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Peticca B, Prudencio TM, Robinson SG, Karhadkar SS. Challenges with non-descriptive compliance labeling of end-stage renal disease patients in accessibility for renal transplantation. World J Nephrol 2024; 13:88967. [PMID: 38596267 PMCID: PMC11000042 DOI: 10.5527/wjn.v13.i1.88967] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/22/2023] [Accepted: 12/22/2023] [Indexed: 03/22/2024] Open
Abstract
Non-descriptive and convenient labels are uninformative and unfairly project blame onto patients. The language clinicians use in the Electronic Medical Record, research, and clinical settings shapes biases and subsequent behaviors of all providers involved in the enterprise of transplantation. Terminology such as noncompliant and nonadherent serve as a reason for waitlist inactivation and limit access to life-saving transplantation. These labels fail to capture all the circumstances surrounding a patient's inability to follow their care regimen, trivialize social determinants of health variables, and bring unsubstantiated subjectivity into decisions regarding organ allocation. Furthermore, insufficient Medicare coverage has forced patients to ration or stop taking medication, leading to allograft failure and their subsequent diagnosis of noncompliant. We argue that perpetuating non-descriptive language adds little substantive information, increases subjectivity to the organ allocation process, and plays a major role in reduced access to transplantation. For patients with existing barriers to care, such as racial/ethnic minorities, these effects may be even more drastic. Transplant committees must ensure thorough documentation to correctly encapsulate the entirety of a patient's position and give voice to an already vulnerable population.
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Affiliation(s)
- Benjamin Peticca
- Department of Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, United States
| | - Tomas M Prudencio
- Department of Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, United States
| | - Samuel G Robinson
- Department of Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, United States
| | - Sunil S Karhadkar
- Department of Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, United States
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Mandel A, Robinson SG, Peticca B, Prudencio TM, Karhadkar SS. Pretransplant malignancy in pediatrics is not a risk factor for renal graft failure. Pediatr Transplant 2024; 28:e14697. [PMID: 38317342 DOI: 10.1111/petr.14697] [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: 07/25/2023] [Revised: 11/25/2023] [Accepted: 12/05/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND In adults, pretransplant malignancy (PTM) negatively impacts patient survival due to immunosuppression regimens influencing post-transplantation tumor growth. Few reports investigate the outcomes of pediatric kidney transplantation with PTM. We compare transplant outcomes for pediatric patients with PTM to matched controls, including cancer types extending beyond Wilms tumor. METHODS The United Network of Organ Sharing Database was queried to identify pediatric transplant recipients with histories of PTM. All PTM patients were matched to non-PTM patients, at a 1:1 ratio, with 0.001 match tolerance. Matching variables included transplant year, recipient age, recipient gender, recipient race, donor type, and prior transplant. Death-censored graft and patient survival were analyzed. All statistics were reported with 95% confidence intervals (CI). RESULTS After propensity matching, 285 PTM and 285 non-PTM patients were identified, with transplant dates from 1990 to 2020. Median Kidney Donor Profile Index values were comparable between cohorts, 17% and 12%, respectively (p = .065). Kaplan-Meier analysis revealed that PTM patients did not have a significantly different rate of death-censored graft failure, compared to the non-PTM group [HR 0.76; 95% CI (0.54-1.1)]. There was also no difference in the overall survival between the two groups of patients [HR 1.1; 95% CI (0.66-2.0)]. CONCLUSION A history of pediatric malignancy has minimal independent effect on their post-transplant survival. Additionally, pediatric patients with PTM demonstrated equivalent rates of graft survival. Thus, in contrast to adults, renal failure in children with history of pediatric malignancies should not be considered a complicating factor for renal transplantation.
