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Quinn KM, Runge LT, Parrado RH, White JA, Talley CL, Streck CJ, Abbott AM. General surgery applicant perspectives: Two years of virtual interview experiences and supplemental application impressions. Am J Surg 2024; 232:26-30. [PMID: 38042720 DOI: 10.1016/j.amjsurg.2023.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/26/2023] [Accepted: 11/24/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND We sought to evaluate the unique benefits and challenges the virtual recruitment and interviewing platform had on general surgery residency applicants. METHODS Applicants who interviewed for a categorical position at our institution during the 2021 and 2022 Match season were contacted to participate in the anonymous online survey focused on applicant behavior related to the virtual interview format. Data were analyzed using chi-square and paired t-tests. RESULTS A response rate of 56.7 % (n = 135) was achieved. Applicants accepted a median of 17 (IQR 13-20) interviews in 2021 and 15 (IQR 11-19) interviews in 2022. More than half (54 %) of applicants indicated they applied to more programs, and 53 % accepted more interviews, because of the virtual format. The greatest advantages of the virtual interviews as cited by applicants were saving money (96.3 %), saving time (49.6 %), and avoiding travel risks (43.7 %). The top limitations of virtual interviews were less exposure to current residents and faculty (61.5 %), to the city or location of the program (58.5 %), and difficultly comparing programs (57.8 %). The 2022 Match cycle included use of the supplemental application; however, 85 % of applicants did not feel that the supplemental improved their overall application. Some applicants (20 %) who "signaled" programs did not receive an interview offer from any of the programs they signaled. CONCLUSION The transition to virtual interviews saved applicants time and money but limited their exposure. Future efforts to maintain virtual interviews will need to be balanced against the intangible benefit of human interaction and observing a program's culture.
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Affiliation(s)
- Kristen M Quinn
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA.
| | - Louis T Runge
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Raphael H Parrado
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Jared A White
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Cynthia L Talley
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Christian J Streck
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Andrea M Abbott
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
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Mehl SC, Vogel AM, Glasgow AE, Moody S, Kotagal M, Williams RF, Kayton ML, Alberto EC, Burd RS, Schroeppel TJ, Baerg JE, Munoz A, Rothstein WB, Boomer LA, Campion EM, Robinson C, Nygaard RM, Richardson CJ, Garcia DI, Streck CJ, Gaffley M, Petty JK, Greenwell C, Pandya S, Waters AM, Russell RT, Yorkgitis BK, Mull J, Pence J, Santore MT, MacArthur TA, Klinkner DB, Safford SD, Trevilian T, Cunningham M, Black C, Rea J, Spurrier RG, Jensen AR, Farr BJ, Mooney DP, Ketha B, Dassinger MS, Goldenberg-Sandau A, Roman JS, Jenkins TM, Falcone RA, Polites SF. Prevalence and Outcomes of High versus Low Ratio Plasma to Red Blood Cell Resuscitation in a Multi-Institutional Cohort of Severely Injured Children. J Trauma Acute Care Surg 2024:01586154-990000000-00661. [PMID: 38497936 DOI: 10.1097/ta.0000000000004301] [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: 03/19/2024]
Abstract
BACKGROUND The benefit of targeting high ratio fresh frozen plasma (FFP):red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP:RBC transfusion and the association with outcomes in children presenting in shock. METHODS A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (>1:2) ratio FFP:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. RESULTS Of 135 children with median (IQR) age 10 (5,14) years and weight 40 (20,64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .05). CONCLUSION Despite increased injury severity, patients who received a high ratio of FFP:RBC had comparable rates of mortality. These data suggest high ratio FFP:RBC resuscitation is not associated with worst outcomes in children who present in shock. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE Prospective cohort study, Level II.
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Affiliation(s)
- Steven C Mehl
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Adam M Vogel
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | | | - Suzanne Moody
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Meera Kotagal
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Mark L Kayton
- Department of Surgery, K. Hovnanian Children's Hospital at Jersey Shore University Medical Center, Hackensack-Meridian Health Network, Neptune, New Jersey
| | | | | | | | | | | | - William B Rothstein
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia
| | - Laura A Boomer
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia
| | | | | | | | | | - Denise I Garcia
- The Medical University of South Carolina, Charleston, South Carolina
| | | | - Michaela Gaffley
- Wake Forest University School of Medicine, Brenner Children's Hospital, Winston-Salem, North Carolina
| | - John K Petty
- Wake Forest University School of Medicine, Brenner Children's Hospital, Winston-Salem, North Carolina
| | | | | | | | | | - Brian K Yorkgitis
- College of Medicine, University of Florida - Jacksonville, Jacksonville, Florida
| | - Jennifer Mull
- College of Medicine, University of Florida - Jacksonville, Jacksonville, Florida
| | | | | | | | | | - Shawn D Safford
- University of Pittsburgh Medical Center, Harrisburg, Pennsylvania
| | - Tanya Trevilian
- Carilion Children's Hospital, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Megan Cunningham
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Christa Black
- ProMedica Toledo and Toledo Children's Hospital, Toledo, Ohio
| | - Jessica Rea
- Children's Hospital Los Angeles, Los Angeles, California
| | | | - Aaron R Jensen
- Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | | | | | - Bavana Ketha
- Arkansas Children's Hospital, Little Rock, Arkansas
| | | | | | | | - Todd M Jenkins
- Mayo Clinic, Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota
| | - Richard A Falcone
- Mayo Clinic, Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota
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Ridings LE, Espeleta HC, Litvitskiy N, Higgins K, Bravoco O, Davidson TM, Streck CJ, Kassam-Adams N, Ruggiero KJ. Behavioral Health Screening and Follow-Up Services in Pediatric Trauma Centers Across the United States. J Pediatr Psychol 2023; 48:960-969. [PMID: 37794767 PMCID: PMC10653355 DOI: 10.1093/jpepsy/jsad067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 09/14/2023] [Accepted: 09/14/2023] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVE Over 120,000 U.S. children are hospitalized for traumatic injury annually, a major risk factor for behavioral health problems such as acute/posttraumatic stress disorder (PTSD) and depression. Pediatric trauma centers (PTCs) are well positioned to address the recent mandate by the American College of Surgeons Committee on Trauma to screen and refer for behavioral health symptoms. However, most PTCs do not provide screening or intervention, or use varying approaches. The objective of this mixed-methods study was to assess PTCs' availability of behavioral health resources and identify barriers and facilitators to service implementation following pediatric traumatic injury (PTI). METHODS Survey data were collected from 83 Level I (75%) and Level II (25%) PTC program managers and coordinators across 36 states. Semistructured, qualitative interviews with participants (N = 24) assessed the feasibility of implementing behavioral health education, screening, and treatment for PTI patients and caregivers. RESULTS Roughly half of centers provide behavioral health screening, predominantly administered by nurses for acute stress/PTSD. Themes from qualitative interviews suggest that (1) service provision varies by behavioral health condition, resource, delivery method, and provider; (2) centers are enthusiastic about service implementation including screening, inpatient brief interventions, and follow-up assessment; but (3) require training and lack staff, time, and funding to implement services. CONCLUSIONS Sustainable, scalable, evidence-based service models are needed to assess behavioral health symptoms after PTI. Leadership investment is needed for successful implementation. Technology-enhanced, stepped-care approaches seem feasible and acceptable to PTCs to ensure the availability of personalized care while addressing barriers to sustainability.
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Affiliation(s)
- Leigh E Ridings
- College of Nursing, Medical University of South Carolina, USA
| | | | | | - Kristen Higgins
- College of Nursing, Medical University of South Carolina, USA
| | - Olivia Bravoco
- College of Nursing, Medical University of South Carolina, USA
| | | | - Christian J Streck
- Department of Surgery, College of Medicine, Medical University of South Carolina, USA
| | - Nancy Kassam-Adams
- Center for Injury Research & Prevention, Children’s Hospital of Philadelphia, USA
- University of Pennsylvania Perelman School of Medicine, USA
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MacArthur TA, Vogel AM, Glasgow AE, Moody S, Kotagal M, Williams RF, Kayton ML, Alberto EC, Burd RS, Schroeppel TJ, Baerg JE, Munoz A, Rothstein WB, Boomer LA, Campion EM, Robinson C, Nygaard RM, Richardson CJ, Garcia DI, Streck CJ, Gaffley M, Petty JK, Ryan M, Pandya S, Russell RT, Yorkgitis BK, Mull J, Pence J, Santore MT, Klinkner DB, Safford SD, Trevilian T, Jensen AR, Mooney DP, Ketha B, Dassinger MS, Goldenberg-Sandau A, Falcone RA, Polites SF. Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis. J Trauma Acute Care Surg 2023; 95:78-86. [PMID: 37072882 DOI: 10.1097/ta.0000000000004013] [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: 04/20/2023]
Abstract
OBJECTIVE This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI. METHODS This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ 2t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses. RESULTS There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010). CONCLUSION Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Taleen A MacArthur
- Department of Surgery, Division of Pediatric Surgery (T.A.M., A.E.G., D.B.K., S.F.P.), Mayo Clinic, Rochester, Minnesota; Department of Pediatric Surgery (A.M.V.), Texas Children's Hospital, Houston, Texas; Division of Pediatric General and Thoracic Surgery (S.M., M.K., R.A.F.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Surgery (R.F.W.), Le Bonheur Children's Hospital, Memphis, Tennessee; Jersey Shore University Medical Center (M.L.K.), Hackensack-Meridian Health Network, Neptune, New Jersey; Department of Pediatric Surgery (E.C.A., R.S.B.), Children's National Hospital, Washington, DC; UCHealth Memorial Hospital (T.J.S.), Pediatric Surgery, Colorado Springs, Colorado; Division of Pediatric Surgery (J.E.B., A.M.), Loma Linda University, Loma Linda, California; Department of Surgery, Virginia Commonwealth University (W.B.R., L.A.B.), Children's Hospital of Richmond, Richmond, Virginia; Department of Surgery (E.M.C., C.R.), Denver Health Medical Center, Denver, Colorado; Department of Surgery (R.M.N., C.J.R.), Hennepin Healthcare, Minneapolis, Minnesota; Department of Surgery (D.I.G., C.J.S.), The Medical University of South Carolina, Charleston, South Carolina; Department of Surgery (M.G., J.K.P.), Wake Forest Baptist Medical Center, Brenner Children's Hospital, Winston-Salem, North Carolina; Department of Surgery (M.R., S.P.), Children's Health Dallas, Dallas, Texas; Department of Pediatric Surgery, (R.T.R.), Children's of Alabama, Birmingham, Alabama; Department of Surgery (B.K.Y., J.M.), College of Medicine, University of Florida Jacksonville, Jacksonville, Florida; Department of Surgery (J.P.), Dayton Children's Hospital, Dayton, Ohio; Department of Surgery (M.T.S.), Children's Healthcare of Atlanta, Atlanta, Georgia; Department of Surgery (S.D.S., T.T.), Carilion Children's Hospital, Carilion Roanoke Memorial Hospital, Roanoke, Virginia; Department of Surgery (A.R.J.), Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Pediatric Surgery (D.P.M.), Boston Children's Hospital, Boston, Massachusetts; Department of Surgery (B.K., M.S.D.), Arkansas Children's Hospital, Little Rock, Arkansas; and Department of Surgery (A.G.-S.), Cooper University Hospital, Camden, New Jersey
