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Cockrell HC, Kwon EG, Savochka L, Dellinger MB, Greenberg SLM, Waldhausen JHT. Long-term Outcomes Following Thoracoscopic Division of Vascular Rings. J Pediatr Surg 2024:S0022-3468(24)00240-9. [PMID: 38658219 DOI: 10.1016/j.jpedsurg.2024.03.057] [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: 11/28/2023] [Revised: 03/15/2024] [Accepted: 03/26/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVES We evaluate long-term symptomatic improvement in vascular ring patients who underwent thoracoscopic division at a single quaternary pediatric surgery center. METHODS All pediatric patients who underwent vascular ring division without Kommerell's diverticulum resection between 01/2007-12/2022 were included. Surgeries were performed by pediatric general and thoracic surgeons. Patient demographic and clinical characteristics were obtained from retrospective chart review. Data on long-term symptomatic improvement were collected with structured telephone interviews. RESULTS 60% of patients were male. Median age at operation was 24 months (IQR: 11, 60 months) with a median weight of 11.3 kg (IQR: 8.7, 19.8 kg). All patients were symptomatic preoperatively with dysphagia being the most frequent complaint (42%), followed by chronic cough (21%). Of 41 patients eligible for the long-term follow-up survey, 8 patients with a primary diagnosis of a double arch with an atretic segment in the non-dominant arch and 9 with a right dominant arch with left ligamentum arteriosum and aberrant left subclavian artery (LSCA) were contacted and consented for participation. Median interval from surgery to survey completion was 95 months (IQR 28, 135 months). Most patients had no, or only minor, symptoms related to breathing and swallowing at the time of long-term follow-up. 88% of patients experienced postoperative symptom improvement, and only one patient reported worsening of symptoms over time. CONCLUSION Division of an atretic arch and/or ligamentum for patients with an aberrant LSCA without Kommerell's resection may be adequate to ensure long-term improvement of breathing and swallowing problems attributable to vascular rings. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Hannah C Cockrell
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA; Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - Eustina G Kwon
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA; Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Liya Savochka
- University of Washington School of Medicine, 1959 NE Pacific Street, A-300 Health Sciences Center, Box 356340, Seattle, WA 98195, USA
| | - Matthew B Dellinger
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA; Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Sarah L M Greenberg
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA; Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - John H T Waldhausen
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA; Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA 98195, USA
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Shah NR, Cockrell HC, Keller NE, Diaz-Miron J, Meckmongkol TT, Yu P, Englum B, Richards MK, Martin K. Debunking Myths of Gender Informed Care: What Every Pediatric Surgeon Should Know. J Pediatr Surg 2023; 58:2286-2293. [PMID: 37690870 DOI: 10.1016/j.jpedsurg.2023.08.009] [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: 06/21/2023] [Revised: 08/09/2023] [Accepted: 08/13/2023] [Indexed: 09/12/2023]
Abstract
As the transgender population in the United States grows, gender-affirming care is becoming increasingly relevant to the practice of pediatric surgery. Medical care for the transgender and gender diverse population is a politically charged topic with significant complexity and opportunities for clarification. It is important for providers to better understand this population's unique health and social needs. This review aims to debunk long-standing myths regarding gender-affirming care and highlight the current therapeutic and legislative landscapes within the scope of pediatric surgical practice. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Nikhil R Shah
- Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI, USA.
