Publications by authors named "Mary L Brandt"

139 Publications

A cross-sectional analysis of compassion fatigue, burnout, and compassion satisfaction in pediatric surgeons in the U.S.

J Pediatr Surg 2021 Feb 4. Epub 2021 Feb 4.

Division of Newborn Medicine, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Box 1508, One Gustave L. Levy Place, New York, NY 10029, USA. Electronic address:

Background/purpose: To determine the prevalence of compassion fatigue (CF), burnout (BO), and compassion satisfaction (CS) and identify potential predictors of these phenomena in pediatric surgeons.

Methods: The Compassion Fatigue and Satisfaction Self-Test and a survey of personal/professional characteristics were distributed electronically to American Pediatric Surgical Association members. Linear regression models for CF, BO, and CS as a function of potential risk factors were constructed.

Results: The analyzeable study response rate was 25.7%. The prevalence of CF, BO, and CS was 22%, 24% and 22, respectively, which were similar to prevalences previously identified in pediatric subspecialists. Higher CF scores were significantly associated with: higher BO scores; solo practice; compensation; ≥5 operating days/week; current distress about a 'clinical situation'; mental health-care for work-related distress; and history of childhood surgery. Lower CF scores were significantly associated with 'talking with a life partner' about work-related distress. Higher BO scores were significantly associated with: higher CF scores; current distress about 'coworkers'; and 'keeping lawsuits confidential'. Lower BO scores were significantly associated with higher CS scores.

Conclusions: CF, BO, and CS are distinct but highly related entities. Pediatric surgeons experience these phenomena at similar rates to other pediatric subspecialists. Establishing local channels for physician peer support may be particularly impactful.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.01.046DOI Listing
February 2021

Drivers of distress and well-being amongst pediatric surgeons.

J Pediatr Surg 2021 Jan 8. Epub 2021 Jan 8.

Department of Surgery, Nemours AI DuPont Hospital for Children in Wilmington, DE and Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, PA, USA.

Introduction: Although pediatric surgeons have lower rates of burnout compared to other surgical subspecialists, they still struggle with work-home conflict, depersonalization, and emotional exhaustion. Prior surveys have measured career satisfaction and burnout, but none have identified factors that contribute to physician well-being or provided potential solutions.

Methods: Members of the American Pediatric Surgical Association were surveyed regarding sources of distress and institutional practices intended to promote well-being. Responses were analyzed using content analysis.

Results: There was a 31.5% response rate to the survey. The most frequently cited sources of distress were administrative issues (45.2%), work/life balance (42.3%), personal issues (18.8%), and relationships with coworkers (17.9%). In open-ended questions, other sources of distress included poor leadership, loss of autonomy, lack of support and mentorship, and patient complications. Successful wellness strategies included relief from clinical burden, substantive wellness programming, surgeon inclusion in administrative decision making, support after adverse events, appropriate compensation and benefits, and opportunities for career development in research, teaching, and clinical care.

Conclusion: Pediatric surgeons are affected by multiple sources of distress. Interventions that ameliorate stress in pediatric surgeons were identified and should be considered by local institutions and national organizations to promote well-being.

Level Of Evidence: n/a.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.01.001DOI Listing
January 2021

Supporting recovery after adverse events: An essential component of surgeon well-being.

J Pediatr Surg 2021 Jan 9. Epub 2021 Jan 9.

Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA.

Background: Failure to recover after a medical error is a major contributor to burnout. The degree to which pediatric surgeons experience errors and the barriers and facilitators to successful recovery are largely unknown.

Methods: We conducted a survey of American Pediatric Surgical Association (APSA) members to measure frequency of personal experience with medical errors resulting in significant patient harm, describe coping mechanisms, and explore surgeon satisfaction with institutional support in the wake of an error.

Results: We found that 80% of respondents have personally experienced a medical error resulting in significant patient harm or death, and that only about one-quarter were satisfied with the support provided by their institution. Only 11% of surgeons would prefer not to be contacted after an adverse event, and most would want to be contacted by their partners. Barriers to providing and receiving support included lack of knowledge, "shame and blame" culture, and lack of trust in the institution as an ally.

Conclusions: Pediatric surgeons routinely experience intense and stressful clinical scenarios and face challenging paths to recovery after adverse events. Institutions and national societies can play a critical role in creating infrastructure to help surgeons recover, in order to prevent burnout and promote well-being.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.12.031DOI Listing
January 2021

The 2020 APSA Robert E. Gross Lecture: Pediatric Surgery, COVID 19, and the moral compass.

Authors:
Mary L Brandt

J Pediatr Surg 2021 01 24;56(1):1-4. Epub 2020 Oct 24.

Tulane University School of Medicine, Pediatric Surgeon, Children's Hospital of New Orleans, 1430 Tulane Avenue, New Orleans, LA 70112.. Electronic address:

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http://dx.doi.org/10.1016/j.jpedsurg.2020.10.015DOI Listing
January 2021

Same Anesthesia Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy: The Pediatric ERCP Database Intiative Experience.

J Pediatr Gastroenterol Nutr 2020 08;71(2):203-207

UT Southwestern Department of Pediatrics, Division of Pediatric Gastroenterology Children's Health-Children's Medical Center, Dallas, TX.

Background: Successful combined Laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) in the Same Session (LESS) has been reported in several studies in adult patients with choledocholithiasis.

Methods: This was a retrospective analysis of data collected prospectively in the Pediatric ERCP Database Initiative using REDCAP. Adverse events were recorded separately and were reviewed for this study. The primary outcome was the hospitalization days. Secondary outcomes included total duration of anesthesia, morbidity, time from diagnosis to procedure.

Results: Twenty-five patients underwent LESS, and 42 underwent the traditional ERCP followed by laparoscopic cholecystectomy. The groups were similar in age, weight, ASA. The median length of stay in the LESS group was 3 days, compared with 4 days (P = .32). Total procedure time was similar between the 2 groups, but anesthesia time was shorter in the LESS group (P = .0401). Morbidity was similarly low between the 2 groups.

