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Wilkinson-Maitland N, Cunningham AJ, Esfahanian M. Postoperative analgesia for Kasai portoenterostomy using external oblique intercostal blocks. Reg Anesth Pain Med 2023; 48:619-621. [PMID: 37474282 DOI: 10.1136/rapm-2023-104510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/02/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND External Oblique Intercostal (EOI) fascial plane blockade is a relatively new regional anesthetic technique used for a variety of upper abdominal surgical procedures. Proponents of this block praise its simple sonoanatomy, extensive local anesthetic (LA) spread, and ease of catheter placement, while avoiding encroachment into the surgical field or dressing sites; nevertheless, it is underutilized in pediatric surgery. Kasai portoenterostomy is a common pediatric surgical procedure for biliary atresia typically done via an open abdominal approach with an extended subcostal incision. Postoperative analgesic management with epidural anesthetic techniques are considered but may be limited by periprocedural coagulopathy concerns. CASE PRESENTATION We present a case of a neonate who underwent successful analgesic management of Kasai portoenterostomy with bilateral EOI block catheters. Opioid consumption and other postoperative outcomes were comparative to previously reported literature of epidural analgesia in this patient population. CONCLUSIONS The purpose of this report is to describe the outcomes and technical approach in a neonate who received EOI blocks as an alternative to epidural anesthetic management. Further studies are needed to compare the efficacy and complication rate of EOI blockade to epidural analgesia for Kasai portoenterostomy surgery.
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Affiliation(s)
- Nigel Wilkinson-Maitland
- Department of Anesthesiology, Perioperative, and Pain Medicine, Division of Pediatric Anesthesiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Aaron J Cunningham
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Mohammad Esfahanian
- Department of Anesthesiology, Perioperative, and Pain Medicine, Division of Pediatric Anesthesiology, Stanford University School of Medicine, Palo Alto, California, USA
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Cunningham AJ, Krakauer K, Schofield C, Kenron D, Krishnaswami S. Reducing Disposable Surgical Items: Decreasing Environmental Impact and Costs at a Children's Hospital, A Pilot Study. J Surg Res 2023; 288:309-314. [PMID: 37058987 DOI: 10.1016/j.jss.2023.02.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 01/21/2023] [Accepted: 02/18/2023] [Indexed: 04/16/2023]
Abstract
INTRODUCTION United States landfill waste generated in the operating room (OR) is estimated to be three billion tons per year. The goal of this study was to analyze the environmental and fiscal impact of right-sizing surgical supplies at a medium-sized children's hospital using lean methodology to reduce physical waste generated in the operating room. METHODS A multidisciplinary task force was created to reduce waste in the OR of an academic children's hospital. A single-center case study, proof-of-concept, and scalability analysis of operative waste reduction was performed. Surgical packs were identified as a target. Pack utilization was monitored during an initial pilot analysis for 12 d then followed by a focused 3-week period, capturing all unused items by participating surgical services. Items discarded in more than 85% of cases were excluded in subsequent preformed packs. RESULTS Pilot review identified 46 items in 113 procedures for removal from surgical packs. Subsequent 3-week analysis focusing on two surgical services, and 359 procedures identified a potential $1,111.88 savings with elimination of minimally used items. Over 1 y, removal of all minimally used items from seven surgical services diverted two tons of plastic landfill waste, saved $27,503 in surgical pack acquisition-costs, and prevented the theoretical loss of $13,824 in wasted supplies. Additional purchasing analysis has resulted in another $70,000 of savings through supply chain streamlining. Application of this process nationally could prevent >6000 tons of waste in the United States per year. CONCLUSIONS Application of a simple iterative process to reduce waste in the OR can result in substantial waste diversion and cost savings. Broad adoption of such a process to reduce OR waste could greatly reduce the environmental impact of surgical care.
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Affiliation(s)
- Aaron J Cunningham
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon.
| | - Kelsi Krakauer
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Corie Schofield
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Daniel Kenron
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Sanjay Krishnaswami
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
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Rao PK, Cunningham AJ, Kenron D, Mshelbwala P, Ameh EA, Krishnaswami S. Applying LEAN Healthcare in Lean Settings: Launching Quality Improvement in Resource-Limited Regions. J Surg Res 2021; 266:398-404. [PMID: 34091087 DOI: 10.1016/j.jss.2021.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Lean methodology is frequently utilized in high income settings to maximize capacity and operational efficiency during process improvement (PI) initiatives. To date there has been little published on the application of these techniques in low- and-middle-income countries (LMIC) despite the potential benefits in resource limited settings. We describe a pilot project developed in 2018 to promote sustainable operating theater efficiency at two hospitals in Abuja, Nigeria. This study details the first known attempt to use Lean techniques to improve surgical care systems in LMIC. METHODS Perioperative committees were established at two Nigerian institutions to evaluate current processes, identify problems, and compile a list of priorities. A physician champion and a PI specialist in conjunction with local physician-partners held a workshop to teach practical applications of PI methodology as part of an ongoing collaboration. Pre and post-workshop surveys were administered, and theme coding was used to categorize free responses. Results were compared with a chi-square test. RESULTS In total, 42 individuals attended the PI workshop. After the workshop, 37 respondents reported the workshop as valuable both personally and for the perioperative committee (P < 0.001), and all reported that PI methodology could benefit the institution overall. CONCLUSIONS By identifying stakeholders, holding a workshop to teach tools of PI, and establishing a committee for ongoing improvement, it is possible to implement quality improvement techniques at LMIC hospitals, which may be of future benefit. Sustainability in this project will be facilitated by tele mentoring, and future efforts include expansion beyond the perioperative setting.
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Affiliation(s)
- Pavithra K Rao
- Department of Surgery, Oregon Health & Science University, Portland, OR.
| | | | - Daniel Kenron
- Department of Surgery, Oregon Health & Science University, Portland, OR
| | - Philip Mshelbwala
- Department of Surgery, University of Abuja, Gwagwalada, FCT, Nigeria
| | - Emmanuel A Ameh
- Department of Surgery, National Hospital, Abuja, FCT, Nigeria
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Cunningham AJ, Rao P, Siddharthan R, Azarow KS, Ashok A, Jafri MA, Krishnaswami S, Hamilton NA, Butler MW, Lofberg KM, Zigman A, Fialkowski EA. Minimizing variance in pediatric surgical care through implementation of a perioperative colon bundle: A multi-institution retrospective cohort study. J Pediatr Surg 2020; 55:2035-2041. [PMID: 32063373 DOI: 10.1016/j.jpedsurg.2020.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 12/24/2019] [Accepted: 01/10/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Employing an institutional initiative to minimize variance in pediatric surgical care, we implemented a set of perioperative bundled interventions for all colorectal procedures to reduce surgical site infections (SSIs). METHODS Implementation of a standard colon bundle at two children's hospitals began in December 2014. Subjects who underwent a colorectal procedure during the study period were analyzed. Demographics, outcomes, and complications were compared with Wilcoxon Rank-Sum, Chi-square and Fisher exact tests, as appropriate. Multivariable logistic regression was performed to assess the influence of time period (independent of protocol implementation) on the rate of subsequent infection. RESULTS One hundred and forty-five patients were identified (preprotocol=68, postprotocol= 77). Gender, diagnosis, procedure performed and wound classification were similar between groups. Superficial SSIs (21% vs. 8%, p=0.031) and readmission (16% vs. 4%, p=0.021) were significantly decreased following implementation of a colon bundle. Median hospital days, cost, reoperation, intraabdominal abscess, and anastomotic leak were unchanged before and after protocol implementation (all p > 0.05). Multivariable logistic regression found time period to be independent of SSIs (OR: 0.810, 95% CI: 0.576-1.140). CONCLUSION Implementation of a standard pediatric perioperative colon bundle can reduce superficial SSIs. Larger prospective studies are needed to evaluate the impact of colon bundles in reducing complications, hospital stay and cost. LEVEL OF EVIDENCE III - Retrospective cohort study.
