Tom Jaksic

Boston Children's Hospital, Boston, Massachusetts, United States

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Publications (124)301.25 Total impact

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    ABSTRACT: Critical illness is associated with significant catabolism, and persistent protein loss correlates with increased morbidity and mortality. Insulin is a potent anticatabolic hormone; high-dose insulin decreases skeletal muscle protein breakdown in critically ill pediatric surgical patients. However, insulin's effect on protein catabolism when given at clinically utilized doses has not been studied. The objective was to evaluate the effect of postoperative tight glycemic control and clinically dosed insulin on skeletal muscle degradation in children after cardiac surgery with cardiopulmonary bypass. Secondary analysis of a two-center, prospective randomized trial comparing tight glycemic control with standard care. Randomization was stratified by study center. Children 0-36 months who were admitted to the ICU after cardiac surgery requiring cardiopulmonary bypass. In the tight glycemic control arm, insulin was titrated to maintain blood glucose between 80 and 110 mg/dL. Patients in the control arm received standard care. Skeletal muscle breakdown was quantified by a ratio of urinary 3-methylhistidine to urinary creatinine. A total of 561 patients were included: 281 in the tight glycemic control arm and 280 receiving standard care. There was no difference in 3-methylhistidine to creatinine between groups (tight glycemic control, 249 ± 127 vs standard care, 253 ± 112, mean ± SD in μmol/g; p = 0.72). In analyses restricted to the patients in tight glycemic control arm, higher 3-methylhistidine to creatinine correlated with younger age, as well as lower weight, weight-for-age z score, length, and body surface area (p < 0.005 for each) and lower postoperative day 3 serum creatinine (r = -0.17; p = 0.02). Sex, prealbumin, and albumin were not associated with 3-methylhistidine to creatinine. During urine collection, 245 patients (87%) received insulin. However, any insulin exposure did not impact 3-methylhistidine to creatinine (t test, p = 0.45), and there was no dose-dependent effect of insulin on 3-methylhistidine to creatinine (r = -0.03; p = 0.60). Although high-dose insulin has an anabolic effect in experimental conditions, at doses necessary to achieve normoglycemia, insulin appears to have no discernible impact on skeletal muscle degradation in critically ill pediatric cardiac surgical patients.
    Pediatric Critical Care Medicine 04/2015; DOI:10.1097/PCC.0000000000000413 · 2.33 Impact Factor
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    ABSTRACT: To describe the natural history of growth patterns and nutritional support in a cohort of infants with short bowel syndrome (SBS), and to characterize risk factors for suboptimal growth. A retrospective chart review of 51 infants with SBS followed by our intestinal rehabilitation program. Weight and length data were converted to age, sex, and gestational age-standardized weight-for-age z-scores (WAZ) and length-for-age z-scores (LAZ). Median (IQR) age at enrollment was 8.3 (0.9-14.6) weeks, and follow-up duration was 10 (8-13) months, including both inpatient and outpatient visits. Both WAZ and LAZ followed a U-shaped curve, with median for newborns (WAZ = -0.28; LAZ = -0.41), a nadir at age 6 months (-2.38 and -2.18), and near recovery by age 1 year (-0.72 and -0.76). Using multivariable regression analysis, diagnosis of necrotizing enterocolitis was independently associated with significant decrements of WAZ (-0.76 ± 0.32; P = .02) and LAZ (-1.24 ± 0.32; P = .0001). ≥2 central line-associated bloodstream infections was also independently associated with decreases in WAZ (-0.95 ± 0.33; P = .004) and LAZ (-0.86 ± 0.32; P = .007). In a cohort of infants with SBS, we observed a unique pattern of somatic growth, with concomitant deceleration of both WAZ and LAZ and near recovery by 1 year. Inflammatory conditions (necrotizing enterocolitis and central line-associated bloodstream infections) represent potentially modifiable risk factors for suboptimal somatic growth. Copyright © 2015 Elsevier Inc. All rights reserved.
