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Reiter AJ, Huang L, Craig BT, Davidoff AM, Talbot LJ, Coggins J, Smith J, Aldrink JH, Bergus KC, MacArthur TA, Polites SF, Boehmer C, Brungardt J, Malek MM, Rinehardt HN, Kastenberg ZJ, Arkin CM, Gourmel A, Piche N, Wallace M, Liang J, Lovvorn HN, Petroze RT, Gillies G, Marquart JP, Becktell K, Le HD, Favela J, Rich BS, Glick RD, Seemann NM, Davidson J, Wilson CA, Roach J, Brown EG, Doyle KE, Coakley BA, Emengo P, Merola P, Grant CN, Tirumani A, Tracy ET, Moya-Mendez ME, Dasgupta R, Lautz TB. Survival outcomes in pediatric patients with metastatic Ewing sarcoma who achieve a rapid complete response of pulmonary metastases. Pediatr Blood Cancer 2024:e31026. [PMID: 38679864 DOI: 10.1002/pbc.31026] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 02/26/2024] [Accepted: 04/05/2024] [Indexed: 05/01/2024]
Abstract
PURPOSE Our objectives were to compare overall survival (OS) and pulmonary relapse between patients with metastatic Ewing sarcoma (EWS) at diagnosis who achieve rapid complete response (RCR) and those with residual pulmonary nodules after induction chemotherapy (non-RCR). PATIENTS AND METHODS This retrospective cohort study included children under 20 years with metastatic EWS treated from 2007 to 2020 at 19 institutions in the Pediatric Surgical Oncology Research Collaborative. Chi-square tests were conducted for differences among groups. Kaplan-Meier curves were generated for OS and pulmonary relapse. RESULTS Among 148 patients with metastatic EWS at diagnosis, 61 (41.2%) achieved RCR. Five-year OS was 71.2% for patients who achieved RCR, and 50.2% for those without RCR (p = .04), and in multivariable regression among patients with isolated pulmonary metastases, RCR (hazards ratio [HR] 0.42; 95% confidence interval [CI]: 0.17-0.99) and whole lung irradiation (WLI) (HR 0.35; 95% CI: 0.16-0.77) were associated with improved survival. Pulmonary relapse occurred in 57 (37%) patients, including 18 (29%) in the RCR and 36 (41%) in the non-RCR groups (p = .14). Five-year pulmonary relapse rates did not significantly differ based on RCR (33.0%) versus non-RCR (47.0%, p = .13), or WLI (38.8%) versus no WLI (46.0%, p = .32). DISCUSSION Patients with EWS who had isolated pulmonary metastases at diagnosis had improved OS if they achieved RCR and received WLI, despite having no significant differences in rates of pulmonary relapse.
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Affiliation(s)
- Audra J Reiter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lynn Huang
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brian T Craig
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Andrew M Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Lindsay J Talbot
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jordan Coggins
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jasmine Smith
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Katherine C Bergus
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | | | | | - Chloe Boehmer
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Joseph Brungardt
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Marcus M Malek
- Division of Pediatric General and Thoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hannah N Rinehardt
- Division of Pediatric General and Thoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Zachary J Kastenberg
- Division of Pediatric Surgery, Department of Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Cameron M Arkin
- Division of Pediatric Surgery, Department of Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Antoine Gourmel
- Department of Pediatric Surgery, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, Québec, Canada
| | - Nelson Piche
- Department of Pediatric Surgery, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, Québec, Canada
| | - Marshall Wallace
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University, Nashville, Tennessee, USA
| | - Jiancong Liang
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University, Nashville, Tennessee, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University, Nashville, Tennessee, USA
| | - Robin T Petroze
- Division of Pediatric Surgery, University of Florida, Gainesville, Florida, USA
| | - Gwendolyn Gillies
- Division of Pediatric Surgery, University of Florida, Gainesville, Florida, USA
| | - John P Marquart
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kerri Becktell
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Hau D Le
- Division of Pediatric Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Juan Favela
- Division of Pediatric Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Barrie S Rich
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Northwell/Hofstra, New Hyde Park, New York, USA
| | - Richard D Glick
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Northwell/Hofstra, New Hyde Park, New York, USA
| | - Natashia M Seemann
- Division of Paediatric Surgery, Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Jacob Davidson
- Division of Paediatric Surgery, Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Claire A Wilson
- Division of Paediatric Surgery, Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Jonathan Roach
- Department of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Erin G Brown
- Division of Pediatric Surgery, University of California Davis, Sacramento, California, USA
| | - Kathleen E Doyle
- Division of Pediatric Surgery, University of California Davis, Sacramento, California, USA
| | - Brian A Coakley
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Pamela Emengo
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Pamela Merola
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christa N Grant
- Division of Pediatric Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Anuritha Tirumani
- Division of Pediatric Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Elisabeth T Tracy
- Division of Pediatric Surgery, Duke Children's Hospital and Health Center, Durham, North Carolina, USA
| | - Mary E Moya-Mendez
- Division of Pediatric Surgery, Duke Children's Hospital and Health Center, Durham, North Carolina, USA
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Timothy B Lautz
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Reiter AJ, Huang R, Iroz CB, Slocum JD, D'Orazio BM, Johnson JK, Stulberg JJ. Adherence to Opioid Prescribing Guidelines in a Statewide Surgical Quality Improvement Collaborative. J Surg Res 2024; 293:274-280. [PMID: 37804797 DOI: 10.1016/j.jss.2023.09.034] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/28/2023] [Accepted: 09/12/2023] [Indexed: 10/09/2023]
Abstract
INTRODUCTION The opioid crisis is an ongoing crisis in the United States. Postoperative patients who receive opioid prescriptions have a 3%-7% risk of developing a chronic opioid abuse problem. This study aims to describe on-target opioid prescribing and use of multimodal pain management strategies 2 y after the implementation of a multicomponent quality improvement initiative across our statewide collaborative. METHODS From July 2020 to September 2021, we prospectively collected data on opioid-prescribing and multimodal strategies for 10 targeted procedures in general, gynecologic, and orthopedic surgery at three hospitals. Prescribing was on-target if a patient was prescribed ≤50 daily morphine milligram equivalents. Multimodal strategies were defined as two or more nonopioid adjuncts used within 48 h of surgery. RESULTS One thousand and eleven targeted procedures were performed with prescription data available for 993 cases. The on-target prescribing rate was 79.6% (n = 790), with general surgery 92.5% (n = 285), gynecology 84.9% (n = 331), and orthopedic surgery 59.0% (n = 174). Patients who received multimodal pain approaches were associated with interventions such as patient education, transversus abdominus plane block, and prescriptions for nonopioid analgesics at discharge. There was no evidence to support a difference in the use of multimodal pain control approaches between patients whose opioid prescribing was on-target or not (73.8% versus 77.3%, P = 0.30). At the first postoperative visit, data on continued opioid use were missing in 57.3% of patients, number of pills used was missing in 93.8%, and adequate pain control was missing in 52.8%. CONCLUSIONS On-target prescribing and multimodal strategies are common but vary by specialty. Additionally, postoperative pain control and opioid use are often not documented. To better match prescribing to patient needs, understanding patient-level and specialty-level opioid use is important.
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Affiliation(s)
- Audra J Reiter
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Reiping Huang
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Cassandra B Iroz
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John D Slocum
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Brianna M D'Orazio
- Surgical Outcomes and Quality Improvement Center, Indiana University School of Medicine, Indianapolis, Indiana
| | - Julie K Johnson
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jonah J Stulberg
- Department of Surgery, University of Texas Health Sciences Center of Houston, McGovern Medical School, Houston, Texas.