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Affiliation(s)
- Aaron J Cunningham
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Pavithra Rao
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Raga Siddharthan
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Kenneth S Azarow
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Arjun Ashok
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Mubeen A Jafri
- Division of Pediatric Surgery, Randall Children's Hospital at Legacy Emanuel, Portland, OR, USA.
| | - Sanjay Krishnaswami
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Nicholas A Hamilton
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Marilyn W Butler
- Division of Pediatric Surgery, Randall Children's Hospital at Legacy Emanuel, Portland, OR, USA.
| | - Katrine M Lofberg
- Division of Pediatric Surgery, Randall Children's Hospital at Legacy Emanuel, Portland, OR, USA.
| | - Andrew Zigman
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Elizabeth A Fialkowski
- Division of Pediatric Surgery, Randall Children's Hospital at Legacy Emanuel, Portland, OR, USA
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Cunningham AJ, McClellan KV, Dewey E, Krishnaswami S, Butler MW, Nolt D, Fialkowski E, Haag MC, Hamilton NA. Perioperative neutropenia is not an independent risk factor for infectious complications of central venous line placement in children: A propensity score-matched analysis. J Pediatr Surg 2020; 55:1339-1343. [PMID: 31515110 DOI: 10.1016/j.jpedsurg.2019.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/08/2019] [Accepted: 08/07/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The infectious risk of central venous line (CVL) placement in children with neutropenia (absolute neutrophil count [ANC] <500/mm3) is not well defined. This study aims to investigate the early (≤30 days) and late (>30 days) infectious complications of CVLs placed in pediatric patients with and without neutropenia. METHODS A retrospective review was conducted of all CVLs placed by pediatric surgeons at two institutions from 2010 to 2017. Multivariable logistic regression was performed to identify risk factors for line infection. Propensity score-matched cohorts of patients with and without neutropenia were compared in a 1:1 ratio. Wilcoxon rank-sum, Chi-square, Fisher's exact, and log-rank tests were also performed. RESULTS Review identified 1,102 CVLs placed in 937 patients. Fifty-four patients were neutropenic at the time of placement. Multivariable analysis demonstrated tunneled catheters and subclavian access as associated with line infection. The propensity score-matched cohort included 94 patients, 47 from each group. Demographic and preoperative data were similar between the groups (p > 0.05). Patients with neutropenia were no more likely to develop early (4.3% vs. 2.1%, p = 1.000) or late (19.1% vs. 17.0%, p = 1.000) infectious complications than patients without neutropenia, with similar median time to infection (141 vs. 222 days, p = 0.370). CONCLUSION A policy of selective CVL placement in neutropenic patients with standardized postoperative line maintenance is safe. Future directions include defining criteria by which neutropenic patients could be prospectively selected for safe CVL placement. LEVEL OF EVIDENCE II - Retrospective cohort study.
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Affiliation(s)
- Aaron J Cunningham
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
| | | | - Elizabeth Dewey
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Sanjay Krishnaswami
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Marilyn W Butler
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Dawn Nolt
- Division of Pediatric Infectious Diseases, Oregon Health & Science University, Portland, OR, USA
| | - Elizabeth Fialkowski
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Meredith C Haag
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Nicholas A Hamilton
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
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Cunningham AJ, Dewey E, Hamilton NA, Schreiber MA, Krishnaswami S, Jafri MA. Validation of a venous thromboembolism prediction algorithm for pediatric trauma: A national trauma data bank (NTDB) analysis. J Pediatr Surg 2020; 55:1127-1133. [PMID: 32247600 DOI: 10.1016/j.jpedsurg.2020.02.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/20/2020] [Indexed: 01/21/2023]
Abstract
PURPOSE We sought to validate a risk model to predict venous thromboembolism (VTE) in pediatric trauma through an analysis of a contemporary cohort in the National Trauma Data Bank (NTDB). STUDY DESIGN Prospective internal validation was performed in 10 randomly stratified samples of children (age 0-17 years) from the NTDB 2013-2016. Model discrimination was determined by calculation of the c-statistic (AUC), and calibration was evaluated through analysis of observed to expected (O:E) ratio. Recalibration was performed with application of a mixed-effects logistic regression. Model parameters were reestimated based on recalibration. RESULTS Retrospective review identified 481,485 pediatric trauma patients with 729 (0.2%) episodes of VTE. Discriminatory ability of the model in all random cohorts was significant with AUC > 0.93 (p < 0.001). Inadequate calibration was noted in 4 of 10 cohorts and the entire dataset (p < 0.001) with an O:E ratio of 1.79. Model recalibration resulted in similar discrimination (AUC = 0.95) with improved calibration (O:E ratio = 1.33, p < 0.0001). CONCLUSION Pediatric trauma prediction models can provide useful data for VTE risk stratification in injured children, but these models must be validated and calibrated prior to use. Recalibration of the model in question resulted in improved accuracy in a contemporary NTDB dataset. These data provide an appropriately calibrated and validated model for clinical use. LEVEL OF EVIDENCE II - Prospective internal validation of a multivariable prediction model.
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Affiliation(s)
- Aaron J Cunningham
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Elizabeth Dewey
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Nicholas A Hamilton
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Martin A Schreiber
- Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Sanjay Krishnaswami
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Mubeen A Jafri
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA; Division of Pediatric Surgery, Randall Children's Hospital at Legacy Emanuel, Portland, OR, USA
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Overman RE, Kartal TT, Cunningham AJ, Fialkowski EA, Naik-Mathuria BJ, Vasudevan SA, Malek MM, Kalsi R, Le HD, Stafford LC, Lautz TB, Many BT, Jones RE, Bütter A, Davidson J, Williams A, Dasgupta R, Lewis J, Troutt M, Aldrink JH, Mansfield SA, Lal DR, Xiao J, Meyers RL, Short SS, Newman EA. Optimization of percutaneous biopsy for diagnosis and pretreatment risk assessment of neuroblastoma. Pediatr Blood Cancer 2020; 67:e28153. [PMID: 32072730 DOI: 10.1002/pbc.28153] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/22/2019] [Accepted: 12/11/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Image-guided percutaneous core needle biopsy (PCNB) is increasingly utilized to diagnose solid tumors. The objective of this study is to determine whether PCNB is adequate for modern biologic characterization of neuroblastoma. PROCEDURE A multi-institutional retrospective study was performed by the Pediatric Surgical Oncology Research Collaborative on children with neuroblastoma at 12 institutions over a 3-year period. Data collected included demographics, clinical details, biopsy technique, complications, and adequacy of biopsies for cytogenetic markers utilized by the Children's Oncology Group for risk stratification. RESULTS A total of 243 children were identified with a diagnosis of neuroblastoma: 79 (32.5%) tumor excision at diagnosis, 94 (38.7%) open incisional biopsy (IB), and 70 (28.8%) PCNB. Compared to IB, there was no significant difference in ability to accurately obtain a primary diagnosis by PCNB (95.7% vs 98.9%, P = .314) or determine MYCN copy number (92.4% vs 97.8%, P = .111). The yield for loss of heterozygosity and tumor ploidy was lower with PCNB versus IB (56.1% vs 90.9%, P < .05; and 58.0% vs. 88.5%, P < .05). Complications did not differ between groups (2.9 % vs 3.3%, P = 1.000), though the PCNB group had fewer blood transfusions and lower opioid usage. Efficacy of PCNB was improved for loss of heterozygosity when a pediatric pathologist evaluated the fresh specimen for adequacy. CONCLUSIONS PCNB is a less invasive alternative to open biopsy for primary diagnosis and MYCN oncogene status in patients with neuroblastoma. Our data suggest that PCNB could be optimized for complete genetic analysis by standardized protocols and real-time pathology assessment of specimen quality.