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Arshad SA, Garcia EI, Bell C, Avritscher EBC, Kumar M, Brahmamdam P, Fraser JA, St Peter SD, Aranda A, Hill M, Marquart J, Van Arendonk K, Plumblee L, Streck CJ, Zamora IJ, Ghani MOA, Reichard KW, Sacks K, Kallis M, Hong A, Richards H, Lin S, Gross ER, Kabeer MH, Reyna T, Paton EA, Camp LB, Stephenson K, Dassinger M, Vali K, Filipescu R, DeUgarte DA, Krishna V, Slater B, Islam S, Thompson G, Moore JT, Englum BR, Scholz S, Sharbaugh E, Gander JW, Tsao K. Multicenter Assessment of Cryoanalgesia Use in Minimally Invasive Repair of Pectus Excavatum: A 20-center Retrospective Cohort Study. Ann Surg 2023; 277:e1373-e1379. [PMID: 35797475 DOI: 10.1097/sla.0000000000005440] [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: 11/26/2022]
Abstract
OBJECTIVE To assess the clinical implications of cryoanalgesia for pain management in children undergoing minimally invasive repair of pectus excavatum (MIRPE). BACKGROUND MIRPE entails significant pain management challenges, often requiring high postoperative opioid use. Cryoanalgesia, which blocks pain signals by temporarily ablating intercostal nerves, has been recently utilized as an analgesic adjunct. We hypothesized that the use of cryoanalgesia during MIRPE would decrease postoperative opioid use and length of stay (LOS). MATERIALS AND METHODS A multicenter retrospective cohort study of 20 US children's hospitals was conducted of children (age below 18 years) undergoing MIRPE from January 1, 2014, to August 1, 2019. Differences in total postoperative, inpatient, oral morphine equivalents per kilogram, and 30-day LOS between patients who received cryoanalgesia versus those who did not were assessed using bivariate and multivariable analysis. P value <0.05 is considered significant. RESULTS Of 898 patients, 136 (15%) received cryoanalgesia. Groups were similar by age, sex, body mass index, comorbidities, and Haller index. Receipt of cryoanalgesia was associated with lower oral morphine equivalents per kilogram (risk ratio=0.43, 95% confidence interval: 0.33-0.57) and a shorter LOS (risk ratio=0.66, 95% confidence interval: 0.50-0.87). Complications were similar between groups (29.8% vs 22.1, P =0.07), including a similar rate of emergency department visit, readmission, and/or reoperation. CONCLUSIONS Use of cryoanalgesia during MIRPE appears to be effective in lowering postoperative opioid requirements and LOS without increasing complication rates. With the exception of preoperative gabapentin, other adjuncts appear to increase and/or be ineffective at reducing opioid utilization. Cryoanalgesia should be considered for patients undergoing this surgery.
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Affiliation(s)
- Seyed A Arshad
- McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Children's Memorial Hermann Hospital, Houston, TX
| | - Elisa I Garcia
- McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Children's Memorial Hermann Hospital, Houston, TX
| | - Cynthia Bell
- McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Children's Memorial Hermann Hospital, Houston, TX
| | - Elenir B C Avritscher
- McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Children's Memorial Hermann Hospital, Houston, TX
| | | | | | | | | | | | | | - John Marquart
- Medical College of Wisconsin/Children's Hospital of Wisconsin
| | | | - Leah Plumblee
- Medical University of South Carolina Shawn Jenkins Children's Hospital
| | | | - Irving J Zamora
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt
| | - Muhammad O A Ghani
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt
| | | | | | | | - Andrew Hong
- Northwell Health/Cohen Children's Medical Center
| | - Holden Richards
- Oregon Health and Science University/Doernbecher Children's Hospital
| | - Saunders Lin
- Oregon Health and Science University/Doernbecher Children's Hospital
| | - Erica R Gross
- Stony Brook Medicine/Stony Brook Children's Hospital
| | | | - Troy Reyna
- The University of California Irvine/CHOC Children's Hospital
| | - Elizabeth A Paton
- The University of Tennessee Health Science Center/Le Bonheur Children's Hospital
| | - Lauren B Camp
- The University of Tennessee Health Science Center/Le Bonheur Children's Hospital
| | - Krista Stephenson
- University of Arkansas for Medical Sciences/Arkansas Children's Hospital
| | - Melvin Dassinger
- University of Arkansas for Medical Sciences/Arkansas Children's Hospital
| | - Kaveh Vali
- University at Buffalo/Oishei Children's Hospital
| | | | | | - Vikram Krishna
- University of California-Los Angeles/Mattel Children's Hospital
| | | | - Saleem Islam
- University of Florida/Shands Children's Hospital
| | | | - James T Moore
- University of Maryland School of Medicine/University of Maryland Children's Hospital
| | - Brian R Englum
- University of Maryland School of Medicine/University of Maryland Children's Hospital
| | - Stefan Scholz
- University of Pittsburgh/UPMC Children's Hospital of Pittsburgh
| | | | - Jeffrey W Gander
- University of Virginia/University of Virginia Children's Hospital. Excluding those from the lead site, authors are listed by alphabetical order of their institution's name
| | - KuoJen Tsao
- McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Children's Memorial Hermann Hospital, Houston, TX
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Quinn KM, Runge LT, Parrado RH, Streck CJ, Abbott AM, Talley CL. General surgery applicants report the impact of virtual interviews on their rank list and match. Global Surg Educ 2022; 1:65. [PMID: 38013703 PMCID: PMC9640838 DOI: 10.1007/s44186-022-00071-8] [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] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 09/20/2022] [Accepted: 10/30/2022] [Indexed: 11/09/2022]
Abstract
Purpose The transition to an all-virtual application cycle for General Surgery Match 2021 significantly altered interview day and the interactions of applicants with residency programs. We sought to evaluate the impact of a virtual match cycle on applicants' rank list and Match results. Methods We surveyed applicants who were offered an interview for a categorical general surgery residency position at our institution during the 2021 match season. Voluntary anonymous surveys were sent after the rank list deadline and again after the Match. Results Out of 108 interviewees, 43 completed the survey (40%). Median age was 26, and 61% of respondents were male and 82% white, which skewed from our diverse interview pool. They completed a median of 17 interviews. 69% felt they had sufficient exposure to make their rank list, and this group reached statistically significant higher confidence in their decisions when compared with those who endorsed not having enough exposure to the residency programs (58% vs 42%, p = 0.02). Applicants cited the most influential interview day factors to be their interview with faculty and the virtual social with residents. Least important was their ability to assess the hospital facility. Among seven different program factors, comradery between faculty and residents (31%) and perceived happiness of the residents (18.6%) were most often selected most influential. Only 56% reported ranking all programs at which they interviewed. After submitting their rank list, 59% of applicants stated they had not visited the city of their top ranked program; however, post-match surveys revealed only 44% matched to a program in a city unknown to them. 57% of applicants stated they reached out to their top choice program with additional questions, but only 47% matched at one of those institutions. Conclusions Even in the constraints of the virtual interviews, most applicants felt they had sufficient exposure to programs to make their rank list. Applicants were willing to highly rank cities they had never visited and to reach out to programs but were ultimately less successful matching at those programs. Understanding what factors and communications most impact applicants and programs may lead to a more successful Match. Supplementary Information The online version contains supplementary material available at 10.1007/s44186-022-00071-8.
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Affiliation(s)
- Kristen M. Quinn
- Department of Surgery, Medical University of South Carolina, Charleston, SC USA
| | - Louis T. Runge
- College of Medicine, Medical University of South Carolina, Charleston, SC USA
| | - Raphael H. Parrado
- Department of Surgery, Medical University of South Carolina, Charleston, SC USA
| | - Christian J. Streck
- Department of Surgery, Medical University of South Carolina, Charleston, SC USA
| | - Andrea M. Abbott
- Department of Surgery, Medical University of South Carolina, Charleston, SC USA
| | - Cynthia L. Talley
- Department of Surgery, Medical University of South Carolina, Charleston, SC USA
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Quinn KM, Campbell L, Mukherjee R, Abbott AM, Streck CJ. Step 1 is Pass/Fail, Now What? Can Clinical Clerkship Grades be Used as a Reliable Metric to Screen General Surgery Residency Applicants? J Surg Res 2022; 279:592-597. [DOI: 10.1016/j.jss.2022.06.047] [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: 12/24/2021] [Revised: 05/30/2022] [Accepted: 06/13/2022] [Indexed: 10/31/2022]
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Ridings LE, Espeleta HC, Streck CJ, Davidson TM, Litvitskiy N, Bravoco O, Kassam-Adams N, Ruggiero KJ. Assessing service quality and access in trauma centers through behavioral health screening, education, and treatment after pediatric injury. J Pediatr Surg 2022; 57:632-636. [PMID: 35090719 PMCID: PMC9287491 DOI: 10.1016/j.jpedsurg.2022.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/07/2022] [Accepted: 01/12/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Over 120,000 U.S. children are hospitalized annually for traumatic injury, with approximately 20% developing acute stress disorder (ASD), posttraumatic stress disorder (PTSD), or depression. The ACS COT recommends that trauma centers address emotional recovery after injury; however, few pediatric trauma centers (PTCs) assess behavioral health symptoms. This study describes results from a survey with PTC providers assessing the landscape of behavioral health screening, education, and treatment. METHODS Trauma program leaders from 83 US Level I and II trauma centers across 36 states completed a survey assessing center characteristics and decision-making, availability, and perceptions of behavioral health resources. RESULTS Nearly half (46%) of centers provide behavioral health screens for pediatric patients, and 18% screen family members, with screens mostly conducted by nurses or social workers for ASD or PTSD. Two-thirds provide child behavioral health education and 47% provide education to caregivers/family. Two-thirds provide treatment connections, typically via referrals or outpatient clinics. Behavioral health screening, education, and treatment connections were rated as very important (M > 8.5/10), with higher ratings for the importance of screening children versus caregivers. Child maltreatment (59%), observed patient distress (53%), child substance use (52%), injury mechanism (42%) and severity (42%) were prioritized in screening decision-making. CONCLUSION Service provision varies by method, resource, and provider, highlighting the lack of a roadmap for centers to provide behavioral health services. Adoption of universal education and screening procedures in PTCs is crucial to increase access to services for injured children and caregivers. PTCs are well-positioned to offer these services. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Leigh E Ridings
- Medical University of South Carolina, College of Nursing, Charleston, SC, United States.
