Publications by authors named "David Gourlay"

65 Publications

Assessment of MRI and US Screening for Tethered Cord Syndrome in Patients Diagnosed With Esophageal Atresia/Tracheoesophageal Fistula.

J Surg Res 2022 Jun 29;279:193-199. Epub 2022 Jun 29.

Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.

Introduction: Infants with esophageal atresia and/or tracheoesophageal fistula (EA/TEF) undergo screening for tethered cord syndrome (TCS) via ultrasound and magnetic resonance imaging. Existing literature lacks data to guide optimal timing of screening and magnetic resonance imaging (MRI) is often delayed until 3-6 mo of age, when it is frequently forgotten. Detethering surgery has a high rate of success in patients with TCS and is often performed prophylactically due to potential irreversible deficits. This study aims to improve screening procedure for infants with EA/TEF.

Methods: A retrospective chart review was done of all EA/TEF patients treated over 6 y (n = 79). The study examined how often each imaging modality was performed and identified a TCS lesion, as well as age of screening/surgical intervention.

Results: Screening for TCS was done with MRI 58% of the time and US 15% of the time. However, 38% of patients did not undergo any screening. Out of the patients with TCS on MRI (n = 19, 41.3%), 73.7% had neurosurgery. Of patients who underwent US (n = 12), nine patients also had MRI later: two reported TCS lesions and subsequently had neurosurgery. Surgical infection rates and complications were 0/14.

Conclusions: MRI demonstrated a higher rate of detecting TCS lesions than US, and patients with TCS frequently had detethering. Patients with ≥3 VACTERL or vertebral anomalies had a higher incidence of TCS on MRI. Patients with vertebral anomalies reported false negative ultrasounds in two cases, suggesting the potential superiority of MRI screening in this subgroup. A third of children did not undergo any imaging and this will require a process improvement.
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http://dx.doi.org/10.1016/j.jss.2022.06.004DOI Listing
June 2022

Utilization and Adequacy of Telemedicine for Outpatient Pediatric Surgical Care.

J Surg Res 2022 Oct 20;278:179-189. Epub 2022 May 20.

Division of Pediatric Surgery, Children's Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin. Electronic address:

Introduction: Telemedicine (TM) use accelerated out of necessity during the COVID-19 pandemic, but the utility of TM within the pediatric surgery population is unclear. This study measured utilization, adequacy, and disparities in uptake of TM in pediatric surgery during the COVID-19 pandemic.

Methods: Scheduled outpatient pediatric surgery clinic encounters at a large academic children's hospital from January 2020 through March 2021 were reviewed. Sub-group analysis examined post-operative (PO) visits after appendectomy and umbilical, epigastric, and inguinal hernia repairs.

Results: Of 9149 scheduled visits, 87.9% were in-person and 12.1% were TM. TM visits were scheduled for PO care (76.9%), new consultations (7.1%), and established patients (16.0%). Although TM visits were more frequently canceled or no shows (P < 0.001), most canceled TM visits were PO visits, of which 41.7% were canceled via electronic communication reporting the absence of any PO concerns. TM visits were adequate for accomplishing visit goals in 98.2%, 95.5%, and 96.2% of PO, new, and established patient visits, respectively. Patients utilizing TM visits were more frequently of white race, privately-insured, from less disadvantaged neighborhoods, and living a greater distance from clinic (P < 0.001 for all comparisons).

Conclusions: TM was adequate for the majority of visits in which it was utilized, including the basic PO visits that occurred via TM. TM was used more by patients with greater travel and less by those of minority race, with public insurance, and from more disadvantaged neighborhoods. Future work is necessary to ensure broad access to this useful tool for all children requiring surgical care.
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http://dx.doi.org/10.1016/j.jss.2022.04.060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9121887PMC
October 2022

Utilizing Near-Infrared Spectroscopy to Identify Pediatric Trauma Patients Needing Lifesaving Interventions: A Prospective Study.

Pediatr Emerg Care 2022 May 17. Epub 2022 May 17.

Children's Wisconsin, Medical College of Wisconsin, Milwaukee, WI.

Objectives: The aim of this study was to prospectively investigate the role of near-infrared spectroscopy (NIRS) in identifying pediatric trauma patients who required lifesaving interventions (LSIs).

Methods: Prospective cohort study of children aged 0 to 18 years who activated the trauma team response between August 15, 2017, and February 12, 2019, at a large, urban pediatric emergency department (ED).The relationship between the lowest somatic NIRS saturation and the need for LSIs (based on published consensus definition) was investigated. Categorical variables were analyzed by χ2 test, and continuous variables were analyzed by Student t test.

Results: A total of 148 pediatric trauma patients had somatic NIRS monitoring and met the inclusion criteria. Overall, 65.5% were male with a mean ± SD age of 10.9 ± 6.0 years. Injuries included 67.6% blunt trauma and 28.4% penetrating trauma with mortality of 3.4% (n = 5). Overall, the median lowest somatic NIRS value was 72% (interquartile range, 58%-88%; range, 15%-95%), and 43.9% of patients had a somatic NIRS value <70%. The median somatic NIRS duration recorded was 11 minutes (interquartile range, 7-17 minutes; range, 1-105 minutes). Overall, 36.5% of patients required an LSI including 53 who required a lifesaving procedure, 17 required blood products, and 17 required vasopressors. Among procedures, requiring a thoracostomy was significant.Pediatric trauma patients with a somatic NIRS value <70% had a significantly increased odds of requiring an LSI (odds ratio, 2.11; 95% confidence interval, 1.07-4.20). Somatic NIRS values <70% had a sensitivity and specificity of 56% and 63%, respectively.

Conclusions: Pediatric trauma patients with somatic NIRS values <70% within 30 minutes of ED arrival have an increased odds of requiring LSIs. Among LSIs, pediatric trauma patients requiring thoracostomy was significant. The role of NIRS in incrementally improving the identification of critically injured children in the ED and prehospital setting should be evaluated in larger prospective multicenter studies.
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http://dx.doi.org/10.1097/PEC.0000000000002710DOI Listing
May 2022

Same-day discharge after appendectomy for uncomplicated appendicitis in children: Potential barriers to increased utilization.