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Reiter AJ, Huang L, Tian Y, Sullivan GA, Hu A, Raval MV. National Trends in Interventions for Pediatric Gallstone Pancreatitis. J Laparoendosc Adv Surg Tech A 2024; 34:82-87. [PMID: 37682559 PMCID: PMC10794827 DOI: 10.1089/lap.2023.0238] [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] [Indexed: 09/09/2023] Open
Abstract
Introduction: Laparoscopic cholecystectomy (LC) during index hospitalization for gallstone pancreatitis is standard in adult populations. The objective of this study was to evaluate trends in use of LC and endoscopic retrograde cholangiopancreatography (ERCP) for children with gallstone pancreatitis. Materials and Methods: This retrospective cohort study used the Kids' Inpatient Database, spanning 2000-2019, to identify patients aged 18 years or younger with a principal diagnosis of gallstone pancreatitis. The Mann-Kendall trend test was used to assess trends over time. Results: Gallstone pancreatitis occurred in 5028 patients. The rate of LC during index hospitalization ranged from 55.4% to 63.8% (P = .76). Trends demonstrate that LC occurred on average hospital day 4.6 in 2000 and decreased to 3.4 in 2019 (P < .01). Among those undergoing LC, average length of stay (LOS) decreased from 6.8 days in 2000 to 5.1 days in 2019 (P < .01). The rate of ERCP alone decreased from 24.8% in 2000 to 14.0% in 2019 (P = .23). For those undergoing ERCP, average hospital day of ERCP decreased from 3.3 in 2000 to 2.3 in 2019 (P = .07). The rate of undergoing both an ERCP and LC decreased from 19.0% in 2000 to 8.5% in 2019 (P = .13). For patients who underwent either LC or ERCP, average LOS decreased from 7.0 days in 2000 to 5.1 days in 2019 (P < .01). For patients who did not undergo a procedure, average LOS decreased from 5.7 days in 2000 to 4.0 days in 2019 (P = .13). Conclusion: The proportion of LC performed during index hospitalizations for children with gallstone pancreatitis has been stable for two decades. However, trends indicate that interventions are occurring earlier, and LOS is becoming shorter.
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Affiliation(s)
- Audra J. Reiter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lynn Huang
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Yao Tian
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gwyneth A. Sullivan
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Andrew Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mehul V. Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Sullivan GA, Reiter AJ, Smith C, Glick RD, Skarda DE, Le HD, Gow KW, Rich BS, Raval MV. Pediatric Surgeon Perceptions on Operating Room Environmental Stewardship and Current Institutional Climate-Smart Actions. J Pediatr Surg 2023; 58:2278-2285. [PMID: 37468347 DOI: 10.1016/j.jpedsurg.2023.06.013] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Operating rooms generate significant greenhouse gas emissions. Our objective was to assess current institutional climate-smart actions and pediatric surgeon perceptions regarding environmental stewardship efforts in the operating room. METHODS A survey was distributed to members of the American Pediatric Surgical Association in June 2022. The survey was piloted among ten general surgery residents and two professional society cohorts of pediatric surgeons. Comparisons were made by demographic and practice characteristics. RESULTS Survey response rate was 15.9% (n = 160/1009) and included surgeons predominantly from urban (n = 93/122, 76.2%) and academic (n = 84/122, 68.9%) institutions. Only 9.8% (n = 12/122) of pediatric surgeons were currently involved in operating room environmental initiatives. The most common climate-smart actions were reusable materials and equipment (n = 120/159, 75.5%) and reprocessing of medical devices (n = 111/160, 69.4%). Most surgeons either strongly agreed (n = 48/121, 39.7%) or agreed (n = 62/121, 51.2%) that incorporation of environmental stewardship practices at work was important. Surgeons identified reusable materials/equipment (extremely important: n = 61/129, 47.3%, important: n = 38/129, 29.5%) and recycling (extremely important: n = 68/129, 52.7%, important: n = 29/129, 22.5%) as the most important climate-smart actions. Commonly perceived barriers were financial (extremely likely: n = 47/123, 38.2%, likely: n = 50/123, 40.7%) and staff resistance to change (extremely likely: n = 29/123, 23.6%, likely: n = 60/123, 48.8%). Regional differences included low adoption of energy efficiency strategies among respondents from southern states (n = 0/26, p = 0.01) despite high perceived importance relative to other regions (median: 5, IQR: 4-5 vs median: 4, IQR 4-5, p = 0.04). CONCLUSIONS While most pediatric surgeons agreed that environmental stewardship was important, less than 10% are currently involved in initiatives at their institutions. Opportunities exist for surgical leadership surrounding implementation of climate-smart actions. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Gwyneth A Sullivan
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Audra J Reiter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Charesa Smith
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Richard D Glick
- Division of Pediatric Surgery, Department of Surgery, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - David E Skarda
- University of Utah, Department of Surgery, Division of Pediatric Surgery, Salt Lake City, UT, USA; Primary Children's Hospital, Intermountain Health Care, Salt Lake City, UT, USA
| | - Hau D Le
- Division of Pediatric Surgery, Department of Surgery, American Family Children's Hospital, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kenneth W Gow
- Seattle Children's Hospital and the University of Washington, Seattle, WA, USA
| | - Barrie S Rich
- Division of Pediatric Surgery, Department of Surgery, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
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Sullivan GA, Reddy S, Reiter AJ, Zeineddin S, Visenio M, Hu A, Mackersie R, Kabre R, Raval MV, Stey AM. Does Trauma Center Volume Account for the Association Between Trauma Center Verification Level and In-Hospital Mortality among Children Injured by Firearms in California? J Am Coll Surg 2023; 237:738-749. [PMID: 37581372 DOI: 10.1097/xcs.0000000000000818] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
BACKGROUND Heterogeneity in trauma center designation and injury volume offer possible explanations for inconsistencies in pediatric trauma center designation's association with lower mortality among children. We hypothesized that rigorous trauma center verification, regardless of volume, would be associated with lower firearm injury-associated mortality in children. STUDY DESIGN This retrospective cohort study leveraged the California Office of Statewide Health Planning and Development patient discharge data. Data from children aged 0 to 14 years in California from 2005 to 2018 directly transported with firearm injuries were analyzed. American College of Surgeons (ACS) trauma center verification level was the primary predictor of in-hospital mortality. Centers' annual firearm injury volume data were analyzed as a mediator of the association between center verification level and in-hospital mortality. Two mixed-effects multivariable logistic regressions modeled in-hospital mortality and the estimated association with center verification while adjusting for patient demographic and clinical characteristics. One model included the center's firearm injury volume and one did not. RESULTS The cohort included 2,409 children with a mortality rate of 8.6% (n = 206). Adjusted odds of mortality were lower for children at adult level I (adjusted odds ratio [aOR] 0.38, 95% CI 0.19 to 0.80), pediatric (aOR 0.17, 95% CI 0.05 to 0.61), and dual (aOR 0.48, 95% CI 0.25 to 0.93) trauma centers compared to nontrauma/level III/IV centers. Firearm injury volume did not mediate the association between ACS trauma center verification and mortality (aOR/10 patient increase in volume 1.01, 95% CI 0.99 to 1.03). CONCLUSIONS Trauma center verification level, regardless of firearm injury volume, was associated with lower firearm injury-associated mortality, suggesting that the ACS verification process is contributing to achieving optimal outcomes.