| | - Hannah C Cockrell
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Noah E Keller
- Department of Pediatric Surgery, Roseville Medical Center, Roseville, CA, USA
| | - Jose Diaz-Miron
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Teerin T Meckmongkol
- Division of Pediatric Surgery, Nemours Children's Health Orlando, Orlando, FL, USA
| | - Peter Yu
- Division of General and Thoracic Surgery, Children's Hospital of Orange County, Orange CA, USA
| | - Brian Englum
- Division of Pediatric Surgery, University of Maryland Children's Hospital, Baltimore, MD, USA
| | - Morgan K Richards
- Division of Pediatric Surgery, St. Luke's Children's Hospital, Boise, ID, USA
| | - Kathryn Martin
- Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY, USA
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3
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Shaw TB, Cockrell HC, Carter KT, Mijalis EM, Buti Y, Sawaya D, Berch BR, Kutcher ME, Morris MW. Population Density and Triage of Pediatric Firearm Injuries in a Rural Trauma System. Am Surg 2023; 89:4559-4564. [PMID: 35993395 DOI: 10.1177/00031348221121554] [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: 12/06/2023]
Abstract
BACKGROUND Rural pediatric firearm injuries require regional pediatric and trauma expertise. We evaluated county-level population density associations with transport, hospital interventions, and patient outcomes at a Level I pediatric trauma center serving a rural, statewide catchment area. MATERIAL AND METHODS The trauma registry of the only in-state pediatric trauma center was reviewed for firearm injuries in patients < 18 between 1/2013 and 3/2020. County-level population density was classified according to the United States Office of Management and Budget definitions for rural, micropolitan, and metropolitan areas. RESULTS 364 patients were identified, including 7 patients who were re-injured. Mean age was 11.3 ± 4.5 y and patients were 79.4% male. 59.3% were transferred from a referring hospital. Median injury severity score was 5 (IQR 1-10); 88.0% required trauma center admission, and 48.2% required operative intervention. 7.4% were injured in a rural county, 46.4% in a micropolitan county, and 46.2% in a metropolitan county. Patients from rural counties were more likely to be unintentionally injured (72.0%) than those from micropolitan (54.4%) or metropolitan counties (44.0%, P = .04). While need for inpatient admission and length of stay were similar, those transported from rural counties had significantly longer transport times (P < .01) and less frequent need for operative intervention (P = .03), as well as trends toward lower injury severity (P = .08) and mortality (P = .06). CONCLUSION Management of pediatric firearm injury is a unique challenge with significant regional variability. Opportunities exist for outreach, telehealth, and decision support to ensure equitable distribution of resources in rural trauma systems. LEVEL OF EVIDENCE Epidemiological, Level III.
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Affiliation(s)
- Taylor B Shaw
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Hannah C Cockrell
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kristen T Carter
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Eleni M Mijalis
- Department of Otolaryngology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Yusef Buti
- University of Southern Mississippi, Hattiesburg, MS, USA
| | - David Sawaya
- Department of Surgery, Division of Pediatric Surgery, Jackson, MS, USA
| | - Barry R Berch
- Department of Surgery, Division of Pediatric Surgery, Jackson, MS, USA
| | - Matthew E Kutcher
- Department of Surgery, Division of Trauma, Critical Care, and Acute Care Surgery, Jackson, MS, USA
| | - Michael W Morris
- Department of Surgery, Division of Pediatric Surgery, Jackson, MS, USA
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Cockrell HC, Greenberg SLM. General Care Considerations for the Pediatric Trauma Patient. Oral Maxillofac Surg Clin North Am 2023; 35:493-499. [PMID: 37625944 DOI: 10.1016/j.coms.2023.05.003] [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] [Indexed: 08/27/2023]
Abstract
Trauma is a leading cause of morbidity and mortality for children in the United States. Access to trauma care, injury burden, and outcomes following injury, are inequitable. There are many anatomic and physiologic differences between children and adults that affect injury patterns and necessary trauma treatment. The principles of advanced trauma life support (ATLS) should be used by clinicians in high-resource settings for the immediate in-hospital treatment of the injured child.
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Affiliation(s)
- Hannah C Cockrell
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA; Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Sarah L M Greenberg
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA; Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific Street, Seattle, WA 98195, USA.
