Stephen Shew

All Publications

• Standardized perioperative care reduces colorectal surgical site infection in children: A Western Pediatric Surgery Research Consortium Multicenter analysis. Journal of pediatric surgery Tobias, J., Padilla, B. E., Lee, J., Chen, S., Wang, K. S., Kelley-Quon, L. I., Mueller, C., Shew, S. B., Joskowitz, K., Ignacio, R. C., Evans, L. L., Jensen, A. R., Acker, S. N., Mason, A., Johnson, A., McConahey, J., Hansen, E., Pandya, S. R., Short, S. S., Russell, K. W., Nicassio, L., Smith, C. A., Fialkowski, E. 2022

  Abstract

  PURPOSE: Surgical site infection (SSI) remains a significant source of patient morbidity and resource utilization in children undergoing colorectal surgery. We examined the utility of a protocolized perioperative care bundle in reducing SSI in pediatric patients undergoing colorectal surgery.METHODS: We conducted a prospective cohort study of patients ≤18 years of age undergoing colorectal surgery at ten United States children's hospitals. Using a perioperative care protocol comprising eight elements, or "colon bundle", we divided patients into low (1-4 elements) or high (5-8 elements) compliance cohorts. Procedures involving colorectal repair or anastomosis with abdominal closure were included. Demographics and clinical outcomes were compared between low and high compliance cohorts. Compliance was compared with a retrospective cohort. The primary outcome was superficial SSI incidence at 30 days.RESULTS: Three hundred and thirty-six patients were included in our analysis: 138 from the low compliance cohort and 198 from the high compliance cohort. Age and gender were similar between groups. Preoperative diagnosis was similar except for more patients in the high compliance cohort having inflammatory bowel disease (18.2% versus 5.8%, p<0.01). The most common procedure performed was small bowel to colorectal anastomosis. Wound classification and procedure acuity were similar between groups. Superficial SSI at 30 days occurred less frequently among the high compliance compared to the low compliance cohort (4% versus 9.7%, p=0.036). Median postoperative length of stay and 30-day rates of readmission, reoperation, intra-abdominal abscess and anastomotic leak requiring operation were not significantly different between groups. None of the individual colon bundle elements were independently protective against superficial SSI.CONCLUSION: Standardization of perioperative care is associated with a reduction in superficial SSI in pediatric colorectal surgery. Expansion of standardized protocols for children undergoing colorectal surgery may improve outcomes and decrease perioperative morbidity.TYPE OF STUDY: Clinical Research Paper LEVEL OF EVIDENCE: Level II.

  View details for DOI 10.1016/j.jpedsurg.2022.09.026

  View details for PubMedID 36289033

• Multi-Institutional Quality Improvement Project to Minimize Opioid Prescribing in Children after Appendectomy Using NSQIP-Pediatric. Journal of the American College of Surgeons Kelley-Quon, L. I., Ourshalimian, S., Lee, J., Russell, K. W., Kling, K., Shew, S. B., Mueller, C., Jensen, A. R., Vu, L., Padilla, B., Ostlie, D., Smith, C., Inge, T., Roach, J., Ignacio, R., Lofberg, K., Radu, S., Rohan, A., Wang, K. S. 2022; 234 (3): 290-298

  Abstract

  BACKGROUND: There is wide variation in opioid prescribing after appendectomy in children and adolescents, with recent increases noted in opioid-related pediatric deaths from prescription and illicit opioids. The goal of this project was to minimize opioid prescribing at the time of discharge for children undergoing appendectomy by using Quality Improvement (QI) methodology.STUDY DESIGN: Children (18 years of age or less) who underwent appendectomy were evaluated from January to December 2019 using NSQIP-Pediatric at 10 children's hospitals within the Western Pediatric Surgery Research Consortium. Before project initiation, 5 hospitals did not routinely prescribe opioids after appendectomy (protocol). At the remaining 5 hospitals, prescribing was not standardized and varied by surgeon (no-protocol). A prospective multi-institutional QI project was used to minimize outpatient opioid prescriptions for children after appendectomy. The proportion of children at each hospital receiving an opioid prescription at discharge was compared for 6 months before and after the intervention using chi-square analysis.RESULTS: Overall, 1,524 children who underwent appendectomy were evaluated from January to December 2019. After the QI intervention, overall opioid prescribing decreased from 18.2% to 4.0% (p < 0.001), with significant decreases in protocol hospitals (2.7% vs 0.8%, p = 0.038) and no-protocol hospitals (37.9% vs 8.8%, p < 0.001). The proportion of 30-day emergency room visits did not change after the QI intervention (8.9% vs 9.9%, p = 0.54) and mean postintervention pain management satisfaction scores were high.CONCLUSION: Opioid prescribing can be minimized in children after appendectomy without increasing emergency room visits or decreasing patient satisfaction. Furthermore, NSQIP-Pediatric can be used as a platform for multi-institutional collaboration for successful implementation of QI projects.

  View details for DOI 10.1097/XCS.0000000000000056

  View details for PubMedID 35213491

• Barriers and facilitators of ct scan reduction in the workup of pediatric appendicitis: A pediatric surgical quality collaborative qualitative study. Journal of pediatric surgery Hu, A., Chaudhury, A. S., Fisher, T., Garcia, E., Berman, L., Tsao, K., Mackow, A., Shew, S. B., Johnson, J., Rangel, S., Lally, K. P., Raval, M. V. 1800

  Abstract

  INTRODUCTION: Despite ongoing efforts to decrease ionizing radiation exposure from computed tomography (CT) use in pediatric appendicitis, high CT utilization rates are still observed across many hospitals. This study aims to identify factors influencing CT use and facilitators and barriers to quality improvement efforts.METHODS: The Pediatric Surgery Quality Collaborative is a voluntary consortium of 42 children's hospitals participating in the National Surgical Quality Improvement Project - Pediatric. Hospitals were compared based on CT utilization from January 1, 2019, to December 31, 2019. Semi-structured interviews were conducted with surgeons, radiologists, emergency medicine physicians, and clinical data abstractors from 7 hospitals with low CT use rates (high performers) and 6 hospitals with high CT use rates (low performers). A mixed deductive and inductive coding approach for analysis of the interview transcripts was used to develop a codebook based on the Theoretical Domains Framework and subsequently identify prominent barriers and facilitators to CT reduction.RESULTS: Thematic saturation was achieved after 13 interviews. We identified four factors that distinguish high-performing from low-performing hospitals: (1) consistent availability of resources such as ultrasound technicians, pediatric radiologists, and magnetic resonance imaging (MRI); (2) presence of and adherence to protocols guiding imaging modality decision making and imaging execution; (3) culture of inter-departmental collaboration; and (4) presence of a radiation reduction champion.CONCLUSIONS: Significant barriers to reducing the use of CT in pediatric appendicitis exist. Our findings highlight that future quality improvement efforts should target resource availability, protocol adherence, collaborative culture, and radiation reduction champions.

  View details for DOI 10.1016/j.jpedsurg.2021.11.026

  View details for PubMedID 34972565

• The need for early Kasai portoenterostomy: a Western Pediatric Surgery Research Consortium study. Pediatric surgery international Kelley-Quon, L. I., Shue, E., Burke, R. V., Smith, C., Kling, K., Mahdi, E., Ourshalimian, S., Fenlon, M., Dellinger, M., Shew, S. B., Lee, J., Padilla, B., Inge, T., Roach, J., Marwan, A. I., Russell, K. W., Ignacio, R., Fialkowski, E., Nijagal, A., Im, C., Azarow, K. S., Ostlie, D. J., Wang, K. 2021

  Abstract

  PURPOSE: The purpose of this study was to investigate factors impacting transplant-free survival among infants with biliary atresia.METHODS: A multi-institutional, retrospective cohort study was performed at nine tertiary-level children's hospitals in the United States. Infants who underwent Kasai portoenterostomy (KP) from January 2009 to May 2017 were identified. Clinical characteristics included age at time of KP, steroid use, surgical approach, liver pathology, and surgeon experience. Likelihood of transplant-free survival (TFS) was evaluated using logistic regression, adjusting for patient and surgeon-level factors. Secondary outcomes at 1 year included readmission, cholangitis, reoperation, mortality, and biliary clearance.RESULTS: Overall, 223 infants underwent KP, and 91 (40.8%) survived with their native liver. Mean age at surgery was 63.9 days (±24.7 days). At 1 year, 78.5% experienced readmission, 56.9% developed cholangitis, 3.8% had a surgical revision, and 5 died. Biliary clearance at 3months was achieved in 76.6%. Controlling for patient and surgeon-level factors, each additional day of age toward operation was associated with a 2% decrease in likelihood of TFS (OR 0.98, 95% CI 0.97-0.99).CONCLUSION: Earlier surgical intervention by Kasai portoenterostomy at tertiary-level centers significantly increases likelihood for TFS. Policy-level interventions to facilitate early screening and surgical referral for infants with biliary atresia are warranted to improve outcomes.

  View details for DOI 10.1007/s00383-021-05047-1

  View details for PubMedID 34854975

• Ethics and multiculturalism in pediatric surgery. Seminars in pediatric surgery Shakhsheer, B. A., Bachier-Rodriguez, M., Shew, S. B., Loeff, D. S. 2021; 30 (5): 151103

  Abstract

  The concept of culture includes many defining characteristics such race, ethnicity, gender, identity, socioeconomic status, beliefs, traditions, and habits. Multiculturalism is a concept that allows for respect, understanding and acknowledgement of a diversity of identities. The cases discussed in this manuscript indicate the importance of multiculturalism in the practice of pediatric surgery.

  View details for DOI 10.1016/j.sempedsurg.2021.151103

  View details for PubMedID 34635286

• Attitudes Affecting Decision-making for Use of Radiologic Enteral Contrast in the Management of Pediatric Adhesive Small Bowel Obstruction: A Survey Study of Pediatric Surgeons. The Journal of surgical research Acker, S. N., Diaz-Miron, J., Ignacio, R. C., Russell, K. W., Lofberg, K., Shew, S. B., Peterson, P. N., Kelley-Quon, L. I., Jensen, A. R., Lee, J., Padilla, B., Smith, C. A., Kastenberg, Z. J., Azarow, K. S., Ostlie, D. J., Wang, K. S., Inge, T. H., Western Pediatric Surgery Research Consortium 2021; 267: 536-543

  Abstract

  BACKGROUND: Pediatric surgeons are often asked to treat clinical problems for which little high-quality data exist. For adults with adhesive small bowel obstruction (ASBO), water soluble contrast-based protocols are used to guide management. Little is known about their utility in children. We aimed to better understand key factors in clinical decision-making processes and integration of adult based data in pediatric surgeon's approach to ASBO.METHODS: We administered a web-based survey to practicing pediatric surgeons at institutions comprising the Western Pediatric Surgery Research Consortium.RESULTS: The response rate was 69% (78/113). Over half of respondents reported using contrast protocols to guide ASBO management either routinely or occasionally (n=47, 60%). Common themes regarding the incorporation of adult-based data into clinical practice included the need to adapt protocols for pediatric patients, the dearth of pediatric specific data, and the quality of the published adult evidence.CONCLUSIONS: Our findings demonstrate that pediatric surgeons use contrast-based protocols for the management of ASBO despite the paucity of pediatric specific data. Furthermore, our survey data help us understand how pediatric surgeons incorporate adult based evidence into their practice.

