CONSORTIUM PUBLICATIONS
“Healthcare-Associated Pressure Injury in Pediatric Trauma Patients with Cervical Spine Immobilization: A Western Pediatric Surgery Research Consortium Multi-Center Retrospective Review” has been accepted as a podium presentation in the Scientific Abstract Session at the 2023 Western Pediatric Trauma Conference
Caroline Melhado MD MS, Katie W. Russell MD, Shannon N. Acker MD, Benjamin E. Padilla MD, Katrine Lofberg MD, Ryan G. Spurrier MD, Bryce Robinson MD MS, Stephanie Chao MD, Romeo C. Ignacio, Jr., MD, MS, MPath, Mark Ryan MD, and Aaron R. Jensen MD MEd MS, on behalf of the Western Pediatric Surgery Research Consortium Cervical Spine Injury Study Group.
Negative Predictive Value of a Normal Cervical Spine CT Compared to MRI for Ligamentous Injury After Blunt Trauma in Children: A Western Pediatric Surgery Research Consortium Multi-Center Retrospective Review for consideration at the 2023 National Conference & Exhibition’s Section on Surgery Program.
Caroline Melhado MD MS, Katie W. Russell MD, Shannon N. Acker MD, Benjamin E. Padilla MD, Katrine Lofberg MD, Ryan G. Spurrier MD, Bryce Robinson MD MS, Stephanie Chao MD, Romeo C. Ignacio, Jr., MD, MS, MPath, Mark Ryan MD, and Aaron R. Jensen MD MEd MS, on behalf of the Western Pediatric Surgery Research Consortium Cervical Spine Injury Study Group.
Machine Learning to Predict Pediatric Choledocholithiasis: A Western Pediatric Surgery Research Consortium Retrospective Study
Gretchen Floan Sachs, MD, Shadassa Ourshalimian, MPH, Aaron R. Jensen, MD, MEd, MS, FACS, Lorraine I. Kelley-Quon, MD, MSHS, FACS , Benjamin E. Padilla, MD, FACS, Stephen B. Shew, MD, FACS, Katrine M. Lofberg, MD, FACS, Caitlin A. Smith, MD, FACS, Jonathan P. Roach, MD, FACS , Samir R. Pandya, MD, FACS, Katie W. Russell, MD, FACS, Romeo C. Ignacio Jr., MD, MS, MPath, FACS, Western Pediatric Surgery Research Consortium Choledocholithiasis Investigative Group
Abstract:
Background: The purpose of this study was to accurately predict pediatric choledocholithiasis with clinical data using a computational machine learning algorithm.
Methods: A multicenter retrospective cohort study was performed on children <18 years of age who underwent cholecystectomy between 2016 to 2019 at 10 pediatric institutions. Demographic data, clinical findings, laboratory, and ultrasound results were evaluated by bivariate analyses. An Extra-Trees machine learning algorithm using k-fold cross-validation was used to determine predictive factors for choledocholithiasis. Model performance was assessed using the area under the receiver operating characteristic curve on a validation dataset.
Results: A cohort of 1,597 patients was included, with an average age of 13.9 ± 3.2 years. Choledocholithiasis was confirmed in 301 patients (18.8%). Obesity was the most common comorbidity in all patients. Choledocholithiasis was associated with the finding of a common bile duct stone on ultrasound, increased common bile duct diameter, and higher serum concentrations of aspartate aminotransferase, alanine transaminase, lipase, and direct and peak total bilirubin. Nine features (age, body mass index, common bile duct stone on ultrasound, common bile duct diameter, aspartate aminotransferase, alanine transaminase, lipase, direct bilirubin, and peak total bilirubin) were clinically important and included in the machine learning algorithm. Our 9-feature model deployed on new patients was found to be highly predictive for choledocholithiasis, with an area under the receiver operating characteristic score of 0.935.
Conclusion: This multicenter study uses machine learning for pediatric choledocholithiasis. Nine clinical factors were highly predictive of choledocholithiasis, and a machine learning model trained using medical and laboratory data was able to identify children at the highest risk for choledocholithiasis
J. Surg. 2023 Aug. https://doi.org/10.1016/j.surg.2023.07.008
The Peds Duct Score: A Highly Specific Predictive Model for Pediatric Choledocholithiasis
Ignacio RC Jr, Kelley-Quon LI, Ourshalimian S, Padilla BE, Jensen AR, Shew SB, Lofberg KM, Smith CA, Roach JP, Pandya SR, Russell KW, Wang K; Western Pediatric Surgery Research Consortium Choledocholithiasis Investigative Group
Abstract:
Introduction: To determine whether adult preoperative factors predicting choledocholithiasis (CD) are reliable in children and to create a validated pediatric-specific risk model.