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Hansen EE, Chiem JL, Righter-Foss K, Zha Y, Cockrell HC, Greenberg SLM, Low DK, Martin LD. Project SPRUCE: Saving Our Planet by Reducing Carbon Emissions, a Pediatric Anesthesia Sustainability Quality Improvement Initiative. Anesth Analg 2023; 137:98-107. [PMID: 37145976 DOI: 10.1213/ane.0000000000006421] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 05/07/2023]
Abstract
BACKGROUND Children are particularly vulnerable to adverse health outcomes related to climate change. Inhalational anesthetics are potent greenhouse gasses (GHGs) and contribute significantly to health care-generated emissions. Desflurane and nitrous oxide have very high global warming potentials. Eliminating their use, as well as lowering fresh gas flows (FGFs), will lead to reduced emissions. METHODS Using published calculations for converting volatile anesthetic concentrations to carbon dioxide equivalents (CO 2 e), we derived the average kilograms (kg) CO 2 e/min for every anesthetic administered in the operating rooms at our pediatric hospital and ambulatory surgical center between October 2017 and October 2022. We leveraged real-world data captured from our electronic medical record systems and used AdaptX to extract and present those data as statistical process control (SPC) charts. We implemented recommended strategies aimed at reducing emissions from inhalational anesthetics, including removing desflurane vaporizers, unplugging nitrous oxide hoses, decreasing the default anesthesia machine FGF, clinical decision support tools, and educational initiatives. Our primary outcome measure was average kg CO 2 e/min. RESULTS A combination of educational initiatives, practice constraints, protocol changes, and access to real-world data were associated with an 87% reduction in measured GHG emissions from inhaled anesthesia agents used in the operating rooms over a 5-year period. Shorter cases (<30 minutes duration) had 3 times higher average CO 2 e, likely due to higher FGF and nitrous oxide use associated with inhalational inductions, and higher proportion of mask-only anesthetics. Removing desflurane vaporizers corresponded with a >50% reduction of CO 2 e. A subsequent decrease in anesthesia machine default FGF was associated with a similarly robust emissions reduction. Another significant decrease in emissions was noted with educational efforts, clinical decision support alerts, and feedback from real-time data. CONCLUSIONS Providing environmentally responsible anesthesia in a pediatric setting is a challenging but achievable goal, and it is imperative to help mitigate the impact of climate change. Large systems changes, such as eliminating desflurane, limiting access to nitrous oxide, and changing default anesthesia machine FGF rates, were associated with rapid and lasting emissions reduction. Measuring and reporting GHG emissions from volatile anesthetics allows practitioners to explore and implement methods of decreasing the environmental impact of their individual anesthesia delivery practices.
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Affiliation(s)
- Elizabeth E Hansen
- From the Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Jennifer L Chiem
- From the Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Kimberly Righter-Foss
- From the Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Yuanting Zha
- From the Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Hannah C Cockrell
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, Washington
- Department of Surgery, University of Washington, Seattle, Washington
| | - Sarah L M Greenberg
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, Washington
- Department of Surgery, University of Washington, Seattle, Washington
| | - Daniel K Low
- From the Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Lynn D Martin
- From the Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
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Cockrell HC, Hrachovec J, Schnuck J, Nchinda N, Meehan J. Implementation of a Cryoablation-based Pain Management Protocol for Pectus Excavatum. J Pediatr Surg 2023:S0022-3468(23)00096-9. [PMID: 36894442 DOI: 10.1016/j.jpedsurg.2023.01.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 01/16/2023] [Accepted: 01/25/2023] [Indexed: 02/17/2023]
Abstract
INTRODUCTION The Nuss repair for pectus excavatum is associated with significant postoperative pain. Our institution developed protocols to standardize pain management for pectus excavatum patients in the immediate postoperative period. We present our experience with protocol implementation and patient outcomes. METHODS We standardized regional anesthesia with a 0.25% bupivacaine incisional soaker catheter (post-implementation 1, PI1) before transitioning to intercostal nerve cryoablation (INC) (post-implementation 2, PI2). Patient outcomes were tracked using statistical process control charts in AdaptX™ OR Advisor and run charts in Tableau. Chi-squared tests assessed demographic differences between cohorts. RESULTS 244 patients were included: 78 pre-implementation, 108 PI1, and 58 PI2. Average age was 15.9-16.5 years. Patients were majority male, non-Hispanic white, and English speaking. Hospital length of stay decreased 4.1-2.4 days. INC increased surgery time (99-125 min) but decreased PACU time (112-78 min). Maximum pain scores improved in PACU (7.7-6.0) and 0-24 h postoperatively (8.3-6.8) but were not different 24-48 h postoperatively (5.4-5.8). Average opioid dosing decreased 0-48 h from 1.9 to 0.8 mg/kg morphine milliequivalents and was associated with reduction in post-operative nausea and constipation. There were no 30-day readmissions. CONCLUSION An institution-wide pain management protocol using INC for pectus excavatum patients was implemented. Intercostal nerve cryoablation was found to be superior to bupivacaine incisional soaker catheters and reduced hospital length of stay, immediate postoperative pain scores, morphine milliequivalent opioid dosing, postoperative nausea, and constipation. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Hannah C Cockrell
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA; Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA, 98195, USA.