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Affiliation(s)
- Gwyneth A Sullivan
- From the Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL (Sullivan, Reiter, Zeineddin, Hu, Kabre, Raval)
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL (Sullivan)
| | - Susheel Reddy
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL (Reddy, Visenio, Stey)
| | - Audra J Reiter
- From the Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL (Sullivan, Reiter, Zeineddin, Hu, Kabre, Raval)
| | - Suhail Zeineddin
- From the Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL (Sullivan, Reiter, Zeineddin, Hu, Kabre, Raval)
| | - Michael Visenio
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL (Reddy, Visenio, Stey)
| | - Andrew Hu
- From the Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL (Sullivan, Reiter, Zeineddin, Hu, Kabre, Raval)
| | - Robert Mackersie
- Department of Surgery, University of California San Francisco, San Francisco, CA (Mackersie)
| | - Rashmi Kabre
- From the Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL (Sullivan, Reiter, Zeineddin, Hu, Kabre, Raval)
| | - Mehul V Raval
- From the Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL (Sullivan, Reiter, Zeineddin, Hu, Kabre, Raval)
| | - Anne M Stey
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL (Reddy, Visenio, Stey)
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Sullivan GA, Reiter AJ, Hu A, Smith C, Storton K, Gulack BC, Shah AN, Dsida R, Raval MV. Operating Room Recycling: Opportunities to Reduce Carbon Emissions Without Increases in Cost. J Pediatr Surg 2023; 58:2187-2191. [PMID: 37188613 DOI: 10.1016/j.jpedsurg.2023.04.011] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/10/2023] [Accepted: 04/16/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND The healthcare industry is a major contributor to greenhouse gas emissions. Within the hospital, operating rooms are responsible for the largest proportion of emissions due to high resource utilization and waste generation. Our aim was to generate estimates of greenhouse gas emissions avoided and cost implications following implementation of a recycling program across operating rooms at our freestanding children's hospital. METHODS Data were collected from three commonly performed pediatric surgical procedures: circumcision, laparoscopic inguinal hernia repair, and laparoscopic gastrostomy tube placement. Five cases of each procedure were observed. Recyclable paper and plastic waste was weighed. Emission equivalencies were determined using the Environmental Protection Agency Greenhouse Gas Equivalencies Calculator. Institutional cost of waste disposal was $66.25 United States Dollars (USD)/ton for recyclable waste and $67.00 USD/ton for solid waste. RESULTS The proportion of recyclable waste ranged from 23.3% for circumcision to 29.5% for laparoscopic gastrostomy tube placement. The amount of waste redirected from landfill to a recycling stream could result in annual avoidance of 58,500 to 91,500 kg carbon dioxide equivalent emissions, or 6583 to 10,296 gallons of gasoline. Establishing a recycling program would not require additional cost and could lead to modest cost savings (range $15 to 24 USD/year). CONCLUSIONS Incorporation of recycling into operating rooms has the potential to reduce greenhouse gas emissions without increased cost. Clinicians and hospital administrators should consider operating room recycling programs as they work towards improved environmental stewardship. LEVEL OF EVIDENCE Level VI - evidence form a single descriptive or qualitative study.
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Affiliation(s)
- Gwyneth A Sullivan
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, USA.
| | - Audra J Reiter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Andrew Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Charesa Smith
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Katelyn Storton
- Supply Chain and Strategic Sourcing Operations, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Brian C Gulack
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Ami N Shah
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Richard Dsida
- Department of Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Reiter AJ, Prinz J, Li Y, Nagle AP, Hungness ES, Teitelbaum EN. Increased bleeding risk with enoxaparin venothromboembolism prophylaxis compared with heparin in patients undergoing bariatric surgery. Surg Endosc 2023; 37:6983-6988. [PMID: 37344753 DOI: 10.1007/s00464-023-10219-2] [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: 05/11/2023] [Accepted: 06/11/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Perioperative venothromboembolism (VTE) chemoprophylaxis is an established tenant of bariatric surgery; however, there is little comparative data to guide medication choice. The objective of this study was to determine if a change in VTE prophylaxis from heparin to enoxaparin was associated with differing rates of postoperative bleeding and VTE occurrence after bariatric surgery. METHODS This retrospective cohort study included patients 18 years or older who underwent primary bariatric surgery (sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB)) at a single institution between March 2012 and December 2021. Subcutaneous unfractionated heparin was utilized for VTE prophylaxis from March 2012 through February 2018 and then enoxaparin was used from March 2018 through December 2021. Postoperative bleeding was defined as requiring a blood transfusion or reoperation for bleeding within 30 days of surgery. Chi-square test was used to test for differences between groups. RESULTS There were 2159 patients who underwent bariatric surgery with 1324 (61.3%) patients in the heparin group and 835 (38.7%) in the enoxaparin group. Overall, 1,503 (69.6%) patients underwent SG and 656 (30.4%) RYGB. There was no difference in the ratio of SG to RYGB between the heparin and enoxaparin groups. Most patients were female (n = 1709, 79.2%) with a median age of 43.2 years (interquartile range (IQR): 35.6-52.2), and median BMI of 44.9 (IQR: 40.9-50.5). Overall postoperative bleeding occurred more frequently in the enoxaparin group (n = 26, 3.1%) compared with the heparin group (n = 12, 0.9%) (p < 0.01). Additionally, reoperation for bleeding was more frequent with enoxaparin (enoxaparin 0.8% vs. heparin 0.2%, p = 0.04). There was no difference in VTE occurrence between the two groups (heparin: n = 14, 1.1%, enoxaparin: n = 7, 0.8% (p = 0.61)). CONCLUSIONS An institutional change from heparin to enoxaparin for bariatric surgery perioperative VTE prophylaxis was associated with a significant increase in postoperative bleeding, with no difference in VTE complications.
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Affiliation(s)
- Audra J Reiter
- Northwestern Quality Improvement, Research, & Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joanne Prinz
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Yan Li
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alexander P Nagle
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Eric S Hungness
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ezra N Teitelbaum
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Balbale SN, Schäfer WLA, Davis TL, Blake SC, Close S, Sullivan GA, Reiter AJ, Hu AJ, Smith CJ, Wilberding MJ, Johnson JK, Holl JL, Raval MV. A mixed-method approach to generate and deliver rapid-cycle evaluation feedback: lessons learned from a multicenter implementation trial in pediatric surgery. Implement Sci Commun 2023; 4:82. [PMID: 37464448 DOI: 10.1186/s43058-023-00463-x] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 06/28/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Rapid-cycle feedback loops provide timely information and actionable feedback to healthcare organizations to accelerate implementation of interventions. We aimed to (1) describe a mixed-method approach for generating and delivering rapid-cycle feedback and (2) explore key lessons learned while implementing an enhanced recovery protocol (ERP) across 18 pediatric surgery centers. METHODS All centers are members of the Pediatric Surgery Research Collaborative (PedSRC, www.pedsrc.org ), participating in the ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) trial. To assess implementation efforts, we conducted a mixed-method sequential explanatory study, administering surveys and follow-up interviews with each center's implementation team 6 and 12 months following implementation. Along with detailed notetaking and iterative discussion within our team, we used these data to generate and deliver a center-specific implementation report card to each center. Report cards used a traffic light approach to quickly visualize implementation status (green = excellent; yellow = needs improvement; red = needs significant improvement) and summarized strengths and opportunities at each timepoint. RESULTS We identified several benefits, challenges, and practical considerations for assessing implementation and using rapid-cycle feedback among pediatric surgery centers. Regarding potential benefits, this approach enabled us to quickly understand variation in implementation and corresponding needs across centers. It allowed us to efficiently provide actionable feedback to centers about implementation. Engaging consistently with center-specific implementation teams also helped facilitate partnerships between centers and the research team. Regarding potential challenges, research teams must still allocate substantial resources to provide feedback rapidly. Additionally, discussions and consensus are needed across team members about the content of center-specific feedback. Practical considerations include carefully balancing timeliness and comprehensiveness when delivering rapid-cycle feedback. In pediatric surgery, moreover, it is essential to actively engage all key stakeholders (including physicians, nurses, patients, caregivers, etc.) and adopt an iterative, reflexive approach in providing feedback. CONCLUSION From a methodological perspective, we identified three key lessons: (1) using a rapid, mixed method evaluation approach is feasible in pediatric surgery and (2) can be beneficial, particularly in quickly understanding variation in implementation across centers; however, (3) there is a need to address several methodological challenges and considerations, particularly in balancing the timeliness and comprehensiveness of feedback. TRIAL REGISTRATION NIH National Library of Medicine Clinical Trials. CLINICALTRIALS gov Identifier: NCT04060303. Registered August 7, 2019, https://clinicaltrials.gov/ct2/show/NCT04060303.
