Marisa Schwab
Clinical Assistant Professor, Surgery - Pediatric Surgery
Clinical Focus
- Pediatric Surgery
Professional Education
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Fellowship: Stanford University Pediatric Surgery (2025) CA
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Board Certification: American Board of Surgery, General Surgery (2023)
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Residency: UCSF Dept of General Surgery (2023) CA
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Medical Education: Georgetown University School of Medicine (2016) DC
https://orcid.org/0000-0001-9217-1840All Publications
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Utility of Neonatal Chest X-ray in Patients with Prenatally Diagnosed Congenital Lung Malformations.
Journal of pediatric surgery
2026: 163261
Abstract
In patients with congenital lung malformations (CLM), prenatal imaging is used to risk stratify patients and delineate algorithms for delivery planning and neonatal care. Most algorithms include a chest x-ray immediately after birth in all patients. This study sought to evaluate whether chest x-ray impacts clinical decision-making, ability to predict symptoms, and the decision to manage patients in the Neonatal Intensive Care Unit (NICU).A single center, retrospective cohort study was performed of patients diagnosed prenatally with a CLM (2015 - 2025). Maternal demographics, pre- and postnatal imaging, surgical details and outcomes were collected. Patients with symptoms at birth were compared to the asymptomatic cohort.124 patients were included, with a median peak Congenital Pulmonary Airway Malformation Volume Ratio (CVR) of 0.79 (IQR 0.38-1.17). Only 15.3% received supplemental oxygen after birth (4% required mechanical ventilation). 72.3% were admitted to the NICU. 47.2% (50/106) had an abnormal x-ray, including 62% with a potential CLM and 38% with a clearly visible CLM. Of those with a clear CLM on x-ray, 84.2% (16/19) didn't have symptoms. The abnormal x-ray did not trigger further imaging or management changes. 13/19 patients with a clear CLM on x-ray were monitored in the NICU. X-ray sensitivity to detect symptomatic patients was 56.3% and specificity was 54.4%. Comparing the symptomatic and asymptomatic cohorts revealed no significant differences in the probability of an abnormal x-ray.Chest x-rays have poor sensitivity and specificity in the initial evaluation of asymptomatic CLM patients and did not change clinical decision-making including whether the patient required NICU-level care.
View details for DOI 10.1016/j.jpedsurg.2026.163261
View details for PubMedID 42349543
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Not All Lucencies are Equal: Distinguishing Pneumatosis in Congenital Heart Disease from Necrotizing Enterocolitis.
Pediatric cardiology
2026
View details for DOI 10.1007/s00246-026-04306-z
View details for PubMedID 42217007
View details for PubMedCentralID 8557173
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US multicentre randomised controlled trial protocol: Comparing Analgesic Regimen Effectiveness and Safety after surgery trial for Kids (CARES for Kids).
BMJ open
2026; 16 (5): e118728
Abstract
Acute pain is an expected symptom for adolescents after outpatient surgery. In the USA, postoperative analgesic regimens frequently include prescription opioids. Increasing attention from clinicians, patients and other healthcare leaders has been directed toward non-opioid strategies, such as combining non-steroidal anti-inflammatory drugs (NSAIDs) plus acetaminophen, as potential first-line options for managing postoperative pain. However, the effectiveness and safety of home regimens that include versus exclude opioids for adolescents are unclear. The Comparing Analgesic Regimen Effectiveness and Safety after surgery for Kids study evaluates the effectiveness and safety of NSAIDs plus acetaminophen alone (NSAID regimen) versus NSAIDs and acetaminophen plus a low-dose opioid regimen (opioid regimen).This study is a pragmatic, multicentre randomised controlled clinical trial recruiting 900 patients aged 12-20 years undergoing three common outpatient surgeries (tonsillectomy, laparoscopic cholecystectomy, knee arthroscopy) across four health systems. We will recruit patients prior to surgery and individuals will be randomised 1:1 with stratification to receive prescriptions for either the NSAID regimen or the opioid regimen. The primary effectiveness outcome is patient-reported pain intensity, while the primary safety outcome is adverse medication-related symptoms both assessed over the first 2 weeks after surgery. Secondary outcomes include quality of recovery, healthcare-related quality of life and rates of problematic substance use and chronic prescription opioid use, assessed up to 1 year after surgery.The study incorporates stakeholder collaboration, including patient partners, surgeons, professional organisations., and health insurance payors, to ensure ethical conduct and relevance. This study is overseen by a single institutional review board with certificate of confidentiality. Findings will be disseminated through academic publications, conferences and community outreach to inform patients, parents, surgical teams and policymakers about optimal pain management strategies for adolescents after surgery.NCT06671002.
View details for DOI 10.1136/bmjopen-2026-118728
View details for PubMedID 42208996
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Single-cell spatiotemporal dissection of the human maternal-fetal interface.
Nature
2026
Abstract
The human maternal-fetal interface is characterized by mosaic intermingling of maternal and fetal cells1. Yet the underlying cellular, molecular and spatial programmes remain incompletely defined. Here we generate a comprehensive atlas of the human maternal-fetal interface across normal pregnancies from early gestation to term by integrating large-scale paired single-nucleus transcriptomic and chromatin accessibility profiling with submicrometre-resolution spatial transcriptomics and CODEX multiplex protein imaging2, substantially boosting the spatiotemporal resolution of prior research3. This framework delineates common and transient cell types, states and spatial niches across the fetal and maternal compartments, reconstructs transcriptional programmes that guide cytotrophoblast and decidual stromal cell differentiation, and resolves recurrent architecture structural units that build this interface. We identify previously unrecognized arterial endothelial state transitions during cytotrophoblast-mediated spiral artery remodelling and develop a machine learning model that predicts cytotrophoblast invasiveness from transcriptomic signatures. We further discover a decidual stromal cell subtype that suppresses cytotrophoblast invasion via endocannabinoid signalling at the human maternal-fetal interface. By integrating the atlas with genome-wide association data, we pinpoint maternal and fetal cells that are most vulnerable to pre-eclampsia, preterm birth or miscarriage. This resource provides a comprehensive spatially resolved single-cell multiomic reference of the human placenta and decidua and offers a framework for decoding their normal and disordered development.
