, and other methods to induce the disease state. Each of these models has been utilized to show the effects of NEC on the premature, undeveloped gut in animals to find a correlation to the disease state present in humans. We found specific advantages and disadvantages for each model.Conclusions: Recent advances in our understanding of NEC and the ongoing therapeutic strategy developments underscore the importance of animal models for this disease.

  View details for DOI 10.1136/wjps-2020-000109

  View details for PubMedID 36474867

• Single site laparoscopic repair of a Morgagni hernia in a pediatric patient JOURNAL OF PEDIATRIC SURGERY CASE REPORTS Munoz, A., Pepper, V., Khan, F. A., Radulescu, A. 2019; 50

  View details for DOI 10.1016/j.epsc.2019.101299

  View details for Web of Science ID 000551491800005

• Bowel perforation in a pediatric patient with congenital generalized lipodystrophy type 4 JOURNAL OF PEDIATRIC SURGERY CASE REPORTS Munoz, A., Radulescu, A., Baerg, J., Mendez, Y., Khan, F. A. 2019; 48

  View details for DOI 10.1016/j.epsc.2019.101257

  View details for Web of Science ID 000484864800004

• Successful treatment of post-infectious pneumatocele via percutaneous drainage in a premature infant JOURNAL OF PEDIATRIC SURGERY CASE REPORTS Munoz, A., Moores, D. C., Khan, F. A., Baerg, J., Radulescu, A. 2019; 47

  View details for DOI 10.1016/j.epsc.2019.101235

  View details for Web of Science ID 000477705900014

• Insights into embryology and development of omphalocele SEMINARS IN PEDIATRIC SURGERY Khan, F. A., Hashmi, A., Islam, S. 2019; 28 (2): 80-83

  Abstract

  Congenital abdominal wall defects are one of the most common human birth defects with an incidence of about 1 in 2000 live births. While often discussed together abdominal wall defects consist mainly of two distinct entities namely gastroschisis and omphalocele. There is no clear consensus explaining the precise embryological mechanisms leading to the development of an omphalocele. Many clinicians and embryologists have attempted to explain congenital malformation as a result of failure of progression of normal embryonic development. This review summarizes the mechanisms involved in normal and abnormal development of the ventral abdominal wall.

  View details for DOI 10.1053/j.sempedsurg.2019.04.003

  View details for Web of Science ID 000468377600002

  View details for PubMedID 31072462

• Life-threatening electrolyte abnormalities in pyloric stenosis JOURNAL OF PEDIATRIC SURGERY CASE REPORTS Jacobs, C., Johnson, K., Khan, F. A., Mustafa, M. M. 2019; 43: 16-18

  View details for DOI 10.1016/j.epsc.2019.01.002

  View details for Web of Science ID 000461189600005

• Duodenal web presenting outside the neonatal period concurrently with malrotation and mid-gut volvulus JOURNAL OF PEDIATRIC SURGERY CASE REPORTS Jacobs, C., Khan, F. A., Apple, C., Larson, S. D. 2018; 39: 35-37

  View details for DOI 10.1016/j.epsc.2018.09.005

  View details for Web of Science ID 000449768900011

• Variability of the f-cell ratio after treatment of traumatic hemorrhagic shock ANNALS OF MEDICINE AND SURGERY Khan, F. A., Mullins, R., Ledgerwood, A. M., Lucas, C. E. 2018; 35: 176-179

  Abstract

  Measuring total blood volume (TBV) in critically ill patients, using isotope techniques to determine red cell volume (RBCV) and plasma volume (PV) is laborious. Recently, PV measurement using a single bolus dose of tracers has been validated, thus, allowing TBV calculation using large venous hematocrit (LVHCT). However, this technique relies on using a correlation factor, the f-cell ratio, to adjust for differences in LVHCT and total body hematocrit (TBHCT). The normal f-cell ratio is 0.9 but has never been studied in patients recovering from hemorrhagic shock (HS). This study assesses the f-cell ratio at different phases after HS to determine accuracy in calculating TBV.114 injured patients requiring immediate operation for HS were studied. All patients had measurements of PV and RBCV via isotope dilution enabling measurements of TBHCT. Correlation of LVHCT and TBHCT were used to calculate the f-cell ratio in the fluid sequestration (n = 81) and in the fluid mobilization period (n = 108).The f-cell ratio (mean ± SD) averaged 0.89 ± 0.15 and 0.90 ± 0.01 in the first and second halves of the fluid sequestration period versus 0.90 ± 0.2 and 0.80 ± 0.07 in the first and second 48 h of the fluid mobilization period. The f-cell ratio was significantly lower (p=<0.001) in the mobilization period.These data show for the first time that using PV and LVHCT to calculate TBV after HS is unreliable. The mechanisms causing this variation in f-cell ratio is unknown but likely related to capillary/interstitial dynamics and needs further scientific study.

  View details for DOI 10.1016/j.amsu.2018.10.001

  View details for Web of Science ID 000448051500037

  View details for PubMedID 30319776

  View details for PubMedCentralID PMC6180436

• Inguinal hernias in premature neonates: exploring optimal timing for repair PEDIATRIC SURGERY INTERNATIONAL Khan, F. A., Zeidan, N., Larson, S. D., Taylor, J. A., Islam, S. 2018; 34 (11): 1157-1161

  Abstract

  Inguinal hernias have been reported in as many as 10-30% premature neonates, making inguinal herniorrhaphy (IHR) one of the most commonly performed surgical procedures. The timing of surgery remains controversial. The purpose of this report is to compare outcomes of IHR while in the NICU (inpatient) versus repair following discharge (outpatient) to determine optimal timing.Premature neonates having undergone IHR over a 5-year period were identified and a retrospective case cohort analysis was performed.263 patients underwent IHR during the 5-year study period with 115 (43.7%) having surgical repair inpatient (IP; prior to discharge) and 148 having outpatient herniorrhaphy (OP). Patients with IHR performed IP had significantly lower birth weight (p < 0.001), gestational age (p < 0.001), longer duration of surgery (p = 0.01) and were more likely to have post-operative ventilator dependence following repair; however, there were no differences in the rate of recurrence (p = 0.44) and incarceration (p = 0.45).Our study demonstrated no significant differences in the rates of incarceration or recurrence, following in- or out-patient IHR. These findings suggest that IHR can potentially be offered as an outpatient procedure following hospital discharge in appropriate patients. The optimal timing of IHR in premature infants remains elusive and will likely require additional multicenter investigation.