    The Journal of pediatrics 04/2015; 167(1). DOI:10.1016/j.jpeds.2015.02.053 · 3.74 Impact Factor
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    ABSTRACT: Intestinal failure-associated liver disease (IFALD) contributes to significant morbidity in pediatric patients with intestinal failure (IF); however, the use of parenteral nutrition (PN) with a fish oil-based intravenous (IV) emulsion (FO) has been associated with biochemical reversal of cholestasis and improved outcomes. Unfortunately, FO increases the complexity of care: because it can be administered only under Food and Drug Administration compassionate use protocols requiring special monitoring, it is not available as a 3-in-1 solution and is more expensive than comparable soy-based IV lipid emulsion (SO). Because of these pragmatic constraints, a series of patient families were switched to low-dose (1 g kg day) SO following biochemical resolution of cholestasis. The present study examines whether reversal of cholestasis and somatic growth are maintained following this transition. The present study is a chart review of all children with IFALD who switched from FO to SO following resolution of cholestasis. Variables are presented as medians (interquartile ranges). Comparisons were performed using the Wilcoxon signed-rank test. Seven patients ages 25.9 (16.2-43.2) months were transitioned to SO following reversal of cholestasis using FO. At a median follow-up of 13.9 (4.3-50.1) months, there were no significant differences between pretransition and post-transition serum alanine and aspartate aminotransferases, direct bilirubin, and weight-for-age z scores. Because of recurrence of cholestasis, 1 patient was restarted on FO after 4 months on SO. Biochemical reversal of IFALD and growth were preserved after transition from FO to SO in 6 of 7 (86%) patients. Given the challenges associated with the use of FO, SO may be a viable alternative in select patients with home PN.
    Journal of Pediatric Gastroenterology and Nutrition 03/2015; 60(3):375-7. DOI:10.1097/MPG.0000000000000609 · 2.87 Impact Factor
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    ABSTRACT: The distribution of surgical care of very low birth weight (VLBW) neonates among centers with varying specialized care remains unknown. This study quantifies operations performed on VLBW neonates nationally with respect to center type. VLBW neonates born 2009-2012 were assessed using a prospectively collected multi-center database encompassing 80% of all VLBW neonates in the United States. Surgical centers were categorized based on availability of pediatric surgery (PS) and anesthesia (PA). 48,711 major procedures (29,512 abdominal operations) were performed on 24,318 neonates. Of all patients, 20,892 (85.9%) underwent surgery at centers with PS and PA available on site. 1663 (6.8%) patients were treated at centers with neither specialty on site. Neonates requiring complex operations were more likely to receive surgery at centers with both PS and PA on staff than those requiring non-complex operations (95.6% vs 93.6%). This study confirms that most operations on VLBW neonates in the U.S. are performed at centers with pediatric surgeons and anesthesiologists on staff. Further research is necessary, however, to elucidate why a significant minority of this challenging population continues to be managed at centers without pediatric specialists. Copyright © 2014 Elsevier Inc. All rights reserved.
    Journal of Pediatric Surgery 12/2014; 49(12):1821-1824.e8. DOI:10.1016/j.jpedsurg.2014.09.032 · 1.31 Impact Factor
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    ABSTRACT: Infants with serious congenital heart disease (CHD) appear to be at increased risk for necrotizing enterocolitis (NEC). This study aimed to quantify the incidence and mortality of NEC among very low birth weight (VLBW) neonates with serious CHD, and identify specific CHD diagnoses at the highest risk for developing NEC. Data were prospectively collected on 257,794 VLBW (401 to 1,500 g) neonates born from 2006 to 2011 and admitted to 674 Vermont Oxford Network US centers. Entries were coded for specific CHD diagnoses and reviewed for completeness and consistency. Survival was defined as alive in-hospital at 1 year or discharge. Of eligible neonates, 1,931 had serious CHD. Of these, 253 (13%) developed NEC (vs 9% in infants without CHD, adjusted odds ratio [AOR] 1.80, p < 0.0001). Mortality for neonates with CHD and no NEC was 34%, vs 55% for those with CHD and NEC (p < 0.0001). Both groups of CHD patients had higher mortality than infants with NEC without CHD (28%, p < 0.0001). Although NEC mortality overall decreases with higher birth weight, mortality for NEC and CHD together does not. The incidence of NEC is significantly higher in VLBW neonates when CHD is present. The mortality of CHD and NEC together is substantially higher than that with each disease alone. Infants with atrioventricular canal appear to have higher risk for developing NEC than other CHD diagnoses. In addition to providing benchmark incidence and mortality data, these findings may have utility in the further study of the pathophysiology of NEC. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