| | - Hannah C Espeleta
- Medical University of South Carolina, College of Nursing, Charleston, SC, United States
| | - Christian J Streck
- Medical University of South Carolina, College of Medicine, Department of Surgery, Charleston, SC, United States
| | - Tatiana M Davidson
- Medical University of South Carolina, College of Nursing, Charleston, SC, United States
| | - Nicole Litvitskiy
- Medical University of South Carolina, College of Nursing, Charleston, SC, United States
| | - Olivia Bravoco
- Medical University of South Carolina, College of Nursing, Charleston, SC, United States
| | - Nancy Kassam-Adams
- Children's Hospital of Philadelphia, Center for Injury Research and Prevention, Philadelphia, PA, United States; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Kenneth J Ruggiero
- Medical University of South Carolina, College of Nursing, Charleston, SC, United States
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Ridings LE, Davidson TM, Walker J, Winkelmann J, Anton MT, Espeleta HC, Nemeth LS, Streck CJ, Ruggiero KJ. Caregivers' and Young Children's Emotional Health Needs After Pediatric Traumatic Injury. Clin Pediatr (Phila) 2022; 61:560-569. [PMID: 35581720 PMCID: PMC9329229 DOI: 10.1177/00099228221097498] [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: 11/15/2022]
Abstract
Pediatric traumatic injury (PTI) is associated with emotional health difficulties, but most US trauma centers do not adequately address emotional recovery needs. This study aimed to assess families' emotional health needs following PTI and determine how technology could be used to inform early interventions. Individual semi-structured, qualitative interviews were conducted with caregivers of children admitted to a Level I trauma center in the Southeastern United States to understand families' experiences in-hospital and post-discharge. Participants included 20 caregivers of PTI patients under age 12 (M = 6.4 years; 70% male, 45% motor vehicle collision). Thematic analysis was used to analyze data from interviews that were conducted until saturation. Caregivers reported varying emotional needs in hospital and difficulties adjusting after discharge. Families responded enthusiastically to the potential of a technology-enhanced resource for families affected by PTI. A cost-effective, scalable intervention is needed to promote recovery and has potential for widespread pediatric hospital uptake.
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Affiliation(s)
- Leigh E. Ridings
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Tatiana M. Davidson
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | | | - Jennifer Winkelmann
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Margaret T. Anton
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Hannah C. Espeleta
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Lynne S. Nemeth
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Christian J. Streck
- Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kenneth J. Ruggiero
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
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10
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Kornblith AE, Singh C, Devlin G, Addo N, Streck CJ, Holmes JF, Kuppermann N, Grupp-Phelan J, Fineman J, Butte AJ, Yu B. Predictability and stability testing to assess clinical decision instrument performance for children after blunt torso trauma. PLOS Digit Health 2022; 1:e0000076. [PMID: 36812570 PMCID: PMC9931266 DOI: 10.1371/journal.pdig.0000076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/14/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The Pediatric Emergency Care Applied Research Network (PECARN) has developed a clinical-decision instrument (CDI) to identify children at very low risk of intra-abdominal injury. However, the CDI has not been externally validated. We sought to vet the PECARN CDI with the Predictability Computability Stability (PCS) data science framework, potentially increasing its chance of a successful external validation. MATERIALS & METHODS We performed a secondary analysis of two prospectively collected datasets: PECARN (12,044 children from 20 emergency departments) and an independent external validation dataset from the Pediatric Surgical Research Collaborative (PedSRC; 2,188 children from 14 emergency departments). We used PCS to reanalyze the original PECARN CDI along with new interpretable PCS CDIs developed using the PECARN dataset. External validation was then measured on the PedSRC dataset. RESULTS Three predictor variables (abdominal wall trauma, Glasgow Coma Scale Score <14, and abdominal tenderness) were found to be stable. A CDI using only these three variables would achieve lower sensitivity than the original PECARN CDI with seven variables on internal PECARN validation but achieve the same performance on external PedSRC validation (sensitivity 96.8% and specificity 44%). Using only these variables, we developed a PCS CDI which had a lower sensitivity than the original PECARN CDI on internal PECARN validation but performed the same on external PedSRC validation (sensitivity 96.8% and specificity 44%). CONCLUSION The PCS data science framework vetted the PECARN CDI and its constituent predictor variables prior to external validation. We found that the 3 stable predictor variables represented all of the PECARN CDI's predictive performance on independent external validation. The PCS framework offers a less resource-intensive method than prospective validation to vet CDIs before external validation. We also found that the PECARN CDI will generalize well to new populations and should be prospectively externally validated. The PCS framework offers a potential strategy to increase the chance of a successful (costly) prospective validation.
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Affiliation(s)
- Aaron E. Kornblith
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, United States of America
- Department of Pediatrics, University of California, San Francisco, San Francisco, United States of America
| | - Chandan Singh
- Department of Electrical Engineering & Computer Science, University of California, Berkeley, Berkeley, United States of America
| | - Gabriel Devlin
- Department of Pediatrics, University of California, San Francisco, San Francisco, United States of America
| | - Newton Addo
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, United States of America
| | - Christian J. Streck
- Department of Surgery, Medical University of South Carolina, Children’s Hospital, Charleston, United States of America
| | - James F. Holmes
- Department of Emergency Medicine, University of California, Davis, Davis, United States of America
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis, Davis, United States of America
- Department of Pediatrics, University of California, Davis, Davis, United States of America
| | - Jacqueline Grupp-Phelan
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, United States of America
- Department of Pediatrics, University of California, San Francisco, San Francisco, United States of America
| | - Jeffrey Fineman
- Department of Pediatrics, University of California, San Francisco, San Francisco, United States of America
| | - Atul J. Butte
- Bakar Computational Health Sciences Institute, University of California, San Francisco, San Francisco, United States of America
| | - Bin Yu
- Department of Electrical Engineering & Computer Science, University of California, Berkeley, Berkeley, United States of America
- Departments of Statistics, University of California, Berkeley, Berkeley, United States of America
- * E-mail:
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11
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Khan HH, Streck CJ, Eklund MJ. A Partial Esophageal Duplication in a Two-Year-Old Female-An Incidental Finding. J Pediatr Gastroenterol Nutr 2022; 74:e127. [PMID: 35579881 DOI: 10.1097/mpg.0000000000003436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
| | | | - Meryle J Eklund
- Department of Pediatric Radiology, Shawn Jenkins Children's Hospital, Medical University of South Carolina, Charleston, SC
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12
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Mehl SC, Cunningham ME, Streck CJ, Pettit R, Huang EY, Santore MT, Tsao K, Falcone RA, Dassinger MS, Haynes JH, Russell RT, Naik-Mathuria BJ, St Peter SD, Mooney D, Upperman J, Blakely ML, Vogel AM. Characteristics and predictors of intensive care unit admission in pediatric blunt abdominal trauma. Pediatr Surg Int 2022; 38:589-597. [PMID: 35124723 PMCID: PMC9087985 DOI: 10.1007/s00383-022-05067-5] [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] [Accepted: 01/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pediatric trauma patients sustaining blunt abdominal trauma (BAT) with intra-abdominal injury (IAI) are frequently admitted to the intensive care unit (ICU). This study was performed to identify predictors for ICU admission following BAT. METHODS Prospective study of children (< 16 years) who presented to 14 Level-One Pediatric Trauma Centers following BAT over a 1-year period. Patients were categorized as ICU or non-ICU patients. Data collected included vitals, physical exam findings, laboratory results, imaging, and traumatic injuries. A multivariable hierarchical logistic regression model was used to identify predictors of ICU admission. Predictive ability of the model was assessed via tenfold cross-validated area under the receiver operating characteristic curves (cvAUC). RESULTS Included were 2,182 children with 21% (n = 463) admitted to the ICU. On univariate analysis, ICU patients were associated with abnormal age-adjusted shock index, increased injury severity scores (ISS), lower Glasgow coma scores (GCS), traumatic brain injury (TBI), and severe solid organ injury (SOI). With multivariable logistic regression, factors associated with ICU admission were severe trauma (ISS > 15), anemia (hematocrit < 30), severe TBI (GCS < 8), cervical spine injury, skull fracture, and severe solid organ injury. The cvAUC for the multivariable model was 0.91 (95% CI 0.88-0.92). CONCLUSION Severe solid organ injury and traumatic brain injury, in association with multisystem trauma, appear to drive ICU admission in pediatric patients with BAT. These results may inform the design of a trauma bay prediction rule to assist in optimizing ICU resource utilization after BAT. STUDY DESIGN Prognosis study. LEVEL OF EVIDENCE: 1
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Affiliation(s)
- Steven C Mehl
- Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street #1210, Houston, TX, 77030, USA
| | - Megan E Cunningham
- Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street #1210, Houston, TX, 77030, USA
| | - Christian J Streck
- Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Rowland Pettit
- Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street #1210, Houston, TX, 77030, USA
| | | | | | - Kuojen Tsao
- Children's Memorial Hermann Hospital, Houston, TX, USA
| | | | | | - Jeffrey H Haynes
- Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA
| | | | - Bindi J Naik-Mathuria
- Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street #1210, Houston, TX, 77030, USA
| | | | | | | | | | - Adam M Vogel
- Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street #1210, Houston, TX, 77030, USA.
