Day 2 :
Keynote Forum
Robert P Foglia
University of Texas Southwestern Medical Center, USA
Keynote: Improving perioperative performance: The use of operations management, communication, and the electronic health record
Time : 09:30-10:10
Biography:
Robert P Foglia, MD is Professor of Surgery and Pediatrics, Chief of Pediatric Surgery at the University of Southwestern Medical Center and Surgeon-in-Chief at Children’s Medical Center Dallas. He is Co-editor of a major textbook of pediatric surgery and has 30+ years of experience in Perioperative Management and Performance Improvement. He is responsible for the clinical growth of surgical programs at Children’s and Leads Process Improvement Initiatives in the areas of quality, service and stewardship.
Abstract:
Our health system had a strategic plan to recruit surgeons, develop new programs and shift volume outside of the Main OR (MOR) suite. Previously, many of perioperative processes were dysfunctional, data with paper charting often had inaccuracies, and physicians had a healthy skepticism of the data, leading to a lack of engagement. Our aims included optimizing space, personnel, and processes, developing performance metrics, setting clear expectations for resource allocation and sharing credible data with stakeholders. Perioperative performance improvement is the orchestration of a multidisciplinary team to achieve a series of goals, which are sustainable. Three elements were essential to achieve these goals, prompt communication with shared goal expectation, operations management, and the electronic health record (EHR).
The results from 2006 to 2015 were: a) cases increased from 19,148 to 29,308 (53%), b) block utilization increased from 47% to 72% (+53% ), c) on time starts increased six-fold (12% to 80%), d) case cancellations reduced 3-fold (14% to 4%), e) MOR cases increased +2%, f) cases outside of MOR increased from 5,606 to 15,443 (+175%), while MOR cases increased 2%, g) revenue increased 99%, from $116M to $231M in 2015. Prompt and consistent communication with physicians and perioperative leadership, the use of operations management to change processes, and the EHR resulted in marked improvement in multiple performance metrics and a concomitant increase in engagement and "buy in" by physicians, administrative and nursing leadership.
Keynote Forum
David Partrick
University of Colorado, USA
Keynote: Blood transfusion is associated with adverse outcomes in pediatric oncology patients following tumor resection
Time : 10:30-11:10
Biography:
David Partrick completed his Docorate of Medicine from the University of Washington, School of Medicine, and completed Clinical Surgical and Pediatric Surgical Training at the University of Colorado. He is the Director of Surgical Endoscopy and Surgical Director of the Digestive Health Institute at Children’s Hospital Colorado, and Professor of Surgery at the University of Colorado. He has published more than 100 papers in reputed journals and is active in many professional societies.
Abstract:
We hypothesized that children with solid tumors who receive a PRBC transfusion within 30 days of tumor resection will have higher rates of recurrence, mortality, and infectious complications.
Materials & Methods: A retrospective review was performed of all children who underwent resection of a solid malignancy over an 11-year period. Outcomes variables included ICU stay, hospital length of stay (LOS), infectious complications, disease free interval, tumor recurrence, and mortality. Univariate and multivariate analyses were performed.
Results: 197/373 patients received a blood transfusion within 30 days of operation (52.8%) for an average nadir hemoglobin of 8.1±1.4 g/dL. On univariate analysis, those who received a transfusion had longer hospital LOS (median 5 vs 7 days, p<0.0001), were more likely to be admitted to the ICU (5.7% vs 35%, p<0.0001), had higher rates of infectious complications (2.9% vs. 13.7%, p<0.0002), higher rates of tumor recurrence (10.9% vs 31%, p<0.0001), shorter disease free interval (39 vs 30 days, p<0.0001) and higher mortality rates (6.3% vs 21.8%, p<0.0001). After controlling for sex, age at tumor resection, nadir hemoglobin, number of units transfused, tumor type, and operation location, patients who received a blood transfusion were more likely to require ICU admission and to experience infectious complications.
Conclusion: Among children with solid tumor malignancies undergoing resection, PRBC transfusion within 30 days of operation is associated with longer hospital LOS, need for ICU stay, higher rates of infectious complications, higher rates
Keynote Forum
Nathalie Rivard
Universite de Sherbrooke, Canada
Keynote: Epithelial SHP-2 protects the intestinal mucosa against colitis and colorectal cancer
Time : 11:10-11:50
Biography:
Nathalie Rivard completed her PhD from Université de Sherbrooke in 1994 and completed a 3.5 year Post-doctorate at the Centre de Biochimie-CNRS, Université de Nice, in France with Dr. J. Pouysségur in 1997. Then, she accepted a faculty position in the Department of Anatomy and Cell Biology at the Faculté de Médecine et des Sciences de la santé de l’Université de Sherbrooke. Since 2008, she is the Chair of the Department of Anatomy and Cell Biology and Chair of the Cancer Axis at Université de Sherbrooke. Her research focuses on “The analysis of signalling pathways that control proliferation, differentiation, tumorigenesis and inflammatory response of intestinal epithelial cells”. She has published more than 80 papers in reputed journals. She is the recipient of 2013 Canadian Association of Gastroenterology Research Excellence Award and holds a Canada Research Chair.