View details for DOI 10.1038/s41586-026-10316-x
View details for PubMedID 41951740
View details for PubMedCentralID 6086938
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Clinical Effectiveness Strategies to Improve Patient Outcomes After Pectus Excavatum Repair
JOURNAL FOR HEALTHCARE QUALITY
2026; 48 (2)
Abstract
Target-based care (TBC) uses institutional data to create a shared mental model of anticipated postoperative milestones. This study evaluated the impact of a clinical effectiveness strategy, combining TBC with a clinical pathway and decision support, on outcomes in patients undergoing pectus excavatum repair.This was a prospective study at a quaternary children's hospital between 2022 and 2024. Patients undergoing repair from 2018 to 2021 were historical controls. Target-based care included displaying bedside targets for length of stay (LOS) (outcome metric), Foley catheter and patient-controlled analgesia (PCA) discontinuation (process metrics), and a multidisciplinary evidence-based clinical pathway with an electronic order set.Overall, 91 patients were included: 52 preintervention and 39 postintervention. Median LOS decreased from 3 to 1.8 days (95% confidence interval [CI] 0.8-1.6, p < .05). The proportion of patients who met the LOS target of 2 days increased from 44.2% to 91.8% ( p < .05). The mean time to PCA discontinuation decreased from 1.6 to 0.8 days (95% CI 34.8-118.7, p < .05). The time to Foley catheter removal diminished from 22.2 to 17.1 hour (95% CI 0.6-9.6, p < .05).A data-driven TBC with a clinical pathway had an immediate and sustained impact on patient care. Length of stay, PCA discontinuation, and time to Foley discontinuation decreased after TBC.
View details for DOI 10.1097/JHQ.0000000000000508
View details for Web of Science ID 001755683800001
View details for PubMedID 41355141
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Endobronchial Valves for Persistent Air Leak in Children: Two Case Reports and Review of the Literature.
Pediatric pulmonology
2026; 61 (4): e71638
View details for DOI 10.1002/ppul.71638
View details for PubMedID 42037149
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Infections following minimally invasive repair of pectus excavatum in pediatric patients: a multi-institutional retrospective cohort study of the Western Pediatric Surgery Research Consortium.
Pediatric surgery international
2026; 42 (1)
Abstract
PURPOSE: This multicenter study aims to describe the rate of postoperative infectious complications following minimally invasive repair of pectus excavatum (MIRPE) and explore the various approaches to treatment of these infections.METHODS: A retrospective review of patients≤21 years of age who underwent MIRPE between 7/2022 and 10/2023 across 10 children's hospitals was conducted. Patient demographics, clinical characteristics, operative details, and postoperative outcomes were collected and analyzed.RESULTS: A total of 523 pediatric patients met inclusion criteria; 450 (86.5%) were males. Postoperative infection occurred in 17 patients (3.3%): 5 superficial surgical site infections (SSI) (29.4%) and 12 deep bar infections (70.6%). There were no significant differences in demographics, clinical characteristics, or operative details between patients with and without postoperative infection, except for race. The proportion of patients with one, two or three bars differed between those with and without superficial SSIs (p=0.002). There was no significant difference in number of bars placed for patients with or without bar infection. All but one postoperative deep bar infection (91.7%) were managed with bar salvage.CONCLUSIONS: The overall incidence of postoperative infectious complications after MIRPE is low. Most deep bar infections can be managed with antibiotics and washout, without need for bar replacement or early removal.
View details for DOI 10.1007/s00383-026-06323-8
View details for PubMedID 41729240
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Opioid Prescriptions Practices Following the Minimally Invasive Repair of Pectus Excavatum: A Western Pediatric Surgery Research Consortium Study.
Journal of pediatric surgery
2025: 162878
Abstract
PURPOSE: Minimally invasive repair of pectus excavatum (MIRPE) is among the most painful elective procedures in pediatric patients and is frequently managed with both inpatient and outpatient opioids. However, opioid prescribing practices vary, and evidence-based discharge guidelines are lacking. This study aimed to evaluate outpatient opioid prescribing patterns following MIRPE across multiple institutions.METHODS: A multicenter retrospective review was performed of patients (<21 years) who underwent MIRPE from 2022 -2023 across 10 hospitals in the Western Pediatric Surgery Research Consortium. Demographic, operative, inpatient, and outpatient opioid data were collected. All opioid doses were converted to oral morphine equivalents (OME) using standardized conversion factors. Associations between inpatient opioid use and discharge prescriptions were assessed with linear regression.RESULTS: Among 532 patients (85.9% male; median age 15.5 years [IQR 14.5-17.1]; median Haller index 4.5 [3.8-5.7]), 91% received intercostal nerve cryoablation. Median hospital length of stay was 1 day [1-2]. Patients were discharged with a median of 10 opioid doses [8-16.5], equivalent to 75 OME [45-120] or 1.32 OME/kg [0.85-2.12]. Discharge prescriptions varied substantially by institution, ranging from 0 [0-10] to 20 [10-20] doses. Discharge OME correlated with inpatient opioid use (beta = 0.35, 95%CI 0.26-0.44) and length of stay (beta = 20.9, 95%CI 13.4-28.3).DISCUSSION: Outpatient opioid prescriptions following MIRPE varied widely across hospitals and were positively associated with inpatient opioid use and hospital stay. These findings underscore the need for standardized discharge analgesia guidelines to reduce variability and minimize excess opioid prescribing in pediatric surgical care.
View details for DOI 10.1016/j.jpedsurg.2025.162878
View details for PubMedID 41412427
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Gastrojejunostomy tubes are safe in patients ≤10kg.
Journal of pediatric gastroenterology and nutrition
2025
View details for DOI 10.1002/jpn3.70277
View details for PubMedID 41251012
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Pectus Excavatum Repair During Lung Transplantation in a 5-Year-Old: A Case Report.
Interdisciplinary cardiovascular and thoracic surgery
2025; 40 (11)
Abstract
Chest wall deformities are considered a risk factor for lung transplantation. A 5-year-old girl with protein surfactant C deficiency, interstitial lung disease, pulmonary hypertension, and pectus excavatum (Haller 5.9) underwent lung transplantation and Nuss bar placement. Correction of her pectus was necessary to accommodate donor lungs. She was discharged after 18 days. We hope this youngest described child who underwent simultaneous transplant and pectus correction with excellent outcomes will lead others to consider concomitant surgeries.
View details for DOI 10.1093/icvts/ivaf263
View details for PubMedID 41169187
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Pediatric inguinal hernia: open versus laparoscopic approaches to surgical management.
Current opinion in pediatrics
2025; 37 (5): 482-487
Abstract
Inguinal hernia repair remains one of the most common pediatric surgical procedures. Advances in minimally invasive techniques have made laparoscopic herniorrhaphy a safe alternative to open surgery. This review summarizes clinical outcomes in open and laparoscopic pediatric inguinal hernia repair, discusses technical considerations including anesthetic choice, and reviews patient and surgical factors relevant to surgical approach and timing.Clinical outcomes appear similar in open and laparoscopic pediatric hernia repairs. Open surgery can be performed under regional or general anesthesia and permits direct visualization of the spermatic cord (in men) and high ligation of the hernia sac. The laparoscopic approach requires general anesthesia but permits same-setting visualization of the contralateral inguinal ring and repair of any contralateral hernia. Both techniques effectively manage recurrent hernias. Premature infants undergoing herniorrhaphy after neonatal ICU (NICU) discharge had fewer adverse events and shorter hospital stays than those undergoing surgery while in the NICU.Both laparoscopic and open pediatric inguinal hernia repairs are generally well tolerated and effective. Surgeons should be skilled in both approaches and knowledgeable about patient characteristics, anesthetic considerations, and anatomic factors that may favor one approach over another.