Am J Surg 2022 07 5;224(1 Pt B):629-634. Epub 2022 Apr 5.

Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI, 53226, USA. Electronic address:

Background: Utilization of same-day discharge (SDD) after appendectomy for uncomplicated appendicitis (UA) was closely examined to explore potential barriers to greater use of SDD.

Methods: Children (≤18 years) who underwent appendectomy for UA between 2015 and 2019 at a tertiary care children's hospital were reviewed. Associations with SDD were evaluated using multivariable regression models.

Results: Among 973 children, SDD was less frequently utilized after appendectomy performed between 12pm and 5pm (aOR 0.14, p < 0.001) and after 5pm (aOR 0.01, p < 0.001) compared to before 12pm. SDD utilization was also less frequent in those from lower resource neighborhoods (adjusted odds ratio [aOR] 0.90 per decile increase in Area Deprivation Index, p = 0.04), females (aOR 0.53, p = 0.005), and patients residing 30-60 min away (aOR 0.56, p = 0.04) compared to <30 min away.

Conclusions: SDD utilization was primarily impacted by operative timing and socioeconomic and travel factors, focuses for quality improvement efforts to further increase utilization of SDD.
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http://dx.doi.org/10.1016/j.amjsurg.2022.03.051DOI Listing
July 2022

Outcomes of gastrostomy placement with and without concomitant tracheostomy among ventilator dependent children.

J Pediatr Surg 2021 Jul 26;56(7):1222-1226. Epub 2021 Mar 26.

Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.

Introduction: Simultaneous gastrostomy tube (GT) and tracheostomy placement in young children offers potential benefit in limiting anesthetic exposure, but it is unknown whether combining these procedures introduces additional morbidity. This study compared outcomes after combined GT and tracheostomy placement versus GT placement alone among similar ventilator-dependent patients.

Methods: Ventilator-dependent children <2-years-old who underwent GT placement alone (MV-GT), simultaneous GT and tracheostomy placement (GT+T), and GT placement alone with a pre-existing tracheostomy (T-GT) were identified using 2012-2018 NSQIP-Pediatric Participant User Files. Multiple logistic regression models were used to compare outcomes while adjusting for other group differences.

Results: Among 1100 children, 351 underwent MV-GT, 494 GT+T, and 255 T-GT. Major complications occurred in 23.6%, 17.0%, and 14.5% of the respective groups (p = 0.01). Major complications with GT+T were similar to T-GT (adjusted odds ratio [aOR]=1.19, 95%CI:0.78-1.83, p = 0.4) and lower than MV-GT (aOR=0.67, 95%CI:0.47-0.95, p = 0.02). Severe complications including mortality, cardiac arrest, and stroke were similar between the three groups (p = 0.8).

Conclusions: Children <2-years-old undergoing GT+T did not experience higher post-operative complications compared to children undergoing T-GT or MV-GT. Utilizing GT+T to limit anesthetic exposure may be reasonable within this high-risk population.

Type Of Study: Treatment Study LEVEL OF EVIDENCE: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.03.028DOI Listing
July 2021

COVID-19 pre-procedural testing strategy and early outcomes at a large tertiary care children's hospital.

Pediatr Surg Int 2021 Jul 14;37(7):871-880. Epub 2021 Mar 14.

Children's Wisconsin and Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 North 92nd Street, Suite CCC 320, Milwaukee, WI, 53226, USA.

Purpose: With the emergence of the coronavirus disease-2019 (COVID-19) pandemic, institutions were tasked with developing individualized pre-procedural testing strategies that allowed for re-initiation of elective procedures within national and state guidelines. This report describes the experience of a single US children's hospital (Children's Wisconsin, CW) in developing a universal pre-procedural COVID-19 testing protocol and reports early outcomes.

Methods: The CW pre-procedural COVID-19 response began with the creation of a multi-disciplinary taskforce that sought to develop a strategy for universal pre-procedural COVID-19 testing which (1) maximized patient safety, (2) prevented in-hospital viral transmission, (3) conserved resources, and (4) allowed for resumption of procedural care within institutional capacity.

Results: Of 11,209 general anesthetics performed at CW from March 16, 2020 to October 31, 2020, 11,150 patients (99.5%) underwent pre-procedural COVID-19 testing. Overall, 1.4% of pre-procedural patients tested positive for COVID-19. By June 2020, CW was operating at near-normal procedural volume and there were no documented cases of in-hospital viral transmission. Only 0.5% of procedures were performed under augmented COVID-19 precautions (negative pressure environment and highest-level personal protective equipment).

Conclusion: CW successfully developed a multi-disciplinary pre-procedural COVID-19 testing protocol that enabled resumption of near-normal procedural volume within three months while limiting in-hospital viral transmission and resource use.
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http://dx.doi.org/10.1007/s00383-021-04878-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955904PMC
July 2021

Venous thromboembolism prophylaxis after pediatric trauma.

Pediatr Surg Int 2021 Jun 19;37(6):679-694. Epub 2021 Jan 19.

Division of Pediatric Surgery, Children's Wisconsin, 999 N 92nd Street, Suite 320, Milwaukee, WI, 53226, USA.

In recent years, there has been an increased focus on developing and validating venous thromboprophylaxis guidelines in the pediatric trauma population. We review the current literature regarding the incidence of and risk factors for venous thromboembolism (VTE) and the use of prophylaxis in the pediatric trauma population. Risk factors such as age, injury severity, central venous catheters, mental status, injury type, surgery, and comorbidities can lead to a higher incidence of VTE. Risk stratification tools have been developed to determine whether mechanical and/or pharmacologic prophylaxis should be implemented depending on the degree of VTE risk. When VTE risk is high, pharmacologic prophylaxis, such as with low molecular weight heparin, is often initiated. However, the timing and duration of VTE prophylaxis is dependent on patient factors including ambulatory status and contraindications such as bleeding. In addition, the utility of screening ultrasound for VTE surveillance has been evaluated and though they are not widely recommended, no formal guidelines exist. While more research has been done in recent years to assess the most appropriate type, timing, and duration of VTE prophylaxis, further studies are warranted to create optimal guidelines for decreasing the risk of VTE after pediatric trauma.
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http://dx.doi.org/10.1007/s00383-020-04855-1DOI Listing
June 2021

Utilizing Near-Infrared Spectroscopy (NIRS) to Identify Pediatric Trauma Patients Needing Lifesaving Interventions (LSIs): A Retrospective Study.