    Journal of the American College of Surgeons 11/2014; 220(6). DOI:10.1016/j.jamcollsurg.2014.11.026 · 4.45 Impact Factor
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    ABSTRACT: Pediatric intestinal failure (IF) patients require many surgical procedures over the course of their illness. The number and variety of surgical procedures, as well as patient characteristics associated with this burden of surgical procedures, remain largely unknown.Methods Data from a large, multicenter retrospective study of pediatric intestinal failure (PIFCON) were reviewed. Infants from 14 multidisciplinary IF programs were enrolled, with study entry defined as PN dependence for > 60 days.ResultsA total of 272 infants were followed for a median (IQR) of 33.5 (16.2, 51.5) months, during which time they underwent 4.0 (3.0, 6.0) abdominal surgical procedures. Intestinal resections were performed in 88/97 (92%) necrotizing enterocolitis patients versus 138/175 (80%) in non-NEC patients (P < 0.05). Patients who underwent ≥ 5 operations had more septic events, compared to those who underwent ≤ 2 operations (3 (1, 6) versus 1 (0, 3), respectively, P < 0.01). Patients treated at centers with transplantation capability had lower odds of undergoing > 2 abdominal operations [OR 0.37 (95% CI: 0.21, 0.65)] after multivariable adjustment.Conclusions Individual and center-specific characteristics may help determine surgical practices experienced by infants with IF. Further study may delineate additional details about the nature of these characteristics, with the goal of optimizing patient care and minimizing individual and overall healthcare burden.
    Journal of Pediatric Surgery 11/2014; 49(12). DOI:10.1016/j.jpedsurg.2014.09.026 · 1.31 Impact Factor
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    ABSTRACT: Although a few techniques for lengthening intestine by mechanical stretch have been described, they are relatively complex, and the majority involve placement of an intraluminal device. Ideally, techniques applicable to humans would be easy to perform and extraluminal to avoid the potential for mucosal injury. This study of distraction enterogenesis used an extraluminal, radially self-expanding shape-memory polymer cylinder and a simple operative approach to both elongate intestine and grow new tissue.
    2014 American Academy of Pediatrics National Conference and Exhibition; 10/2014
  • 2014 American Academy of Pediatrics National Conference and Exhibition; 10/2014
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    ABSTRACT: In a large cohort of children with intestinal failure (IF), we sought to determine the cumulative incidence of achieving enteral autonomy and identify patient and institutional characteristics associated with enteral autonomy. A multicenter, retrospective cohort analysis from the Pediatric Intestinal Failure Consortium was performed. IF was defined as severe congenital or acquired gastrointestinal diseases during infancy with dependence on parenteral nutrition (PN) >60 days. Enteral autonomy was defined as PN discontinuation >3 months. A total of 272 infants were followed for a median (IQR) of 33.5 (16.2-51.5) months. Enteral autonomy was achieved in 118 (43%); 36 (13%) remained PN dependent and 118 (43%) patients died or underwent transplantation. Multivariable analysis identified necrotizing enterocolitis (NEC; OR 2.42, 95% CI 1.33-4.47), care at an IF site without an associated intestinal transplantation program (OR 2.73, 95% CI 1.56-4.78), and an intact ileocecal valve (OR 2.80, 95% CI 1.63-4.83) as independent risk factors for enteral autonomy. A second model (n = 144) that included only patients with intraoperatively measured residual small bowel length found NEC (OR 3.44, 95% CI 1.36-8.71), care at a nonintestinal transplantation center (OR 6.56, 95% CI 2.53-16.98), and residual small bowel length (OR 1.04 cm, 95% CI 1.02-1.06 cm) to be independently associated with enteral autonomy. A substantial proportion of infants with IF can achieve enteral autonomy. Underlying NEC, preserved ileocecal valve, and longer bowel length are associated with achieving enteral autonomy. It is likely that variations in institutional practices and referral patterns also affect outcomes in children with IF. Copyright © 2015 Elsevier Inc. All rights reserved.