View details for DOI 10.1097/MOP.0000000000001498
View details for PubMedID 40904247
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Antibiotic Stewardship in Pediatric Complicated Appendicitis: Assessing the Role of Oral Antibiotics after Discharge.
Journal of pediatric surgery
2025: 162594
Abstract
To determine whether home oral antibiotic (OA) use after appendectomy for pediatric complicated appendicitis reduces post-discharge complications in children who are afebrile prior to discharge.We queried the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) dataset for children aged 1-18 years who underwent appendectomy for complicated appendicitis between 2019-2023. Patients were included if they were afebrile and had no infective complications (i.e. fever, surgical site infections etc.) at discharge. All patients were stratified into age groups (ages 1-5, 5-10 and 10-18) and were subsequently grouped by whether they were prescribed home OA. The primary outcome measure was post-discharge intra-abdominal abscess (IAA). The relationship between home OA use and post-discharge outcomes was analyzed using multivariable logistic regression.A total of 20,190 patients met criteria, with a median age of 10.0 years (IQR: 6.9-13.1). Approximately 70.9% of patients received home OA and 29.1% did not. Patient characteristics including age, preoperative WBC count, operative time, and length of stay appeared similar at baseline on unadjusted analysis. On multivariable analysis, home OA use did not reduce the odds of IAA in any age group (Age 1-5: aOR=1.27, 95% CI=0.80-2.09; Age 5-10: aOR=1.15, 95% CI=0.90-1.50; Age 10-18: aOR=1.05, 95% CI=0.86-1.30). A subset analysis conducted for patients aged 5-18 years with intraoperative findings of perforated appendicitis also failed to identify any association between home OA use and post-discharge IAA (aOR=1.09, 95% C.I.=0.92-1.29).There appears to be limited benefit to prescribing home OA for children with complicated appendicitis who are afebrile after appendectomy.Retrospective Cohort Study LEVEL OF EVIDENCE: Level III evidence.
View details for DOI 10.1016/j.jpedsurg.2025.162594
View details for PubMedID 40845978
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Is There a Role for ERCP in the Management of Gallstone Pancreatitis in Children? A Western Pediatric Surgery Research Consortium Study.
Journal of pediatric surgery
2025: 162595
Abstract
BACKGROUND: Guidelines for adult gallstone pancreatitis (GP) in adults recommend endoscopic retrograde cholangiopancreatography (ERCP) for ongoing biliary obstruction. Studies in children are limited by small sample sizes. We sought to explore whether factors predictive of choledocholithiasis (CDL) are correlated with ERCP findings of stones in pediatric GP.METHODS: We analyzed a subgroup of GP patients from a retrospective pediatric cohort undergoing cholecystectomy across ten hospitals from 2016-2019. Those with incomplete records and cholangitis were excluded. The absence of CDL was defined as ERCP that was either negative or not performed because of the resolution of obstruction. Comparative analyses were made between ERCP and non-ERCP patients.RESULTS: Among 1,601 children undergoing cholecystectomy, 125 with GP were identified of which 30 (24%) underwent preoperative ERCP. ERCP patients had a greater mean bilirubin (4.1 vs. 2.4, p= 0.02), median CBD diameter (9 vs. 5mm, p<0.001), and visualized stone on MRCP (36.7 vs. 4.2%, p<.001). However, among patients with hyperbilirubinemia (≥1.8 mg/dL) or a dilated CBD (≥6mm), 71% of patients did not have CDL. In contrast, only 40% of patients with a visualized stone on MRCP had a negative ERCP. ERCP was not associated with prolonged length of stay (LOS) or readmissions.CONCLUSION: In children with GP, hyperbilirubinemia and CBD dilation were not reliable predictors of a positive ERCP, potentially leading to unnecessary radiation and/or anesthesia. MRCP with visualized stone was the best predictor of CDL. Although ERCP did not result in greater LOS or readmissions, the use of MRCP prior to ERCP may reduce unnecessary procedures for children with gallstone pancreatitis.
View details for DOI 10.1016/j.jpedsurg.2025.162595
View details for PubMedID 40834917
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Effect of Activity Restrictions on Pectus Bar Displacement Following Minimally Invasive Repair of Pectus Excavatum - A Western Pediatric Surgery Research Consortium Study.
Journal of pediatric surgery
2025: 162520
Abstract
INTRODUCTION: Activity restrictions following the minimally invasive repair of pectus excavatum (MIRPE) are often given with the intention of reducing pectus bar displacement (PBD). We aimed to assess the effect of activity restrictions on PBD following MIPRE.METHODS: A ten-center retrospective review was conducted among patients < 21 years undergoing MIRPE between 7/1/2022-10/31/2023. Postoperative activity restrictions were categorized into two groups: no restrictions versus any activity restrictions. PBD was defined as bar migration requiring reoperation within 90 days of MIRPE. We compared the incidence of PBD and postoperative outcomes between cohorts.RESULTS: A total of 532 patients were included (mean age - 15.9 ± 2.0 years, male - 86%, median Haller index - 4.5 [IQR:3.8-5.8]). Postoperatively, 24% of patients (127/532) were not given activity restrictions. Patients with activity restriction had a higher proportion of pericostal suture use (78% vs 43%, p<0.001) and subpectoral tunneling (58% vs 36%, P<0.001), and a lower proportion of sternal elevation (63% vs 80%, p<0.001) and cryoanalgesia (88% vs 100%, p<0.001) during MIRPE. Overall, PBD occurred in 1.6% of patients, with no difference in the incidence of PBD between those patients with and without activity restrictions (1.7% vs 0.8%, p=0.468). Additionally, there were no significant differences in other postoperative complications between these groups.CONCLUSION: Ad libitum physical activity after MIRPE was not associated with an increased risk of pectus bar displacement. Activity restrictions may be unnecessary, and consideration should be given to their elimination to accelerate recovery.