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Affiliation(s)
- Salva N Balbale
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA.
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Center of Innovation for Complex Chronic Healthcare, Health Services Research & Development, Jr. VA Hospital, Edward Hines, Hines, IL, 60141, USA.
| | - Willemijn L A Schäfer
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Teaniese L Davis
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, USA
| | - Sarah C Blake
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sharron Close
- Department of Pediatric Advanced Practice Nursing, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Gwyneth A Sullivan
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Audra J Reiter
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Andrew J Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Charesa J Smith
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Maxwell J Wilberding
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Julie K Johnson
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jane L Holl
- Department of Neurology, Biological Sciences Division and Center for Healthcare Delivery Science and Innovation, University of Chicago, Chicago, IL, USA
| | - Mehul V Raval
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Reiter AJ, Farina DA, Fronza JS, Komanduri S. Magnetic sphincter augmentation: considerations for use in Barrett's esophagus. Dis Esophagus 2023; 36:doac096. [PMID: 36575922 PMCID: PMC10267686 DOI: 10.1093/dote/doac096] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/11/2022] [Accepted: 11/23/2022] [Indexed: 12/29/2022]
Abstract
Barrett's esophagus (BE) occurs in 5-15% of patients with gastroesophageal reflux disease (GERD). While acid suppressive therapy is a critical component of BE management to minimize the risk of progression to esophageal adenocarcinoma, surgical control of mechanical reflux is sometimes necessary. Magnetic sphincter augmentation (MSA) is an increasingly utilized anti-reflux surgical therapy for GERD. While the use of MSA is listed as a precaution by the United States Food and Drug Administration, there are limited data showing effective BE regression with MSA. MSA offers several advantages in BE including effective reflux control, anti-reflux barrier restoration and reduced hiatal hernia recurrence. However, careful patient selection for MSA is necessary.
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Affiliation(s)
- Audra J Reiter
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Domenico A Farina
- Department of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jeffrey S Fronza
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Srinadh Komanduri
- Department of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Reiter AJ, Warner SG, Chen H, Ingraham AM, Hunter CJ, Freischlag J, Raval MV. Translating the Value of the Academic Surgeon Into Salary, Time, and Resources. J Surg Res 2023; 285:A1-A6. [PMID: 36682973 DOI: 10.1016/j.jss.2022.12.039] [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: 12/07/2022] [Revised: 12/15/2022] [Accepted: 12/25/2022] [Indexed: 01/21/2023]
Abstract
Academic surgeons provide tremendous value to institutions including notoriety, publicity, cutting-edge clinical advances, extramural funding, and academic growth and development. In turn, these attributes may result in improved reputation scores and hospital or medical center rankings. While many hospital systems, schools of medicine, and departments of surgery claim to have a major commitment to academic surgery and research, academic surgeons are often undercompensated compared to clinically focused counterparts. Existing salary benchmarks (e.g., the Medical Group Management Association (MGMA) or the Association of American Medical Colleges (AAMC)) are often used but are imperfect. Thus, the value proposition for academic surgeons goes beyond compensation and often includes protected time for academic pursuit, nonsalary financial support, and other intangible benefits to being associated with a major academic center (e.g., abundance of scientific collaborators, infrastructure for grant management). As a result, institution-specific practices have developed and academic surgeons are left to negotiate salary support including bonus structures, protected time, and recruitment packages on a case-by-case basis without a clear roadmap. A diverse panel representing a range of academic surgical experiences was convened at the 2022 Academic Surgical Congress to illuminate this complex, often stress-inducing, aspect of an academic surgeon's professional career.
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Affiliation(s)
- Audra J Reiter
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Susanne G Warner
- Division of Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Herbert Chen
- Chair of the Department of Surgery, Surgeon in Chief, University of Alabama at Birmingham, Birmingham, Alabama
| | - Angela M Ingraham
- Division of Acute Care and Regional General Surgery, Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
| | - Catherine J Hunter
- Division of Pediatric Surgery, Department of Surgery, Oklahoma University, Oklahoma City, Oklahoma
| | - Julie Freischlag
- Dean Wake Forest University School of Medicine, Chief Executive Officer Atrium Health Wake Forest Baptist, Chief Academic Officer Atrium Health Enterprise, Winston Salem, North Carolina
| | - Mehul V Raval
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Sullivan GA, Sincavage J, Reiter AJ, Hu AJ, Rangel M, Smith CJ, Ritz EM, Shah AN, Gulack BC, Raval MV. Disparities in Utilization of Same-Day Discharge Following Appendectomy in Children. J Surg Res 2023; 288:1-9. [PMID: 36934656 DOI: 10.1016/j.jss.2023.02.033] [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: 11/29/2022] [Revised: 01/12/2023] [Accepted: 02/18/2023] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Disparities in the delivery of pediatric surgical care exist for racial and ethnic minority groups. Utilization of same-day discharge (SDD) following appendectomy for acute, uncomplicated appendicitis is increasing; however, rates among diverse populations have not been explored to evaluate equitable care delivery and healthcare utilization. Our objective was to determine whether race and ethnicity are associated with rates of SDD and postdischarge healthcare utilization. We hypothesized that racial and ethnic minority groups would have lower rates of SDD. METHODS This retrospective cohort study used data from the 2015-2019 American College of Surgeons National Surgical Quality Improvement Program-Pediatric clinical registry and included children who underwent appendectomy. Patients with complicated appendicitis were excluded. Primary exposure was racial or ethnic group. The primary outcome was SDD, and secondary outcomes included postdischarge emergency department visits and hospital readmissions. RESULTS Of 37,579 simple appendicitis patients, SDD after appendectomy occurred in 10,012 (26.6%). On multivariable analysis, Black or African American race was associated with lower likelihood of SDD (adjusted odds ratio [aOR]: 0.85; 95% confidence interval [95% CI]:0.79-0.92; P < 0.0001). Hispanic ethnicity was associated with higher likelihood of SDD (aOR: 1.19; 95% CI: 1.12-1.25; P < 0.0001). Likelihood of postoperative emergency department visits was higher in Black or African American patients (aOR: 1.36; 95% CI: 1.14-1.62; P < 0.001) and Hispanic patients (aOR: 1.37; 95% CI: 1.12-1.58; P < 0.0001). Hospital readmission rates were similar across groups. CONCLUSIONS Rates of SDD following appendectomy vary among racial and ethnic groups. Interventions to achieve equitable healthcare delivery including SDD after appendectomy are needed.