Methods: A multicenter retrospective cohort study was performed including children (<18 yo) who underwent cholecystectomy for gallstone disease at 10 Western Pediatric Surgical Research Consortium children’s hospitals between 2016-2019. Multivariable regression analyses and ROC curves were used to determine predictive factors and optimal cutoff values for CD. The predictive model was tested with a 20% hold-out sample.
Results: The cohort comprised 979 children after cholecystectomy with an average age of 14.1+3.0 years, 75.1% female, 59.2% Hispanic, BMI was 27.7+8.3. Choledocholithiasis was confirmed in 222 patients (22.7%) by MRCP, ERCP, and/or IOC. Multivariable analyses with ROC curves identified three predictive factors for CD 1) a Dilated CBD>6mm, 2) Ultrasound (US) with visualized CBD stone, and 3) Total bilirubin>1.8 mg/dL (Peds DUCT criteria). These criteria demonstrated appropriate accuracies (>76%), specificities (>78%), and negative predictive values (>79%). Other factors commonly used in adults (elevated AST/ALT, pancreatitis, BMI, and age) were not independently predictive of CD in children. When tested on a hold-out sample, higher stratified risk groups demonstrated high accuracy, specificity, and negative predictive values similar to the adult CD literature.
Conclusion: Unique to children, dilated CBD>6mm, US findings of CBD stone, and total bilirubin>1.8 mg/dL are three highly-specific clinical variables predictive of choledocholithiasis. The Peds DUCT score is simple, practical, and validated on a large, multi-institutional pediatric data set and should become standard for choledocholithiasis risk assessment in children.
J Am Coll Surg. 2023 May 1;236(5):961-970. doi: 10.1097/XCS.0000000000000650. Epub 2023 Feb 14. PMID: 36786471.
Standardized Perioperative Care Reduces Colorectal Surgical Site Infection: A Western Pediatric Surgery Research Consortium Multicenter Analysis
Joe Tobias, MD, Ben Padilla, MD, Justin Lee, MD, Stephanie Chen, MD, Kasper Wang, MD, Lorraine Kelley-Quon MD, MSHS, Claudia Mueller, PhD, MD, Steve Shew, MD, Katie Joskowitz, Romeo Ignacio, MD, Lauren Evans, MD, Aaron Jensen, MD MEd MS, Shannon Acker, MD, Andrew Mason, Alicia Johnson, Jessica McConahey, MD, Erik Hansen, MD, Samir Pandya, MD, Scott S. Short, MD, Katie W. Russell, MD, Lauren Nicassio, MD, Caitlin A. Smith, MD, Elizabeth Fialkowski, MD
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.
J Pediatr Surg. 2022 Sep 26. doi: 10.1016/j.jpedsurg.2022.09.026
Adolescent Vaping-Associated Trauma in the Western United States
Katie W. Russell, Micah G. Katz, Ryan C. Phillips, Lorraine I. Kelley-Quon, Shannon N. Acker, Niti Shahi, Justin H. Lee, Elizabeth A. Fialkowski, Deepthi Nacharaju, Caitlin A. Smith, Aaron R. Jensen, Claudia M. Mueller, Benjamin E. Padilla, Romeo C. Ignacio, Shadassa Ourshalimian, Kasper S. Wang, Daniel J. Ostlie, Stephen J. Fenton , Zachary J. Kastenberg. On behalf of the Western Pediatric Surgery Research Consortium.
Abstract:
Introduction: Electronic cigarettes (e-cigarettes) are handheld, battery-powered vaporizing devices. It is estimated that more than 25% of youth have used these devices recreationally. While vaping-associated lung injury is an increasingly recognized risk, little is known about the risk of traumatic injuries associated with e-cigarette malfunction.
Methods: A multi-institutional retrospective study was performed by querying the electronic health records at nine children's hospitals. Patients who sustained traumatic injuries while vaping from January 2016 through December 2019 were identified. Patient demographics, injury characteristics, and the details of trauma management were reviewed.
Results: 15 children sustained traumatic injuries due to e-cigarette explosion. The median age was 17 y (range 13-18). The median injury severity score was 2 (range 1-5). Three patients reported that their injury coincided with their first vaping experience. Ten patients required hospital admission, three of whom required intensive care unit admission. Admitted patients had a median length of stay of 3 d (range 1-6). The injuries sustained were: facial burns (6), loss of multiple teeth (5), thigh and groin burns (5), hand burns (4), ocular burns (4), a radial nerve injury, a facial laceration, and a mandible fracture. Six children required operative intervention, one of whom required multiple operations for a severe hand injury.
Conclusions: In addition to vaping-associated lung injury, vaping-associated traumatic injuries are an emerging and worrisome injury pattern sustained by adolescents in the United States. This report highlights another means by which e-cigarettes pose an increasing risk to a vulnerable youth population.