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Affiliation(s)
- Richard E Overman
- Division of Pediatric Surgery, Department of Surgery, C. S. Mott Children's Hospital, The University of Michigan, Ann Arbor, Michigan
| | - Tanvi T Kartal
- Division of Pediatric Surgery, Department of Surgery, C. S. Mott Children's Hospital, The University of Michigan, Ann Arbor, Michigan
| | - Aaron J Cunningham
- Department of Surgery, Division of Pediatric Surgery, Oregon Health and Science University, Portland, Oregon
| | - Elizabeth A Fialkowski
- Department of Surgery, Division of Pediatric Surgery, Oregon Health and Science University, Portland, Oregon
| | - Bindi J Naik-Mathuria
- Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Sanjeev A Vasudevan
- Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Marcus M Malek
- Division of Pediatric General and Thoracic Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ranjeet Kalsi
- Division of Pediatric General and Thoracic Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Hau D Le
- Division of Pediatric Surgery, American Family Children's Hospital, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Linda Cherney Stafford
- Division of Pediatric Surgery, American Family Children's Hospital, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Timothy B Lautz
- Division of Pediatric Surgery, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Evanston, Illinois
| | - Benjamin T Many
- Division of Pediatric Surgery, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Evanston, Illinois
| | - Rachel E Jones
- Division of Pediatric Surgery, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Evanston, Illinois
| | - Andreana Bütter
- Division of Pediatric Surgery, Children's Hospital, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Jacob Davidson
- Division of Pediatric Surgery, Children's Hospital, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Andrew Williams
- Division of Pediatric Surgery, Children's Hospital, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jana Lewis
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Misty Troutt
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Sara A Mansfield
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Dave R Lal
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Jerry Xiao
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Rebecka L Meyers
- Division of Pediatric Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Scott S Short
- Division of Pediatric Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Erika A Newman
- Division of Pediatric Surgery, Department of Surgery, C. S. Mott Children's Hospital, The University of Michigan, Ann Arbor, Michigan
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Cunningham AJ, Howell B, Polites S, Krishnaswami S, Hughey E, Terry S, Fox J, Azarow K. Establishing best practices for structured NSQIP review. Am J Surg 2020; 219:865-868. [PMID: 32234240 DOI: 10.1016/j.amjsurg.2020.02.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 02/28/2020] [Accepted: 02/29/2020] [Indexed: 11/15/2022]
Abstract
INTRODUCTION We describe an institutional program (INR- Interval NSQIP Review), to augment NSQIP utility through structured, multidisciplinary review of surgical outcomes in order to create near 'real-time' adverse event (AE) monitoring and improve surgeon awareness. METHODS INR is a monthly meeting of quality analysts, surgeons and nursing leadership initiated to validate AE with NSQIP criteria, review data in real-time, and perform in-depth case analyses. Occurrence classification concerns were referred for national NSQIP review. Monthly reports were distributed to surgeons with AE rates and case-specific details. RESULTS Since implementation, 377/3,026 AE underwent in-depth review. Of those, 7 occurrences were referred for clarification by central NSQIP review. Overall 37 (1.2%) were not consistent with NSQIP-defined AE after INR. Time from occurrence to surgeon review decreased by 223 days (296 vs. 73 days, p = 0.006). DISCUSSION Structured monthly institutional review of AE prior to submission can create greater transparency and confidence of NSQIP data, reduce time from occurrence to surgeon recognition, and improve stakeholder understanding of AE definitions. This approach can be tailored to institutional needs and should be evaluated for downstream improvement in patient outcomes.
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Affiliation(s)
- Aaron J Cunningham
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Brian Howell
- Quality Management, Oregon Health & Science University, Portland, OR, USA
| | - Stephanie Polites
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Sanjay Krishnaswami
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA; Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Eryn Hughey
- Quality Management, Oregon Health & Science University, Portland, OR, USA; Perioperative Services, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR, USA
| | - Susan Terry
- Perioperative Services, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR, USA
| | - Jenn Fox
- Quality Management, Oregon Health & Science University, Portland, OR, USA
| | - Kenneth Azarow
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA; Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
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Cunningham AJ, Dewey E, Lin S, Haley KM, Burns EC, Connelly CR, Moss L, Downie K, Hamilton NA, Krishnaswami S, Schreiber MA, Jafri MA. Pediatric trauma venous thromboembolism prediction algorithm outperforms current anticoagulation prophylaxis guidelines: a pilot study. Pediatr Surg Int 2020; 36:373-381. [PMID: 31900592 PMCID: PMC7223182 DOI: 10.1007/s00383-019-04613-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Venous thromboembolism (VTE) in injured children is rare, but sequelae can be morbid and life-threatening. Recent trauma society guidelines suggesting that all children over 15 years old should receive thromboprophylaxis may result in overtreatment. We sought to evaluate the efficacy of a previously published VTE prediction algorithm and compare it to current recommendations. METHODS Two institutional trauma registries were queried for all pediatric (age < 18 years) patients admitted from 2007 to 2018. Clinical data were applied to the algorithm and the area under the receiver operating characteristic (AUROC) curve was calculated to test algorithm efficacy. RESULTS A retrospective review identified 8271 patients with 30 episodes of VTE (0.36%). The VTE prediction algorithm classified 51 (0.6%) as high risk (> 5% risk), 322 (3.9%) as moderate risk (1-5% risk) and 7898 (95.5%) as low risk (< 1% risk). AUROC was 0.93 (95% CI 0.89-0.97). In our population, prophylaxis of the 'moderate-' and 'high-risk' cohorts would outperform the sensitivity (60% vs. 53%) and specificity (96% vs. 77%) of current guidelines while anticoagulating substantially fewer patients (373 vs. 1935, p < 0.001). CONCLUSION A VTE prediction algorithm using clinical variables can identify injured children at risk for venous thromboembolic disease with more discrimination than current guidelines. Prospective studies are needed to investigate the validity of this model. LEVEL OF EVIDENCE III-Clinical decision rule evaluated in a single population.