View details for DOI 10.1016/j.jpedsurg.2025.162520
View details for PubMedID 40784579
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Fourth branchial cleft cyst presenting as a mediastinal mass in a neonate: a case report
JOURNAL OF PEDIATRIC SURGERY CASE REPORTS
2025; 117
View details for DOI 10.1016/j.epsc.2025.103017
View details for Web of Science ID 001477454200001
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Pediatric Cholecystectomy Case Volume and Complexity Following the COVID-19 Pandemic
PEDIATRICS
2025; 155 (3)
Abstract
Historically, cholecystectomy was infrequently performed in children. Lifestyle changes, delays in health care access, and increases in childhood obesity occurred during the COVID-19 pandemic. The impact of these shifts on need for cholecystectomy are poorly understood. We evaluate trends in cholecystectomy case volume among children during the COVID-19 pandemic.A multi-institutional retrospective cohort study was conducted for children ages 18 years and younger who underwent cholecystectomy from January 1, 2016, to July 31, 2022, at 10 children's hospitals. Differences in cholecystectomy case mix and volume before and during the pandemic were identified using bivariate comparisons and interrupted time series analysis.Overall, 4282 children were identified: 2122 before the pandemic and 2160 during the pandemic. Most were female (74.2%) with a median age of 15 years (IQR, 13.0-16.0 years). The proportion of Hispanic (55.0% vs 60.1%; P = .01) patients, body mass index (BMI) (26.0 vs 27.1; P < .001), and obesity (BMI > 30) (30.8% vs 37.4%; P < .001) increased during the pandemic. Predicted monthly case volume increased from 40 to 100 during the pandemic. Patients transferred from an outside hospital increased (21.3% vs 28.5%; P < .001). Significant increases in acute cholecystitis (12.2% vs 17.3%; P < .001), choledocholithiasis (12.8% vs 16.5%; P = .001), gallstone pancreatitis (10.6% vs 12.4%; P = .064), and chronic cholecystitis (1.4% vs 3.2%; P < .001) also occurred. On interrupted time series analysis, change in month-to-month case count significantly increased during the pandemic (Figure 1; P < .001), which persisted after exclusion of transferred patients.Pediatric cholecystectomy case volume and complexity increased during the COVID-19 pandemic. These findings may be secondary to changes in childhood health, transfer patterns, and shifts in access, highlighting an increased health care burden on children's hospitals.
View details for DOI 10.1542/peds.2024-068065
View details for Web of Science ID 001565661500011
View details for PubMedID 39978405
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Home Antibiotic Use after Appendectomy for Complicated Appendicitis Does Not Influence Outcomes in Children Without Postoperative Signs of Infection: A NSQIP-P Observational Study
LIPPINCOTT WILLIAMS & WILKINS. 2024: S349-S350
View details for Web of Science ID 001348680702172
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Barriers and facilitators to screening for intimate partner violence at a level 1 trauma center.
Surgery
2024; 176 (5): 1525-1531
Abstract
Intimate partner violence (IPV) is a significant public health problem that is associated with substantial health sequelae, including traumatic injury. Surgical professional societies recommend universal intimate partner violence screening in patients presenting after trauma, but this recommendation is not uniformly implemented. We designed and implemented a quality improvement project at our institution in July 2020 to enhance intimate partner violence screening. Although screening rates improved, they remained suboptimal. Therefore, we sought to examine barriers and facilitators to intimate partner violence screening from trauma clinicians' perspectives.We conducted a qualitative study using in-depth, semistructured interviews to understand the perspectives and experiences of trauma clinicians conducting intimate partner violence screening. A constructivist paradigm informed our study whereby our data collection approaches aimed to understand intimate partner violence screening from the perspectives of those tasked with implementing screening within real-world clinical settings. We used thematic analysis to analyze our data and generate themes related to barriers and facilitators to screening.We conducted interviews with 12 resident physicians and 2 advance practice providers. We identified 6 themes, 3 reflecting facilitator themes as (1) standardized education and workflow, (2) benefits of interdisciplinary teamwork, and (3) context of screening, and 3 reflecting barrier themes as (1) lack of time, (2) language misinterpretation, and (3) perceived inappropriateness of universal screening.Trauma clinicians described multiple facilitators and barriers to screening for intimate partner violence following traumatic injury, some of which were unique to the trauma setting. Projects seeking to achieve universal screening following traumatic injury may benefit from accounting for these factors when designing interventions.
View details for DOI 10.1016/j.surg.2024.07.033
View details for PubMedID 39174441
View details for PubMedCentralID PMC11890200
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Prenatal AAV9-GFP administration in fetal lambs results in transduction of female germ cells and maternal exposure to virus.
Molecular therapy. Methods & clinical development
2024; 32 (2): 101263
Abstract
Prenatal somatic cell gene therapy (PSCGT) could potentially treat severe, early-onset genetic disorders such as spinal muscular atrophy (SMA) or muscular dystrophy. Given the approval of adeno-associated virus serotype 9 (AAV9) vectors in infants with SMA by the U.S. Food and Drug Administration, we tested the safety and biodistribution of AAV9-GFP (clinical-grade and dose) in fetal lambs to understand safety and efficacy after umbilical vein or intracranial injection on embryonic day 75 (E75) . Umbilical vein injection led to widespread biodistribution of vector genomes in all examined lamb tissues and in maternal uteruses at harvest (E96 or E140; term = E150). There was robust GFP expression in brain, spinal cord, dorsal root ganglia (DRGs), without DRG toxicity and excellent transduction of diaphragm and quadriceps muscles. However, we found evidence of systemic toxicity (fetal growth restriction) and maternal exposure to the viral vector (transient elevation of total bilirubin and a trend toward elevation in anti-AAV9 antibodies). There were no antibodies against GFP in ewes or lambs. Analysis of fetal gonads demonstrated GFP expression in female (but not male) germ cells, with low levels of integration-specific reads, without integration in select proto-oncogenes. These results suggest potential therapeutic benefit of AAV9 PSCGT for neuromuscular disorders, but warrant caution for exposure of female germ cells.
View details for DOI 10.1016/j.omtm.2024.101263
View details for PubMedID 38827250
View details for PubMedCentralID PMC11141462
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Screening for Intimate Partner Violence in Trauma: Results of a Quality Improvement Project.
The Journal of surgical research
2024; 295: 376-384
Abstract
Intimate partner violence (IPV) is common, especially among patients presenting with traumatic injury. We implemented an IPV screening program for patients admitted after trauma. We sought to determine whether specific demographic or clinical characteristics were associated with being screened or not screened for IPV and with IPV screen results.Retrospective cohort study evaluating all patients admitted after trauma from July 2020-July 2022 in an Adult Level 1 Trauma Center.There were 4147 admissions following traumatic injury, of which 70% were men and 30% were women. The cohort was 46% White, 20% Asian, 15% Black, and 17% other races. Twenty-three percent were Hispanic or Latino/a. Seventy-seven percent were admitted for blunt injuries and 16% for penetrating injuries. Thirteen percent (n = 559) of the cohort was successfully screened for IPV. Screening rates did not differ by gender, race, or ethnicity. After adjustment for demographic and clinical factors, patients admitted to the intensive care unit were significantly less likely to be screened. Of the screened patients, 30% (165) screened positive. These patients were more commonly Hispanic or Latino/a, insured by Medicaid and presented with a penetrating injury. There were no differences in injury severity in patients who screened positive versus those who screened negative.There are significant barriers to universal screening for IPV, including injury acuity, in patients admitted following trauma. However, the 30% rate of positive screens for IPV in patients admitted following trauma highlights the urgent need to understand and address barriers to screening in trauma settings to enable universal screening.
