Dr. Seema Anandalwar, Dr. Alexander Chalphin, Dr. Jonathan Dunlap, and Dr. Sarah Tracy - Research Fellowship In Review

I'm going to go back to Brigham. It's been great work with you all clinically and seeing your amazing work in the lab. To update you all, so SEMA is going back to a BI as a three. John, when we go back to Brigham, this resume is a four and applying next year for fellowship. And Alex and Sarah also heading back to BI as three. So we look forward to seeing great things ahead for all of them. Thank you. Thank you for the opportunity to present the projects I've been working on during my research fellowship. The focus of these years falls under three categories. Number one, developing here comparative effectiveness reporting for appendicitis. Number two, improving antibiotic stewardship and pediatric surgery. And number three, creating a methodology to develop comparative performance report cards for surgical antibiotic prophylaxis. In order to accomplish the first scene, we completed the study entitled, In the Influence of Interoperative Findings on Outcomes and Resource Utilization and Children with Complicated Appendicitis. Complicated appendicitis presents along a wide spectrum of disease severity. And little is known how different presentations influence resource utilization and risk of adverse outcomes. A more thorough understanding of this relationship may have implications for refining reimbursement compared to performance benchmarking and clinical research reporting guidelines. Therefore, the aim of the study was to characterize the influence of intraoperative findings on adverse events and resource utilization in children with complicated appendicitis. This was a retrospective cohort study using two complementary data sources. The study cohort and adverse event data were obtained from the NESQP pediatric appendectomy pilot database. And resource utilization data was obtained from the pediatric health information system database. We included patients ages three to 18 who underwent appendectomy for complicated appendicitis in a two-year period. Briefly, the NESQP pediatric appendectomy pilot database was established in 2013 as part of a collaborative effort among 29 hospitals to capture supplemental appendicitis specific outcome measures. The pediatric health information system database includes administrative and billing data from 52 children's hospitals. We included 1,333 patients for analysis of adverse event outcomes and 785 patients in the merged cohort for cost and length of say analysis. In all, multiple intraoperative findings were reported in 44% of cases. The most frequently reported combinations of intraoperative findings included a visible hole to fuse fibrointopsyrilinexidate, a visible hole with exidate and abscess, and a visible hole with abscess. This graph illustrates the predicted surgical site infection rate and 95% confidence interval associated with each combination of intraoperative findings. Multiple letters together indicate multiple findings. For instance, on the floor left of the graph, we have an SSI rate of 7.5% for fecalate as the only intraoperative finding, and on the far right of the graph an SSI rate of 27.2% for cases of wear a hole to fuse exidate, abscess, and fecalate for cousin together. Overall, we found a 3.6-fold difference in predicted overall SSI rates across the different combinations of findings. This graph illustrates the predicted rates of 30-day hospital revisits associated with each combination. Overall, there was a 2.6-fold difference in revisit rates across different categories of findings, which ranged from 8.9% in the presence of exidate alone to 22.9% when all four findings were present. And this graph illustrates the predicted rates of cumulative length of stay associated with each combination of intraoperative findings. Overall, there was a 2.2-fold difference in predicted average cumulative length of stay across different categories of findings, which ranged from 4 days in the presence of exidate alone to as high as 9 days when all four findings were present. And finally, this graph illustrates the predicted mean cumulative hospital cost associated with each combination. Overall, there was a 2.4-fold difference in costs across different categories of findings ranging from $13,000 per case in the presence of exidate alone to a more than doubling at $32,000 per case when all four findings were present. Based on the results of this study, we concluded that intraoperative findings significantly influenced adverse cement rates and resource utilization and children with complicated appendicitis. A more granular classification of disease severity for complicated appendicitis may create better understanding and matching of reimbursement to disease severity by refining current ICD and DRG coding classification, improve severity adjustment for appendicitis focus comparative performance reporting such as that provided by NESCO pediatric, and finally improve the utility and validity of comparative effectiveness research. Using the knowledge we gained from the previous study and to answer the next aim of improving antibiotics stewardship and pediatric surgery, we completed this next study entitled influence of oral antibiotics following discharge on organs, face infections, and children with complicated appendicitis. Published data examining the utility of post-discharge antibiotics is currently limited by either single-central experiences or the inability to adjust for disease severity and hospital level effect. The most recent multi-central analysis found almost a 50% increase in SSI rates and patients who received oral antibiotics at discharge, which on face value seems implausible that more antibiotics would cause more infections, which bears a question of whether there was appropriate adjustment for disease severity, i.e., more severe patients were getting oral antibiotics at discharge. In the context of these limitations of a literature and with our previous study shown the intraoperative findings as a reliable surrogate for disease severity, our next study aimed to examine the influence of oral antibiotics following discharge on organs, face infections. This was a retrospective cohort study using the NESCO pediatric pilot database. The study cohort included children ages 3 to 18 who underwent an appendectomy for complicated appendicitis at one of 17 NESCO hospitals over a two and a half year period. The primary outcome was organ space infection within 30 days post-operatively and the secondary outcome was any hospital revisit to the ED or in patient setting. We also completed a high severe subgroup analysis to find as patients with a length of state greater than or equal to 60s or patients who had greater than one intraoperative finding of complicated disease. We found that hospitals gave oral antibiotics at discharge ranging from 3% of the time to as high as 100% of the time represented here by the gray bars. In this figure, the hospital OSI rate is represented by the blue diamonds and revisit rate by the white circles. As you can see, there appears to be no correlation