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Papers by Candace Style

Research paper thumbnail of A Review of Hypertrophic Scar and Keloid Treatment and Prevention in the Pediatric Population: Where Are We Now?

Advances in Wound Care

SIGNIFICANCE This body of work gives a concise and comprehensive overview for the clinician and s... more SIGNIFICANCE This body of work gives a concise and comprehensive overview for the clinician and scientist on the latest treatment modalities for hypertrophic scars (HTS) and keloids in the pediatric population, as well as the most promising methods of prevention currently being investigated. This review will serve as a guide to the clinician for treatment selection and as an efficient tool for the scientist to achieve a comprehensive overview of the scientific literature to guide their future experiments aimed at pathologic scar prevention. Recent Advances: Current studies in the literature suggest carbon dioxide (CO2) laser and E-light (bipolar radiofrequency, intense pulsed light, and cooling) are two of the most effective treatment modalities for HTS while surgical excision + CO2 laser + triamcinolone injection was one of the most successful treatments for keloids. In animal models, drug impregnated electrospun nanofiber dressings offer encouraging results for HTS prevention while Kelulut honey showed promising results for keloid prevention. CRITICAL ISSUES Treatment outcome reproducibility is hindered by small cohorts of patients, inadequate follow up, and variability in assessment tools. Prevention studies show multiple ways of achieving the same result yet fall short of complete prevention. Furthermore, some studies that have purported full prevention have not been validated. FUTURE DIRECTIONS In order to establish a standard of care, large clinical trials of the most successful modalities in small cohorts are needed. The key for prevention will be validation in animal models of the most successful methods, followed by translational and clinical studies.

Research paper thumbnail of Fetal endoscopic tracheal occlusion and pulmonary hypertension in moderate congenital diaphragmatic hernia

The Journal of Maternal-Fetal & Neonatal Medicine, 2021

OBJECTIVE To study the role of fetal endoscopic tracheal occlusion (FETO) on resolution of pulmon... more OBJECTIVE To study the role of fetal endoscopic tracheal occlusion (FETO) on resolution of pulmonary hypertension (PH) in fetuses with isolated moderate left-sided diaphragmatic hernia (CDH). METHODS This retrospective study included fetuses with CDH evaluated between February 2004 and July 2017. Using the tracheal occlusion to accelerate lung growth (TOTAL) trial definition, we classified fetuses into moderate left CDH if O/E-LHR (observed/expected-lung head ratio) was 25-34.9% regardless of liver position or O/E-LHR of 35-44.9% if liver was in the chest. Postnatal echocardiograms were used to diagnose PH. Logistic regression analyses were performed to determine the relationship of FETO with study outcomes. RESULTS Of 184 cases with no other major anomalies, 30 (16%) met criteria. There were nine FETO and 21 non-FETO cases. By hospital discharge, a higher proportion of infants in the FETO group had resolution of PH (87.5 (7/8) vs. 40% (8/20); p=.013). FETO was associated with adjusted odds ratio of 17.3 (95% CI: 1.75-171; p=.015) to resolve PH by hospital discharge. No significant differences were noted in need for ECMO or survival to discharge between groups. CONCLUSIONS Infants with moderate left-sided CDH according to O/E-LHR, FETO is associated with resolution of PH by the time of hospital discharge.

Research paper thumbnail of Intravenous Arginine and Citrulline Supplementation Increases Rate of Nitric Oxide Formation, Near-Infrared Spectroscopy Values and Decreases the Incidence of Necrotizing Enterocolitis in a Premature Piglet Model

Journal of the American College of Surgeons, 2017

Research paper thumbnail of 89: Fetal endoscopic tracheal occlusion (FETO) reduces pulmonary hypertension in severe congenital diaphragmatic hernia (CDH)

American Journal of Obstetrics and Gynecology, 2018

Research paper thumbnail of Intermittent bolus feeding does not enhance protein synthesis, myonuclear accretion, or lean growth more than continuous feeding in a premature piglet model

American Journal of Physiology-Endocrinology and Metabolism, 2021

Extrauterine growth restriction often occurs in premature infants but may be mitigated by optimiz... more Extrauterine growth restriction often occurs in premature infants but may be mitigated by optimizing enteral feeding strategies. We show that intermittent bolus feeding does not increase skeletal muscle protein synthesis, myonuclear accretion, or lean growth more than continuous feeding in preterm pigs. This attenuated anabolic response of muscle to intermittent bolus feeding, compared with previous observations in pigs born at term, may contribute to deficits in lean mass that many premature infants exhibit into adulthood.