  View details for DOI 10.1007/s00383-018-4356-8

  View details for Web of Science ID 000447263600004

  View details for PubMedID 30255352

• Whole Body Protein Turnover and Net Protein Balance After Pediatric Thoracic Surgery: A Noninvasive Single-Dose N-15 Glycine Stable Isotope Protocol With End-Product Enrichment JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Fullerton, B. S., Sparks, E. A., Khan, F. A., Fisher, J. G., Anzaldi, R., Scoville, M. R., Yu, Y., Wagner, D. A., Jaksic, T., Mehta, N. M. 2018; 42 (2): 361-370

  Abstract

  We used the 15 N glycine urinary end-product enrichment technique to quantify whole body protein turnover following thoracic surgery.A single dose of 15 N glycine (2 mg/kg) was administered orally on postoperative day 1 to children (1-18 years) following thoracic surgery. 15 N enrichment of ammonia and urea was measured in mixed urine after 12 and 24 hours, respectively, and protein synthesis, breakdown, and net balance determined. Nitrogen balance (dietary intake minus urinary excretion) was calculated. Urinary 3-methylhistidine:creatinine ratio was measured as a marker of skeletal muscle protein breakdown.We enrolled 19 subjects-median (interquartile range): age, 13.8 years (12.2-15.1); weight, 49.2 kg (38.4-60.8)-who underwent thoracotomy (n = 12) or thoracoscopic (n = 7) surgery. Protein synthesis and breakdown by 15 N enrichment were 7.1 (5.5-9) and 7.1 (5.6-9) g·kg-1 ·d-1 with ammonia (12 hours) as the end product, and 5.8 (3.8-6.7) and 6.7 (4.5-7.6) with urea (24 hours), respectively. Net protein balance by the 15 N glycine and urinary urea nitrogen methods were -0.34 (-0.47, -0.3) and -0.48 (-0.65, -0.28) g·kg-1 ·d-1 , respectively (rs = 0.828, P < .001). Postoperative change in 3-methylhistidine:creatinine ratio did not correlate significantly with protein breakdown or balance.The single-dose oral administration of 15 N glycine stable isotope with measurement of urinary end-product enrichment is a feasible and noninvasive method to investigate whole body protein turnover in children. After major surgery, children manifest increased protein turnover and net negative balance due to increased protein breakdown.

  View details for DOI 10.1177/0148607116678831

  View details for Web of Science ID 000425094500012

  View details for PubMedID 29443397

• Use of intraoperative index finger pulse oximetery during radial forearm flap harvest to prevent finger ischemia for reconstruction of hand burn and crush injuries BURNS Hashmi, A., Burkat, A. J., Khan, F. A., Mcgee, C., Al-Mufarrej, F. 2017; 43 (7): 1604-1605

  View details for DOI 10.1016/j.burns.2017.03.024

  View details for Web of Science ID 000414444200032

  View details for PubMedID 28442166

• A survey of current state of training of plastic surgery residents. BMC research notes Hashmi, A., Khan, F. A., Herman, F., Narasimhan, N., Khan, S., Kubiak, C., Gursel, E., Edelman, D. A. 2017; 10 (1): 234

  Abstract

  BACKGROUND: Plastic surgery training is undergoing major changes however there is paucity of data detailing the current state of training as perceived by plastic surgical trainees. Our aim was to determine the quality of training as perceived by the current trainee pool and their future plans.METHODS: A 25-item anonymous survey with three discrete sections (demographics, quality of training, and post-graduate career plans) was developed and distributed to plastic surgery residents during the academic year 2013. With the confidence interval of 95% and margin of error of 10%, our target response rate was 87 responders.RESULTS: We received a total of 114 respondents with all levels of Post Graduate Year in training represented. Upon comparison of residents with debt of <100,000 to residents with a debt of >250,000, those with higher debt were significantly less interested in fellowship training (p value 0.05) and were more likely to pursue private practice (p value <0.01). Disciplines within plastic surgery least offered as a separate rotation were microsurgery (45%) followed by aesthetic surgery (33%). 53.7% of the residents felt that they were least trained in aesthetic surgery followed by burn surgery 45.4%. Of note 56.4% intended to seek additional training after residency. Moreover residents with an average of 6.4months of experience in an individual subspecialty were more likely to feel comfortable with that specialty.CONCLUSIONS: This survey highlights the areas and subspecialties that deserve attention as perceived by the current trainee pool.

  View details for DOI 10.1186/s13104-017-2561-5

  View details for PubMedID 28655336

• Pseudoaneurysm of superficial and deep arch of the hand after penetrating wound EUROPEAN JOURNAL OF PLASTIC SURGERY Hashmi, A., Schumaier, A., Khan, F., Gursel, T., Nava, G. 2017; 40 (1): 75-78

  View details for DOI 10.1007/s00238-016-1235-1

  View details for Web of Science ID 000392626000013

• Ileostomy Prolapse in Children with Intestinal Dysmotility GASTROENTEROLOGY RESEARCH AND PRACTICE Sparks, E. A., Velazco, C. S., Fullerton, B. S., Fisher, J. G., Khan, F. A., Hall, A. M., Jaksic, T., Rodriguez, L., Modi, B. P. 2017; 2017: 7182429

  Abstract

  A relationship between intestinal motility and ileostomy prolapse has been suggested but not demonstrated objectively.This study evaluated the association between ileostomy prolapse and intestinal dysmotility in children.IRB-approved retrospective review of 163 patients with ileostomies (1998-2014) at a single institution. Patients were categorized as having clinical dysmotility as a primary diagnosis (n = 33), clinically suspected dysmotility based on underlying diagnosis (n = 60), or intestinal dysmotility unlikely (n = 70) at the time of ileostomy present. Intestinal manometry was categorized as normal (n = 13) or abnormal (n = 10). Primary outcome was pathologic stoma prolapse. Multivariate analysis using a logistic regression model and log-rank test to compare stoma prolapse rates over time between motility groups were used.Clinical diagnosis of dysmotility (p ≤ 0.001) and manometric findings of dysmotility (p = 0.024) were independently associated with stoma prolapse. Clinical dysmotility correlated with manometric findings (κ = 0.53). Prolapse occurred in 42% of patients with dysmotility, 34% of patients with suspected dysmotility, and 24% of patients with normal motility. One-year prolapse-free stoma "survival" was 45% for dysmotility, 72% for suspected dysmotility, and 85% for intestinal dysmotility unlikely groups (p = 0.006).Children with intestinal dysmotility are at great risk for stoma prolapse. Intestinal manometry could help identify these patients preoperatively.

