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Hwang CK, Matta R, Woolstenhulme J, Britt AK, Schaeffer AJ, Zakaluzny SA, Kleber KT, Sheikali A, Flynn-O'Brien KT, Sandilos G, Shimonovich S, Fox N, Hess AB, Zeller KA, Koberlein GC, Levy BE, Draus JM, Sacks M, Chen C, Luo-Owen X, Stephens JR, Shah M, Burks F, Moses RA, Rezaee ME, Vemulakonda VM, Halstead NV, LaCouture HM, Nabavizadeh B, Copp H, Breyer B, Schwartz I, Feia K, Pagliara T, Shi J, Neuville P, Hagedorn JC. Management of pediatric renal trauma: Results from the American Association for Surgery and Trauma Multi-Institutional Pediatric Acute Renal Trauma Study. J Trauma Acute Care Surg 2024; 96:805-812. [PMID: 37966460 DOI: 10.1097/ta.0000000000004198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
BACKGROUND Pediatric renal trauma is rare and lacks sufficient population-specific data to generate evidence-based management guidelines. A nonoperative approach is preferred and has been shown to be safe. However, bleeding risk assessment and management of collecting system injury are not well understood. We introduce the Multi-institutional Pediatric Acute Renal Trauma Study (Mi-PARTS), a retrospective cohort study designed to address these questions. This article describes the demographics and contemporary management of pediatric renal trauma at Level I trauma centers in the United States. METHODS Retrospective data were collected at 13 participating Level I trauma centers on pediatric patients presenting with renal trauma between 2010 and 2019. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Descriptive statistics were used to report on demographics, acute management, and outcomes. RESULTS In total, 1,216 cases were included in this study. Of all patients, 67.2% were male, and 93.8% had a blunt injury mechanism. In addition, 29.3% had isolated renal injuries, and 65.6% were high-grade (American Association for the Surgery of Trauma Grades III-V) injuries. The mean Injury Severity Score was 20.5. Most patients were managed nonoperatively (86.4%), and 3.9% had an open surgical intervention, including 2.7% having nephrectomy. Angioembolization was performed in 0.9%. Collecting system intervention was performed in 7.9%. Overall mortality was 3.3% and was only observed in patients with multiple injuries. The rate of avoidable transfer was 28.2%. CONCLUSION The management and outcomes of pediatric renal trauma lack data to inform evidence-based guidelines. Nonoperative management of bleeding following renal injury is a well-established practice. Intervention for renal trauma is rare. Our findings reinforce differences from the adult population and highlights opportunities for further investigation. With data made available through Mi-PARTS, we aimed to answer pediatric specific questions, including a pediatric-specific bleeding risk nomogram, and better understanding indications for interventions for collecting system injuries. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Catalina K Hwang
- From the Department of Urology (C.K.H.), University of Washington, Seattle, Washington; Division of Urology, Department of Surgery (R.M.), School of Medicine (J.W.), and Division of Urology, Department of Surgery (R.M., J.W., A.K.B., A.J.S.), Intermountain Primary Children's Hospital, University of Utah, Salt Lake City, Utah; Department of Surgery (S.A.Z., K.T.K.), University of California Davis, Sacramento, California; Medical College of Wisconsin, School of Medicine (A.S.); Department of Surgery (K.T.F.-O'.B.), Medical College of Wisconsin and Children's Wisconsin, Milwaukee, Wisconsin; Division of Trauma, Department of General Surgery (G.S., S.S., N.F.), Cooper University Health Care, Camden, New Jersey; Department of Surgery (A.B.H.), WakeMed, Raleigh; Department of General Surgery (K.A.Z.), Section of Pediatric Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Radiology (G.C.K.), Nemours Children's Hospital, Orlando, Florida; Division of Pediatric Surgery, Department of Surgery (B.E.L.), University of Kentucky, Lexington, Kentucky; Nemours Children's Health (J.M.D.), Jacksonville, Florida; Department of Surgery (M.S.), Department of Urology (C.C.), and Department of Surgery (X.L.-O.), Loma Linda University Medical Center and Children's Hospital, Loma Linda, California; Department of Urology (J.R.S., M.S., F.B.), Beaumont Health-Royal Oak, Royal Oak, Michigan; Department of Surgery (R.A.M., M.E.R.), Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Pediatric Urology Research Enterprise, Department of Pediatric Urology (V.M.V., N.V.H., H.M.L.), Children's Hospital Colorado; Division of Urology, Department of Surgery (V.M.V., N.V.H., H.M.L.), University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado; Department of Urology (B.N.), Cornell University; Department of Urology (H.C., B.B.), University of California San Francisco, San Francisco, California; Division of Urology (I.S., K.F., T.P.), Hennepin Healthcare, Minneapolis, Minnesota; Harborview Injury Prevention and Research Center (J.S.); and Department of Urology (P.N., J.C.H.), University of Washington, Seattle, Washington
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Levy BE, Mangino AA, Castle JT, Stephens WA, McDonald HG, Patel JA, Beck SJ, Bhakta AS. Effect of Medicaid expansion on inflammatory bowel disease and healthcare utilization. Am J Surg 2024:S0002-9610(24)00017-5. [PMID: 38281872 DOI: 10.1016/j.amjsurg.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 01/08/2024] [Accepted: 01/17/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Kentucky was among the first to adopt Medicaid expansion, resulting in reducing uninsured rates from 14.3% to 6.4%. We hypothesize that Medicaid expansion resulted in increased elective healthcare utilization and reductions in emergency treatments by patients suffering Inflammatory Bowel Disease (IBD). METHODS The Hospital Inpatient Discharge and Outpatient Services Database (HIDOSD) identified all encounters related to IBD from 2009 to 2020 in Kentucky. Several demographic variables were compared in pre- and post-Medicaid expansion adoption. RESULTS Our study analyzed 3386 pre-expansion and 24,255 post-expansion encounters for IBD patients. Results showed that hospitalization rates dropped (47.7%-8.4%), outpatient visits increased (52.3%-91.6%) and Emergency visits decreased (36.7%-11.4%). Admission following a clinical referral similarly increased with a corresponding drop in emergency room admissions. Hospital costs and lengths of stay also dropped following Medicaid expansion. CONCLUSION In the IBD population, Medicaid expansion improved access to preventative care, reduced hospital costs by decreasing emergency care, and increased elective care pathways.