  View details for DOI 10.1016/j.jss.2021.06.004

  View details for PubMedID 34256196

• Impact of Clinical Factors on the Intestinal Microbiome in Infants With Gastroschisis. JPEN. Journal of parenteral and enteral nutrition Wu, A. J., Lee, D. J., Li, F. n., Tobin, N. H., Aldrovandi, G. M., Shew, S. B., Calkins, K. L. 2020

  Abstract

  Infants with gastroschisis require operations and lengthy hospitalizations due to intestinal dysmotility. Dysbiosis may contribute to these problems. Little is known on the microbiome of gastroschisis infants.The purpose of this study was to investigate the fecal microbiome in gastroschisis infants. Microbiome profiling was performed by sequencing the V4 region of the 16S rRNA gene. The microbiome of gastroschisis infants was compared to the microbiome of healthy controls, and the effects of mode of birth delivery, gestational age, antibiotic duration, and nutrition type on microbial composition and diversity were investigated.The microbiome of gastroschisis infants (n = 13) was less diverse (Chao1, P < 0.001), lacked Bifidobacterium (P = 0.001) and had increased Staphylococcus (P = 0.007) compared to controls (n = 83). Mode of delivery (R2 = 0.04, P = 0.001), antibiotics duration greater than or equal to seven days (R2 = 0.03, P = 0.003), age at sample collection (R2 = 0.03, P = 0.009), and gestational age (R2 = 0.02, P = 0.035) explained a small portion of microbiome variation. In gastroschisis infants, Escherichia-Shigella was the predominate genus, and those delivered via cesarean section had different microbial communities, predominantly Staphylococcus and Streptococcus, from those delivered vaginally. While antibiotic duration contributed to the variation in microbiome composition, there were no significant differences in taxa distribution or alpha diversity by antibiotic duration or nutrition type. CONCLUSION: The microbiome of gastroschisis infants is dysbiotic, and mode of birth delivery, antibiotic duration, and gestational age appear to contribute to microbial variation. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1002/jpen.1926

  View details for PubMedID 32441784

• Intravenous Fish Oil and Serum Fatty Acid Profiles in Pediatric Patients With Intestinal Failure-Associated Liver Disease JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Ong, M. L., Venick, R. S., Shew, S. B., Dunn, J. Y., Reyen, L., Grogan, T., Calkins, K. L. 2019; 43 (6): 717–25

  View details for DOI 10.1002/jpen.1532

  View details for Web of Science ID 000479319600003

• Long-Term Outcomes in Children With Intestinal Failure-Associated Liver Disease Treated With 6 Months of Intravenous Fish Oil Followed by Resumption of Intravenous Soybean Oil JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Wang, C., Venick, R. S., Shew, S. B., Dunn, J. Y., Reyen, L., Gou, R., Calkins, K. L. 2019; 43 (6): 708–16

  View details for DOI 10.1002/jpen.1463

  View details for Web of Science ID 000479319600002

• Intravenous Fish Oil and Serum Fatty Acid Profiles in Pediatric Patients With Intestinal Failure-Associated Liver Disease. JPEN. Journal of parenteral and enteral nutrition Ong, M. L., Venick, R. S., Shew, S. B., Dunn, J. C., Reyen, L., Grogan, T., Calkins, K. L. 2019

  Abstract

  BACKGROUND: Intravenous fish oil (FO) treats pediatric intestinal failure-associated liver disease (IFALD). There are concerns that a lipid emulsion composed of omega-3 fatty acids will cause an essential fatty acid deficiency (EFAD). This study's objective was to quantify the risk for abnormal fatty acid concentrations in children treated with FO.METHODS: Inclusion criteria for this prospective study were children with intestinal failure. Intravenous soybean oil (SO) was replaced with FO for no longer than 6 months. Serum fatty acids were analyzed using linear and logistic models, and compared with age-based norms to determine the percentage of subjects with low and high concentrations.RESULTS: Subjects (n=17) started receiving FO at a median of 3.6 months (interquartile range 2.4-9.6 months). Over time, alpha-linolenic, linoleic, arachidonic, and Mead acid decreased, whereas docosahexaenoic and eicosapentaenoic acid increased (P<0.001 for all). Triene-tetraene ratios remained unchanged (P=1). Although subjects were 1.8 times more likely to develop a low linoleic acid while receiving FO vs SO (95% CI: 1.4-2.3, P<0.01), there was not a significant risk for low arachidonic acid. Subjects were 1.6 times more likely to develop high docosahexaenoic acid while receiving FO vs SO; however, this was not significant (95% CI: 0.9-2.6, P=0.08).CONCLUSION: In this cohort of parenteral nutrition-dependent children, switching from SO to FO led to a decrease in essential fatty acid concentrations, but an EFAD was not evident. Low and high levels of fatty acids developed. Further investigation is needed to clarify if this is clinically significant.

  View details for PubMedID 30900274

• Long-Term Outcomes in Children With Intestinal Failure-Associated Liver Disease Treated With 6 Months of Intravenous Fish Oil Followed by Resumption of Intravenous Soybean Oil. JPEN. Journal of parenteral and enteral nutrition Wang, C., Venick, R. S., Shew, S. B., Dunn, J. C., Reyen, L., Gou, R., Calkins, K. L. 2018

  Abstract

  BACKGROUND: Intravenous soybean oil (SO) is a commonly used lipid emulsion for children with intestinal failure (IF); however, it is associated with IF-associated liver disease (IFALD). Studies have demonstrated that intravenous fish oil (FO) is an effective treatment for IFALD. However, there is a lack of long-term data on children who stop FO and resume SO. This study's objective was to investigate our institution's outcomes for children with IFALD treated with 6months of FO and who then restarted SO.METHODS: Inclusion criteria for FO included children with IFALD. Parenteral nutrition (PN)-dependent children resumed SO after FO and were prospectively followed for 4.5 years or until death, transplant, or PN discontinuation. The primary outcome was the cumulative incidence rate (CIR) for cholestasis after FO.RESULTS: Forty-eight subjects received FO, and conjugated bilirubin decreased over time (-0.22mg/dL/week; 95% confidence interval [CI]: -0.25, -0.19; P< .001). The CIR for cholestasis resolution after 6months of FO was 71% (95% CI: 54%, 82%). Twenty-seven subjects resumed SO and were followed for a median of 16months (range 3-51months). While the CIR for enteral autonomy after 3 years of follow-up was 40% (95% CI: 17%, 26%), the CIR for cholestasis and transplant was 26% (95% CI: 8%, 47%) and 6% (95% CI: 0.3%, 25%), respectively.CONCLUSION: In this study, FO effectively treated cholestasis, and SO resumption was associated with cholestasis redevelopment in nearly one-fourth of subjects. Long-term FO may be warranted to prevent end-stage liver disease.

  View details for PubMedID 30411372

• Impact of societal factors and health care delivery systems on gastroschisis outcomes. Seminars in pediatric surgery Taylor, J. S., Shew, S. B. 2018; 27 (5): 316–20

  Abstract

  Care of infants with gastroschisis is associated with a significant burden on health care delivery systems. Mortality rates in patients with gastroschisis have significantly improved over the past few decades. However, the condition is still associated with significant short-term and potentially long-term morbidity. Significant variations in clinical outcomes and resource utilization may be explained by several factors including provider and hospital experience, level of neonatal intensive care, variations in hospital regionalization of care, and differences in healthcare delivery systems. Reviewing and assessing these hospital and healthcare system related factors are paramount in addressing variations in gastroschisis care and improving outcomes for these vulnerable infants.

  View details for PubMedID 30413263

• Nonoperative Management of Appendicitis. Clinical pediatrics Scott, A., Lee, S. L., DeUgarte, D. A., Shew, S. B., Dunn, J. C., Shekherdimian, S. 2017: 9922817696465

  Abstract

  We evaluated the outcomes for nonoperative management (NOM) of all children with suspected nonperforated appendicitis, including those patients with an appendicolith. Parents of all children with suspected nonperforated appendicitis were offered NOM versus laparoscopic appendectomy. NOM included administration of intravenous antibiotics and hospital admission. If no improvement within 24 hours, laparoscopic appendectomy was performed. Primary outcomes were initial success rate and recurrence rate. Fifty patients selected NOM. The initial failure rate for NOM was 20%. Of the 10 who failed, 7 had complicated appendicitis. The recurrence rate was 13%. Overall, 34 (68%) patients avoided appendectomy. Patients with an appendicolith had a higher initial failure rate (37%) compared to patients without an appendicolith (10%; P < .05). NOM is feasible and effective in pediatric nonperforated appendicitis. The presence of an appendicolith was associated with a higher failure rate but is not an absolute contraindication for NOM.

  View details for DOI 10.1177/0009922817696465

  View details for PubMedID 28952357

• Low-Dose Parenteral Soybean Oil for the Prevention of Parenteral Nutrition-Associated Liver Disease in Neonates With Gastrointestinal Disorders. JPEN. Journal of parenteral and enteral nutrition Calkins, K. L., Havranek, T., Kelley-Quon, L. I., Cerny, L., Flores, M., Grogan, T., Shew, S. B. 2017; 41 (3): 404-411

  Abstract

  Neonates with gastrointestinal disorders (GDs) are at high risk for parenteral nutrition-associated liver disease (PNALD). Soybean-based intravenous lipid emulsions (S-ILE) have been associated with PNALD. This study's objective was to determine if a lower dose compared with a higher dose of S-ILE prevents cholestasis without compromising growth.This multicenter randomized controlled pilot study enrolled patients with GDs who were ≤5 days of age to a low dose (~1 g/kg/d) (LOW) or control dose of S-ILE (~3 g/kg/d) (CON). The primary outcome was cholestasis (direct bilirubin [DB] >2 mg/dL) after the first 7 days of age. Secondary outcomes included growth, PN duration, and late-onset sepsis.Baseline characteristics were similar between the LOW (n = 20) and CON groups (n = 16). When the LOW group was compared with the CON group, there was no difference in cholestasis (30% vs 38%, P = .7) or secondary outcomes. However, mean ± SE DB rate of change over the first 8 weeks (0.07 ± 0.04 vs 0.3 ± 0.09 mg/dL/wk, P = .01) and entire study (0.008 ± 0.03 vs 0.2 ± 0.07 mg/dL/wk, P = .02) was lower in the LOW group compared with the CON group.In neonates with GDs who received a lower dose of S-ILE, DB increased at a slower rate in comparison to neonates who received a higher dose of S-ILE. Growth was comparable between the groups. This study demonstrates a need for a larger, randomized controlled trial comparing 2 different S-ILE doses for cholestasis prevention in neonates at risk for PNALD.

  View details for DOI 10.1177/0148607115588334

  View details for PubMedID 26024828

  View details for PubMedCentralID PMC4663189

• Is there a relationship between hospital volume and patient outcomes in gastroschisis repair? JOURNAL OF PEDIATRIC SURGERY Sacks, G. D., Ulloa, J. G., Shew, S. B. 2016; 51 (10): 1650-1654

  Abstract

  Given the well-established relationship between surgical volume and outcomes for many surgical procedures, we examined whether the same relationship exists for gastroschisis closure.We conducted a retrospective analysis of infants who underwent gastroschisis closure between 1999 and 2007 using a California birth-linked cohort. Hospitals were divided into terciles based on the number of gastroschisis closures performed annually. Using regression techniques, we examined the effects of hospital volume on patient mortality and length of stay while controlling for patient and hospital confounders.We identified 1537 infants who underwent gastroschisis repair at 55 hospitals, 4 of which were high-volume and 42 of which were low-volume. The overall in-hospital mortality rate was 4.8% and the median length of stay was 46.5days. After controlling for other factors, patients treated at high-volume hospitals had significantly lower odds of inpatient mortality (OR 0.40; 95% CI 0.21, 0.76). There was a near-significant trend towards shorter hospital length of stay at highvolume hospitals (p=0.066).Patients who undergo gastroschisis closure at high-volume hospitals in California experience lower odds of in-hospital mortality compared to those treated at low-volume hospitals. These findings offer initial evidence to support policies that limit the number of hospitals providing complex newborn surgical care.

  View details for DOI 10.1016/j.jpedsurg.2016.04.009

  View details for Web of Science ID 000386587500014

  View details for PubMedID 27139881

• Effect of High-Dose Cysteine Supplementation on Erythrocyte Glutathione: A Double-Blinded, Randomized Placebo-Controlled Pilot Study in Critically Ill Neonates. JPEN. Journal of parenteral and enteral nutrition Calkins, K. L., Sanchez, L. A., Tseng, C., Faull, K. F., Yoon, A. J., Ryan, C. M., Le, T., Shew, S. B. 2016; 40 (2): 226-234

  Abstract

  This study's objective was to determine if parenteral cysteine when compared with isonitrogenous noncysteine supplementation increases erythrocyte reduced glutathione (GSH) in neonates at high risk for inflammatory injury.Neonates with a score for neonatal acute physiology >10 requiring mechanical ventilation and parenteral nutrition (PN) were randomized in a double-blinded, placebo-controlled study to receive parenteral cysteine-HCl (CYS group) or additional PN amino acids (ISO group) at 121 mg/kg/d for ≥7 days. A 6-hour [(13)C2] glycine IV infusion was administered at study week 1 to determine the fractional synthetic rate of GSH (FSR-GSH).Baseline characteristics were similar between the CYS (n = 17) and ISO groups (n = 21). Erythrocyte GSH and total glutathione concentrations, GSH:oxidized GSH (GSSG), and FSR-GSH after treatment were not different between groups. However, the CYS group had a larger individual positive change in GSH and total glutathione (infusion day - baseline) compared with the ISO group (P = .02 for each). After adjusting for treatment, a lower enrollment weight and rate of red blood cell transfusion were associated with a decreased change in total glutathione and GSH (P < .05 for each).When compared with isonitrogenous noncysteine supplementation, high-dose cysteine supplementation for at least 1 week in critically ill neonates resulted in a larger and more positive individual change in GSH. Smaller infants and those who received transfused blood demonstrated less effective change in GSH with cysteine supplementation. The benefit of cysteine remains promising and deserves further investigation.