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Affiliation(s)
- Aaron J. Cunningham
- Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., CDW7, Portland, OR 97239 USA
| | - Elizabeth Dewey
- Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., CDW7, Portland, OR 97239 USA
| | - Saunders Lin
- Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., CDW7, Portland, OR 97239 USA
| | - Kristina M. Haley
- Division of Hematology and Oncology, Department of Pediatrics, Oregon Health and Science University, Portland, OR USA
| | - Erin C. Burns
- Division of Critical Care, Department of Pediatrics, Oregon Health and Science University, Portland, OR USA
| | - Christopher R. Connelly
- Section of Transplantation Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI USA
| | - Lori Moss
- Doernbecher Children’s Hospital, Oregon Health and Science University, Portland, OR USA
| | - Katie Downie
- Randall Children’s Hospital at Legacy Emanuel, Portland, OR USA
| | - Nicholas A. Hamilton
- Division of Pediatric Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR USA
| | - Sanjay Krishnaswami
- Division of Pediatric Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR USA
| | - Martin A. Schreiber
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR USA
| | - Mubeen A. Jafri
- Division of Pediatric Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR USA
- Division of Pediatric Surgery, Randall Children’s Hospital at Legacy Emanuel, Portland, OR USA
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Cunningham AJ, Haag MB, McClellan KV, Krishnaswami S, Hamilton NA. Routine Chest Radiographs in Children After Image-Guided Central Lines Offer Little Diagnostic Value. J Surg Res 2020; 247:234-240. [DOI: 10.1016/j.jss.2019.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 09/24/2019] [Accepted: 10/01/2019] [Indexed: 11/17/2022]
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Wilson RE, Rao PK, Cunningham AJ, Dewey EN, Krishnaswami S, Hamilton NA. A Natural History of Gastrojejunostomy Tubes in Children. J Surg Res 2020; 245:461-466. [DOI: 10.1016/j.jss.2019.07.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 06/27/2019] [Accepted: 07/17/2019] [Indexed: 11/28/2022]
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Cunningham AJ, Dewey B, Hamilton N, Schreiber MA, Krishnaswami S, Jafri M. Venous Thromboembolism Prediction Algorithm for Pediatric Trauma Outperforms Current National Guidelines: A National Trauma Data Bank Propensity Score-Matched Analysis. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Rowland KJ, Cunningham AJ, Jazrawi SF, Prauner R, Butler MW, Jafri M. Novel application of SpyGlass™ cholangioscopy in the diagnosis and treatment of extrahepatic biliary obstruction in infants. Journal of Pediatric Surgery Case Reports 2018. [DOI: 10.1016/j.epsc.2018.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Cunningham AJ, Lofberg KM, Krishnaswami S, Butler MW, Azarow KS, Hamilton NA, Fialkowski EA, Bilyeu P, Ohm E, Burns EC, Hendrickson M, Krishnan P, Gingalewski C, Jafri MA. Minimizing variance in Care of Pediatric Blunt Solid Organ Injury through Utilization of a hemodynamic-driven protocol: a multi-institution study. J Pediatr Surg 2017; 52:2026-2030. [PMID: 28941929 DOI: 10.1016/j.jpedsurg.2017.08.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 08/28/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND An expedited recovery protocol for management of pediatric blunt solid organ injury (spleen, liver, and kidney) was instituted across two Level 1 Trauma Centers, managed by nine pediatric surgeons within three hospital systems. METHODS Data were collected for 18months on consecutive patients after protocol implementation. Patient demographics (including grade of injury), surgeon compliance, National Surgical Quality Improvement Program (NSQIP) complications, direct hospital cost, length of stay, time in the ICU, phlebotomy, and re-admission were compared to an 18-month control period immediately preceding study initiation. RESULTS A total of 106 patients were treated (control=55, protocol=51). Demographics were similar among groups, and compliance was 78%. Hospital stay (4.6 vs. 3.5days, p=0.04), ICU stay (1.9 vs. 1.0days, p=0.02), and total phlebotomy (7.7 vs. 5.3 draws, p=0.007) were significantly less in the protocol group. A decrease in direct hospital costs was also observed ($11,965 vs. $8795, p=0.09). Complication rates (1.8% vs. 3.9%, p=0.86, no deaths) were similar. CONCLUSIONS An expedited, hemodynamic-driven, pediatric solid organ injury protocol is achievable across hospital systems and surgeons. Through implementation we maintained quality while impacting length of stay, ICU utilization, phlebotomy, and cost. Future protocols should work to further limit resource utilization. TYPE OF STUDY Retrospective cohort study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Aaron J Cunningham
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health Science University, Portland, OR
| | - Katrine M Lofberg
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ
| | - Sanjay Krishnaswami
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health Science University, Portland, OR
| | - Marilyn W Butler
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health Science University, Portland, OR; Division of Pediatric Surgery, Randall Children's Hospital at Legacy Emanuel, Portland, OR
| | - Kenneth S Azarow
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health Science University, Portland, OR
| | - Nicholas A Hamilton
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health Science University, Portland, OR
| | - Elizabeth A Fialkowski
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health Science University, Portland, OR
| | - Pamela Bilyeu
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Erika Ohm
- Division of Pediatric Surgery, Randall Children's Hospital at Legacy Emanuel, Portland, OR
| | - Erin C Burns
- Department of Pediatrics, Critical Care, Doernbecher Children's Hospital, Oregon Health Science University, Portland, OR
| | - Margo Hendrickson
- Division of Pediatric Surgery, Kaiser Permanente Northwest, Portland, OR
| | - Preetha Krishnan
- Department of Pediatrics, Critical Care, Randall Children's Hospital at Legacy Emanuel, Portland, OR
| | - Cynthia Gingalewski
- Division of Pediatric Surgery, Randall Children's Hospital at Legacy Emanuel, Portland, OR
| | - Mubeen A Jafri
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health Science University, Portland, OR; Division of Pediatric Surgery, Randall Children's Hospital at Legacy Emanuel, Portland, OR.
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Cunningham AJ, Ham PB, King RG, Rahardja A, Toscano M, Hatley RM, Pipkin WL. Congenital Jejunal Tubular Duplication in a Patient with a Congenital Thoracic Meningocele. Am Surg 2015; 81:e332-e333. [PMID: 26350649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Aaron J Cunningham
- Department of Surgery, Children's Hospital of Georgia, Medical College of Georgia, Georgia Regents University, Augusta, Georgia, USA
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Cunningham AJ, Ham PB, King RG, Rahardja A, Toscano M, Hatley RM, Pipkin WL. Congenital Jejunal Tubular Duplication in a Patient with a Congenital Thoracic Meningocele. Am Surg 2015. [DOI: 10.1177/000313481508100905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Aaron J. Cunningham
- Department of Surgery Children's Hospital of Georgia Medical College of Georgia Georgia Regents University Augusta, Georgia
| | - P. Benson Ham
- Department of Surgery Children's Hospital of Georgia Medical College of Georgia Georgia Regents University Augusta, Georgia
| | - Ray G. King
- Department of Surgery Children's Hospital of Georgia Medical College of Georgia Georgia Regents University Augusta, Georgia
| | - Andy Rahardja
- Department of Pathology Medical College of Georgia Georgia Regents University Augusta, Georgia
| | - Michael Toscano
- Department of Pathology Medical College of Georgia Georgia Regents University Augusta, Georgia
| | - Robyn M. Hatley
- Department of Surgery Children's Hospital of Georgia Medical College of Georgia Georgia Regents University Augusta, Georgia
| | - Walter L. Pipkin
- Department of Surgery Children's Hospital of Georgia Medical College of Georgia Georgia Regents University Augusta, Georgia
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Jones MC, Rueggeberg FA, Cunningham AJ, Faircloth HA, Jana T, Mettenburg D, Waller JL, Postma GN, Weinberger PM. Biomechanical changes from long-term freezer storage and cellular reduction of tracheal scaffoldings. Laryngoscope 2014; 125:E16-22. [PMID: 25092543 DOI: 10.1002/lary.24853] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 07/02/2014] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine structural biomechanical changes in tracheal scaffolds resulting from cellular reduction and storage at -80(o) C. STUDY DESIGN Laboratory-based study. METHODS Forty-four rabbit tracheal segments were separated into four treatment groups: untreated (group A, control), cellular-reduced (group B), storage at -80(o) C followed by cellular reduction (group C), and cellular-reduced followed by storage at -80(o) C (group D). Tracheal segments were subjected to uniaxial tension (n = 21) or compression (n = 23) using a universal testing machine to determine sutured tensile yield load and radial compressive strengths at 50% lumen occlusion. Mean differences among groups for tension and compression were compared by analysis of variance with post-hoc Tukey-Kramer test. RESULTS The untreated trachea (group A) demonstrated mean yield strength of 5.93 (± 1.65) N and compressive strength of 2.10 (± 0.51) N. Following treatment/storage, the tensile yield strength was not impaired (group B = 6.79 [± 1.58] N, C = 6.21 [± 1.40] N, D = 6.26 [± 1.18]; P > 0.10 each). Following cellular reduction, there was a significant reduction in compressive strength (group B = 0.44 N [± 0.13], P < 0.0001), but no further reduction due to storage (group C = 0.39 N [± 0.10]; P = 0.97 compared to group B). CONCLUSION The data suggest cellular reduction leads to loss of compressive strength. Freezing at -80°C (either before, or subsequent to cellular reduction) may be a viable storage method for tracheal grafts.