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Affiliation(s)
- Brittany E Levy
- University of Kentucky Department of Surgery, 780 Rose Street, Lexington, KY, 40536, USA.
| | - Anthony A Mangino
- University of Kentucky Department of Biostatistics, 111 Washington Ave, Lexington, KY, 40536, USA.
| | - Jennifer T Castle
- University of Kentucky Department of Surgery, 780 Rose Street, Lexington, KY, 40536, USA.
| | - Wesley A Stephens
- University of Kentucky Department of Surgery, 780 Rose Street, Lexington, KY, 40536, USA.
| | - Hannah G McDonald
- University of Kentucky Department of Surgery, 780 Rose Street, Lexington, KY, 40536, USA.
| | - Jitesh A Patel
- University of Kentucky Division of Colorectal Surgery, 780 Rose Street, Lexington, KY 40536, USA.
| | - Sandra J Beck
- University of Kentucky Division of Colorectal Surgery, 780 Rose Street, Lexington, KY 40536, USA.
| | - Avinash S Bhakta
- University of Kentucky Division of Colorectal Surgery, 780 Rose Street, Lexington, KY 40536, USA.
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Levy BE, Quattrone M, Castle JT, Doud AN, Draus JM, Worhunsky DJ. Injury Pattern and Outcomes Following All-Terrain Vehicle Accidents in Kentucky Children: A Retrospective Study. Am Surg 2023; 89:5874-5880. [PMID: 37203181 DOI: 10.1177/00031348231173955] [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: 05/20/2023]
Abstract
PURPOSE All-terrain vehicles (ATVs) pose a significant risk for morbidity and mortality amongst children. We hypothesize that current vague legislation regarding helmet use impacts injury patterns and outcomes in pediatric ATV accidents. METHODS The institutional trauma registry was queried for pediatric patients involved in ATV accidents from 2006 to 2019. Patient demographics and helmet wearing status were identified in addition to patient outcomes, such as injury pattern, injury severity score, mortality, length of stay, and discharge disposition. These elements were analyzed for statistical significance. RESULTS 720 patients presented during the study period, which were predominantly male (71%, n = 511) and less than 16 years old (76%, n = 543). Most patients were not wearing a helmet (82%, n = 589) at time of injury. Notably, there were 7 fatalities. A lack of helmet use is positively associated with head injury (42% vs 23%, P < .01), intracranial hemorrhage (15% vs 7%, P = .03), and associated with lower Glasgow Coma Scale (13.9 vs 14.4, P < .01). Children 16 years and older were least likely to wear a helmet and most likely to incur injuries. Patients over 16 years had longer lengths of stay, higher mortality, and higher need for rehabilitation. CONCLUSION Not wearing a helmet is directly correlated with injury severity and concerning rates of head injury. Children 16 years and older are at greatest risk for injury, but younger children are still at risk. Stricter state laws regarding helmet use are necessary to reduce pediatric ATV-related injury burden. LEVEL OF EVIDENCE level III retrospective comparative study.
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Affiliation(s)
- Brittany E Levy
- Department of Pediatric Surgery, University of KentuckyChildren's Hospital, Lexington, KY, USA
| | - McKell Quattrone
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Jennifer T Castle
- Department of Pediatric Surgery, University of KentuckyChildren's Hospital, Lexington, KY, USA
| | - Andrea N Doud
- Department of Pediatric Surgery, University of KentuckyChildren's Hospital, Lexington, KY, USA
| | - John M Draus
- Department of Surgery, Nemours Children's Health, Jacksonville, FL, USA
| | - David J Worhunsky
- Department of Pediatric Surgery, University of KentuckyChildren's Hospital, Lexington, KY, USA
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Castle JT, Levy BE, Wilt WS, Draus JM. Reducing Emergency Department Length of Stay in Critically Injured Pediatric Trauma Patients: A Quality Improvement Initiative. Am Surg 2023; 89:4367-4372. [PMID: 35768184 DOI: 10.1177/00031348221111514] [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: 11/17/2022]
Abstract
BACKGROUND Efficient transfer of adult trauma patients to the intensive care unit (ICU) is associated with decreased emergency department (ED) length of stay (ED LOS) and improved patient outcomes. While well studied in adults, quality improvement (QI) initiatives focused on the rapid transfer of pediatric trauma patients are lacking. We report the effect of institutional system changes directed at expediting the transfer of pediatric trauma patients to the pediatric ICU (PICU). METHODS This initiative commenced in 2013. Preliminary data regarding ED LOS for pediatric trauma patients were collected from January through December 2012 as the pre-implementation cohort. Using the plan-do-study-act (PDSA) framework of QI, the first PDSA cycle was implemented in January 2013. In subsequent PDSA cycles, we implemented the mandatory attendance of the PICU charge nurse and the PICU attending physician to all highest-level pediatric trauma activations. Throughout, ED LOS was collected and mapped on a run chart. ED LOS and variance were compared between all cycles of implementation. RESULTS One hundred and fifty-one pediatric patients arrived or were upgraded to the highest-level pediatric trauma activation and admitted to the PICU from 2012 through 2019. We observed a decrease in median ED LOS of 105 minutes between the pre- and post-implementation groups. With each PDSA cycle, we observed a decrease in median ED LOS and variation. CONCLUSION The inclusion of the PICU charge nurse and attending physician at highest-level pediatric trauma activations facilitated more rapid access to the PICU with decreased ED LOS.