Conclusions: Relative to 2 interventions, a single session combining ERCP and laparoscopic cholecystectomy in pediatric patients is effective with a similar adverse event rate and length of stay. The use of a single sedation and reduced total anesthesia time are potential benefits of this approach. This modality may be considered for pediatric patients with choledocholithiasis with or without hemolytic disease.
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http://dx.doi.org/10.1097/MPG.0000000000002722DOI Listing
August 2020

Does academic authorship reflect gender bias in pediatric surgery? An analysis of the Journal of Pediatric Surgery, 2007-2017.

J Pediatr Surg 2020 Oct 23;55(10):2071-2074. Epub 2020 May 23.

Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, NY; Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY. Electronic address:

Background: Gender representation in academic publications has been considered a surrogate for gender equity in medicine, although this concept has not been evaluated in pediatric surgery.

Methods: First and last author genders for Journal of Pediatric Surgery articles from United States and/or Canadian institutions (2007, 2012, 2017) were identified. These data were compared to gender proportions for applicants to and matriculants in pediatric surgery fellowships as well as among American Pediatric Surgical Association (APSA) members.

Results: Authorship gender was identified for 632/640 primary articles (98.8%). From 2007 to 2017, the proportion of women as first authors increased from 33.0% to 53.9% (p < 0.001) and as last authors from 16.2% to 26.4% (p = 0.01). The proportion of women fellowship applicants rose from 35.9% to 57.6% (p < 0.001); among those who successfully matched the rise was nonlinear (20.5%-34.0%, p = 0.16). APSA junior and senior women membership proportions rose during the study period [from 28.1% to 43.4% (p = 0.06 for linear trend) and 17.9% to 24.4% (p = 0.005 for linear trend), respectively].

Conclusions: Over the past decade, the overall proportion of women authors in a leading academic pediatric surgery journal has increased significantly, although representation among last authors remains disproportionately low. The numbers of women applicants to pediatric surgery fellowship increased but there was not a concordant rise in the number of women accepted into training positions.

Type Of Study: Bibliometric analysis.

Level Of Evidence: n/a.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.05.020DOI Listing
October 2020

Diagnostic Yield of Newborn Screening for Biliary Atresia Using Direct or Conjugated Bilirubin Measurements.

JAMA 2020 03;323(12):1141-1150

Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston.

Importance: Treating biliary atresia in newborns earlier can delay or prevent the need for liver transplant; however, treatment typically occurs later because biliary atresia is difficult to detect during its early stages.

Objective: To determine the diagnostic yield of newborn screening for biliary atresia with direct or conjugated bilirubin measurements and to evaluate the association of screening implementation with clinical outcomes.

Design, Setting, And Participants: A cross-sectional screening study of 124 385 infants born at 14 Texas hospitals between January 2015 and June 2018; and a pre-post study of 43 infants who underwent the Kasai portoenterostomy as treatment for biliary atresia at the region's largest pediatric hepatology center before (January 2008-June 2011) or after (January 2015-June 2018) screening implementation. Final follow-up occurred on July 15, 2019.

Exposures: Two-stage screening with direct or conjugated bilirubin measurements. In stage 1, all newborns were tested within the first 60 hours of life, with a positive screening result defined as bilirubin levels exceeding derived 95th percentile reference intervals. In stage 2, infants who had a positive screening result in stage 1 were retested at or before the 2-week well-child visit, with a positive screening result defined as bilirubin levels greater than the stage 1 result or greater than 1 mg/dL.

Main Outcomes And Measures: The primary outcomes of the screening study were sensitivity, specificity, positive predictive value, and negative predictive value based on infants testing positive in both stages. The reference standard was biliary atresia diagnosed at the region's pediatric hepatology centers. The primary outcome of the pre-post study was the age infants underwent the Kasai portoenterostomy for treatment of biliary atresia.

Results: Of 124 385 newborns in the screening study, 49.2% were female, 87.6% were of term gestational age, 70.0% were white, and 48.1% were Hispanic. Screening identified the 7 known infants with biliary atresia with a sensitivity of 100% (95% CI, 56.1%-100.0%), a specificity of 99.9% (95% CI, 99.9%-99.9%), a positive predictive value of 5.9% (95% CI, 2.6%-12.2%), and a negative predictive value of 100.0% (95% CI, 100.0%-100.0%). In the pre-post study, 24 infants were treated before screening implementation and 19 infants were treated after screening implementation (including 6 of 7 from the screening study, 7 from screening at nonstudy hospitals, and 6 from referrals because of clinical symptoms). The age infants underwent the Kasai portoenterostomy was significantly younger after screening was implemented (mean age, 56 days [SD, 19 days] before screening implementation vs 36 days [SD, 22 days] after screening implementation; between-group difference, 19 days [95% CI, 7-32 days]; P = .004).

Conclusions And Relevance: Newborn screening with direct or conjugated bilirubin measurements detected all known infants with biliary atresia in the study population, although the 95% CI around the sensitivity estimate was wide and the study design did not ensure complete ascertainment of false-negative results. Research is needed in larger populations to obtain more precise estimates of diagnostic yield and to better understand the clinical outcomes and cost-effectiveness of this screening approach.
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http://dx.doi.org/10.1001/jama.2020.0837DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7093763PMC
March 2020

An assessment of provider satisfaction with the use of a standardized visual aid for informed consent for appendectomy in children.

J Pediatr Surg 2020 May 1;55(5):913-916. Epub 2020 Feb 1.

Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX. Electronic address:

Purpose: We previously validated a visual aid for the use in the consent process for an appendectomy showing improved parental satisfaction and understanding. In this study, we evaluated provider satisfaction and perceived value of using the visual aid.

Methods: An IRB approved survey was developed assessing provider experience with use of the visual aid. This was distributed and analyzed via Research Electronic Data Capture (RedCap) Database.

Results: We administered 58 surveys (45% response rate). Participants included faculty (n = 2), fellows (n = 1), residents (n = 6), and physician assistants (n = 17). The visual aid was used >10 times by 50% of providers. The most common reason for not using the visual aid was not remembering it was available. Nearly half (40%) did not feel the visual aid added any time. 9/20 (45%) felt it added a small amount of time. Slightly over half of providers (52%) felt using the visual aid significantly increased family ability to give informed consent and made the consenting process easier for both providers and families.

Conclusion: Using a visual aid in consenting families for appendectomy does not add significant time and subjectively improves the process for providers and increases provider perception of parental understanding.