  View details for DOI 10.1177/0148607114546375

  View details for PubMedID 25139979

  View details for PubMedCentralID PMC4573914

• Innovation in Pediatric Surgical Education for General Surgery Residents: A Mobile Web Resource JOURNAL OF SURGICAL EDUCATION Rouch, J. D., Wagner, J. P., Scott, A., Sullins, V. F., Chen, D. C., DeUgarte, D. A., Shew, S. B., Tillou, A., Dunn, J. C., Lee, S. L. 2015; 72 (6): 1190-1194

  Abstract

  General surgery residents lack a standardized educational experience in pediatric surgery. We hypothesized that the development of a mobile educational interface would provide general surgery residents broader access to pediatric surgical education materials.We created an educational mobile website for general surgery residents rotating on pediatric surgery, which included a curriculum, multimedia resources, the Operative Performance Rating Scale (OPRS), and Twitter functionality. Residents were instructed to consult the curriculum. Residents and faculty posted media using the Twitter hashtag, #UCLAPedSurg, and following each surgical procedure reviewed performance via the OPRS. Site visits, Twitter posts, and OPRS submissions were quantified from September 2013 to July 2014.The pediatric surgery mobile website received 257 hits; 108 to the homepage, 107 to multimedia, 28 to the syllabus, and 19 to the OPRS. All eligible residents accessed the content. The Twitter hashtag, #UCLAPedSurg, was assigned to 20 posts; the overall audience reach was 85 individuals. Participants in the mobile OPRS included 11 general surgery residents and 4 pediatric surgery faculty.Pediatric surgical education resources and operative performance evaluations are effectively administered to general surgery residents via a structured mobile platform.

  View details for DOI 10.1016/j.jsurg.2015.06.025

  View details for Web of Science ID 000366240200019

  View details for PubMedID 26276304

• Maternal Factors Associated with the Occurrence of Gastroschisis AMERICAN JOURNAL OF MEDICAL GENETICS PART A Baer, R. J., Chambers, C. D., Jones, K. L., Shew, S. B., MacKenzie, T. C., Shaw, G. M., Jelliffe-Pawlowski, L. L. 2015; 167A (7): 1534-1541

  Abstract

  We sought to identify age group specific maternal risk factors for gastroschisis. Maternal characteristics and prenatal factors were compared for 1,279 live born infants with gastroschisis and 3,069,678 without. Data were obtained using the California database containing linked hospital discharge, birth certificate and death records from 1 year prior to the birth to 1 year after the birth. Backwards-stepwise logistic regression models were used with maternal factors where initial inclusion was determined by a threshold of p < 0.10 on initial crude analyses. Due to the strong association of gastroschisis with young maternal age, models were stratified by age groups and odds ratios were calculated. These final models identified maternal infection as the only risk factor common to all age groups and a protective effect of obesity and gestational hypertension. In addition, age specific risk factors were identified. Although gestation at the time of infection was not available, a sexually transmitted disease complicating pregnancy was associated with increased risk in the less than 20 years of age grouping whereas viral infection was associated with increased risk only in the 20-24 and more than 24 years of age groupings. Urinary tract infection remained in the final logistic model for women less than 20 years. Short interpregnancy interval was not found to be a risk factor for any age group. Our findings support the need to explore maternal infection by type and gestational timing. © 2015 Wiley Periodicals, Inc.

  View details for DOI 10.1002/ajmg.a.37016

  View details for Web of Science ID 000356676200063

• Maternal factors associated with the occurrence of gastroschisis. American journal of medical genetics. Part A Baer, R. J., Chambers, C. D., Jones, K. L., Shew, S. B., MacKenzie, T. C., Shaw, G. M., Jelliffe-Pawlowski, L. L. 2015; 167 (7): 1534-1541

  Abstract

  We sought to identify age group specific maternal risk factors for gastroschisis. Maternal characteristics and prenatal factors were compared for 1,279 live born infants with gastroschisis and 3,069,678 without. Data were obtained using the California database containing linked hospital discharge, birth certificate and death records from 1 year prior to the birth to 1 year after the birth. Backwards-stepwise logistic regression models were used with maternal factors where initial inclusion was determined by a threshold of p < 0.10 on initial crude analyses. Due to the strong association of gastroschisis with young maternal age, models were stratified by age groups and odds ratios were calculated. These final models identified maternal infection as the only risk factor common to all age groups and a protective effect of obesity and gestational hypertension. In addition, age specific risk factors were identified. Although gestation at the time of infection was not available, a sexually transmitted disease complicating pregnancy was associated with increased risk in the less than 20 years of age grouping whereas viral infection was associated with increased risk only in the 20-24 and more than 24 years of age groupings. Urinary tract infection remained in the final logistic model for women less than 20 years. Short interpregnancy interval was not found to be a risk factor for any age group. Our findings support the need to explore maternal infection by type and gestational timing. © 2015 Wiley Periodicals, Inc.

  View details for DOI 10.1002/ajmg.a.37016

  View details for PubMedID 25913847

• Academic-community partnerships improve outcomes in pediatric trauma care JOURNAL OF PEDIATRIC SURGERY Kelley-Quon, L. I., Crowley, M. A., Applebaum, H., Cummings, K., Kang, R. J., Tseng, C., Mangione, C. M., Shew, S. B. 2015; 50 (6): 1032-1036

  Abstract

  To address the specialized needs of injured children, pediatric trauma centers (PTCs) were established at many large, academic hospitals. This study explores clinical outcomes observed for injured children treated at an academic-sponsored community facility.In partnership with an academic medical center in a major metropolitan area, a not-for-profit community hospital became a designated Level II PTC in October 2010. Data for injured children <15 years old treated prior to PTC designation from January 2000 to September 2010 were prospectively collected using the Trauma and Emergency Medicine Information System and compared to data collected after PTC designation from January 2011 to December 2013.Overall, 681 injured children were treated at the community hospital from January 2011 to December 2013. Children treated after PTC designation were less likely to undergo computed tomography (CT) (50.9% vs. 81.3%, p<0.01), even when controlling for age, gender, injury type, injury severity, and year (OR 0.18, 95%CI 0.08-0.37). Specifically, fewer head (45.7% vs. 68.7%, p<0.01) and abdominal CTs (13.2% vs. 26.5%, p<0.01) were performed. Hospital length of stay was significantly shorter (2.8 ± 3.7 days vs. 3.7 ± 5.9 days, p<0.01). Mortality was low overall, but also decreased after PTC designation (0.4% vs. 2.0%, p=0.02).These results indicate that academic-community partnerships in pediatric trauma care are a feasible alternative and may lead to improved outcomes for injured children.

  View details for DOI 10.1016/j.jpedsurg.2015.03.033

  View details for Web of Science ID 000354551700031

  View details for PubMedID 25812442

• Outcomes and Costs of Surgical Treatments of Necrotizing Enterocolitis PEDIATRICS Stey, A., Barnert, E. S., Tseng, C., Keeler, E., Needleman, J., Leng, M., Kelley-Quon, L. I., Shew, S. B. 2015; 135 (5): E1190-E1197

  Abstract

  Despite previous studies demonstrating no difference in mortality or morbidity, the various surgical approaches for necrotizing enterocolitis (NEC) in infants have not been evaluated economically. Our goal was to compare total in-hospital cost and mortality by using propensity score-matched infants treated with peritoneal drainage alone, peritoneal drainage followed by laparotomy, or laparotomy alone for surgical NEC.Utilizing the California OSHPD Linked Birth File Dataset, 1375 infants with surgical NEC between 1999 and 2007 were retrospectively propensity score matched according to intervention type. Total in-hospital costs were converted from longitudinal patient charges. A multivariate mixed effects model compared adjusted costs and mortality between groups.Successful propensity score matching was performed with 699 infants (peritoneal drainage, n = 101; peritoneal drainage followed by laparotomy, n = 172; and laparotomy, n = 426). Average adjusted cost for peritoneal drainage followed by laparotomy was $398,173 (95% confidence interval [CI]: 287,784-550,907), which was more than for peritoneal drainage ($276,076 [95% CI: 196,238-388,394]; P = .004) and similar to laparotomy ($341,911 [95% CI: 251,304-465,186]; P = .08). Adjusted mortality was highest after peritoneal drainage (56% [95% CI: 34-75]) versus peritoneal drainage followed by laparotomy (35% [95% CI: 19-56]; P = .01) and laparotomy (29% [95% CI: 19-56]; P < .001). Mortality for peritoneal drainage was similar to laparotomy.Propensity score-matched analysis of surgical NEC treatment found that peritoneal drainage followed by laparotomy was associated with decreased mortality compared with peritoneal drainage alone but at significantly increased costs.

  View details for DOI 10.1542/peds.2014-1058

  View details for Web of Science ID 000353728400010

  View details for PubMedID 25869373

  View details for PubMedCentralID PMC4411777

• Multi-institutional practice patterns and outcomes in uncomplicated gastroschisis: A report from the University of California Fetal Consortium (UCfC) JOURNAL OF PEDIATRIC SURGERY Lusk, L. A., Brown, E. G., Overcash, R. T., Grogan, T. R., Keller, R. L., Kim, J. H., Poulain, F. R., Shew, S. B., Uy, C., DeUgarte, D. A. 2014; 49 (12): 1782-1786

  Abstract

  Gastroschisis is a resource-intensive birth defect without consensus regarding optimal surgical and medical management. We sought to determine best-practice guidelines by examining differences in multi-institutional practices and outcomes.Site-specific practice patterns were queried, and infant-maternal chart review was retrospectively performed for gastroschisis infants treated at 5 UCfC institutions (2007-2012). The primary outcome was length of stay. Univariate analysis was done to assess variation practices and outcomes by site. Multivariate models were constructed with site as an instrumental variable and with sites grouped by silo practice pattern adjusting for confounding factors.Of 191 gastroschisis infants, 164 infants were uncomplicated. Among uncomplicated patients, there were no deaths and only one case of necrotizing enterocolitis. Bivariate analysis revealed significant differences in practices and outcomes by site. Despite wide variations in practice patterns, there were no major differences in outcome among sites or by silo practice, after adjusting for confounding factors.Wide variability exists in institutional practice patterns for infants with gastroschisis, but poor outcomes were not associated with expeditious silo or primary closure, avoidance of routine paralysis, or limited central line and antibiotic durations. Development of clinical pathways incorporating these practices may help standardize care and reduce health care costs.

  View details for DOI 10.1016/j.jpedsurg.2014.09.018

  View details for Web of Science ID 000345965000020

  View details for PubMedID 25487483

  View details for PubMedCentralID PMC4261143

• Evaluation of Hospital Readmissions in Surgical Patients Do Administrative Data Tell the Real Story? JAMA SURGERY Sacks, G. D., Dawes, A. J., Russell, M. M., Lin, A. Y., Maggard-Gibbons, M., Winograd, D., Chung, H. R., Tomlinson, J., Tillou, A., Shew, S. B., Hiyama, D. T., Cryer, H. G., Brunicardi, F. C., Hiatt, J. R., Ko, C. 2014; 149 (8): 759-764

  Abstract

  The Centers for Medicare & Medicaid Services has developed an all-cause readmission measure that uses administrative data to measure readmission rates and financially penalize hospitals with higher-than-expected readmission rates.To examine the accuracy of administrative codes in determining the cause of readmission as determined by medical record review, to evaluate the readmission measure's ability to accurately identify a readmission as planned, and to document the frequency of readmissions for reasons clinically unrelated to the original hospital stay.Retrospective review of all consecutive patients discharged from general surgery services at a tertiary care, university-affiliated teaching hospital during 8 consecutive quarters (quarter 4 [October through December] of 2009 through quarter 3 [July through September] of 2011). Clinical readmission diagnosis determined from direct medical record review was compared with the administrative diagnosis recorded in a claims database. The number of planned hospital readmissions defined by the readmission measure was compared with the number identified using clinical data. Readmissions unrelated to the original hospital stay were identified using clinical data.Discordance rate between administrative and clinical diagnoses for all hospital readmissions, discrepancy between planned readmissions defined by the readmission measure and identified by clinical medical record review, and fraction of hospital readmissions unrelated to the original hospital stay.Of the 315 hospital readmissions, the readmission diagnosis listed in the administrative claims data differed from the clinical diagnosis in 97 readmissions (30.8%). The readmission measure identified 15 readmissions (4.8%) as planned, whereas clinical data identified 43 readmissions (13.7%) as planned. Unrelated readmissions comprised 70 of the 258 unplanned readmissions (27.1%).Administrative billing data, as used by the readmission measure, do not reliably describe the reason for readmission. The readmission measure accounts for less than half of the planned readmissions and does not account for the nearly one-third of readmissions unrelated to the original hospital stay. Implementation of this readmission measure may result in unwarranted financial penalties for hospitals.