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Affiliation(s)
| | - Brittany E Levy
- Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Wesley S Wilt
- Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - John M Draus
- Division of Pediatric Surgery, University of Kentucky, Lexington, KY, USA
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Levy BE, Castle JT, Virodov A, Wilt WS, Bumgardner C, Brim T, McAtee E, Schellenberg M, Inaba K, Warriner ZD. Artificial intelligence evaluation of focused assessment with sonography in trauma. J Trauma Acute Care Surg 2023; 95:706-712. [PMID: 37165477 DOI: 10.1097/ta.0000000000004021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND The focused assessment with sonography in trauma (FAST) is a widely used imaging modality to identify the location of life-threatening hemorrhage in a hemodynamically unstable trauma patient. This study evaluates the role of artificial intelligence in interpretation of the FAST examination abdominal views, as it pertains to adequacy of the view and accuracy of fluid survey positivity. METHODS Focused assessment with sonography for trauma examination images from 2015 to 2022, from trauma activations, were acquired from a quaternary care level 1 trauma center with more than 3,500 adult trauma evaluations, annually. Images pertaining to the right upper quadrant and left upper quadrant views were obtained and read by a surgeon or radiologist. Positivity was defined as fluid present in the hepatorenal or splenorenal fossa, while adequacy was defined by the presence of both the liver and kidney or the spleen and kidney for the right upper quadrant or left upper quadrant views, respectively. Four convolutional neural network architecture models (DenseNet121, InceptionV3, ResNet50, Vgg11bn) were evaluated. RESULTS A total of 6,608 images, representing 109 cases were included for analysis within the "adequate" and "positive" data sets. The models relayed 88.7% accuracy, 83.3% sensitivity, and 93.6% specificity for the adequate test cohort, while the positive cohort conferred 98.0% accuracy, 89.6% sensitivity, and 100.0% specificity against similar models. Augmentation improved the accuracy and sensitivity of the positive models to 95.1% accurate and 94.0% sensitive. DenseNet121 demonstrated the best accuracy across tasks. CONCLUSION Artificial intelligence can detect positivity and adequacy of FAST examinations with 94% and 97% accuracy, aiding in the standardization of care delivery with minimal expert clinician input. Artificial intelligence is a feasible modality to improve patient care imaging interpretation accuracy and should be pursued as a point-of-care clinical decision-making tool. LEVEL OF EVIDENCE Diagnostic Test/Criteria; Level III.
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Affiliation(s)
- Brittany E Levy
- From the Department of Surgery (B.E.L., J.T.C., W.S.W., E.M.), Institute for Biomedical Informatics (A.V.), Department of Pathology (C.B.), and Department of Radiology (T.B.), University of Kentucky, Lexington, Kentucky; Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery (M.S., K.I.), University of Southern California, Los Angeles, California; and Division of Trauma Critical Care and Acute Care Surgery, Department of Surgery (Z.D.W.), University of Kentucky, Lexington, Kentucky
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Levy BE, Wilt WS, Lantz S, Ballert E, Harris A. Standardization and Visualization of the Surgical Time-Out. J Patient Saf 2023; 19:453-459. [PMID: 37729643 DOI: 10.1097/pts.0000000000001156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
INTRODUCTION The time-out (TO) can prevent adverse events but is subject to TO engagement. We hypothesize transforming the TO to an auditable, active process will improve compliance and engagement. METHODS The passive nature of the current TO was identified as a potential safety issue on staff patient safety culture surveys. Subsequently, the Time Out Engagement and Standardization quality improvement initiative was developed and included a whiteboard checklist to be used in the operating room. As a baseline, 11 TOs were audited concerning engagement and content. Key stakeholders were engaged to determine potential interventions. A TO consisting of 15 elements using a TO whiteboard checklist with role-specific objectives was developed. Plan, Do, Study, Act cycles commenced. After implementation, 17 TOs were audited based on engagement and content. RESULTS Before intervention, engagement varied with nurse participating in 100% compared with anesthesia provider or surgeon participating in 18%. No TO included all 15 elements and only 13% of elements included in all TOs. After implementation of Time Out Engagement and Standardization, anesthesia and surgeon who participated increased to 100% and 76.5%, respectively (P < 0.0001, P = 0.006). The 15 standardized elements of the TO were discussed in 90% of cases. Overall, preintervention 88 elements (57.1%) were completed across all TOs, while postintervention 243 elements (98.8%) were completed (P < 0.001). CONCLUSIONS We identified a need for increased engagement of the TO based on staff concerns, which were verified through auditing. Implementation of a team-driven intervention and 3 rapid Plan, Do, Study, Act cycles led to measurable improvement of the surgical TO.