Level Of Evidence: Cost effectiveness, Level IV.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.01.044DOI Listing
May 2020

Weight Loss and Health Status 5 Years After Adjustable Gastric Banding in Adolescents.

Obes Surg 2020 06;30(6):2388-2394

Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.

Objective: This prospective cohort analysis describes changes in weight, cardiometabolic health, and weight-related quality of life (WRQOL) following adolescent LAGB.

Methods: Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) collected demographic, anthropometric, micronutrient, cardiometabolic risk, and WRQOL data for 242 adolescents. Data through 5 years were analyzed for 14 participants who underwent LAGB with 2 patients lost to follow-up.

Results: Participants (mean age 18.2 ± 0.4 years) were mostly female (86%) and white (71%) with a median body mass index (BMI) of 48.7 kg/m (45.5-54.1). Preoperatively, 100%(13/13), 62%(8/13), 57%(8/14), and 7%(1/14) had elevated high sensitivity C-reactive protein (hs-CRP), dyslipidemia, elevated blood pressure (EBP), and type 2 diabetes (T2D), respectively. At 5 years, mean BMI decreased by 3.3% (51.0 vs. 49.3 kg/m, p = 0.6), 43%(6/14) had BMI values exceeding baseline and 21% (3/14) underwent band removal. Postoperative prevalence of hs-CRP, dyslipidemia, EBP, and T2D was 45% (4/11), 36% (5/11), 33% (4/12), and 0% (0/11), respectively.

Conclusion: Adolescents undergoing LAGB experienced modest initial weight loss and improvements in cardiovascular risk factors with later weight regain and frequent need for band removal. Despite the small sample size, this prospective study highlights long-term outcomes with high rates of participant retention over time.

Clinical Trial Registration: NCT00465829.
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http://dx.doi.org/10.1007/s11695-020-04504-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7205573PMC
June 2020

Principles of Financing the Medical Home for Children.

Pediatrics 2020 01;145(1)

Department of Pediatrics, College of Medicine, University of Florida-Jacksonville, Jacksonville, Florida.

A well-implemented and adequately funded medical home not only is the best approach to optimize the health of the individual patient but also can function as an effective instrument for improving population health. Key financing elements to providing quality, effective, comprehensive care in the pediatric medical home include the following: (1) first dollar coverage without deductibles, copays, or other cost-sharing for necessary preventive care services as recommended by ; (2) adoption of a uniform definition of medical necessity across payers that embraces services that promote optimal growth and development and prevent, diagnose, and treat the full range of pediatric physical, mental, behavioral, and developmental conditions, in accord with evidence-based science or evidence-informed expert opinion; (3) payment models that promote appropriate use of pediatric primary care and pediatric specialty services and discourage inappropriate, inefficient, or excessive use of medical services; and (4) payment models that strengthen the patient- and family-physician relationship and do not impose additional administrative burdens that will only erode the effectiveness of the medical home. These goals can be met by designing payment models that provide adequate funding of the cost of medical encounters, care coordination, population health services, and quality improvement activities; provide incentives for quality and effectiveness of care; and ease administrative burdens.
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http://dx.doi.org/10.1542/peds.2019-3451DOI Listing
January 2020

Cost-Effectiveness Analysis of the Surgical Management of Infants Less than One Year of Age with Feeding Difficulties.

J Pediatr Surg 2020 Jan 25;55(1):187-193. Epub 2019 Oct 25.

Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX. Electronic address:

Background: We compared the cost-effectiveness of the common surgical strategies for the management of infants with feeding difficulty.

Methods: Infants with feeding difficulty undergoing gastrostomy alone (GT), GT and fundoplication, or gastrojejunostomy (GJ) tube were enrolled between 2/2017 and 2/2018. A validated GERD symptom severity questionnaire (GSQ) and visual analog scale (VAS) to assess quality of life (QOL) were administered at baseline, 1 month, and every 6 months. Data collected included demographics, resource utilization, diagnostic studies, and costs. VAS scores were converted to quality adjusted life months (QALMs), and costs per QALM were compared using a decision tree model.

Results: Fifty patients initially had a GT alone (71% laparoscopically), and one had a primary GJ. Median age was 4 months (IQR 3-8 months). Median follow-up was 11 months (IQR 5-13 months). Forty-three did well with GT alone. Six (12%) required conversion from GT to GJ tube, and one required a fundoplication. Of those with GT alone, six (14%) improved significantly so that their GT was removed after a mean of 7 ± 3 months. Overall, the median GSQ score improved from 173 at baseline to 18 after 1 year (p < 0.001). VAS scores also improved from 70/100 at baseline to 85/100 at 1 year (p < 0.001). ED visits (59%), readmissions (47%), and clinic visits (88%) cost $58,091, $1,442,139, and $216,739, respectively. GJ tube had significantly higher costs for diagnostic testing compared to GT (median $8768 vs. $1007, p < 0.001). Conversion to GJ tube resulted in costs of $68,241 per QALM gained compared to GT only.

Conclusions: Most patients improved with GT alone without needing GJ tube or fundoplication. GT and GJ tube were associated with improvement in symptoms and QOL. GJ tube patients reported greater gains in QALMS but incurred higher costs. Further analysis of willingness to pay for each additional QALM will help determine the value of care.

Study And Level Of Evidence: Cost-effectiveness study, Level II.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.09.076DOI Listing
January 2020

Nutritional Risks in Adolescents After Bariatric Surgery.

Clin Gastroenterol Hepatol 2020 May 6;18(5):1070-1081.e5. Epub 2019 Nov 6.

Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.

Background & Aims: Little is known about prevalence and risk factors for nutritional deficiencies in adolescents after metabolic bariatric surgery. We performed a 5-year prospective cohort study of these.

Methods: Adolescents who had Roux-en-Y gastric bypass (RYGB, n = 161) or vertical sleeve gastrectomy (VSG, n = 67) were enrolled at 5 tertiary-care centers from March 2007 through February 2012. The final analysis cohort included 226 participants (161 who had RYGB and 65 who had VSG). We measured serum levels of ferritin; red blood cell folate; vitamins A, D, B, B; and parathyroid hormone at baseline and annually for 5 years. General linear mixed models were used to examine changes over time and identify factors associated with nutritional deficiencies.