Abstract:
SHP-2 is a Src homology 2-containing protein tyrosine phosphatase (PTP) expressed in most embryonic and adult tissues. SHP-2 regulates many cellular functions including growth, differentiation, innate immune response, chemotaxis and survival. Genetic and biochemical evidence demonstrate that SHP-2 can regulate major signalling pathways including the RAS/MAPK, PI3K/Akt and JAK/STAT pathways. Interestingly, variations within the human gene locus encoding SHP-2 have been associated with increased susceptibility to develop ulcerative colitis. We thus analyzed the role of SHP-2 in the intestine by first generating mice with an intestinal epithelial cell (IEC)-specific deletion of SHP-2 expression (SHP-2IEC-KO mice). Interestingly, these mice rapidly develop inflammation one month after birth, with clinical and histopathological features similar to ulcerative colitis. Alterations in goblet/aaneth cell ratio were observed two weeks after birth, before the onset of inflammation and were associated with significant alterations in microbiota composition. With age, SHP-2IEC-KO mice developed colitis-associated adenocarcinomas. To further analyze the protective role of SHP-2 in the intestinal epithelium, we have also generated mice expressing a constitutive active form of SHP-2 specifically in IECs (SHP-2IEC-E76K mice). These mice were either challenged with Dextran Sulfate Sodium (DSS) to induce chemical colitis or with Citrobacter rodentium to induce infectious colitis. Results showed that SHP-2IEC-E76K mice were resistant to DSS treatment or C. rodentium infection. Thus, SHP-2 activation exerts protective actions against mucosal damage and during infection with an A/E bacterial pathogen. Finally, we found reduced SHP-2 expression in intestinal biopsies from patients with active colitis, emphasizing the inverse relationship between SHP-2 expression and colonic inflammatory phenotype. Overall, our results indicate that SHP-2 maintains barrier function in the colon and thereby, helps to prevent spontaneous microbiota-driven inflammation and colitis-associated cancer development.
Keynote Forum
Nathalie Rivard
Universite de Sherbrooke, Canada
Keynote: Epithelial SHP-2 protects the intestinal mucosa against colitis and colorectal cancer
Time : 10:30-11:10
Biography:
Nathalie Rivard completed her PhD from Université de Sherbrooke in 1994 and completed a 3.5 year Post-doctorate at the Centre de Biochimie-CNRS, Université de Nice, in France with Dr. J. Pouysségur in 1997. Then, she accepted a faculty position in the Department of Anatomy and Cell Biology at the Faculté de Médecine et des Sciences de la santé de l’Université de Sherbrooke. Since 2008, she is the Chair of the Department of Anatomy and Cell Biology and Chair of the Cancer Axis at Université de Sherbrooke. Her research focuses on “The analysis of signalling pathways that control proliferation, differentiation, tumorigenesis and inflammatory response of intestinal epithelial cells”. She has published more than 80 papers in reputed journals. She is the recipient of 2013 Canadian Association of Gastroenterology Research Excellence Award and holds a Canada Research Chair.
Abstract:
SHP-2 is a Src homology 2-containing protein tyrosine phosphatase (PTP) expressed in most embryonic and adult tissues. SHP-2 regulates many cellular functions including growth, differentiation, innate immune response, chemotaxis and survival. Genetic and biochemical evidence demonstrate that SHP-2 can regulate major signalling pathways including the RAS/MAPK, PI3K/Akt and JAK/STAT pathways. Interestingly, variations within the human gene locus encoding SHP-2 have been associated with increased susceptibility to develop ulcerative colitis. We thus analyzed the role of SHP-2 in the intestine by first generating mice with an intestinal epithelial cell (IEC)-specific deletion of SHP-2 expression (SHP-2IEC-KO mice). Interestingly, these mice rapidly develop inflammation one month after birth, with clinical and histopathological features similar to ulcerative colitis. Alterations in goblet/aaneth cell ratio were observed two weeks after birth, before the onset of inflammation and were associated with significant alterations in microbiota composition. With age, SHP-2IEC-KO mice developed colitis-associated adenocarcinomas. To further analyze the protective role of SHP-2 in the intestinal epithelium, we have also generated mice expressing a constitutive active form of SHP-2 specifically in IECs (SHP-2IEC-E76K mice). These mice were either challenged with Dextran Sulfate Sodium (DSS) to induce chemical colitis or with Citrobacter rodentium to induce infectious colitis. Results showed that SHP-2IEC-E76K mice were resistant to DSS treatment or C. rodentium infection. Thus, SHP-2 activation exerts protective actions against mucosal damage and during infection with an A/E bacterial pathogen. Finally, we found reduced SHP-2 expression in intestinal biopsies from patients with active colitis, emphasizing the inverse relationship between SHP-2 expression and colonic inflammatory phenotype. Overall, our results indicate that SHP-2 maintains barrier function in the colon and thereby, helps to prevent spontaneous microbiota-driven inflammation and colitis-associated cancer development.