Pediatr Emerg Care 2022 Jan;38(1):e193-e199

Medical College of Wisconsin and Children's Hospital of Wisconsin, Wauwatosa, WI.

Objectives: The aim of this study was to investigate the role of near-infrared spectroscopy (NIRS) in identifying pediatric trauma patients who required lifesaving interventions (LSIs).

Methods: Retrospective chart review of children age 0 to 18 years who activated the trauma team response between January 1, 2015 and August 14, 2017, at a large, urban pediatric emergency department. The lowest somatic NIRS saturation and the need for LSIs (based on published consensus definition) were abstracted from the chart. χ2 and descriptive statistics were used for analysis.

Results: The charts of 84 pediatric trauma patients were reviewed. Overall, 80% were boys with a mean age of 10.4 years (SD, 6.2 years). Injuries included 56% blunt trauma and 36% penetrating trauma with mortality of 10.7% (n = 9). Overall, the median lowest NIRS value was 67% (interquartile range, 51-80%; range, 15%-95%) and 54.8% of the patients had a NIRS value less than 70%. The median somatic NIRS duration recorded was 12 minutes (interquartile range, 6-17 minutes; range, 1-59 minutes). Overall, 50% of patients required a LSI, including 39 who required a lifesaving procedure, 11 required blood products, and 14 required vasopressors. Pediatric trauma patients with NIRS less than 70% had a significantly increased odds of requiring a LSI (odds ratio, 2.67; 95% confidence interval, 1.10-6.47). NIRS less than 70% had a sensitivity and specificity of 67% and 57% respectively.

Conclusions: Pediatric trauma patients with somatic NIRS less than 70% within 30 minutes of emergency department arrival are associated with the need for LSIs. Continuous NIRS monitoring in the pediatric trauma population should be evaluated prospectively.
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http://dx.doi.org/10.1097/PEC.0000000000002211DOI Listing
January 2022

Reducing opioid utilization after appendectomy: A lesson in implementation of a multidisciplinary quality improvement project.

Surg Open Sci 2020 Jan 22;2(1):27-33. Epub 2019 Oct 22.

Children's Hospital of Wisconsin and Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.

Background: Perioperative care after appendectomy may be the first exposure to opioids for many children. A quality improvement project was implemented to assess current practice of prescribing pain medications after a laparoscopic appendectomy to decrease unnecessary opioid use via simple, targeted steps.

Methods: Three measures were implemented in patients undergoing laparoscopic appendectomy for acute appendicitis: (1) ice packs to incision in postanesthesia care unit, (2) standard pain scores within 30 minutes of admission to ward postoperatively, and (3) standardized postoperative order set minimizing opioid utilization and limited number of opioids prescribed at discharge. Pre- and postimplementation data were compared with the primary outcome variable: opioid utilization during the postoperative period.

Results: There were no statistically significant differences in age or gender between the 814 preimplementation and 263 postimplementation patients. Postimplementation compliance is 66.9% for icepacks, 88% for pain scores, and 94.7% for postoperative order set. There were statistically significant decreases in intravenous and enteral opioids administered, number of opioid doses prescribed at discharge, and patients discharged with an opioid prescription.

Conclusion: By using a multidisciplinary assessment of current state, culture, and management of parental, patient, and nursing expectations, our institution was able to reduce overall opioid consumption.
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http://dx.doi.org/10.1016/j.sopen.2019.08.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7391896PMC
January 2020

Does Mechanism of Injury Predict Trauma Center Need for Children?

Prehosp Emerg Care 2021 Jan-Feb;25(1):95-102. Epub 2020 Mar 24.

Objective: To determine if the Mechanism of Injury Criteria of the Field Triage Decision Scheme (FTDS) are accurate for identifying children who need the resources of a trauma center.

Methods: EMS providers transporting any injured child ≤15 years, regardless of severity, to a pediatric trauma center in 3 midsized communities over 3 years were interviewed. Data collected through the interview included EMS observed physiologic condition, suspected anatomic injuries, and mechanism. Patients were then followed to determine if they needed the resources of a trauma center by reviewing their medical record after hospital discharge. Patients were considered to need a trauma center if they received an intervention included in a previously published consensus definition. Data were analyzed with descriptive statistics including positive likelihood ratios (+LR) and 95% confidence intervals (95%CI).

Results: 9,483 provider interviews were conducted and linked to hospital outcome data. Of those, 230 (2.4%) met the consensus definition for needing a trauma center. 1,572 enrolled patients were excluded from further analysis because they met the Physiologic or Anatomic Criteria of the FTDS. Of the remaining 7,911 cases, 62 met the consensus definition for needing a trauma center (TC). Taken as a whole, the Mechanism of Injury Criteria of the FTDS identified 14 of the remaining 62 children who needed the resources of a trauma center for a 77% under-triage rate. The mechanisms sustained were 36% fall (16 needed TC), 28% motor vehicle crash (MVC) (20 needed TC), 7% struck by a vehicle (10 needed TC), <1% motorcycle crash (none needed TC), and 29% had a mechanism not included in the FTDS (16 needed TC). Of those who sustained a mechanisms not listed in the FTDS, the most common mechanisms were sport related injuries not including falls (24% of 2,283 cases with a mechanism not included) and assault (13%). Among those who fell from a height greater than 10 feet, 4 needed a TC (+LR 5.9; 95%CI 2.8-12.6). Among those in a MVC, 41 were reported to have been ejected and none needed a TC, while 31 had reported meeting the intrusion criteria and 0 needed a TC. There were 32 reported as having a death in the same vehicle, and 2 needed a TC (+LR 7.42; 95%CI: 1.90-29.0).