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Affiliation(s)
| | - Wesley S Wilt
- From the Department of Surgery, University of Kentucky
| | - Sherry Lantz
- Department of Surgery, Lexington Veteran's Affairs Medical Center
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Castle JT, Levy BE, Mangino AA, McDonald HG, McAtee E, Patel JA, Evers BM, Bhakta AS. Impact of the Affordable Care Act on Providing Equitable Healthcare Access for IBD in the Kentucky Appalachian Region. Dis Colon Rectum 2023; 66:1273-1281. [PMID: 37399124 PMCID: PMC10527721 DOI: 10.1097/dcr.0000000000002942] [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] [Indexed: 07/05/2023]
Abstract
BACKGROUND Medicaid expansion improved insurance coverage for patients with chronic conditions and low income. The effect of Medicaid expansion on patients with IBD from high-poverty communities is unknown. OBJECTIVE This study aimed to evaluate the impact of Medicaid expansion in Kentucky on care for patients with IBD from the Eastern Kentucky Appalachian community, a historically impoverished area. DESIGN This study was a retrospective, descriptive, and ecological study. SETTINGS This study was conducted in Kentucky using the Hospital Inpatient Discharge and Outpatient Services Database. PATIENTS All encounters for IBD care for 2009-2020 for patients from the Eastern Kentucky Appalachian region were included. MAIN OUTCOME MEASURES The primary outcomes measured were proportions of inpatient and emergency encounters, total hospital charge, and hospital length of stay. RESULTS Eight hundred twenty-five preexpansion and 5726 postexpansion encounters were identified. Postexpansion demonstrated decreases in the uninsured (9.2%-1.0%; p < 0.001), inpatient encounters (42.7%-8.1%; p < 0.001), emergency admissions (36.7%-12.3%; p < 0.001), admissions from the emergency department (8.0%-0.2%; p < 0.001), median total hospital charge ($7080-$3260; p < 0.001), and median total hospital length of stay (4-3 days; p < 0.001). Similarly, postexpansion demonstrated increases in Medicaid coverage (18.8%-27.7%; p < 0.001), outpatient encounters (57.3%-91.9%; p < 0.001), elective admissions (46.9%-76.2%; p < 0.001), admissions from the clinic (78.4%-90.2%; p < 0.001), and discharges to home (43.8%-88.2%; p < 0.001). LIMITATIONS This study is subject to the limitations inherent in being retrospective and using a partially de-identified database. CONCLUSION This study is the first to demonstrate the changes in trends in care after Medicaid expansion for patients with IBD in the Commonwealth of Kentucky, especially Appalachian Kentucky, showing significantly increased outpatient care utilization, reduced emergency department encounters, and decreased length of stays. IMPACTO DE LA LEY DEL CUIDADO DE SALUD A BAJO PRECIO EN LA PROVISIN DE ACCESO EQUITATIVO A LA ATENCIN MDICA PARA LA ENFERMEDAD INFLAMATORIA INTESTINAL EN LA REGIN DE LOS APALACHES DE KENTUCKY ANTECEDENTES: La expansión de Medicaid mejoró la cobertura de seguro para pacientes con enfermedades crónicas y bajos ingresos. Se desconoce el efecto de la expansión de Medicaid en pacientes con enfermedad inflamatoria intestinal de comunidades de alta pobreza.OBJETIVO: Este estudio tuvo como objetivo evaluar el impacto de la expansión de Medicaid en Kentucky en la atención de pacientes con enfermedad inflamatoria intestinal de la comunidad de los Apalaches del este de Kentucky, un área históricamente empobrecida.DISEÑO: Este estudio fue un estudio retrospectivo, descriptivo, ecológico.ESCENARIO: Este estudio se realizó en Kentucky utilizando la base de datos de servicios ambulatorios y de alta hospitalaria en pacientes hospitalizados.PACIENTES: Se incluyeron todos los encuentros para la atención de la enfermedad inflamatoria intestinal de 2009-2020 para pacientes de la región de los Apalaches del este de Kentucky.MEDIDAS DE RESULTADO PRINCIPALES: Los resultados primarios medidos fueron proporciones de encuentros de pacientes hospitalizados y de emergencia, cargo hospitalario total y duración de la estancia hospitalaria.RESULTADOS: Se identificaron 825 encuentros previos a la expansión y 5726 posteriores a la expansión. La posexpansión demostró disminuciones en los no asegurados (9.2% a 1.0%, p < 0.001), encuentros de pacientes hospitalizados (42.7% a 8.1%, p < 0.001), admisiones de emergencia (36.7% a 12.3%, p < 0,001), admisiones desde el servicio de urgencias (8.0% a 0.2%, p < 0.001), la mediana de los gastos hospitalarios totales ($7080 a $3260, p < 0.001) y la mediana de la estancia hospitalaria total (4 a 3 días, p < 0.001). De manera similar, la cobertura de Medicaid (18.8% a 27.7%, p < 0.001), consultas ambulatorias (57.3% a 91.9%, p < 0.001), admisiones electivas (46.9% a 76.2%, p < 0.001), admisiones desde la clínica (78.4% al 90.2%, p < 0.001), y las altas domiciliarias (43.8% al 88.2%, p < 0.001) aumentaron después de la expansión.LIMITACIONES: Este estudio está sujeto a las limitaciones inherentes de ser retrospectivo y utilizar una base de datos parcialmente desidentificada.CONCLUSIONES: Este estudio es el primero en demostrar los cambios en las tendencias en la atención después de la expansión de Medicaid para pacientes con enfermedad inflamatoria intestinal en el Estado de Kentucky, especialmente en los Apalaches de Kentucky, mostrando un aumento significativo en la utilización de la atención ambulatoria, visitas reducidas al departamento de emergencias y menor duración de la estancia hospitalaria. (Traducción-Dr. Jorge Silva Velazco ).
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Affiliation(s)
- Jennifer T. Castle
- Department of Surgery, University of Kentucky, Lexington, Kentucky
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Brittany E. Levy
- Department of Surgery, University of Kentucky, Lexington, Kentucky
| | - Anthony A. Mangino
- Department of Biostatistics, University of Kentucky, Lexington, Kentucky
| | - Hannah G. McDonald
- Department of Surgery, University of Kentucky, Lexington, Kentucky
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Erin McAtee
- Department of Surgery, University of Kentucky, Lexington, Kentucky
| | - Jitesh A. Patel
- Department of Surgery, University of Kentucky, Lexington, Kentucky
- Division of Colorectal Surgery, University of Kentucky, Lexington, Kentucky
| | - B. Mark Evers
- Department of Surgery, University of Kentucky, Lexington, Kentucky
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Avinash S. Bhakta
- Department of Surgery, University of Kentucky, Lexington, Kentucky
- Division of Colorectal Surgery, University of Kentucky, Lexington, Kentucky
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Levy BE, Castle JT, Wilt WS, Fedder K, Riser J, Burke ED, Hourigan JS, Bhakta AS. Improving physician documentation for malnutrition: A sustainable quality improvement initiative. PLoS One 2023; 18:e0287124. [PMID: 37561733 PMCID: PMC10414681 DOI: 10.1371/journal.pone.0287124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 05/31/2023] [Indexed: 08/12/2023] Open
Abstract
This study compares documentation and reimbursement rates before and after provider education in nutritional status documentation. Our study aimed to evaluate accurate documentation of nutrition status between registered dietitian nutritionists and licensed independent practitioners before and after the implementation of a dietitian-led Nutrition-Focused Physical Exam intervention at an academic medical center in the southeastern US. ICD-10 codes identified patients from 10/1/2016-1/31/2018 with malnutrition. The percentage of patients with an appropriate diagnosis of malnutrition and reimbursement outcomes attributed to malnutrition documentation were calculated up to 24 months post-intervention. 528 patients were analyzed. Pre-intervention, 8.64% of patients had accurate documentation compared to 46.3% post-intervention. Post-intervention, 68 encounters coded for malnutrition resulted in an estimated $571,281 of additional reimbursement, sustained at 6, 12, 18, and 24 months. A multidisciplinary intervention improved physician documentation accuracy of malnutrition status and increased reimbursement rates.