    2014 American Academy of Pediatrics National Conference and Exhibition; 10/2014
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    ABSTRACT: Background Malnutrition is prevalent among congenital diaphragmatic hernia (CDH) survivors. We aimed to describe the nutritional status and factors that impact growth over the 12-months following discharge from the pediatric intensive care unit (PICU) in this cohort. Methods CDH survivors, who were discharged from the PICU from 2000 to 2010 with follow-up of at least 12 months, were included. Nutritional intake, anthropometric, and clinical variables were recorded. Multivariable linear regression was used to determine factors associated with weight-for-age Z-scores (WAZ) at 12 months. Results Data from 110 infants, 67% male, 50% patch repair, were analyzed. Median (IQR) WAZ for the cohort was − 1.4 (− 2.4 to − 0.3) at PICU discharge and − 0.4 (− 1.3 to 0.2) at 12-months. The percentage of infants with significant malnutrition (WAZ < − 2) decreased from 26% to 8.5% (p < 0.001). Patch repair (p = 0.009), protein intake < 2.3 g/kg/day (p = 0.014), and birth weight (BW) < 2.5 kg (p < 0.001) were associated with lower WAZ at 12-months. Conclusions CDH survivors had a significantly improved nutritional status in the 12-months after PICU discharge. Patch repair, lower BW, and inadequate protein intake were significant predictors of lower WAZ at 12-months. A minimum protein intake in the PICU of 2.3 g/kg/day was essential to ensure optimal growth in this cohort.
    Journal of Pediatric Surgery 10/2014; 50(1). DOI:10.1016/j.jpedsurg.2014.10.003 · 1.31 Impact Factor
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    ABSTRACT: Purpose Patients with intestinal failure (IF) are known to have impaired absorption of nutrients required for maintenance of skeletal mass. Rates and risk factors of low bone mineral density (BMD) are unknown in pediatric IF patients. Methods Following IRB approval, patients with IF having undergone DXA scans were identified and laboratory, clinical, and nutritional intake variables were recorded. Low BMD was defined by a z-score of less than or equal to − 2.0. Univariate followed by multivariable regression analysis was performed. Results Sixty-five patients underwent a total of 99 routine DXA scans. Twenty-seven (41%) had vitamin D deficiency, 22 (34%) had low BMD, and nineteen (29%) had a history of fractures. Variables noted to be associated with low BMD (p < 0.1) on univariate analysis were considered for multivariable regression. Multivariable regression identified WAZ and serum calcium levels (p < 0.05) as independent predictors of low BMD z-score. None of the other evaluated factors were associated with the risk of low BMD. Low BMD was not associated with risk of fractures. Conclusion There is a significant incidence of low BMD in children with IF. WAZ and lower serum calcium levels are associated with risk of low BMD. Additional long term prospective studies are needed to further characterize the risk factors associated with low BMD.
    Journal of Pediatric Surgery 10/2014; 50(1). DOI:10.1016/j.jpedsurg.2014.10.010 · 1.31 Impact Factor
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    ABSTRACT: Background: Children with intestinal failure (IF) frequently require gastrostomy tubes (GTs) for long-term nutrition support. Risk factors for persistent gastrocutaneous fistulae (GCFs) in pediatric patients with IF are largely unknown but may include underlying nutrition status and duration of indwelling GT. Materials and Methods: Records of patients with IF having undergone GT removal and allowed a trial at spontaneous closure were reviewed. Nonparametric continuous variables were analyzed using the Wilcoxon rank sum test. Post hoc analysis was performed to identify the optimal threshold of GT duration predicting probability of spontaneous closure identified using receiver operating characteristic curve analysis. Results: Fifty-nine children with IF undergoing GT removal were identified. Spontaneous closure occurred in 36 (61%) sites, while 23 (39%) underwent operative closure at a median 67 days after GT removal. The duration of indwelling GT was significantly shorter in the spontaneous closure group (11.5 vs 21 months, P = .002). Of 33 GT indwelling for ≤18 months, 28 (85%) closed spontaneously, compared with only 9 of 26 (35%) with duration >18 months (P < .001). With GCF persisting beyond 7 days, only 21% (6/28) of sites closed spontaneously, but this dropped to 6% (1/18) of cases with concurrent GT duration >18 months. Conclusions: Of the risk factors evaluated, only prolonged GT duration was associated with an increased likelihood of failure to close spontaneously. It is significantly less likely in pediatric patients with IF in whom GCF persists >7 days, particularly if the duration of GT is >18 months. Relatively earlier operative closure should be considered in this group.