  View details for DOI 10.1155/2017/7182429

  View details for Web of Science ID 000411064800001

  View details for PubMedID 29075290

  View details for PubMedCentralID PMC5624168

• How Informative are the Plastic Surgery Residency Websites to Prospective Applicants? JOURNAL OF SURGICAL EDUCATION Hashmi, A., Policherla, R., Campbell, H., Khan, F. A., Schumaier, A., Al-Mufarrej, F. 2017; 74 (1): 74-78

  Abstract

  To evaluate the comprehensiveness of plastic surgery program websites.American Medical Association interactive database was accessed for the list of integrated plastic surgery programs, in June 2015. Since then, 67 plastic surgery program websites were accessed and searched for the presence or absence of 31 criteria, which were further grouped into 5 categories: First, program contact information; second, training and research; third, program setup; fourth, benefits and facilities; and fifth, information for applicants. Programs were categorized based on US census bureau designated regions, and number of residency positions available. One-way ANOVA test was used for comparison.Only 25% (17) program website had information available on more than two-thirds (21 or more of 31) of the criteria. The 3 least factors commonly available by program websites were: operative log (10%), contract (10%), and information on night float (25%). The 3 most commonly available factors included: coordinator information (92%), number of residents (92%), and comprehensive faculty list (88%). Less than 50% of the programs provided information regarding fellowship opportunities, active and previous research projects, and operative logs. There was no difference in amount of information on program websites when analyzed for program size or program geographic location.Programs should consider revising their websites to include aforementioned 31 criteria. This would make applicants and potential resident physicians better informed of the programs before the interview process such that they would be more likely to apply to only those programs that match their specific aspirations.

  View details for DOI 10.1016/j.jsurg.2016.08.002

  View details for Web of Science ID 000392259200012

  View details for PubMedID 27717704

• Publication Trends in Craniofacial Distraction: A Bibliometrical Analysis JOURNAL OF CRANIOFACIAL SURGERY Hashmi, A., Schumaier, A., White, S., Yi, C., Khan, F. A., Hanba, C. J., Al-Mufarrej, F. 2017; 28 (1): 139-142

  Abstract

  The purpose of this study was to analyze the craniofacial distraction literature published over the last 50 years and to determine various trends in publications.A literature search was conducted in November and December 2015. The date search range was 1965 to 2015. Databases searched included Medline, Web of Science, Biosis, SciELO, Data Citation, and Zoologic Records. Data were collected on distraction type, author specialty, date of publication, country, state (if United States), number of citations, journal name, journal type, and Le Fort type (for midfacial distractions).Total number of craniofacial distraction publications was 1729. Cranial distraction accounted for (11%), midfacial (11%), and mandibular (78%). Largest increase in publications was in the 1990s, with 48 publications from 1991 to 1995 rising to 261 publications from 1996 to 2000. Among the cranial distraction publications, Plastic and Reconstructive Surgery (PRS) (67%) were the most frequent authors but among the midfacial and mandibular distraction publications, Oral and Maxillofacial Surgery (OMFS) were the most frequent authors (68% and 64%, respectively). Total number of citations was 26,281 with OMFS (50.4%) and PRS (37%) being cited most frequently. Oral and Maxillofacial Surgery was cited most for mandibular and midfacial distraction, and PRS was cited most for cranial distraction.Research on craniofacial distraction has significantly increased since the 1970s, with mandibular distraction accounting for the majority of this rise. Among specialties, OMFS and PRS account for the majority of the literature. The United States leads the publication. Authors tend to publish distraction literature in their corresponding journal specialty, with the exception of PRS who publishes most frequently in OMFS journals.

  View details for DOI 10.1097/SCS.0000000000003270

  View details for Web of Science ID 000392299200032

  View details for PubMedID 27922963

• No Place like Home: Is There Selection Bias in Plastic Surgery Residency Match Process? PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN Hashmi, A., Khan, F. A., Policherla, R., Hamamdjian, C. S., Al-Mufarrej, F. 2017; 5 (1): e1207

  View details for DOI 10.1097/GOX.0000000000001207

  View details for Web of Science ID 000427875600014

  View details for PubMedID 28203507

  View details for PubMedCentralID PMC5293305

• Extrahepatic biliary obstrution secondary to neuroendocrine tumor of the common hepatic duct INTERNATIONAL JOURNAL OF SURGERY CASE REPORTS Khan, F. A., Stevens-Chase, A., Chaudhry, R., Hashmi, A., Edelman, D., Weaver, D. 2017; 30: 46-49

  Abstract

  Primary neuroendocrine tumors (NET) of the extrahepatic biliary tree are a rare entity with less than 100 reported cases in the literature.Here, we report a case of NET of the extrahepatic bile duct in a 64-year-old male patient presenting with painless jaundice, direct hyperbilirubinemia, and mildly elevated transaminases. Diagnostic workup with an ultrasound revealed dilation of the intrahepatic biliary ducts, without cholelithiasis or choledocholithiasis. Additional cross sectional imaging identified a stricture at the confluence of the common hepatic and cystic duct junction. Given lack of additional findings presumptive diagnosis of localized klatskin's tumor was made. The patient subsequently underwent resection of the common bile duct and roux-en-y hepaticojejunostomy reconstruction. Final pathologic diagnosis showed G2 well-differentiated NET of the extrahepatic bile duct, measuring 1.3×1.1×1cm.When a patient is evaluated for a primary bile duct neoplasm, differentiation between cholangiocarcinoma and an unusual bile duct tumor, such as a NET is very difficult before surgical resection and histologic review.NET of the extrahepatic biliary tree are a rare entity. Typical presentation is with painless jaundice and other symptoms related to obstruction of the biliary tree and the diagnosis is usually made post-operatively.