| | - Jennifer Hrachovec
- Center for Quality & Patient Safety, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Jamie Schnuck
- Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Nzuekoh Nchinda
- Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - John Meehan
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA; Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA, 98195, USA
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7
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Cockrell HC, Oyetunji TA, Martin K, Siddiqui SM. Disparities research: Not all studies are equal. J Pediatr Surg 2022; 57:1034-1035. [PMID: 35850736 DOI: 10.1016/j.jpedsurg.2022.06.011] [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: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Hannah C Cockrell
- Division of General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy, 2401 Gillham Rd Kansas City, MO 64108, USA
| | - Kathryn Martin
- Division of Pediatric Surgery, Maria Fareri Children's Hospital, Westchester Medical Center, 100 Woods Rd, MFCH 1123, Valhalla, NY 10595, USA
| | - Sabina M Siddiqui
- Division of Pediatric Surgery, Arkansas Children's Northwest Hospital, 2601 Gene George Blvd, Springdale, AR 72762, USA
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Cockrell HC, Maine RG, Hansen EE, Mehta K, Salazar DR, Stewart BT, Greenberg SLM. Environmental impact of telehealth use for pediatric surgery. J Pediatr Surg 2022; 57:865-869. [PMID: 35918239 DOI: 10.1016/j.jpedsurg.2022.06.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/20/2022] [Accepted: 06/24/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND The healthcare sector is responsible for 10% of US greenhouse gas emissions. Telehealth use may decrease healthcare's carbon footprint. Our institution introduced telehealth to support SARS-CoV-2 social distancing. We aimed to evaluate the environmental impact of telehealth rollout. METHODS We conducted a retrospective cohort study of pediatric patients seen by a surgical or pre anesthesia provider between March 1, 2020 and March 1, 2021. We measured patient-miles saved and CO2 emissions prevented to quantify the environmental impact of telehealth. Miles saved were calculated by geodesic distance between patient home address and our institution. Emissions prevented were calculated assuming 25 miles per gallon fuel efficiency and 19.4 pounds of CO2 produced per gallon of gasoline consumed. Unadjusted Poisson regression was used to assess relationships between patient demographics, geography, and telehealth use. RESULTS 60,773 in-person and 10,626 telehealth encounters were included. This represented an 8,755% increase in telehealth use compared to the year prior. Telehealth resulted in 887,006 patient-miles saved and 688,317 fewer pounds of CO2 emitted. Demographics significantly associated with decreased telehealth use included Asian and Black/African American racial identity, Hispanic ethnic identity, and primary language other than English. Further distance from the hospital and higher area deprivation index were associated with increased telehealth use (IRR 1.0006 and 1.0077, respectively). CONCLUSION Incorporating telehealth into pediatric surgical and pre anesthesia clinics resulted in significant CO2 emission reductions. Expanded telehealth use could mitigate surgical and anesthesia service contributions to climate change. Racial and linguistic minority status were associated with significantly lower rates of telehealth utilization, necessitating additional inquiry into equitable telemedicine use for minoritized populations. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Hannah C Cockrell
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA; Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - Rebecca G Maine
- Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Elizabeth E Hansen
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, 4800 Sand Point Way, NE, Seattle WA 98105, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Box 356540, 1959 Pacific Street, BB-1469, Seattle, WA 98195, USA
| | - Kajal Mehta
- Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Daniela Rebollo Salazar
- Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Barclay T Stewart
- Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Sarah L M Greenberg
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA; Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA 98195, USA
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9
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Cockrell HC, Anderson JE, Hansen EE, Waldhausen JHT, Greenberg SLM. An imperative for the pediatric surgical community to prioritize climate change. J Pediatr Surg 2022; 57:782-783. [PMID: 34895739 DOI: 10.1016/j.jpedsurg.2021.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/01/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Hannah C Cockrell
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA; Department of Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Jamie E Anderson
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA; Department of Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Elizabeth E Hansen
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Box 356540, 1959 NE Pacific Street, BB 1469, Seattle, WA 98195, USA
| | - John H T Waldhausen
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA; Department of Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Sarah L M Greenberg
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA; Department of Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA.