Research paper thumbnail of Lung Masses

Anesthesia for Maternal-Fetal Surgery, 2021

Research paper thumbnail of Fetal Endoscopic Tracheal Occlusion (FETO)

Anesthesia for Maternal-Fetal Surgery, 2021

Research paper thumbnail of Central diaphragmatic hernia and congenital short esophagus: Embryology and long-term follow-up

Journal of Pediatric Surgery Case Reports, 2021

Research paper thumbnail of Neurocognitive Effects of Fetal Exposure to Anesthesia

Anesthesiology Clinics, 2021

Surgery during pregnancy occurs when maternal or fetal needs outweigh the status quo, yet much un... more Surgery during pregnancy occurs when maternal or fetal needs outweigh the status quo, yet much uncertainty remains regarding the effects of anesthesia and surgery on fetal neurodevelopment. This article will review common maternal and fetal indications for invasive procedures, along with contemporary research on fetal neurodevelopment following anesthesia and surgery, focusing on future areas of investigation.

Research paper thumbnail of Remote Ischemic Conditioning to Improve Splanchnic Perfusion and Prevent Necrotizing Enterocolitis in Premature Piglets

Journal of the American College of Surgeons, 2021

Research paper thumbnail of Does creating a dome reduce recurrence in congenital diaphragmatic hernia following patch repair?

Journal of Pediatric Surgery, 2021

To develop a quantifiable approach to identify a dome shape of the repaired diaphragm using post-... more To develop a quantifiable approach to identify a dome shape of the repaired diaphragm using post-operative chest radiograph and to determine if a dome-shaped prosthetic patch repair is associated with a decreased rate of CDH recurrence. We conducted a retrospective review of all neonates evaluated at our institution from January 2004 to August 2017 with left- and right-sided CDH with at least 6 months of follow-up after CDH repair. Patch use, post-operative imaging and postnatal outcomes were analyzed. Neonates with patch repair were divided into two groups based on the presence of a dome. Using postoperative chest radiographs, the presence of a dome was classified as having a vertical-horizontal diaphragm ratio (VHDR) greater than 20%. Primary outcome was CDH recurrence after repair. We identified 192 neonates who met our inclusion criteria. Cohort survival was 96%, recurrence rate was 15%, 78% had a left-sided CDH; 54% received a patch repair, of which 58% had a type C defect. Of the 104 infants with patch repairs, the CDH recurrence rate was 22% (n = 23) at a median age of 8.5 months (3.8, 20.1). Although neonates with a dome repair had more ECMO use and longer hospital stay, their recurrence rate was about half of those with a non-dome repair (14% vs 28%, p = 0.07). A dome-shaped repair may reduce recurrence following prosthetic patch repair of congenital diaphragmatic hernia. A larger, multi-institutional study is needed to statistically validate this clinically significant observation. Retrospective review. III.

Research paper thumbnail of Prematurity blunts the insulin- and amino acid-induced stimulation of translation initiation and protein synthesis in skeletal muscle of neonatal pigs

American Journal of Physiology-Endocrinology and Metabolism, 2021

Extrauterine growth faltering is a major complication of premature birth, but the underlying caus... more Extrauterine growth faltering is a major complication of premature birth, but the underlying cause is poorly understood. Our results demonstrate that preterm birth blunts both the insulin-and amino acid-induced activation of mTORC1-dependent translation initiation and protein synthesis in skeletal muscle, thereby limiting the anabolic response to feeding. This anabolic resistance likely contributes to the reduced accretion of lean mass and extrauterine growth restriction of premature infants.

Research paper thumbnail of Depletion and enrichment of phytosterols in soybean oil lipid emulsions directly associate with serum markers of cholestasis in preterm parenteral nutrition–fed pigs

Journal of Parenteral and Enteral Nutrition, 2021

BackgroundClinical reports show a positive correlation between phytosterol concentrations and sev... more BackgroundClinical reports show a positive correlation between phytosterol concentrations and severity of cholestatic liver disease markers in infants during long‐term administration of parenteral lipid emulsions. Establishing a causal link between phytosterols and cholestasis has been complicated by confounding factors of lipid emulsion load, fatty acid composition, and vitamin E in many of these studies. The goal of this study is to determine whether altering the phytosterol concentration within a common soybean oil–based emulsion will alter the onset and severity of cholestasis in parenterally fed preterm piglets.MethodsPreterm piglets were administered, for 21 days, either enteral nutrition (ENT) or parenteral nutrition (PN) prepared from a soybean oil–based emulsion containing either 24.0% (depleted [DEP]), 100% (Intralipid; normal phytosterol [NP] concentration), or 144% (enriched [ENR]) total phytosterol concentration.ResultsAt the end of the study, plasma and liver phytoster...