between the rate of oral and a biotic use at discharge and rates of OSI and revisits at least at the hospital level. We then turned our attention to the patient level analysis. Following propensely matching, there were no differences remaining in covariates between the comparison groups of patients receiving and not receiving antibiotics following discharge and we were left with 287 patients in each group for comparison. For the entire study cohort, there was no statistically significant difference in patients discharged with or without oral antibiotics in the odds of an OSI or revisit. However, in the high severity cohort, we found a statistically significant 61% reduction in the odds of an OSI with the use of oral antibiotics. Based on these results, we concluded that there is market variation in the use of oral antibiotics following discharge across hospitals. The use of post-discharge antibiotics may be protected against the development of organ space infection in children with more severe disease. However, further studies are needed to identify the specific subset of patients who would most benefit from this extended antibiotic treatment. In this next study, we sought to assess compliance with surgical antibiotic prophylaxis guidelines and pediatric surgery. Surgical antibiotic prophylaxis is used to minimize the risk of a post-operative surgical site infection. However, antibiotic overutilization has become an alarming public health concern with the rise of antimicrobial resistant organisms. Consensus guidelines have been developed that outline the appropriate indication, spectrum of coverage, and duration for surgical prophylaxis for each procedure. Therefore, the aim of the study was to assess the compliance with these guidelines and pediatric surgery. This was a retrospective cohort study of 20 procedures, including more than 55,000 patients using the pediatric health information system database. The study cohort included children less than 18 years of age who wonder on an elective, clean, or clean contaminated procedure. Guidelines say that clean procedures should not receive surgical prophylaxis and clean contaminated procedures should receive the appropriate spectrum agent until wound closure. Non-compliance rates and burden of non-compliance were calculated for each metric, indication, spectrum of coverage, and duration, as well as for overall SAP use to find as any case not meeting one of these guidelines. The overall rate of clean cases that received antibiotic prophylaxis was 33%. This figure illustrates the rate of SAP given when not indicated on the Y-axis and the relative burden of non-compliance with these indication guidelines on the X-axis. The rate of cases that inappropriately received antibiotic prophylaxis range from 10% for circumcision to as high as 86% for elective co-assistectamies. Clean procedures with the highest relative burden of non-compliance with SAP guidelines were co-assistectomy, inguinal hernia, repair, and abilical hernia repair. These three procedures made up more than 63% of all clean cases non-compliant with indication guidelines. The overall rate of broader than recommended spectrum of coverage and clean contaminated procedures and clean procedures for foreign body implantation was 26%. This figure plots the rate of extended spectrum on the Y-axis and the relative burden of extended spectrum on the X-axis for clean contaminated procedures. The rate of extended spectrum use range from 9% for long procedures to as high as 80% for small bowel procedures. 55% of cases extended SAP duration beyond the recommended guidelines ranging from 35% for gastric procedures to 78% for colorectal procedures. 26% of cases extended antibiotics into post-operative day number two and when added together the extension of antibiotics beyond wound closure led to more than 25,000 unindicated antibiotic days in the study cohort. This figure illustrates the overall non-compliance with guidelines. We identified 10 high priority procedures with colorectomy, small bowel procedures, and inguinal hernia repair leading the pack. And finally to develop a hospital-level stewardship report card for surgical antimicrobial prophylaxis, we conducted this next study. We use the same cohort of patients but included only 30 hospitals that completed more than 500 cases during the study period. The next few figures illustrate the variation in antibiotic stewardship metrics across hospitals. Hospitals were considered outliers that their 95% confidence interval did not overlap with the aggregate rate marked by the dashed line. High performing outliers are marked in green and low performing outliers in red. As you can see in this figure, compliance with surgical prophylaxis indication guidelines for clean procedures range from 12% to 85% across hospitals, with 9 high performing hospitals and 16 low performing hospitals. Compliance with surgical prophylaxis spectrum of coverage range from 39% to 80% with 12 high performing hospitals and 9 low performing hospitals. Compliance with appropriate duration range from 13% to 72% with 11 high performing hospitals and 8 low performing hospitals. And finally compliance with overall surgical prophylaxis guidelines range from 19% to as high as 75% across hospitals, with 9 high performing hospitals and 12% across hospitals. And this is what the report card for hospitals would look like. Aligning each metric in a hospital's compliance rate and outliers status marked with the colors. The green indicating high performing outliers and the red indicating low performing outliers. As you can see of the high performing hospitals, 44% were low performers and at least one metric. Similarly among low performing hospitals, 73% were high performers and at least one metric. No hospital was a non outlier in all metrics of antibiotics stewardship. Based on these results, we found remarkably low compliance with surgical antibiotic prophylaxis guidelines and pediatric surgery, with low compliance rates and all three metrics of antibiotics stewardship. In addition, there appears to be large variability in the rates of compliance across hospitals. This shows us that every hospital has something to teach and something to learn. These report cards can be used for granular stewardship data for internal quality improvement efforts and to help build knowledge here in collaborative. One of which is currently being set up by the NESQA pediatric for antibiotic stewardship. The same methodology can be used to identify high priority conditions in other surgical or medical fields. The next steps which we're conducting right now is to evaluate the consequence of these low surgical prophylaxis guidelines by evaluating its association with SSIs and other adverse events rates. So I'd like to first thank my mentor, Dr. Rengau. It's been a true privilege and incredible learning experience to work with him and everyone else in our lab. I also have to thank Dion, Carly and Patrice for all their statistical work. And of course a big thank you to all the people that hear of Boston Children who have been amazingly supportive of all the