  View details for DOI 10.1016/j.ijscr.2016.11.043

  View details for Web of Science ID 000397134800013

  View details for PubMedID 27902955

  View details for PubMedCentralID PMC5133469

• The role of pharmacological steroid therapy in preservation of renal function in severely injured patients requiring massive transfusion EUROPEAN JOURNAL OF TRAUMA AND EMERGENCY SURGERY Khan, F. A., Ledgerwood, A. M., Lucas, C. E. 2016; 42 (4): 477-481

  Abstract

  Glucocorticoids (GC) attenuate the post-insult inflammatory response and have been observed to confer end-organ protection following a variety of ischemic insults. We aim to assess this benefit on renal perfusion and function in injured patients requiring massive transfusion.The effect of pharmacologic methylprednisolone (MP) therapy was studied in 118 patients (pts), of whom 60, by random, received 1 g MP intraoperatively and 15 mg/kg for an additional 3 days. Postoperative measurements were made of effective renal plasma flow (ERPF), glomerular filtration by inulin (CIn), creatinine clearance (CCr) and clearances of osmoles (CCosm), sodium (CNa), and free water ([Formula: see text]). Continuous variables were compared between the two groups using the student's t test.Enrolled pts on average received 13.5 units of PRBCs with no differences in the resuscitation regimen. There were no statistically significant differences in the postoperative renal function as measured by ERPF (p = 0.57), CIn (p = 0.84), CCr (p = 0.99), CNa (p = 0.07), COsm (p = 0.95), and [Formula: see text] (p = 0.33). The incidence of renal compromise, as determined by an inulin clearance of <25 mL/min or serum creatinine greater than 3.0 mg/dL, was also similar. Three patients in the MP treatment group had renal compromise compared to one in the control group.In the absence of larger studies, this study demonstrates that GC likely have no role in preserving renal function in severely injured patients.

  View details for DOI 10.1007/s00068-015-0563-3

  View details for Web of Science ID 000380712500013

  View details for PubMedID 26253887

• Small bowel obstruction caused by self-anchoring suture used for peritoneal closure following robotic inguinal hernia repair JOURNAL OF SURGICAL CASE REPORTS Khan, F. A., Hashmi, A., Edelman, D. A. 2016

  Abstract

  Laparoscopic inguinal herniorraphy is a commonly performed procedure given the reported decrease in pain and earlier return to activity when compared with the open approach. Moreover, robotic assistance offers the operating surgeon considerable ergonomic advantages, making it an attractive alternative to conventional laparoscopic herniorraphy. Robotic herniorraphy utilizes the transabdominal preperitoneal approach where following repair peritoneal closure is necessary to avoid mesh exposure to the viscera. Self-anchoring sutures are frequently used to this end given the ease of use and knotless application. We present an unusual case of post-operative small bowel obstruction following robotic inguinal hernia repair caused by the self-anchoring suture used for peritoneal closure. This patient presented 3 days post-procedure with symptoms and cross-sectional imaging indicative of small bowel obstruction with a clear transition point. Underwent laparoscopic lysis of a single adhesive band originating from the loose intraperitoneal end of the suture leading to resolution of symptoms.

  View details for DOI 10.1093/jscr/rjw117

  View details for Web of Science ID 000381194200018

  View details for PubMedID 27340230

  View details for PubMedCentralID PMC4918405

• Necrotizing enterocolitis is associated with earlier achievement of enteral autonomy in children with short bowel syndrome JOURNAL OF PEDIATRIC SURGERY Sparks, E. A., Khan, F. A., Fisher, J. G., Fullerton, B. S., Hall, A., Raphael, B. P., Duggan, C., Modi, B. P., Jaksic, T. 2016; 51 (1): 92-95

  Abstract

  Necrotizing enterocolitis (NEC) remains one of the most common underlying diagnoses of short bowel syndrome (SBS) in children. The relationship between the etiology of SBS and ultimate enteral autonomy has not been well studied. This investigation sought to evaluate the rate of achievement of enteral autonomy in SBS patients with and without NEC.Following IRB approval, 109 patients (2002-2014) at a multidisciplinary intestinal rehabilitation program were reviewed. The primary outcome evaluated was achievement of enteral autonomy (i.e. fully weaning from parenteral nutrition). Patient demographics, primary diagnosis, residual small bowel length, percent expected small bowel length, median serum citrulline level, number of abdominal operations, status of the ileocecal valve (ICV), presence of ileostomy, liver function tests, and treatment for bacterial overgrowth were recorded for each patient.Median age at PN onset was 0 weeks [IQR 0-0]. Median residual small bowel length was 33.5 cm [IQR 20-70]. NEC was present in 37 of 109 (33.9%) of patients. 45 patients (41%) achieved enteral autonomy after a median PN duration of 15.3 [IQR 7.2-38.4]months. Overall, 64.9% of patients with NEC achieved enteral autonomy compared to 29.2% of patients with a different primary diagnosis (p=0.001, Fig. 1). Patients with NEC remained more likely than those without NEC to achieve enteral autonomy after two (45.5% vs. 12.0%) and four (35.7% vs. 6.3%) years on PN (Fig. 1). Logistic regression analysis demonstrated the following parameters as independent predictors of enteral autonomy: diagnosis of NEC (p<0.002), median serum citrulline level (p<0.02), absence of a jejunostomy or ileostomy (p=0.013), and percent expected small bowel length (p=0.005).Children with SBS because of NEC have a significantly higher likelihood of fully weaning from parenteral nutrition compared to children with other causes of SBS. Additionally, patients with NEC may attain enteral autonomy even after long durations of parenteral support.

  View details for DOI 10.1016/j.jpedsurg.2015.10.023

  View details for Web of Science ID 000367696600018

  View details for PubMedID 26700691

  View details for PubMedCentralID PMC4878438

• Factors Affecting Spontaneous Closure of Gastrocutaneous Fistulae After Removal of Gastrostomy Tubes in Children With Intestinal Failure JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Khan, F. A., Fisher, J. G., Sparks, E. A., Iglesias, J., Zurakowski, D., Modi, B. P., Duggan, C., Jaksic, T. 2015; 39 (7): 860-863

  Abstract

  Children with intestinal failure (IF) frequently require gastrostomy tubes (GTs) for long-term nutrition support. Risk factors for persistent gastrocutaneous fistulae (GCFs) in pediatric patients with IF are largely unknown but may include underlying nutrition status and duration of indwelling GT.Records of patients with IF having undergone GT removal and allowed a trial at spontaneous closure were reviewed. Nonparametric continuous variables were analyzed using the Wilcoxon rank sum test. Post hoc analysis was performed to identify the optimal threshold of GT duration predicting probability of spontaneous closure identified using receiver operating characteristic curve analysis.Fifty-nine children with IF undergoing GT removal were identified. Spontaneous closure occurred in 36 (61%) sites, while 23 (39%) underwent operative closure at a median 67 days after GT removal. The duration of indwelling GT was significantly shorter in the spontaneous closure group (11.5 vs 21 months, P = .002). Of 33 GT indwelling for ≤ 18 months, 28 (85%) closed spontaneously, compared with only 9 of 26 (35%) with duration >18 months (P < .001). With GCF persisting beyond 7 days, only 21% (6/28) of sites closed spontaneously, but this dropped to 6% (1/18) of cases with concurrent GT duration >18 months.Of the risk factors evaluated, only prolonged GT duration was associated with an increased likelihood of failure to close spontaneously. It is significantly less likely in pediatric patients with IF in whom GCF persists >7 days, particularly if the duration of GT is >18 months. Relatively earlier operative closure should be considered in this group.