Research paper thumbnail of Continuous Feeding Does Not Blunt Satellite Cell Abundance, Myonuclear Accretion, or Lean Growth in a Neonatal Piglet Model of Prematurity

Current Developments in Nutrition, 2020

Objectives Lean growth in preterm neonates is poor and may increase the lifelong risk for adverse... more Objectives Lean growth in preterm neonates is poor and may increase the lifelong risk for adverse health outcomes. Strategies are needed to promote skeletal muscle growth in the postnatal period. Skeletal muscle growth, which accounts for the largest fraction of lean mass accretion, requires the coordinated activation of protein synthesis, satellite cell (SC; muscle stem cell) proliferation, differentiation, and fusion into muscle fibers. The objective of this study was to determine the effect of feeding modality on SC abundance, myonuclear accretion, and lean growth in preterm neonatal pigs. Methods Pigs delivered 10 d preterm by C-section (952 ± 205 g) were fitted with an umbilical artery catheter (later replaced with jugular vein catheter) and an orogastric tube for parenteral and enteral nutrition, respectively. Pigs were assigned to continuous (CONT; n = 14; 7.5 mL/[kg·h]) or intermittent bolus (INT; n = 30; 30 mL/kg every 4 h) feeding for 21 d (210 kcal/kg and 16 g protein/kg ...

Research paper thumbnail of Development of a multidisciplinary colorectal and pelvic health program: Program implementation and clinical impact

Journal of Pediatric Surgery, 2020

Introduction: Pediatric patients with complex colorectal and genitourinary conditions often requi... more Introduction: Pediatric patients with complex colorectal and genitourinary conditions often require coordinated multidisciplinary care; however, this coordinated care can be hard to structure and deliver. The purpose of this paper is to review the development and implementation of a multidisciplinary colorectal and pelvic health program, one year after the program's initiation. Methods: This is an observational retrospective 1-year study (10/1/2017 to 9/30/2018). In fiscal year (FY) 2018, a multidisciplinary colorectal and pelvic health program was initiated. The program development incorporated bimonthly team meetings, educational conferences, and initiation of three clinics: a complex colorectal and genitourinary reconstruction clinic, a bowel management clinic, and a colonic motility clinic. Conditions treated included complex anorectal and cloacal malformations, Hirschsprung disease, and idiopathic constipation. The fiscal year was selected to provide comparative administrative data after program implementation. Results: During the study period, 121 patients underwent comprehensive collaborative evaluation of which 58 (47%) were new to the institution compared to 12 (19%) new patients in the previous year (p b 0.001). In FY 2018, there were 130 procedures performed and 512 collaborative visits with an average of 47 visits per month. This was a 3.4-fold increase in visits compared to FY2017 (171 visits). Of the new patients, 60% (35/ 58), traveled a median of 181 miles, representing 33 statewide counties, and 4 states compared to a median of 93 miles in the previous fiscal year (p = 0.004). Conclusion: The development of a colorectal and pelvic health program is feasible and requires a collaborative approach, necessitating multiple service lines within an institution. Program creation and implementation can result in rapid institutional clinical growth by filling a local and regional need through coordinated multidisciplinary care.

Research paper thumbnail of Accuracy of prenatal and postnatal imaging for management of congenital lung malformations

Journal of Pediatric Surgery, 2020

The purpose of this study was to compare the accuracy of prenatal and postnatal imaging modalitie... more The purpose of this study was to compare the accuracy of prenatal and postnatal imaging modalities for evaluation and management of congenital lung malformations (CLMs). Methods: A retrospective review was performed of all fetuses evaluated for a CLM between December 2001 and January 2018. Pre and postnatal imaging findings, operative treatment, and patient outcomes were collected. Patients were included in analysis if they had fetal imaging (US and/or fetal MRI), a postnatal chest CT, and surgical pathology. Results: Over the study period, we identified 157 patients with prenatal imaging that also had a follow-up with postnatal chest CT at a median age of 2.1 [1.4, 3.2] months. Of these, 75% (n = 117) had surgical resection. Diagnostic accuracy (DA) for localization of unilobar lesions was 100% for pre-and postnatal imaging and 97% vs 98% for multilobar disease, respectively. On comparison for identification of aberrant vasculature and pathology prediction, pre-and postnatal imaging DAs were similar. However, postnatal CT had the highest specificity for diagnosing lesions overall (p b 0.05). Conclusion: Prenatal imaging provides valuable information for counseling and possible fetal intervention. However, this study suggests that postnatal CT scan continues to provide important information for preoperative counseling and surgical management.