Journal of Surgical Research, Volume 276, August 2022,Pages 251-255, ISSN 0022-4804, https://doi.org/10.1016/j.jss.2022.02.026
A Multi-Institutional Quality Improvement Project to Minimize Opioid Prescribing in Children after Appendectomy Using NSQIP-Pediatric
Lorraine I. Kelley-Quon, MD, MSHS, Shadassa Ourshalimian, MPH, Justin Lee, MD, Katie W. Russell, MD, Karen Kling, MD, Stephen Shew, MD, Claudia Mueller, MD, Aaron Jensen, MD, Lan Vu, MD, Benjamin Padilla, MD, Daniel Ostlie, MD, Caitlin Smith, MD, Thomas Inge, MD, Jonathan Roach, MD, Romeo Ignacio, MD, Katrine Lofberg, MD, Stephanie Radu, MCR, Autumn Rohan, Kasper Wang, MD
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.
J Am Coll Surg. 2022 Mar 1; 234(3):290-298. doi: 10.1097/XCS.0000000000000056. PMID: 35213491.
The Need for Early Kasai Portoenterostomy: A Western Pediatric Surgery Research Consortium Study
Lorraine I. Kelley-Quon, MD, MSHS, Eveline Shue, MD, Rita V. Burke, PhD, MPH, Caitlin Smith, MD, Karen Kling, MD, Elaa Mahdi, MD, Shadassa Ourshalimian, MPH, Michael Fenlon, MD, Matthew Dellinger, MD, Stephen B. Shew, MD, Justin Lee, MD, Benjamin Padilla, MD, Thomas Inge, MD, Jonathan Roach, MD, Ahmed I. Marwan, MD, Katie W. Russell, MD, Romeo Ignacio, MD, Elizabeth Fialkowski, MD, Amar Nijagal, MD, Cecilia Im, BS, Ken Azarow, MD, Daniel Ostlie, MD, Kasper Wang, MD
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 3 months 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.
Keywords: Biliary atresia; Kasai portoenterostomy; Liver transplant; Transplant-free survival.
Pediatr Surg Int. 2022 Feb;38(2):193-199. doi: 10.1007/s00383-021-05047-1. Epub 2021 Dec 2. PMID: 34854975; PMCID: PMC8742784.
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
Acker SN, Diaz-Miron J, Ignacio RC, Russell KW, Lofberg K, Shew SB, Peterson PN, Kelley-Quon LI, Jensen AR, Lee J, Padilla B, Smith CA, Kastenberg ZJ, Azarow KS, Ostlie DJ, Wang KS, Inge TH; Western Pediatric Surgery Research Consortium.
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.
Keywords: Contrast protocol; Pediatric surgeon survey; Small bowel obstruction.
J Surg Res. 2021 Nov;267:536-543.doi: 10.1016/j.jss.2021.06.004 .Epub 2021 Jul 10.
Child Physical Abuse and COVID-19: Trends from Nine Pediatric Trauma Centers
Katie W. Russell, Shannon N. Acker, Romeo C. Ignacio, Katrine M. Lofberg, Erin M. Garvey, Stephanie D. Chao, David W. Bliss, Caitlin A. Smith, Deepika Nehra, Melissa L. Anderson, Brittney L. Bunnell, Niti Shahi, John M. Perry, Lauren L. Evans, Jacky Z. Kwong, Joseph Tobias, Autumn Rohan, Kaci L. Pickett, Jill L. Kaar, Zachary J. Kastenberga, Antoinette L. Laskey, Eric R. Scaifea, Aaron R. Jensen
Abstract:
Background: Economic, social, and psychologic stressors are associated with an increased risk for abusive injuries in children. Prolonged physical proximity between adults and children under conditions of severe external stress, such as witnessed during the COVID-19 pandemic with "shelter-in-place orders", may be associated with additional increased risk for child physical abuse. We hypothesized that child physical abuse rates and associated severity of injury would increase during the early months of the pandemic as compared to the prior benchmark period.
Methods: We conducted a nine-center retrospective review of suspected child physical abuse admissions across the Western Pediatric Surgery Research Consortium. Cases were identified for the period of April 1-June 30, 2020 (COVID-19) and compared to the identical period in 2019. We collected patient demographics, injury characteristics, and outcome data.
Results: There were no significant differences in child physical abuse cases between the time periods in the consortium as a whole or at individual hospitals. There were no differences between the study periods with regard to patient characteristics, injury types or severity, resource utilization, disposition, or mortality.
Conclusions: Apparent rates of new injuries related to child physical abuse did not increase early in the COVID-19 pandemic. While this may suggest that pediatric physical abuse was not impacted by pandemic restrictions and stresses, it is possible that under-reporting, under-detection, or delays in presentation of abusive injuries increased during the pandemic. Long-term follow-up of subsequent rates and severity of child abuse is needed to assess for unrecognized injuries that may have occurred.
Keywords: COVID-19; Child abuse; Nonaccidental trauma; SARS-CoV-2.
J Pediatr Surg. 2021 Oct 8;S0022-3468(21)00679-5. doi: 10.1016/j.jpedsurg.2021.09.050 .Online ahead of print