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Cockrell HC, O'Brien R, Carter KT, Shaw TB, Baran DA, Kutcher ME, Copeland JG, Copeland H. Better together: a reappraisal of heterotopic heart transplantation. Transpl Int 2021; 34:2184-2191. [PMID: 34562279 DOI: 10.1111/tri.14116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 08/23/2021] [Accepted: 09/03/2021] [Indexed: 11/30/2022]
Abstract
Heterotopic heart transplantation (HHT) is rare in the modern era. When used as a biologic left ventricular assist, HHT provides pulsatile flow, supports the left ventricle with a physiologic cardiac output, responds to humoral stimuli, and with modern immunosuppression may offer long-term untethered survival. This study was undertaken to compare survival of HHT with orthotopic heart transplantation (OHT) to assess its viability in the modern era. In the United Network for Organ Sharing database, from January 1999 to December 2020, there were 27691 bicaval OHT, 13836 biatrial OHT, 1271 total OHT, and 51 HHT with sufficient follow-up. Survival was analyzed using restricted mean survival time (RMST) through 4 years as the outcome. In the first 4 years after transplant, compared with HHT, differences in RMST were 0.1 years (99% CI: -0.4 to 0.5 years) for bicaval OHT, 0.0 years (99% CI: -0.4 to 0.5 years) for biatrial OHT, and 0.0 years (99% CI: -0.5 to 0.4 years) for total OHT. In this cohort, survival was indistinguishable between HHT and OHT recipients in the first four years. Thus, HHT might be a viable alternative to durable mechanical circulatory assist particularly with size mismatched grafts or for patients with refractory pulmonary hypertension.
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Affiliation(s)
- Hannah C Cockrell
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Robert O'Brien
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS, USA.,Department of Data Science, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kristen T Carter
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Taylor B Shaw
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - David A Baran
- Advanced Heart Failure Center, Sentara Heart Hospital, Norfolk, VA, USA
| | - Matthew E Kutcher
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jack G Copeland
- Department of Surgery, Division of Cardiothoracic Surgery, University of Arizona, Tucson, AZ, USA
| | - Hannah Copeland
- Lutheran Medical Group, Lutheran Hospital Fort Wayne, Indiana, Fort Wayne, IN, USA.,Fort Wayne (IUSM - FW), Indiana University School of Medicine, Fort Wayne, IN, USA
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11
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Cockrell HC, Cottrell-Cumber S, Brown K, Murphy JG. Sevelamer crystals-an unusual cause of large bowel obstruction. J Surg Case Rep 2021; 2021:rjab228. [PMID: 34150192 PMCID: PMC8208801 DOI: 10.1093/jscr/rjab228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/11/2021] [Indexed: 11/16/2022] Open
Abstract
Sevelamer is a common phosphate binder used to manage hyperphosphatemia in end-stage renal disease. The medication has a well-documented gastrointestinal side-effect profile including nausea, vomiting and abdominal pain. There are few case reports of Sevelamer crystal deposition causing gastrointestinal mucosal injury, pseudotumor or obstruction. Here, we discuss a patient on Sevelamer who required operative management of a sigmoid obstruction. Surgical pathology showed pericolonic abscess with Sevelamer crystals.