Conclusion: Over a quarter of the children who needed the resources of a trauma center were not identified using the Physiologic or Anatomic Criteria of the Field Triage Decision Scheme. The Mechanism of Injury Criteria did not apply to over a quarter of the mechanisms experienced by children transported by EMS for injury. Use of the Mechanism Criteria did not greatly enhance identification of children who need a trauma center. More work is needed to improve the tool used to assist EMS providers in the identification of children who need the resources of a trauma center.
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http://dx.doi.org/10.1080/10903127.2020.1737281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7641009PMC
June 2021

Esophagojejunal Anastomosis by Circular Stapler in Pediatric Patients: Size Minima Defined by Experience and Geometry.

J Laparoendosc Adv Surg Tech A 2019 Oct 24;29(10):1311-1314. Epub 2019 Sep 24.

Pediatric General and Thoracic Surgery, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.

Esophagojejunostomy is facilitated by use of a circular stapler, particularly when performed laparoscopically. The minimum patient size that will allow use of circular staplers in the small intestine is unknown. Retrospective review of esophagogastric dissociations performed at a single tertiary care institution for 48 months. This was combined with a geometric derivation of a size-estimation formula. From the 7 cases identified, patients weighing >16 kg easily accommodated the 21 mm stapler. There was a narrow fit in the patient weighing 13.6 kg, and the 6 kg patient was too small for the stapler. Through a combination of clinical observation and physical reasoning, circular stapler applicability in small intestine is predicted by patient weight or intestinal measurement. Patients weighing >16 kg will accept the stapler, whereas patients <13 kg are likely too small. Alternately, on the basis of a geometric derivation, if the width of the flat intestine is >1.6 × the device diameter, the device will fit. This calculation can be applied broadly (e.g., incision length for laparoscopic ports or single-port access devices).
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http://dx.doi.org/10.1089/lap.2019.0092DOI Listing
October 2019

A SORT Plus a GHOST Equals: Experience of Two Forward Medical Teams Supporting Special Operations in Afghanistan 2019.

J Spec Oper Med 2019 ;19(3):117-121

Theater Special Operations Force (SOF) medical planners have been using Army forward surgical teams (FSTs) to maintain a golden hour for US SOF during Operation Freedom's Sentinel in the form of Golden Hour Offset Surgical Treatment Teams (GHOST-Ts) in Afghanistan. Recently, the Special Operations Resuscitation Team (SORT) was designed to decompress and augment a GHOST-T to help extend a golden hour ring in key strategic locations. This article describes both teams working together in Operation Freedom's Sentinel while deployed in support of SOF in central Afghanistan during the summer fighting season.
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http://dx.doi.org/10.55460/4KB6-VDU3DOI Listing
October 2019

A tiered approach to optimize pediatric laparoscopic appendectomy outcomes.

J Pediatr Surg 2019 Dec 30;54(12):2539-2545. Epub 2019 Aug 30.

Department of Surgery, The Medical College of Wisconsin, Milwaukee, WI, USA; Division of Pediatric Surgery, Children's Hospital of Wisconsin, Milwaukee, WI, USA.

Background/purpose: Surgical management of appendicitis accounts for ~30% of total expenditure in the practice of pediatric surgery and is associated with high cost variation. We hypothesize that incorporating single-incision laparoscopy (SILS) and the resultant by-product dual-incision laparoscopy (DILS) into a historically three-incision laparoscopic (TILS) appendectomy practice affords equal outcomes at lower cost.

Methods: Appendectomies performed at a large-volume tertiary care children's hospital from 1/2015-12/2017 were retrospectively reviewed. Appendectomy technique and appendicitis severity were stratified against operative and admission direct variable (DV) costs. Secondary outcomes included perioperative time course and 30-day postoperative outcomes.

Results: A total of 970 appendectomies were analyzed during the study period (61% acute, 39% complex appendicitis). SILS and DILS had significantly lower mean DV costs and OR times compared to TILS for both acute and complex appendicitis while maintaining equivalent outcomes.

Conclusions: SILS and DILS appendectomy techniques can be incorporated into pediatric surgical practice at lower cost than TILS appendectomy while maintaining equivalent outcomes. Further, the introduction of a tiered approach to laparoscopic appendectomy, in which all cases are started as SILS with additional incisions added based on operative difficulty, is estimated to save $74,580 annually in operative DV costs at a pediatric surgical center averaging 314 laparoscopic appendectomies per year.

Type Of Study: Treatment Study.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.08.034DOI Listing
December 2019

Multiple Small Magnets: Why Would Not They Pass and Why Did Not We See Them on Endoscopy?

J Pediatr Gastroenterol Nutr 2020 03;70(3):e63

Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics.

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http://dx.doi.org/10.1097/MPG.0000000000002368DOI Listing
March 2020

Efficacy of surveillance ultrasound for venous thromboembolism diagnosis in critically ill children after trauma.

J Pediatr Surg 2018 Nov 20;53(11):2195-2201. Epub 2018 Jun 20.

Division of Pediatric Surgery, The Children's Hospital of Wisconsin. Electronic address:

Introduction: Venous thromboembolism (VTE) is increasingly prevalent in injured children admitted to the intensive care unit (ICU). Few data exist to support VTE pharmacologic prophylaxis or ultrasound (US) surveillance in children with high bleeding risk. After implementation of screening US guidelines, we sought to describe our experience, hypothesizing that screening US of children at highest risk for VTE results in earlier detection and management.

Study Design: A retrospective analysis was conducted on prospectively collected data of injured children admitted to an American College of Surgeons Verified level 1 Pediatric Trauma Center from 2010 to 2015. In patients at high risk for both VTE and bleeding (HRHR), guidelines recommended deferral of pharmacologic prophylaxis and a screening US at ≥7 ICU days if bleeding risk remained. Outcomes analyzed included VTE rates, guideline compliance, and US timing. The rate of deep vein thrombosis (DVT) detection (number of DVT captured/number of US obtained) was examined.