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Quinn KM, Parrado RH, Talley CL, Streck CJ, Abbott AM. The General Surgery Residency Applicant Perspective: Virtual Interviews Limit Current Resident and Faculty Exposure, But Save Money. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.478] [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: 11/27/2022]
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14
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Evans LL, Williams RF, Jin C, Plumblee L, Naik-Mathuria B, Streck CJ, Jensen AR. Hospital-based intervention is rarely needed for children with low-grade blunt abdominal solid organ injury: An analysis of the Trauma Quality Improvement Program registry. J Trauma Acute Care Surg 2021; 91:590-598. [PMID: 34559162 PMCID: PMC8553177 DOI: 10.1097/ta.0000000000003206] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Children with low-grade blunt solid organ injury (SOI) have historically been admitted to an inpatient setting for monitoring, but the evidence supporting the necessity of this practice is lacking. The purpose of this study was to quantify the frequency and timing of intervention for hemorrhage and to describe hospital-based resource utilization for low-grade SOI in the absence of other major injuries (OMIs). METHODS A cohort of children (aged <16 years) with blunt American Association for the Surgery of Trauma grade 1 or 2 SOI from the American College of Surgeons Trauma Quality Improvement Program registry (2007-2017) was analyzed. Children were excluded if they had confounding factors associated with intervention for hemorrhage (comorbidities, OMIs, or extra-abdominal surgical procedures). Outcomes included frequency and timing of intervention (laparotomy, angiography, or transfusion) for hemorrhage, as well as hospital-based resource utilization. RESULTS A total of 1,019 children were identified with low-grade blunt SOI and no OMIs. Nine hundred eighty-six (96.8%) of these children were admitted to an inpatient unit. Admitted children with low-grade SOI had a median length-of-stay of 2 days and a 23.9% intensive care unit admission rate. Only 1.7% (n = 17) of patients with low-grade SOI underwent an intervention, with the median time to intervention being the first hospital day. No child who underwent angiography was transfused or had an abnormal initial ED shock index. CONCLUSION Children with low-grade SOI are routinely admitted to the hospital and often to the intensive care unit but rarely undergo hospital-based intervention. The most common intervention was angiography, with questionable indications in this cohort. These data question the need for inpatient admission for low-grade SOI and suggest that discharge from the emergency room may be safe. Prospective investigation into granular risk factors to identify the rare patient needing hospital-based intervention is needed, as is validation of the safety of ambulatory management. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
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Affiliation(s)
- Lauren L Evans
- Division of Pediatric Surgery, University of California San Francisco Benioff Children’s Hospital Oakland, Oakland, CA 94611
| | - Regan F Williams
- Division of Pediatric Surgery, Le Bonheur Children’s Hospital, The University of Tennessee Health Science Center, Memphis, TN, 38103
| | - Chengshi Jin
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, 94143
| | - Leah Plumblee
- Division of Pediatric Surgery, Children’s Health, Medical University of South Carolina, Charleston, SC, 29425
| | - Bindi Naik-Mathuria
- Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, 77030
| | - Christian J Streck
- Division of Pediatric Surgery, Children’s Health, Medical University of South Carolina, Charleston, SC, 29425
| | - Aaron R Jensen
- Division of Pediatric Surgery, University of California San Francisco Benioff Children’s Hospital Oakland, Oakland, CA 94611
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA 93721
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15
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Garcia DI, Baker C, Patel S, Hebra AV, Cina RA, Streck CJ, Lesher AP. Long-term outcomes of pediatric laparoscopic needled-assisted inguinal hernia repair: A 10-year experience. J Pediatr Surg 2021; 56:121-125. [PMID: 33246576 PMCID: PMC7818020 DOI: 10.1016/j.jpedsurg.2020.09.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/22/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE Laparoscopic inguinal hernia repair (LIHR) has gained wide acceptance over the past decade, although studies with longer term follow-up are lacking. We present one of the largest cohorts of children undergoing laparoscopic needle-assisted repair (LNAR) with long-term follow-up. METHODS A clinical quality database was maintained for children ≤14 years of age who underwent laparoscopic needle-assisted repair between 2009 and 2017 with review of follow-up through 2019. De-identified data was reviewed. RESULTS 1023 patients with 1457 LNAR were included during the 10-year period. Mean age at surgery was 2.56 years (2 days to14 years). The overall hernia recurrence rate was 0.75% (11/1457). A total of four postoperative hydroceles required intervention. Preterm infant repair done <60w post conceptional age had a significantly lower recurrence rate (0.63%) than other patients (0.82%) (p < 0.01). 64.2% of patients had clinical follow-up over a period of 11 years with a mean follow-up of 5.97 years. CONCLUSION We present a large cohort study of consecutive pediatric laparoscopic hernia repairs followed over an 11-year period. LNAR is safe and effective for term and preterm patients with similar complication rates to other techniques, including open repair. Additionally, our results suggest that preterm infants may have superior outcomes with this method. LEVEL OF EVIDENCE Level III - Retrospective Comparative Study.
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Affiliation(s)
| | - Charles Baker
- Medical University of South Carolina, Charleston, SC
| | - Sahil Patel
- Medical University of South Carolina, Charleston, SC
| | | | - Robert A Cina
- Medical University of South Carolina, Charleston, SC; MUSC Health Shawn Jenkins Children's Hospital, Charleston, SC
| | - Christian J Streck
- Medical University of South Carolina, Charleston, SC; MUSC Health Shawn Jenkins Children's Hospital, Charleston, SC
| | - Aaron P Lesher
- Medical University of South Carolina, Charleston, SC; MUSC Health Shawn Jenkins Children's Hospital, Charleston, SC.
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16
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Garcia DI, Pannuccio A, Gallegos J, Mullner D, Cameron J, Mukherjee R, Streck CJ, Abbott AM. Resident-Driven Wellness Initiatives Improve Resident Wellness and Perception of Work Environment. J Surg Res 2020; 258:8-16. [PMID: 32971339 DOI: 10.1016/j.jss.2020.06.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/27/2020] [Accepted: 06/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Resident burnout is associated with increased adverse patient events and increased incidence of resident depression and suicide when compared to the general population. We hypothesized that resident-driven assessment and implementation of wellness measures would allow implementation of desired interventions and facilitate improvement in wellness. METHODS A wellness intervention team was established to address resident wellness and job satisfaction. A needs assessment to determine desired interventions as well as a three-part anonymous 5-point Likert scale survey was developed and distributed to general surgery residents. Following implementation of three measures, a postintervention survey was administered at 6 and 15 mo to the same cohort. Analysis of variance test was used to evaluate for significant difference between preintervention and postintervention surveys. RESULTS Three interventions were implemented: two protected weekday personal days per year, modernization of resident workspace, and additional meal funds. There were statistically significant changes in perceptions of wellness opportunities (3.14 versus 3.88 and 3.7; P < 0.05), time for wellness (2.53 versus 3.42 and 3.2; P < 0.05), work/life balance satisfaction (2.86 versus 3.71 and 3.41; P < 0.05), and improved quality of life (2.67 versus 3.3 and 3.0; P < 0.05) in both 6-mo and 15-mo postintervention responses. CONCLUSIONS Implementation of resident-selected wellness measures was found to influence overall resident satisfaction and improved perception of the working environment. Several scores of wellness items showed sustained improvement at 15 mo. These results suggest that resident-driven wellness interventions can positively affect working conditions for residents.
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Affiliation(s)
- Denise I Garcia
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina; Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina
| | - Alexandria Pannuccio
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Jose Gallegos
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Donna Mullner
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - June Cameron
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Rupak Mukherjee
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Christian J Streck
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Andrea M Abbott
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina; Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina.
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17
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Lalich M, Streck CJ, Kane I. A 13-Year-Old Male With Hematuria and Abdominal Pain Following Low-Impact Trauma. Clin Pediatr (Phila) 2020; 59:831-833. [PMID: 32336129 DOI: 10.1177/0009922820916893] [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] [Indexed: 11/16/2022]
Affiliation(s)
- Missy Lalich
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Ian Kane
- Medical University of South Carolina, Charleston, SC, USA
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18
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Ridings LE, Anton MT, Winkelmann J, Davidson TM, Wray L, Streck CJ, Ruggiero KJ. Trauma Resilience and Recovery Program: Addressing Mental Health in Pediatric Trauma Centers. J Pediatr Psychol 2020; 44:1046-1056. [PMID: 31298276 DOI: 10.1093/jpepsy/jsz053] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 10/31/2018] [Revised: 05/23/2019] [Accepted: 06/03/2019] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE Approximately 225,000 children sustain injuries requiring hospitalization annually. Posttraumatic stress disorder (PTSD) and depression are prevalent among pediatric patients and caregivers post-injury. Most U.S. trauma centers do not address patients' mental health needs. Better models of care are needed to address emotional recovery. This article describes the engagement and recovery trajectories of pediatric patients enrolled in the Trauma Resilience and Recovery Program (TRRP), a stepped-care model to accelerate emotional recovery following hospitalization. METHODS TRRP is designed to (a) provide in-hospital education about post-injury emotional recovery and assess child and caregiver distress; (b) track mental health symptoms via a 30-day text-messaging program; (c) complete 30-day PTSD and depression phone screens; and (d) provide evidence-based treatment via telehealth or in-person services or referrals, if needed. All 154 families approached were offered TRRP services, 96% of whom agreed to enroll in TRRP. Most patients were boys (59.8%), and average age was 9.12 years [standard deviation (SD) = 5.42]. Most injuries (45.8%) were sustained from motor vehicle accidents. RESULTS In hospital, 68.5% of caregivers and 78.3% of children reported clinically significant distress levels. Over 60% of families enrolled in the texting service. TRRP re-engaged 40.1% of families for the 30-day screen, 35.5% of whom reported clinically significant PTSD (M = 13.90, SD = 11.42) and/or depression (M = 13.35, SD = 11.16). Most (76%) patients with clinically significant symptomology agreed to treatment. CONCLUSIONS Our intervention model was feasible and increased reach to families who needed services. Efforts to improve follow-up engagement are discussed, as are initial successes in implementing this model in other pediatric trauma centers.