  View details for DOI 10.1177/0148607114538058

  View details for Web of Science ID 000360413700014

  View details for PubMedID 24993864

  View details for PubMedCentralID PMC4625387

• Tight Glycemic Control With Insulin Does Not Affect Skeletal Muscle Degradation During the Early Postoperative Period Following Pediatric Cardiac Surgery PEDIATRIC CRITICAL CARE MEDICINE Fisher, J. G., Sparks, E. A., Khan, F. A., Alexander, J. L., Asaro, L. A., Wypij, D., Gaies, M., Modi, B. P., Duggan, C., Agus, M. D., Yu, Y., Jaksic, T. 2015; 16 (6): 515-521

  Abstract

  Critical illness is associated with significant catabolism, and persistent protein loss correlates with increased morbidity and mortality. Insulin is a potent anticatabolic hormone; high-dose insulin decreases skeletal muscle protein breakdown in critically ill pediatric surgical patients. However, insulin's effect on protein catabolism when given at clinically utilized doses has not been studied. The objective was to evaluate the effect of postoperative tight glycemic control and clinically dosed insulin on skeletal muscle degradation in children after cardiac surgery with cardiopulmonary bypass.Secondary analysis of a two-center, prospective randomized trial comparing tight glycemic control with standard care. Randomization was stratified by study center.Children 0-36 months who were admitted to the ICU after cardiac surgery requiring cardiopulmonary bypass.In the tight glycemic control arm, insulin was titrated to maintain blood glucose between 80 and 110 mg/dL. Patients in the control arm received standard care. Skeletal muscle breakdown was quantified by a ratio of urinary 3-methylhistidine to urinary creatinine.A total of 561 patients were included: 281 in the tight glycemic control arm and 280 receiving standard care. There was no difference in 3-methylhistidine to creatinine between groups (tight glycemic control, 249 ± 127 vs standard care, 253 ± 112, mean ± SD in μmol/g; p = 0.72). In analyses restricted to the patients in tight glycemic control arm, higher 3-methylhistidine to creatinine correlated with younger age, as well as lower weight, weight-for-age z score, length, and body surface area (p < 0.005 for each) and lower postoperative day 3 serum creatinine (r = -0.17; p = 0.02). Sex, prealbumin, and albumin were not associated with 3-methylhistidine to creatinine. During urine collection, 245 patients (87%) received insulin. However, any insulin exposure did not impact 3-methylhistidine to creatinine (t test, p = 0.45), and there was no dose-dependent effect of insulin on 3-methylhistidine to creatinine (r = -0.03; p = 0.60).Although high-dose insulin has an anabolic effect in experimental conditions, at doses necessary to achieve normoglycemia, insulin appears to have no discernible impact on skeletal muscle degradation in critically ill pediatric cardiac surgical patients.

  View details for DOI 10.1097/PCC.0000000000000413

  View details for Web of Science ID 000358289700003

  View details for PubMedID 25850865

  View details for PubMedCentralID PMC4497866

• Predictors of Enteral Autonomy in Children with Intestinal Failure: A Multicenter Cohort Study JOURNAL OF PEDIATRICS Khan, F. A., Squires, R. H., Litman, H. J., Balint, J., Carter, B. A., Fisher, J. G., Horslen, S. P., Jaksic, T., Kocoshis, S., Martinez, J., Mercer, D., Rhee, S., Rudolph, J. A., Soden, J., Sudan, D., Superina, R. A., Teitelbaum, D. H., Venick, R., Wales, P. W., Duggan, C., Pediat Intestinal Failure Consorti 2015; 167 (1): 29-U379

  Abstract

  In a large cohort of children with intestinal failure (IF), we sought to determine the cumulative incidence of achieving enteral autonomy and identify patient and institutional characteristics associated with enteral autonomy.A multicenter, retrospective cohort analysis from the Pediatric Intestinal Failure Consortium was performed. IF was defined as severe congenital or acquired gastrointestinal diseases during infancy with dependence on parenteral nutrition (PN) >60 days. Enteral autonomy was defined as PN discontinuation >3 months.A total of 272 infants were followed for a median (IQR) of 33.5 (16.2-51.5) months. Enteral autonomy was achieved in 118 (43%); 36 (13%) remained PN dependent and 118 (43%) patients died or underwent transplantation. Multivariable analysis identified necrotizing enterocolitis (NEC; OR 2.42, 95% CI 1.33-4.47), care at an IF site without an associated intestinal transplantation program (OR 2.73, 95% CI 1.56-4.78), and an intact ileocecal valve (OR 2.80, 95% CI 1.63-4.83) as independent risk factors for enteral autonomy. A second model (n = 144) that included only patients with intraoperatively measured residual small bowel length found NEC (OR 3.44, 95% CI 1.36-8.71), care at a nonintestinal transplantation center (OR 6.56, 95% CI 2.53-16.98), and residual small bowel length (OR 1.04 cm, 95% CI 1.02-1.06 cm) to be independently associated with enteral autonomy.A substantial proportion of infants with IF can achieve enteral autonomy. Underlying NEC, preserved ileocecal valve, and longer bowel length are associated with achieving enteral autonomy. It is likely that variations in institutional practices and referral patterns also affect outcomes in children with IF.

  View details for DOI 10.1016/j.jpeds.2015.03.040

  View details for Web of Science ID 000362453900010

  View details for PubMedID 25917765

  View details for PubMedCentralID PMC4485931

• Paget-Schroetter Syndrome in 21 Children: Outcomes after Multidisciplinary Care JOURNAL OF PEDIATRICS Trenor, C. C., Fisher, J. G., Khan, F. A., Sparks, E. A., Duzan, J., Harney, K., Dillon, B., Menard, M., Modi, B. P. 2015; 166 (6): 1493-+

  Abstract

  To review the presentation, management, and outcomes of Paget-Schroetter syndrome (PSS) in children and propose a multidisciplinary treatment algorithm involving pediatric and vascular surgery, interventional radiology, and hematology.Patients with PSS presenting between 2003 and 2013 were reviewed. Demographics, symptoms, therapies, and functional outcomes were noted. Data from early patients informed the development of a multidisciplinary treatment algorithm applied to later patients.Of 21 patients, mean ± SD age was 16 ± 1.6 years and 11 (52%) were male. Of patients with complete presentation data, common symptoms were edema (84%), discoloration (58%), and pain (58%). Thrombophilia workup revealed one heterozygote for factor V Leiden, 2 patients with factor VIII elevation and 1 patient with mildly low antithrombin. The most recent 8 patients were treated according to an algorithm developed by a multidisciplinary working group through experience with the first 13 cases. All patients underwent a venogram, endovascular intervention (including 15 receiving catheter-directed thrombolysis), and operative ipsilateral thoracic outlet decompression (first rib resection, anterior scalenectomy, and venolysis). Postoperative complications included hemothorax (2), pneumothorax (1), and recurrent thrombosis (2). Follow up duration was 12 ± 9.5 months. Symptoms recurred transiently in 1 patient.Pediatric patients with PSS can be treated successfully using a multidisciplinary treatment algorithm including anticoagulation, catheter-directed thrombolysis, and operative decompression of the thoracic outlet. Early outcomes are promising.