View details for DOI 10.1016/j.jss.2023.11.044
View details for PubMedID 38064979
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Portal Vein Thrombosis After Transarterial Embolization for Hepatocellular Carcinoma.
JAMA surgery
2024; 159 (3): 345-347
View details for DOI 10.1001/jamasurg.2023.5909
View details for PubMedID 38150246
View details for PubMedCentralID PMC10753434
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Robotic repair of perineal hernias: a video vignette and review of the literature.
Surgical endoscopy
2023; 37 (3): 2290-2294
Abstract
Perineal hernias can be secondarily acquired following abdominoperineal resection of the rectum. While transabdominal minimally invasive techniques have traditionally used laparoscopy, there are few studies published on the robotic platform, which has been gaining popularity for other types of hernia repairs. We review the existing literature, share a video vignette, and provide practical tips for surgeons interested in adopting this approach.A literature search in Pubmed was performed to include all articles in English describing robotic repair of perineal hernias with identification of variables of interest related to repair. A case presentation with an accompanying video vignette and lessons learned from the experience are provided.Seven case reports (four containing video) published between 2019 and 2022 were included. Most articles (n = 5) utilized the Da Vinci Si or Xi, and most patients (n = 5) had undergone abdominoperineal resection with neoadjuvant chemotherapy to treat rectal cancer. Patients were positioned in Trendelenburg with rightward tilt (n = 2), modified lithotomy (n = 1), or a combination of the two (n = 1). All articles (n = 7) reported closing the defect and using mesh. Three articles describe placing five ports (one camera, three robotic, one assistant). There were no significant intraoperative or postoperative complications reported, and no recurrence noted at 3-27 months follow-up. Based on our experience, as shown in the video vignette, we recommend lithotomy positioning, using porous polypropylene mesh anchored to the periosteum of the sacrum and peritoneum overlying the bladder and side wall, and placing a drain above the mesh.A robotic transabdominal approach to perineal hernia repair is a viable alternate to laparoscopy based on low complication rates and lack of recurrence. Prospective and longer duration data are needed to compare the techniques.
View details for DOI 10.1007/s00464-022-09521-2
View details for PubMedID 35982283
View details for PubMedCentralID PMC10017789
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Pediatric DUCT Score: A Highly Specific Predictive Model for Choledocholithiasis in Children.
Journal of the American College of Surgeons
2023
Abstract
Current adult guidelines in the management of choledocholithiasis (CDL) may not be appropriate for children. We hypothesized adult preoperative predictive factors are not reliable for predicting CDL in children.A multicenter retrospective cohort study was performed evaluating children (≤18 years of age) who underwent cholecystectomy for gallstone disease at 10 children's hospitals. Univariate and multivariable analyses were used to identify factors independently associated with CDL. Patients were stratified into risk groups demonstrating based on the presence of predictive factors for CDL. Statistical analyses were performed, and chi-square analyses were used with a significance of p<0.05.A total of 979 cholecystectomy patients were analyzed. The diagnosis of CDL was confirmed in 222 patients (22.7%) by MRCP, ERCP, or IOC. Three predictive factors were identified 1) D ilated common bile duct (CBD) ≥6mm, 2) U ltrasound (US) with C holedocholithiasis, and 3) T otal bilirubin ≥1.8 mg/dL (Pediatric DUCT criteria). Risk groups were based on the number of predictive factors: Very High (3), High (2), Intermediate (1) and Low (0). The Pediatric DUCT criteria demonstrated accuracies of >76%, specificity of >78%, and negative predictive values of >79%. Adult factors (elevated AST/ALT, pancreatitis, BMI, and age) did not independently predict CDL. Based on risk stratification, the high and very-high risk groups demonstrated higher predictive capacity for CDL.Our study demonstrated that the Pediatric DUCT criteria, incorporating CBD dilation, choledocholithiasis seen on US, and total bilirubin ≥1.8 mg/dL, highly predicts the presence of choledocholithiasis in children. Other adult preoperative factors are not predictive of CBD stones in children.
View details for DOI 10.1097/XCS.0000000000000650
View details for PubMedID 36786471
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Pandemic Recovery: Persistent Disparities in Access to Elective Surgical Procedures.
Annals of surgery
2023; 277 (1): 57-65
Abstract
To examine potential disparities in patient access to elective procedures during the recovery phase of the COVID-19 pandemic.Elective surgeries during the pandemic were limited acutely. Access to surgical care was restored in a recovery phase but backlogs and societal shifts are hypothesized to impact surgical access.Adults with electronic health record orders for procedures ("procedure requests"), from March 16 to August 25, 2019 and March 16 to August 25, 2020, were included. Logistic regression was performed for requested procedures that were not scheduled. Linear regression was performed for wait time from request to scheduled or completed procedure.The number of patients with procedure requests decreased 20.8%, from 26,789 in 2019 to 21,162 in 2020. Patients aged 36-50 and >65 years, those speaking non-English languages, those with Medicare or no insurance, and those living >100 miles away had disproportionately larger decreases. Requested procedures had significantly increased adjusted odds ratios (aORs) of not being scheduled for patients with primary languages other than English, Spanish, or Cantonese [aOR 1.60, 95% confidence interval (CI) 1.12-2.28]; unpartnered marital status (aOR 1.21, 95% CI 1.07-1.37); uninsured or self-pay (aOR 2.03, 95% CI 1.53-2.70). Significantly longer wait times were seen for patients aged 36-65 years; with Medi-Cal insurance; from ZIP codes with lower incomes; and from ZIP codes >100 miles away.Patient access to elective surgeries decreased during the pandemic recovery phase with disparities based on patient age, language, marital status, insurance, socioeconomic status, and distance from care. Steps to address modifiable disparities have been taken.
View details for DOI 10.1097/SLA.0000000000004848
View details for PubMedID 33914483
View details for PubMedCentralID PMC8542562
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Survey of intrauterine red blood cell (RBC) transfusion practices in the United States.