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Affiliation(s)
| | | | | | | | - Lauren Wray
- Department of Psychiatry and Behavioral Sciences, National Crime Victims Center, Medical University of South Carolina
| | - Christian J Streck
- Department of Surgery, College of Medicine, Medical University of South Carolina
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19
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Vogel AM, Zhang J, Mauldin PD, Williams RF, Huang EY, Santore MT, Tsao K, Falcone RA, Dassinger MS, Haynes JH, Blakely ML, Russell RT, Naik-Mathuria BJ, St Peter SD, Mooney D, Upperman JS, Streck CJ. Variability in the evalution of pediatric blunt abdominal trauma. Pediatr Surg Int 2019; 35:479-485. [PMID: 30426222 DOI: 10.1007/s00383-018-4417-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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] [Accepted: 11/03/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe the practice pattern for routine laboratory and imaging assessment of children following blunt abdominal trauma (BAT). METHODS Children (age < 16 years) presenting to 14 pediatric trauma centers following BAT over a 1-year period were prospectively identified. Injury, demographic, routine laboratory and imaging utilization data were collected. Descriptive, comparative, and correlation analysis was performed. RESULTS 2188 children with a median age of 8 (4,12) years were included and the median injury severity score was 5 (1,10). There were significant differences in activation status, injury severity, and mechanism across centers; however, there was no correlation of level of activation, injury severity, or severe mechanism with test utilization. Routine laboratory and imaging utilization for hematocrit, hepatic enzymes, pancreatic enzymes, base deficit urine microscopy, chest and pelvis X-ray, and abdominal computed tomography (CT) varied significantly among centers. Only obtaining a hematocrit had a moderate correlation with CT use. There was no correlation between centers that were high or low frequency laboratory utilizers with CT use. CONCLUSIONS Wide variability exists in the routine initial laboratory and imaging assessment in children following BAT. This represents an opportunity for quality improvement in pediatric trauma. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Adam M Vogel
- Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX, 77030, USA.
| | - Jingwen Zhang
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Regan F Williams
- University of Tennessee Health Science Center at Memphis, Memphis, TN, USA
| | - Eunice Y Huang
- University of Tennessee Health Science Center at Memphis, Memphis, TN, USA
| | | | - Kuojen Tsao
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | | | | | | | - Robert T Russell
- University of Alabama Birmingham School of Medicine, Birmingham, AL, USA
| | - Bindi J Naik-Mathuria
- Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX, 77030, USA
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20
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Calder BW, Sakran JV, Streck CJ, Cina RA. What Happened to the Complication? The Importance of ACS NSQIP Pediatric in Optimizing Quality Improvement Initiatives for Resident Education. J Surg Educ 2017; 74:431-436. [PMID: 28089474 DOI: 10.1016/j.jsurg.2016.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 11/18/2016] [Accepted: 11/24/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Morbidity and Mortality (M&M) conference is considered the golden hour of surgical education. Most training programs lack standardized methods to evaluate self-reported outcomes and contributions to resident education. The purpose of this study was to determine whether residents underreport pediatric postoperative complications thereby limiting a comprehensive educational opportunity and the ability to adequately perform quality improvement during M&M conference. DESIGN A retrospective analysis of resident reports submitted to the M&M committee at an academic medical center was conducted over 1 year. All complications were compared to the American College of Surgeons (ACS) Pediatric National Surgical Quality Improvement Program (NSQIP) data abstracted over the same period. A descriptive analysis of perioperative events was performed. SETTING This study was conducted at the Medical University of South Carolina Medical Center and MUSC Children's Hospital, an academic tertiary care center located in Charleston, South Carolina. RESULTS Overall, 81 complications were captured. Resident and NSQIP databases captured 27 (33%) and 68 (84%) complications, respectively. Residents were more likely to report major complications. More common sources of postoperative morbidity, including surgical site infection and transfusion, were underreported at 20% and 5%, respectively. CONCLUSIONS Resident reporting inadequately captures the full complement of pediatric perioperative complications. NSQIP-abstracted data serve as a useful adjunct to traditional M&M reporting in capturing complications underreported by trainees.
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Affiliation(s)
- Bennett W Calder
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Joseph V Sakran
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Christian J Streck
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Robert A Cina
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina.
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Streck CJ, Vogel AM, Zhang J, Huang EY, Santore MT, Tsao K, Falcone RA, Dassinger MS, Russell RT, Blakely ML, Mauldin PD, Calder BW, Savoie KB, Haynes JH, Naik-Mathuria BJ, St Peter SD, Mooney DP, Onwubiko C, Upperman JS. Identifying Children at Very Low Risk for Blunt Intra-Abdominal Injury in Whom CT of the Abdomen Can Be Avoided Safely. J Am Coll Surg 2017; 224:449-458.e3. [DOI: 10.1016/j.jamcollsurg.2016.12.041] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 12/19/2016] [Indexed: 11/29/2022]
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Putnam LR, Levy SM, Blakely ML, Lally KP, Wyrick DL, Dassinger MS, Russell RT, Huang EY, Vogel AM, Streck CJ, Kawaguchi AL, Calkins CM, St Peter SD, Abbas PI, Lopez ME, Tsao K. A multicenter, pediatric quality improvement initiative improves surgical wound class assignment, but is it enough? J Pediatr Surg 2016; 51:639-44. [PMID: 26590473 DOI: 10.1016/j.jpedsurg.2015.10.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [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: 06/07/2015] [Revised: 08/21/2015] [Accepted: 10/10/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE Surgical wound classification (SWC) is widely utilized for surgical site infection (SSI) risk stratification and hospital comparisons. We previously demonstrated that nearly half of common pediatric operations are incorrectly classified in eleven hospitals. We aimed to improve multicenter, intraoperative SWC assignment through targeted quality improvement (QI) interventions. METHODS A before-and-after study from 2011-2014 at eleven children's hospitals was conducted. The SWC recorded in the hospital's intraoperative record (hospital-based SWC) was compared to the SWC assigned by a surgeon reviewer utilizing a standardized algorithm. Study centers independently performed QI interventions. Agreement between the hospital-based and surgeon SWC was analyzed with Cohen's weighted kappa and chi square. RESULTS Surgeons reviewed 2034 cases from 2011 (Period 1) and 1998 cases from 2013 (Period 2). Overall SWC agreement improved from 56% to 76% (p<0.01) and weighted kappa from 0.45 (95% CI 0.42-0.48) to 0.73 (95% CI 0.70-0.75). Median (range) improvement per institution was 23% (7-35%). A dose-response-like pattern was found between the number of interventions implemented and the amount of improvement in SWC agreement at each institution. CONCLUSIONS Intraoperative SWC assignment significantly improved after resource-intensive, multifaceted interventions. However, inaccurate wound classification still commonly occurred. SWC used in SSI risk-stratification models for hospital comparisons should be carefully evaluated.
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Affiliation(s)
- Luke R Putnam
- Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA
| | - Shauna M Levy
- Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA
| | - Martin L Blakely
- Vanderbilt Children's Hospital, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kevin P Lally
- Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA
| | - Deidre L Wyrick
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Melvin S Dassinger
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Robert T Russell
- Children's of Alabama, University of Alabama Birmingham School of Medicine, Birmingham, AL, USA
| | - Eunice Y Huang
- Le Bonheur Children's Hospital, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Adam M Vogel
- St. Louis Children's Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Christian J Streck
- MUSC Children's Hospital, Medical University of South Carolina, Charleston, SC, USA
| | - Akemi L Kawaguchi
- Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA; Children's Hospital Los Angeles, Keck Medical Center of USC, Los Angeles, CA, USA
| | - Casey M Calkins
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Shawn D St Peter
- Children's Mercy Hospital, University of Missouri - Kansas City School of Medicine, Kansas City, MO, USA
| | - Paulette I Abbas
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Monica E Lopez
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - KuoJen Tsao
- Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA.
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Dassinger MS, Renaud EJ, Goldin A, Huang EY, Russell RT, Streck CJ, Tang X, Blakely ML. Use of real-time ultrasound during central venous catheter placement: Results of an APSA survey. J Pediatr Surg 2015; 50:1162-7. [PMID: 25783346 DOI: 10.1016/j.jpedsurg.2015.03.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 02/23/2015] [Accepted: 03/06/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to document the attitudes and practice patterns of pediatric surgeons regarding use of RTUS with CVC placement. METHODS An analytic survey composed of 20 questions was sent via APSA headquarters to all practicing members. Answers were summarized as frequency and percentage. Distributions of answers were compared using the chi-square tests. P-values ≤0.05 were considered statistically significant. RESULTS 361 of 1072 members chose to participate for a response rate of 34%. Most placed CVCs into the subclavian veins (SCV) of patients without coagulopathy, with the left SCV chosen approximately four times more often than the right. Conversely, RTUS use at the internal jugular vein (IJV) was significantly greater than that for the SCV (p<0.001). Coagulopathy, multiple previous catheters, and morbid obesity were identified as patient characteristics that would encourage RTUS use. The most commonly cited potential barriers to RTUS use were lack of formal ultrasound training and the belief that ultrasound is not necessary. CONCLUSIONS Variability exists among pediatric surgeons regarding use of RTUS during CVC placement. Additional studies are needed to document actual frequency of use, how RTUS is implemented, and its efficacy of preventing adverse events in children.
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Affiliation(s)
- Melvin S Dassinger
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR.
| | | | - Adam Goldin
- Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Eunice Y Huang
- University of Tennessee Health Sciences Center, Memphis, TN
| | - Robert T Russell
- Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, AL
| | | | - Xinyu Tang
- Biostatistics Program, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Martin L Blakely
- Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
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Levy SM, Lally KP, Blakely ML, Calkins CM, Dassinger MS, Duggan E, Huang EY, Kawaguchi AL, Lopez ME, Russell RT, St Peter SD, Streck CJ, Vogel AM, Tsao K. Surgical Wound Misclassification: A Multicenter Evaluation. J Am Coll Surg 2015; 220:323-9. [DOI: 10.1016/j.jamcollsurg.2014.11.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Revised: 11/16/2014] [Accepted: 11/17/2014] [Indexed: 11/28/2022]
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Affiliation(s)
- Christian J. Streck
- Division of Pediatric Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Pinckney J. Maxwell
- Division of Gastrointestinal and Laparoscopic Surgery, Medical University of South Carolina, Charleston, South Carolina
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26
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Streck CJ, Maxwell PJ. A brief history of appendicitis: familiar names and interesting patients. Am Surg 2014; 80:105-108. [PMID: 24480208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Christian J Streck
- Division of Pediatric Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Thompson AJ, McSwain SD, Webb SA, Stroud MA, Streck CJ. Venous thromboembolism prophylaxis in the pediatric trauma population. J Pediatr Surg 2013; 48:1413-21. [PMID: 23845640 DOI: 10.1016/j.jpedsurg.2013.02.059] [Citation(s) in RCA: 38] [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: 07/08/2012] [Revised: 02/13/2013] [Accepted: 02/15/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND/PURPOSE The aim of this study was to review evidence-based literature addressing pertinent questions about venous thromboembolism (VTE) after traumatic injury in children. METHODS Data were obtained from English-language articles identified through Pubmed published from 1995 until November 2012, and from bibliographies of relevant articles. Studies were included if they contributed evidence to one of the following questions. In the pediatric traumatic injury population: (1) What is the overall incidence of VTE? (2) Is age (adolescence versus pre-adolescence) associated with higher VTE incidence? (3) Which risk factors are associated with higher VTE incidence? (4) Does mechanical and/or pharmacological prophylaxis impact outcomes? RESULTS Eighteen articles were included in this systematic review. The evidence regarding each question was evaluated, graded by author consensus, and summarized. CONCLUSIONS The overall incidence of VTE is low. Older (>13years) and more severely injured patients are at higher VTE risk. Additional factors including injury type or presence of a central venous catheter also place a patient at higher VTE risk. Implementation of a risk-based clinical practice guideline for VTE prophylaxis has been associated with reduced symptomatic VTE at one institution. Randomized, prospective trials analyzing outcomes of VTE prophylaxis in pediatric trauma victims are needed.