research fellows, including Dr. Schamburger, Dr. Falsett, Dr. Zakowski, Dr. Jaxick, Dr. Lilahai, and of course Terry McCartney. And then last but definitely not least, I'd like to say a big thank you to all the attendings that have had the opportunity to work with on call. Every moment, patient and conversation I've had has been an amazing learning experience that I'll never forget. So thank you very much. Appreciate your time. All right. Good morning, everyone. I want to start out. I'll say most of my thank yous to the end, but I want to start out by saying just how incredible this experience has been these last two years. And just how grateful I am for the opportunity to work care of Boston Children's. Over the past two years, the majority of my research has been under the leadership of Dr. Daria Falsett. But I've also been fortunate enough to work with a number of other faculty members on clinical projects, including Dr. Chen, Dr. Buckmiller and Dr. Mooney. But in the interest of times today, since we only have 12 or so minutes, I'm going to be focusing just on the translational projects and trans-emniotic stem cell therapy. So in order to put trans-emniotic stem cell therapy or trace it in context, we must remember that cell therapies come into main varieties, broad impact, which can target multiple diseases, and niche impact, which tend to target single diseases. A unifying characteristic of broad impact cell therapies is that they require no modification of donor cells. We only ask these cells to do what they do in normal physiology. So for example, in blood transfusion and bone marrow transplantation, we only ask donor cells to do what they usually do. Carry oxygen or differentiate into normal blood cells. This is also a central characteristic of tracin, which mesenchymal stem cells or MSCs, naturally occurring in the amniotic fluid, are reintroduced into the amniotic fluid. This is produced into the amniotic cavity after simple expansion to large numbers, so it's to boost their intrinsic biological activity. This approach is applicable to multiple diseases and requires no modification of donor cells, as is the case for broad impact cell therapies. As to which biological activity is being harnessed, in previous experiments in our lab, we found that MSCs, naturally occurring in the amniotic fluid, contribute to fetal tissue repair, as shown by the presence of labeled AFMSCs in fetal wounds, as you can see on the bottom right. As well as some other data, which I want to have time to go over in detail today. And it is this role that is leveraged and traced. So far, tracid has shown promise experimentally in neural tube and abdominal wall defects, and most recently in CDH. Most of my work in the lab has involved abdominal wall defects in CDH, and this morning, I'll start out by discussing tracid and abdominal wall defects. In previous studies on rap and rabate surgical models of gastroskeesis, Christina Fang, one of the previous fellows of the lab found that tracid with AFMSCs mitigates intestinal damage when compared with untreated and saling treated controls. In these studies, Q.Lavalled MSCs were identified directly and grafted in the herniated bowel, but was unknown if donor cells home to other sites in this setting. Thus, the goal of my first study in the lab was to comprehensively scrutinize donor and resentful stem cell kinetics after trace it in the rodent model of gastroskeesis. To do this, we used the surgical rap model of fetal gastroskeesis. This is my first opportunity to do fetal surgery and was an amazing experience. So this engineer at AFMSCs were phenotype-opolisytometry and transfective with the list of race reporter gene. Feetuses were divided into two groups. Goup-Bron received intra-emiotic injections of the cypherase labeled AFMSCs at the time of defect creation, while Goup-2 received an A-cellular suspension of the cypherase protein. The purpose of this group was to control for the possibility of trafficking of free-luciferase protein in the absence of a viable donor cell. Animals were euthanized at term and specimens from 11 anatomical sites as listed here were procured. Spesements from the bowel, liver, and spleen were subdivided into exposed and non-exposed and analyzed separately as such. Using the conventional cutoff of two standard deviations above the mean of blank readings, we found significantly higher luminescence in the basenta and exposed bowel, or compared to A-cellular-acipherase controls, pointing to the presence of donor cells at these sites. Interestingly, we found no correlation between positive luminescence in the basenta and exposed bowel, suggesting that homing to these sites constitutes mutually independent processes. Another important area of investigation in our group is determining the optimal cell sourcing for tracet. Although we had focused on using MSCs from the amniotic fluid, MSCs can be procured from a number of sites in fetal life. The amniotic fluid in the basenta are a particular interest as these cells can be procured early in development and be a minimally invasive techniques. As a result, these cells have been well studied. While their biological appears very similar, it remains unclear whether they have the same potential for clinical therapies. In this study, we sought to compare MSCs derived from the basenta and amniotic fluid as donor cells retrace it in the rodent model of gastroskeases. Feuduses were identified into four groups following gastroskeases creation, receiving either no treatment, sham treatment, AFMSCs or PMSCs. We found that both cell treatment groups demonstrated significantly thinner, segmental and overall bowel-walt thickness compared to controls, and furthermore, the AFMSC treated group showed enhanced results compared to the PMSC treated group. We also wanted to assess the consistency of the treatment effect across our experimental groups. Levine's test indicates a lack of homogeneity of variants across the groups, with the AFMSC treated group demonstrating the least variability in segmental and overall bowel-walt thickness. The goal of our next study was to determine the mechanisms by which trace it mitigates bowel damage in gastroskeases, starting with intestinal remodeling and anti-inflammatory pathways in which MSCs are known to participate in other settings. Feuduses were again divided into four groups, group one underwent no-deficuation or treatment, while the rest underwent gastroskeases creation and received either no treatment, sham treatment or AFMSCs. Curinative bowel was procured at term for QRGPCR. A variety of pericomphrophic factors were assessed, including IGF1, HDF, FGF2, VEGFA and TGF beta1. The expression of each factor was found to be decreased in the herenative bowel of fetuses with gastroskeases compared to normal bowel, and in no case were any significant differences in expression detected between trace-at-true defeatuses and controls. When we assessed the expression of LGR5, a marker of intestinal stem cells, the same pattern felt true. We then assessed proinvent inflammatory markers IL1 beta and IL6 and antideinflammatory factor