Transfusion
2022; 62 (12): 2449-2453
Abstract
A paucity of data exists about the current practice of fetal red blood cell (RBC) transfusion in the United States (US). This investigation describes intrauterine transfusion (IUT) RBC product selection and processing practices at different US institutions.A transfusion medicine and maternal-fetal medicine (MFM) team designed a survey to interrogate and characterize RBCs utilized for IUT. This survey was distributed to seventy US institutions with fetal treatment centers (October 2020-April 2021) identified through the NAFTNet (North American Fetal Therapy Network).Thirty-seven institutions responded (response rate 53%, 37/70), but five were excluded for not performing IUTs. Most (84%; 27/32) performed 1-24 IUTs annually; two performed >50 IUTs/year. Group O, Rh(D) negative RBC units were always used by 66% (21/32), and 75% (24/32) provided hemoconcentrated RBCs by washing (17/24) or dry packing (6/24). Overall, 66% (21/32) targeted a hematocrit ≥75%. Fifty percent provided both leukocyte-reduced and CMV-negative RBC units. Irradiation of RBC units was performed within 6 h of issue at 63% (20/32) of sites. Most (81%, 26/32) used RBC units at <7 days of age after collection, 56% (18/32) always provided washed RBC units, while 19% (6/32) issued washed RBC only if fresh units are unavailable. Implicated maternal RBC alloantibodies were matched for 78% (25/32) of the time. The transfused volume was universally determined by the MFMs.Heterogeneity and lack of standardization exist in RBC product selection and special processing steps for IUTs in the US. Hence, the establishment of a consensus to standardize IUT protocols is needed.
View details for DOI 10.1111/trf.17134
View details for PubMedID 36193867
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In Utero Enzyme-Replacement Therapy for Infantile-Onset Pompe's Disease
NEW ENGLAND JOURNAL OF MEDICINE
2022; 387 (23): 2150-2158
Abstract
Patients with early-onset lysosomal storage diseases are ideal candidates for prenatal therapy because organ damage starts in utero. We report the safety and efficacy results of in utero enzyme-replacement therapy (ERT) in a fetus with CRIM (cross-reactive immunologic material)-negative infantile-onset Pompe's disease. The family history was positive for infantile-onset Pompe's disease with cardiomyopathy in two previously affected deceased siblings. After receiving in utero ERT and standard postnatal therapy, the current patient had normal cardiac and age-appropriate motor function postnatally, was meeting developmental milestones, had normal biomarker levels, and was feeding and growing well at 13 months of age.
View details for DOI 10.1056/NEJMoa2200587
View details for Web of Science ID 000882254200001
View details for PubMedID 36351280
View details for PubMedCentralID PMC10794051
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The impact of in utero transfusions on perinatal outcomes in patients with alpha thalassemia major: the UCSF registry.
Blood advances
2022
Abstract
Alpha thalassemia major (ATM) is a hemoglobinopathy that usually results in perinatal demise if in utero transfusions (IUTs) are not performed. We established an international registry (NCT04872179) to evaluate the impact of IUTs on survival to discharge (primary outcome) as well as perinatal and neurodevelopmental secondary outcomes. Forty-nine patients were diagnosed prenatally and 11 were diagnosed postnatally: all 11 spontaneous survivors' genotypes had preserved embryonic zeta globin. We compared three groups of patients; Group 1 were prenatally diagnosed and alive at hospital discharge (n=14), Group 2 were prenatally diagnosed and deceased perinatally (n=5), Group 3 were postnatally diagnosed and alive at hospital discharge (n=11). Group 1 had better outcomes than Groups 2 and 3 in resolution of hydrops, delivery closer to term, shorter hospitalizations, and more frequent average or greater neurodevelopmental outcomes. Earlier IUT initiation correlated with higher neurodevelopmental (Vineland-3) scores (r= -0.72, P=0.02). Preterm delivery after IUT was seen in 3/16 (19%) of patients who continued their pregnancy. When we combined our data with those from two published series, patients who received ≥2 IUTs had better outcomes than those with 0-1 IUT, including resolution of hydrops, delivery ≥34 weeks' gestation, and 5-minute Apgar scores ≥7. Neurodevelopmental assessments were normal in 17/18 of the ≥2 IUT versus 5/13 of the 0-1 IUT group (OR 2.74; P=0.01). Thus, fetal transfusions enable survival of patients with ATM with normal neurodevelopment even in patients presenting with hydrops. Non-directive prenatal counseling of expectant parents should include the option of IUTs.
View details for DOI 10.1182/bloodadvances.2022007823
View details for PubMedID 36306387
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Oral Feeding in Infants After Congenital Diaphragmatic Hernia Repair While on Non-invasive Positive Pressure Ventilation: The Impact of a Dysphagia Provider-Led Protocol.
Dysphagia
2022; 37 (5): 1305-1313
Abstract
Infants with congenital diaphragmatic hernia (CDH) who require non-invasive positive pressure ventilation or high flow nasal cannula are at risk for aspiration and delayed initiation of oral feeding. We developed a dysphagia provider-led protocol that involved early consultation with an occupational therapist or speech/language pathologist and modified barium swallow study (MBSS) to assess for readiness for oral feeding initiation/advancement on non-invasive positive pressure ventilation. The objective of this study was to retrospectively compare this intervention cohort to a historical control cohort to evaluate the protocol's impact on the time to initiate oral feeding. We describe the development and implementation of the protocol, the MBSS findings of the intervention cohort, and compared the control (n = 64) and intervention (n = 37) cohorts using Fischer's exact test and Mann-Whitney test. We found that both cohorts had similar prenatal and neonatal characteristics including age at extubation. Significantly more infants in the intervention cohort were on non-invasive positive pressure ventilation or high flow nasal cannula at the time of oral feeding initiation (84% vs. 28%, p < 0.0001). None of the control cohort infants underwent MBSS while on respiratory support. Of the intervention cohort, 15 infants underwent a MBSS while on non-invasive positive pressure ventilation; 6 had no evidence of laryngeal penetration and/or aspiration during swallowing. Infants in the control cohort initiated oral feeds significantly sooner after extubation (6 versus 11 days, p = 0.001) and attained full oral feeds earlier (20 days versus 28 days, p = 0.02) than the intervention group. There was no difference in the rate of gastrostomy tube placement (38%). Appropriate monitoring by a dysphagia provider and evaluation with clinical and radiological means are crucial to determine the safety of initiating oral feeding in term infants with CDH. Continued surveillance is needed to determine the long-term impact on oral feeding progression in this population.
View details for DOI 10.1007/s00455-021-10391-4
View details for PubMedID 34981254
View details for PubMedCentralID 8522368
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Investigating attitudes toward prenatal diagnosis and fetal therapy for spinal muscular atrophy
PRENATAL DIAGNOSIS
2022; 42 (11): 1409-1419
Abstract
In utero SMA treatment could improve survival and neurologic outcomes. We investigated the attitudes of patients and parents with SMA regarding prenatal diagnosis, fetal therapies, and clinical trials.A multidisciplinary team designed a questionnaire that Cure SMA electronically distributed to parents and patients (>18 years old) affected by SMA. Multivariable ordinal logistic regression was used to analyze associations between respondent characteristics and attitudes.Of 114 respondents (60% of whom were patients), only 2 were prenatally diagnosed. However, 91% supported prenatal testing and 81% felt there had been a delay in their diagnosis. Overall, 55% would enroll in a phase I trial for fetal antisense oligonucleotide (ASO) while 79% would choose an established fetal ASO/small molecule therapy. Overall, 61% would enroll in fetal gene therapy trials and 87% would choose fetal gene therapies. Patients were less likely to enroll in a fetal gene therapy trial than parents enrolling a child (OR 0.31, p < 0.05). Older parental age and believing there had been excessive delay in diagnosis were associated with an interest in enrolling in a fetal ASO trial (OR 1.04, 7.38, respectively, p < 0.05).In utero therapies are promising for severe genetic diseases. Patients with SMA and their parents view prenatal testing and therapies positively, with gene therapy being favored.