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Affiliation(s)
- Matthew C Jones
- Center for Voice, Airway and Swallowing, Department of Otolaryngology, Augusta, Georgia, U.S.A
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Jones MC, Rueggeberg FA, Faircloth HA, Cunningham AJ, Bush CM, Prosser JD, Waller JL, Postma GN, Weinberger PM. Defining the biomechanical properties of the rabbit trachea. Laryngoscope 2014; 124:2352-8. [PMID: 24782429 DOI: 10.1002/lary.24739] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 04/02/2014] [Accepted: 04/22/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Surgical advancements rely heavily on validated animal models. The New Zealand White (NZW) rabbit is a widely used model for airway research, including regenerative medicine applications. Currently, the biomechanical properties of the normal rabbit trachea are not known. Our objective was to define these properties to assist in the standardization and understanding of future airway research using this model. STUDY DESIGN Laboratory-based study. METHODS Fresh tracheas from four adult NZW rabbits were dissected into 20 segments. To examine the biomechanical properties, segments were subjected to uniaxial tension (n = 9) and compression (n = 11) testing. Yield and maximum load (tension) and force at 50% displacement (compression) were recorded, and differences between segments were examined using analysis of covariance. RESULTS Normative data for native rabbit trachea show mean maximum load = 6.44 newtons (N), yield load = 5.93 N, and compressive strength = 2.10 N. In addition to establishing the baseline measurements, statistically significant differences in tensile measures based on location along the trachea and diameter were identified. Proximal segments had significantly higher maximum load (P = .0029) and yield load (P = .0062) than distal segments. Association between diameter and both maximum load (P = .0139) and yield load (P = .0082) was observed. CONCLUSIONS The adult NZW rabbit trachea is intrinsically less able to withstand tensile and compressive forces, compared to other airway models such as sheep or cadaveric human. Establishment of normative values will enable future research into changes in tracheal biomechanical properties during regenerative medicine manipulation and processing.
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Affiliation(s)
- Matthew C Jones
- Center for Voice, Airway and Swallowing, Department of Otolaryngology, Georgia Regents University, Augusta, Georgia, U.S.A
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Kormos CE, Wilkinson AJ, Davey CJ, Cunningham AJ. Low birth weight and intelligence in adolescence and early adulthood: a meta-analysis. J Public Health (Oxf) 2013; 36:213-24. [PMID: 23896861 DOI: 10.1093/pubmed/fdt071] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Research has demonstrated an association between low birth weight (LBW; <2500 g) and adverse intelligence quotient (IQ) outcomes in childhood and early adolescence. We systematically evaluated whether this association persists into late adolescence and early adulthood and also assessed the influence of age of IQ assessment on effect size. METHODS During Stage 1 (meta-analysis of data on adolescents/adults), we searched for relevant articles in PsychINFO, PubMed, Ovid, CINAHL, ProQuest and ERIC until February 2011 (no lower limit). Studies which assessed full-scale IQ among LBW individuals (<2500 g), aged 13 years and older, with a normal birth weight (NBW; ≥2500 g) comparison group were eligible. A random-effects meta-analysis provided a pooled estimate of the difference in IQ scores between LBW and NBW individuals. Publication bias was assessed using Rosenthal's classic fail-safe N and Duval and Tweedie's Trim and Fill. During Stage 2, we added data from the Kerr-Wilson et al. meta-analysis (which included data from children; in Meta-analysis of the association between preterm delivery and intelligence. Journal Public Health 2011;33:1-8) to our sample from Stage 1 and conducted a meta-regression to evaluate the effect of age of IQ assessment. RESULTS Using a total of 15 studies in Stage 1, it was demonstrated that NBW individuals scored an average of 7.63 IQ points higher than LBW individuals, CI = 5.95-9.31. After adjusting for publication bias, NBW samples demonstrated an IQ of 4.98 points higher than LBW samples, CI = 3.20-6.77. Furthermore, age at IQ assessment was a significant moderator of the association between birth weight and IQ, in that the effect size decreased from childhood into young adulthood. CONCLUSIONS Cognitive impairments associated with LBW persist into adolescence and early adulthood; however, the influence of LBW on IQ decreases from childhood to young adulthood. These conclusions must be interpreted with caution due to unmeasured variables and possible influence from publication bias.
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Affiliation(s)
- C E Kormos
- Department of Psychology, University of Victoria, Victoria, Canada V8W 3P5
| | - A J Wilkinson
- Department of Psychology, Ryerson University, Toronto, Canada M5B 2K3
| | - C J Davey
- Department of Psychology, Ryerson University, Toronto, Canada M5B 2K3
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Abstract
Research on the factors that promote healing of the body through mind and spirit is at a very early stage. Reliance on experimental designs seems premature; we need much more exploratory research to identify relevant variables and useful therapeutic approaches before applying to them the same methods used to evaluate drugs. The Healing Journey is a program that has been in operation since 1982 at the Princess Margaret Hospital, Toronto, Ontario. Observational data collection, followed by qualitative analysis has demonstrated benefits for many cancer patients.
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Affiliation(s)
- A J Cunningham
- Ontario Cancer Institute/Princess Margaret Hospital, Toronto, Ontario.
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Iohom G, Ni Chonghaile M, O'Brien JK, Cunningham AJ, Fitzgerald DF, Shields DC. An investigation of potential genetic determinants of propofol requirements and recovery from anaesthesia. Eur J Anaesthesiol 2007; 24:912-9. [PMID: 17555608 DOI: 10.1017/s0265021507000476] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND OBJECTIVE The objectives of this study were, firstly, to characterize the inter-patient variability in the dose of propofol required to achieve a bispectral index <70 and 'time to eye opening' following propofol infusion and, secondly, to determine if the pharmacodynamic parameter 'time to achieve bispectral index <70' was influenced by genotype of the sex-linked drug receptor gene GABRE or if pharmacokinetic parameters such as clearance and 'time to eye opening' were influenced by the genotype of the metabolizing enzyme CYP2B6. METHODS One hundred and fifty patients received a standardized anaesthetic. Apparent systemic clearance values were estimated. Correlation was sought between carriers of different CYP2B6 and GABRE genotypes and apparent systemic clearance, 'time to achieve bispectral index <70' and 'time to eye opening'. RESULTS Propofol induction/emergence characteristics varied, with slow recovery times in a subset of males. Time to loss of verbal contact and time to bispectral index <70 varied 6.6- and 4.3-fold, respectively. At emergence, there was a 15.5- to 111-fold variability in the measured time intervals. Clearance varied from 9.1 to 55.8 mL min-1 kg-1. The CYP2B6 C1459T (R487C) genotype frequencies were TT 1%, TC 22% and CC 67%. The three major haplotypes of CYP2B6 (R487C, K262R and Q172H variants) were not significantly associated with time to eye opening or clearance. Clearance was similar in 487C carriers and 487RR genotypes. There was no statistically significant correlation between the four major haplotypes of GABRE variants investigated ([mRNA358]G/T, 20118C/T, 20326C/T and 20502 A/T) and the observed anaesthesia induction time. CONCLUSIONS Great inter-patient variability exists in the dose of propofol required to achieve bispectral index <70, apparent systemic propofol clearance and time to eye opening. Common haplotypic differences at the CYP2B6 and GABRE genes do not appear to account for the majority of the observed inter-patient variability.
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Affiliation(s)
- G Iohom
- Beaumont Hospital, Department of Anaesthesia and Intensive Care Medicine, Dublin, Ireland.
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Langdon MG, Cunningham AJ. High-fidelity simulation in post-graduate training and assessment: an Irish perspective. Ir J Med Sci 2007; 176:267-71. [PMID: 17762919 DOI: 10.1007/s11845-007-0074-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2007] [Accepted: 07/19/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Lack of financial resources was internationally ranked as the greatest limitation to the application of human physiological simulation in clinical teaching. The Beaumont Simulation Centre in the Republic of Ireland is solely funded by once-off grant payments. Attracting a range of health care specialties through course diversity can offset costs. AIMS This survey of simulator course evaluations aimed to determine attitudes of an array of Irish health care professionals towards full-scale simulation. METHODS Anaesthetists (n = 51), nurses (n = 48) and dentists (n = 12) rated simulator-based courses and use of simulation for competency assessment with a self-reporting questionnaire with a five-point scale (1 = poor, 5 = excellent). RESULTS Participants rated the courses from very good to excellent and were of the opinion that full-scale simulation is acceptable and appropriate for both education and competency assessment. CONCLUSIONS This study demonstrates successful post-graduate course development in a simulation centre with narrow budgetary restrictions. In addition, it is the first to examine Irish anaesthetists', nurses' and dentists' attitudes towards full-scale simulation as an assessment tool.