  View details for DOI 10.1001/jamasurg.2014.18

  View details for Web of Science ID 000340834300002

  View details for PubMedID 24920156

• Pediatric Intestinal Failure-Associated Liver Disease Is Reversed With 6 Months of Intravenous Fish Oil JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Calkins, K. L., Dunn, J. C., Shew, S. B., Reyen, L., Farmer, D. G., Devaskar, S. U., Venick, R. S. 2014; 38 (6): 682-692

  Abstract

  Studies have suggested that when intravenous (IV) soybean oil (SO) is replaced with fish oil (FO), direct hyperbilirubinemia is more likely to resolve. The necessary duration of FO has not been established. This study seeks to determine if 24 weeks of FO is an effective and safe therapy for intestinal failure-associated liver disease (IFALD).This is a clinical trial using patients with IFALD between the ages of 2 weeks and 18 years. SO was replaced with FO (1 g/kg/d) in 10 patients who were receiving most of their calories from parenteral nutrition (PN). Patients were compared with 20 historic controls receiving SO. SO for both groups was prescribed by the primary medical team at variable doses. The primary outcome was time to reversal of cholestasis. Secondary outcomes were death, transplant, and full enteral feeds. Safety measurements included growth, essential fatty acid deficiency, and laboratory markers to assess bleeding risk.The Kaplan-Meier method estimated that 75% in the FO group would experience resolution of cholestasis by 17 weeks vs 6% in the SO group (P < .0001). When compared with the SO group, the FO group had decreased serum direct bilirubin concentrations at weeks 8 (P = .03) and 12, 16, 20, and 24 weeks (P < .0001). Although length z score at the end of the study increased in the FO group compared with baseline (P = .03), there were no significant differences in other outcomes.A limited duration of FO appears to be safe and effective in reversing IFALD.

  View details for DOI 10.1177/0148607113495416

  View details for Web of Science ID 000340202200004

  View details for PubMedID 23894176

  View details for PubMedCentralID PMC4254367

• Reply to letter to the editor. Journal of pediatric surgery Shew, S. B. 2014; 49 (5): 845-847

  View details for DOI 10.1016/j.jpedsurg.2014.02.086

  View details for PubMedID 24851783

• Complications of Pediatric Cholecystectomy: Impact from Hospital Experience and Use of Cholangiography JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Kelley-Quon, L. I., Dokey, A., Jen, H. C., Shew, S. B. 2014; 218 (1): 73-81

  Abstract

  Complications after cholecystectomy in children are poorly characterized. The aim of this study was to assess risk factors for major surgical complications for children undergoing cholecystectomy.All children 4 to 18 years old with gallbladder disease who underwent cholecystectomy from 1999 to 2006 were identified from the California Patient Discharge Database. Patient, hospital, and surgical factors were analyzed using multivariate logistic regression analysis to identify factors predictive of bile duct injury (BDI) and postoperative ERCP.A cohort of 6,931 children treated at 360 hospitals was evaluated. Most children underwent cholecystectomy at a non-children's hospital (84%). Intraoperative cholangiogram (IOC) was performed in 2,053 (30%) children. Of 5,101 children tracked through the year after cholecystectomy, 153 (3%) required readmission for surgical complications. Bile duct injury occurred in 25 (0.36%) children, and postoperative ERCP was performed in 711 (10%) children. Older age (odds ratio = 0.80; 99% CI, 0.67-0.95) was associated with decreased risk of BDI. Increased hospital tendency for routine IOC use was associated with increased likelihood of BDI (odds ratio = 12.92; 99% CI, 1.31-127.15). Receiving surgical care at a children's hospital was associated with a decreased likelihood of postoperative ERCP (odds ratio = 0.39; 99% CI, 0.23-0.66). As anticipated, choledocholithiasis, cholecystitis, IOC, and laparoscopic cholecystectomy were associated with increased risk of postoperative ERCP (p < 0.01).Serious complications and readmissions from pediatric cholecystectomy are uncommon. Surgeons performing cholecystectomy in young children must have an elevated concern about BDI. Routine IOC or surgical volume might not be helpful in lowering BDI rates.

  View details for DOI 10.1016/j.jamcollsurg.2013.09.018

  View details for Web of Science ID 000328749200014

  View details for PubMedID 24355877

• Congenital malformations associated with assisted reproductive technology: A California statewide analysis JOURNAL OF PEDIATRIC SURGERY Kelley-Quon, L. I., Tseng, C., Janzen, C., Shew, S. B. 2013; 48 (6): 1218-1224

  Abstract

  Management of congenital malformations comprises a large part of pediatric surgical care. Despite increasing utilization of assisted reproductive technology (ART) and fertility-related services (FRS), associations with birth defects are poorly understood.Infants born after ART or FRS were identified from the California Linked Birth Cohort Dataset from 2006 to 2007 and compared to propensity matched infants conceived naturally. Factors associated with major congenital malformations were evaluated using Firth logistic regression.With a cohort of 4,795 infants born after ART and 46,025 naturally conceived matched controls, major congenital malformations were identified in 3,463 infants. Malformations were increased for ART infants (9.0% vs. 6.6%, p<0.001). After adjusting for infant and maternal factors, ART infants exhibited increased odds of major malformations overall (OR 1.25, 95% CI 1.12-1.39), specifically defects of the eye (OR 1.81, 95% CI 1.04-3.16), head and neck (OR 1.37, 95% CI 1.00-1.86), heart (OR 1.41, 95% CI 1.22-1.64), and genitourinary system (OR 1.40, 95% CI 1.09-1.82). The likelihood of birth defects was increased for multiples (OR 1.35, 95% CI 1.18-1.54) and not singletons. Odds of congenital malformation after FRS alone (n=1,749) were non-significant.ART contributes a significant risk of congenital malformation and may be more pronounced for multiples. Accurate counseling for parents considering ART and multidisciplinary coordination of care prior to delivery are warranted.

  View details for DOI 10.1016/j.jpedsurg.2013.03.017

  View details for Web of Science ID 000322158600018

  View details for PubMedID 23845610

• Short-term intravenous fish oil and pediatric intestinal failure associated liver disease: 3-year follow-up on liver function and nutrition JOURNAL OF PEDIATRIC SURGERY Calkins, K., Lowe, A., Shew, S. B., Dunn, J. C., Reyen, L., Farmer, D. G., Devaskar, S. U., Venick, R. 2013; 48 (1): 228-232

  Abstract

  Intravenous fish oil (FO) has changed the management of intestinal failure associated liver disease (IFALD). This report describes two IFALD patients who received FO for 5 and 10 months, respectively and reports on their 3-year follow-up.

  View details for DOI 10.1016/j.jpedsurg.2012.10.044

  View details for Web of Science ID 000313879800048

  View details for PubMedID 23331820

  View details for PubMedCentralID PMC3553503

• Hospital Type as a Metric for Racial Disparities in Pediatric Appendicitis JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Kelley-Quon, L. I., Tseng, C., Jen, H. C., Lee, S. L., Shew, S. B. 2013; 216 (1): 74-82

  Abstract

  Appendiceal perforation (AP) is a marker of health care disparities. We propose that racial disparities in children, as measured by AP, may change according to the type of hospital in which a child receives care.Children 2 to 18 years old, with appendicitis diagnosed from 1999 to 2007, were retrospectively reviewed from the California Patient Discharge Dataset and sorted by community, children's, and county hospitals. Risk of AP within and between hospital types was analyzed with multivariate logistic regression controlling for hospital and patient level factors.Overall, 107,727 children (white, 36%; Hispanic, 53%; black, 3%; Asian, 5%; other, 8%) were treated at 386 California hospitals (community, 74%; children's, 17%; county, 10%). Hispanic (odds ratio [OR] 1.23, 99% CI 1.16 to 1.32) and Asian (OR 1.34, 99% CI 1.19 to 1.52) children treated at community hospitals experienced increased risk of AP compared with white children. Hispanic children cared for at children's hospitals also exhibited increased odds of AP (OR 1.18, 99% CI 1.05 to 1.33). Odds of AP did not differ by race within county hospitals. When comparing AP risk between hospital types, black children treated at county (OR 1.12, 99% CI 0.90 to 1.38) and children's (OR 2.01, 99% CI 1.18 to 3.42) hospitals exhibited increased odds of AP compared with black children treated at community hospitals.These results underscore differential patterns of AP at the hospital level and deserve immediate attention because they may reflect far larger disparities in access and quality of care for children in California. Future interventions aimed at eliminating racial disparities in children must account for racial differences in access to timely diagnostic and surgical intervention for rapidly progressive and preventable clinical conditions such as AP.

  View details for DOI 10.1016/j.jamcollsurg.2012.09.018

  View details for Web of Science ID 000314027300010

  View details for PubMedID 23177269

• Postoperative complications and health care use in children undergoing surgery for ulcerative colitis JOURNAL OF PEDIATRIC SURGERY Kelley-Quon, L. I., Tseng, C., Jen, H. C., Ziring, D. A., Shew, S. B. 2012; 47 (11): 2063-2070

  Abstract

  Medical and surgical approaches toward children with ulcerative colitis (UC) vary and have differing implications for health care use. The goal of this study was to define hospital use and complications for children with UC before and after staged restorative proctocolectomy.A retrospective study of the California Patient Discharge Dataset from 1999 to 2007 of children aged 2 to 18 years with UC who underwent colectomy was performed (N = 218). Surgical staging was determined alongside hospital type (children's vs non-children's) and surgical case volume. Postoperative complications and hospital length of stay were analyzed using multivariate regression.The cohort was mostly male (56%) and white (80%), had private insurance (78%), and underwent colectomy at a children's hospital (62%). Overall, 65% required a separate hospital admission before admission for colectomy. Single-, 2-, and 3-stage procedures were performed in 19 (9%), 144 (66%), and 38 (17%) children. The mean admissions per patient were 1.8 ± 2.4 before colectomy and 0.7 ± 1.6 after surgical completion. Surgical complications occurred in 100 (49%) children, with 39% being attributed to postoperative infection. Children with public insurance (odds ratio, 2.18; 95% confidence interval, 1.0-4.85) and those who underwent colectomy at a non-children's hospital (odds ratio, 2.53; 95% confidence interval, 1.0-6.37) had increased likelihood of surgical complications. Finally, nonwhite race, surgical staging, and undergoing colectomy at a low- or medium-volume hospital resulted in prolonged hospitalization (P < .05).Children with UC who undergo colectomy use a large number of hospital resources before surgery and exhibit decreased hospital use after surgical completion. Children undergoing colectomy at children's and high-volume hospitals experience fewer surgical complications and shorter hospitalization.

  View details for DOI 10.1016/j.jpedsurg.2012.07.001

  View details for Web of Science ID 000311222500029

  View details for PubMedID 23163999

• Predictors of Proctocolectomy in Children With Ulcerative Colitis JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION Kelley-Quon, L. I., Jen, H. C., Ziring, D. A., Gupta, N., Kirschner, B. S., Ferry, G. D., Cohen, S. A., Winter, H. S., Heyman, M. B., Gold, B. D., Shew, S. B. 2012; 55 (5): 534-540

  Abstract

  Few clinical predictors are associated with definitive proctocolectomy in children with ulcerative colitis (UC). The purpose of the present study was to identify clinical predictors associated with surgery in children with UC using a disease-specific database.Children diagnosed with UC at age <18 years were identified using the Pediatric Inflammatory Bowel Disease Consortium (PediIBDC) database. Demographic and clinical variables from January 1999 to November 2003 were extracted alongside incidence and surgical staging.Review of the PediIBDC database identified 406 children with UC. Approximately half were girls (51%) with an average age at diagnosis of 10.6 ± 4.4 years in both boys and girls. Average follow-up was 6.8 (±4.0) years. Of the 57 (14%) who underwent surgery, median time to surgery was 3.8 (interquartile range 4.9) years after initial diagnosis. Children presenting with weight loss (hazard ratio [HR] 2.55, 99% confidence interval [CI] 1.21-5.35) or serum albumin <3.5 g/dL (HR 6.05, 99% CI 2.15-17.04) at time of diagnosis and children with a first-degree relative with UC (HR 1.81, 99% CI 1.25-2.61) required earlier surgical intervention. Furthermore, children treated with cyclosporine (HR 6.11, 99% CI 3.90-9.57) or tacrolimus (HR 3.66, 99% CI 1.60-8.39) also required earlier surgical management. Other symptoms, laboratory tests, and medical therapies were not predictive for need of surgery.Children with UC presenting with hypoalbuminemia, weight loss, a family history of UC, and those treated with calcineurin inhibitors frequently require restorative proctocolectomy for definitive treatment. Early identification and recognition of these factors should be used to shape treatment goals and initiate multidisciplinary care at the time of diagnosis.