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Affiliation(s)
- Asher Mandel
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Samuel G Robinson
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Benjamin Peticca
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Tomas M Prudencio
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Sunil S Karhadkar
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
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Panichella JC, Araya S, Nannapaneni S, Robinson SG, You S, Gubara SM, Gebreyesus MT, Webster T, Patel SA, Hamidian Jahromi A. Cancer screening and management in the transgender population: Review of literature and special considerations for gender affirmation surgery. World J Clin Oncol 2023; 14:265-284. [PMID: 37583948 PMCID: PMC10424092 DOI: 10.5306/wjco.v14.i7.265] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 05/15/2023] [Accepted: 06/27/2023] [Indexed: 07/19/2023] Open
Abstract
BACKGROUND Literature focused on cancer screening and management is lacking in the transgender population. AIM To action to increase contributions to the scientific literature that drives the creation of cancer screening and management protocols for transgender and gender nonconforming (TGNC) patients. METHODS We performed a systematic search of PubMed on January 5th, 2022, with the following terms: "TGNC", OR "transgender", OR "gender non-conforming", OR "gender nonbinary" AND "cancer screening", AND "breast cancer", AND "cervical cancer", AND "uterine cancer", AND "ovarian cancer", AND "prostate cancer", AND "testicular cancer", AND "surveillance", AND "follow-up", AND "management". 70 unique publications were used. The findings are discussed under "Screening" and "Management" categories. RESULTS Screening: Current cancer screening recommendations default to cis-gender protocols. However, long-term gender-affirming hormone therapy and loss to follow-up from the gender-specific specialties contribute to a higher risk for cancer development and possible delayed detection. The only known screening guidelines made specifically for this population are from the American College of Radiology for breast cancer. Management: Prior to undergoing Gender Affirmation Surgery (GAS), discussion should address cancer screening and management in the organs remaining in situ. Cancer treatment in this population requires consideration for chemotherapy, radiation, surgery and/or reconstruction. Modification of hormone therapy is decided on a case-by-case basis. The use of prophylactic vs aesthetic techniques in surgery is still debated. CONCLUSION When assessing transgender individuals for GAS, a discussion on the future oncologic risk of the sex-specific organs remaining in situ is essential. Cancer management in this population requires a multidisciplinary approach while the care should be highly individualized with considerations to social, medical, surgical and gender affirming surgery related specifications. Special considerations have to be made during planning for GAS as surgery will alter the anatomy and may render the organ difficult to sample for screening purposes. A discussion with the patient regarding the oncologic risk of remaining organs is imperative prior to GAS. Other special considerations to screening such as the conscious or unconscious will to unassociated with their remaining organs is also a key point to address. We currently lack high quality studies pertinent to the cancer topic in the gender affirmation literature. Further research is required to ensure more comprehensive and individualized care for this population.
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Affiliation(s)
- Juliet C Panichella
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, United States
| | - Sthefano Araya
- Division of Plastic and Reconstructive Surgery, Fox Chase Cancer Center, Philadelphia, PA 19111, United States
| | - Siddhartha Nannapaneni
- Division of Plastic and Reconstructive Surgery, Fox Chase Cancer Center, Philadelphia, PA 19111, United States
| | - Samuel G Robinson
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, United States
| | - Susan You
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, United States
| | - Sarah M Gubara
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, United States
| | - Maria T Gebreyesus
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, United States
| | - Theresa Webster
- Department of Plastic Surgery, Temple University, Philadelphia, PA 18045, United States
| | - Sameer A Patel
- Division of Plastic and Reconstructive Surgery, Fox Chase Cancer Center, Philadelphia, PA 19111, United States
| | - Alireza Hamidian Jahromi
- Division of Plastic and Reconstructive Surgery, Temple University Hospitals, Philadelphia, PA 19140, United States
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Robinson SG, Mandel A, Nicosia J, Siegel J, Hamidian Jahromi A. Racial Disparity in Gender Affirming Surgery: A Comparative Study on Plastic Surgeon Social Media Use. Plast Reconstr Surg Glob Open 2023; 11:e5009. [PMID: 37197009 PMCID: PMC10184994 DOI: 10.1097/gox.0000000000005009] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/19/2022] [Indexed: 05/19/2023]
Abstract
In the past 5 years, social media use among plastic surgeons has grown to become a common modality used to promote one's practice. However, surgeons lack the necessary ethical training to understand how their published content impacts patient opinions and behavior. Social media trends among plastic surgeons may contribute to the reduced rate of Black (non-White) patients accessing gender affirming surgery. Methods In total, 250 gender affirming surgeons and 51,698 individual posts from social media platform, Instagram, were manually extracted and analyzed. Posts were assessed for inclusion and categorized by the subject's skin color (White versus non-White) using the Fitzpatrick scale. Results Of the 3101 included posts, 375 (12.1%) portrayed non-White subjects. Of the 56 included surgeons, White surgeons were found to be 2.3 times less likely to include non-White subjects in their posts, compared with non-White surgeons. Regionally, surgeons practicing in the Northeast had the most racially diverse social media accounts, with over 20% of all posts including a non-White subject. Analyzing data over the past 5 years demonstrated no relative increase in the amount of non-White subjects being displayed on social media, while social media use by gender affirming surgeons had increased by over 200%. Conclusions The low number of non-White individuals portrayed by surgeons on social media perpetuates the racial disparity seen in patients accessing gender affirming surgery. Surgeons must be conscious of the demographic they portray on social media, as a lack of representation may influence patients' self-identify and decision to utilize gender affirming surgical treatment.