Research paper thumbnail of Prospective Application of a Computational Algorithm Using Trend Analysis of Abdominal NIRS Predicts the Onset of Necrotizing Enterocolitis in Neonates with Congenital Heart Disease: From Bench to Bedside

Journal of the American College of Surgeons, 2019

Research paper thumbnail of OC18.06: Fetal endoscopic tracheal occlusion is associated with resolution of pulmonary hypertension in moderate congenital diaphragmatic hernia

Ultrasound in Obstetrics & Gynecology, 2019

Oral communication abstracts Objectives: The two types of maternal skin incision for in-utero spi... more Oral communication abstracts Objectives: The two types of maternal skin incision for in-utero spina bifida repair are low transverse (LT) incision and midline longitudinal (ML) incision. Our objective was to compare short and long-term outcomes associated with these two types of skin incisions for in-utero spina bifida repair. Methods: Prospective cohort of 72 patients undergoing fetal spina bifida repair from September 2011 to November 2018. Decision for the type of incision was at the discretion of the surgeons. Primary outcome was the total operative time. Secondary outcomes were incisional pain score on post-operative day 3, length of stay (LOS) and wound complications. Patient Scar Assessment Questionnaire, was obtained using five categories (appearance, symptoms, consciousness, satisfaction with appearance and with symptoms) with higher scores reflecting a poorer perception of the scar. Results: There were 43 women (59.7%) in LT group and 29 (40.3%) in ML group. There was no difference in GA at intervention and delivery. The total operative time was higher in the LT group by 33 minutes (p < 0.001), mainly contributed by the abdominal wall incision time (figure 1). There was no significant difference in the pain score, LOS or wound complications. Fifty-two patients (72%) responded to the questionnaire, there was an increase in symptoms in the LT group (p<0.001), secondary to increased numbness and pain. No difference in the scores of appearance and satisfaction between the groups. Conclusions: Midline skin incision shortens the operative time and reduces long-term incision related symptoms when compared to low transverse incision. Rate of wound complications following each type of incision should be assessed in larger studies.

Research paper thumbnail of Prenatal Imaging Features and Postnatal Factors Associated with Gastrointestinal Morbidity in Congenital Diaphragmatic Hernia

Fetal Diagnosis and Therapy, 2019

Background: To perform a comprehensive assessment of postnatal gastrointestinal (GI) morbidity an... more Background: To perform a comprehensive assessment of postnatal gastrointestinal (GI) morbidity and determine the prenatal imaging features and postnatal factors associated with its development in patients with congenital diaphragmatic hernia (CDH). Materials and Methods: A retrospective review was conducted of all infants evaluated for CDH at a quaternary fetal center from February 2004 to May 2017. Prenatal imaging features and postnatal variables were analyzed. GI morbidity was the primary outcome. The Mann-Whitney U test, the Kruskal-Wallis test with Dunnett’s T3 post hoc analysis and logistic regression, and the χ2 test were performed when appropriate. Results: We evaluated 256 infants; 191 (75%) underwent CDH repair and had at least 6 months of follow-up. Of this cohort, 60% had gastroesophageal reflux disease (GERD), 13% had gastroparesis, 32% received a gastrostomy tube (G-tube), and 17% needed a fundoplication. Large defect, patch repair, extracorporeal membrane oxygenation ...

Research paper thumbnail of Continuous Feeding Does Not Blunt Skeletal Muscle Protein Synthesis and Lean Growth Compared to Intermittent Bolus Feeding in the Preterm Piglet (OR26-06-19)

Current Developments in Nutrition, 2019

Objectives Refining early feeding strategies for premature infants is essential for mitigating ad... more Objectives Refining early feeding strategies for premature infants is essential for mitigating adverse outcomes of prematurity. In neonatal term piglets, continuous feeding blunts growth compared to intermittent bolus feeding. Our objective was to determine the impact of feeding modality on lean growth in preterm pigs. We hypothesized that intermittent bolus feeding can mitigate low lean growth rates in preterm neonates compared to continuous feeding. Methods Pigs obtained by C-section (105 d gestation; 952 ± 205 g body weight) were fitted with an umbilical artery catheter (later replaced with jugular vein catheter) and an orogastric tube for parenteral and enteral nutrition, respectively. Pigs were assigned to continuous (CONT; 7.5 mL/[kg·h]) or intermittent bolus (INT; 30 mL/kg every 4 h over 15 min) feeding for 21 d. Pigs initially received parenteral nutrition and were advanced to full oral feeds over 6 d (220 kcal/kg and 16 g/kg protein per day). Body composition (by DXA), plas...