  View details for DOI 10.1097/MPG.0b013e3182619d26

  View details for Web of Science ID 000310571700017

  View details for PubMedID 22684351

  View details for PubMedCentralID PMC4378533

• Hospital type predicts surgical complications for infants with hypertrophic pyloric stenosis. American surgeon Kelley-Quon, L. I., Tseng, C., Jen, H. C., Shew, S. B. 2012; 78 (10): 1079-1082

  Abstract

  Pyloromyotomy is a common surgery performed for hypertrophic pyloric stenosis at community and children's hospitals. To determine hospital-level factors that may affect clinical outcomes, infants requiring pyloromyotomy from 1999 to 2007 (n=8379) were retrospectively reviewed from the California linked birth cohort data set. Hospital case volume and type (community, children's, adult hospital with children's unit) were examined. Surgical complications, prolonged length of stay (LOS), and 30-day readmission were analyzed with multivariate logistic regression. Overall, surgical complications occurred in 166 (2%) infants, 35 (21%) after discharge. Readmission occurred in 285 (3.4%) infants with 69 (24%) admitted to hospitals that did not perform the initial surgery. Infants treated at community hospitals (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.1 to 4.0) experienced an increased likelihood of surgical complications. Odds of surgical complications did not vary by hospital case volume. Prolonged LOS was increased at community hospitals (OR, 1.7; 95% CI, 1.2 to 2.3), low- (OR, 2.1; 95% CI, 1.3 to 3.4), and medium-volume (OR, 1.6; 95% CI, 1.0 to 2.7) hospitals. Hospital type and volume did not impact 30-day readmission. In conclusion, specialized surgical care for infants administered at pediatric centers appears to influence pyloromyotomy complications more than hospital case volume. Institutional components contributing to improved outcomes in specialty centers warrant further investigation.

  View details for PubMedID 23025945

• Does hospital transfer predict mortality in very low birth weight infants requiring surgery for necrotizing enterocolitis? SURGERY Kelley-Quon, L. I., Tseng, C., Scott, A., Jen, H. C., Calkins, K. L., Shew, S. B. 2012; 152 (3): 337-343

  Abstract

  Necrotizing enterocolitis (NEC) is a leading cause of infant mortality, and the most common reason for emergent surgery in very low birth weight (VLBW, < 1,500 g) infants. We investigated whether transfer for higher level of surgical care affects mortality in this population.VLBW infants who underwent NEC surgery were reviewed retrospectively from the California Patient Discharge Linked Birth Cohort Database (1999-2007). Transfer for emergent operation was defined as surgery ≤2 days after transfer. Mortality was analyzed with multivariate logistic regression.Overall, 1,272 VLBW infants with surgical NEC were identified, with a 39% mortality. Transfer for operative care occurred in 406 (32%) infants. Unadjusted mortality was not increased for infants who were transferred compared with not transferred (37% vs. 40%; P = .25). Adjusted mortality for infants transferred for operative care did not differ from those who received operative care at their primary neonatal intensive care unit (odds ratio 0.75, 95% confidence interval 0.42-1.32). Lower birth weight, lack of prenatal care, peritoneal drainage as sole surgical intervention, and pulmonary interstitial emphysema/pulmonary hemorrhage were associated with increased odds of mortality (P < .05).VLBW infants with surgical NEC do not demonstrate increased risk of mortality when transferred emergently for operative care. Future efforts must engage health professionals caring for this vulnerable population to maximize resource allocation and safety.

  View details for DOI 10.1016/j.surg.2012.05.036

  View details for Web of Science ID 000308623500007

  View details for PubMedID 22770955

  View details for PubMedCentralID PMC3432725

• Liver herniation in gastroschisis: incidence and prognosis JOURNAL OF PEDIATRIC SURGERY McClellan, E. B., Shew, S. B., Lee, S. S., Dunn, J. C., DeUgarte, D. A. 2011; 46 (11): 2115-2118

  Abstract

  Liver herniation is a rare occurrence in gastroschisis. We sought to determine the incidence and prognosis of liver herniation in patients with gastroschisis.From December 1995 to March 2010, 117 patients with gastroschisis received care by our division. Operative reports were reviewed to identify patients with liver herniation. Logistic regression was used to determine the impact of liver herniation on survival, taking into account gestational age and birth weight.The incidence of liver herniation was 6%. Survival rates were 43% with liver herniation and 97% without liver herniation. Liver herniation was associated with a significantly higher rate of mortality, taking into account estimated gestational age and birth weight (P < .001). Patients who had liver herniation documented by prenatal ultrasound had significant liver herniation at birth and died postnatally. Patients with liver herniation who died required large silos and were noted to have comorbidities including lower birth weight, pulmonary hypoplasia, and sepsis. Biologic patches were necessary for closure in patients with greater extent of liver herniation.Liver herniation was found in 6% of patients with gastroschisis and was associated with a high rate of mortality. Liver herniation appears to be a risk factor for poor outcome in gastroschisis. Documentation of liver herniation may be helpful in prenatal consultation for gastroschisis.

  View details for DOI 10.1016/j.jpedsurg.2011.07.010

  View details for Web of Science ID 000296869100018

  View details for PubMedID 22075341

• Trends and Outcomes of Adolescent Bariatric Surgery in California, 2005-2007 PEDIATRICS Jen, H. C., Rickard, D. G., Shew, S. B., Maggard, M. A., Slusser, W. M., Dutson, E. P., DeUgarte, D. A. 2010; 126 (4): E746-E753

  Abstract

  The goal of this study was to evaluate trends, and outcomes of adolescents who undergo bariatric surgery.Patients younger than 21 years who underwent elective bariatric surgery between 2005 and 2007 were identified from the California Office of Statewide Health Planning and Development database. Multivariate logistic regression was used to identify factors associated with the type of surgery.Overall, 590 adolescents (aged 13-20 years) underwent bariatric surgery in 86 hospitals. White adolescents represented 28% of those who were overweight but accounted for 65% of the procedures. Rates of laparoscopic adjustable gastric banding (LAGB) increased 6.9-fold from 0.3 to 1.5 per 100,000 population (P<.01), whereas laparoscopic Roux-en-Y gastric bypass (LRYGB) rates decreased from 3.8 to 2.7 per 100 000 population (P<.01). Self-payers were more likely to undergo LAGB (relative risk [RR]: 3.51 [95% confidence interval: 2.11-5.32]) and less likely to undergo LRYGB (RR: 0.45 [95% confidence interval: 0.33-0.58]) compared with privately insured adolescents. The rate of major in-hospital complication was 1%, and no deaths were reported. Of the patients who received LAGB, 4.7% had band revision/removal. In contrast, 2.9% of those who received LRYGB required reoperations.White adolescent girls disproportionately underwent bariatric surgery. Although LAGB has not been approved by the US Food and Drug Administration for use in children, its use has increased dramatically. There was a complication rate and no deaths. Long-term studies are needed to fully assess the efficacy, safety, and health care costs of these procedures in adolescents.

  View details for DOI 10.1542/peds.2010-0412

  View details for Web of Science ID 000282526100001

  View details for PubMedID 20855388

• Disparity in Management and Long-term Outcomes of Pediatric Splenic Injury in California ANNALS OF SURGERY Jen, H. C., Tillou, A., Cryer, H. G., Shew, S. B. 2010; 251 (6): 1162-1166

  Abstract

  To determine the impact of evidence-based guidelines on the disparities in management of pediatric splenic injuries (PSI).Several studies have highlighted a disparity in the utilization of nonoperative management (NOM) for PSI based on hospital and surgeon characteristics. Whether evidence-based guidelines had an impact on mitigating this disparity is uncertain.From 1999 to 2006, children < or = 18 years with PSI were extracted from California's Patient Discharge Database (n = 5089). Patient demographics, injury grade, immediate and delayed operations, readmissions, and complications were analyzed.The overall rates of immediate operative management (IOM) decreased significantly from 23% in 1999 to 15% in 2006 (P < 0.001). This decline was attributed entirely to reduction of IOM at non-children's hospitals (NCH) (29% to 20%, P < 0.001). In contrast, IOM rates were low and unchanged at children's hospital (CH) (9%, P = NS). Failed NOM (3.3%), readmissions for complications (0.6%), and operations (0.3%) were rare and unaffected by NOM increase. NCH had increased risk of IOM compared to CH in multivariate analysis (OR: 2.00, 99% CI: 1.09-3.57). The rate of delayed splenic rupture was 0.2%. There were no differences when comparing the rates of readmissions (1.0% vs. 0.4%, P = NS) and readmit operations (0.3% vs. 0.3%, P = NS) between IOM versus NOM.A steady increase in the utilization of NOM for PSI in California over time was attributed entirely to changing practices at NCH. Increasing NOM has occurred without a concurrent increase in complications. Delayed splenic ruptures were rare. Although IOM rates at NCH decreased over time, disparity in NOM utilization still exists between NCH and CH.

  View details for DOI 10.1097/SLA.0b013e3181c98271

  View details for Web of Science ID 000278561700026

  View details for PubMedID 20485153

• Hospital Readmissions and Survival After Nonneonatal Pediatric ECMO PEDIATRICS Jen, H. C., Shew, S. B. 2010; 125 (6): 1217-1223

  Abstract

  The late effects of treatment with extracorporeal membrane oxygenation (ECMO) in nonneonatal pediatric patients remain unclear. The aims of our study were to better characterize the long-term survival and hospital readmission rates for pediatric patients after ECMO treatment.From 1999 to 2006, data on children aged 1 month to 18 years who underwent ECMO were extracted from the California Patient Discharge Database. Data from patients with diagnoses of congenital cardiac disease were excluded. We analyzed patient data on initial hospital course, subsequent readmissions, development of long-term morbidities, and long-term survival.The study cohort consisted of 188 children from 13 California hospitals. The median age was 3 years, and 46% of the patients survived to hospital discharge. ECMO indications included acquired heart disease in 81 patients, pneumonia in 56, other respiratory failure in 22, sepsis in 8, trauma in 8, and other indications in 12. Of the 87 survivors, 56 were tracked for a median period of 3.7 years. The readmission rate was 62%, and the mean time to first readmission was 1.2 years. Readmissions for respiratory infections were observed in 34% of the patients and for reactive airway disease in 7%. Neurologically debilitating conditions (epilepsy [7%] and developmental delay [9%]) occurred in 16%. Late deaths occurred in 5% of the children. Readmitted survivors had a cumulative length of readmission hospitalization of 8 days and hospital charge of $43 000. Cox proportional hazard regression demonstrated a positive relationship between treatment-center case volume and long-term survival outcomes (hazard ratio: 0.98 per case; P < .01).Pediatric ECMO survivors suffered from significant long-term morbidities after initial hospital discharge. More than 60% of these children required subsequent readmissions, and late deaths were observed in 5%. Furthermore, hospitals with high case volumes were associated with improved long-term survival.