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Affiliation(s)
- Samuel G. Robinson
- From the Lewis Katz School of Medicine at Temple University, Philadelphia, Pa
| | - Asher Mandel
- From the Lewis Katz School of Medicine at Temple University, Philadelphia, Pa
| | - Jeanette Nicosia
- From the Lewis Katz School of Medicine at Temple University, Philadelphia, Pa
| | - Jacob Siegel
- From the Lewis Katz School of Medicine at Temple University, Philadelphia, Pa
| | - Alireza Hamidian Jahromi
- From the Lewis Katz School of Medicine at Temple University, Philadelphia, Pa
- Division of Plastic and Reconstructive Surgery, Gender Affirmation Surgery Center, Temple University Medical Center, Philadelphia, Pa
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Wachnik AA, Welch-Coltrane JL, Adams MCB, Blumstein HA, Pariyadath M, Robinson SG, Saha A, Summers EC, Hurley RW. A Standardized Emergency Department Order Set Decreases Admission Rates and In-Patient Length of Stay for Adults Patients with Sickle Cell Disease. Pain Med 2022; 23:2050-2060. [PMID: 35708651 PMCID: PMC9714532 DOI: 10.1093/pm/pnac096] [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] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/20/2022] [Accepted: 06/10/2022] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Pain associated with sickle cell disease (SCD) causes severe complications and frequent presentation to the emergency department (ED). Patients with SCD frequently report inadequate pain treatment in the ED, resulting in hospital admission. A retrospective analysis was conducted to assess a quality improvement project to standardize ED care for patients presenting with pain associated with SCD. METHODS A 3-year prospective quality improvement initiative was performed. Our multidisciplinary team of providers implemented an ED order set in 2019 to improve care and provide adequate analgesia management. Our primary outcome was the overall hospital admission rate for patients after the intervention. Secondary outcome measures included ED disposition, rate of return to the ED within 72 hours, ED pain scores at admission and discharge, ED treatment time, in-patient length of stay, non-opioid medication use, and opioid medication use. RESULTS There was an overall 67% reduction in the hospital admission rate after implementation of the order set (P = 0.005) and a significant decrease in the percentage admission rate month over month (P = 0.047). Time to the first non-opioid analgesic decreased by 71 minutes (P > 0.001), and there was no change in time to the first opioid medication. The rate of return to the ED within 72 hours remained unchanged (7.0% vs 7.1%) (P = 0.93), and the ED elopement rate remained unchanged (1.3% vs 1.85%) (P = 0.93). After the implementation, there were significant increases in the prescribing of orally administered acetaminophen (7%), celecoxib (1.2%), and tizanidine (12.5%) and intravenous ketamine (30.5%) and ketorolac (27%). ED pain scores at discharge were unchanged for both hospital-admitted (7.12 vs 7.08) (P = 0.93) and non-admitted (5.51 vs 6.11) (P = 0.27) patients. The resulting potential cost reduction was determined to be $193,440 during the 12-month observation period, with the mean cost per visit decreasing by $792. CONCLUSIONS Use of a standardized and multimodal ED order set reduced hospital admission rates and the timeliness of analgesia without negatively impacting patients' pain.
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Affiliation(s)
| | | | | | | | | | | | - Amit Saha
- Department of Anesthesiology and Pain Service Line
| | - Erik C Summers
- Department of Internal Medicine Section of Hospital Medicine
| | - Robert W Hurley
- Correspondence to: Robert W. Hurley, MD, PhD, FASA, Department of Anesthesiology, Neurobiology and Anatomy, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27051, USA. Tel: 336-716-2266; Fax: 336-716-8773; E-mail:
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Speggiorin S, Robinson SG, Harvey C, Westrope C, Faulkner GM, Kirkland P, Peek GJ. Experience with the Avalon® bicaval double-lumen veno-venous cannula for neonatal respiratory ECMO. Perfusion 2014; 30:250-4. [PMID: 24972812 DOI: 10.1177/0267659114540020] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We report a single centre experience of neonatal respiratory ECMO using the Avalon® double-lumen venous cannula and compare it with reports in the literature. RESULTS Between 2008 and 2012, the Avalon® cannula was used in 72 neonates: median age at cannulation was 1.8 days (IQR 1.2-2.8 days) and bodyweight 3.4 Kg (3.0-3.7 Kg). Meconium aspiration syndrome (61.1%), persistent hypertension of the newborn (25%) and congenital diaphragmatic hernia (5.6%) were the most common diagnoses. Complications occurred in 19 patients (26.4%): cannula site bleeding in 6 (8.3%), the cannula perforating the right atrial wall and requiring emergency midline sternotomy in 5 (6.9%) and the cannula needing repositioning in 3 (4.2%). Overall survival at discharge or transfer to the referring hospital was 88.8%. Successful wean off ECMO occurred in 68 patients (94.4%) after a median of 90.5 hours (63.4-136.11). ECMO support was withdrawn in 4 patients (5.6%). CONCLUSIONS The Avalon® dual-lumen veno-venous cannula can be used for respiratory ECMO in the neonatal population. However, as the incidence of right atrial perforation is not negligible, we suspended its used in this group of patients.