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Affiliation(s)
- Hannah C Cockrell
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Kathryn Brown
- Department of Pathology, Mississippi Baptist Hospital, Jackson, MS, USA
| | - Jason G Murphy
- Surgical Clinic Associates, Mississippi Baptist Hospital, Jackson, MS, USA
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Affiliation(s)
- Hannah C Cockrell
- 21693 Department of Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Matthew W Maready
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - James M Shiflett
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Michael W Morris
- Division of Pediatric Surgery, University of Mississippi Medical Center, Jackson, MS, USA
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DeAntonio JH, Kang HS, Cockrell HC, Rothstein W, Oiticica C, Lanning DA. Utilization of a handheld telemedicine device in postoperative pediatric surgical care. J Pediatr Surg 2019; 54:1005-1008. [PMID: 30782441 DOI: 10.1016/j.jpedsurg.2019.01.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/27/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE The purpose of this study was to assess the utilization of a handheld telemedicine (TM) device in the postoperative care of pediatric surgical patients. METHODS We performed postoperative TM evaluations using an advanced medical tablet immediately prior to seeing the patients in clinic as well as at two different time points from their home. The caregivers and physicians were surveyed about their overall satisfaction. RESULTS Twenty-four postoperative patients who underwent a variety of general surgical operations were included. There were no changes to the TM plan of care following "in person" evaluations (n = 12) and no complications, missed diagnoses, emergency department visits, or additional clinic visits in those who only had TM postoperative evaluations (n = 12). Caregiver satisfaction ratings were 3.92 ± 0.28 out of 4 (4 = very satisfied). Ninety-two percent of caregivers responded that they would be comfortable with a TM-only postoperative evaluation in the future. The physician was able to formulate an accurate assessment and plan using the device. The average travel distance saved was 44.7 ± 45.5 miles (range = 10-150 miles). CONCLUSIONS These preliminary data suggest safe and effective care with high caregiver and physician satisfaction can be provided by utilizing TM in the postoperative care of pediatric surgical patients. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jonathan H DeAntonio
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Hae Sung Kang
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Hannah C Cockrell
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA
| | - William Rothstein
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Claudio Oiticica
- Children's Hospital of Richmond at Virginia Commonwealth University, Children's Pavilion, Richmond, VA
| | - David A Lanning
- Children's Hospital of Richmond at Virginia Commonwealth University, Children's Pavilion, Richmond, VA.
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14
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Mugeni C, Levine AC, Munyaneza RM, Mulindahabi E, Cockrell HC, Glavis-Bloom J, Nutt CT, Wagner CM, Gaju E, Rukundo A, Habimana JP, Karema C, Ngabo F, Binagwaho A. Nationwide implementation of integrated community case management of childhood illness in Rwanda. Glob Health Sci Pract 2014; 2:328-41. [PMID: 25276592 PMCID: PMC4168626 DOI: 10.9745/ghsp-d-14-00080] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 07/10/2014] [Indexed: 11/15/2022]
Abstract
Between 2008 and 2011, Rwanda introduced iCCM of childhood illness nationwide. One year after iCCM rollout, community-based treatment for diarrhea and pneumonia had increased significantly, and under-5 mortality and overall health facility use had declined significantly. Background: Between 2008 and 2011, Rwanda introduced integrated community case management (iCCM) of childhood illness nationwide. Community health workers in each of Rwanda's nearly 15,000 villages were trained in iCCM and equipped for empirical diagnosis and treatment of pneumonia, diarrhea, and malaria; for malnutrition surveillance; and for comprehensive reporting and referral services. Methods: We used data from the Rwanda health management information system (HMIS) to calculate monthly all-cause under-5 mortality rates, health facility use rates, and community-based treatment rates for childhood illness in each district. We then compared a 3-month baseline period prior to iCCM implementation with a seasonally matched comparison period 1 year after iCCM implementation. Finally, we compared the actual changes in all-cause child mortality and health facility use over this time period with the changes that would have been expected based on baseline trends in Rwanda. Results: The number of children receiving community-based treatment for diarrhea and pneumonia increased significantly in the 1-year period after iCCM implementation, from 0.83 cases/1,000 child-months to 3.80 cases/1,000 child-months (P = .01) and 0.25 cases/1,000 child-months to 5.28 cases/1,000 child-months (P<.001), respectively. On average, total under-5 mortality rates declined significantly by 38% (P<.001), and health facility use declined significantly by 15% (P = .006). These decreases were significantly greater than would have been expected based on baseline trends. Conclusions: This is the first study to demonstrate decreases in both child mortality and health facility use after implementing iCCM of childhood illness at a national level. While our study design does not allow for direct attribution of these changes to implementation of iCCM, these results are in line with those of prior studies conducted at the sub-national level in other low-income countries.