  View details for DOI 10.1016/j.jpeds.2015.03.030

  View details for Web of Science ID 000355018200031

  View details for PubMedID 25882874

• Extraluminal distraction enterogenesis using shape-memory polymer Fisher, J. G., Sparks, E. A., Khan, F. A., Dionigi, B., Wu, H., Brazzo, J., Fauza, D., Modi, B., Safranski, D. L., Jaksic, T. W B SAUNDERS CO-ELSEVIER INC. 2015: 938-942

  Abstract

  Although a few techniques for lengthening intestine by mechanical stretch have been described, they are relatively complex, and the majority involve placement of an intraluminal device. Ideally, techniques applicable to humans would be easy to perform and extraluminal to avoid the potential for mucosal injury. This study of distraction enterogenesis used an extraluminal, radially self-expanding shape-memory polymer cylinder and a simple operative approach to both elongate intestine and grow new tissue.Young Sprague Dawley rats (250-350 g) underwent Roux-en-Y isolation of a small intestinal limb and were divided in three groups: no further manipulation (Control 1, C1); placement of a nonexpanding device (Control 2, C2); or placement of a radially expanding device by the limb (Experimental, Exp). For C2 and Exp animals, the blind end of the limb was wrapped around the radially expanding cylindrical device with the limb-end sutured back to the limb-side. Bowel length was measured at operation and at necropsy (14 days) both in-situ and ex-vivo under standard tension (6g weight). Change in length is shown as mean ± standard deviation. A blinded gastrointestinal pathologist reviewed histology and recorded multiple measures of intestinal adaptation. The DNA to protein ratio was quantified as a surrogate for cellular proliferation. Changes in length, histologic measures, and DNA:protein were compared using analysis of variance, with significance set at P<0.05.The length of the Roux limb in situ increased significantly in Exp animals (n=8, 29.0 ± 5.8mm) compared with C1 animals (n=5, -11.2 ± 9.0mm, P<0.01). The length of the Roux limb ex vivo under standard tension increased in the Exp group (25.8 ± 4.2mm) compared with the C2 group (n=6, -4.3 ± 6.0, P<0.01). There were no differences in histologic measures of bowel adaptation between the groups, namely villous height and width, crypt depth, crypt density, and crypt fission rate (all P ≥ 0.08). Muscularis mucosal thickness was also not different (P=0.25). There was no difference in DNA:protein between groups (P=0.47).An extraluminally placed, radially expanding shape-memory polymer cylinder successfully lengthened intestine, without damaging mucosa. Lack of difference in muscularis thickness and a constant DNA:protein ratio suggests that this process may be related to actual growth rather than mere stretch. This study demonstrated a simple approach that warrants further study aiming at potential clinical applicability.

  View details for DOI 10.1016/j.jpedsurg.2015.03.013

  View details for Web of Science ID 000354551700011

  View details for PubMedID 25812443

• Serious Congenital Heart Disease and Necrotizing Enterocolitis in Very Low Birth Weight Neonates JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Fisher, J. G., Bairdain, S., Sparks, E. A., Khan, F. A., Archer, J. M., Kenny, M., Edwards, E. M., Soll, R. F., Modi, B. P., Yeager, S., Horbar, J. D., Jaksic, T. 2015; 220 (6): 1018-1026

  Abstract

  Infants with serious congenital heart disease (CHD) appear to be at increased risk for necrotizing enterocolitis (NEC). This study aimed to quantify the incidence and mortality of NEC among very low birth weight (VLBW) neonates with serious CHD, and identify specific CHD diagnoses at the highest risk for developing NEC.Data were prospectively collected on 257,794 VLBW (401 to 1,500 g) neonates born from 2006 to 2011 and admitted to 674 Vermont Oxford Network US centers. Entries were coded for specific CHD diagnoses and reviewed for completeness and consistency. Survival was defined as alive in-hospital at 1 year or discharge.Of eligible neonates, 1,931 had serious CHD. Of these, 253 (13%) developed NEC (vs 9% in infants without CHD, adjusted odds ratio [AOR] 1.80, p<0.0001). Mortality for neonates with CHD and no NEC was 34%, vs 55% for those with CHD and NEC (p<0.0001). Both groups of CHD patients had higher mortality than infants with NEC without CHD (28%, p<0.0001). Although NEC mortality overall decreases with higher birth weight, mortality for NEC and CHD together does not.The incidence of NEC is significantly higher in VLBW neonates when CHD is present. The mortality of CHD and NEC together is substantially higher than that with each disease alone. Infants with atrioventricular canal appear to have higher risk for developing NEC than other CHD diagnoses. In addition to providing benchmark incidence and mortality data, these findings may have utility in the further study of the pathophysiology of NEC.