  View details for DOI 10.1542/peds.2009-0696

  View details for Web of Science ID 000278268600016

  View details for PubMedID 20478938

• Laparoscopic Versus Open Appendectomy in Children: Outcomes Comparison Based on a Statewide Analysis JOURNAL OF SURGICAL RESEARCH Jen, H. C., Shew, S. B. 2010; 161 (1): 13-17

  Abstract

  To compare the differences in hospital utilization and complications between laparoscopic (LA) and open appendectomy (OA) for pediatric appendicitis.A retrospective study from 1999 to 2006 of children aged 1 to 18 y with appendicitis, from the California Patient Discharge Database was performed. Children with significant comorbidities were excluded. Initial hospital course, subsequent readmissions, and the need for additional procedures were analyzed.The use of LA increased steadily from 19% in 1999 to 52% in 2006. Overall, 95,806 children were studied. Readmissions were tracked over a median period of 3 y. LA was associated with increased need for postoperative intra-abdominal abscess drainage for both perforated appendicitis (4.9% versus 3.8%, P<0.001) and nonperforated appendicitis (0.6% versus 0.3%, P<0.001) compared with OA. Multivariate regression showed an increased risk of postoperative abscess drainage for children after LA compared with OA (RR 1.81, 99% CI 1.41-2.27). However, the lengths of readmission hospitalizations were the same between the two groups (5.8 versus 5.7 d, P=NS).LA has become the preferred operation for pediatric appendicitis. The need for postoperative abscess drainage is small, and laparoscopy appears to increase this risk slightly. However, LA did not affect long-term hospital utilizations.

  View details for DOI 10.1016/j.jss.2009.06.033

  View details for Web of Science ID 000277537200003

  View details for PubMedID 20031168

• Creation of Inpatient Capacity During a Major Hospital Relocation Lessons for Disaster Planning ARCHIVES OF SURGERY Jen, H. C., Shew, S. B., Atkinson, J. B., Rosenthal, J. T., Hiatt, J. R. 2009; 144 (9): 859-864

  Abstract

  To identify tools to aid the creation of disaster surge capacity using a model of planned inpatient census reduction prior to relocation of a university hospital.Prospective analysis of hospital operations for 1-week periods beginning 2 weeks (baseline) and 1 week (transition) prior to move day; analysis of regional hospital and emergency department capacity.Large metropolitan university teaching hospital.Hospital census figures and patient outcomes.Census was reduced by 36% from 537 at baseline to 345 on move day, a rate of 18 patients/d (P < .005). Census reduction was greater for surgical services than nonsurgical services (46% vs 30%; P = .02). Daily volume of elective operations also decreased significantly, while the number of emergency operations was unchanged. Hospital admissions were decreased by 42%, and the adjusted discharges per occupied bed were increased by 8% (both P < .05). Inpatient mortality was not affected. Regional capacity to absorb new patients was limited. During a period in which southern California population grew by 8.5%, acute care beds fell by 3.3%, while Los Angeles County emergency departments experienced a 13% diversion rate due to overcrowding.Local or regional disasters of any size can overwhelm the system's ability to respond. Our strategy produced a surge capacity of 36% without interruption of emergency department and trauma services but required 3 to 4 days for implementation, making it applicable to disasters and mass casualty events with longer lead times. These principles may aid in disaster preparedness and planning.

  View details for Web of Science ID 000269833500011

  View details for PubMedID 19797112

• Hospital Differences in Short-Term Outcomes for Uncomplicated Pediatric Patients With Gallbladder Disease JOURNAL OF SURGICAL RESEARCH Jen, H. C., Shew, S. B. 2009; 153 (2): 195-200

  Abstract

  To examine the differences in short-term outcomes and laparoscopic cholecystectomy rates between children's hospitals and non-children's hospitals for uncomplicated pediatric gallbladder disease.A retrospective study was performed of cholecystectomy patients aged 4 to 12 years in 2003 from the Kid's In-Patient Database. Patients with significant comorbidities were excluded. We compared length of hospitalization, complication rates, and laparoscopic cholecystectomy utilization between hospital types.Five-hundred fifty-six cholecystectomies were performed for children aged 4 to 12 years in 2003 after exclusion. Children's hospital patients had longer hospitalizations (3.34 versus 2.52 days, P < 0.001), and more complications (3.4 versus 0.9%, P = 0.05) despite fewer emergency admissions. Utilization of laparoscopic cholecystectomy was lower at children's hospitals (91 versus 97% P < 0.005). After excluding sickle cell patients, children's hospitals patients still had lower laparoscopic cholecystectomy rates (89 versus 97%, P < 0.005) and longer hospitalizations (3.12 versus 2.44 days, P < 0.01). Hospital and surgeon volumes were not associated with better outcomes. Factors associated with longer hospitalization included treatment at children's hospitals, nonelective admission, sickle cell disease, and complications (P < 0.001).Children without significant comorbidities have longer hospitalizations when treated at children's hospitals for cholecystectomies compared with those at non-children's hospitals. Laparoscopic cholecystectomy use was lower at children's hospitals and similar differences in outcomes remained when comparing only laparoscopic cholecystectomy patients.

  View details for DOI 10.1016/j.jss.2008.03.031

  View details for Web of Science ID 000265585100003

  View details for PubMedID 18674786

• Surgical concerns in malrotation and midgut volvulus. Pediatric radiology Shew, S. B. 2009; 39: S167-71

  Abstract

  Appropriate management of the child with malrotation and/or midgut volvulus requires a multi-disciplinary approach with early clinical suspicion, rapid confirmation of diagnosis, and expedient operative intervention in order to obtain the most effective outcomes.

  View details for DOI 10.1007/s00247-008-1129-x

  View details for PubMedID 19308380

• The impact of hospital type and experience on the operative utilization in pediatric intussusception: a nationwide study JOURNAL OF PEDIATRIC SURGERY Jen, H. C., Shew, S. B. 2009; 44 (1): 241-246

  Abstract

  To determine the impact in clinical outcomes of pediatric idiopathic intussusceptions from hospital experience and designation as children's hospitals (CH) and non-children's hospitals (NCH) in the US.A retrospective study was performed on 1263 children with idiopathic intussusception, 2 months to 3 years of age in 2000 and 2003 by extracting data from the Healthcare Cost and Utilization Project Kid's Inpatient Database. Main outcome measures were utilizations of operation and radiologic reduction. Statistical significance was defined as P < .05.The median hospital volume of intussusceptions was higher at CH (2.5 vs 0.5 cases per year, P < .001) compared to NCH. Children treated at CH had lower risk of operation (55 vs 68%, P < .001) and higher likelihood of radiologic reduction (39 vs 26%, P < .001) compared to NCH. Multivariate regression analysis showed a 17% reduction of operative utilization at CH vs NCH. Outcomes were positively related to experience as high-volume hospitals reduced operative utilization by 19%. Rates of successful radiologic reduction were similar between hospital types, which was 85% nationally.Children with intussusception have decreased likelihood of operation when treated at CH compared to NCH. This decreased operative utilization can be attributed to the increased experience and utilization of radiologic reduction at these specialty hospitals.

  View details for DOI 10.1016/j.jpedsurg.2008.10.050

  View details for Web of Science ID 000263154300049

  View details for PubMedID 19159750

• Recombinant activated factor VII use in critically ill infants with active hemorrhage JOURNAL OF PEDIATRIC SURGERY Jen, H., Shew, S. 2008; 43 (12): 2235-2238

  Abstract

  Recombinant activated factor VII (rFVIIa) is infrequently used off-label in infants despite a paucity of data in this population. We report a retrospective review of rFVIIa use in infants focusing on safety and efficacy.Between 2002 and 2007, 32 critically ill nonhemophiliac infants less than 1 year old received rFVIIa at our institution. Indications of rFVIIa and post-rFVIIa venous thrombosis were reviewed. Transfusion requirements were calculated 8 hours before and after rFVIIa administration.Infants received on average 2 doses of rFVIIa at a mean dosage of 90 microg/kg. Active hemorrhage was the indication for rFVIIa in 24 infants, which included postoperative bleeding in 16 and nonsurgical bleeding in 8. The remaining 8 infants had preoperative coagulopathy. Thrombosis was noted in 4 infants (13%) and was not related to transfusion requirements, the number of doses, or dosage of rFVIIa. For infants who had active hemorrhage, rFVIIa was able to significantly reduce the requirements of packed red blood cells by 36.17 mL/kg (P < .005), platelets by 10.31 mL/kg (P < .01), and cryoprecipitates by 2.19 mL/kg (P < .05).This is the first large case series demonstrating the efficacy of rFVIIa in critically ill infants with active hemorrhage by reducing their transfusion requirements. Furthermore, venous thrombosis was not associated with increase in either the number of doses or dosage of rFVIIa.

  View details for DOI 10.1016/j.jpedsurg.2008.08.053

  View details for Web of Science ID 000261853700021

  View details for PubMedID 19040942

• Management of High-Grade Splenic Injury in Children AMERICAN SURGEON Jim, J., Leonardi, M. J., Cryer, H. G., Hiatt, J. R., Shew, S., Cohen, M., Tillou, A. 2008; 74 (10): 988-992

  Abstract

  Using the National Trauma Databank, we identified 413 children (age < or = 14 years) who sustained high-grade blunt splenic injury (Abbreviated Injury Scale scores > or = 4) from 2001 to 2005. Overall mortality was 13.5 per cent. Early operation within 6 hours of injury (EOM) was performed in 128 patients (31%). Patients not undergoing EOM (n = 285) were assumed to have been treated with initial nonoperative management (NOM). NOM was successful in 84 per cent of patients. Operative intervention was necessary in 42 per cent of cases with 74 per cent of these undergoing early operation (EOM). Total splenectomy was the most common procedure (83%). EOM and failure of NOM were both associated with lower systolic blood pressure and lower Glasgow Coma Scale score at admission, higher Injury Severity Score, longer hospital stay, and higher mortality. Need for surgery was independent of patient age and gender. Failure of NOM was associated with increased mortality compared with successful NOM, but had similar mortality and length of hospital or intensive care unit stay compared with EOM. We conclude that operative treatment is necessary in nearly half of pediatric patients with high-grade splenic injury. With careful selection, nonoperative management is usually successful but must include close monitoring, because 16 per cent required delayed operation.

  View details for Web of Science ID 000260095100023

  View details for PubMedID 18942629

• Use of esophagocrural sutures and minimal esophageal dissection reduces the incidence of postoperative transmigration of laparoscopic Nissen fundoplication wrap JOURNAL OF PEDIATRIC SURGERY St Peter, S. D., Valusek, P. A., Calkins, C. M., Shew, S. B., Ostlie, D. J., Holcomb, G. W. 2007; 42 (1): 25-30

  Abstract

  Herniation of the fundoplication wrap through the esophageal hiatus is a common reason for surgical failure in children who have undergone laparoscopic Nissen fundoplication. Extensive mobilization of the gastroesophageal junction in combination with decreased adhesions after laparoscopy may contribute to the development of this complication. In an attempt to decrease the incidence of wrap migration, we changed our technique to minimal mobilization of the intraabdominal esophagus and to placement of esophageal-crural sutures. In this study, we investigate the impact of these modifications on outcome.A retrospective analysis was performed on all patients undergoing laparoscopic fundoplication by the senior author (GWH) from January 2000 through December 2004. Those undergoing operation with extensive esophageal mobilization and without esophagocrural sutures (January 2000 to March 2002) (group I) were compared with those in whom there was minimal esophageal dissection with placement of these esophagocrural sutures (April 2002 to December 2004) (group II).Two hundred forty-nine patients underwent laparoscopic Nissen fundoplication during the study period. One hundred thirty patients were in group I, and 119 patients were in group II. The rate of transmigration decreased from 12% in group I to 5% in group II (P = .072). The relative risk of transmigration with extensive esophageal mobilization and without the esophagocrural sutures was 2.29.This retrospective study has shown that placement of esophagocrural sutures and minimization of the dissection around the esophagus results in a more than 2-fold reduction in the risk of wrap transmigration after laparoscopic Nissen fundoplication.

  View details for DOI 10.1016/j.jpedsurg.2006.09.051

  View details for Web of Science ID 000243707100004

  View details for PubMedID 17208536

• Management of postoperative infections after the minimally invasive pectus excavatum repair JOURNAL OF PEDIATRIC SURGERY Calkins, C. M., Shew, S. B., Sharp, R. J., Ostlie, D. J., Yoder, S. M., Gittes, G. K., Snyder, C. L., Guevel, W., Holcomb, G. W. 2005; 40 (6): 1004-1008

  Abstract

  Pectus excavatum is frequently repaired using the minimally invasive placement of a substernal bar (Nuss procedure). Infectious complications after the Nuss procedure are potentially devastating. To date, the management of postoperative infectious complications has not been well described.A retrospective review of all patients (N = 168) who underwent the Nuss procedure from January 1, 1997, to October 1, 2003, at our institution was performed. Six patients (4%) had postoperative infections, and their medical records were reviewed.Of the 6 patients, 5 underwent operative drainage for wound abscesses that developed 2 to 76 weeks postoperatively. The other patient developed cellulitis 12 months postoperatively and was treated effectively with antibiotics alone. Recurrent infections were treated in 3 of 6 patients, one of whom eventually required removal of the bar resulting in a mild, residual pectus excavatum defect. One of 6 patients has had the substernal bar removed electively. The remaining 4 continue to be without clinically apparent infection at this time and are over 1 year removed from their infection.Although uncommon, infectious complications after the Nuss procedure require complex management strategies. Despite recurrent infection in some cases, most infectious complications occurring after the minimally invasive repair can be effectively treated without having to remove the substernal bar.