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Affiliation(s)
- M G Langdon
- RCSI, Education and Research Centre, Beaumont Hospital, Dublin 9, Ireland.
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Cunningham AJ, Knape JTA, Adriaensen H, Blunnie WP, Buchser E, Goldik Z, Ilias W, Paver-Erzen V. Guidelines for anaesthesiologist specialist training in pain medicine. Eur J Anaesthesiol 2007; 24:568-70. [PMID: 17568473 DOI: 10.1017/s0265021507000336] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The Section and Board of Anaesthesiology of the European Union of Medical Specialists aims (EUMS/UEMS) at harmonization of training of anaesthesiologists and at improvement of patient care throughout Europe. Pain medicine is considered to be an area of expertise in anaesthesiology although exclusivity is not claimed. The Section and Board has approved both a core syllabus for pain medicine to be part of the specialist training in anaesthesiology and an additional qualification in pain medicine following the completion of a 5 yr basic specialty training in anaesthesiology. These proposals were prepared by the Working Party on Pain Medicine of the Section and Board. It considers a multidisciplinary approach to pain to contribute to quality in care and has taken the initiative to set up a Multidisciplinary Joint Committee on Pain Medicine within the EUMS/UEMS, for which these guidelines define the area of expertise of anaesthesiology.
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Affiliation(s)
- A J Cunningham
- Beaumont Hospital, Department of Anaesthesia, Beamont Road, Dublin, Ireland
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Iohom G, Fitzgerald D, Cunningham AJ. Re: Iohom G, Fitzgerald D, Cunningham AJ. Principles of pharmacogenetics--implications for the anaesthetist. Br J Anaesth 2004; 93: 440-50. Br J Anaesth 2005; 95:728. [PMID: 16342366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
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Affiliation(s)
- G Iohom
- Department of Anaesthesia and Intensive Care Medicine, Beaumont Hospital, Dublin 9, Ireland
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Abstract
BACKGROUND AND OBJECTIVE Preoperative bedside screening tests for difficult tracheal intubation may be neither sensitive nor specific enough for clinical use. The aim was to investigate if a combination of the Mallampati classification of the oropharyngeal view with either the thyromental or sternomental distance measurement improved the predictive value. METHODS A total of 212 (109 male, 103 female) non-obstetric surgical patients, aged >18 yr, undergoing elective surgical procedures requiring tracheal intubation were assessed preoperatively with respect to the oropharyngeal (modified Mallampati) classification, thyromental and sternomental distances. An experienced anaesthetist, blinded to the preoperative airway assessment, performed laryngoscopy and graded the view according to Cormack and Lehane's classification. RESULTS Twenty tracheal intubations (9%) were difficult as defined by a Cormack and Lehane Grade 3 or 4, or the requirement for a bougie in patients with Cormack and Lehane Grade 2. Used alone, the Mallampati oropharyngeal view, and thyromental and sternomental distances were associated with poor sensitivity, specificity and positive predictive values. Combining the Mallampati Class III or IV with either a thyromental distance <6.5cm or a sternomental distance <12.5cm decreased the sensitivity (from 40 to 25 and 20%, respectively), but maintained a negative predictive value of 93%. The specificity and positive predictive values increased from 89 and 27% respectively for Mallampati alone to 100%. CONCLUSIONS The findings suggest that the Mallampati classification, in conjunction with measurement of the thyromental and sternomental distances, may be a useful routine screening test for preoperative prediction of difficult tracheal intubation.
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Affiliation(s)
- G Iohom
- Beaumont Hospital, Department of Anaesthesia and Intensive Care, Dublin, Ireland.
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Abstract
BACKGROUND A practical and reliable monitor of depth of anaesthesia would be a major advance on current clinical practice. None of the present monitors is both simple to use and accurate. Ocular microtremor (OMT) is a physiological tremor that is suppressed by propofol in a dose-dependent manner. We studied OMT during propofol induction and nitrous oxide-oxygen-sevoflurane maintenance of anaesthesia in 30 patients, and compared OMT with the bispectral index (BIS) as a predictor of response to verbal command. METHODS OMT was measured using the closed-eye piezoelectric strain-gauge technique. OMT and BIS were measured at specific times during the anaesthetic, including at loss of consciousness, at end-tidal sevoflurane 1 and 2%, and at emergence. RESULTS OMT decreased significantly after induction, did not decrease as end-tidal sevoflurane was increased from 1 to 2%, and increased at emergence in all patients. By logistic regression, OMT was more sensitive and specific than BIS in distinguishing the awake from the anaesthetized state (OMT, 84.9 and 93.1% respectively; BIS, 75.7 and 69.0%). CONCLUSIONS OMT is suppressed by sevoflurane and accurately predicts response to verbal command. OMT may be a useful monitor of depth of hypnosis.
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Affiliation(s)
- L G Kevin
- Department of Anaesthesia, Beaumont Hospital, Dublin 9, Ireland
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Halpenny M, Rushe C, Breen P, Cunningham AJ, Boucher-Hayes D, Shorten GD. The effects of fenoldopam on renal function in patients undergoing elective aortic surgery. Eur J Anaesthesiol 2002; 19:32-9. [PMID: 11913801 DOI: 10.1017/s0265021502000054] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE Postoperative renal impairment is a recognized complication of infrarenal aortic cross-clamping. Our hypothesis was that the renal vasodilating and natriuretic effects of fenoldopam mesylate, a selective dopamine (DA1) agonist, would preserve renal function in patients undergoing elective infrarenal aortic cross-clamping. METHODS A prospective, randomized, double blind controlled clinical trial was performed. Twenty-eight ASA II-III patients undergoing elective aortic surgery requiring infrarenal aortic cross-clamping were studied. According to random allocation, patients received either fenoldopam (0.1 microg kg(-1) min(-1)) or placebo intravenously prior to surgical skin incision until release of the aortic clamp. Plasma creatinine, creatinine clearance, urinary output, fractional excretion of sodium, and free water clearance were measured: (a) prior to admission to hospital; (b) during the period from insertion of the urinary catheter until application of the aortic cross-clamp; (c) during the period of aortic cross-clamping; (d) 0-4 h, and (e) 4-8 h after release of the clamp and on days 1, 2, 3, and 5 postoperatively. RESULTS Fenoldopam (0.1 microg kg(-1)min(-1)) administration was not associated with haemodynamic instability. On application of the aortic cross-clamp creatinine clearance decreased significantly in the placebo (83 +/- 20 to 42 +/- 29 mL min(-1) (mean +/- SD)) (P < 0.01) but not in the fenoldopam group, and this decrease persisted for at least 8 h after release of the cross-clamp (83 +/- 20 to 54 +/- 33 mL min(-1) (mean +/- SD)) (P < 0.05). Plasma creatinine concentration increased significantly from baseline on the first postoperative day in the placebo group (87 +/- 12 to 103 +/- 28 micromolL(-1) (mean +/- SD)) (P < 0.01) but not in the fenoldopam group. CONCLUSIONS These findings are consistent with the hypothesis that fenoldopam possesses a renoprotective effect during and after infrarenal aortic cross-clamping.
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Affiliation(s)
- M Halpenny
- Department of Anaesthesia and Intensive Care Medicine, University College Cork, Ireland.