TSG6. Again, no differences were identified between trace-at-true defeatuses and controls. You'll note here that the magnitude of the full change in expression varies widely, especially within the untreated group. We also assessed constituents of NFKAPA-B signaling, a key mediator of inflammation. We found no change in the expression of NFKAPA-B inhibitor, the expression of which reflects proinvent inflammatory signaling and translocation of NFKAPA-B to the nucleus. The expression of RLA, a subunit of NFKAPA-B, the expression of which is usually not significantly impacted by inflammatory signaling, was lower in the bowel of trace-at-true defeatuses were compared to untreated and normal fetuses, and the implications of this finding remain unclear. Again, you can appreciate some of the wide ranges in some of these groups. In short, we were unable to conclusively link any of the various previously known pericain factors assessed to the bowel protection observed in the setting, likely due to the heterogeneity in the gastroskeces defects between specimens within the same groups. We were worked to improve our experimental design to better account for this variation and assess additional classes of mechanistic surrogates, such as chaperone and immemodulatory effects and other pericain and non-pericain factors. While there is still much to learn about trace-at, we believe that these results are promising enough to warrant moving towards clinical translation. This slide shows an excerpt from a pre-I&D meeting this last fall. The FDA requires that we provide post-nail data before moving forward of clinical trials. To satisfy these requirements, we have set out to recapitulate our rat and rabbit studies in the OVIN model, with the additional goal of repairing the defect and delivering by C-section just before term, and then surviving the lambs beyond birth. We operated in our first sheep just a few weeks ago, she's doing well. And these are interoperative images showing a surgery-created gastroskeces defects in the twin-feetal lambs from that mother. And this is from the control arm of the city. At this point, I'm going to switch gears a little bit from gastroskeces to CDH. You may be wondering how and why we made the leap from using trace-at-in defects exposed to the amniotic space, like neural tube and abdominal walled defects, to unexposed defects. Previously, Hesca Shea, comprehensively screened for the cipherace-labeled AFM-SCs using myquate luminometry, similar to the first study that is discussed. She identified donor cells at sites throughout the fetal circulation, including the placenta and fetal bone marrow of both normal fetuses and those of spina bifida. These results are an exciting, in part, because they may indicate that congenital anomalies not exposed to the amniotic space may also be reasonable targets for trace-at. And to test the site hypothesis, we turned to CDH. The goal of our first study was to determine if trace-at impacts any of three fundamental components of pulmonary development in the nitrogen model of CDH. Nitrogen, a pesticide, induces CDH in a subset of fetuses when gavage fed to dams under stational day 9. Most importantly, this model recapitulates the pulmonary hypertension and pulmonary hypoplasia characteristic of human CDH. Fetuses in this experiment were divided into four groups, with group 1 receiving no nitrogen and no treatment, while the rest received nitrogen and either no treatment, sham treatment, or AFM-SCs. Long tissue, epsilon- and contralateral, to the diaphragmatic defect, was procured at term for QRG-VCR. We assessed the expression of FGF-10, which is involved in alveolar growth and development, FGF-A, which is involved in lung vascularization, and to factor in protein-C, which is involved in alveolar maturation. We found that trace-at decreases expression of FGF-10 and FGF-A, while increasing expression of C-F-10-C. In short, our screen confirmed that trace-at does indeed impact expression of select surrogates of pulmonary development, though at this stage the clinical implications of this change is one clear. Thank you. In the nitrogen model, again using my plate humanometry and the surface label donor cells. Animals euthanized at term and specimens from 11 anatomical sites as the sit here were procured. Long and diaphragm tissue, epsilon- or contralateral, to the diaphragmatic defect, were procured separately. We identified label donor cells in the bone marrow and the umbilical cord without significant evidence of homing to the lung or diaphragm. We found no correlation between positive amino acids in the bone marrow or umbilical cord, against suggesting that these are mutually independent processes. Well, we're excited by these initial results. There's still much to learn about CDH and trace it. In these last few remaining a week and a half or so, um, before our gender residency, I hope to wrap up our analysis on the effect of trace it on vast, their impulmonary morphometrics in the nitrogen model. I'm interested in timing and a couple things a little bit short, but I do want to thank, of course, my mentor, Dr. Fazza for all of his patients, his open door policy and all of his time that he devotes to making us better surgeons and scientists. I of course want to thank Dr. Shamberger and the rest of the department for supporting this research. My clinical mentors, such as Buck Miller, Mooney and Shen, Dr. Zyrkowski, my co-fellows Sarah and Stephanie, Ena and Andru for their hard work in our summer interns, Adam and Chris. Thank you very much. Okay, good morning. Thank you for the opportunity to share my work with you. I have no disclosures. My research time at Boston Children's has been a collaboration between the Department of Surgery under Sean, Dr. Sean Rangel and the Department of Pediatrics under their T32 pediatric health services research fellowship. In my first year of this fellowship, I completed an MPH at Harvard School of Public Health and during that time, Dr. Rangel and I started to explore ideas for how to perform disparities related research in pediatric surgery. My second year of fellowship has involved a series of studies pursuing that goal and it's my pleasure to give you a brief journey through that year now. So through a series of studies and interventions, my overall research objective was to gain a better understanding of the practice variation associated with elective, umbilical, hernia repair and children. The ultimate goal was to move the needle by improving guideline compliance and reducing disparities in care for children who may be at risk for potentially unnecessary surgery. By way of background, as you all know, umbilical hernia is one of the most common surgical conditions in children. In fact, in nearly 20% or up to 800,000 children in the US annually alone. Fortunately, the majority of these hernias will close spontaneously in the first few years of life and only rarely do they cause complications such as intestinal incarceration. Although robust population-based epidemiological data is lacking to support this data, contemporary record recommendations from the