Results: The participants were 75% female and 72% white, with a mean age of 16.5 ± 1.6 years and mean body mass index of 52.7 ± 9.4 kg/m at surgery. Mean body mass index decreased 23% at 5 years, and did not differ significantly between procedures. After RYGB, but not VSG, serum concentrations of vitamin B significantly decreased whereas serum levels of transferrin and parathyroid hormone increased. Ferritin levels decreased significantly after both procedures. Hypo-ferritinemia was observed in 2.5% of patients before RYGB and 71% at 5 y after RYGB (P < .0001), and 11% of patients before VSG and 45% 5 y after VSG (P = .002). No significant changes in serum levels of folate or vitamins A, B, or D were found between baseline and 5 y after either procedure. By 5 y, 59% of RYGB and 27% of VSG recipients had 2 or more nutritional deficiencies. Risk factors associated with specific deficiencies included surgery type, female sex, black race, supplementation intake, weight regain, and for females, pregnancy.

Conclusions: In a prospective study of adolescents who underwent RYGB or VSG, we observed nutritional deficiencies by 5 y after the procedures-particularly in iron and B after RYGB. Ongoing nutrient monitoring and supplementation are recommended for all patients, but surgery type, supplementation intake, sex, and race might affect risk. (Clinical trial registration: Adolescent Bariatrics: Assessing Health Benefits and Risk [also known as Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS)], NCT00474318.).
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http://dx.doi.org/10.1016/j.cgh.2019.10.048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7166172PMC
May 2020

The significance of abdominal radiographs with paucity of gas in pediatric adhesive small bowel obstruction.

Am J Surg 2020 07 29;220(1):208-213. Epub 2019 Oct 29.

Department of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street, #1210, Houston, TX, 77030, USA. Electronic address:

Purpose: Management of children with adhesive small bowel obstruction (ASBO) is often based on abdominal radiographs (AXR). Our purpose was to determine the significance of paucity of gas on initial AXR.

Methods: Retrospective, single center review of children with ASBO between 2011 and 2015. Analysis included chi-square, non-parametric tests and multivariate regression.

Results: Of 207 cases, 99 were operative. Initial AXR showed paucity of gas in 41% and gaseous loops in 59%. Paucity was more common in operative patients (49% vs. 32%, p = 0.01). At operation, 71% of patients with paucity had closed loop or high-grade obstruction, compared to 29% of patients with gaseous loops (p = <0.001).

Conclusion: For children with ASBO with paucity of gas on AXR, complicated obstruction (closed loop or high-grade) should be considered. In children with high clinical suspicion of complicated obstruction, additional imaging with CT or SBFT may clarify the clinical picture.
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http://dx.doi.org/10.1016/j.amjsurg.2019.10.035DOI Listing
July 2020

The Bouffant Hat Debate and the Illusion of Quality Improvement.

Ann Surg 2020 04;271(4):635-636

Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.

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http://dx.doi.org/10.1097/SLA.0000000000003623DOI Listing
April 2020

A phase 2 trial of N-Acetylcysteine in Biliary atresia after Kasai portoenterostomy.

Contemp Clin Trials Commun 2019 Sep 2;15:100370. Epub 2019 May 2.

Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine and Texas Children's Hospital, 6621 Fannin Street, CCC 1010, Houston, TX, 77030, USA.

Background: Biliary atresia (BA) is a life-threatening liver disease of infancy, characterized by extrahepatic biliary obstruction, bile retention, and progressive liver injury. The Kasai portoenterostomy (KP) is BA's only nontransplant treatment. Its success is variable and depends on restoration of hepatic bile flow. Many adjunctive therapeutics have been studied to improve outcomes after the KP, but none demonstrate effectiveness. This study tests if N-acetylcysteine (NAC), a precursor to the choleretic glutathione, improves bile flow after KP.

Methods: This report describes the design of an open-label, single center, Phase 2 study to determine the effect of NAC following KP on markers of bile flow and outcomes in BA. The intervention is intravenous NAC (150 mg/kg/day) administered continuously for seven days starting 0-24 h after KP. The primary outcome is normalization of total serum bile acid (TSBA) concentrations within 24 weeks of KP. The secondary objectives are to describe NAC therapy's effect on other clinical parameters followed in BA for 24 months and to report adverse events occurring with therapy. This study follows the "minimax" clinical trial design.

Discussion: This is the first clinical trial to test NAC's effectiveness in improving bile flow after KP in BA. It introduces three important concepts for future BA therapeutic trials: (1) the "minimax" study design, a pertinent design for rare diseases because it detects potential effects quickly with small subject size; (2) the more sensitive bile flow marker, TSBAs, which may correlate with positive long-term outcomes better than traditional bile flow markers such as serum bilirubin; and (3) liver enzyme changes immediately after KP, which can be a guideline for potential drug-induced liver injury in other BA peri-operative adjunctive therapeutic trials.
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http://dx.doi.org/10.1016/j.conctc.2019.100370DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6542754PMC
September 2019

Five-Year Outcomes of Gastric Bypass in Adolescents as Compared with Adults.

N Engl J Med 2019 05 16;380(22):2136-2145. Epub 2019 May 16.

From the University of Colorado, Denver and Children's Hospital Colorado, Aurora (T.H.I.); University of Pittsburgh Medical Center, Pittsburgh (A.P.C.); Cincinnati Children's Hospital Medical Center (T.M.J., S.A.X., M.A.H.) and University of Cincinnati (C.X.), Cincinnati, and Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (M.P.M.) - all in Ohio; Texas Children's Hospital, Baylor College of Medicine, Houston (M.L.B.); Baker Heart and Diabetes Institute, Melbourne, VIC, Australia (J.B.D.); John R. Oishei Children's Hospital and Jacobs School of Medicine and Biosciences-SUNY University at Buffalo, Buffalo, NY (C.M.H.); the University of Alabama at Birmingham, Birmingham (M.K.C.); and the National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (M.E.E.).

Background: Bariatric surgery results in weight loss and health improvements in adults and adolescents. However, whether outcomes differ according to the age of the patient at the time of surgery is unclear.

Methods: We evaluated the health effects of Roux-en-Y gastric bypass in a cohort of adolescents (161 patients enrolled from 2006 through 2012) and a cohort of adults (396 patients enrolled from 2006 through 2009). The two cohorts were participants in two related but independent studies. Linear mixed and Poisson mixed models were used to compare outcomes with regard to weight and coexisting conditions between the cohorts 5 years after surgery. The rates of death and subsequent abdominal operations and selected micronutrient levels (up to 2 years after surgery) were also compared between the cohorts.