Research paper thumbnail of A Review of Hypertrophic Scar and Keloid Treatment and Prevention in the Pediatric Population: Where Are We Now?

Advances in Wound Care

SIGNIFICANCE This body of work gives a concise and comprehensive overview for the clinician and s... more SIGNIFICANCE This body of work gives a concise and comprehensive overview for the clinician and scientist on the latest treatment modalities for hypertrophic scars (HTS) and keloids in the pediatric population, as well as the most promising methods of prevention currently being investigated. This review will serve as a guide to the clinician for treatment selection and as an efficient tool for the scientist to achieve a comprehensive overview of the scientific literature to guide their future experiments aimed at pathologic scar prevention. Recent Advances: Current studies in the literature suggest carbon dioxide (CO2) laser and E-light (bipolar radiofrequency, intense pulsed light, and cooling) are two of the most effective treatment modalities for HTS while surgical excision + CO2 laser + triamcinolone injection was one of the most successful treatments for keloids. In animal models, drug impregnated electrospun nanofiber dressings offer encouraging results for HTS prevention while Kelulut honey showed promising results for keloid prevention. CRITICAL ISSUES Treatment outcome reproducibility is hindered by small cohorts of patients, inadequate follow up, and variability in assessment tools. Prevention studies show multiple ways of achieving the same result yet fall short of complete prevention. Furthermore, some studies that have purported full prevention have not been validated. FUTURE DIRECTIONS In order to establish a standard of care, large clinical trials of the most successful modalities in small cohorts are needed. The key for prevention will be validation in animal models of the most successful methods, followed by translational and clinical studies.

Research paper thumbnail of Fetal endoscopic tracheal occlusion and pulmonary hypertension in moderate congenital diaphragmatic hernia

The Journal of Maternal-Fetal & Neonatal Medicine, 2021

OBJECTIVE To study the role of fetal endoscopic tracheal occlusion (FETO) on resolution of pulmon... more OBJECTIVE To study the role of fetal endoscopic tracheal occlusion (FETO) on resolution of pulmonary hypertension (PH) in fetuses with isolated moderate left-sided diaphragmatic hernia (CDH). METHODS This retrospective study included fetuses with CDH evaluated between February 2004 and July 2017. Using the tracheal occlusion to accelerate lung growth (TOTAL) trial definition, we classified fetuses into moderate left CDH if O/E-LHR (observed/expected-lung head ratio) was 25-34.9% regardless of liver position or O/E-LHR of 35-44.9% if liver was in the chest. Postnatal echocardiograms were used to diagnose PH. Logistic regression analyses were performed to determine the relationship of FETO with study outcomes. RESULTS Of 184 cases with no other major anomalies, 30 (16%) met criteria. There were nine FETO and 21 non-FETO cases. By hospital discharge, a higher proportion of infants in the FETO group had resolution of PH (87.5 (7/8) vs. 40% (8/20); p=.013). FETO was associated with adjusted odds ratio of 17.3 (95% CI: 1.75-171; p=.015) to resolve PH by hospital discharge. No significant differences were noted in need for ECMO or survival to discharge between groups. CONCLUSIONS Infants with moderate left-sided CDH according to O/E-LHR, FETO is associated with resolution of PH by the time of hospital discharge.

Research paper thumbnail of Intravenous Arginine and Citrulline Supplementation Increases Rate of Nitric Oxide Formation, Near-Infrared Spectroscopy Values and Decreases the Incidence of Necrotizing Enterocolitis in a Premature Piglet Model

Journal of the American College of Surgeons, 2017

Research paper thumbnail of 89: Fetal endoscopic tracheal occlusion (FETO) reduces pulmonary hypertension in severe congenital diaphragmatic hernia (CDH)

American Journal of Obstetrics and Gynecology, 2018

Research paper thumbnail of Intermittent bolus feeding does not enhance protein synthesis, myonuclear accretion, or lean growth more than continuous feeding in a premature piglet model

American Journal of Physiology-Endocrinology and Metabolism, 2021

Extrauterine growth restriction often occurs in premature infants but may be mitigated by optimiz... more Extrauterine growth restriction often occurs in premature infants but may be mitigated by optimizing enteral feeding strategies. We show that intermittent bolus feeding does not increase skeletal muscle protein synthesis, myonuclear accretion, or lean growth more than continuous feeding in preterm pigs. This attenuated anabolic response of muscle to intermittent bolus feeding, compared with previous observations in pigs born at term, may contribute to deficits in lean mass that many premature infants exhibit into adulthood.