  View details for DOI 10.1016/j.jpedsurg.2005.03.017

  View details for Web of Science ID 000230621800020

  View details for PubMedID 15991186

• Assessment of cysteine synthesis in very low-birth weight neonates using a [C-13(6)]glucose tracer JOURNAL OF PEDIATRIC SURGERY Shew, S. B., Keshen, T. H., Jahoor, F., Jaksic, T. 2005; 40 (1): 52-56

  Abstract

  Cysteine is an amino acid necessary for the synthesis of all proteins, the antioxidant glutathione, and the neuromodulator taurine. Whether cysteine is an essential amino acid for premature neonates remains controversial. Using a [13C6]glucose precursor in very-low-birth weight (VLBW) premature neonates, we measured the 13C content of cysteine in hepatically derived apolipoprotein (apo) B-100 and in the plasma to determine whether cysteine synthesis occurs and to relate minimum synthetic capacity to neonatal maturity.Twelve VLBW premature neonates (birth weight, 907 +/- 274 [SD] g; gestational age, 26.8 +/- 2.4 weeks) were studied on day of life 7.8 +/- 4.2 while on total parenteral nutrition (TPN) for 5.6 +/- 4.5 days. A 4-hour intravenous infusion of [13C6]glucose was administered. Blood samples were obtained immediately before and at the end of the infusion. Isotopic enrichment of cysteine was determined by gas chromatography/mass spectrometry. Analysis of variance, Student's t test, and linear regression were used for comparisons.The 13C isotope ratio of apo B-100-derived cysteine after the [13C6]glucose infusion was significantly higher than baseline (18.57 +/- 0.38 [SEM] vs 17.54 +/- 0.25 mol%, P < .05). The 13C isotope ratio of plasma cysteine was also significantly higher than baseline (17.36 +/- 0.25 vs 16.91 +/- 0.16 mol%, P < .05). When expressed as a product/precursor ratio, the mole percent above baseline of [13C]apo B-100 cysteine/[13C6]glucose correlated with birth weight (r = 0.74, P < .01).Very low-birth weight neonates are capable of cysteine synthesis as evidenced by incorporation of 13C label into hepatically derived apo B-100 cysteine and plasma cysteine from a glucose precursor. The minimum capacity for intrahepatic cysteine synthesis appears to be directly proportional to the maturity of the neonate and may impact the capabilities of VLBW neonates to counteract oxidative stresses such as bronchopulmonary dysplasia and necrotizing enterocolitis.

  View details for DOI 10.1016/j.jpedsurg.2004.09.011

  View details for Web of Science ID 000226927000011

  View details for PubMedID 15868558

• The parental perspective regarding the contralateral inguinal region in a child with a known unilateral inguinal hernia JOURNAL OF PEDIATRIC SURGERY Holcomb, G. W., Miller, K. A., Chaignaud, B. E., Shew, S. B., Ostlie, D. J. 2004; 39 (3): 480-482

  Abstract

  The management of the contralateral region in a child with a known inguinal hernia has been debated by surgeons for more than 50 years. However, the perspective of the child's parents has not been sought, and this study was designed to evaluate parental views on this topic.After IRB approval, all patients less than 10 years of age with a unilateral inguinal hernia seen by the senior surgeon were studied prospectively from November 2001 through February 2003. A study sheet was given to the parents about the nature of an inguinal hernia, the incidence of 20% to 40% of a contralateral patent processus vaginalis (CPPV), and the possible surgical options (perform repair of the unilateral inguinal hernia only, repair the unilateral inguinal hernia with contralateral exploration and repair if indicated, or unilateral inguinal hernia repair with laparoscopy through the ipsilateral hernia sac and repair of a CPPV if discovered). The parents of the last 113 patients requesting contralateral inspection were asked their motives (convenience or anesthesia concerns) regarding their decision.One hundred sixty-seven patients comprise the study group. Twelve parents chose unilateral repair alone, 13 chose bilateral incisions with contralateral repair if a CPPV was found, and 142 chose unilateral hernia repair with laparoscopic contralateral inspection followed by repair if needed. Regarding their motives, 90 of the last 113 parents requesting contralateral inspection indicated that convenience was the primary motive. Surprisingly, only 21 exhibited concerns about their child undergoing a second anesthesia.When presented options regarding management of a unilateral inguinal hernia, parents preferred laparoscopic inspection and repair of the contralateral region, if needed, more for convenience than for concerns about a second procedure and anesthesia.

  View details for DOI 10.1016/j.jpedsurg.2003.11.018

  View details for Web of Science ID 000220539500071

  View details for PubMedID 15017573

• Energy expenditure in ill premature neonates JOURNAL OF PEDIATRIC SURGERY Garza, J. J., Shew, S. B., Keshen, T. H., Dzakovic, A., Jahoor, F., Jaksic, T. 2002; 37 (3): 289-293

  Abstract

  The energy needs of critically ill premature neonates undergoing surgery remain to be defined. Results of studies in adults would suggest that these neonates should have markedly increased energy expenditures. To test this hypothesis, a recently validated stable isotopic technique was used to measure accurately the resting energy expenditure (REE) of critically ill premature neonates before and after patent ductus arteriosus (PDA) ligation.Six ventilated, fully total parenteral nutrition (TPN)-fed, premature neonates (24.5 plus minus 0.5 weeks' gestational age) were studied at day of life 7.5 plus minus 0.7, immediately before and 16 plus minus 3.7 hours after standard PDA ligation. REE was measured with a primed continuous infusion of NaH(13)CO(3), and breath samples were analyzed by isotope ratio mass spectroscopy. Serum CRP and cortisol concentrations also were obtained. Statistical analyses were made by paired sample t tests and linear regression.The resting energy expenditures pre- and post-PDA ligation were 37.2 plus minus 9.6 and 34.8 plus minus 10.1 kcal/kg/d (not significant, P =.61). Only preoperative energy expenditure significantly (P <.01) predicted postoperative energy expenditure (R(2) = 88.0%). Pre- and postoperative determinations of CRP were 2.1 plus minus 1.5 and 7.1 plus minus 4.2 mg/dL (not significant, P =.34), and cortisol levels were 14.1 plus minus 2.3 and 14.9 plus minus 2.1 microgram/dL (not significant, P =.52).Thus, critically ill premature neonates do not have elevated REE, and, further, there is no increase in REE evident the first day after surgery. This suggests that routine allotments of excess calories are not necessary either pre-or postoperatively in critically ill premature neonates. Given the high interindividual variability in REE, actual measurement is prudent if protracted nutritional support is required.

  View details for DOI 10.1053/jpsu.2002.30821

  View details for Web of Science ID 000174160700003

  View details for PubMedID 11877636

• Do critically ill surgical neonates have increased energy expenditure? JOURNAL OF PEDIATRIC SURGERY Jaksic, T., Shew, S. B., Keshen, T. H., Dzakovic, A., Jahoor, F. 2001; 36 (1): 63-67

  Abstract

  Adult metabolic studies suggest that critically ill patients have increased energy expenditures and thus require higher caloric allotments. To assess whether this is true in surgical neonates the authors utilized a validated, gas leak-independent, nonradioactive, isotopic technique to measure the energy expenditures of a stable postoperative group and a severely stressed cohort.Eight (3.46+/-1.0 kg), hemodynamically stable, total parenteral nutrition (TPN)-fed, nonventilated, surgical neonates (5 with gastroschisis, 2 with intestinal atresia, and 1 with intestinal volvulus) were studied on postoperative day 15.5+/-11.9. These were compared with 10 (BW = 3.20+/-0.2 kg), TPN-fed, extracorporeal life support (ECLS)-dependent neonates, studied on day of life 7.0+/- 2.8. Energy expenditure was obtained using a primed, 3-hour infusion of NaH(13)CO(3'), breath (13)CO(2) enrichment determination by isotope ratio mass spectroscopy, and the application of a standard regression equation. Interleukin (IL)-6 levels and C-reactive protein (CRP) concentrations were measured to assess metabolic stress. Comparisons between groups were made using 2 sample Student's t tests.The mean energy expenditure was 53+/-5.1 kcal/kg/d (range, 45.6 to 59.8 kcal/kg/d) for the stable cohort and 55+/-20 kcal/kg/d (range, 32 to 79 kcal/kg/d) for the ECLS group (not significant, P =.83). The IL-6 and CRP levels were significantly higher in the ECLS group (29 +/-11.5 v 0.7+/-0.6 pg/mL [P<.001], and 31+/-22 v 0.6+/-1.3 mg/L [P<.001], respectively). Mortality rate was 0% for the stable postoperative patients and 30% for the ECLS group.Severely stressed surgical neonates, compared with controls, generally do not show increased energy expenditures as assessed by isotopic dilution methods. These data suggest that the routine administration of excess calories may not be warranted in critically ill surgical neonates and support the hypothesis that neonates obligately redirect energy, normally used for growth, to fuel the stress response. This is a US government work. There are no restrictions on its use.

  View details for Web of Science ID 000166180500011

  View details for PubMedID 11150439

• Ligation of a patent ductus arteriosus under fentanyl anesthesia improves protein metabolism in premature neonates JOURNAL OF PEDIATRIC SURGERY Shew, S. B., Keshen, T. H., Glass, N. L., Jahoor, F., Jaksic, T. 2000; 35 (9): 1277-1281

  Abstract

  Although surgical ligation effectively reverses the cardiopulmonary failure associated with patent ductus arteriosus (PDA), previous findings have suggested that such surgery itself elicits a catabolic response in premature neonates. Therefore, the authors sought to quantitatively assess whether PDA ligation under fentanyl anesthesia aggravated or improved the protein metabolism of premature neonates.Seven ventilated, premature neonates (birth weight 815 +/- 69 g) underwent PDA ligation with standardized fentanyl anesthesia (15 microg/kg) on day-of-life 8.4 +/- 1.2 and were studied immediately pre- and 16 to 24 hours postoperatively while receiving continuous total parenteral nutrition (TPN). Whole-body protein kinetics were calculated using intravenous 1-[13C]leucine, and skeletal muscle protein breakdown was measured from the urinary 3-methylhistidine to creatinine ratio (MH:Cr).Whole-body protein breakdown (10.9 +/- 1.2 v8.9 +/- 0.8 g/kg/d, P < .05), turnover (17.4 +/- 1.2 v 15.4 +/- 0.8 g/kg/d, P< .05), and MH:Cr (1.95 +/- 0.20 v 1.71 +/- 0.16 micromol:mg, P< .05) decreased significantly after operation. This resulted in a 60% improvement in protein balance (1.6 +/- 0.8 v 2.6 +/- 0.6 g/kg/d, P = 0.08) postoperatively.Because of decreased whole-body protein breakdown, whole-body protein turnover, skeletal muscle protein breakdown, and increased protein accrual, surgical PDA ligation under fentanyl anesthesia promptly improves the protein metabolism of premature neonates enduring the stress of a PDA.

  View details for Web of Science ID 000089146600001

  View details for PubMedID 10999678

• Validation of a [C-13]bicarbonate tracer technique to measure neonatal energy expenditure PEDIATRIC RESEARCH Shew, S. B., Beckett, P. R., Keshen, T. H., Jahoor, F., Jaksic, T. 2000; 47 (6): 787-791

  Abstract

  The use of a stable isotope-labeled [13C]bicarbonate infusion to measure energy expenditure is advantageous, as a complete collection of expired air is not required. This technique allows for facile measurements of energy expenditure in intubated neonates. The aim of the present study was to determine the accuracy of energy expenditure estimates in postsurgical neonates by using the [13C]bicarbonate method compared with the current standard, indirect calorimetry. Eight neonates who were receiving total parenteral nutrition [98 +/- 21 (SD) kcal x kg(-1) x d(-1); 3.1 +/- 0.7 (SD) protein g x kg(-1) x d(-1)] were studied on postoperative d 15.5 +/- 11.9. A primed continuous 3-h intravenous infusion of NaH13CO3 and indirect calorimetry were performed simultaneously. Energy expenditure was calculated separately from the Weir equation and from the dilution of 13CO2 in the breath in combination with the individual energy equivalents of CO2 from the diet. The rate of CO2 appearance and energy expenditure calculated from the bicarbonate method (0.725 +/- 0.021 mol x kg(-1) x d(-1); 89.5 +/- 2.5 kcal x kg(-1) x d(-1)) highly correlated (r = 0.94 and 0.98, respectively) with the CO2 excretion and energy expenditure determined by indirect calorimetry (0.489 +/- 0.016 mol x kg(-1) x d(-1); 60.2 +/- 2.0 kcal x kg(-1) x d(-1)) when analyzed nonproportionately to weight. Bland-Altman analysis demonstrated the 95% confidence interval to be +/- 8.2 kcal x kg(-1) x d(-1). Linear regression analysis revealed a highly statistically significant equation relating the two energy expenditures: Indircal (kcal/d) = -9.341 + [0.705 x Bicarb (dcal/d)]; p < 0.001, r2 = 96.4%. We conclude that energy expenditure in neonates can be accurately determined using the [13C]bicarbonate method and a regression equation. Therefore, the bicarbonate method may be useful for determining energy expenditure in neonates not readily accessible to indirect calorimetry, such as those being mechanically ventilated or on extracorporeal life support.