ACS, APSA, up to date and public systematic reviews suggest delaying repair of asymptomatic, umbilical hernias until at least four or five years of age. Review the literature, let us to ask a fairly straightforward initial study question, which was, do pediatric surgeons follow contemporary age specific recommendations for delay repair of asymptomatic, umbilical hernia. This was a retrospective cohort study of more than 23,000 children undergoing elective undergoing, umbilical hernia repair at 38 free standing children's hospitals participating in the fifth database over a five year period. We included all children less than 18 years of age and excluded those undergoing multiple procedures, as well as those with recurrent hernia. And we performed multi variable mixed effects, logistic aggression, adjusting for the compounders and predictors listed here. There are two key definitions that I'll be referring to throughout the remaining presentation. Patients for categories is having an early umbilical hernia repair if they underwent surgical repair at three years of age or younger. We also categorized children as having an emergent or urgent repair if cases were associated with ICD or CPT codes for severe disease or if surgery was performed within the same admission or within two weeks of an ED visit. The goal of this categorization was to also capture children undergoing early repair that may have been indicated on the basis of a history of incarceration, but where administrative codes may have indicated uncomplicated disease at the time of repair. Here's what we found. So in the X-axis is age in years and you can see that children underwent repair at every age, but that over 30% of repairs took place in children who were three years of age or younger. The majority of cases were elective represented by the gray bars and only 3.8% of repairs were categorized as emergent or urgent represented by the blue bars. When we analyze rates of early repair by individual hospitals represented along the X-axis, we identified an eight full variation in rates of early repair. These rates indicated by the black dots range from 7% in hospital one to almost 55% in hospital 38. The blue squares represent the hospital level rates of emergent or urgent repairs, which do not correlate with hospital level rates of early repair. So what's going on here? We hypothesized that some of the variation might be explained by differences in patient characteristics, but after adjusting for sex, phrase ethnicity, insurance, income, medical comorbidities, and emergent urgent presentations, we now observed a nine full variation in hospital level. I observed to expect ad ratios for early repair. This observation and variation prompted a second study question for us, which was how much of this hospital level variation is due to surgeon level variation within those hospitals. We're currently doing a deep dive to answer this question, but here are some pretty compelling preliminary results. Again, using the FIS database, we were able to calculate the rates of early repair for 322 pediatric surgeons at 37 children's hospitals. Only surgeons performing greater than 25 cases were included in the study, and in this figure, individual surgeons are represented along the X-axis. Overall, you can see that surgeon level rates of early repair range from 0% to 75% represented by the red dots. When analyzing these data by hospital, we observed some very compelling findings. Each box on the X-axis now represents a single hospital surgeon level data. Variable lengths of the box and the list are suggest wide variation in surgeon level rates of earlier pair within hospitals. So for many surgeons, the overall hospital rate of early repair may not reflect their individual rate of early repair. For example, one surgeon at this hospital has an early repair rate of 8%, while their hospital's overall early repair rate is over 40%. From these studies, we concluded that significant variation exists in the rates of early repair across freestanding children's hospitals that cannot be explained by differences in patient characteristics or a cutie of presentation. Furthermore, provider level variation within hospitals suggests that surgeons in the same department may have highly variable management practices. In these findings raised, the possibility that many children may be undergoing potentially unnecessary repair of asymptomatic and billiacol hernias that may close spontaneously with further observation. This possibility prompted our next study question. Do certain children as compared to their peers have a higher risk of undergoing early potentially unnecessary, umbilical herniar repair? Using similar study design with the FIS database, we answered this question, which was a resounding yes. In the above forest plot, odds ratio point estimates to the right of the center line favor early repair. In this multi variable analysis, children with public insurance and lower income were significantly more likely to undergo early repair than their higher socioeconomic status or SES peers. You will also notice the girls were more likely to undergo early repair than boys. To further highlight the above disparities being publicly insured and in the lowest income quintile, conferred of even higher 2.2 fold increased odds of early repair. To prove that children from these socioeconomic groups did not present to the hospital with higher rates of incarcerated disease, we repeated our analysis in the study group of children who underwent only emergent or urgent repairs and found no significant associations. Finally, we performed a hospital level analysis to assess whether a single hospital or group of hospitals were accounting for the overall effects that we were seeing. To orient you to these forest plots, insurance is on the left income in the middle and gender on the right. Hospitals are now on the y-axis. In each figure, almost every hospital has an odds ratio greater than one represented by the black vertical lines. And many hospitals have odds ratios greater than the overall effect for that predictor as represented by the red lines. You can clearly see that the vast majority of hospitals contribute to the overall effect for each of our significant predictors. We therefore concluded that public insurance, lower income and female sex were independently associated with earlier pair of asymptomatic umbilical hernia in children, and the effect of low SES surrogates appears to be additive. These findings brought us to look into surgeon level practice. How do pediatric surgeons think they manage, managed children with asymptomatic umbilical hernia? And what clinical or nonclinical factors can influence them to operate on a child earlier than they might normally do? To answer these questions, we designed a web-based survey that was approved by the AFSA outcomes and evidence-based practice committee and distributed this past April to the 846 regular AFSA members. Many of you may remember seeing this email from Dr. Ringo. Over three distributions, we achieved a 44% response rate. To go over all of the study results would take me