View details for DOI 10.1002/pd.6228
View details for Web of Science ID 000849511700001
View details for PubMedID 36029101
View details for PubMedCentralID PMC10128916
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Young Adult Healthcare Exposure and Future Opioid Misuse: A Prospective Cohort Study.
American journal of preventive medicine
2022; 62 (6): 914-920
Abstract
Outpatient opioid prescribing is associated with opioid misuse in young adults, but the longitudinal association between general healthcare exposure and opioid misuse has not been explored. The objective of this study is to examine the association between healthcare exposure in young adulthood and future opioid misuse.Data were drawn from the National Longitudinal Study of Adolescent to Adult Health (2001-2018) and analyzed in 2021. Healthcare exposure (i.e., inpatient hospitalization and visits to the clinic, emergency department, mental-health facility, or dentist) between individuals aged 18 and 26 years was the primary independent variable; only patients who did not report opioid misuse at baseline were included. Opioid misuse was defined as using prescription painkillers without a doctor's permission and was measured 17 years after exposure. Multivariable logistic regression was used to examine any associations with opioid misuse (ages 33-43 years).A total of 8,225 young adults with a mean baseline age of 21.8 (SE=0.12) years met inclusion criteria. Approximately 13.7% reported new opioid misuse at follow-up. Those reporting opioid misuse at follow-up were more likely to be White, lack a college education, or report depression. Those exposed to inpatient hospitalization, emergency departments, or mental-health facilities had an increased risk of future opioid misuse.In young adults reporting no opioid misuse at baseline, healthcare exposure was associated with an increased risk of opioid misuse later in adulthood in this large, national cohort. Physicians encounter this at-risk population daily, reinforcing the importance of responsible prescribing practices and the need for targeted screening, patient education, and intervention efforts in the healthcare setting.
View details for DOI 10.1016/j.amepre.2021.12.026
View details for PubMedID 35300890
View details for PubMedCentralID PMC10012501
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Comparison of advanced techniques for local excision of rectal lesions: a case series.
BMC surgery
2022; 22 (1): 117
Abstract
Robotic transanal minimally invasive surgery (R-TAMIS) is an appealing alternative to transanal minimally invasive surgery (TAMIS) and transanal endoscopic microsurgery (TEM) for benign and early malignant rectal lesions that are not amenable to traditional open transanal excision. However, no studies to our knowledge have directly compared the three techniques. This study sought to compare peri-operative and pathologic outcomes of the three approaches.The records of 29 consecutive patients who underwent TEM, TAMIS, or R-TAMIS at a single academic center between 2016 and 2020 were reviewed. Intra-operative details, pathological diagnosis and margins, and post-operative outcomes were recorded. The three groups were compared using chi-square and Kruskal-Wallis tests.Overall, 16/29 patients were women and the median age was 57 (interquartile range (IQR): 28-81). Thirteen patients underwent TEM, six had TAMIS, and 10 had R-TAMIS. BMI was lower in the R-TAMIS patients (24.7; IQR 23.8-28.7), than in TEM (29.3; IQR 19.9-30.2), and TAMIS (30.4; IQR 26.6-32.9) patients. High grade dysplasia and/or invasive cancer was more common in TAMIS (80%) and R-TAMIS (66.7%) patients than in TEM patients (41.7%). The three groups did not differ significantly in tumor type or distance from the anal verge. No R-TAMIS patients had a positive surgical margin compared to 23.1% in the TEM group and 16.7% in the TAMIS group. Length of stay (median 1 day for TEM and R-TAMIS patients, 0 days for TAMIS patients) and 30-day readmission rates (7.7% of TEM, 0% of TAMIS, 10% of R-TAMIS patients) also did not differ among the groups. Median operative time was 110 min for TEM, 105 min for TAMIS, and 76 min for R-TAMIS patients.R-TAMIS may have several advantages over other advanced techniques for transanal excisions. R-TAMIS tended to be faster and to more often result in negative surgical margins compared to the two other techniques.
View details for DOI 10.1186/s12893-022-01543-w
View details for PubMedID 35346146
View details for PubMedCentralID PMC8962117
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A problem at any age: a case report of congenital malrotation with bowel ischemia in an 84-year-old.
BMC surgery
1800; 22 (1): 35
Abstract
BACKGROUND: Malrotation with bowel ischemia is classically thought of as a disease of infants. However, the true prevalence of malrotation in both the pediatric and adult population is unknown due to the unclear number of asymptomatic patients.CASE PRESENTATION: A previously healthy 84-year-old man with no prior abdominal surgeries presented with an acute abdomen and was found on CT to have small bowel located in the right hemiabdomen and an abnormal SMA-SMV relationship suggestive of intestinal malrotation, as well as pneumatosis intestinalis. He underwent an exploratory laparotomy, where he was found to have a paraduodenal space which did not contain any bowel but was the likely source of an internal hernia. His duodenojejunal flexure was located to the right of the spinal column, the cecum in the left lower quadrant, a thick congenital band at the proximal jejunum, and multiple Ladd's bands at the level of the duodenum. The bowel appeared viable and a Ladd's procedure was performed. The patient had an uneventful post-operative course.CONCLUSIONS: There is a lack of guidelines regarding screening for and management of asymptomatic malrotation in older children and adults. However, the traditional thinking is that asymptomatic malrotation diagnosed after two years of age poses minimal risk. This case illustrates the potential risk of an internal hernia in the setting of malrotation at any time during one's lifetime.
View details for DOI 10.1186/s12893-022-01482-6
View details for PubMedID 35093040
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Fetal therapies and trials for lysosomal storage diseases: a survey of attitudes of parents and patients.