    Journal of Parenteral and Enteral Nutrition 07/2014; DOI:10.1177/0148607114538058 · 3.14 Impact Factor
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    ABSTRACT: Purpose Citrulline, a non-protein amino acid synthesized by enterocytes, is a biomarker of bowel length and the capacity to wean from parenteral nutrition. However, the potentially variant effect of jejunal versus ileal excision on plasma citrulline concentration [CIT] has not been studied. This investigation compared serial serum [CIT] and mucosal adaptive potential after proximal versus distal small bowel resection. Methods Enterally-fed Sprague-Dawley rats underwent sham operation or 50% small bowel resection. Either proximal (PR) or distal (DR). [CIT] was measured at operation and weekly for 8 weeks. At necropsy, histologic features reflecting bowel adaptation were evaluated. Results By week 6-7, [CIT] in both resection groups significantly decreased from baseline (P < 0.05) and was significantly lower than the concentration in sham animals (P < 0.05). There was no difference in [CIT] between PR and DR at any point. Villus height and crypt density were higher in the PR than in the DR group (P ≤ 0.02). Conclusion CIT] effectively differentiates animals undergoing major bowel resection from those with preserved intestinal length. The region of intestinal resection was not a determinant of [CIT]. The remaining bowel in the PR group demonstrated greater adaptive potential histologically. [CIT] is a robust biomarker for intestinal length, irrespective of location of small intestine lost.
    Journal of Pediatric Surgery 05/2014; DOI:10.1016/j.jpedsurg.2014.02.056 · 1.31 Impact Factor
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    ABSTRACT: Purpose Serial transverse enteroplasty (STEP) lengthens and tapers bowel in patients with intestinal failure. Evaluation and treatment of serious late gastrointestinal bleeding (GIB) in three STEP patients is described. Methods Patients participating in an interdisciplinary intestinal rehabilitation program were reviewed to identify those who underwent STEP and had GIB requiring transfusion. Results Of 296 patients, 23 underwent STEP, and 3 (13%) had subsequent GIB requiring transfusion. Diagnoses were vanishing gastroschisis/atresia, malrotation/atresia, and gastroschisis.. STEP was performed at ages 3–5 months, using 5–15 stapler-firings with an increase in mean bowel length from 39 to 62 cm. GIB was diagnosed 5–30 months post-op and resulted in 1–7 transfusions per patient. Endoscopy demonstrated staple-line ulceration in two patients and eosinophilic enterocolitis in the third. All were treated with enteral antibiotics, sulfasalazine, and luminal steroids. Those with ulcers responded to bowel rest, and the patient with eosinophilic enterocolitis stabilized with luminal steroids. In all three, hemoglobin levels improved despite persistent occult bleeding. Conclusions Significant GIB is a potential late complication of STEP. Endoscopy identified the underlying source of GIB in all three patients. A combination of enteral antibiotics, anti-inflammatory medications, and bowel rest was effective in treating post-STEP GIB, without the need for additional bowel resection.