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Affiliation(s)
- Gwyneth A Sullivan
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - John Sincavage
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Audra J Reiter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Andrew J Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Melissa Rangel
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Charesa J Smith
- Department of Surgery, University of Illinois Chicago, Chicago, Illinois
| | - Ethan M Ritz
- Rush Research Informatics Core, Rush University Medical Center, Chicago, Illinois
| | - Ami N Shah
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Brian C Gulack
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
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12
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Reiter AJ, Hu A, Sullivan GA, Stein E, Samis JH, Josefson JL, Rastatter JC, Raval MV. Short-Term Complications After Total Thyroidectomy in Children. J Surg Res 2023; 283:758-763. [PMID: 36470200 PMCID: PMC9877187 DOI: 10.1016/j.jss.2022.11.035] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/03/2022] [Accepted: 11/16/2022] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Total thyroidectomy for benign disease is becoming more common among children. The purpose of this study was to evaluate 30-day outcomes in children undergoing total thyroidectomy and determine if the short-term outcomes are different in those with a malignant versus benign indication for surgery. METHODS This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-Pediatric) to identify all children who underwent total thyroidectomy from 2015 to 2019. Fisher's exact test was used to compare postoperative outcomes between benign and malignant indications for thyroidectomy. RESULTS Among 1595 total thyroidectomy patients, 1091 (68.4%) had a benign indication and 504 (31.6%) had a malignant indication. There were 1234 (77.4%) females, and the median age was 14.9 y (interquartile range [IQR] 12.5, 16.6). Average length of stay (LOS) was similar between cohorts (1.7 d for benign and 1.9 d for malignant, P = 0.30). Parathyroid auto-transplantation was performed in 71 (6.5%) patients in the benign cohort and 43 (8.6%) in the malignant cohort (P = 0.15). The most common complications were readmissions (23 [2.1%] benign and 15 [3.0%] malignant, P = 0.29) and reoperations (7 [0.6%] benign and 5 [1.0%] malignant, P = 0.54). Complication profiles were similar between benign and malignant cohorts (2.8% and 4.6%, respectively [P = 0.10]). CONCLUSIONS Children undergoing total thyroidectomy for benign and malignant indications have low rates of 30-d postoperative complications, suggesting that total thyroidectomy is a safe option for children with benign disease. Evaluation of long-term outcomes is needed.
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Affiliation(s)
- Audra J Reiter
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Andrew Hu
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Gwyneth A Sullivan
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Eli Stein
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jill H Samis
- Division of Endocrinology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Jami L Josefson
- Division of Endocrinology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Jeffrey C Rastatter
- Division of Pediatric Otolaryngology, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Mehul V Raval
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois.
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Sullivan GA, Huang LW, Schäfer WLA, Tian Y, Reiter AJ, Essner B, Hu A, Ingram MC, Balbale S, Johnson JK, Holl JL, Raval MV. Association of Multimodal Pain Control with Patient-Reported Outcomes in Children Undergoing Surgery. J Pediatr Surg 2023; 58:1206-1212. [PMID: 36948934 DOI: 10.1016/j.jpedsurg.2023.02.028] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 02/10/2023] [Indexed: 02/21/2023]
Abstract
INTRODUCTION Our aim was to describe practices in multimodal pain management at US children's hospitals and evaluate the association between non-opioid pain management strategies and pediatric patient-reported outcomes (PROs). METHODS Data were collected as part of the 18-hospital ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) clinical trial. Non-opioid pain management strategies included use of preoperative and postoperative non-opioid analgesics, regional anesthetic blocks, and a biobehavioral intervention. PROs included perioperative nervousness, pain-related functional disability, health-related quality of life (HRQoL). Associations were analyzed using multinomial logistic regression models. RESULTS Among 186 patients, 62 (33%) received preoperative analgesics, 186 (100%) postoperative analgesics, 81 (44%) regional anesthetic block, and 135 (73%) used a biobehavioral intervention. Patients were less likely to report worsened as compared to stable nervousness following regional anesthetic block (relative risk ratio [RRR]:0.31, 95% confidence interval [CI]:0.11-0.85), use of a biobehavioral technique (RRR:0.26, 95% CI:0.10-0.70), and both in combination (RRR:0.08, 95% CI:0.02-0.34). There were no associations of non-opioid pain control modalities with pain-related functional disability or HRQoL. CONCLUSION Use of postoperative non-opioid analgesics have been largely adopted, while preoperative non-opioid analgesics and regional anesthetic blocks are used less frequently. Regional anesthetic blocks and biobehavioral interventions may mitigate postoperative nervousness in children. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Gwyneth A Sullivan
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, USA.
| | - Lynn Wei Huang
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Willemijn L A Schäfer
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Yao Tian
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Audra J Reiter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Bonnie Essner
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Andrew Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Martha C Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Salva Balbale
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Julie K Johnson
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jane L Holl
- Biological Sciences Division, Department of Neurology, Center for Healthcare Delivery Science and Innovation, University of Chicago, IL, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Reiter AJ, Sullivan GA, Hu A, Tian Y, Ingram MCE, Balbale SN, Johnson JK, Schäfer W, Holl JL, Raval MV. Pediatric Patient and Caregiver Agreement on Perioperative Expectations and Self-Reported Outcomes. J Surg Res 2023; 282:47-52. [PMID: 36252362 PMCID: PMC10232682 DOI: 10.1016/j.jss.2022.09.020] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 08/25/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Alignment between pediatric patients and caregiver perspectives on patient-reported outcome (PRO) data is contingent upon context. We aimed to assess agreement between patient and caregiver responses to a series of perioperative domains. METHODS Agreement between pediatric patients and caregiver responses to preoperative and postoperative surveys about surgery preparedness, perioperative expectations, PRO Measurement Information System (PROMIS) measures for overall health and pain, and reaching milestones gathered as part of an ongoing clinical trial for children undergoing gastrointestinal surgery, was evaluated. Gwet's AC and Spearman's correlation coefficients were calculated, as appropriate, to assess agreement. RESULTS Of 209 enrolled patients, 65 (31.1%) dyads completed all three surveys and were included. For the domains of education, expectations, and comprehension, patients and caregivers had good agreement with Gwet AC1 with values of 0.80, 0.61, and 0.64, respectively. For milestones, patients and caregivers had very good agreement (Gwet AC1 of 0.95). Milestones measured whether patients achieved certain goals within a prespecified time, including enteral intake (Gwet AC1 0.91 and 0.92 respectively), transition to oral pain medication (Gwet AC1 0.94), ambulation (Gwet AC1 1.00), and return of bowel function (Gwet AC1 0.97). There was moderate to strong agreement between patients and caregivers on PROMIS pain questions (Spearman's correlation: 0.71 preoperatively and 0.51 postoperatively). On PROMIS global health questions, there was strong agreement (0.69 preoperatively and 0.65 postoperatively). CONCLUSIONS Pediatric patient and caregiver agreement on perioperative survey items ranged from moderate to strong. Caregivers' responses may be acceptable when some patient-level responses are not available.
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Affiliation(s)
- Audra J Reiter
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Gwyneth A Sullivan
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Andrew Hu
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Yao Tian
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Martha-Conley E Ingram
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Salva N Balbale
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julie K Johnson
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Willemijn Schäfer
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jane L Holl
- Biological Sciences Division, University of Chicago, Chicago, Illinois
| | - Mehul V Raval
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois.