  View details for DOI 10.1016/j.jamcollsurg.2014.11.026

  View details for Web of Science ID 000354826900012

  View details for PubMedID 25868405

• Preservation of Biochemical Liver Function With Low-Dose Soy-Based Lipids in Children With Intestinal Failure-Associated Liver Disease JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION Khan, F. A., Fisher, J. G., Sparks, E. A., Potemkin, A., Duggan, C., Raphael, B. P., Modi, B. P., Jaksic, T. 2015; 60 (3): 375-377

  Abstract

  Intestinal failure-associated liver disease (IFALD) contributes to significant morbidity in pediatric patients with intestinal failure (IF); however, the use of parenteral nutrition (PN) with a fish oil-based intravenous (IV) emulsion (FO) has been associated with biochemical reversal of cholestasis and improved outcomes. Unfortunately, FO increases the complexity of care: because it can be administered only under Food and Drug Administration compassionate use protocols requiring special monitoring, it is not available as a 3-in-1 solution and is more expensive than comparable soy-based IV lipid emulsion (SO). Because of these pragmatic constraints, a series of patient families were switched to low-dose (1 g kg(-1) day(-1)) SO following biochemical resolution of cholestasis. The present study examines whether reversal of cholestasis and somatic growth are maintained following this transition.The present study is a chart review of all children with IFALD who switched from FO to SO following resolution of cholestasis. Variables are presented as medians (interquartile ranges). Comparisons were performed using the Wilcoxon signed-rank test.Seven patients ages 25.9 (16.2-43.2) months were transitioned to SO following reversal of cholestasis using FO. At a median follow-up of 13.9 (4.3-50.1) months, there were no significant differences between pretransition and post-transition serum alanine and aspartate aminotransferases, direct bilirubin, and weight-for-age z scores. Because of recurrence of cholestasis, 1 patient was restarted on FO after 4 months on SO.Biochemical reversal of IFALD and growth were preserved after transition from FO to SO in 6 of 7 (86%) patients. Given the challenges associated with the use of FO, SO may be a viable alternative in select patients with home PN.

  View details for DOI 10.1097/MPG.0000000000000609

  View details for Web of Science ID 000350527100021

  View details for PubMedID 25714580

  View details for PubMedCentralID PMC4341952

• Operative indications in recurrent ileocolic intussusception JOURNAL OF PEDIATRIC SURGERY Fisher, J. G., Sparks, E. A., Turner, C. B., Klein, J. D., Pennington, E., Khan, F. A., Zurakowski, D., Durkin, E. T., Fauza, D. O., Modi, B. P. 2015; 50 (1): 126-130

  Abstract

  Air-contrast enema (ACE) is standard treatment for primary ileocolic intussusception. Management of recurrences is less clear. This study aimed to delineate appropriate therapy by quantifying the relationship between recurrence and need for bowel resection, pathologic lead points (PLP), and complication rates.After IRB approval, a single institution review of patients with ileocolic intussusception from 1997 to 2013 was performed, noting recurrences, outcomes, and complications. Fisher's exact and t-tests were used.Of 716 intussusceptions, 666 were ileocecal. Forty-four underwent bowel resection, with 29 PLPs and 9 ischemia/perforation. Recurrence after ACE occurred in 96 (14%). Recurrence did not predict PLP (P=0.25). Recurrence (≥3) was associated with higher resection rate (P=0.03), but not ischemia/perforation (P=0.75). ACE-related complications occurred in 4 (0.5%) patients. Successful initial ACE had 98% negative predictive value for resection and PLP (e.g., after successful ACE, 2% had resections, 2% PLP). After failed initial ACE, 36% received resection, and 23% had PLP (P<0.001).Recurrence is associated with a greater risk of resection but not PLP or ACE-complication. Failed ACE is associated with increased risk for harboring PLP and receiving resection. ACE should be the standard treatment in recurrent intussusception, regardless of number of recurrences.

  View details for DOI 10.1016/j.jpedsurg.2014.10.012

  View details for Web of Science ID 000348043500026

  View details for PubMedID 25598108

• Nutritional outcomes in survivors of congenital diaphragmatic hernia (CDH)-Factors associated with growth at one year JOURNAL OF PEDIATRIC SURGERY Bairdain, S., Khan, F. A., Fisher, J., Zurakowski, D., Ariagno, K., Cauley, R. P., Zalieckas, J., Wilson, J. M., Jaksic, T., Mehta, N. M. 2015; 50 (1): 74-77

  Abstract

  Malnutrition is prevalent among congenital diaphragmatic hernia (CDH) survivors. We aimed to describe the nutritional status and factors that impact growth over the 12-months following discharge from the pediatric intensive care unit (PICU) in this cohort.CDH survivors, who were discharged from the PICU from 2000 to 2010 with follow-up of at least 12months, were included. Nutritional intake, anthropometric, and clinical variables were recorded. Multivariable linear regression was used to determine factors associated with weight-for-age Z-scores (WAZ) at 12months.Data from 110 infants, 67% male, 50% patch repair, were analyzed. Median (IQR) WAZ for the cohort was -1.4 (-2.4 to -0.3) at PICU discharge and -0.4 (-1.3 to 0.2) at 12-months. The percentage of infants with significant malnutrition (WAZ<-2) decreased from 26% to 8.5% (p<0.001). Patch repair (p=0.009), protein intake<2.3g/kg/day (p=0.014), and birth weight (BW)<2.5kg (p<0.001) were associated with lower WAZ at 12-months.CDH survivors had a significantly improved nutritional status in the 12-months after PICU discharge. Patch repair, lower BW, and inadequate protein intake were significant predictors of lower WAZ at 12-months. A minimum protein intake in the PICU of 2.3g/kg/day was essential to ensure optimal growth in this cohort.

  View details for DOI 10.1016/j.jpedsurg.2014.10.003

  View details for Web of Science ID 000348043500015

  View details for PubMedID 25598097

• Metabolic bone disease in pediatric intestinal failure patients: Prevalence and risk factors Khan, F. A., Fisher, J. G., Bairdain, S., Sparks, E. A., Zurakowski, D., Modi, B. P., Duggan, C., Jaksic, T. W B SAUNDERS CO-ELSEVIER INC. 2015: 136-139

  Abstract

  Patients with intestinal failure (IF) are known to have impaired absorption of nutrients required for maintenance of skeletal mass. Rates and risk factors of low bone mineral density (BMD) are unknown in pediatric IF patients.Following IRB approval, patients with IF having undergone DXA scans were identified and laboratory, clinical, and nutritional intake variables were recorded. Low BMD was defined by a z-score of less than or equal to -2.0. Univariate followed by multivariable regression analysis was performed.Sixty-five patients underwent a total of 99 routine DXA scans. Twenty-seven (41%) had vitamin D deficiency, 22 (34%) had low BMD, and nineteen (29%) had a history of fractures. Variables noted to be associated with low BMD (p<0.1) on univariate analysis were considered for multivariable regression. Multivariable regression identified WAZ and serum calcium levels (p<0.05) as independent predictors of low BMD z-score. None of the other evaluated factors were associated with the risk of low BMD. Low BMD was not associated with risk of fractures.There is a significant incidence of low BMD in children with IF. WAZ and lower serum calcium levels are associated with risk of low BMD. Additional long term prospective studies are needed to further characterize the risk factors associated with low BMD.