Research paper thumbnail of Lung Masses

Anesthesia for Maternal-Fetal Surgery, 2021

Research paper thumbnail of Fetal Endoscopic Tracheal Occlusion (FETO)

Anesthesia for Maternal-Fetal Surgery, 2021

Research paper thumbnail of Central diaphragmatic hernia and congenital short esophagus: Embryology and long-term follow-up

Journal of Pediatric Surgery Case Reports, 2021

Research paper thumbnail of Neurocognitive Effects of Fetal Exposure to Anesthesia

Anesthesiology Clinics, 2021

Surgery during pregnancy occurs when maternal or fetal needs outweigh the status quo, yet much un... more Surgery during pregnancy occurs when maternal or fetal needs outweigh the status quo, yet much uncertainty remains regarding the effects of anesthesia and surgery on fetal neurodevelopment. This article will review common maternal and fetal indications for invasive procedures, along with contemporary research on fetal neurodevelopment following anesthesia and surgery, focusing on future areas of investigation.

Research paper thumbnail of Remote Ischemic Conditioning to Improve Splanchnic Perfusion and Prevent Necrotizing Enterocolitis in Premature Piglets

Journal of the American College of Surgeons, 2021

Research paper thumbnail of Does creating a dome reduce recurrence in congenital diaphragmatic hernia following patch repair?

Journal of Pediatric Surgery, 2021

To develop a quantifiable approach to identify a dome shape of the repaired diaphragm using post-... more To develop a quantifiable approach to identify a dome shape of the repaired diaphragm using post-operative chest radiograph and to determine if a dome-shaped prosthetic patch repair is associated with a decreased rate of CDH recurrence. We conducted a retrospective review of all neonates evaluated at our institution from January 2004 to August 2017 with left- and right-sided CDH with at least 6 months of follow-up after CDH repair. Patch use, post-operative imaging and postnatal outcomes were analyzed. Neonates with patch repair were divided into two groups based on the presence of a dome. Using postoperative chest radiographs, the presence of a dome was classified as having a vertical-horizontal diaphragm ratio (VHDR) greater than 20%. Primary outcome was CDH recurrence after repair. We identified 192 neonates who met our inclusion criteria. Cohort survival was 96%, recurrence rate was 15%, 78% had a left-sided CDH; 54% received a patch repair, of which 58% had a type C defect. Of the 104 infants with patch repairs, the CDH recurrence rate was 22% (n = 23) at a median age of 8.5 months (3.8, 20.1). Although neonates with a dome repair had more ECMO use and longer hospital stay, their recurrence rate was about half of those with a non-dome repair (14% vs 28%, p = 0.07). A dome-shaped repair may reduce recurrence following prosthetic patch repair of congenital diaphragmatic hernia. A larger, multi-institutional study is needed to statistically validate this clinically significant observation. Retrospective review. III.

Research paper thumbnail of Prematurity blunts the insulin- and amino acid-induced stimulation of translation initiation and protein synthesis in skeletal muscle of neonatal pigs

American Journal of Physiology-Endocrinology and Metabolism, 2021

Extrauterine growth faltering is a major complication of premature birth, but the underlying caus... more Extrauterine growth faltering is a major complication of premature birth, but the underlying cause is poorly understood. Our results demonstrate that preterm birth blunts both the insulin-and amino acid-induced activation of mTORC1-dependent translation initiation and protein synthesis in skeletal muscle, thereby limiting the anabolic response to feeding. This anabolic resistance likely contributes to the reduced accretion of lean mass and extrauterine growth restriction of premature infants.

Research paper thumbnail of Depletion and enrichment of phytosterols in soybean oil lipid emulsions directly associate with serum markers of cholestasis in preterm parenteral nutrition–fed pigs

Journal of Parenteral and Enteral Nutrition, 2021

BackgroundClinical reports show a positive correlation between phytosterol concentrations and sev... more BackgroundClinical reports show a positive correlation between phytosterol concentrations and severity of cholestatic liver disease markers in infants during long‐term administration of parenteral lipid emulsions. Establishing a causal link between phytosterols and cholestasis has been complicated by confounding factors of lipid emulsion load, fatty acid composition, and vitamin E in many of these studies. The goal of this study is to determine whether altering the phytosterol concentration within a common soybean oil–based emulsion will alter the onset and severity of cholestasis in parenterally fed preterm piglets.MethodsPreterm piglets were administered, for 21 days, either enteral nutrition (ENT) or parenteral nutrition (PN) prepared from a soybean oil–based emulsion containing either 24.0% (depleted [DEP]), 100% (Intralipid; normal phytosterol [NP] concentration), or 144% (enriched [ENR]) total phytosterol concentration.ResultsAt the end of the study, plasma and liver phytoster...