Results: Of 4061 trauma patients, 588 (14.5%) were critically injured including 112 patients who met HRHR criteria. The rate of VTE in the HRHR group ≥7 ICU days was 25% (14/56). Of 23 VTE diagnosed in the ICU, 17 were detected by 49 US performed (34.7%), with the remaining 6 diagnosed by computed tomography. DVT was detected earlier than the US guideline recommended 7 days, independent of symptoms. Guideline compliance was 86%.

Conclusion: Critically injured children at risk for bleeding frequently develop VTE. Surveillance ultrasound in patients at high risk for both VTE and bleeding allows earlier detection and treatment.

Level Of Evidence: Therapeutic study, level II.
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http://dx.doi.org/10.1016/j.jpedsurg.2018.06.013DOI Listing
November 2018

Factors Known to Influence the Development of Necrotizing Enterocolitis to Modify Expression and Activity of Intestinal Alkaline Phosphatase in a Newborn Neonatal Rat Model.

Eur J Pediatr Surg 2019 Jun 3;29(3):290-297. Epub 2018 May 3.

Division of Pediatric Surgery, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, United States.

Introduction:  Prematurity, formula feeding, and early weaning strongly influence enterocyte differentiation. Intestinal alkaline phosphatase (IAP), an endogenous protein expressed in the intestines, is one enzyme that is affected by these factors. IAP supplementation decreases the severity of necrotizing enterocolitis (NEC) injury. We, therefore, hypothesized that prematurity predisposes this population to NEC due to IAP deficiency and investigated IAP expression and function in a neonatal rat model.

Materials And Methods:  Pre- and full-term newborn Sprague-Dawley rat pups were sacrificed on consecutive days of life both after vaginal or cesarean birth and following either breast or formula feeding.

Results:  Compared with controls, cesarean delivery and formula feeding are associated with lower levels of IAP. The formula-fed pups continued to have low baseline IAP activity. Neither prematurity nor formula feeding led to differences of intestinal injury.

Conclusion:  Prematurity and formula feeding are associated with inhibition of IAP expression and activity. Both may increase the risk of NEC and early enteral supplementation of IAP to newborns at risk of NEC may be of therapeutic benefit.
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http://dx.doi.org/10.1055/s-0038-1646959DOI Listing
June 2019

Pediatric and Congenital Colorectal Diseases in the Adult Patient.

Authors:
David M Gourlay

Clin Colon Rectal Surg 2018 Mar 25;31(2):49-50. Epub 2018 Feb 25.

Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.

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http://dx.doi.org/10.1055/s-0037-1604047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5825857PMC
March 2018

Role of intestinal Hsp70 in barrier maintenance: contribution of milk to the induction of Hsp70.2.

Pediatr Surg Int 2018 Mar 1;34(3):323-330. Epub 2017 Dec 1.

Department of Pediatrics and Critical Care, Albert Einstein College of Medicine, Montefiore Medical Center, 3411 Wayne Ave, 8th Floor, Bronx, NY, 10467, USA.

Background: Necrotizing enterocolitis (NEC) is a gastrointestinal disease of complex etiology resulting in devastating systemic inflammation and often death in premature newborns. We previously demonstrated that formula feeding inhibits ileal expression of heat shock protein-70 (Hsp70), a critical stress protein within the intestine. Barrier function for the premature intestine is critical. We sought to determine whether reduced Hsp70 protein expression increases neonatal intestinal permeability.

Methods: Young adult mouse colon cells (YAMC) were utilized to evaluate barrier function as well as intestine from Hsp70-/- pups (KO). Sections of intestine were analyzed by Western blot, immunohistochemistry, and real time PCR. YAMC cells were sub-lethally heated or treated with expressed milk (EM) to induce Hsp70.

Results: Immunostaining demonstrates co-localized Hsp70 and tight junction protein zona occludens-1 (ZO-1), suggesting physical interaction to protect tight junction function. The permeability of YAMC monolayers increases following oxidant injury and is partially blocked by Hsp70 induction either by prior heat stress or EM. RT-PCR analysis demonstrated that the Hsp70 isoforms, 70.1 and 70.3, predominate in WT pup; however, Hsp70.2 predominates in the KO pups. While Hsp70 is present in WT milk, it is not present in KO EM. Hsp70 associates with ZO-1 to maintain epithelial barrier function.

Conclusion: Both induction of Hsp70 and exposure to EM prevent stress-induced increased permeability. Hsp70.2 is present in both WT and KO neonatal intestine, suggesting a crucial role in epithelial integrity. Induction of the Hsp70.2 isoform appears to be mediated by mother's milk. These results suggest that mother's milk feeding modulates Hsp70.2 expression and could attenuate injury leading to NEC.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1007/s00383-017-4211-3DOI Listing
March 2018

Intestinal alkaline phosphatase deficiency leads to dysbiosis and bacterial translocation in the newborn intestine.

J Surg Res 2017 10 13;218:35-42. Epub 2017 Apr 13.

Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, Wisconsin. Electronic address:

Background: Intestinal alkaline phosphatase (IAP) has been shown to help maintain intestinal homeostasis. Decreased expression of IAP has been linked with pediatric intestinal diseases associated with bacterial overgrowth and subsequent inflammation. We hypothesize that the absence of IAP leads to dysbiosis, with increased inflammation and permeability of the newborn intestine.

Methods: Sprague-Dawley heterozygote IAP cross-matches were bred. Pups were dam fed ad lib and euthanized at weaning. The microbiotas of terminal ileum (TI) and colon was determined by quantitative real-time polymerase chain reaction (qRT-PCR) of subphylum-specific bacterial 16S ribosomal RNA. RT-PCR was performed on TI for inflammatory cytokines. Intestinal permeability was quantified by fluorescein isothiocyanate-dextran permeability and bacterial translocation by qRT-PCR for bacterial 16S ribosomal RNA in mesenteric lymph nodes. Statistical analysis was done by chi-square analysis.