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Sullivan GA, Petit HJ, Reiter AJ, Westrick JC, Hu A, Dunn JB, Gulack BC, Shah AN, Dsida R, Raval MV. Environmental Impact and Cost Savings of Operating Room Quality Improvement Initiatives: A Scoping Review. J Am Coll Surg 2023; 236:411-423. [PMID: 36648269 DOI: 10.1097/xcs.0000000000000478] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [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: 01/18/2023]
Abstract
BACKGROUND Operating rooms are major contributors to a hospital's carbon footprint due to the large volumes of resources consumed and waste produced. The objective of this study was to identify quality improvement initiatives that aimed to reduce the environmental impact of the operating room while decreasing costs. STUDY DESIGN A literature search was performed using PubMed, Scopus, CINAHL, and Google Scholar and included broad terms for "operating room," "costs," and "environment" or "sustainability." The "triple bottom line" framework, which considers the environmental, financial, and social impacts of interventions to guide decision making, was used to inform data extraction. The studies were then categorized using the 5 "Rs" of sustainability-refuse, reduce, reuse, repurpose, and recycle-and the impacts were discussed using the triple bottom line framework. RESULTS A total of 23 unique quality improvement initiatives describing 28 interventions were included. Interventions were categorized as "refuse" (n = 11; 39.3%), "reduce" (n = 8; 28.6%), "reuse" (n = 3; 10.7%), and "recycle" (n = 6; 21.4%). While methods of measuring environmental impact and cost savings varied greatly among studies, potential annual cost savings ranged from $873 (intervention: education on diverting recyclable materials from sharps containers; environmental impact: 11.4 kg sharps waste diverted per month) to $694,141 (intervention: education to reduce regulated medical waste; environmental impact: 30% reduction in regulated medical waste). CONCLUSIONS Quality improvement initiatives that reduce both cost and environmental impact have been successfully implemented across a variety of centers both nationally and globally. Surgeons, healthcare practitioners, and administrators interested in environmental stewardship and working toward a culture of sustainability may consider similar interventions in their institutions.
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Affiliation(s)
- Gwyneth A Sullivan
- From the Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine (Sullivan, Reiter, Hu, Raval)
- the Division of Pediatric Surgery, Department of Surgery (Sullivan, Petit)
| | - Hayley J Petit
- the Division of Pediatric Surgery, Department of Surgery (Sullivan, Petit)
| | - Audra J Reiter
- From the Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine (Sullivan, Reiter, Hu, Raval)
| | - Jennifer C Westrick
- the Library of Rush Medical Center (Westrick), Rush University Medical Center, Chicago, IL
| | - Andrew Hu
- From the Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine (Sullivan, Reiter, Hu, Raval)
| | - Jennifer B Dunn
- the Chemical and Biological Engineering, Northwestern University, Evanston, IL (Dunn)
| | - Brian C Gulack
- From the Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine (Sullivan, Reiter, Hu, Raval)
- the Department of Anesthesiology (Dsida), Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL
- the Division of Pediatric Surgery, Department of Surgery (Sullivan, Petit)
- the Library of Rush Medical Center (Westrick), Rush University Medical Center, Chicago, IL
- the Chemical and Biological Engineering, Northwestern University, Evanston, IL (Dunn)
| | - Ami N Shah
- From the Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine (Sullivan, Reiter, Hu, Raval)
- the Department of Anesthesiology (Dsida), Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL
- the Division of Pediatric Surgery, Department of Surgery (Sullivan, Petit)
- the Library of Rush Medical Center (Westrick), Rush University Medical Center, Chicago, IL
- the Chemical and Biological Engineering, Northwestern University, Evanston, IL (Dunn)
| | - Richard Dsida
- the Department of Anesthesiology (Dsida), Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL
| | - Mehul V Raval
- From the Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine (Sullivan, Reiter, Hu, Raval)
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16
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Reiter AJ, Ingram MCE, Raval MV, Garcia E, Hill M, Aranda A, Chandler NM, Gonzalez R, Born K, Mack S, Lamoshi A, Lipskar AM, Han XY, Fialkowski E, Spencer B, Kulaylat AN, Barde A, Shah AN, Adoumie M, Gross E, Mehl SC, Lopez ME, Polcz V, Mustafa MM, Gander JW, Sullivan TM, Sulkowski JP, Ghani O, Huang EY, Rothstein D, Muenks EP, St. Peter SD, Fisher JC, Levy-Lambert D, Reichl A, Ignacio RC, Slater BJ, Tsao K, Berman L. Postoperative respiratory complications in SARS-CoV-2 positive pediatric patients across 20 United States hospitals: A Cohort Study. J Pediatr Surg 2022:S0022-3468(22)00716-3. [PMID: 36428183 PMCID: PMC9632239 DOI: 10.1016/j.jpedsurg.2022.10.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/20/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Data examining rates of postoperative complications among SARS-CoV-2 positive children are limited. The purpose of this study was to evaluate the impact of symptomatic and asymptomatic SARS-CoV-2 positive status on postoperative respiratory outcomes for children. METHODS This retrospective cohort study included SARS-CoV-2 positive pediatric patients across 20 hospitals who underwent general anesthesia from March to October 2020. The primary outcome was frequency of postoperative respiratory complications, including: high-flow nasal cannula/non invasive ventilation, reintubation, pneumonia, Extracorporeal Membrane Oxygenation (ECMO), and 30-day respiratory-related readmissions or emergency department (ED) visits. Univariate analyses were used to evaluate associations between patient and procedure characteristics and stratified analyses by symptoms were performed examining incidence of complications. RESULTS Of 266 SARS-CoV-2 positive patients, 163 (61.7%) were male, and the median age was 10 years (interquartile range 4-14). The majority of procedures were emergent or urgent (n = 214, 80.5%). The most common procedures were appendectomies (n = 78, 29.3%) and fracture repairs (n = 40,15.0%). 13 patients (4.9%) had preoperative symptoms including cough or dyspnea. 26 patients (9.8%) had postoperative respiratory complications, including 15 requiring high-flow oxygen, 8 with pneumonia, 4 requiring non invasive ventilation, 3 respiratory ED visits, and 2 respiratory readmissions. Respiratory complications were more common among symptomatic patients than asymptomatic patients (30.8% vs. 8.7%, p = 0.01). Higher ASA class and comorbidities were also associated with postoperative respiratory complications. CONCLUSIONS Postoperative respiratory complications are less common in asymptomatic versus symptomatic SARS-COV-2 positive children. Relaxation of COVID-19-related restrictions for time-sensitive, non urgent procedures in selected asymptomatic patients may be reasonably considered. Additionally, further research is needed to evaluate the costs and benefits of routine testing for asymptomatic patients. LEVEL OF EVIDENCE Iii, Respiratory complications.