    Journal of Pediatric Surgery 05/2014; DOI:10.1016/j.jpedsurg.2014.02.060 · 1.31 Impact Factor
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    ABSTRACT: To examine the agreement of multifrequency bioelectric impedance analysis (BIA) and anthropometry with reference methods for body composition assessment in children with intestinal failure (IF). We conducted a prospective pilot study in children 14 years of age or younger with IF resulting from either short bowel syndrome (SBS) or motility disorders. Bland Altman analysis was used to examine the agreement between BIA and deuterium dilution in measuring total body water (TBW) and lean body mass (LBM); and between BIA and dual X-ray absorptiometry (DXA) techniques in measuring LBM and FM. Fat mass (FM) and percent body fat (%BF) measurements by BIA and anthropometry, were also compared in relation to those measured by deuterium dilution. Fifteen children with IF, median (IQR) age 7.2 (5.0, 10.0) years, 10 (67%) male, were studied. BIA and deuterium dilution were in good agreement with a mean bias (limits of agreement) of 0.9 (-3.2, 5.0) for TBW (L) and 0.1 (-5.4 to 5.6) for LBM (kg) measurements. The mean bias (limits) for FM (kg) and %BF measurements were 0.4 (-3.8, 4.6) kg and 1.7 (-16.9, 20.3)% respectively. The limits of agreement were within 1 SD of the mean bias in 12/14 (86%) subjects for TBW and LBM, and in 11/14 (79%) for FM and %BF measurements. Mean bias (limits) for LBM (kg) and FM (kg) between BIA and DXA were 1.6 (-3.0 to 6.3) kg and -0.1 (-3.2 to 3.1) kg, respectively. Mean bias (limits) for FM (kg) and %BF between anthropometry and deuterium dilution were 0.2 (-4.2, 4.6) and -0.2 (-19.5 to 19.1), respectively. The limits of agreement were within 1 SD of the mean bias in 10/14 (71%) subjects. In children with intestinal failure, TBW and LBM measurements by multifrequency BIA method were in agreement with isotope dilution and DXA methods, with small mean bias and clinically acceptable limits of agreement. In comparison to deuterium dilution, BIA was comparable to anthropometry for FM and %BF assessments with small mean bias, but the limits of agreement were large. BIA is a reliable method for TBW and LBM assessments in population studies. However, its reliability in individual patients, especially for FM assessments, cannot be guaranteed.
    Journal of pediatric gastroenterology and nutrition 03/2014; 59(1). DOI:10.1097/MPG.0000000000000364 · 2.87 Impact Factor
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    ABSTRACT: Since its introduction as an alternative intestinal lengthening technique, serial transverse enteroplasty (STEP) has been increasingly used as the surgical treatment of choice for patients with refractory short bowel syndrome (SBS). While primary STEP for the treatment of congenital conditions was proposed in the original description of the procedure, emphasis was placed on a delayed or staged approach to these patients. To date, a comprehensive review of the outcomes from this sub-population has not been reported by the International STEP Data Registry. A retrospective review of the International STEP Data Registry was performed to identify all patients who underwent STEP as a primary operative procedure for the treatment of congenital SBS. Changes in pre- and post-STEP values were assessed using paired t-tests with significance set at p<0.05. Data are presented as mean ± standard deviation. Fifteen patients underwent primary STEP for congenital SBS between September 1, 2004, and April 10, 2012. Thirteen patients had follow-up information available. Causes of congenital SBS included closing gastroschisis, small bowel atresia, and midgut volvulus. Twelve patients had pre- and post-STEP bowel measurements taken. Average pre- and post-STEP bowel lengths were 32 ± 16 cm and 47 ± 22 cm, respectively. Intestinal length was increased by a mean of 15 ± 12 cm for a relative small bowel length increase of 50.4 ± 27.3% (p<0.001). Only one patient required an ostomy at the time of primary STEP. A second patient required a temporary ostomy at 3months of age that was later closed. There was one death from intestinal failure associated liver disease (IFALD). Another patient experienced IFALD progression and required liver and intestinal transplantation. The most commonly reported complication following primary STEP was obstruction or bowel re-dilatation requiring additional operative interventions. Nine patients underwent second STEP procedures under these circumstances. Eight patients remain dependent on parenteral nutrition, while three patients achieved enteral autonomy. Primary STEP is a feasible and safe surgical option for the treatment of congenital conditions resulting in SBS. Primary STEP establishes early bowel continuity, creates intestinal length from congenitally dilated bowel, and appears to obviate the need for interval stomas and their associated loss of bowel length in neonates with congenital SBS. However, with recent changes in SBS management emphasizing intestinal rehabilitation, additional studies are needed to assess the long-term impact on intestinal adaptation of STEP performed in the neonatal period prior to adoption of this technique.