Results: There was no significant difference in percent weight change between adolescents (-26%; 95% confidence interval [CI], -29 to -23) and adults (-29%; 95% CI, -31 to -27) 5 years after surgery (P = 0.08). After surgery, adolescents were significantly more likely than adults to have remission of type 2 diabetes (86% vs. 53%; risk ratio, 1.27; 95% CI, 1.03 to 1.57) and of hypertension (68% vs. 41%; risk ratio, 1.51; 95% CI, 1.21 to 1.88). Three adolescents (1.9%) and seven adults (1.8%) died in the 5 years after surgery. The rate of abdominal reoperations was significantly higher among adolescents than among adults (19 vs. 10 reoperations per 500 person-years, P = 0.003). More adolescents than adults had low ferritin levels (72 of 132 patients [48%] vs. 54 of 179 patients [29%], P = 0.004).

Conclusions: Adolescents and adults who underwent gastric bypass had marked weight loss that was similar in magnitude 5 years after surgery. Adolescents had remission of diabetes and hypertension more often than adults. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases; ClinicalTrials.gov number, NCT00474318.).
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http://dx.doi.org/10.1056/NEJMoa1813909DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7345847PMC
May 2019

High-resolution manometric guidance during laparoscopic Heller myotomy: Impact on quality of life and symptom severity for children with achalasia.

J Pediatr Surg 2019 May 5;54(5):1063-1068. Epub 2019 Feb 5.

Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.

Background: High-resolution esophageal manometry (HREM) during laparoscopic Heller myotomy (LHM) with fundoplication for achalasia allows tailoring of myotomy length and wrap tightness. The purpose of this study is to quantify long-term postoperative symptom severity and quality of life using validated questionnaires.

Methods: Children ≤18 years with achalasia who previously underwent LHM with intraoperative HREM from 2010 to 2017 were prospectively surveyed. Eckardt Symptom Score (ESS), Achalasia Severity Questionnaire (ASQ), Pediatric Quality of Life Inventory (PedsQL), and Pediatric GERD Symptom and Quality of Life (PGSQ) questionnaires were administered. Scores for historical controls were obtained from prior survey instrument validation studies as comparison.

Results: Of 30 eligible patients, 12 (40%) completed the surveys. Mean age at time of surgery was 13 ± 3 years. Assessment was performed at least 10 months after surgery with mean time elapsed of 3.6 ± 2 years. Average premyotomy lower esophageal sphincter (LES) pressure, postmyotomy LES pressure, and postfundoplication LES pressure were 30 ± 10 mmHg, 14 ± 6 mmHg, and 18 ± 9, respectively. ESS (2.3/12), ASQ (39/100 ± 16), PGSQ (symptom: 0.6/4 ± 0.4, school: 0.4/4 ± 0.4), and overall PedsQL (82/100 ± 15) were similar to those of healthy historical controls.

Conclusion: Children with achalasia undergoing LHM with intraoperative HREM had sustained long-term symptom improvement and quality of life scores comparable to healthy patients.

Study And Level Of Evidence: Retrospective, II.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.01.041DOI Listing
May 2019

Bowel preparation for colostomy reversal in children.

J Pediatr Surg 2019 May 2;54(5):1045-1048. Epub 2019 Feb 2.

Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX. Electronic address:

Purpose: Pediatric bowel preparation protocols used before colostomy reversal vary. The aim of this study is to determine institutional practices at our institution and evaluate the impact of bowel preparations on postoperative outcomes and hospital length of stay in children.

Methods: This was a retrospective review of children ≤18 years old undergoing colostomy reversal at Texas Children's Hospital (TCH) between 12/2013 and 8/2017. Preoperative bowel regimens and outcomes were collected and analyzed using descriptive statistics, Wilcoxon Rank-Sum and Fishers Exact tests. Continuous variables are presented as median [IQR].

Results: Sixty-one children underwent colostomy reversal. Thirty-eight (62%) did not receive a preoperative bowel preparation. The two cohorts were similar in age, gender, and race. The most common indication for colostomy was anorectal malformation for thirty-seven (61%). Time from admission to surgery (19 h [17, 23] vs 3 [2, 3]; p < 0.01) and HLOS (6 days [5, 8] vs 5 [4, 6]; p = 0.02) were both longer in the bowel preparation cohort. Complications (3 [13%] vs 5 [22%]; p = 0.12) and 90-day readmissions (3 [13%] vs 6 [16%]; p = 0.64) were similar in both cohorts.

Conclusion: Foregoing bowel preparation may have the potential to improve cost and reduce morbidity in children undergoing colostomy closure.

Level Of Evidence: III.

Study Type: Treatment study.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.01.037DOI Listing
May 2019

Peritoneal dialysis catheter outcomes in infants initiating peritoneal dialysis for end-stage renal disease.

BMC Nephrol 2018 09 14;19(1):231. Epub 2018 Sep 14.

Renal Section, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, 1102 Bates Avenue, Suite 245, Houston, TX, 77030, USA.

Background: End-stage renal disease (ESRD) although rare among infants presents many management challenges. We sought to evaluate factors associated with PD catheter failure among infants initiated on chronic PD.

Methods: A retrospective chart review of all children under two years of age who had PD catheters placed for initiation of chronic PD from 2002 to 2015. Data was extracted for catheter related events occurring within 12 months of catheter placement. Cox and Poisson regression models were used to delineate factors associated catheter complications.

Results: Twenty-five infants with median age 18 days had PD catheters placed for chronic dialysis. Common complications included leakage around the exit site (31%), blockage (26%), migration or malposition (23%), catheter-related infections (18%), and other complications (2%). Predictors of initial PD catheter failure were age less than one month at catheter placement (hazard ratio (HR) 7.77, 95% CI, 1.70-35.39, p = 0.008), use of catheter within three days of placement (HR 5.67, 95% CI, 1.39-23.10, p = 0.015) and presence of a hernia (HR 8.64, 95% CI, 1.19-62.36, p = 0.033). In an adjusted Poisson regression model, PD catheter use within three days of placement was the only predictor of any catheter complication over the12 months of follow up.