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Affiliation(s)
- Audra J. Reiter
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, 633N. St. Clair St., 20th floor, Chicago, IL 60611, United States,Corresponding author
| | - Martha-Conley E. Ingram
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, 633N. St. Clair St., 20th floor, Chicago, IL 60611, United States
| | - Mehul V. Raval
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, 633N. St. Clair St., 20th floor, Chicago, IL 60611, United States
| | - Elisa Garcia
- Division of Pediatric Surgery, Department of Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston TX, United States
| | - Madelyn Hill
- Division of Pediatric Surgery, Dayton Children's Hospital, Wright State University, Dayton, OH, United States
| | - Arturo Aranda
- Division of Pediatric Surgery, Dayton Children's Hospital, Wright State University, Dayton, OH, United States
| | - Nicole M Chandler
- Division of Pediatric Surgery, Department of Surgery, John's Hopkins All Children's Hospital, St. Petersburg, FL, United States
| | - Raquel Gonzalez
- Division of Pediatric Surgery, Department of Surgery, John's Hopkins All Children's Hospital, St. Petersburg, FL, United States
| | - Kristen Born
- Division of Pediatric Surgery, Department of Surgery, Nemours Children's Hospital - Delaware, Wilmington DE, United States
| | - Shale Mack
- Division of Pediatric Surgery, Department of Surgery, Nemours Children's Hospital - Delaware, Wilmington DE, United States
| | - Abdulraouf Lamoshi
- Department of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY, United States
| | - Aaron M. Lipskar
- Department of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY, United States
| | - Xiao-Yue Han
- Division of Pediatric Surgery, Department of Surgery, OHSU School of Medicine, Doernbecher Children's Hospital, Portland, OR, United States
| | - Elizabeth Fialkowski
- Division of Pediatric Surgery, Department of Surgery, OHSU School of Medicine, Doernbecher Children's Hospital, Portland, OR, United States
| | - Brianna Spencer
- Division of Pediatric Surgery, Department of Surgery, Penn State Children's Hospital, Hershey, PA, United States
| | - Afif N. Kulaylat
- Division of Pediatric Surgery, Department of Surgery, Penn State Children's Hospital, Hershey, PA, United States
| | - Amrene Barde
- Division of Pediatric Surgery, Department of Surgery, Rush University, Chicago, IL, United States
| | - Ami N. Shah
- Division of Pediatric Surgery, Department of Surgery, Rush University, Chicago, IL, United States
| | - Maeva Adoumie
- Division of Pediatric Surgery, Department of Surgery, Stony Brook Children's Hospital, Stony Brook, NY, United States
| | - Erica Gross
- Division of Pediatric Surgery, Department of Surgery, Stony Brook Children's Hospital, Stony Brook, NY, United States
| | - Steven C. Mehl
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston TX, United States
| | - Monica E. Lopez
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, Nashville TN, United States
| | - Valerie Polcz
- Division of Pediatric Surgery, Department of Surgery, UF Health, University of Florida, Gainesville, FL, United States
| | - Moiz M. Mustafa
- Division of Pediatric Surgery, Department of Surgery, UF Health, University of Florida, Gainesville, FL, United States
| | - Jeffrey W. Gander
- Division of Pediatric Surgery, Department of Surgery, UVA Children's Hospital, Charlottesville, VA, United States
| | - Travis M. Sullivan
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital of Richmond at VCU, Richmond VA, United States
| | - Jason P. Sulkowski
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital of Richmond at VCU, Richmond VA, United States
| | - Owais Ghani
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, Nashville TN, United States
| | - Eunice Y. Huang
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, Nashville TN, United States
| | - David Rothstein
- Division of Pediatric Surgery, Department of Surgery, Seattle Children's Hospital, Seattle WA, United States
| | - E. Peter Muenks
- Division of Pediatric Surgery, Department of Surgery, Children's Mercy Kansas City, Kansas City MO, United States
| | - Shawn D. St. Peter
- Division of Pediatric Surgery, Department of Surgery, Children's Mercy Kansas City, Kansas City MO, United States
| | - Jason C. Fisher
- Division of Pediatric Surgery, Department of Surgery, Hassenfeld Children's Hospital at NYU Langone, New York City, NY, United States
| | - Dina Levy-Lambert
- Division of Pediatric Surgery, Department of Surgery, Hassenfeld Children's Hospital at NYU Langone, New York City, NY, United States
| | - Allison Reichl
- Division of Pediatric Surgery, Department of Surgery, Rady Children's Hospital, University of California San Diego School of Medicine, San Diego, CA, United States
| | - Romeo C. Ignacio
- Division of Pediatric Surgery, Department of Surgery, Rady Children's Hospital, University of California San Diego School of Medicine, San Diego, CA, United States
| | - Bethany J. Slater
- Division of Pediatric Surgery, Department of Surgery, Comer Children's Hospital, University of Chicago, Chicago, IL, United States
| | - KuoJen Tsao
- Division of Pediatric Surgery, Department of Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston TX, United States
| | - Loren Berman
- Division of Pediatric Surgery, Department of Surgery, Nemours Children's Hospital - Delaware, Wilmington DE, United States
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Abstract
IMPORTANCE Although children's hospitals (CH) provide a substantial proportion of highly specialized pediatric care in the United States, the value of CH compared with non-children's hospitals (NCH) for routine surgical procedures is unknown. OBJECTIVE To examine the value of CH for routine surgical procedures by assessing clinical outcomes and payment data. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study examined pediatric patients undergoing 1 of 13 commonly performed surgical procedures between 2010 and 2015 with 90-day follow-up using administrative data from the Health Care Cost Institute. Data analysis was conducted from July 2019 to December 2021. EXPOSURES The primary exposure was tier of CH status, defined using self-reported pediatric services, affiliation with pediatric focused programs, and validated based on proportion of pediatric admissions. MAIN OUTCOMES AND MEASURES Payments for common surgical procedures from private insurers and overall complication and readmission rates at 30, 60, and 90 days. RESULTS There were 368 220 pediatric patients who underwent one of the surgical procedures of interest; 220 899 (60.0%) of the patients were male; 118 977 (32.3%) had their procedure at freestanding CH (CH-A), 75 256 (20.4%) at CH attached to an adult hospital (CH-B), and 173 987 (47.3%) at NCH. The mean (SD) payment for all procedures at CH-A was $6533.56 ($6399.97), $5847.50 ($4947.47) at CH-B, and $5034.25 ($4787.07) at NCH. The mean (SD) overall complication rate was 0.004 (0.06) at CH-A, 0.01 (0.07) at CH-B, and 0.003 (0.06) at NCH. Readmission rates at 30, 60, and 90 days were similar across all hospital types. After adjusting for zip code, year, surgery, surgery setting, and observable patient, hospital, and county characteristics, the estimated payments for inpatient common procedures were 39% higher at CH-A than at NCH. Payments for outpatient common procedures were 34% higher at CH-A than at NCH. CONCLUSIONS AND RELEVANCE In this cohort study, children who underwent common surgical procedures had equivalent clinical outcomes at CH and NCH but the procedures were associated with higher payments and, thus, overall lower value care. To ensure delivery of optimal value to patients and payers, more research is needed to evaluate mechanisms to ensure access, decrease costs, and improve value at both CH and NCH.