Results: All three genotypes had similar concentrations of bacteria in the TI and colon. However, IAP knockout (IAP-KO) had significantly decreased diversity of bacterial species in their colonic stool compared with heterozygous and wild-type (WT). IAP-KO pups had a nonstatistically significant 3.9-fold increased inducible nitric oxide synthase messenger RNA expression compared with WT (IAP-KO, 3.92 ± 1.36; WT, 1.0 ± 0.27; P = 0.03). IAP-KO also had significantly increased bacterial translocation to mesenteric lymph nodes occurred in IAP-KO (IAP-KO, 7625 RFU/g ± 3469; WT, 4957 RFU/g ± 1552; P = 0.04). Furthermore, IAP-KO had increased permeability (IAP-KO, 0.297 mg/mL ± 0.2; WT, 0.189 mg/mL ± 0.15 P = 0.07), but was not statistically significant.

Conclusions: Deficiency of IAP in the newborn intestine is associated with dysbiosis and increased inflammation, permeability, and bacterial translocation.
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http://dx.doi.org/10.1016/j.jss.2017.03.049DOI Listing
October 2017

Single-Immunoglobulin Interleukin-1-Related Receptor regulates vulnerability to TLR4-mediated necrotizing enterocolitis in a mouse model.

Pediatr Res 2018 01 4;83(1-1):164-174. Epub 2017 Oct 4.

Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri.

BackgroundThe mechanisms underlying aberrant activation of intestinal Toll-like receptor 4 (TLR4) signaling in necrotizing enterocolitis (NEC) remain unclear. In this study, we examined the role of single-immunoglobulin interleukin-1 receptor-related molecule (SIGIRR), an inhibitor of TLR signaling, in modulating experimental NEC vulnerability in mice.MethodsExperimental NEC was induced in neonatal wild-type and SIGIRR-/- mice using hypoxia, formula-feeding, and lipopolysaccharide administration. Intestinal TLR canonical signaling, inflammation, apoptosis, and severity of experimental NEC were examined at baseline and after NEC induction in mice.ResultsSIGIRR is developmentally regulated in the neonatal intestine with a restricted expression after birth and a gradual increase by day 8. At baseline, breast-fed SIGIRR-/- mouse pups exhibited low-grade inflammation and TLR pathway activation compared with SIGIRR+/+ pups. With experimental NEC, SIGIRR-/- mice had significantly more intestinal interleukin (IL)-1β, KC (mouse homolog to IL-8), intercellular adhesion molecule-1 (ICAM-1), and interferon-beta (IFN-β) expression in association with the amplified TLR pathway activation. Terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) staining, cleaved caspase 3, and severity of intestinal injury with NEC were worse in SIGIRR-/- mice in comparison with SIGIRR+/+ mice.ConclusionSIGIRR is a negative regulator of TLR4 signaling in the developing intestine, and its insufficiency results in native intestinal TLR hyper-responsiveness conducive to the development of severe experimental NEC in mice.
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http://dx.doi.org/10.1038/pr.2017.211DOI Listing
January 2018

Evaluation of guidelines for injured children at high risk for venous thromboembolism: A prospective observational study.

J Trauma Acute Care Surg 2017 05;82(5):836-844

From the Department of Surgery (R.M.L.), Division of Pediatric Surgery (K.B., D.M.G.), and the Department of Pediatrics (S.J.H., R.C.P.), Division of Critical Care and Division of Hematology/Oncology, The Children's Hospital of Wisconsin; and Institute for Health and Equity (L.D.C.), Medical College of Wisconsin, Milwaukee, Wisconsin.

Background: Pharmacologic prophylaxis for venous thromboembolism (VTE) is a widely accepted practice in adult trauma patients to prevent associated morbidity and mortality. However, VTE prophylaxis has not been standardized in injured pediatric patients. Our institution identified factors potentially associated with a high risk of VTE in critically injured children that led to prospective implementation of VTE prophylaxis guidelines. We hypothesize that the guidelines are accurate in predicting children at risk for VTE.

Methods: Data were prospectively collected on injured children from August 2010 to August 2015. Pharmacologic prophylaxis was indicated for patients identified by the guidelines as high risk for VTE. Prophylaxis was deferred and a screening ultrasound was performed if the high-risk VTE patients were also at high risk for bleeding. To assess the accuracy of predicting confirmed cases of VTE, stepwise logistic regression analysis was used to measure the association of individual risk factors with VTE controlling for age (≥13 years). A receiver operating characteristic curve measured the accuracy of the final model to predict a VTE.

Results: Of 4,061 trauma patients, 588 were admitted to the ICU, with the guidelines identifying 199 as high risk for VTE. VTE occurred in 3.9% (23/588) of the ICU population and 10% (20/199) of the high risk group. The median age of VTE patients in the ICU was 9.7 years. Statistically significant predictors (p < 0.05) of VTE in the multivariate model included presence of a central venous catheter (OR = 5.2), inotropes (OR = 7.7), immobilization (OR = 5.5), and a Glasgow Coma Scale of <9 (OR = 1.3). The area under receiver operating characteristic curve of this model was 0.92, demonstrating its excellent predictive ability.

Conclusion: Specific clinical factors in critically injured children are associated with a high risk for VTE. Incorporating these risk factors in VTE prophylaxis guidelines facilitates more accurate risk stratification and may allow for improved VTE prevention in pediatric trauma.

Level Of Evidence: Prognostic study, level II.
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http://dx.doi.org/10.1097/TA.0000000000001404DOI Listing
May 2017

Pediatric Trauma Assessment and Management Database: Leveraging Existing Data Systems to Predict Mortality and Functional Status after Pediatric Injury.

J Am Coll Surg 2017 May 22;224(5):933-944.e5. Epub 2017 Feb 22.

Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA; Department of Pediatrics, University of Washington, Seattle, WA.