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Affiliation(s)
- Brittany E. Levy
- Graduate Medical Education, General Surgery Residency Program, University of Kentucky College of Medicine, Lexington, Kentucky, United States of America
| | - Jennifer T. Castle
- Graduate Medical Education, General Surgery Residency Program, University of Kentucky College of Medicine, Lexington, Kentucky, United States of America
| | - Wesley S. Wilt
- Graduate Medical Education, General Surgery Residency Program, University of Kentucky College of Medicine, Lexington, Kentucky, United States of America
| | - Kelly Fedder
- Department of Clinical Nutrition, Center for Health Services Research, University of Kentucky College of Health Sciences, Lexington, Kentucky, United States of America
| | - Jeremy Riser
- Department of Clinical Nutrition, Center for Health Services Research, University of Kentucky College of Health Sciences, Lexington, Kentucky, United States of America
| | - Erin D. Burke
- Division of Colorectal Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky, United States of America
| | - Jon S. Hourigan
- Division of Colorectal Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky, United States of America
| | - Avinash S. Bhakta
- Division of Colorectal Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky, United States of America
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Castle JT, Levy BE, Allison DB, Rodeberg DA, Rellinger EJ. Pediatric Rhabdomyosarcomas of the Genitourinary Tract. Cancers (Basel) 2023; 15:2864. [PMID: 37345202 PMCID: PMC10216134 DOI: 10.3390/cancers15102864] [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: 05/01/2023] [Revised: 05/19/2023] [Accepted: 05/20/2023] [Indexed: 06/23/2023] Open
Abstract
Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in the pediatric and adolescent population, with 350 new cases diagnosed each year. While they can develop anywhere in the body, the genitourinary tract is the second most common primary location for an RMS to develop. Overall survival has improved through the increased use of protocols and multidisciplinary approaches. However, the guidelines for management continue to change as systemic and radiation therapeutics advance. Given the relative rarity of this disease compared to other non-solid childhood malignancies, healthcare providers not directly managing RMS may not be familiar with their presentation and updated management. This review aims to provide foundational knowledge of the management of RMSs with an emphasis on specific management paradigms for those arising from the genitourinary tract. The genitourinary tract is the second most common location for an RMS to develop but varies greatly in symptomology and survival depending on the organ of origin. As the clinical understanding of these tumors advances, treatment paradigms have evolved. Herein, we describe the breadth of presentations for genitourinary RMSs with diagnostic and treatment management considerations, incorporating the most recently available guidelines and societal consensus recommendations.
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Affiliation(s)
- Jennifer T. Castle
- Department of Surgery, Markey Cancer Center, University of Kentucky, Lexington, KY 40536, USA;
| | - Brittany E. Levy
- Department of Surgery, University of Kentucky, Lexington, KY 40536, USA;
| | - Derek B. Allison
- Department of Pathology and Laboratory Medicine, Department of Urology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536, USA;
| | - David A. Rodeberg
- Department of Surgery, Department of Pediatric Surgery, University of Kentucky, Lexington, KY 40536, USA;
| | - Eric J. Rellinger
- Department of Surgery, Department of Pediatric Surgery, Markey Cancer Center, University of Kentucky, Lexington, KY 40536, USA
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Levy BE, Wilt WS, Johnson J, Wallace H, Ballert E, Newcomb M, Cavatassi W, Harris A. Procedure-Based Telehealth Utilization in General Surgery. Am J Med Qual 2023; 38:154-159. [PMID: 37125671 DOI: 10.1097/jmq.0000000000000122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
The authors hypothesize that standardized telehealth (TH) scheduling processes will improve TH utilization without increasing adverse events. Fifty visits preimplementation and 67 visits postimplementation were audited from June 2021 to January 2022. Both leadership and frontline stakeholders were engaged to identify current workflows and potential interventions targeting outpatient elective procedures. Process mapping outlined current TH scheduling workflows. Outcomes related to TH completion, cost, and TH scheduling were collected after implementation. Preimplementation TH scheduling rate was 32%. The intervention required TH postoperative appointments to be scheduled in clinic at the time of surgery scheduling with TH being the default postsurgical appointment for a standardized list of eligible procedures. Following implementation, 95% of patients undergoing eligible procedures had TH follow-up. This provided improved access to surgical follow-up care, by reducing travel needs to the Veterans Affairs facility. Secondarily, this intervention increased clinic appointment availability and resulted in possible increased revenue for billable visits. Standardizing TH scheduling based on the procedure improves the utilization of TH resulting in improved clinic efficiency and increased revenue, without increasing adverse events.