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Affiliation(s)
- A Jill Thompson
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC, USA.
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Perna MJ, Streck CJ. A large solitary desmoplastic small round cell tumor. Am Surg 2012; 78:E316-E317. [PMID: 22643247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Mark J Perna
- Medical University of South Carolina, Charleston, South Carolina, USA.
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29
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Affiliation(s)
- Mark J. Perna
- Medical University of South Carolina Charleston, South Carolina
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30
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Lesher AP, Curry RH, Evans J, Smith VA, Fitzgerald MT, Cina RA, Streck CJ, Hebra AV. Effectiveness of Biobrane for treatment of partial-thickness burns in children. J Pediatr Surg 2011; 46:1759-63. [PMID: 21929986 PMCID: PMC4257603 DOI: 10.1016/j.jpedsurg.2011.03.070] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [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: 11/20/2010] [Revised: 03/28/2011] [Accepted: 03/28/2011] [Indexed: 11/25/2022]
Abstract
PURPOSE Wound care for partial-thickness burns should alleviate pain, decrease hospital length of stay, and be readily applied to a variety of wounds. The effectiveness of Biobrane (UDL Laboratories, Rockford, IL) is compared with that of Beta Glucan Collagen (BGC; Brennan Medical, St. Paul, MN) in a retrospective cohort study. METHODS A retrospective chart review of all children treated at a tertiary care pediatric hospital between 2003 and 2009 identified patients with partial-thickness burns treated with Biobrane. These patients were compared with historical controls treated with BGC. RESULTS A total of 235 children between the ages of 4 weeks and 18 years with an average of 6.0% body surface area partial-thickness burns were treated with Biobrane. In a multivariate statistical analysis, patients treated with Biobrane healed significantly faster than those treated with BGC (Biobrane vs BGC: median, 9 vs 13 days; P = .019; hazard ratio, 1.68). In addition, patients who required inpatient treatment trended toward having shorter length of hospital stay in the Biobrane group (2.6 vs 4.1 days, P = .079). CONCLUSION Partial-thickness burn care consists of early debridement and application of a burn wound dressing. Biobrane dressings result in faster healing compared with BGC and may decrease hospital length of stay for patients requiring inpatient admission.
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Affiliation(s)
| | | | | | | | | | | | | | - Andre V. Hebra
- Corresponding author. Tel.: +1 843 792 3851. (A.V. Hebra)
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31
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Feldman S, Krishnamurthy S, Gillanders W, Gittleman M, Beitsch PD, Young PR, Streck CJ, Whitworth PW, Levine EA, Boolbol S, Han LK, Hermann R, Hoon DSB, Giuliano AE, Meric-Bernstam F. A novel automated assay for the rapid identification of metastatic breast carcinoma in sentinel lymph nodes. Cancer 2011; 117:2599-607. [PMID: 21226034 DOI: 10.1002/cncr.25822] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 10/29/2010] [Accepted: 11/02/2010] [Indexed: 11/07/2022]
Abstract
BACKGROUND The authors prospectively evaluated the performance of a proprietary molecular testing platform using one-step nucleic acid amplification (OSNA) for the detection of metastatic carcinoma in sentinel lymph nodes (SLNs) in a large multicenter trial and compared the OSNA results with the results from a detailed postoperative histopathologic evaluation (reference pathology) and from intraoperative imprint cytology (IC). METHODS In total, 1044 SLN samples from 496 patients at 11 clinical sites were analyzed. Alternate 1-mm sections were subjected to either detailed histopathologic evaluation with hematoxylin and eosin and pancytokeratin immunostaining or the OSNA Breast Cancer System, which was calibrated to detect tumor deposits >0.2 mm by measuring cytokeratin 19 messenger RNA. At 7 sites, IC was performed before permanent section. The OSNA results were classified as negative (<250 copies/μL), micrometastases (from ≥250 to <5000 copies/μL), or macrometastases (≥5000 copies/μL). RESULTS The sensitivity and specificity of the OSNA breast cancer system compared with reference pathology were 77.5% (95% confidence interval, 69.7%-84.2%) and 95.8% (95% confidence interval, 94.3%-97.0%), respectively, before discordant case analyses (DCA). Sensitivity and specificity after DCA were 82.7% and 97.7%, and final concordance was 95.8%. Performance for invasive lobular carcinoma demonstrated 88.2% sensitivity (95% confidence interval, 63.6%-98.5%) and 98.5% specificity (95% confidence interval, 92%-100%). The sensitivity of OSNA was significantly better than that of IC (80% vs 63%; P = .0229). CONCLUSIONS The OSNA breast cancer system proved to be highly accurate for the detection of metastatic breast cancer in axillary SLNs. Sensitivity was comparable to that predicted for conventional postoperative histologic examination at 2-mm intervals and was significantly more sensitive than IC. Automation, semiquantitative results enabling the differentiation of macrometastasis and micrometastasis, and rapid results render the assay suitable for intraoperative and/or permanent evaluation of SLNs.
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Affiliation(s)
- Sheldon Feldman
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Lesher AP, Myers TJ, Tecklenburg F, Streck CJ. Anti-N-methyl-D-aspartate receptor encephalitis associated with an ovarian teratoma in an adolescent female. J Pediatr Surg 2010; 45:1550-3. [PMID: 20638543 DOI: 10.1016/j.jpedsurg.2010.04.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Revised: 04/01/2010] [Accepted: 04/05/2010] [Indexed: 01/17/2023]
Abstract
Anti-N-methyl-d-aspartate (NMDA) receptor encephalitis is a recently described paraneoplastic syndrome with prominent neuropsychiatric symptoms. We report a case of NMDA receptor encephalitis in a 15-year-old female related to the development of NMDA receptor autoantibodies triggered by an ovarian teratoma. Removal of the mature teratoma proved curative with eventual resolution of the paraneoplastic disease process and associated psychiatric symptoms. Increasingly, reports of anti-NMDA receptor encephalitis associated with ovarian teratomas in pediatric patients, as well as a novel assay to measure these antibodies, suggest an etiology for this disease process that may be amenable to prompt surgical excision. The clinical presentation, diagnosis, and surgical management of the disease, as well as a review of the literature, are included.
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Affiliation(s)
- Aaron P Lesher
- Division of Pediatric Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC 29425, USA
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33
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Castellano JJ, Streck CJ, Toms DR. An eosinophilic abdominal wall mass in a pediatric patient. Am Surg 2010; 76:E52-E53. [PMID: 21418768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Wilson EM, Smith CD, Streck CJ. Large anterior mediastinal mass in an infant. Am Surg 2010; 76:E61-E62. [PMID: 21418772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Wilson EM, Smith CD, Streck CJ. Large Anterior Mediastinal Mass in an Infant. Am Surg 2010. [DOI: 10.1177/000313481007600612] [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: 11/16/2022]
Affiliation(s)
- Eric M. Wilson
- Department of Surgery Medical University of South Carolina Charleston, South Carolina
| | - C. D. Smith
- Department of Surgery Medical University of South Carolina Charleston, South Carolina
| | - Christian J. Streck
- Department of Surgery Medical University of South Carolina Charleston, South Carolina
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36
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Castellano JJ, Streck CJ, Toms DR. An Eosinophilic Abdominal Wall Mass in a Pediatric Patient. Am Surg 2010. [DOI: 10.1177/000313481007600608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | - Daniel R. Toms
- Medical University of South Carolina Charleston, South Carolina
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37
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Tracey L, Streck CJ, Du Z, Williams RF, Pfeffer LM, Nathwani AC, Davidoff AM. NF-kappaB activation mediates resistance to IFN beta in MLL-rearranged acute lymphoblastic leukemia. Leukemia 2010; 24:806-12. [PMID: 20130599 DOI: 10.1038/leu.2010.2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Acute lymphoblastic leukemia (ALL) harboring the t(4;11) translocation is associated with a very poor prognosis; innovative treatment strategies are required to improve the current 5-year survival rate of 30-40%. Interferon beta (IFN beta) has shown promise in the treatment of both solid and hematologic malignancies, although the short half-life and toxicity associated with high doses have limited its clinical utility. To overcome these limitations, we investigated the effect of continuous, gene transfer-mediated delivery of IFN beta using adeno-associated virus (AAV)-mediated expression, on ALL cells with the t(4;11) translocation. We found that this method of IFN beta delivery resulted in complete remission of leukemia in a murine model. However, leukemic cells eventually became resistant to IFN beta and relapse was observed. Activation of NF-kappaB was identified as a mechanism for IFN beta resistance, and inhibition of NF-kappaB activity in resistant cells sensitized cells to IFN beta. IFN beta combined with agents that inhibit NF-kappaB could have therapeutic potential in the treatment of children with mixed lineage leukemia subtype ALL.
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Affiliation(s)
- L Tracey
- Department of Surgery, St Jude Children's Research Hospital, Memphis, TN 38105, USA
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38
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Williams RF, Blakely ML, Fischer PE, Streck CJ, Dassinger MS, Gupta H, Renaud EJ, Eubanks JW, Huang EY, Hixson SD, Langham MR. Diagnosing Ruptured Appendicitis Preoperatively in Pediatric Patients. J Am Coll Surg 2009; 208:819-25; discussion 826-8. [DOI: 10.1016/j.jamcollsurg.2009.01.029] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Accepted: 01/14/2009] [Indexed: 10/21/2022]
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Dickson PV, Sims TL, Streck CJ, McCarville MB, Santana VM, McGregor LM, Furman WL, Davidoff AM. Avoiding misdiagnosing neuroblastoma as Wilms tumor. J Pediatr Surg 2008; 43:1159-63. [PMID: 18558200 PMCID: PMC3214966 DOI: 10.1016/j.jpedsurg.2008.02.047] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [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: 02/07/2008] [Accepted: 02/09/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE Although occasionally difficult, distinguishing abdominal neuroblastoma (NBL) from Wilms tumor (WT) at presentation is important, as surgical management differs significantly. We reviewed our 20-year experience (1987-2006) treating patients with NBL, focusing on those with an initial diagnosis of WT, to determine presenting features that would have suggested the correct preoperative diagnosis. METHODS Retrospective case cohort study reviewing charts and imaging of patients with NBL initially diagnosed clinically with WT. Preoperative symptoms, laboratory studies, and imaging were evaluated. Similar variables were assessed in the 20 patients with WT most recently treated at our institution. RESULTS Nine patients with NBL were identified as those who had an exploratory laparotomy with a preoperative diagnosis of WT; 8 underwent nephrectomy at exploration. Children with NBL had symptoms such as fever and weight loss at presentation (67%) more often than patients with WT (20%). Preoperative computed tomography demonstrated intratumoral calcifications, vascular encasement, or both in 78% of patients with NBL but were never seen in WT patients. Of interest, preoperative urinary catecholamines were elevated in 5 patients ultimately diagnosed with NBL. CONCLUSION Although NBL can be mistaken for WT at presentation, the presence of constitutional symptoms, or intratumoral calcification or vascular encasement on preoperative imaging should heighten suspicion for NBL. In addition, laboratory evaluation, including urinary catecholamines, should be completed before surgery when the etiology of an abdominal tumor is uncertain.