well over an hour, so I'll just highlight a couple of those for you now. The majority of questions stemmed from a single clinical vignette where surgeons were asked the following question, how would you manage a healthy boy with a 5-millimeter stable, reducible, asymptomatic umbilical hernia, who importantly just turned three years of age? This graph shows you the responses from our surgeons. In orange, the majority of surgeons recommended delaying repair until a later age. In blue, 20% encouraged the parents to decide. In green, 20% encouraged the parents, excuse me, in blue, 18% recommended repair as their preferred approach. And only 4% did not recommend repair at any age unless the hernia characteristics changed. So from these data, nearly 40% of surgeons would operate on this boy who recently turned three years old. However, when surgeons were asked what their best estimate was for the future risk of an emergency surgery in this child, greater than 97% of surgeons believe that there was a less than 5% risk of future incarceration or strangulation. So this begs the question, what are the factors that will influence so many surgeons to operate earlier and offer an elective repair to this child? Those are ones that you'll have to wait for for the paper, but what I can tell you is the results are fascinating. But for now, what is abundantly clear is that more robust data is desperately needed to characterize the natural history of asymptomatic umbilical hernia, the true risk of incarceration over time, and then also the likelihood of spontaneous closure as children get older. So that was a brief overview of my research over this past year, and we're certainly not done. As Alex alluded to, we only have about a week left, but there are many more projects to go. But I think that is the nature of research. And so we're in the midst of a study right now that will calculate the true risk of incarceration before age four using a longitudinal cohort study design. That data is actually fresh off the press as of last night, and what I can tell you is that the incarceration rate before a child turns four years of age is well below 1% each year. So we're looking forward to getting that data out to you soon. We're also planning to characterize the total cost and potential savings secondary to early and billical hernia repair management. And then we will start a series of interventional projects to improve guideline compliance and reduce practice variation. As insurance policies may be critically important, we will also explore how coverage changes at the state and national level may reduce disparities in care, especially for publicly insured kids. So I want to thank you to Dr. Rangel for his incredible mentorship and dedication to me in this project. I'd also like to thank the rest of our lab and my program directors from the pediatric St. S. R fellowship. Finally, a special thanks to not only those listed on the slide, but the entire Department of Surgery, especially Dr. Shamberger. It's been an incredible year, and I'm truly grateful for the opportunity to have spent more time with you all. And as Dr. DiMerry alluded to, I'll be headed not too far just back across the bridge for my PG by 4 and look forward to applying to fellowship this fall. Hope to see you all again soon and thanks for your time. Thank you. All right, I want to thank you for this opportunity to present today. In this year, our five projects that I've had the privilege to lead during my time in the lab with Dr. Fausa. I'll be spending most of my time today focusing on the floor that I've highlighted. In addition to my translational work, I've been able to work with Dr. Seth Miller and Chen on two clinical projects. Dr. Rook Miller and I analyze the sensitivity and specificity of the distended fetal hypothyringes as a prenatal predictor of a soft geolatreja. And Dr. Chen and I are in the process of completing a multi-institutional review assessing the utility of abdominal ultrasound for the diagnosis of net. The first translational project I will discuss today is an in vitro study comparing two types of human and cumulsam cell derived exosomes. Exosomes are nanosized exocelular vesicles that contain microRNA, TRNA, and other cellular components. And they're currently under intense scrutiny for both their diagnostic and therapeutic potential. Well, exosomes cannot recapitulate all the biological activities of their cell sources. There affects and potential greater amenability to regulatory approval, justified their use in select translational efforts. In this study, we sought to compare exosomes derived from two sources, human bone marrow and antibiotic fluid. These are clinically relevant to perinatal and pediatric surgical disease. MSC phenotypes were confirmed by Phyllis Atometry and cells underwent 24-hour serum-servation prior to isolation by reagent enhanced centrifugation. Characterization included flow exometry with magnetic beads and three widely employed tetra-spanen markers, CD-81, 9 and 63. Morphological analysis by transmission electron microscopy and particle concentrations and size distributions were compared after removal of larger particles by size exclusion chromatography. We found comparable expressions of each tetra-spanen marker with phyllis-salmeteries pictured on the left. Appropriate size and morphology of vesicles was confirmed from both sources is indicated by the arrows in the top right corner. One important difference is exosome yield highlighted with gray shading, which was greater from antibiotic fluid compared with bone marrow MSCs, independent of cell count by an estimated 25% as determined by anova. Thus, antibiotic fluid may be a preferable source of exosomes for perinatal clinical applications such as trans-ambiotic therapy. I'm going to switch gears now and talk about my next project, which involves cells not exosomes in the context of trans-ambiotic stem cell therapy or tracet. MSCs have been isolated from placenta, corion, and amyon and used for a variety of therapeutic purposes. However, the mapping and interchange of these and other stem cell pools throughout gestation, along with the mechanisms that govern their movements, remain poorly understood. Tracet, as described by Alex earlier this morning, utilizes select fetal-drived MSCs and harnesses their biological activity in utero. After tracet, donor MSCs and the document in both the fetal and maternal circulations. Specifically, they've been identified in rodent placental tissue, fetal bone marrow, and certain sites of tissue injury in the mother. This pattern suggests that human tolerance routing is a component of tracet, but how do the cells reach the blood in these sites? We hypothesize that one path may be through the gestational membranes, which are in close proximity to the placenta. We tested this hypothesis, first using an in vivo experimental design with healthy rodents. 