Research paper thumbnail of Continuous Feeding Does Not Blunt Satellite Cell Abundance, Myonuclear Accretion, or Lean Growth in a Neonatal Piglet Model of Prematurity

Current Developments in Nutrition, 2020

Objectives Lean growth in preterm neonates is poor and may increase the lifelong risk for adverse... more Objectives Lean growth in preterm neonates is poor and may increase the lifelong risk for adverse health outcomes. Strategies are needed to promote skeletal muscle growth in the postnatal period. Skeletal muscle growth, which accounts for the largest fraction of lean mass accretion, requires the coordinated activation of protein synthesis, satellite cell (SC; muscle stem cell) proliferation, differentiation, and fusion into muscle fibers. The objective of this study was to determine the effect of feeding modality on SC abundance, myonuclear accretion, and lean growth in preterm neonatal pigs. Methods Pigs delivered 10 d preterm by C-section (952 ± 205 g) were fitted with an umbilical artery catheter (later replaced with jugular vein catheter) and an orogastric tube for parenteral and enteral nutrition, respectively. Pigs were assigned to continuous (CONT; n = 14; 7.5 mL/[kg·h]) or intermittent bolus (INT; n = 30; 30 mL/kg every 4 h) feeding for 21 d (210 kcal/kg and 16 g protein/kg ...

Research paper thumbnail of Development of a multidisciplinary colorectal and pelvic health program: Program implementation and clinical impact

Journal of Pediatric Surgery, 2020

Introduction: Pediatric patients with complex colorectal and genitourinary conditions often requi... more Introduction: Pediatric patients with complex colorectal and genitourinary conditions often require coordinated multidisciplinary care; however, this coordinated care can be hard to structure and deliver. The purpose of this paper is to review the development and implementation of a multidisciplinary colorectal and pelvic health program, one year after the program's initiation. Methods: This is an observational retrospective 1-year study (10/1/2017 to 9/30/2018). In fiscal year (FY) 2018, a multidisciplinary colorectal and pelvic health program was initiated. The program development incorporated bimonthly team meetings, educational conferences, and initiation of three clinics: a complex colorectal and genitourinary reconstruction clinic, a bowel management clinic, and a colonic motility clinic. Conditions treated included complex anorectal and cloacal malformations, Hirschsprung disease, and idiopathic constipation. The fiscal year was selected to provide comparative administrative data after program implementation. Results: During the study period, 121 patients underwent comprehensive collaborative evaluation of which 58 (47%) were new to the institution compared to 12 (19%) new patients in the previous year (p b 0.001). In FY 2018, there were 130 procedures performed and 512 collaborative visits with an average of 47 visits per month. This was a 3.4-fold increase in visits compared to FY2017 (171 visits). Of the new patients, 60% (35/ 58), traveled a median of 181 miles, representing 33 statewide counties, and 4 states compared to a median of 93 miles in the previous fiscal year (p = 0.004). Conclusion: The development of a colorectal and pelvic health program is feasible and requires a collaborative approach, necessitating multiple service lines within an institution. Program creation and implementation can result in rapid institutional clinical growth by filling a local and regional need through coordinated multidisciplinary care.

Research paper thumbnail of Accuracy of prenatal and postnatal imaging for management of congenital lung malformations

Journal of Pediatric Surgery, 2020

The purpose of this study was to compare the accuracy of prenatal and postnatal imaging modalitie... more The purpose of this study was to compare the accuracy of prenatal and postnatal imaging modalities for evaluation and management of congenital lung malformations (CLMs). Methods: A retrospective review was performed of all fetuses evaluated for a CLM between December 2001 and January 2018. Pre and postnatal imaging findings, operative treatment, and patient outcomes were collected. Patients were included in analysis if they had fetal imaging (US and/or fetal MRI), a postnatal chest CT, and surgical pathology. Results: Over the study period, we identified 157 patients with prenatal imaging that also had a follow-up with postnatal chest CT at a median age of 2.1 [1.4, 3.2] months. Of these, 75% (n = 117) had surgical resection. Diagnostic accuracy (DA) for localization of unilobar lesions was 100% for pre-and postnatal imaging and 97% vs 98% for multilobar disease, respectively. On comparison for identification of aberrant vasculature and pathology prediction, pre-and postnatal imaging DAs were similar. However, postnatal CT had the highest specificity for diagnosing lesions overall (p b 0.05). Conclusion: Prenatal imaging provides valuable information for counseling and possible fetal intervention. However, this study suggests that postnatal CT scan continues to provide important information for preoperative counseling and surgical management.