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Affiliation(s)
- Paxton V. Dickson
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN,Department of Surgery, University of Tennessee-Memphis Health Science Center, Memphis, TN
| | - Thomas L. Sims
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN,Department of Surgery, University of Tennessee-Memphis Health Science Center, Memphis, TN
| | - Christian J. Streck
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN,Department of Surgery, University of Tennessee-Memphis Health Science Center, Memphis, TN
| | - M. Beth McCarville
- Department of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Victor M. Santana
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN,Department of Pediatrics, University of Tennessee-Memphis Health Science Center, Memphis, TN
| | - Lisa M. McGregor
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN,Department of Pediatrics, University of Tennessee-Memphis Health Science Center, Memphis, TN
| | - Wayne L. Furman
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN,Department of Pediatrics, University of Tennessee-Memphis Health Science Center, Memphis, TN
| | - Andrew M. Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN,Department of Surgery, University of Tennessee-Memphis Health Science Center, Memphis, TN,Department of Pediatrics, University of Tennessee-Memphis Health Science Center, Memphis, TN
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40
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Dickson PV, Hamner JB, Streck CJ, Ng CYC, McCarville MB, Calabrese C, Gilbertson RJ, Stewart CF, Wilson CM, Gaber MW, Pfeffer LM, Skapek SX, Nathwani AC, Davidoff AM. Continuous delivery of IFN-beta promotes sustained maturation of intratumoral vasculature. Mol Cancer Res 2007; 5:531-42. [PMID: 17579115 DOI: 10.1158/1541-7786.mcr-06-0259] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [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: 11/16/2022]
Abstract
IFNs have pleiotropic antitumor mechanisms of action. The purpose of this study was to further investigate the effects of IFN-beta on the vasculature of human xenografts in immunodeficient mice. We found that continuous, systemic IFN-beta delivery, established with liver-targeted adeno-associated virus vectors, led to sustained morphologic and functional changes of the tumor vasculature that were consistent with vessel maturation. These changes included increased smooth muscle cell coverage of tumor vessels, improved intratumoral blood flow, and decreased vessel permeability, tumor interstitial pressure, and intratumoral hypoxia. Although these changes in the tumor vasculature resulted in more efficient tumor perfusion, further tumor growth was restricted, as the mature vasculature seemed to be unable to expand to support further tumor growth. In addition, maturation of the intratumoral vasculature resulted in increased intratumoral penetration of systemically administered chemotherapy. Finally, molecular analysis revealed increased expression by treated tumors of angiopoietin-1, a cytokine known to promote vessel stabilization. Induction of angiopoietin-1 expression in response to IFN-beta was broadly observed in different tumor lines but not in those with defects in IFN signaling. In addition, IFN-beta-mediated vascular changes were prevented when angiopoietin signaling was blocked with a decoy receptor. Thus, we have identified an alternative approach for achieving sustained vascular remodeling-continuous delivery of IFN-beta. In addition to restricting tumor growth by inhibiting further angiogenesis, maturation of the tumor vasculature also improved the efficiency of delivery of adjuvant therapy. These results have significant implications for the planning of combination anticancer therapy.
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Affiliation(s)
- Paxton V Dickson
- Department of Surgery, St. Jude Children's Research Hospital, 332 North Lauderdale, Memphis, TN 38105, USA
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Abstract
PURPOSE The aim of this study was to evaluate the laparoscopic repair of isolated intestinal injuries in children who sustain focal abdominal trauma. METHODS A retrospective review was conducted of all patients 16 years and younger who required surgery for traumatic bowel injuries during a 5-year period at 2 university children's hospitals. The study population was composed of hemodynamically stable patients who sustained focal energy transfer to the abdomen and were diagnosed preoperatively with intestinal injury. Children sustaining multisystem injuries and gunshot wounds or who were hemodynamically unstable were excluded. RESULTS Fifty hemodynamically stable children were explored for preoperatively documented intestinal injury sustained after focal abdominal trauma. Laparoscopy was used to repair intracorporeally gastrointestinal injuries in 8 children. Mean operating time, time to diet, and time to discharge after laparoscopic bowel repair compared favorably with patients managed by laparotomy. An additional 6 patients had a laparoscopic-assisted bowel resection or repair after exteriorization only of the ruptured intestine through a short extension of the nearest port site. No early (missed injury, wound infection, bleeding) or late (obstruction) complications resulted after laparoscopic repair. CONCLUSIONS Laparoscopic primary or assisted repair of injured bowel is an appropriate surgical option in hemodynamically stable children who sustain focal abdominal trauma and may be associated with a more prompt return of intestinal function and shorter hospital stay.
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Affiliation(s)
- Christian J Streck
- Department of Pediatric Surgery, University of Tennessee-Memphis Health Science Center, Memphis, TN 38163, USA
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Streck CJ, Dickson PV, Ng CYC, Zhou J, Hall MM, Gray JT, Nathwani AC, Davidoff AM. Antitumor efficacy of AAV-mediated systemic delivery of interferon-beta. Cancer Gene Ther 2006; 13:99-106. [PMID: 16052229 DOI: 10.1038/sj.cgt.7700878] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [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: 11/08/2022]
Abstract
Type I interferons (alpha/beta) have significant antitumor activity although their short half-life and systemic side effects have limited their clinical utility. An alternative dosing schedule of continuous, low-level delivery, as is achieved by gene therapy, rather than intermittent, high concentration pulsed-dosing, might avoid the toxicity of interferon while maintaining its antitumor efficacy. We have tested a gene therapy approach in murine tumor models to treat malignancies that have shown responsiveness to interferon in clinical trials. The tumor cell lines used were moderately sensitive to the direct effects of human interferon-beta (hIFN-beta) in vitro. For in vivo testing, systemic delivery of hIFN-beta was generated following liver-targeted delivery of adeno-associated virus (AAV) vector carrying the hIFN-beta transgene. This prevented engraftment of subcutaneous human gliomas, and orthotopic, localized (intrarenal) and disseminated (primarily pulmonary) human renal cell carcinomas; and caused regression of established tumors at these sites. In a syngeneic, immunocompetent model of melanoma, AAV IFN-beta treatment limited subcutaneous tumor growth and prevented disseminated disease. A significant decrease in mean intratumoral vessel density was demonstrated in hIFN-beta-treated tumors, suggesting that in addition to a direct tumoricidal effect, the antitumor efficacy of AAV IFN-beta in this study was due to its ability to inhibit angiogenesis.
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Affiliation(s)
- C J Streck
- Department of Surgery, St Jude Children's Research Hospital, TN 38105, USA
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McCarville MB, Streck CJ, Dickson PV, Li CS, Nathwani AC, Davidoff AM. Angiogenesis inhibitors in a murine neuroblastoma model: quantitative assessment of intratumoral blood flow with contrast-enhanced gray-scale US. Radiology 2006; 240:73-81. [PMID: 16793972 DOI: 10.1148/radiol.2401050709] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [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: 11/11/2022]
Abstract
PURPOSE To quantify intratumoral ultrasonographic (US) contrast agent flow at gray-scale imaging as a measure of functional tumor vascularity in an orthotopic murine neuroblastoma model treated with angiogenesis inhibitors. MATERIALS AND METHODS After Institutional Animal Care and Use Committee approval, retroperitoneal neuroblastomas were established in mice with unmodified NXS2 cells (n = 13) or with cells engineered to overexpress an angiogenesis inhibitor--either tissue inhibitor of matrix metalloproteinase-3 (n = 22) or a truncated soluble form of the vascular endothelial growth factor receptor-2 (truncated soluble fetal liver kinase-1; n = 13). When tumors were approximately 600 mm3, contrast material-enhanced gray-scale US was performed, and the imaging was recorded on cine clips. Regions of interest within tumors were analyzed off-line to determine postcontrast change in signal intensity (SI) from baseline to initial peak (deltaSI), rate of SI increase from baseline to initial peak (RSI), and contrast material washout. The Mann-Whitney test was used to evaluate potential differences in these US parameters between treatment groups. The mean intratumoral endothelial cell (CD34) and pericyte (smooth muscle actin [SMA]) counts at immunohistochemical analysis were also evaluated. Spearman correlation test was used to investigate the relation between US parameters and these histologic markers. RESULTS The deltaSI and RSI were lower in tumors overexpressing an angiogenesis inhibitor than in control tumors (all P < .03). Contrast material washout did not differ between groups. For the entire cohort, the RSI correlated with the immunohistochemical assessment of tumor vascularity (SMA and CD34 counts) (P < .003). CONCLUSION Quantification of intratumoral flow of a US contrast agent at gray-scale imaging shows promise for monitoring tumor vascular response to antiangiogenic therapy.
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Affiliation(s)
- M Beth McCarville
- Department of Radiological Sciences, St Jude Children's Research Hospital, 332 N Lauderdale St, Memphis, TN 38105-2794, USA.
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Streck CJ, Ng CYC, Zhang Y, Zhou J, Nathwani AC, Davidoff AM. Interferon-mediated anti-angiogenic therapy for neuroblastoma. Cancer Lett 2005; 228:163-70. [PMID: 15927362 DOI: 10.1016/j.canlet.2004.11.063] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [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] [Received: 11/23/2004] [Accepted: 11/30/2004] [Indexed: 11/18/2022]
Abstract
Angiogenesis appears to be a fundamental requirement for tumor growth, invasion and metastasis. Evidence also exists to suggest that inhibition of tumor-associated angiogenesis can retard tumor growth and prevent tumor spread. Several naturally occurring angiogenesis inhibitors have been identified, including type I interferons (alpha/beta). These proteins are potent inhibitors of angiogenesis and may also have direct anti-tumor and immunomodulatory effects. Because anti-angiogenic therapy is likely cytostatic, long-term delivery of angiogenesis inhibitors may be required for the successful treatment of cancer. We have, therefore, explored the utility of a gene therapy-mediated approach for the delivery of interferon-beta and tested this approach, both alone and in combination with conventional chemotherapy, in murine models of neuroblastoma.