226 rat fetuses were divided into two groups based on the content of entranomiotic injections on gestation day 17. fetuses received either the cipherase liable amniotic fluid MSCs or acyllular luciferase in order to control for the possibility of cell death and transport of this protein. Samples from placenta, corion, amnion, amniotic fluid, and a billical cord were procured at five daily time points until term for luciferase activity screening. Stomach fluid was also collected to look for any swallowed cells. In a separate in vitro analysis, we evaluated the capability of donor MSCs to invade and migrate through, firstly procured membranes using a commercially available transwell assay. 53 intact sets of amnion and corion were procured from healthy rats with no previous manipulations at term, and hermetically secured to transwell inserts with the amnion side facing the insert well. The cipherase labeled amniotic fluid MSCs in nutrient deficient media were loaded into each insert well and receiving wells were filled with nutrient division media or complete media with collagen coden. After a three day incubation period, receiving well contents were screened for the presence of suspended and or attached cells via microplate luminometry. In a subset of transwell inserts, the gestational membranes were also screened for the presence of attached or intramural cells. Temples were incubated with cell lysos buffer and tissues were homogenized. If labeled cells were present and lysed, luciferase protein was released in the addition of substrates led to a reaction that produced light. The amount of light was quantified by luminometry and the output interpreted as relative light units results were analyzed by logistic regression, the wall test, the manwant knee u test, and Fisher's exact test. There were no differences in fetal survival between tracit and control groups in the in-bibil model. Nor were there any differences in luminescence detected from a biblical chord, fetal stomach fluid, or amniotic fluid samples. There was, however, a significant increase in the luminescence within the amniotic coreon and fosanta from fetuses that received cells. More detailed analyses of these three sites were then undertaken based on the five daily time points. In order MSC homing patterns of the amniotic coreon were similar, it was significant increases in luminescence compared with controls, particularly one day after injection and again close to term. There was a peak in median luminescence at gestation day 21 in the amniotic and at days 21 in 22 in the coreon. Homing patterns in the placenta were similar to previous to the reported findings with increased luminescence one day after injection and again at term. Combining the data we observed a shared nonlinear relationship between luminescence and gestation age in the placenta, coron, and amniotic. Following a parabolic bimodal pattern characterized by significantly higher post-injection and late term activities. A common vertex was shared by all three sites at gestation ages 19 to 20 and overall higher luminescence was observed in the amniotic compared with the coron at placenta. The presence of cells is documented by luminometry in 40% of the receiving wells, its suspension and or attached to the plastic substrate, and in all screen gestational membrane sets. Neither college encoding nor the presence of a nutritional gradient had any impact on increasing transmembrane cell migration. In conclusion, the chronology of donor MSC trafficking after intrammionic injection in particular the bimodal u-shaped pattern suggests controlled cell routing as opposed to passive clearance. Furthermore, transport through the gestational membranes appears to be one path for donor cells to reach the placenta and fetal circulation. These findings warrant further studies to determine how donor cells might adhere to and travel through the gestational membranes, along with the factors that govern such migration. Regardless, insights provided by this study, in conjunction with our previous work, lend further support to the notion of the amniotic cavity could be an access point for select cells to reach the fetal circulation via the placenta, significantly expanding foreseeable therapeutic applications of tracet. My next project was purely an in vivo study evaluating the effects of repeat dosing of tracet and the retinoic acid rodent model of synabiphytica. In previous experiments, we found that MSC's present in amniotic fluid contribute to fetal tissue repair, and this led to the development of tracet, which we first trialed in the setting of spinal bifida. When tracet was applied, in both rat and rabbit models of spinal bifida, we witnessed enhanced rates of either partial or complete defect coverage by a rudimentary host-rived skin. Interestingly, donor cells were not found in this neoscine, but it sites reachable through the bloodstream, particularly the fetal bone marrow. In this study, we sought to assess the fetal response to single versus repeat dosing regimens in an effort to better understand how tracet works. Fetal rats with retinoic acid induced spinal bifida were divided into three groups. One group was left untreated, and two groups underwent tracet at either one or two time points. Syngetic donor cells were phenotype bifilose atometry and labeled a GFP. Animals were euthanized at term for various analyses. Repeat injection was associated with significant reduction in field survival. We found no significant differences in defect size among the three groups when controlling for fetal doors in surface area. The single injection group had a significantly higher rate of histologically confirmed defect coverage, whether partial or complete, compared with the untreated and repeat injection groups. Droner cells were seen at fetal bone in both treatment groups, but once again, not in muous skin or spinal cord. In conclusion, despite the limitation of the short-ratchestation, these findings suggest that the effects of tracet may not be dose dependent. Given the presence of donor cells in fetal bone marrow as documented by our previous work, these effects may derive from a lasting host response, possibly based on bone marrow activity. Further investigation into such a response could lead to additional non-surgical strategies for the prenatal coverage of spina bifida, and perhaps even cell-free therapies. The final project I will discuss is still ongoing. This is the first time we have tried to target a maternal disease process with tracet, and we chose to focus on preeclampsia. Why preeclampsia? With this bend diagram, you can see the commonality of the placenta as a site for donor MSC homing in gastroscesis, myelomin and gaseal, and healthy rodent models. And with this busy cartoon, I demonstrate how the placenta is believed to be a key driver in the pathology of preeclampsia in humans. This is a disease with a high impact globally on both mothers and neonates. Preeclampsia complicates 2-8% of pregnancies with an increasing incidence of severe preeclampsia noted over time. Rists for the baby include poor growth and pre-macharity, and when severe, this disease can be devastating and light threatening for both mother and baby. The only treatment currently available is preterm delivery. Pre-macharity and lower birth weights are associated