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Affiliation(s)
- Brittany E Levy
- Department of General Surgery, University of Kentucky, Lexington, KY
| | - Wesley S Wilt
- Department of General Surgery, University of Kentucky, Lexington, KY
| | | | | | - Erik Ballert
- Department of General Surgery, University of Kentucky, Lexington, KY
- Lexington Veteran's Affairs Medical Center, Lexington, KY
| | - Melissa Newcomb
- Department of General Surgery, University of Kentucky, Lexington, KY
- Lexington Veteran's Affairs Medical Center, Lexington, KY
| | - William Cavatassi
- Department of General Surgery, University of Kentucky, Lexington, KY
- Lexington Veteran's Affairs Medical Center, Lexington, KY
| | - Andrew Harris
- Lexington Veteran's Affairs Medical Center, Lexington, KY
- Department of Urology, University of Kentucky, Lexington, KY
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Levy BE, MacDonald M, Bontrager N, Castle JT, Draus JM, Worhunsky DJ. Evaluation of the learning curve for laparoscopic pyloromyotomy. Surg Endosc 2023:10.1007/s00464-023-09962-3. [PMID: 36922426 DOI: 10.1007/s00464-023-09962-3] [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: 11/15/2022] [Accepted: 02/12/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Laparoscopic pyloromyotomy is the preferred surgical management of hypertrophic pyloric stenosis at most centers. We aimed to analyze the learning curve for laparoscopic pyloromyotomy using the experience of five fellowship-trained pediatric surgeons. METHODS A retrospective review of consecutive patients undergoing laparoscopic pyloromyotomy was performed. All cases were performed with general surgery residents. Cumulative sum (CUSUM) analysis for operating time was performed for up to the first 150 consecutive cases for individual surgeons. Outcomes were compared to identify different phases of the learning curve for operative competency. RESULTS A total of 414 patients were included in the analysis as not all surgeons had reached 150 cases at time of analysis. The mean operating time was 29.2 min for all cases across the 5 surgeons. CUSUM analysis for mean operating time revealed three phases of learning: Learning Phase (cases 1-16), Plateau Phase (cases 17-87), and a Proficiency Phase (cases 88-150). The mean operating time during the three phases was 34.1, 29.0, and 28.3 min, respectively (P = 0.005). There were no differences in complications, reoperations, length of stay, or readmissions across the three phases. CONCLUSION Three distinct phases of learning for laparoscopic pyloromyotomy were identified with no differences in outcomes across the phases. The operating time differed only for the Learning Phase, suggesting that some degree of proficiency occurs after 16 cases.
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Affiliation(s)
- Brittany E Levy
- Division of Pediatric Surgery, Department of Surgery, University of Kentucky and Kentucky Children's Hospital, 800 Rose Street, MS463A, Lexington, KY, 40536, USA
| | - Mia MacDonald
- Department of General Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Nicholas Bontrager
- Division of Pediatric Surgery, Department of Surgery, University of Kentucky and Kentucky Children's Hospital, 800 Rose Street, MS463A, Lexington, KY, 40536, USA
| | - Jennifer T Castle
- Division of Pediatric Surgery, Department of Surgery, University of Kentucky and Kentucky Children's Hospital, 800 Rose Street, MS463A, Lexington, KY, 40536, USA
| | - John M Draus
- Department of Surgery, Nemours Children's Health, Jacksonville, FL, USA
| | - David J Worhunsky
- Division of Pediatric Surgery, Department of Surgery, University of Kentucky and Kentucky Children's Hospital, 800 Rose Street, MS463A, Lexington, KY, 40536, USA.
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Levy BE, Wilt WS, Castle JT, McAtee E, Walling SC, Davenport DL, Bhakta A, Patel JA. Surgical Site Infections in Colorectal Resections: What is the Cost? J Surg Res 2023; 283:336-343. [PMID: 36427443 DOI: 10.1016/j.jss.2022.10.076] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 04/12/2022] [Revised: 08/26/2022] [Accepted: 10/15/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Although surgical site infections (SSIs) associated with colectomy are tracked by the National Healthcare Safety Network/Center for Disease Control, untracked codes, mainly related to patients undergoing proctectomy, are not. These untracked codes are performed less often yet they may be at a greater risk of SSI due to their greater complexity. Determining the impact and predictors of SSI are critical in the development of quality improvement initiatives. METHODS Following an institutional review board approval, National Surgery Quality Improvement Program, institutional National Surgery Quality Improvement Program, and financial databases were queried for tracked colorectal resections and untracked colorectal resections (UCR). National data were obtained for January 2019-December 2019, and local procedures were identified between January 2013 and December 2019. Data were analyzed for preoperative SSI predictors, operative characteristics, outcomes, and 30-day postdischarge costs (30dPDC). RESULTS Nationally, 71,705 colorectal resections were identified, and institutionally, 2233 patients were identified. UCR accounted for 7.9% nationally and 11.8% of all colorectal resections institutionally. Tracked colorectal resection patients had a higher incidence of SSI predictors including sepsis, hypoalbuminemia, coagulopathy, hypertension, and American Society of Anesthesiologists class. UCR patients had a higher rate of SSIs [12.9% (P < 0.001), 15.2% (P = 0.064)], readmission, and unplanned return to the operating room. Index hospitalization and 30dPDC were significantly higher in patients experiencing an SSI. CONCLUSIONS SSI was associated with nearly a two-fold increase in index hospitalization costs and six-fold in 30dPDC. These data suggest opportunities to improve hospitalization costs and outcomes for patients undergoing UCR through protocols for SSI reduction and preventing readmissions.
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Affiliation(s)
- Brittany E Levy
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky.
| | - Wesley S Wilt
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Jennifer T Castle
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Erin McAtee
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Samuel C Walling
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Daniel L Davenport
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Avinash Bhakta
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Jitesh A Patel
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
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Levy BE, Castle JT, Ebbitt LM, Kennon C, McAtee E, Davenport DL, Evers BM, Bhakta A. Opioid Use After Colorectal Resection: Identifying Preoperative Risk Factors for Postoperative Use. J Surg Res 2023; 283:296-304. [PMID: 36423479 DOI: 10.1016/j.jss.2022.10.051] [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: 05/24/2022] [Revised: 09/30/2022] [Accepted: 10/17/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Appropriate prescribing practices are imperative to ensure adequate pain control, without excess opioid dispensing across colorectal patients. METHODS National Surgical Quality Improvement Program, Kentucky All Scheduled Prescription Electronic Reporting, and patient charts were queried to complete a retrospective study of elective colorectal resections, performed by a fellowship-trained colorectal surgeon, from January 2013 to December 2020. Opioid use at 14 d and 30 d posthospital discharge converted into morphine milligram equivalents (MMEs) were analyzed and compared across preadmission and inpatient factors. RESULTS One thousand four hundred twenty seven colorectal surgeries including 56.1% (N = 800) partial colectomy, 24.1% (N = 344) low anterior resection, 8.3% (N = 119) abdominoperineal resection, 8.4% (N = 121) sub/total colectomy, and 3.0% (N = 43) total proctocolectomy. Abdominoperineal resection and sub/total colectomy patients had higher 30-day postdischarge MMEs (P < 0.001, P = 0.041). An operative approach did not affect postdischarge MMEs (P = 0.440). Trans abdominal plane blocks do not predict postdischarge MMEs (0.616). Epidural usage provides a 15% increase in postdischarge MMEs (P = 0.020). Age (P < 0.001), smoking (P < 0.001), chronic obstructive pulmonary disease (P = 0.006, < 0.001), dyspnea (P = 0.001, < 0.001), albumin < 3.5 (P = 0.085, 0.010), disseminated cancer (P = 0.018, 0.001), and preadmission MMEs (P < 0.001) predict elevated 14-day and 30-day postdischarge MMEs. CONCLUSIONS We conclude that perioperative analgesic procedures, as enhanced recovery pathway suggests, are neither predictive nor protective of postoperative discharge MMEs in colorectal surgery. Provider should account for preoperative risk factors when prescribing discharge opioid medications. Furthermore, providers should identify appropriate adjunct procedures to improve discharge opioid prescription stewardship.