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Affiliation(s)
- Christian J Streck
- Department of Surgery, St Jude Children's Research Hospital, Memphis, Tennessee, USA
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Streck CJ, Dickson PV, Ng CYC, Zhou J, Gray JT, Nathwani AC, Davidoff AM. Adeno-Associated Virus Vector-Mediated Systemic Delivery of IFN-β Combined with Low-Dose Cyclophosphamide Affects Tumor Regression in Murine Neuroblastoma Models. Clin Cancer Res 2005; 11:6020-9. [PMID: 16115947 DOI: 10.1158/1078-0432.ccr-05-0502] [Citation(s) in RCA: 38] [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: 11/16/2022]
Abstract
PURPOSE Type I IFNs (IFN-alpha/beta) have shown significant antitumor activity in preclinical models but limited efficacy and significant toxicity in clinical trials. We hypothesized that the antitumor activity of type I IFNs could be enhanced by chronic, low-dose systemic delivery and sought to test this in murine neuroblastoma models. EXPERIMENTAL DESIGN Continuous liver-generated expression of human IFN-beta (hINF-beta) was achieved through a gene therapy-mediated approach using adeno-associated virus vectors encoding hIFN-beta (AAV hINF-beta). Orthotopic localized retroperitoneal and disseminated models of neuroblastoma were established using three different xenografts. Immunohistochemical analysis and ELISA were used to evaluate the antiangiogenic effect of therapy. RESULTS The development of both localized orthotopic (retroperitoneal) and disseminated neuroblastoma was prevented in all mice expressing hINF-beta. Continued growth of established retroperitoneal tumors, treated with AAV hINF-beta as monotherapy, was significantly restricted, and survival for mice with established, disseminated disease was significantly prolonged following administration of AAV hINF-beta. Analysis of treated tumors revealed a significant antiangiogenic effect. Mean intratumoral vessel density was diminished and expression of the angiogenic factors vascular endothelial growth factor and basic fibroblast growth factor were both decreased. Finally, combination therapy in which AAV hIFN-beta was used together with low-dose cyclophosphamide resulted in regression of both established retroperitoneal and disseminated disease. CONCLUSIONS AAV-mediated delivery of hIFN-beta when used as monotherapy was able to restrict neuroblastoma growth due in part to inhibition of angiogenesis. When used in combination with conventional chemotherapy, AAV hIFN-beta was able to effect complete tumor regression.
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Affiliation(s)
- Christian J Streck
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
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Davidoff AM, Ng CYC, Zhang Y, Streck CJ, Mabry SJ, Barton SH, Baudino T, Zhou J, Kerbel RS, Vanin EF, Nathwani AC. Careful decoy receptor titering is required to inhibit tumor angiogenesis while avoiding adversely altering VEGF bioavailability. Mol Ther 2005; 11:300-10. [PMID: 15668142 DOI: 10.1016/j.ymthe.2004.09.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [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] [Received: 10/08/2003] [Accepted: 09/15/2004] [Indexed: 01/16/2023] Open
Abstract
To inhibit tumor-induced angiogenesis, the VEGF signaling pathway was targeted using AAV vectors encoding a VEGF decoy receptor, a truncated, soluble form of the murine VEGF receptor-2 (tsFlk-1). This approach initially had significant anti-neuroblastoma efficacy in murine xenograft models of local and metastatic disease, but when higher circulating levels of tsFlk-1 were established, tumor growth was more aggressive than even in control mice. Part of the mechanism for this apparent tumor resistance was increased human VEGF expression by the tumor cells. However, further investigation revealed that although a greater amount of VEGF could be bound by higher levels of tsFlk-1, more VEGF also existed in an unbound state and was, therefore, available to support angiogenesis. This novel, tumor-independent mechanism for resistance to antiangiogenic strategies suggests that careful titering of angiogenesis inhibitors may be required to achieve maximal antitumor efficacy and avoid therapy resistance mediated, in part, by ligand bioavailability. This has important implications for therapeutic strategies that use decoy receptors and other agents, such as antibodies, to bind angiogenic factors, in an attempt to inhibit tumor neovascularization.
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Affiliation(s)
- Andrew M Davidoff
- Department of Surgery St. Jude Children's Research Hospital, Memphis, TN 38105, USA
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Streck CJ, Zhang Y, Zhou J, Ng C, Nathwani AC, Davidoff AM. Adeno-associated virus vector-mediated delivery of pigment epithelium-derived factor restricts neuroblastoma angiogenesis and growth. J Pediatr Surg 2005; 40:236-43. [PMID: 15868591 DOI: 10.1016/j.jpedsurg.2004.09.049] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the ability of adeno-associated virus (AAV) vector-mediated delivery of pigment epithelium-derived factor (PEDF) to inhibit neuroblastoma (NB) xenograft growth. Pigment epithelium-derived factor was chosen for this study because, in addition to being a potent inhibitor of angiogenesis, it is capable of inducing neuronal differentiation. METHODS Cohorts of mice received either recombinant AAV encoding human PEDF (rAAV-hPEDF) at a range of doses or control vector via tail vein. Subsequent hPEDF expression was measured by enzyme-linked immunoassay. After 6 weeks, the mice were given human NB cells by retroperitoneal injection and then killed 5 weeks later. Tumor weight, microvessel density, tumor differentiation, apoptosis, and levels of intratumoral vascular endothelial growth factor (VEGF) expression were determined at that time. In subsequent cohorts of mice, AAV-mediated murine PEDF expression was tested against both human NB xenografts and murine tumors. RESULTS In a series of in vitro studies, PEDF was shown to inhibit endothelial cell activation and to stimulate differentiation of NB cell lines. After tail vein injection of rAAV-hPEDF, stable transgene expression was generated and correlated with levels of vector administration. Human NB xenograft growth was restricted by hPEDF in a dose-dependent fashion. Intratumoral VEGF expression and microvessel density were decreased, and tumor cell apoptosis was increased in PEDF-treated mice. CONCLUSIONS Treatment with PEDF had a significant impact on NB growth in mice when delivered continuously using a gene therapy-mediated approach. The activity of PEDF appears to be mediated in part by inhibition of tumor-induced angiogenesis through down-regulation of tumor-elaborated VEGF, with subsequent intratumoral apoptosis. Furthermore, hPEDF was able to induce NB differentiation in vitro and in vivo. In addition, antitumor efficacy was seen when mouse PEDF was used to treat syngeneic murine tumors. In our murine models, gene therapy-mediated delivery of PEDF appears promising for the treatment of neuroblastoma.
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Affiliation(s)
- Christian J Streck
- Department of Surgery, St. Jude Children's Research Hospital and University of Tennessee-Memphis Health Science Center, Memphis, TN 38105, USA
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Abstract
PURPOSE We tested the hypothesis that the antiangiogenic activity of the type I interferons (IFNs), could affect tumor engraftment and growth in murine xenograft models of neuroblastoma. METHODS Subcutaneous and retroperitoneal human neuroblastoma xenografts were established in SCID mice. Five days after tumor cell inoculation, daily subcutaneous injections of human IFN-alpha at several different doses were initiated and continued for 30 days. The effectiveness of continuous delivery of low-dose interferon was then tested using a gene therapy approach in which an adeno-associated virus vector encoding IFN-beta (rAAV-IFN-beta) was used to mediate expression prior to retroperitoneal tumor implantation. RESULTS Subcutaneous and retroperitoneal tumors were significantly smaller in IFN-alpha-treated mice, as compared with control mice. Intratumoral basic fibroblast growth factor and vascular endothelial growth factor expression were also decreased, as was mean intratumoral endothelial cell density. Interestingly, the lower doses of IFN-alpha were more effective than the higher dose. No tumors developed in any of the mice given rAAV-IFN-beta, whereas each of the mice that received control vector developed large tumors. CONCLUSIONS Treatment with IFN had a significant impact on neuroblastoma engraftment and growth in mice, particularly when delivered continuously using a gene therapy approach. This activity appears to be mediated in part by inhibition of tumor-induced angiogenesis through the downregulation of tumor-elaborated factors, including basic fibroblast growth factor and vascular endothelial growth factor.
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Affiliation(s)
- Christian J Streck
- Department of Surgery, St. Jude Children's Research Hospital and the University of Tennessee Health Science Center, Memphis, TN 38105, USA
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Streck CJ, Zhou J, Ng CY, Zhang Y, Nathwani AC, Davidoff AM. Longterm recombinant adeno-associated, virus-mediated, liver-generated expression of an angiogenesis inhibitor improves survival in mice with disseminated neuroblastoma. J Am Coll Surg 2004; 199:78-86. [PMID: 15217634 DOI: 10.1016/j.jamcollsurg.2004.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2003] [Revised: 02/06/2004] [Accepted: 02/06/2004] [Indexed: 01/29/2023]
Abstract
BACKGROUND A gene therapy-mediated approach to the delivery of antiangiogenic agents using adeno-associated virus (AAV) vectors has a number of advantages including the potential for sustained expression. The purpose of this study was to attempt to restrict the growth of disseminated neuroblastoma through delivery of a truncated, soluble form of the vascular endothelial growth factor receptor-2 (VEGFR-2 fetal liver kinase [Flk]-1), a decoy receptor for VEGF. STUDY DESIGN Mice underwent portal vein injection of vector, either AAV-CAGG-tsFlk-1 or control vector. Subsequent truncated soluble fetal liver kinase-1 (tsFlk-1) expression was confirmed and quantified by ELISA. After 8 weeks, mice were given human neuroblastoma cells through the tail vein to establish disseminated disease and were sacrificed after 40 days. The weight of liver metastasis was measured. Intrahepatic tumor microvessel density and levels of apoptosis were determined. Survival was assessed in a second cohort of mice. RESULTS After intraportal injection of AAV-CAGG-tsFlk-1, high-level, stable transgene expression was generated. Sera from these mice inhibited endothelial cell activation in vitro and Matrigel plug (BD Biosciences) neovascularization in vivo, suggesting that a systemic state of angiogenesis inhibition had been established. After neuroblastoma injection, mice expressing tsFlk-1 had a smaller tumor burden in the liver when sacrificed, as compared with control mice. The decrease in tumor weight in the liver correlated with lower intratumoral microvessel density and higher levels of tumor cell apoptosis in the tsFlk-1-treated tumors, supporting the hypothesis that decreased angiogenesis had occurred. In a second cohort of mice, survival of tsFlk-1-expressing mice after tumor cell challenge was longer than in control mice. CONCLUSIONS Longterm in vivo expression of a functional VEGF inhibitor was established using an AAV-mediated gene therapy approach, and it demonstrated antiangiogenic and anticancer efficacy in a murine model of disseminated neuroblastoma.
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Affiliation(s)
- Christian J Streck
- Department of Surgery, St Jude Children's Research Hospital, Memphis, TN 38105, USA
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