Conclusions: Use of PD catheters within three days of placement was associated with catheter failure. We recommend that when possible, catheters should be allowed to heal for at least three days prior to use to reduce risk of complications and improve catheter survival.
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http://dx.doi.org/10.1186/s12882-018-1015-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6137733PMC
September 2018

Considerations for total thyroidectomy in an adolescent with mutation.

Ther Adv Endocrinol Metab 2018 Sep 4;9(9):299-301. Epub 2018 Jul 4.

Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.

Individuals with PTEN Hamartoma Tumor Syndrome (PHTS) are at greatly increased risk for developing well-differentiated thyroid cancer. Specific circumstances in which total thyroidectomies should be considered have not been defined. A 14-year-old macrocephalic female with history of developmental delay and lipoma over her left flank presented with neck swelling and was found have multinodular goiter and auto-immune thyroiditis. Asymptomatic tracheal narrowing was also detected on her initial diagnostic imaging. Later on, she developed positional dyspnea during sleep. Genetic testing revealed a heterozygous pathogenic variant in the gene (c.463T>A). A total thyroidectomy was performed. In addition to addressing the symptomology in our case, a total thyroidectomy also fortuitously eliminated the thyroid cancer risk. This case spurred us on further to identify specific clinical scenarios where total thyroidectomy may be considered as a true prophylactic measure to manage thyroid cancer risk in PHTS patients.
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http://dx.doi.org/10.1177/2042018818784517DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6116769PMC
September 2018

Use of standardized visual aids improves informed consent for appendectomy in children: A randomized control trial.

Am J Surg 2018 10 24;216(4):730-735. Epub 2018 Jul 24.

Michael E. DeBakey Department of Surgery, Pediatric Surgery Division, Texas Children's Hospital, Houston, TX, United States. Electronic address:

Background: Obtaining informed consent for surgical procedures is often compromised by patient and family educational background, complexity of the forms, and language barriers. We developed and tested a visual aid in order to improve the informed consent process for families of children with appendicitis.

Methods: Families were randomized to receive either a standard surgical consent or a standard consent plus visual aid. Univariate and multivariate analyses were performed to assess the effectiveness of adding the visual aid to the consent procedure.

Results: Parents in both cohorts were similar in age, gender and education level (p > 0.05). On multivariate analysis, visual consent had the strongest influence on parent/guardian comprehension (OR 4.0; 95%CI 2.2-7.2; p < 0.01), followed by post-secondary education (OR 2.7; 95%CI 1.5-4.9; p < 0.01), and use of external resources to look up appendicitis (OR 2.0; 95%CI 1.1-3.6; p = 0.02).

Conclusion: Visual aids improve understanding and retention of information given during the informed consent process of children with appendicitis.
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http://dx.doi.org/10.1016/j.amjsurg.2018.07.032DOI Listing
October 2018

Surgical interventions and anesthesia in the 1st year of life for lower urinary tract obstruction.

J Pediatr Surg 2019 Apr 6;54(4):820-824. Epub 2018 Jul 6.

Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, TX.

Background: Patients with a prenatal diagnosis of lower urinary tract obstruction (LUTO) may undergo prenatal interventions, such as vesicoamniotic shunt (VAS) placement, as a temporary solution for relieving urinary tract obstruction. A recent FDA communication has raised awareness of the potential neurocognitive adverse effects of anesthesia in children. We hypothesized as to whether a prenatal LUTO staging system was predictive of the number of anesthesia events for prenatally diagnosed LUTO patients.

Methods: We retrospectively reviewed the prenatal and postnatal clinical records for patients with prenatally diagnosed LUTO from 2012 to 2015. Patients were stratified by prenatal VAS status and by LUTO disease severity according to Ruano et al. (Ultrasound Obstet Gynecol. 2016).

Results: 31 patients were identified with a prenatal LUTO diagnosis, and postnatal records were available for 21 patients (seven patients in each stage). When combining prenatal and postnatal anesthesia, there was a significant difference in the number of anesthesia encounters by stage (1.6, 3.7, and 6.7 for Stage I, II, and III respectively, p = .034). Upon univariate analysis, higher gestational age (GA) at birth was associated with a decreased number of anesthesia events in the first year (p = .031).

Conclusions: The majority of infants with prenatally diagnosed LUTO will undergo postnatal procedures with general anesthesia exposure in the first year of life. Patients with higher prenatal LUTO severity experienced a higher number of both prenatal and postnatal anesthesia encounters. In addition, higher GA at birth was associated with fewer anesthesia encounters in the first year.

Level Of Evidence: This is a prognostic study with Level IV evidence.
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http://dx.doi.org/10.1016/j.jpedsurg.2018.06.033DOI Listing
April 2019

How Long Does it Take to Diagnose Appendicitis? Time Point Process Mapping in the Emergency Department.

Pediatr Emerg Care 2018 Jun;34(6):381-384

Department of Pediatrics, Baylor College of Medicine, Houston, TX.

Objectives: Appendicitis is the most common surgical emergency encountered in the pediatric emergency department (ED). We analyzed the time course of children evaluated for suspected appendicitis in relation to implementation of a risk-stratified ultrasound scoring system and structured reporting template (Appy-Score).

Methods: In July 2013, a 6-level ultrasound (US)-based appendicitis scoring system was developed and implemented. The records of children (age ≤18 years) who underwent limited abdominal US exams for suspected appendicitis at a large academic pediatric ED were reviewed retrospectively. Time periods evaluated were from January 1 to April 1, 2013 (before implementation of the US scoring system, "PRE") and July 1 to October 1, 2013 (after implementation of the US scoring system, "POST"). Times are presented as medians with interquartile range.

Results: A total of 926 children were included (median age, 9.5 years [range, 0.1-18 years]; 49% female). Four hundred eighty-one patients were evaluated PRE and 445 POST. When comparing the 2 groups, there were no differences in the PRE and POST periods with regard to time from US ordered to first read (102 vs 112 minutes, P = 0.30), US ordered to disposition (215 vs 208 minutes, P = 0.40) and operating room posting (121 vs 122 minutes, P = 0.59), and overall ED stay (329 vs 333 minutes, P = 0.39).