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Affiliation(s)
- Brittany E Levy
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky
| | - Jennifer T Castle
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky
| | - Laura M Ebbitt
- College of Pharmacy, University of Kentucky, Lexington, Kentucky
| | - Caleb Kennon
- Department of Anesthesiology Residency Program, University of Kentucky, Lexington, Kentucky
| | - Erin McAtee
- Division of UK Healthcare Outcomes and Optimal Patient Services, University of Kentucky, Lexington, Kentucky
| | - Daniel L Davenport
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky; Division of UK Healthcare Outcomes and Optimal Patient Services, University of Kentucky, Lexington, Kentucky
| | - B Mark Evers
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky; Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Avinash Bhakta
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky; Division of Colon and Rectal Surgery, University of Kentucky, Lexington, Kentucky.
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Castle JT, Adatorwovor R, Levy BE, Marcinkowski EF, Merritt A, Stapleton JL, Burke EE. ASO Visual Abstract: Completion Lymph Node Dissection for Melanoma Before and After the Multicenter Selective Lymphadenectomy Trial-II in the USA. Ann Surg Oncol 2023; 30:1194. [PMID: 36417003 DOI: 10.1245/s10434-022-12815-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Jennifer T Castle
- Department of Surgery, College of Medicine, University of Kentucky, Lexington, KY, USA
| | | | - Brittany E Levy
- Department of Surgery, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Emily F Marcinkowski
- Department of Surgery, College of Medicine, University of Kentucky, Lexington, KY, USA
- Division of Surgical Oncology, University of Kentucky, Lexington, KY, USA
| | - Allison Merritt
- Department of Health, Behavior and Society, University of Kentucky, Lexington, KY, USA
| | - Jerod L Stapleton
- Department of Biostatistics, University of Kentucky, Lexington, KY, USA
| | - Erin E Burke
- Department of Surgery, College of Medicine, University of Kentucky, Lexington, KY, USA.
- Division of Surgical Oncology, University of Kentucky, Lexington, KY, USA.
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Castle JT, Adatorwovor R, Levy BE, Marcinkowski EF, Merritt A, Stapleton JL, Burke EE. Completion Lymph Node Dissection for Melanoma Before and After the Multicenter Selective Lymphadenectomy Trial-II in the United States. Ann Surg Oncol 2023; 30:1184-1193. [PMID: 36331660 DOI: 10.1245/s10434-022-12745-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The Multicenter Selective Lymphadenectomy Trial-II (MSLT-II) revealed completion lymph node dissection (CLND) after positive sentinel lymph node biopsy (SLNB) did not improve melanoma-specific survival compared with surveillance. Given these findings and the morbidity associated with CLND, this study investigated trends in rates and predictors of CLND after MSLT-II. METHODS Analysis of the National Cancer Database was performed for all patients aged ≥18 years with melanoma and a positive SLNB for 2012-2019. Rates of CLND before and after publication of MSLT-II were identified and logistic regression used to identify factors associated with CLND. RESULTS Patients undergoing CLND declined from 55.9% pre-MSLT-II (n = 9725) to 19.5% post-MSLT-II (n = 9419) (odds ratio [OR] 0.32, 95% confidence interval [CI] 0.29-0.35). CLND was less likely in females (OR 0.83; 95% CI 0.78-0.89), older patients (vs. 18-39 yr; 40-64 yr OR 0.80, 95% CI 0.65-0.98; 65-79 yr OR 0.67, 95% CI 0.53-0.84; >80 yr OR 0.38, 95% CI 0.30-0.49), sicker patients (Deyo category ≥2 OR 0.85, 95% CI 0.73-0.99), thinner primary lesions (vs. 0.01-0.79 mm; 1.01-4.00 mm OR 1.16, 95% CI 1.01-1.33; ≥4.01 mm OR 1.31, 95% CI 1.08-1.59), patients from metro areas (Rural OR 1.31, 95% CI 1.00-1.70; Urban OR 1.15, 95% CI 1.03-1.29), and those treated at lower-volume centers (vs. lowest-volume; highest-volume OR 1.31, 95% CI 1.14-1.50; high-volume OR 1.40, 95% CI 1.24-1.57). CONCLUSIONS MSLT-II has impacted clinical care; however, male gender, thicker lesions, rural/urban residence, younger age, fewer comorbidities, and treatment at higher-volume centers confer a greater likelihood of undergoing CLND. Further investigations should focus on whether these populations benefit from more aggressive surgical care.
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Affiliation(s)
- Jennifer T Castle
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | | | - Brittany E Levy
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Emily F Marcinkowski
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA.,Division of Surgical Oncology, University of Kentucky, Lexington, KY, USA
| | - Allison Merritt
- Department of Health, Behavior and Society, University of Kentucky, Lexington, KY, USA
| | - Jerod L Stapleton
- Department of Biostatistics, University of Kentucky, Lexington, KY, USA
| | - Erin E Burke
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA. .,Division of Surgical Oncology, University of Kentucky, Lexington, KY, USA.