with increased rates of neck, and preeclampsia is associated with an odds ratio of 2 for developing severe neck. There are several rat models of preeclampsia. The one I chose to use was a model based on the theory that preeclampsia may be part of an inflammatory response. And this model involves the administration of an ultra-low dose endotoxin or LPS infusion via the tail vein at the time of pleasantation on gestation day 5. This results in maternal hypertension and protein urea. Our hypothesis is that trace it with MSCs may mitigate the effects of placental hypo perfusion and immune dysregulation, as MSCs are known to secrete angiogenic factors and possess immunosuppressive properties. Our experimental design induces symptoms of preeclampsia with an ultra-low dose LPS infusion on gestation day 5. Then on day 17, pregnant dams are assigned to one of three groups. Trace it with amyotic fluid MSCs, volume-match sealing and tranmotic injections, or sham lab rotomy, all rats undergo clear of euthanasia on day 21 or term. We are taking a shot through an approach looking at multiple outcome variables for any difference in treated versus control group animals. Picture here are an initial maternal non-abase of blood pressure results. There may be some advantage of both trace it and saline injection and reducing the severity of maternal hypertension on day 19 compared to the sham lab rotomy controls. However, this is only one outcome variable and more data is needed to interpret whether trace it has any advantageous effects over saline injection with this model. I couldn't have done any of this work without the support of my co-workers in the lab. Neither could I have done this without the support of Dr. Shamberger, the faculty and staff of the department of surgery and my research mentors, especially Dr. Fousa. Last but not all least, I have to thank my family, especially my husband Kyle, who's here today. He's been my greatest supporter and confidant. Together, we've somehow managed with the help of family friends and a strong community network to help this tidy human thrive and grow over the past two years. We both juggle demanding schedules with our research and clinical work. This is an incredible list of people that I have to thank and I'm glad to call my work family. I've been so grateful for the opportunities I've had here at Children's and I look forward to returning for another clinical rotation in my fourth year. Thank you. Well, I'll see you, Alex, Jonathan. Sarah, I want to congratulate you all on the excellent presentations this morning. They were very polished and quite prototypical of the presentations that you've given on the national stage for us. Particularly proud of your presentations at apps and AP and all these other meetings. I think you've documented very nicely all of the work that you've accomplished in this period of time for what you really need to be congratulated. So I think we're going to start. Maybe I have to question to make up. Okay, so I'll start with questions from the your statements from the audience and then we'll move to a final video from Dr. Rangel Dr. Fowse. I saw your hand up. Go up first. I don't know if this should be the right order, but as Farouk said, all the fellows that presented today are local. They plan to attend the change party. So I'll be expanding on my comments on my own fellows at that time. For now, I'm just going to say that I could not be more pleased with the intense commitment and dedication that they both showed during the fellowship you saw from their work. And importantly, with their personal development, they came in very green as it's often the case and are leading at a different level. It's very gratifying to see that. Dr. Schumberger alluded to they represented us very well at the meetings. They've been at all the major meetings, the water to our specialty, including internationally. Between them, they have won three awards so far at the local regional and international levels and will be contending for more in the coming months. So be more presentations coming. Importantly, they worked very well as a team, very smoothly and that's always easier for everybody. So congratulations on a great job. This is as I said, is to be continued. I could not be more grateful. And on behalf of the department, I extend that gratitude to all the fellows that presented today and last week. This has been a special group. You've made us proud and will be following your journey with great interest. Thank you. Additional comments. Dr. Zierkowski. Well, just to echo with Dr. Fauzegiuse. I have also seen and felt a tremendous amount of kindness that you share together. And you're truly four remarkable individuals doing remarkable work. And my congratulations to you as well. I do have one question for SEMA. And one question that I've been wondering about is with all the epindectomy work that you've been doing and cost effectiveness, trying to translate that into decision making. When you look at risk factors and you look at outcomes like revisit rates, you see a lot of hospital variation as well. Is there some integration of some clinical net benefit that you see based on a spectrum of risk factors, where something like surgical antibiotic prophylectics treatment, or a antibiotics as an example, might infect, have some benefit depending upon certain combinations of risk factors. That's a very good question. That's exactly what we were trying to see if that if that's what really contributed to what people are seeing with oral antibiotics and causing with its benefit in preventing adverse events. And what we did see was that there's probably a high risk group that overall it probably doesn't benefit everybody, but there potentially is this high risk group that may benefit from oral antibiotics at discharge. Now what we obviously define high risk in our co-horn is with our limitations of the database for length of state greater than or equal to 60s and greater or greater than one in trough for finding. But I think more work needs to be done in this. I think is in contrast to the previous literature that described either no benefit or actually adverse outcomes with the oral antibiotics with increased surgical site infections. I think this our work now says we probably need more perspective or randomized trials to say what what's the exact criteria we should set for these patients that to help surgeon see which patients would benefit. Unfortunately with revisit rates we did look into this quite a bit and there wasn't any significant effect. But I think that's because revisit rates are you know can can happen for many different reasons including oral antibiotics side effects. So then kind of and so balancing out the revisit on both sides. So that's why our primary outcome of surgical site infections. Yeah. And Dr. Ringel was not able to be here today so he asked me to share this video on his behalf. Thank you. So I think we'll have to call it quits with that staff and followers can can get for the photograph this morning. So thank you again for all of your great work this last multiple years. Thank you.