Conclusions: The development of a radiographic appendicitis score, although allowing for a standardized reporting method, did not significantly alter the ED process flow for evaluation of appendicitis. This reflects the complexities in ED throughput and reveals the need for additional factors to change to improve patient flow.
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http://dx.doi.org/10.1097/PEC.0000000000000720DOI Listing
June 2018

Surgical outcomes in Alagille syndrome and PFIC: A single institution's 20-year experience.

J Pediatr Surg 2018 May 9;53(5):976-979. Epub 2018 Feb 9.

Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States. Electronic address:

Background: Alagille Syndrome (AGS) and Progressive Familial Intrahepatic Cholestasis (PFIC) are rare pediatric biliary disorders that lead to progressive liver disease. This study reviews our experience with the surgical management of these disorders over the last 20years.

Methods: We retrospectively reviewed the records of children diagnosed with AGS or PFIC from January 1996 to December 2016. Data collected included demographics, surgical intervention (liver transplant or biliary diversion), and complications.

Results: Of 37 patients identified with these disorders, 17 patients (8 AGS,9 PFIC) underwent surgical intervention. Mean postsurgical follow-up was 6.9±4.7years. Liver transplantation was the most common procedure (n=14). Two patients who were initially thought to have biliary atresia underwent hepatoportoenterostomy, but were subsequently shown to have Alagille syndrome. Biliary diversion procedures were performed in 3 patients (external n=1, internal n=2). PFIC patients tended to be older at the time of liver transplant compared to AGS (4.3±3.9years vs. 2.4±1.1years, p=0.25). The AGS patient with external diversion had resolution of symptoms and no complications (follow-up: 12.5years). Both PFIC patients with internal diversion (conduit between gallbladder and transverse colon) had resolution of pruritus and no progression of liver disease (follow-up: 3.8 and 4.5years).

Conclusions: AGS and PFIC are rare biliary disorders in children which result in pruritus and progressive liver failure. Three patients in this series (8%) benefited from biliary diversion for control of pruritus and have not to date required transplantation for progressive liver disease. 38% underwent transplantation owing to pruritus and severe liver dysfunction.

Level Of Evidence: 2b.
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http://dx.doi.org/10.1016/j.jpedsurg.2018.02.026DOI Listing
May 2018

Comparison of Surgical and Medical Therapy for Type 2 Diabetes in Severely Obese Adolescents.

JAMA Pediatr 2018 05;172(5):452-460

Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Denver, Aurora.

Importance: Because of the substantial increase in the occurrence of type 2 diabetes in the pediatric population and the medical complications of this condition, therapies are urgently needed that will achieve better glycemic control than standard medical management.

Objective: To compare glycemic control in cohorts of severely obese adolescents with type 2 diabetes undergoing medical and surgical interventions.

Design, Setting, And Participants: A secondary analysis of data collected by the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) and Treatment Options of Type 2 Diabetes in Adolescents and Youth (TODAY) consortia was performed. Teen-LABS enrolled 242 adolescents (≤19 years of age) from March 1, 2007, through December 31, 2011. TODAY randomized 699 participants (aged 10-17 years) from July 24, 2004, through February 25, 2009. Data analysis was performed from July 6, 2015, to June 24, 2017. Anthropometric, clinical, and laboratory data from adolescents with severe obesity and type 2 diabetes who underwent treatment with metabolic or bariatric surgery in the Teen-LABS study or medical therapy in the TODAY study were compared.

Interventions: Teen-LABS participants underwent a primary bariatric surgical procedure; TODAY participants were randomized to receive metformin therapy alone or in combination with rosiglitazone or an intensive lifestyle intervention; insulin therapy was given in cases of progression of disease.

Main Outcomes And Measures: Glycemic control, body mass index, prevalence of elevated blood pressure, dyslipidemia, abnormal kidney function, and clinical adverse events were measured.

Results: Data from 30 participants from Teen-LABS (mean [SD] age at baseline, 16.9 [1.3] years; 21 [70%] female; 18 [66%] white) and 63 from TODAY (mean [SD] age at baseline, 15.3 [1.3] years; 28 [44%] female; 45 [71%] white) were analyzed. During 2 years, mean hemoglobin A1c concentration decreased from 6.8% (95% CI, 6.4%-7.3%) to 5.5% (95% CI, 4.7% -6.3%) in Teen-LABS and increased from 6.4% (95% CI, 6.1%-6.7%) to 7.8% (95% CI, 7.2%-8.3%) in TODAY. Compared with baseline, the body mass index decreased by 29% (95% CI, 24%-34%) in Teen-LABS and increased by 3.7% (95% CI, 0.8%-6.7%) in TODAY. Twenty-three percent of Teen-LABS participants required a subsequent operation during the 2-year follow-up.

Conclusions And Relevance: Compared with medical therapy, surgical treatment of severely obese adolescents with type 2 diabetes was associated with better glycemic control, reduced weight, and improvement of other comorbidities. These data support the need for a well-designed, prospective controlled study to define the role of surgery for adolescents with type 2 diabetes, including health and surgical outcomes.
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http://dx.doi.org/10.1001/jamapediatrics.2017.5763DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5875354PMC
May 2018

Factors Influencing Time-to-diagnosis of Biliary Atresia.

J Pediatr Gastroenterol Nutr 2018 Jun;66(6):850-856

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

Objectives: Diagnosing biliary atresia (BA) quickly is critical, because earlier treatment correlates with delayed or reduced need for liver transplantation. However, diagnosing BA quickly is also difficult, with infants usually treated after 60 days of life. In this study, we aim to accelerate BA diagnosis and treatment, by better understanding factors influencing the diagnostic timeline.

Methods: Infants born between 2007 and 2014 and diagnosed with BA at our institution were included (n = 65). Two periods were examined retrospectively: P1, the time from birth to specialist referral, and P2, the time from specialist referral to treatment. How sociodemographic factors associate with P1 and P2 were analyzed with Kaplan-Meier curves and Cox proportional hazard models. In addition, to better characterize P2, laboratory results and early tissue histology were studied.

Results: P1 associated with race/ethnicity, with shorter times in non-Hispanic white infants compared to non-Hispanic black and Hispanic infants (P = 0.007 and P = 0.004, respectively). P2 associated with referral age, with shorter times in infants referred after 30, 45, or 60 days of life (P < 0.001, P < 0.001, and P = 0.001, respectively). One potential reason for longer P2 in infants referred ≤30 days is that aminotransferase levels were normal or near-normal. However, despite reassuring laboratory values, tissue histology in early cases showed key features of BA.