Research paper thumbnail of Prospective Application of a Computational Algorithm Using Trend Analysis of Abdominal NIRS Predicts the Onset of Necrotizing Enterocolitis in Neonates with Congenital Heart Disease: From Bench to Bedside

Journal of the American College of Surgeons, 2019

Research paper thumbnail of OC18.06: Fetal endoscopic tracheal occlusion is associated with resolution of pulmonary hypertension in moderate congenital diaphragmatic hernia

Ultrasound in Obstetrics & Gynecology, 2019

Oral communication abstracts Objectives: The two types of maternal skin incision for in-utero spi... more Oral communication abstracts Objectives: The two types of maternal skin incision for in-utero spina bifida repair are low transverse (LT) incision and midline longitudinal (ML) incision. Our objective was to compare short and long-term outcomes associated with these two types of skin incisions for in-utero spina bifida repair. Methods: Prospective cohort of 72 patients undergoing fetal spina bifida repair from September 2011 to November 2018. Decision for the type of incision was at the discretion of the surgeons. Primary outcome was the total operative time. Secondary outcomes were incisional pain score on post-operative day 3, length of stay (LOS) and wound complications. Patient Scar Assessment Questionnaire, was obtained using five categories (appearance, symptoms, consciousness, satisfaction with appearance and with symptoms) with higher scores reflecting a poorer perception of the scar. Results: There were 43 women (59.7%) in LT group and 29 (40.3%) in ML group. There was no difference in GA at intervention and delivery. The total operative time was higher in the LT group by 33 minutes (p < 0.001), mainly contributed by the abdominal wall incision time (figure 1). There was no significant difference in the pain score, LOS or wound complications. Fifty-two patients (72%) responded to the questionnaire, there was an increase in symptoms in the LT group (p<0.001), secondary to increased numbness and pain. No difference in the scores of appearance and satisfaction between the groups. Conclusions: Midline skin incision shortens the operative time and reduces long-term incision related symptoms when compared to low transverse incision. Rate of wound complications following each type of incision should be assessed in larger studies.

Research paper thumbnail of Prenatal Imaging Features and Postnatal Factors Associated with Gastrointestinal Morbidity in Congenital Diaphragmatic Hernia

Fetal Diagnosis and Therapy, 2019

Background: To perform a comprehensive assessment of postnatal gastrointestinal (GI) morbidity an... more Background: To perform a comprehensive assessment of postnatal gastrointestinal (GI) morbidity and determine the prenatal imaging features and postnatal factors associated with its development in patients with congenital diaphragmatic hernia (CDH). Materials and Methods: A retrospective review was conducted of all infants evaluated for CDH at a quaternary fetal center from February 2004 to May 2017. Prenatal imaging features and postnatal variables were analyzed. GI morbidity was the primary outcome. The Mann-Whitney U test, the Kruskal-Wallis test with Dunnett’s T3 post hoc analysis and logistic regression, and the χ2 test were performed when appropriate. Results: We evaluated 256 infants; 191 (75%) underwent CDH repair and had at least 6 months of follow-up. Of this cohort, 60% had gastroesophageal reflux disease (GERD), 13% had gastroparesis, 32% received a gastrostomy tube (G-tube), and 17% needed a fundoplication. Large defect, patch repair, extracorporeal membrane oxygenation ...

Research paper thumbnail of Continuous Feeding Does Not Blunt Skeletal Muscle Protein Synthesis and Lean Growth Compared to Intermittent Bolus Feeding in the Preterm Piglet (OR26-06-19)

Current Developments in Nutrition, 2019

Objectives Refining early feeding strategies for premature infants is essential for mitigating ad... more Objectives Refining early feeding strategies for premature infants is essential for mitigating adverse outcomes of prematurity. In neonatal term piglets, continuous feeding blunts growth compared to intermittent bolus feeding. Our objective was to determine the impact of feeding modality on lean growth in preterm pigs. We hypothesized that intermittent bolus feeding can mitigate low lean growth rates in preterm neonates compared to continuous feeding. Methods Pigs obtained by C-section (105 d gestation; 952 ± 205 g body weight) were fitted with an umbilical artery catheter (later replaced with jugular vein catheter) and an orogastric tube for parenteral and enteral nutrition, respectively. Pigs were assigned to continuous (CONT; 7.5 mL/[kg·h]) or intermittent bolus (INT; 30 mL/kg every 4 h over 15 min) feeding for 21 d. Pigs initially received parenteral nutrition and were advanced to full oral feeds over 6 d (220 kcal/kg and 16 g/kg protein per day). Body composition (by DXA), plas...