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Affiliation(s)
- S Speggiorin
- Heartlink ECMO Centre, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - S G Robinson
- Heartlink ECMO Centre, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - C Harvey
- Heartlink ECMO Centre, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - C Westrope
- Heartlink ECMO Centre, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - G M Faulkner
- Heartlink ECMO Centre, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - P Kirkland
- Heartlink ECMO Centre, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - G J Peek
- Heartlink ECMO Centre, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
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Gnanalingham MG, Robinson SG, Hawley DP, Gnanalingham KK. A 30 year perspective of the quality of evidence published in 25 clinical journals: signs of change? Postgrad Med J 2006; 82:397-9. [PMID: 16754709 PMCID: PMC2563750 DOI: 10.1136/pgmj.2005.041251] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
METHODS The quality of clinical studies published in five different specialties, over three decades was evaluated. Computerised search of the Medline database was undertaken to evaluate the articles published in 25 clinical journals in 1983, 1993, and 2003 from five different specialties (medicine, surgery, paediatrics, anaesthesia, and psychiatry). The number of randomised controlled trials (RCTs), meta-analyses, and other clinical trials (non-RCT) were noted. RESULTS From the 27,030 articles evaluated, there were 2283 (8.4%) RCTs, 166 (0.6%) meta-analyses, and 4153 (15.4%) other clinical trials. For the proportion of RCTs, the rank order of the specialties was; anaesthesia (503; 18%), psychiatry (294; 9.6%), medicine (899; 8.1%), paediatrics (326; 6.4%), and surgery (261; 5.3%) (p<0.001). For the proportion of meta-analysis, the rank order of the specialties was; psychiatry (36; 1.2%), medicine (105; 0.9%), paediatrics (15; 0.3%), anaesthesia (6; 0.2%), and surgery (4; 0.1%) (p<0.001). Overall, from 1983 to 2003, there were increases in the proportion of RCTs (449, 5.9% to 1027, 9.6%), meta-analysis (0, 0% to 127, 1.2%), and other clinical trials (897, 12% to 1983, 19%) (p<0.001). This trend was apparent in each clinical specialty (p<0.001). CONCLUSIONS Over the three decades evaluated, clinical trials, notably RCTs and meta-analysis form only a small proportion of articles published in prominent journals from five clinical specialties. This is notwithstanding the modest increases in the proportions of RCTs and meta-analysis over the same period.
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Affiliation(s)
- M G Gnanalingham
- Department of Paediatrics, Queens Medical Centre, Nottingham, UK.
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Abstract
During the development of the nervous system embryonic neurons are incorporated into neural networks that underlie behaviour. For example, during embryogenesis in Drosophila, motor neurons in every body segment are wired into the circuitry that drives the simple peristaltic locomotion of the larva. Very little is known about the way in which the necessary central synapses are formed in such a network or how their properties are controlled. One possibility is that presynaptic and postsynaptic elements form relatively independently of each other. Alternatively, there might be an interaction between presynaptic and postsynaptic neurons that allows for adjustment and plasticity in the embryonic network. Here we have addressed this issue by analysing the role of synaptic transmission in the formation of synaptic inputs onto identified motorneurons as the locomotor circuitry is assembled in the Drosophila embryo. We targeted the expression of tetanus toxin light chain (TeTxLC) to single identified neurons using the GAL4 system. TeTxLC prevents the evoked release of neurotransmitter by enzymatically cleaving the synaptic-vesicle-associated protein neuronal-Synaptobrevin (n-Syb) [1]. Unexpectedly, we found that the cells that expressed TeTxLC, which were themselves incapable of evoked release, showed a dramatic reduction in synaptic input. We detected this reduction both electrophysiologically and ultrastructurally.
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Affiliation(s)
- R A Baines
- Department of Zoology, University of Cambridge, Cambridge, CB2 3EJ, UK.
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Abstract
Coolants used for freezing biological specimens were tested for cooling performance in the continuous plunge mode. Results from bare thermocouples showed that ethane cooled faster than propane or a propane:pentane mixture, even when warmed to 25 K above its freezing point. Propane coolants were more efficient than Freon 22 and the slowest cooling occurred in boiling liquid nitrogen. Hydrated gelatin specimens showed similar results with ethane cooling about 33% faster than propane. Epoxy resin specimens cooled faster than hydrated gelatin specimens of similar size. Hydrated and resin specimens cooled over increasing distances as plunge velocity increased. A bare thermocouple, however, cooled over a constant distance when plunged above a critical velocity. This phenomenon may reflect vapour formation and its suppression at high plunge velocities. The rate of cooling in hydrated specimens is shown to have an absolute limit and cannot be modelled by bare thermocouples or resin specimens.
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