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Affiliation(s)
- Mehul V. Raval
- Department of Surgery and Pediatrics, Surgical Outcomes and Quality Improvement Center, Center for Healthcare Studies, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Audra J. Reiter
- Department of Surgery and Pediatrics, Surgical Outcomes and Quality Improvement Center, Center for Healthcare Studies, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
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Hall BJ, Reiter AJ, Englum BR, Rothman JA, Rice HE. Long‐term hematologic and clinical outcomes of splenectomy in children with hereditary spherocytosis and sickle cell disease. Pediatr Blood Cancer 2020; 67. [PMID: 37132000 PMCID: PMC10151035 DOI: 10.1002/pbc.28290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Total splenectomy (TS) and partial splenectomy (PS) are used for children with congenital hemolytic anemia (CHA), although the long-term outcomes of these procedures are poorly defined. This report describes long-term outcomes of children with CHA requiring TS or PS. Procedure We collected data from children ages 2-17 with hereditary spherocytosis (HS) or sickle cell disease (SCD) requiring TS or PS from 1996 to 2016 from 14 sites in the Splenectomy in Congenital Hemolytic Anemia (SICHA) consortium using a prospective, observational patient registry. We summarized hematologic outcomes, clinical outcomes, and adverse events to 5 years after surgery. Hematologic outcomes were compared using mixed effects modeling. Results Over the study period, 110 children with HS and 97 children with SCD underwent TS or PS. From preoperatively compared to postoperatively, children with HS increased their mean hemoglobin level by 3.4 g/dL, decreased their mean reticulocyte percentage by 6.7%, and decreased their mean bilirubin by 2.4mg/dL. Hematologic improvements and improved clinical outcomes were sustained over 5 years of follow-up. For children with SCD, there was no change in hemoglobin after PS or TS following surgery, although all clinical outcomes were improved. Over 5 years, there was one child with HS and 5 children with SCD who developed post-splenectomy sepsis. Conclusions For children with HS, there are excellent long-term hematologic and clinical outcomes following either PS or TS. Although hemoglobin levels do not change after TS or PS in SCD, the long-term clinical outcomes for children with SCD are favorable.
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Affiliation(s)
- Bria J. Hall
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Audra J. Reiter
- Department of Surgery, Northwestern Memorial Hospital, Chicago, IL
| | - Brian R. Englum
- Department of Surgery, University of Maryland, Baltimore, MD
| | | | - Henry E. Rice
- Department of Surgery, Duke University School of Medicine, Durham, NC
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Reiter AJ, Schlottmann F, Kajombo C, Gallaher J, Charles AG. Surgical Outcomes of Acute Appendicitis in High- Middle- and Low-Income Countries. Am Surg 2019; 85:e97-e99. [PMID: 30819316] [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: 06/09/2023]
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Schmidt JL, Tweten DJ, Badachhape AA, Reiter AJ, Okamoto RJ, Garbow JR, Bayly PV. Measurement of anisotropic mechanical properties in porcine brain white matter ex vivo using magnetic resonance elastography. J Mech Behav Biomed Mater 2017; 79:30-37. [PMID: 29253729 DOI: 10.1016/j.jmbbm.2017.11.045] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [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: 08/10/2017] [Revised: 11/12/2017] [Accepted: 11/27/2017] [Indexed: 02/05/2023]
Abstract
The mechanical properties of brain tissue, particularly those of white matter (WM), need to be characterized accurately for use in finite element (FE) models of brain biomechanics and traumatic brain injury (TBI). Magnetic resonance elastography (MRE) is a powerful tool for non-invasive estimation of the mechanical properties of soft tissues. While several studies involving direct mechanical tests of brain tissue have shown mechanical anisotropy, most MRE studies of brain tissue assume an isotropic model. In this study, an incompressible transversely isotropic (TI) material model parameterized by minimum shear modulus (μ2), shear anisotropy parameter (ϕ), and tensile anisotropy parameter (ζ) is applied to analyze MRE measurements of ex vivo porcine white matter (WM) brain tissue. To characterize shear anisotropy, "slow" (pure transverse) shear waves were propagated at 100, 200 and 300Hz through sections of ex vivo brain tissue including both WM and gray matter (GM). Shear waves were found to propagate with elliptical fronts, consistent with TI material behavior. Shear wave fields were also analyzed within regions of interest (ROI) to find local shear wavelengths parallel and perpendicular to fiber orientation. FE simulations of a TI material with a range of plausible shear modulus (μ2) and shear anisotropy parameters (ϕ) were run and the results were analyzed in the same fashion as the experimental case. Parameters of the FE simulations which most closely matched each experiment were taken to represent the mechanical properties of that particular sample. Using this approach, WM in the ex vivo porcine brain was found to be mildly anisotropic in shear with estimates of minimum shear modulus (actuation frequencies listed in parenthesis): μ2= 1.04 ± 0.12 kPa (at 100Hz), μ2= 1.94 ± 0.29 kPa (at 200Hz), and μ2= 2.88 ± 0.34 kPa (at 300Hz) and corresponding shear anisotropy factors of ϕ= 0.27 ± 0.09 (at 100Hz), ϕ= 0.29 ± 0.14 (at 200Hz) and ϕ= 0.34 ± 0.13 (at 300Hz). Future MRE studies will focus on tensile anisotropy, which will require both slow and fast shear waves for accurate estimation.
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Affiliation(s)
- J L Schmidt
- Mechanical Engineering and Materials Science, Washington University in Saint Louis, MO 63130, United States.
| | - D J Tweten
- Mechanical Engineering and Materials Science, Washington University in Saint Louis, MO 63130, United States
| | - A A Badachhape
- Biomedical Engineering, Washington University in Saint Louis, MO 63130, United States
| | - A J Reiter
- Mechanical Engineering and Materials Science, Washington University in Saint Louis, MO 63130, United States
| | - R J Okamoto
- Mechanical Engineering and Materials Science, Washington University in Saint Louis, MO 63130, United States
| | - J R Garbow
- Radiology, Washington University in Saint Louis, MO 63130, United States
| | - P V Bayly
- Mechanical Engineering and Materials Science, Washington University in Saint Louis, MO 63130, United States; Biomedical Engineering, Washington University in Saint Louis, MO 63130, United States
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Hollander MM, Reiter AJ, Horner WH, Cooper AJ. Conversion of canavanine to alpha-keto-gamma-guanidinooxybutyrate and to vinylglyoxylate and 2-hydroxyguanidine. Arch Biochem Biophys 1989; 270:698-713. [PMID: 2565101 DOI: 10.1016/0003-9861(89)90553-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
It was observed previously that hydroxyguanidine is formed in the reaction of canavanine(2-amino-4-guanidinooxybutanoate) with amino acid oxidases. The present work shows that hydroxyguanidine is formed by a nonenzymatic beta,gamma-elimination reaction following enzymatic oxidation at the alpha-C and that the abstraction of the beta-H is general-base catalyzed. The elimination reaction requires the presence in the alpha-position of an anion-stabilizing group--the protonated imino group (iminium ion group) or the carbonyl group. The iminium ion group is more activating than the carbonyl group. Elimination is further facilitated by protonation of the guanidinooxy group. The other product formed in the elimination reaction was identified as vinylglyoxylate (2-oxo-3-butenoate), a very highly electrophilic substance. The product resulting from hydrolysis following oxidation was identified as alpha-keto-gamma-guanidinooxybutyrate (ketocanavanine). The ratio of hydroxyguanidine to ketocanavanine depended upon the concentration and degree of basicity of the basic catalyst and on pH. In the presence of semicarbazide, the elimination reaction was prevented because the imino group in the semicarbazone derivative of ketocanavanine is not significantly protonated. Incubation of canavanine with 5'-deoxypyridoxal also yielded hydroxyguanidine. Since the elimination reactions take place under mild conditions, they may occur in vivo following oxidation at the alpha-C of L-canavanine (ingested or formed endogenously) or of other amino acids with a good leaving group in the gamma-position (e.g., S-adenosylmethionine, methionine sulfoximine, homocyst(e)ine, or cysteine-homocysteine mixed disulfide) by an L-amino acid oxidase, a transaminase, or a dehydrogenase. Therefore, vinylglyoxylate may be a normal metabolite in mammals which at elevated concentrations may contribute to the in vivo toxicity of canavanine and of some of the other above-mentioned amino acids.
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Affiliation(s)
- M M Hollander
- Department of Biochemistry, Georgetown University Medical Center, Washington, D.C. 20007
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