- Pediatric Emergency Medicine
Pediatric Immunology
Pediatric Surgery
Pediatric Neurosurgery
Session Introduction
Silvia Strambi
University of Pisa, Italy
Title: Pediatric circumcision using n-butyl-cyanoacrylate plus MS monomer: Bacteriostatic and cosmetic advantages over suture
Time : 12:50-13:20
Biography:
Silvia Strambi is a Post-graduate Pediatric Surgery student and a Scientific Consultant of Department of Surgical, Medical, and Molecular Pathology and of the Critical Area of University of Pisa (Italy). She is actively involved in clinical care and surgery, as well as in research activities. Her studies have materialized to date in 15 published articles, 9 conference abstracts and 2 books; 1 of them, about sexual development disorders, as author. She has personally presented, as speaker, the results of her original researches in 2 Italian and 4 international conferences.
Abstract:
The aim of this study is to carry out a comparison of n-butyl-cyanoacrylate plus MS monomer (NBCA-MS) versus suture in pediatric circumcision. 100 boys (age 18 months-14 years) were prospectively randomized in two groups: In 50 boys the wound margins were approximated by NBCA-MS glue while in other 50 boys interrupted polyglycolic acid 5-0 stitches were used. After surgery, 25 patients of each group (subgroup A) received 6 days of Amoxicillin/clavulanic acid and Neomycin sulfate cream, while the other 25 (subgroup B) did not receive any post-operative therapy. Wound was checked on 7th postoperative day to evidence potential infection or other complications, while resultant scar was examined 30 and 180 days after surgery for assessment of cosmetic outcome. Operative time, pain score, infective complications and cosmesis were statistically evaluated. Operative time was significantly higher in the suture group. Pain severity and duration were less in the glue group but not significantly different. In the glue group, no complications occurred, while the suture group presented 7 (14%) cases of postoperative edema and 5 (10%) cases of infection (in subgroup B). The incidence of infection in suture group as compared to glue group was statistically significant. Cosmetic results were significantly better in the glue group after 1 and 6 months follow-up. NBCA-MS glue is confirmed to be a safe and effective alternative for wound approximation in pediatric circumcision.
Yannick Bleyenheuft
Université catholique de Louvain, Belgium
Title: Capturing neuroplastic changes after intensive rehabilitation in children with unilateral cerebral palsy using DTI, TMS and fMRI
Time : 13:20-13:50
Biography:
Yannick Bleyenheuft is Faculty Member at the Université catholique de Louvain (UCL), Institute of Neuroscience. She was trained as a Physiotherapist and completed her PhD in the field of Motor Control in children with cerebral palsy (CP) in 2009 at UCL. She completed her Post-doctorate, sharing her time between UCL and Columbia University (New York), working on intensive rehabilitation processes for children with CP. In 2014, she was appointed as tenured of the Chair for neurophysiological evidences in intensive neurorehabilitation at the Institute of Neuroscience, UCL. She is now Head of the “Motor Skill Learning and intensive neurorehabilitation lab” that was developped in 2015.
Abstract:
Intensive rehabilitation interventions have been shown to be efficacious in improving upper extremity function in children with unilateral spastic cerebral palsy (USCP). These interventions are based on motor learning principles and engage children in skillful movements. Improvements in upper extremity function are believed to be associated with neuroplastic changes. However, these neuroplastic changes have not been well-described in children with cerebral palsy, likely due to challenges in defining and implementing the optimal tools and tests in children. In this study, three different neurological assessments (diffusion tensor imaging-DTI, transcranial magnetic stimulation-TMS and functional magnetic resonance imaging-fMRI) will be documented before and after a bimanual intensive treatment of upper and lower extremities intervention (HABIT-ILE) in children with USCP presenting differential corticospinal developmental reorganization (ipsilateral and contralateral). The aim of this study is to show how to capture neurophysiological changes in maps, brain activity, and associated white matter tracts, and to document the complementary relationship between these measures. Independent of cortical reorganization, children showed changes in activation and increase in size of the motor areas controlling the affected hand, quantified with different techniques. In addition, DTI demonstrated unexpected changes in corticospinal tracts.