    Journal of Pediatric Surgery 01/2014; 49(1):104-8. DOI:10.1016/j.jpedsurg.2013.09.037 · 1.31 Impact Factor
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    ABSTRACT: To determine, in a cohort of young children with intestinal failure (IF), if estimates of basal metabolic rate (BMR) by standard equations, approximate measured REE by indirect calorimetry (IC). IC was performed by dilutional canopy technique. REE measurements were compared to standard, age-based estimation equations (WHO) for BMR. Subjects were classified as hypermetabolic (REE > 110% BMR), hypometabolic (REE < 90% BMR), or normal (REE = 90-110% BMR). Twenty-eight IF patients (11 female, 17 male) had an underlying diagnosis of necrotizing enterocolitis (n = 10) or a congenital gastrointestinal defect (n = 18). Median age was 5.3 months. Median (IQR) REE was 46 (42, 58) kcal/kg/day. Median (IQR) total energy intake provided 209 (172, 257)% of REE, with parenteral nutrition providing 76% (23%) of total energy intake. REE was variable, with 39% (n = 11) of measurements hypermetabolic, 39% (n = 11) hypometabolic, and the remaining 21% (n = 6) normal. Although REE was well correlated with estimated BMR (r = 0.82, P < 0.0001), estimated BMR was not consistently an adequate predictor of REE. BMR over- or under-estimated REE by more than 10 kcal/kg/d in 15/28 (54%) patients. REE was not significantly correlated with severity of liver disease, nutritional status, total energy intake or gestational age. Energy expenditure is variable among children with IF and IFALD, with nearly 80% of our cohort exhibiting either hypo- or hypermetabolism. Standard estimation equations frequently do not correctly predict individual REE. Longitudinal studies of energy expenditure and body composition may be needed to guide provision of nutrition regimens.
    Journal of pediatric gastroenterology and nutrition 12/2013; DOI:10.1097/MPG.0000000000000288 · 2.87 Impact Factor
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    ABSTRACT: Children who require long-term parenteral nutrition (PN) have central venous catheters (CVCs) in place to allow the safe and effective infusion of life-sustaining fluids and nutrition. Many consider recreational swimming to be a common part of childhood, but for some, the risk may outweigh the benefit. Children with CVCs may be at increased risk of exit site, tunnel, and catheter-related bloodstream infections (CRBSIs) if these catheters are immersed in water. The purpose of this review is to evaluate the current literature regarding the risk of infection for patients with CVCs who swim and determine if there is consensus among home PN (HPN) programs on this controversial issue. A total 45 articles were reviewed and 16 pediatric HPN programs were surveyed regarding swimming and CVCs. Due to the limited data available, a firm recommendation cannot be made. Recreational water associated outbreaks are well documented in the general public, as is the presence of human pathogens even in chlorinated swimming pools. As a medical team, practitioners can provide information and education regarding the potential risk, but ultimately the decision lies with the parents. If the parents decide swimming is worth the risk, they are encouraged to use products designed for this use and to change their child's dressing immediately after swimming. Due to our experience with a fatal event immediately after swimming, we continue to strongly discourage patients with CVCs from swimming. Further large and well-designed studies regarding the risk of swimming with a CVC are needed to make a strong, evidence-based recommendation.
    Nutrition in Clinical Practice 12/2013; 29(1). DOI:10.1177/0884533613515931 · 2.06 Impact Factor

Publication Stats

3k Citations
301.25 Total Impact Points

Institutions

  • 2003–2015
    • Boston Children's Hospital
      • • Center for Advanced Intestinal Rehabilitation
      • • Department of Radiology
      Boston, Massachusetts, United States
  • 2001–2014
    • Harvard Medical School
      • Department of Surgery
      Boston, Massachusetts, United States
    • Harvard University
      Cambridge, Massachusetts, United States
    • University of Chicago
      • Specialty of Pediatric Surgery
      Chicago, IL, United States
  • 2006
    • Beverly Hospital, Boston MA
      Beverly, Massachusetts, United States
  • 2000–2003
    • University of Massachusetts Boston
      Boston, Massachusetts, United States
  • 1998–2003
    • University of Houston
      Houston, Texas, United States
    • University of Texas Medical School
      • • Department of Surgery
      • • Department of Pediatrics
      Houston, Texas, United States
  • 2002
    • Children's Hospital of Richmond
      Ричмонд, Virginia, United States
  • 2000–2001
    • Texas Children's Hospital
      Houston, Texas, United States
  • 1995–1999
    • Baylor College of Medicine
      • Department of Surgery
      Houston, TX, United States
  • 1992
    • SickKids
      • Division of General Surgery
      Toronto, Ontario, Canada