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Affiliation(s)
| | - Adam C Levine
- The Warren Alpert Medical School of Brown University , Providence, RI , USA ; Co-first authors
| | | | | | - Hannah C Cockrell
- Brown University, Watson Institute for International Studies, Development Studies Program , Providence, RI , USA
| | | | - Cameron T Nutt
- Dartmouth Center for Health Care Delivery Science , Hanover, NH , USA
| | | | - Erick Gaju
- Rwanda Ministry of Health , Kigali , Rwanda
| | - Alphonse Rukundo
- Malaria and other Parasitic Diseases Division, Rwanda Biomedical Center , Kigali , Rwanda
| | - Jean Pierre Habimana
- Malaria and other Parasitic Diseases Division, Rwanda Biomedical Center , Kigali , Rwanda
| | - Corine Karema
- Malaria and other Parasitic Diseases Division, Rwanda Biomedical Center , Kigali , Rwanda
| | | | - Agnes Binagwaho
- Rwanda Ministry of Health , Kigali , Rwanda ; Harvard Medical School, Department of Global Health and Social Medicine , Boston, MA , USA ; Dartmouth College, Geisel School of Medicine , Hanover, NH , USA
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15
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Levine AC, Munyaneza RM, Glavis-Bloom J, Redditt V, Cockrell HC, Kalimba B, Kabemba V, Musavuli J, Gakwerere M, Umurungi JPDC, Shah SP, Drobac PC. Prediction of severe disease in children with diarrhea in a resource-limited setting. PLoS One 2013; 8:e82386. [PMID: 24349271 PMCID: PMC3857792 DOI: 10.1371/journal.pone.0082386] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 10/29/2013] [Indexed: 12/04/2022] Open
Abstract
Objective To investigate the accuracy of three clinical scales for predicting severe disease (severe dehydration or death) in children with diarrhea in a resource-limited setting. Methods Participants included 178 children admitted to three Rwandan hospitals with diarrhea. A local physician or nurse assessed each child on arrival using the World Health Organization (WHO) severe dehydration scale and the Centers for Disease Control (CDC) scale. Children were weighed on arrival and daily until they achieved a stable weight, with a 10% increase between admission weight and stable weight considered severe dehydration. The Clinical Dehydration Scale was then constructed post-hoc using the data collected for the other two scales. Receiver Operator Characteristic (ROC) curves were constructed for each scale compared to the composite outcome of severe dehydration or death. Results The WHO severe dehydration scale, CDC scale, and Clinical Dehydration Scale had areas under the ROC curves (AUCs) of 0.72 (95% CI 0.60, 0.85), 0.73 (95% CI 0.62, 0.84), and 0.80 (95% CI 0.71, 0.89), respectively, in the full cohort. Only the Clinical Dehydration Scale was a significant predictor of severe disease when used in infants, with an AUC of 0.77 (95% CI 0.61, 0.93), and when used by nurses, with an AUC of 0.78 (95% CI 0.63, 0.93). Conclusions While all three scales were moderate predictors of severe disease in children with diarrhea, scale accuracy varied based on provider training and age of the child. Future research should focus on developing or validating clinical tools that can be used accurately by nurses and other less-skilled providers to assess all children with diarrhea in resource-limited settings.
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Affiliation(s)
- Adam C. Levine
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America
- * E-mail:
| | - Richard M. Munyaneza
- Department of Community Health, Rwanda Ministry of Health, Kigali, Kigali Province, Rwanda
| | - Justin Glavis-Bloom
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America
| | - Vanessa Redditt
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Hannah C. Cockrell
- Watson Institute for International Studies, Brown University, Providence, Rhode Island, United States of America
| | - Bantu Kalimba
- Department of Medicine, Kirehe Hospital, Kirehe, Eastern Province, Rwanda
| | - Valentin Kabemba
- Department of Medicine, Kirehe Hospital, Kirehe, Eastern Province, Rwanda
| | - Juvenal Musavuli
- Department of Medicine, Butaro Hospital, Butaro, Northern Province, Rwanda
| | - Mathias Gakwerere
- Department of Medicine, Butaro Hospital, Butaro, Northern Province, Rwanda
| | | | - Sachita P. Shah
- Division of Emergency Medicine, University of Washington Medical Center, Seattle, Washington, United States of America
| | - Peter C. Drobac
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Research Department, Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Eastern Province, Rwanda
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