  View details for DOI 10.1016/j.jpedsurg.2014.10.010

  View details for Web of Science ID 000348043500028

  View details for PubMedID 25598110

  View details for PubMedCentralID PMC4620573

• Patterns of surgical practice in very low birth weight neonates born in the United States: a Vermont Oxford Network analysis JOURNAL OF PEDIATRIC SURGERY Sparks, E. A., Gutierrez, I. M., Fisher, J. G., Khan, F. A., Kang, K., Morrow, K. A., Soll, R. F., Edwards, E. M., Horbar, J. D., Jaksic, T., Modi, B. P. 2014; 49 (12): 1821-+

  Abstract

  The distribution of surgical care of very low birth weight (VLBW) neonates among centers with varying specialized care remains unknown. This study quantifies operations performed on VLBW neonates nationally with respect to center type.VLBW neonates born 2009-2012 were assessed using a prospectively collected multi-center database encompassing 80% of all VLBW neonates in the United States. Surgical centers were categorized based on availability of pediatric surgery (PS) and anesthesia (PA).48,711 major procedures (29,512 abdominal operations) were performed on 24,318 neonates. Of all patients, 20,892 (85.9%) underwent surgery at centers with PS and PA available on site. 1663 (6.8%) patients were treated at centers with neither specialty on site. Neonates requiring complex operations were more likely to receive surgery at centers with both PS and PA on staff than those requiring non-complex operations (95.6% vs 93.6%).This study confirms that most operations on VLBW neonates in the U.S. are performed at centers with pediatric surgeons and anesthesiologists on staff. Further research is necessary, however, to elucidate why a significant minority of this challenging population continues to be managed at centers without pediatric specialists.

  View details for DOI 10.1016/j.jpedsurg.2014.09.032

  View details for Web of Science ID 000345965000029

  View details for PubMedID 25487492

• Magnitude of surgical burden associated with pediatric intestinal failure: A multicenter cohort analysis JOURNAL OF PEDIATRIC SURGERY Khan, F. A., Mitchell, P. D., Fisher, J. G., Sparks, E. A., Jaksic, T., Duggan, C., Teitelbaum, D. H., Modi, B. P., Pediat Intestinal Failure Consorti 2014; 49 (12): 1795-1798

  Abstract

  Pediatric intestinal failure (IF) patients require many surgical procedures over the course of their illness. The number and variety of surgical procedures, as well as patient characteristics associated with this burden of surgical procedures, remain largely unknown.Data from a large, multicenter retrospective study of pediatric intestinal failure (PIFCON) were reviewed. Infants from 14 multidisciplinary IF programs were enrolled, with study entry defined as PN dependence for >60days.A total of 272 infants were followed for a median (IQR) of 33.5 (16.2, 51.5) months, during which time they underwent 4.0 (3.0, 6.0) abdominal surgical procedures. Intestinal resections were performed in 88/97 (92%) necrotizing enterocolitis patients versus 138/175 (80%) in non-NEC patients (P<0.05). Patients who underwent ≥5 operations had more septic events, compared to those who underwent ≤2 operations (3 (1, 6) versus 1 (0, 3), respectively, P<0.01). Patients treated at centers with transplantation capability had lower odds of undergoing >2 abdominal operations [OR 0.37 (95% CI: 0.21, 0.65)] after multivariable adjustment.Individual and center-specific characteristics may help determine surgical practices experienced by infants with IF. Further study may delineate additional details about the nature of these characteristics, with the goal of optimizing patient care and minimizing individual and overall healthcare burden.

  View details for DOI 10.1016/j.jpedsurg.2014.09.026

  View details for Web of Science ID 000345965000023

  View details for PubMedID 25487486

  View details for PubMedCentralID PMC4620568

• A Modern Cohort of Duodenal Obstruction Patients: Predictors of Delayed Transition to Full Enteral Nutrition JOURNAL OF NUTRITION AND METABOLISM Bairdain, S., Yu, D. C., Lien, C., Khan, F., Pathak, B., Grabowski, M. J., Zurakowski, D., Linden, B. C. 2014; 2014: 850820

  Abstract

  Background. A common site for neonatal intestinal obstruction is the duodenum. Delayed establishment of enteral nutritional autonomy continues to challenge surgeons and, since early institution of nutritional support is critical in postoperative newborns, identification of patients likely to require alternative nutritional support may improve their outcomes. Therefore, we aimed to investigate risk factors leading to delayed establishment of full enteral nutrition in these patients. Methods. 87 patients who were surgically treated for intrinsic duodenal obstructions from 1998 to 2012 were reviewed. Variables were tested as potential risk factors. Median time to full enteral nutrition was estimated using the Kaplan-Meier method. Independent risk factors of delayed transition were identified using the multivariate Cox proportional hazards regression model. Results. Median time to transition to full enteral nutrition was 12 days (interquartile range: 9-17 days). Multivariate Cox analysis identified three significant risk factors for delayed enteral nutrition: gestational age (GA) ≤ 35 weeks (P < .001), congenital heart disease (CHD) (P = .02), and malrotation (P = .03). Conclusions. CHD and Prematurity are most commonly associated with delayed transition to full enteral nutrition. Thus, in these patients, supportive nutrition should strongly be considered pending enteral nutritional autonomy.

  View details for DOI 10.1155/2014/850820

  View details for Web of Science ID 000214826300021

  View details for PubMedID 25210625

  View details for PubMedCentralID PMC4150512

• Predictive model of blood transfusion during CABG surgery in Pakistan. JPMA. The Journal of the Pakistan Medical Association Shoukat, S., Gowani, S. A., Khimani, F., Khan, F. A., Zaman, M., Sharif, H. 2008; 58 (8): 421-6

  Abstract

  OBJECTIVE: To determine predictors of need for transfusion of blood and blood products and create a clinical predictive model to reduce indiscriminate use of blood products during surgery.METHOD: We conducted a retrospective chart review of 485 patients who underwent coronary artery bypass surgery from January 2004 to December 2004 at a Tertiary Care Hospital in Karachi, Pakistan. Independent predictors associated with transfusion were identified and a clinical prediction model developed.RESULTS: The transfusion rate was 37.1%. A predictive model was created based on the presence of pulmonary disease, diabetes mellitus, low ejection fraction and recent/ongoing myocardial infarction.CONCLUSION: The study identifies some predictors of need for blood transfusion in patients undergoing Coronary Artery Bypass Grafting. However, prospective studies with a larger sample of patients are needed to determine other predictors and their applicability in patient selection across institutions.

  View details for PubMedID 18822637