Bradley A Kuch
Children’s Hospital of Pittsburgh of UPMC, USA
Title: Severity of illness in the early pre-surgical management of congenital diaphragmatic hernia
Time : 13:50-14:20
Biography:
Bradley A Kuch is a graduate from Ohio University with a Master in Health Care Administration and Services and Transport Team at Children’s Hospital of Pittsburgh of UPMC. His past roles included Neonatal/Pediatric Transport Therapist and ECMO Coordinator/Researcher in the Dept. of Pediatric Cardiothoracic Surgery. His current research interests include Pediatric Acute Lung Injury and Neonatal/Pediatric Severity of illness modeling during ECMO. His team’s work “First 24-h SNAP-II score and Highest PaCO2 predicts the need for ECMO in Congenital Diaphragmatic hernia” was published in the Journal of Pediatric Surgery.
Abstract:
Congenital diaphragmatic hernia (CDH) continues to carry significant morbidity and mortality despite critical and surgical advances. It is estimated that only 60%-70% survive–usually in high-volume centers. Early pre-surgical management is often complicated by physiologic derangement secondary to varying degrees of lung hypoplasia, pulmonary hypertension and a need for inter-facility transport. Infants who fail to achieve adequate oxygenation and/or perfusion with maximum medical support are regularly supported by extracorporeal membrane oxygenation (ECMO), further complicating the hospital course. These aforementioned challenges have led to a large body of evidence, evaluating best practice outcomes; however, questions remain regarding the best practice approaches to early stabilization and patient selection for ECMO. We have previously reported that pre-transport blood gases, fluid boluses, and ventilation parameters were associated with outcome; however only SNAPP-II score was found to be independently associated with ECMO (OR 1.13 [1.04-1.24]: p=0.007) and mortality (OR 1.11 [1.05-1.12]: p<0.0001) in out-born infants with CDH. In a larger dataset, we demonstrated that SNAPP-II (AUC: 0.77 vs. 0.67) performs better in predicted mortality compared to PaCO2 in the first 24 hours of life. Discussed will be the importance of severity of illness modeling in the CDH population, as it relates to stabilizing intervention and ECMO support. Current evidence concerning antenatal imaging of CDH and its relationship with severity of illness in the first 24 hours of life and outcome will be presented.
Biography:
Rania Hosny Tomerak is a Professor of Pediatrics and Neonatology in Cairo University. She has completed her graduation in 1994, Master’s in Pediatrics in 1998 and Doctorate in Pediatrics in 2001. She is an international board certified Lactation Consultant since 2004. She is a board member of Lactation Education Accreditation and Approval Committee in USA, which provides approval and accreditation to all breastfeeding programs all over the world. She has published 21 scientific papers.
Abstract:
Misconceptions run as an ice ball among people. Regarding breastfeeding, misconceptions are widespread and the mother receives a lot of confusing information from her family, friends, nurses and even pediatricians. Breastfeeding is an easy come, easy go process. It can go by one false advice, depriving the mother and her baby from the benefits of breastfeeding. In this presentation, all the common misconceptions about breastfeeding among mothers and paediatricians will be trouble-shooted. Malpractice among paediatricians and obstetricians is also discussed and corrected such as basic advices to breastfeed the healthy new-born, management of insufficient weight gain in a breastfed baby, management of breast infections, nutritional advices to the mothers, and breastfeeding guidelines of the incubated baby. Despite that all these misconceptions can easily drive the mother to terminate breastfeeding, it can be easily avoided and this is the aim of this presentation.
Marieke Witvliet
University Medical Center Groningen, Netherlands
Title: Qualitative analysis of studies concerning quality of life in children and adults with anorectal malformations
Biography:
M J Witvliet is Pediatric Surgeon in the Netherlands. She has done her Fellowship in Amsterdam and Groningen and finished this in June 2016. From October 2016, she will be Consultant in Pediatric Surgery in the Wilhelmina Children’s Hospital in Utrecht. During her Fellowship, she also worked at a PhD project about quality of life of patients with anorectal malformations or Hirschsprungs disease. This project will be finished in the beginning of 2017.