Background: Efforts to improve pediatric trauma outcomes need detailed data, optimally collected at lowest cost, to assess processes of care. We developed a novel database by merging 2 national data systems for 5 pediatric trauma centers to provide benchmarking metrics for mortality and non-mortality outcomes and to assess care provided throughout the care continuum.

Study Design: Trauma registry and Virtual Pediatric Systems, LLC (VPS) from 5 pediatric trauma centers were merged for children younger than 18 years discharged in 2013 from a pediatric ICU after traumatic injury. For inpatient mortality, we compared risk-adjusted models for trauma registry only, VPS only, and a combination of trauma registry and VPS variables (trauma registry+VPS). To estimate risk-adjusted functional status, we created a prediction model de novo through purposeful covariate selection using dichotomized Pediatric Overall Performance Category scale.

Results: Of 688 children included, 77.3% were discharged from the ICU with good performance or mild overall disability and 17.6% with moderate or severe overall disability or coma. Inpatient mortality was 5.1%. The combined dataset provided the best-performing risk-adjusted model for predicting mortality, as measured by the C-statistic, pseudo-R, and Akaike Information Criterion, when compared with the trauma registry-only model. The final Pediatric Overall Performance Category model demonstrated adequate discrimination (C-statistic = 0.896) and calibration (Hosmer-Lemeshow goodness-of-fit p = 0.65). The probability of poor outcomes varied significantly by site (p < 0.0001).

Conclusions: Merging 2 data systems allowed for improved risk-adjusted modeling for mortality and functional status. The merged database allowed for patient evaluation throughout the care continuum on a multi-institutional level. Merging existing data is feasible, innovative, and has potential to impact care with minimal new resources.
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http://dx.doi.org/10.1016/j.jamcollsurg.2017.01.061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6475528PMC
May 2017

Validation of a hand-held point of care device for lactate in adult and pediatric patients using traditional and locally-smoothed median and maximum absolute difference curves.

Clin Chim Acta 2017 May 21;468:145-149. Epub 2017 Feb 21.

Department of Emergency Medicine, Medical College of Wisconsin, United States.

Background: Lactate is commonly used in septic patients and is a viable biomarker for trauma patients. Its pre-hospital use could assist triaging and managing patients with these conditions.

Methods: We evaluated the analytical performance of the point-of-care (POC) StatStrip Xpress Lactate Meter (Nova Biomedical) and compared it to the ABL 800 (Radiometer). We measured lactate in 250 adult and 250 pediatric whole blood samples in 2 laboratories. The performance of the POC meter was assessed by traditional linear regression and Bland-Altman plots, and locally-smoothed (LS) median absolute difference and maximum absolute difference (MAD and MaxAD) curves.

Results: The StatStrip was linear with acceptable reproducibility at clinically relevant concentrations. Correlation with the ABL800 showed a negative bias for both populations with slope, bias ±SD (% bias) of 0.78, -0.4±0.7 (-14.5%) in children and 0.80-0.3±0.6 (-13.3%) in adults. The proportional bias appeared more significant at concentrations >4mmol/l (36.0mg/dl). The StatStrip misclassified 7.6 and 8.8% pediatric and adult samples, respectively, to lower risk categories defined using guidelines driven cut-offs. The LS MAD curves identified one breakout, concentration where the LS MAD exceeds the total allowable error limit of 0.3mmol/l (2.7mg/dl), at lactate concentrations of 3.8 and 3.2mmol/l (34.2 and 28.8mg/dl) in the pediatric and adult curves, respectively. Breakthroughs, points at which the LS MaxAD curve exceeds the 95th percentile of MaxADs, occur at concentrations above 7.5mmol/l (67.6mg/dl) for both populations where the performance of the POC meter became erratic. We concluded that if serial lactate measurements are performed, the same method should be used for baseline and follow up measurements. The LS MAD and LS MaxAD curves allowed visual and quantitative mapping of the performance of the lactate POC meter over the range of concentrations measured.

Conclusions: This approach seems useful for the identification of points at which the performance of a POC meter differs significantly from a comparison method and thresholds of poor analytical performance.
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http://dx.doi.org/10.1016/j.cca.2017.02.015DOI Listing
May 2017

Effects of anticipated neonatal surgical intervention on maternal milk cytokine production.

J Pediatr Surg 2017 Jan 27;52(1):45-49. Epub 2016 Oct 27.

Department of Pediatrics and Critical Care, Albert Einstein College Medicine, Montefiore Medical Center, New York, NY.

Background: Maternal stress on neonatal outcomes of infants admitted to the NICU is incompletely understood. We previously demonstrated breast milk derived cytokines remain biologically active in the neonatal intestine. We hypothesized that the need for neonatal surgical intervention would be stimulus leading to maternal cytokine production thus affecting neonatal outcome.

Methods: Discarded expressed breast milk (EBM) in the first 3weeks following delivery was analyzed for IL-23 and IL-10 by ELISA. Variables analyzed included: the need for a pediatric surgical procedure, the need for cardiac surgical procedure, no surgical interventions, and survival. All values are expressed as mean±SEM. Statistical analysis utilized Kruskal and Mann-Whitney test.

Results: EBM from mothers whose infants required any surgical procedure (n=19) revealed significant elevation in IL-10 but not IL-23 compared to nonsurgical EBM (n=18). Subdivided by procedure type, there was no difference between those undergoing a cardiac (n=9) versus pediatric surgical (n=10) procedure in both IL-10 and IL-23. Mothers whose infants requiring surgical intervention or whose infants did not survive in the first 3weeks of life had elevation of IL-10.

Conclusion: Results suggest maternal stress impacts the cytokine profile of breast milk.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2016.10.017DOI Listing
January 2017

Radiation-induced changes in intestinal and tissue-nonspecific alkaline phosphatase: implications for recovery after radiation therapy.

Am J Surg 2016 Oct 18;212(4):602-608. Epub 2016 Jul 18.

Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA; Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.

Background: Exogenous replacement of depleted enterocyte intestinal alkaline phosphatase (IAP) decreases intestinal injury in models of colitis. We determined whether radiation-induced intestinal injury could be mitigated by oral IAP supplementation and the impact on tissue-nonspecific AP.