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Dowd NP, Scully M, Adderley SR, Cunningham AJ, Fitzgerald DJ. Inhibition of cyclooxygenase-2 aggravates doxorubicin-mediated cardiac injury in vivo. J Clin Invest 2001; 108:585-90. [PMID: 11518732 PMCID: PMC209394 DOI: 10.1172/jci11334] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The clinical use of doxorubicin, an anthracycline chemotherapeutic agent, is limited by cardiotoxicity, particularly when combined with herceptin, an antibody that blocks the HER2 receptor. Doxorubicin induces cyclooxygenase-2 (COX-2) activity in rat neonatal cardiomyocytes. This expression of COX-2 limits doxorubicin-induced cardiac cell injury, raising the possibility that the administration of a prostaglandin may protect the heart during the in vivo administration of doxorubicin. Doxorubicin (15 mg/kg) administered to adult male Sprague Dawley rats induced COX-2 expression and activity in cardiac tissue. Prostacyclin generation measured as the excretion of 2,3-dinor-6-keto-PGF(1alpha) also increased, and this was blocked by a COX-2 inhibitor, SC236. In contrast, administration of a COX-1 inhibitor SC560 at a dose that reduced serum thromboxane B2 by more than 80% did not prevent the doxorubicin-induced increase in prostacyclin generation. Doxorubicin increased cardiac injury, detected as a rise in plasma cardiac troponin T, serum lactate dehydrogenase, and cardiomyocyte apoptosis; this was aggravated by coadministration of SC236 but not SC560. The degree of injury in animals treated with a combination of doxorubicin and SC236 was attenuated by prior administration of the prostacyclin analogue iloprost. These data raise the possibility of protecting the heart during the administration of doxorubicin by prior administration of prostacyclin.
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Affiliation(s)
- N P Dowd
- Department of Anaesthesia and Intensive Care, Beaumont Hospital, Dublin, Ireland
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McGinley J, Lynch L, Hubbard K, McCoy D, Cunningham AJ. Dopexamine hydrochloride does not modify hemodynamic response or tissue oxygenation or gut permeability during abdominal aortic surgery. Can J Anaesth 2001; 48:238-44. [PMID: 11305823 DOI: 10.1007/bf03019752] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To assess the effects of intraoperative infusion of dopexamine (a DA-1 and B2 adrenoreceptor agonist) on hemodynamic function, tissue oxygen delivery and consumption, splanchnic perfusion and gut permeability following aortic cross- clamp and release. METHODS In a randomised double blind controlled trial 24 patients scheduled for elective infrarenal abdominal aortic aneurysm repair were studied in two centres and were assigned to one of two treatment groups. Group I received a dopexamine infusion starting at 0.5 microg x kg(-1) x min(-1) increased to 2 microg x kg(-1) x min(-1) maintaining a stable heart rate; Group II received a placebo infusion titrated in the same volumes following induction of anesthesia. Measured and derived hemodynamic data, tissue oxygen delivery and extraction and gut permeability were recorded at set time points throughout the procedure. RESULTS Dopexamine infusion (0.5 -2 microg x kg x min(-1)) was associated with enhanced hemodynamic function (MAP 65 +/- 5.5 vs 92 +/- 5.7 mm Hg, P = <0.05) only during the period of aortic cross clamping. However, during the most part of infrarenal abdominal aortic surgery, dopexamine did not reduce systemic vascular resistance index, mean arterial pressure nor oxygen extraction compared with the control group. The lactulose/ rhamnose permeation ratio was elevated above normal in both groups (0.22 and 0.29 in groups I and II respectively). CONCLUSIONS Dopexamine infusion (0.5 -2 microg x kg(-1) x min(-1)) did not enhance hemodynamic function and tissue oxygenation values during elective infrarenal abdominal aortic aneurysm repair.
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Affiliation(s)
- J McGinley
- Department of Anaesthesia, Beaumont Hospital, Dublin, Ireland
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Abstract
The short-term benefits of minimal access techniques include less pain, early mobilization, and shorter hospital stay. Nonetheless, significant data have accumulated regarding the complications associated with laparoscopic techniques, including those that are unique to laparoscopic surgery such as bile duct injury and disruption of major blood vessels. Other problems such as myocardial ischemia and respiratory acidosis are associated with the cardiopulmonary effects of pneumoperitoneum and systemic CO2 absorption. These physiologic changes, although tolerated by healthy patients, could have particular adverse consequences for infirm and critically ill patients. It would appear that minimizing IAP during insufflation decreases the risk of potentially marked cardiovascular changes and regional blood flow alterations. In turn, this could arguably decrease the risk of perioperative myocardial events, or organ dysfunction or failure. Laparoscopy in the critically ill patient is questionable because the role is not established. An ICU patient has little to gain from the benefits of early mobilization. Conversely, in the presence of raised ICP or borderline organ function, the physiologic changes associated with pneumoperitoneum and laparoscopy could have profound detrimental effects.
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Affiliation(s)
- C O'Malley
- Department of Anaesthesia, Beaumont Hospital/Royal College of Surgeons, Ireland, Beaumont Hospital, Dublin, Ireland
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Cunningham AJ, Phillips C, Lockwood GA, Hedley DW, Edmonds CV. Association of involvement in psychological self-regulation with longer survival in patients with metastatic cancer: an exploratory study. Adv Mind Body Med 2001; 16:276-87. [PMID: 11015769 DOI: 10.1054/ambm.2000.0217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
There have been numerous anecdotal claims that when patients are dedicated users of a variety of psychological self-regulation strategies, including relaxation, mental imaging, cognitive restructuring and meditation, such dedication may have a life-prolonging effect. Our aim was to test this possibility more rigorously, in patients with metastatic cancer.A prospective, longitudinal, correlative study was carried out on 22 patients with varying kinds of medically incurable metastatic cancer. The intervention was one year of weekly group psychological therapy. Extensive verbal data (patients' written homework and therapists' notes) were collected over the year. The extent of each patient's involvement with psychological work was estimated following a qualitative analysis of these data. Patients were classed as showing high, moderate, or low involvement on the basis of a quantitative rating of categories defined by the analysis. These three subgroups did not differ significantly in their expected median survival duration as estimated from independent quantitative predictions by a large panel of oncologists who analyzed the patients' medical charts at time of study entry.A significant relationship was found between degree of involvement in psychological work and survival duration. Results are presented as Kaplan-Meier survival curves (Fig. 2;P = 0. 006, Log Rank test) and as a graphic display of the median survival of each of the three groups (Fig. 3). The main likely confounders (medical status, age, quality of life, and attendance at therapy) were similar across subgroups and did not change the relation between psychological work and survival duration. Limitations in the design are discussed. However, the strong effects observed support clinical observations that dedicated involvement in psychological self-regulation may prolong the life of some patients with metastatic cancer.
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Affiliation(s)
- A J Cunningham
- Ontario Cancer Institute/Princess Margaret Hospital, Toronto, Ontario, Canada
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Cunningham AJ, Hobson RM. Dissociative recombination at elevated temperatures. I. Experimental measurements in krypton afterglows. ACTA ACUST UNITED AC 2001. [DOI: 10.1088/0022-3700/5/9/020] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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O'Malley TF, Cunningham AJ, Hobson RM. Dissociative recombination at elevated temperatures. II. Comparison between theory and experiment in neon and argon afterglows. ACTA ACUST UNITED AC 2001. [DOI: 10.1088/0022-3700/5/11/019] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Duncan MA, Dowd N, Rawluk D, Cunningham AJ. Traumatic bilateral internal carotid artery dissection following airbag deployment in a patient with fibromuscular dysplasia. Br J Anaesth 2000; 85:476-8. [PMID: 11103196 DOI: 10.1093/bja/85.3.476] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This case describes a 39-yr-old male, presenting with left hemiplegia after a road traffic accident involving frontal deceleration and airbag deployment. Brain computerized tomography (CT) scan revealed a right parietal lobe infarct. Contrast angiography demonstrated bilateral internal carotid artery dissection and fibromuscular dysplasia. The patient was treated with systemic heparinization. Neurological improvement, evidenced by full return of touch sensation, proprioception and nociception began 10 days after the injury. To our knowledge, this is the first case report of carotid artery dissection associated with airbag deployment. Forced neck extension in such settings may result in carotid artery dissection because of shear force injury at the junction of the extracranial and intrapetrous segments of the vessel. Clinicians should consider carotid artery injury when deterioration in neurological status occurs after airbag deployment. We propose that the risk of carotid artery dissection was increased by the presence of fibromuscular dysplasia.