Abstract:
Introduction: Anorectal malformations are relative common congenital anomalies in pediatric surgery. After definitive surgery constipation, soiling and fecal incontinence are frequently seen problems. Quality of life (QoL) can be influenced by these problems. The last decades’ QoL has become an important aspect in the treatment and follow-up of patients with anorectal malformations. This resulted in various reports concerning QoL. In order to deduce whether the drawn conclusions in the different studies are correct and can be used to adjust standard care for patients with ARM, a qualitative analysis of the studies was performed.
Material & Methods: A literature study was performed in Pubmed, psychinfo, web of science and the Cochrane library (240 hits). After applying our inclusion-criteria and analyzing the articles, 30 articles could be used. A methodological qualitative analysis was performed and QoL outcome was assessed.
Results: Six authors (20.0%) used validated QoL questionnaires. Four articles were longitudinal and had more than 1 measure moment. Eleven studies (36.7%) used only non-validated questionnaires and 8 studies (26.6%) used only validated questionnaires. Nineteen studies correlated fecal continence to QoL, 7 studies established no correlation. Three of these 7 studies used validated QoL questionnaires. All 12 studies, who did establish a correlation, used non-validated QoL questionnaires.
Conclusions: 83.3 percent of the studies did not use validated QoL questionnaires. Conclusions concerning QoL often were based on functional outcomes, for example fecal incontinence. Longitudinal, high quality research on QoL in this group has not been done so far.
Benslimane Hammou
children hospital of Oran/Algeria
Title: Urethral duplication in girl/boy
Time : 15:20-15:50
Biography:
Benslimane hammou belongs to pediatric Urology department he published many of the research articles which are related to urethral problems in children. He had completed his MD at the age of 30 years from Oran school of medicine. Currently working as a pediatric surgeon at Becher hospital in Algeria
Abstract:
Material and method A girl aged 01 year and a half admitted for UTI.
Examination revealed a distended bladder, and a slightly hypertrophic clitoris. Meatus accessory epispadias
ULTRASOUND: bilateral ureteral hydro nephrosis, large capacity bladder thick walls.
UCR: right unilateral reflux .second path epispadias meatus.
TREATMENT:
Initially: a straight-sided configuration Cohen guy with a blindness of the second path by epispadias bladder way.
Secondly treatment of hypospadias
DISCUSSION
The ureteral duplication for the girl is easy to diagnose when viewing the meatus épispadias.
II- Given the small number of cases described in this pathology no classification has been described.
Conclusion
The duplication of the urethra is one of the rarest abnormalities of the urinary tract.
Its diagnosis and determining its type rely on VCUG and endoscopy
If resection of the accessory urethra is relatively easy prognosis depends mainly on the sub bladder obstacle whose surgical treatment is difficult.
Robert E Cilley
Penn State University, USA
Title: Improving the care of pediatric trauma patients by reducing radiation exposure during cervical spine radiography: A better technique, cephalic stabilization
Time : 15:50-16:20
Biography:
Robert E Cilley completed General and Pediatric Surgery training at the University of Michigan. He is currently Professor of Surgery and Pediatrics and Ballantine Professor of Surgery at Penn State College of Medicine, Hershey, PA, USA. He is the Chief, Division of Pediatric Surgery and Surgeon-in-Chief at Penn State Children’s Hospital, Milton S. Hershey Medical Center. He was previously the medical director of the Pediatric Trauma Program. He has published over 80 peer-reviewed articles and more than 30 book chapters. His areas of scholarly and professional interest include pediatric trauma, ECMO, lung development, surgical quality and safety.
Abstract:
Plain radiographs continue to play a role in cervical spine clearance. Inadequate radiographs commonly necessitate repeat x-rays or computed tomography imaging (10×radiation dose). We have used the technique of cephalic stabilization (CS) to improve the results of plain radiographs. Cephalic stabilization lateral radiographs are obtained, with one assistant applying traction to the arms while another placing fingers in the patient's ears and stabilizing the head. This study tests the hypothesis that CS improves visualization of the cervicothoracic junction during lateral cervical spine radiographs. A 2-year review of institutional pediatric trauma registry identified 46 patients with CS, matched 1:3 with controls. Randomized lateral radiographs were evaluated independently by 2 pediatric radiologists to determine adequate visualization of the craniocervical and cervicothoracic junctions. Reviewers were blinded to CS through image cropping. The proportion of adequate visualization of the cervicothoracic junction was 0.85 for cases with stabilization and 0.60 for controls. Odds of obtaining adequate visualization with stabilization are 3.8 times those without stabilization (P=.001) and were even greater for patients younger than 13 years. Cephalic stabilization improves visualization of the cervicothoracic junction in lateral cervical spine radiographs and can reduce radiation exposure in patients who would otherwise require further imaging.