Conclusions: Our findings suggest 2 opportunities to accelerate BA diagnosis and treatment. First, to achieve prompt referrals for all races/ethnicities, universal screening strategies should be considered. Second, to ensure efficient evaluations independent of age, algorithms designed to detect early features of BA can be developed.
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http://dx.doi.org/10.1097/MPG.0000000000001887DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5963977PMC
June 2018

Cardiovascular Risk Factors After Adolescent Bariatric Surgery.

Pediatrics 2018 02 8;141(2). Epub 2018 Jan 8.

Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, Ohio.

Background And Objectives: Severely obese adolescents harbor numerous cardiovascular disease risk factors (CVD-RFs), which improve after metabolic and bariatric surgery (MBS). However, predictors of change in CVD-RFs among adolescents have not yet been reported.

Methods: The Teen-Longitudinal Assessment of Bariatric Surgery study (NCT00474318) prospectively collected anthropometric and health status data on 242 adolescents undergoing MBS at 5 centers. Predictors of change in CVD-RFs (blood pressure, lipids, glucose homeostasis, and inflammation) 3 years after Roux-en-Y gastric bypass and vertical sleeve gastrectomy were examined.

Results: The mean (±SD) age of participants at baseline was 17 ± 1.6 years; 76% were girls, and 72% were white, with a median BMI of 51. Participants underwent Roux-en-Y gastric bypass ( = 161), vertical sleeve gastrectomy ( = 67), or adjustable gastric banding ( = 14). Increasing weight loss was an independent predictor of normalization in dyslipidemia, elevated blood pressure (EBP), hyperinsulinemia, diabetes, and elevated high-sensitivity C-reactive protein. Older participants at time of surgery were less likely to resolve dyslipidemia compared with younger participants, whereas girls were more likely than boys to demonstrate improvements in EBP. Even those participants without frank dyslipidemia or EBP at baseline showed significant improvements in lipid and blood pressure values over time.

Conclusions: Numerous CVD-RFs improve among adolescents undergoing MBS. Increased weight loss, female sex, and younger age predict a higher probability of resolution of specific CVD-RFs. The elucidation of predictors of change in CVD-RFs may lead to refinements in patient selection and optimal timing of adolescent bariatric surgery designed to improve clinical outcomes.
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http://dx.doi.org/10.1542/peds.2017-2485DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5810605PMC
February 2018

Sustaining a career in surgery.

Authors:
Mary L Brandt

Am J Surg 2017 Oct 27;214(4):707-714. Epub 2017 Jun 27.

Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA. Electronic address:

Surgery is a demanding career with great rewards and equally great challenges. In order to sustain our careers as well as the careers of our colleagues, it is important to understand and address the physical, psychological and spiritual challenges of surgery. With rare exception, the majority of surgery residents and practicing surgeons who prematurely leave surgery do so because they find the work to be physically, emotionally or spiritually incompatible with the vision they have for their life. Understanding these issues and providing solutions to improve surgeon wellness can help prevent societal loss of these highly trained professionals and suffering for surgeons and their families.
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http://dx.doi.org/10.1016/j.amjsurg.2017.06.022DOI Listing
October 2017

Changes in Dietary Intake and Eating Behavior in Adolescents After Bariatric Surgery: an Ancillary Study to the Teen-LABS Consortium.

Obes Surg 2017 12;27(12):3082-3091

Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA.

Background: A growing number of studies suggest that bariatric surgery is safe and effective for adolescents with severe obesity. However, surprisingly little is known about changes in dietary intake and eating behavior of adolescents who undergo bariatric surgery.

Objective: Investigate changes in dietary intake and eating behavior of adolescents with obesity who underwent bariatric surgery (n = 119) or lifestyle modification (LM) (n = 169).

Setting: University-based health systems METHODS: A prospective investigation of 288 participants (219 female and 69 male) prior to bariatric surgery or LM and again 6, 12, and 24 months (surgery patients only) after treatment. Measures included changes in weight, macronutrient intake, eating behavior, and relevant demographic and physiological variables.

Results: Adolescents who underwent bariatric surgery experienced significantly greater weight loss than those who received LM. The two groups differed in self-reported intake of a number of macronutrients at 6 and 12 months from baseline, but not total caloric intake. Patients treated with surgery, compared to those treated with LM, also reported significantly greater reductions in a number of disordered eating symptoms. After bariatric surgery, greater weight loss from postoperative month 6 to 12 was associated with self-reported weight consciousness, craving for sweets, and consumption of zinc.

Conclusions: Adolescents who underwent bariatric surgery, compared to those who received LM, reported significantly greater reductions in weight after 1 year. They also reported greater reductions in disordered eating symptoms. These findings provide new information on changes in dietary intake and eating behavior among adolescents who undergo bariatric surgery.
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http://dx.doi.org/10.1007/s11695-017-2764-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5747929PMC
December 2017

The seven attributes of the academic surgeon: Critical aspects of the archetype and contributions to the surgical community.

Am J Surg 2017 Aug 20;214(2):165-179. Epub 2017 Feb 20.

Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.

Background: "Academic surgeon" describes a member of a medical school department of surgery, but this term does not fully define the important role of such physician-scientists in advancing surgical science through translational research and innovation.

Methods: The curriculum vitae and self-descriptive vignettes of the records of achievement of seven surgeons possessing documented records of academic leadership, innovation, and dissemination of knowledge were reviewed.

Results: Out analysis yielded seven attributes of the archetypal academic surgeon: 1) identifies complex clinical problems ignored or thought unsolvable by others, 2) becomes an expert, 3) innovates to advance treatment, 4) observes outcomes to further improve and innovate, 5) disseminates knowledge and expertise, 6) asks important questions to further improve care, and 7) trains the next generation of surgeons and scientists.

Conclusion: Although alternative pathways to innovation and academic contribution also exist, the academic surgeon typically devotes years of careful observation, analysis, and iterative investigation to identify and solve challenging or unexplored clinical problems, ideally leverages resources available in academic medical centers to support these endeavors.
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http://dx.doi.org/10.1016/j.amjsurg.2017.02.003DOI Listing
August 2017