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Affiliation(s)
- M A Duncan
- Department of Anaesthesia, Intensive Care Medicine and Neurosurgery, Beaumont Hospital, Dublin, Ireland
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Abstract
A comparison is made between the models guiding the administration of adjuvant material remedies, such as chemotherapy, and 'adjunctive psychological therapy' (APT), in the treatment of cancer. It is argued that patients would benefit if APT were supplied subject to the same indications as adjuvant chemotherapy.
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Cunningham AJ. A new study (Watson et al.) on "fighting spirit" and breast cancer. Adv Mind Body Med 2000; 16:118-20. [PMID: 10835768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Cunningham AJ, Edmonds CV, Phillips C, Soots KI, Hedley D, Lockwood GA. A prospective, longitudinal study of the relationship of psychological work to duration of survival in patients with metastatic cancer. Psychooncology 2000; 9:323-39. [PMID: 10960930 DOI: 10.1002/1099-1611(200007/08)9:4<323::aid-pon465>3.0.co;2-b] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This study is a prospective, longitudinal investigation of the psychological factors associated with the duration of survival in patients with metastatic cancers of various kinds who were receiving group psychotherapy. A correlative approach rather than an experimental (trials) design was used in the study because our aim was to relate the psychological attributes of each individual to survival rather than to test the efficacy of the intervention. Twenty-two patients with medically incurable metastatic cancer of various kinds received weekly group psychotherapy for up to 1 year, the great majority remaining well enough to attend the group for at least 8 months. During this time, they provided extensive verbal data, through written homework, and from notes taken by the therapists at interviews and during group sessions. These data were subjected to detailed qualitative analysis, as a result of which a number of psychological themes were defined. A quantitative rating was assigned to the data for each theme in each individual patient through team discussions. The scores for the individual themes were summed to produce a 'total psychological score', representing the degree of each patient's involvement with psychological self-help work. The values for each patient were then related to his or her survival duration. Cox regression analyses showed that this composite score, and five of six major themes, were significantly related to survival duration. These themes were: ability to act and change; willingness to initiate change; application to self-help work; relationships with others; and quality of experience. In contrast, there was no relationship between survival and four standard psychometric measures taken at the onset of therapy. However, results on a 5-point scale measuring the subject's expectancy that psychological efforts would affect the disease showed a strong relationship to survival. To control for differences in severity of disease as a factor possibly influencing psychological work, the analyses were repeated, using the survival duration predicted for each patient by a panel of oncologists as a covariate. Closely similar results were obtained. Limitations on the interpretation of the results are discussed. Within these limits, it appears that there is a strong association between longer survival and psychological factors related to the involvement of cancer patients in psychological self-help activities. While causality cannot be inferred, reasons are given for believing that this is not a result of the disease influencing the patients' psychology, but rather the converse.
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Affiliation(s)
- A J Cunningham
- Department of Epidemiology, Statistics and Behavioral Science, Ontario Cancer Institute/Princess Margaret Hospital, Toronto, Ontario, Canada
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Cunningham AJ. Mind-body research in psychooncology: what directions will be most useful? Adv Mind Body Med 2000; 15:252-5; discussion 275-81. [PMID: 10555395 DOI: 10.1054/ambm.1999.0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
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Connolly J, Cunningham AJ. Preoperative fasting and administration of regular medications in adult patients presenting for elective surgery. Has new evidence changed clinical practice? Eur J Anaesthesiol 2000; 17:219-20. [PMID: 10866003 DOI: 10.1046/j.1365-2346.2000.00603.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Lennox P, Cunningham AJ. Preoperative anaesthesia information--what do patients need to know? Ir J Med Sci 2000; 169:93, 95. [PMID: 11006660 DOI: 10.1007/bf03166906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
A previously healthy 25-yr-old female developed flaccid areflexic tetraplegia, with intact cranial nerve function, 36 h after the diagnosis of bacterial meningitis. Polymerase chain reaction studies of cerebrospinal fluid and blood were positive for Neisseria meningitidis, serogroup B. Magnetic resonance of the cervicothoracic spine revealed increased signal intensity and expansion in the lower medulla, upper cervical cord and cerebellar tonsils. Neurosurgical consultation recommended hyperventilation, dexamethasone and regular mannitol therapy rather than decompressive intervention. The clinical course over the following 12 days was complicated by the development of progressive central nervous and multisystem organ failure with disseminated intravascular coagulopathy. Autopsy revealed cerebral oedema with cystic infarction extending from the medulla to the upper cervical cord and cerebellar tonsils. Flaccid areflexic tetraplegia with spinal cord infarction has not been reported following bacterial infection in an adult. The clinical implications would suggest complete central nervous system evaluation of patients recovering from meningococcal meningitis, since spinal cord lesions, although uncommon, do occur. In those very rare situations where a patient develops significant peripheral neurological deficits, urgent magnetic resonance imaging is warranted, to rule out an infective focus or an underlying anatomical anomaly.
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Affiliation(s)
- R O'Farrell
- Department of Anaesthesia/Critical Care Medicine, Beaumont Hospital/Royal College of Surgeons, Dublin, Ireland
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Cunningham AJ, Watson KD. Staging in cancer. Cancer Prev Control 1999; 3:173, 175. [PMID: 10474763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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Kelly DJ, Walsh F, Norman GS, Cunningham AJ. The effects of midazolam on pure tone audiometry, speech audiometry, and audiological reaction times in human volunteers. Anesth Analg 1999; 88:1064-8. [PMID: 10320169 DOI: 10.1097/00000539-199905000-00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Auditory evoked potentials are effected by benzodiazepines, as is cortical processing of auditory stimuli. The effect of benzodiazepines on auditory sensitivity has not, however, been studied. We designed the present study to investigate the effect of sedative doses of midazolam on pure tone and speech audiometry and on audiological reaction times in healthy volunteers. Thirty volunteers underwent baseline audiological assessment for pure tones and speech and had their audiological reaction times measured at 10 and 50 dB above their threshold hearing level at a frequency of 1 kHz. Subjects were then randomly assigned to one of two groups. Group A (n = 15) received midazolam (0.04 mg/kg) IV, and Group B (n = 15) received a similar volume of placebo IV. The audiological tests were repeated 5 min later, and performance was compared with baseline data. Scheffé post hoc tests were used to assess the significance of changes in each group. There was no pre- to posttest change in audiological performance in either the placebo group (P = 0.194) or the midazolam group (P = 0.957). Speech audiometry performance was likewise unaffected by midazolam (P = 0.154). Reaction time at the 10-dB and 50-dB sensation levels were both significantly prolonged after midazolam administration (P = 0.023 and P = 0.012, respectively). In this study, we demonstrate that sedation with midazolam (0.04 mg/kg) does not alter pure tone or speech audiometric thresholds, but it does significantly delay the reaction time to auditory stimuli. Medical practitioners should advise midazolam-sedated patients of their impaired reaction to auditory warning signals (e.g., traffic and car horns) as part of the day-ward discharge recommendations. IMPLICATIONS In this study, we demonstrate that sedation of healthy volunteers with the benzodiazepine midazolam, in the common clinical dosage, does not affect their hearing capability as measured by pure tone and speech audiometry. However, one's ability to react to auditory signals is impaired after midazolam, which may have implications for patients after day-case procedures.
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Affiliation(s)
- D J Kelly
- Department of Anaesthesia, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin
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