Methods: WAG/RjjCmcr rats (n = 5 per group) received lower hemibody irradiation (13 Gy) followed by daily gavage with phosphate-buffered saline or IAP (40 U/kg/d) for 4 days. Real-time polymerase chain reaction, AP activity, and microbiota analysis were performed on intestine. Lipopolysaccharide and cytokine analysis was performed on serum. Data were expressed as a mean ± SEM with P greater than .05 considered significant.

Results: Intestine of irradiated animals demonstrates lower hemibody irradiation and is associated with upregulation of tissue-nonspecific AP, downregulation of IAP, decreased AP activity, and altered composition of the intestinal microbiome.

Conclusions: Supplemental IAP after radiation may be beneficial in mitigating intestinal radiation syndrome as evidenced by improved histologic injury, decreased acute intestinal inflammation, and normalization of intestinal microbiome.
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http://dx.doi.org/10.1016/j.amjsurg.2016.06.005DOI Listing
October 2016

Intestinal alkaline phosphatase: a summary of its role in clinical disease.

J Surg Res 2016 May 17;202(1):225-34. Epub 2015 Dec 17.

Department of Surgery, Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee; Department of Surgery, Division of Pediatric Surgery, Children's Hospital of Wisconsin, Milwaukee. Electronic address:

Over the past few years, there is increasing evidence implicating a novel role for Intestinal Alkaline Phosphatase (IAP) in mitigating inflammatory mediated disorders. IAP is an endogenous protein expressed by the intestinal epithelium that is believed to play a vital role in maintaining gut homeostasis. Loss of IAP expression or function is associated with increased intestinal inflammation, dysbiosis, bacterial translocation and subsequently systemic inflammation. As these events are a cornerstone of the pathophysiology of many diseases relevant to surgeons, we sought to review recent research in both animal and humans on IAP's physiologic function, mechanisms of action and current research in specific surgical diseases.
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http://dx.doi.org/10.1016/j.jss.2015.12.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4834149PMC
May 2016

Helicopter interfacility transport of pediatric trauma patients: Are we overusing a costly resource?

J Trauma Acute Care Surg 2016 Feb;80(2):313-7

From the Departments of Pediatrics (M.T.M., K.C.W., P.C.D., M.D.S.), Surgery (D.M.G.), Emergency Medicine and Pediatrics (E.B.L.), Medical College of Wisconsin; and Children's Hospital of Wisconsin (C.W.), Milwaukee, Wisconsin.

Background: Helicopter emergency medical services (HEMS) provide an important service to decrease interfacility transport times compared with ground ambulances. Although transport via HEMS is typically faster, the decreased transportation time comes at the expense of increased risks to the patient and flight crew and higher costs. Therefore, it is important to balance the immediate patient needs with the risk and expense of HEMS transport. Our objective was to determine how frequently pediatric patients who are interfacility transported to a Level 1 pediatric trauma center (PTC) receive a time-sensitive intervention.

Methods: This was a 4-year (2008-2012) retrospective study of children aged 0 year to 18 years who were interfacility transported to a single Level 1 PTC by HEMS. Patients were identified using the trauma registry at the PTC. A previously published outcome was used to determine if patients received time-sensitive interventions. Driving distance to the PTC was determined using Google Maps. Data were analyzed using descriptive statistics.

Results: A total of 207 cases were identified (median age, 7 years; interquartile range, 2-12 years; 29% female; median Injury Severity Score [ISS], 11; median Revised Trauma Score [RTS], 8). Forty-three percent (90 patients; 95% confidence interval, 37-50%) of patients received a time-sensitive intervention; these cases had a median age of 6 years (interquartile range, 2-11 years; 32% female; median ISS, 13; median RTS, 8). Of the 117 patients who did not receive time-sensitive interventions, 81% were within 120 driving miles of the PTC and 49% were within 60 miles.

Conclusion: This study suggests an overuse of HEMS for interfacility transfer of injured pediatric patients to a PTC. Although these patients likely required the resources of a PTC, they could perhaps have been transported by ground ambulance without detriment. Further research is needed to investigate how interfacility transport modes are selected and if these decisions can be improved without increasing evaluation times at transferring facilities.

Level Of Evidence: Epidemiologic study, level V.
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http://dx.doi.org/10.1097/TA.0000000000000904DOI Listing
February 2016

Interleukin-23 Increases Intestinal Epithelial Cell Permeability In Vitro.

Eur J Pediatr Surg 2016 Jun 22;26(3):260-6. Epub 2015 May 22.

Division of Critical Care, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, United States.

Background Breast milk has a heterogeneous composition that differs between mothers and changes throughout the first weeks after birth. The proinflammatory cytokine IL-23 has a highly variable expression in human breast milk. We hypothesize that IL-23 found in human breast milk is biologically active and promotes epithelial barrier dysfunction. Methods The immature rat small intestinal epithelial cell line, IEC-18, was grown on cell inserts or standard cell culture plates. Confluent cultures were exposed to human breast milk with high or low levels of IL-23 and barrier function was measured using a flux of fluorescein isothiocyanate-dextran (FD-70). In addition, protein and mRNA expression of occludin and ZO-1 were measured and immunofluorescence used to stain occludin and ZO-1. Results Exposure to breast milk with high levels of IL-23 caused an increase flux of FD-70 compared with both controls and breast milk with low levels of IL-23. The protein expression of ZO-1 but not occludin was decreased by exposure to high levels of IL-23. These results correlate with immunofluorescent staining of ZO-1 and occludin which show decreased staining of occludin in both the groups exposed to breast milk with high and low IL-23. Conversely, cells exposed to high IL-23 breast milk had little peripheral staining of ZO-1 compared with controls and low IL-23 breast milk. Conclusion IL-23 in human breast milk is biologically active and negatively affects the barrier function of intestinal epithelial cells through the degradation of tight junction proteins.
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http://dx.doi.org/10.1055/s-0035-1551563DOI Listing
June 2016
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