  View details for Web of Science ID 000087127600017

  View details for PubMedID 10832739

• The metabolic needs of critically ill children and neonates. Seminars in pediatric surgery Shew, S. B., Jaksic, T. 1999; 8 (3): 131-139

  Abstract

  The pediatric metabolic response to injury and operation is proportional to the degree of stress and causes an increase in the turnover of proteins, fats, and carbohydrates. Thereby, substrates are made readily available for the immune response and wound healing. Because this process requires energy, the resting energy expenditure of ill patients increases. Whole-body protein degradation rates are elevated out of proportion to synthetic rates, and negative protein balance also ensues. Neonates and children are particularly susceptible to the loss of lean body mass and its attendant increased morbidity and mortality caused by an intrinsic lack of endogenous stores and greater baseline requirements. An appropriately designed mixed fuel system of nutritional support replete in protein does not quell this metabolic response but can result in anabolism and continued growth in ill children. In addition, the use of adequate analgesia and anesthesia is a readily available and proven means of reducing the magnitude of the catabolism associated with operation and injury. Finally, as hormonal- and cytokine-mediated metabolic alterations are better understood, therapeutic interventions may become available to directly modulate the metabolic response to illness, thus potentially further improving clinical outcome in pediatric surgical patients.

  View details for PubMedID 10461326

• The determinants of protein catabolism in neonates on extracorporeal membrane oxygenation JOURNAL OF PEDIATRIC SURGERY Shew, S. B., Keshen, T. H., Jahoor, F., Jaksic, T. 1999; 34 (7): 1086-1090

  Abstract

  Protein catabolism appears to be markedly elevated among neonates on extracorporeal membrane oxygenation (ECMO). The aim of this study was to determine the effect of dietary caloric intake on protein catabolism in neonates on ECMO to help construct therapies that may promote anabolism.Twelve total parenteral nutrition (TPN)-fed (88.1 +/- 5.0 [SE] kcal/kg/d; range, 60 to 113 kcal/kg/d; 2.3 +/- 0.2 g/kg/d protein) neonates were studied on ECMO at day of life 7.2 +/- 0.8 d. Protein kinetics were determined using infusions of NaH13CO3 and 1-[13C]leucine.As expected, C-reactive protein levels were significantly elevated compared with normal controls (44.0 +/- 7.6 mg/L v 1.9 +/- 1.1 mg/L; P < .001). Negative protein balance (-2.3 +/- 0.6 g/kg/d; range, 1 to -6.4 g/kg/d) highly correlated (r = -0.88, P < .001) with total protein turnover. Increased dietary caloric intake correlated with increased amino acid oxidation (r = 0.85, P < .001), increased total protein turnover (r = 0.73, P < .01), continued negative protein balance (r = 0.72, P < .01), increased whole-body protein breakdown (r = 0.66, P < .05), and increased CO2 production rate (r = 0.73, P < .01).A surplus of dietary caloric intake does not improve protein catabolism and merely increases CO2 production in these highly stressed neonates. Thus, judicious caloric supplementation is warranted.

  View details for Web of Science ID 000081475300011

  View details for PubMedID 10442596

• Does extracorporeal membrane oxygenation improve survival in neonates with congenital diaphragmatic hernia? The Congenital Diaphragmatic Hernia Study Group. Journal of pediatric surgery 1999; 34 (5): 720-724

  Abstract

  The benefit of extracorporeal membrane oxygenation (ECMO) in improving survival of neonates with congenital diaphragmatic hernia (CDH) has never been clearly demonstrated. This may be due to comparisons made between treatment groups of unequal illness severity and the low statistical power of analyses from previous studies. The authors analyzed the data from the multicenter CDH registry to determine if ECMO improves survival in CDH neonates with a high risk of mortality.A total of 730 neonates were enrolled in the CDH Registry from January 1995 to November 1997. Of these, 632 neonates had a complete data set and were eligible for ECMO by the weight criterion of greater than 2.0 kg. Multivariate logistic regression analysis was used to assess mortality risk for each neonate based on previously validated independent predictors of survival: birth weight and 5-minute Apgar. Five quintile groups were defined based on increasing predictive mortality risk. Multivariate logistic regression and chi2 analyses with birth weight, Apgar score at 5 minutes, and predictive mortality risk as covariates were then performed to assess survival benefit of ECMO compared with conventional therapy alone. Patient survival rate was defined as survival to discharge from hospital.When analyzing all 632 neonates, ECMO neonates (n = 289) had a decidedly lower survival rate (52.9% v 77.3%, P< .001) than non-ECMO neonates (n = 343) without standardizing for the degree of illness. However, when taking into account the patients' predictive mortality risk, ECMO was associated with improved survival in the neonates with mortality risk < or = 80% (P < .05). Furthermore, ECMO was shown to be a positive independent predictor of survival when accounting for the covariates of birth weight, 5-minute Apgar, and mortality risk (P < .05).ECMO significantly improves survival rates for those CDH neonates with a predictive mortality risk > or = 80%. Generally, the more critically ill the patient with CDH, the more marked the survival benefit obtained.

  View details for PubMedID 10359171

• Growth deficiency and malnutrition in Bloom syndrome JOURNAL OF PEDIATRICS Keller, C., Keller, K. R., Shew, S. B., Plon, S. E. 1999; 134 (4): 472-479

  Abstract

  To describe the growth and nutritional status of a pediatric population with Bloom syndrome.Longitudinal growth data from 148 patients in the Bloom's Syndrome Registry (85 male, 63 female) were compiled retrospectively from physician and parent records to develop graphed statistics of weight-for-age, height-for-age, fronto-occipital circumference-for-age, and weight-for-height for both sexes with comparisons with the normal population.Term birth measurements confirm that the growth deficiency of Bloom syndrome has prenatal onset. Stunting persists throughout life, and an adolescent growth spurt is not apparent from the smoothed data. Growth continues by at least 1 cm/yr until age 21 years for both sexes. More than half of children with Bloom syndrome are significantly wasted until age 8 years, which is not related to early death or underlying malignancy. The mean body mass index for adults with Bloom syndrome after age 25 years is low normal (n = 22, mean = 20.2 kg/m2).Children with Bloom syndrome have significant growth retardation and wasting.

  View details for Web of Science ID 000079648400015

  View details for PubMedID 10190923

• Does extracorporeal membrane oxygenation benefit neonates with congenital diaphragmatic hernia? Application of a predictive equation JOURNAL OF PEDIATRIC SURGERY Keshen, T. H., Gursoy, M., Shew, S. B., Smith, E., MILLER, R. G., Wearden, M. E., Moise, A. A., Jaksic, T. 1997; 32 (6): 818-822

  Abstract

  The overall survival of neonates with congenital diaphragmatic hernia (CDH) remains poor despite the advent of extracorporeal membrane oxygenation (ECMO). Attempts at accurately predicting survival have been largely unsuccessful. The purpose of this study was twofold: (1) to identify independent predictors of survival from a cohort of CDH neonates treated at the authors' institution when ECMO was not available and combine them to form a predictive equation, and (2) to apply the equation prospectively in a cohort of CDH neonates, treated at the same institution when ECMO was available, to determine whether ECMO improves outcome. From the clinical data of 62 CDH neonates treated at the authors' center by the same team of university neonatologists and pediatric surgeons between 1983 and 1993 (before ECMO availability), 15 preoperative and seven operative variables were selected as potential independent predictors. When subjected to multivariate, stepwise logistic regression analysis, four variables were identified as statistically significant (P < .05), independent predictors of survival: (1) ventilatory index (VI), (2) best preoperative PaCO2, (3) birth weight (BW), and (4) Apgar score at 5 minutes. When combined via logistic regression analysis, the following predictive equation was formulated: P (probability of survival to discharge) = [1 + e(x)]-1 where x = 4.9 - 0.68 (Apgar) - 0.0032 (BW) + 0.0063 (VI) + 0.063 (PaCO2). Applying a standard cut-off rate of survival at less than 20%, the equation yielded a sensitivity of 94% and a specificity of 82% in identifying the correct outcome of patients treated with conventional ventilatory management. The overall survival rate was 66%. Since the availability of ECMO at the center, 32 CDH neonates were treated using the same conventional ventilatory treatment and surgical repair by the same university staff. The overall survival rate was 69%. The predictive equation was applied prospectively to all neonates to determine predicted outcome, but was not used to decide the treatment method. Eighteen neonates received conventional therapy alone; 16 of 18 survived (89%). Fifteen of the 16 patients who survived had their outcomes predicted correctly (94%). Fourteen neonates did not respond to conventional therapy and required ECMO; 6 of 14 survived (43%). Six of the eight patients predicted to survive, lived (75%). All six patients predicted to die, died despite the addition of ECMO therapy (100%). The mean hospital cost, per ECMO patient who died, was $277,264.75 +/- $59,500.71 (SE). An odds ratio analysis, using the four independent predictors to standardize for degree of illness, was performed to assess the risk associated with adding ECMO therapy. The result was 1.25 (P = 0.75). Although the cohort was not large enough to eliminate significant beta error, the data strongly suggested no advantage of ECMO. At this center, absolute survival rates for neonates with CDH have not been significantly altered since ECMO has become available (66% v 69%). The authors conclude that the predictive equation remains an accurate measurement of survival at their center even when ECMO is used as a salvage therapy. The method of creating a predictive equation may be applied at any institution to determine the potential outcome of CDH neonates and assess the effect of ECMO, or other salvage therapies, on survival rates.

  View details for Web of Science ID A1997XE96200005

  View details for PubMedID 9200077

• Compartmentation of endogenously synthesized amino acids in neonates JOURNAL OF SURGICAL RESEARCH MILLER, R. G., Keshen, T. H., Jahoor, F., Shew, S. B., Jaksic, T. 1996; 63 (1): 199-203

  Abstract

  The conversion of D-[U-13C]glucose to proline (Pro), aspartate (Asp), and cysteine (Cys) is limited in premature neonates, implying that these amino acids (AA) are conditionally essential. This study was performed to determine whether these findings resulted from an insufficient precursor dose or intracellular compartmentation of newly synthesized amino acids, rather than inadequate synthesis. In the first phase of this study, seven total parenteral nutrition-fed, premature neonates received IV D-[U-13C]glucose at 5 mg/kg/min for 4 hr. In the second phase, a separate cohort of eight patients received an identical infusion. Blood was obtained before and at the end of the infusion. Isotopic enrichments of the free plasma AA and glucose were measured using gas chromatography/mass spectrometry in both studies. In phase 2, the isotopic enrichments of the AA bound to the hepatically synthesized proteins, fibrinogen and VLDL-apolipoprotein B-100 (apo B-100), were measured. In phase 1, despite a glucose precursor enrichment greater than 66%, Pro, Asp, and Cys remained the least enriched of all amino acids studied (P < 0.05). Asp, but not Pro, demonstrated very high enrichments in apo B-100 (P < 0.001), reflecting distinct intracellular compartmentation. We conclude that the limited conversion Of D-[U-13C]glucose to Pro, Asp, and Cys did not result from low precursor glucose enrichment and that there is evidence of Asp compartmentation (intracellular) in premature neonates. However, the low Pro enrichment in the free plasma AA pool and the absence of intracellular Pro compartmentation suggest that Pro may be a conditionally essential AA for premature neonates.

  View details for Web of Science ID A1996UU47100036

  View details for PubMedID 8661197