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16
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Wagner V, Levy BE, Castle JT, Plymale M, Roth JS, Totten C. Absorbable mesh in a contaminated field: hernia repair outcomes. Updates Surg 2022:10.1007/s13304-022-01433-z. [DOI: 10.1007/s13304-022-01433-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/17/2022] [Indexed: 12/05/2022]
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17
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Encisco EM, Gerardo RG, Tombash E, Levy BE, Ponsky TA. Storytelling for pediatric surgical education and beyond. J Pediatr Surg 2022; 57:1036. [PMID: 35907710 DOI: 10.1016/j.jpedsurg.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 06/20/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Ellen M Encisco
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatric Surgery, Akron Children's Hospital, 215 West Bowery Street, Level 6, Akron, OH 44308, Akron, OH, United States.
| | - Rodrigo G Gerardo
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Edzhem Tombash
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Brittany E Levy
- Department of General Surgery, University of Kentucky, Lexington, KY, United States
| | - Todd A Ponsky
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatric Surgery, Akron Children's Hospital, 215 West Bowery Street, Level 6, Akron, OH 44308, Akron, OH, United States
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Levy BE, Harris AM. EDITORIAL COMMENT. Urology 2022; 169:265. [DOI: 10.1016/j.urology.2022.06.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/07/2022] [Indexed: 11/11/2022]
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Castle JT, Levy BE, Chauhan A. Pediatric Neuroendocrine Neoplasms: Rare Malignancies with Incredible Variability. Cancers (Basel) 2022; 14:cancers14205049. [PMID: 36291833 PMCID: PMC9599522 DOI: 10.3390/cancers14205049] [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: 09/21/2022] [Revised: 10/07/2022] [Accepted: 10/13/2022] [Indexed: 11/16/2022] Open
Abstract
Neuroendocrine neoplasms (NENs) encompass a variety of neuroendocrine tumors (NETs) and neuroendocrine carcinomas (NECs) which can arise anywhere in the body. While relatively rare in the pediatric population, the incidence of NENs has increased in the past few decades. These neoplasms can be devastating if not diagnosed and treated early, however, symptoms are variable and can be indolent for many years. There is a reported median of 10 years from the appearance of the first symptoms to time of diagnosis. Considering some of these neoplasms have a mortality rate as high as 90%, it is crucial healthcare providers are aware of NENs and remain vigilant. With better provider education and easily accessible resources for information about these neoplasms, awareness can be improved leading to earlier disease recognition and diagnosis. This manuscript aims to provide an overview of both the most common NENs as well as the rarer NENs with high lethality in the pediatric population. This review provides up to date evidence and recommendations, encompassing recent changes in classification and advances in treatment modalities, including recently completed and ongoing clinical trials.
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Affiliation(s)
- Jennifer T. Castle
- Department of Surgery, Markey Cancer Center, University of Kentucky, 800 Rose Street, Lexington, KY 40536, USA
| | - Brittany E. Levy
- Department of Surgery, University of Kentucky, 800 Rose Street, Lexington, KY 40536, USA
| | - Aman Chauhan
- Department of Internal Medicine-Medical Oncology, Markey Cancer Center, University of Kentucky, 800 Rose Street, Lexington, KY 40536, USA
- Correspondence: or
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Castle JT, Levy BE, Rodeberg DA. Abdominal Tumors. Surg Clin North Am 2022; 102:715-737. [DOI: 10.1016/j.suc.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Cocca AT, Levy BE, Castle JT, Wilt WS, Fleming MD, Kejner AE, Aouad RK, Tyagi SC. Management of Double Carotid Blow Out with Definitive Repair After Temporizing Stent Graft Placement. J Vasc Surg Cases Innov Tech 2022; 8:606-609. [PMID: 36248383 PMCID: PMC9556593 DOI: 10.1016/j.jvscit.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/10/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
Abstract
Carotid blowout syndrome is a life-threatening complication for patients with head and neck cancer. Temporizing stent graft procedures improve short-term survival and can be the definitive treatment for various reasons, including a poor oncologic prognosis, unsuitability for definitive reconstruction, or a lack of operative options. A second carotid blowout will often be fatal. Preventing such events requires multidisciplinary strategic planning because of a hostile reoperative field. We have described a case of a 44-year-old man with a history of laryngeal cancer who had experienced a carotid blowout. Treated with a stent graft, the patient had experienced a second event 6 weeks later. Treatment involved excision and suture ligation with rotational muscle flap coverage.
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Babikian VL, Stefansson K, Dieperink ME, Arnason BG, Marton LS, Levy BE. Paraneoplastic myelopathy: antibodies against protein in normal spinal cord and underlying neoplasm. Lancet 1985; 2:49-50. [PMID: 2861503 DOI: 10.1016/s0140-6736(85)90107-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Abstract
A six-year-old girl with induration, swelling and discoloration of the lower eyelid, a temporal mass, preauricular adenopathy and enlarged parotid gland, underwent biopsy, She was initially diagnosed as having a malignant disorder of histiocytic origin. All lesions resolved without therapy. Further evaluation revealed that the child had oculoglandular cat-scratch disease. Cat-scratch disease should be added to the list of nonmalignant disorders which may simulate a malignant neoplasm in its clinical and histologic appearance. Recognition of this fact is important in order to avoid erroneous diagnosis, unnecessary procedures and hazardous therapy.
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Abstract
Several granulocytic sarcomas (chloromas) developed in a patient with acute myelogenous leukemia while in hematologic remission. A positive diagnosis of the symptomatic lesion was made by means of open biopsy examination. The other lesions, which were unsuspected, were detected with a 67Ga-citrate scan. Subsequent 67Ga-citrate scans indicated a favorable response to treatment. The incidence and significance of silent granulocytic sarcomas in patients in hematologic remission is not known. Documentation of such lesions might prove valuable for diagnosing extramedullary relapse or for delivering intensive local therapy.
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