Orphanet journal of rare diseases
2022; 17 (1): 25
Abstract
Lysosomal storage diseases (LSDs) are inherited metabolic disorders that may lead to severe multi-organ disease. Current ERTs are limited by anti-drug antibodies, the blood-brain barrier, and early disease onset and progression before ERT is started. We have opened a phase I clinical trial of enzyme replacement therapy (ERT) for fetuses with LSDs (NCT04532047). We evaluated the attitudes of parents and patients with LSDs towards fetal clinical trials and therapies.A multidisciplinary team designed a survey which was distributed by five international patient advocacy groups. We collected patients' demographic, diagnostic, and treatment information. Associations between respondent characteristics and attitudes towards fetal therapies/trials were analyzed using multivariate ordinal logistic regression.The survey was completed by 181 adults from 19 countries. The majority of respondents were mothers from the United States. The most common diseases were MPS1 (26%), MPS3 (19%), and infantile-onset Pompe (14%). Most patients (88%) were diagnosed after birth, at a median of 21 months. Altogether, 65% of participating patients and children of participants had received ERT, 27% a stem cell transplant, and 4% gene therapy. We found that half (49%) of respondents were unlikely to terminate a future affected pregnancy, 55% would enroll in a phase I clinical trial for fetal ERT, and 46% would enroll in a fetal gene therapy trial. Respondents who received postnatal ERT were significantly more likely enroll in a trial for fetal ERT or gene therapy (ERT OR 4.48, 95% CI 2.13-9.44, p < 0.0001; gene therapy OR 3.03, 95% CI 1.43-6.43, p = 0.0038). Respondents who used clinicaltrials.gov as a main source of information were more likely to choose to participate in a fetal trial (ERT OR 2.43, 95% CI 1.18-5.01, p = 0.016; gene therapy OR 2.86, 95% CI 1.27-6.46, p = 0.011).Familiarity with postnatal ERT increased respondents' likelihood of pursuing fetal therapies. Families who use clinicaltrials.gov may be more receptive to innovative fetal treatments. The patient community has a favorable attitude towards fetal therapy; over half of respondents would enroll in a phase I clinical trial to assess the safety and efficacy of fetal ERT.
View details for DOI 10.1186/s13023-022-02178-z
View details for PubMedID 35093147
View details for PubMedCentralID PMC8800365
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Exome sequencing of fetuses with congenital diaphragmatic hernia supports a causal role for NR2F2, PTPN11, and WT1 variants.
American journal of surgery
2022; 223 (1): 182-186
Abstract
To identify genes associated with congenital diaphragmatic hernia (CDH) to help understand the etiology and inform prognosis.We performed exome sequencing on fetuses with CDH and their parents to identify rare genetic variants likely to mediate risk. We reviewed prenatal characteristics and neonatal outcomes.Data were generated for 22 parent-offspring trios. Six Likely Damaging (LD) variants were identified in five families (23 %). Three LD variants were in genes that contain variants in other CDH cohorts (NR2F2, PTPN11, WT1), while three were in genes that do not (CTR9, HDAC6, TP53). Integrating these data bolsters the evidence of association of NR2F2, PTPN11, and WT1 with CDH in humans. Of the five fetuses with a genetic diagnosis, one was terminated, two underwent perinatal demise, while two survived until repair.Exome sequencing expands the diagnostic yield of genetic testing in CDH. Correlating CDH patients' exomes with clinical outcomes may enable personalized counseling and therapies.
View details for DOI 10.1016/j.amjsurg.2021.07.016
View details for PubMedID 34315577
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Consensus statement for the perinatal management of patients with α thalassemia major.
Blood advances
2021; 5 (24): 5636-5639
View details for DOI 10.1182/bloodadvances.2021005916
View details for PubMedID 34749399
View details for PubMedCentralID PMC8714716
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Designing an Intimate Partner Violence Screening Program for Surgical Residents in Trauma.
The Journal of surgical research
2021; 267: 747-754
Abstract
BACKGROUND: Intimate partner violence (IPV) commonly affects surgical patients, particularly trauma patients. However, baseline knowledge of IPV is poor among surgeons and screening is variable. We designed a project to educate surgical residents on IPV and standardize screening in all trauma patients.MATERIALS AND METHODS: Quality improvement frameworks and the Modified Provider Survey were used to examine residents' attitudes and behaviors regarding IPV at a level one trauma center. An educational curriculum was designed with a trainee-led, multidisciplinary team to address knowledge gaps, barriers, and relevant reporting laws, and provide framing language that normalized screening.RESULTS: Fifty-seven surgical residents (64% response rate) spanning post-graduate years 1-7 completed surveys. All respondents believed IPV was relevant to their patients, yet only 4% correctly identified the prevalence of IPV. Only 15% felt comfortable screening for IPV and 75% felt they had received inadequate training. The most common barriers to screening were insufficient knowledge of community resources and what to do if patients screened positive. Most residents grossly underestimated the incidence of IPV and 19% believe healthcare providers have a limited role in being able to help IPV victims. There were no significant differences in responses between male and female residents or among residents from different postgraduate levels.CONCLUSIONS: Surgical residents believe IPV is relevant, but few feel they have adequate training. Residents vastly underestimated the societal prevalence of IPV and the majority never screened patients for IPV. A residency-wide curriculum can address common misperceptions and perceived barriers.
View details for DOI 10.1016/j.jss.2021.03.064
View details for PubMedID 34253375
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Factors and Growth Trends Associated With the Need for Gastrostomy Tube in Neonates With Congenital Diaphragmatic Hernia.
Journal of pediatric gastroenterology and nutrition
2021; 73 (4): 555-559
Abstract
A third of infants with congenital diaphragmatic hernia (CDH) require a gastrostomy tube (GT) for nutritional support. We compared CDH infants who are GT-dependent to those able to meet their nutritional needs orally, to identify factors associated with requiring a GT and evaluate their long-term growth.Patients with CDH repaired at a single institution between 2012 and 2020 were included. Charts were retrospectively reviewed for demographic, surgical, and post-operative details. Mann-Whitney test and Fischer exact test were performed to compare GT-dependent neonates (n = 38, experimental) with orally fed neonates (n = 63, control). Significance was set at <0.05.Thirty-eight percent received a GT (median 67 days, interquartile range [IQR] 50-88). GT-dependent neonates were significantly more likely to have a lower lung-to-head ratio (median 1.2, IQR 0.9-1.4, vs 1.6, IQR 1.3-2.0, IQR P < 0.0001), undergone patch or flap repair (79% vs 33%, P < 0.0001), and been hospitalized longer (median 47, IQR 24-75 vs 28 days, P < 0.0001). Fourteen of 38 had their GT removed (median 26 months, IQR 14-36). GT-dependent neonates initiated oral feeds (calculated as time since extubation) later (median 21, IQR 8-26, vs 8 days, IQR 4-13, P = 0.006). Height-for-age z scores remained stable after GT removal, while weight-for-age z scores dropped initially and began improving a year later.The need for a gastrostomy for nutritional support is associated with more severe CDH. Over a third of patients no longer needed a GT at a median of 26 months. Linear growth generally remains stable after removal. These results may help counsel parents regarding nutritional expectations.
View details for DOI 10.1097/MPG.0000000000003203
View details for PubMedID 34117194
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Standardizing Discharge Opioid Prescriptions in Kidney Transplant Patients Decreases Opioid Usage.
The Journal of surgical research
2021; 265: 153-158
Abstract
Kidney transplant recipients are frequently prescribed excess opioids at discharge relative to their inpatient requirements. Recipients who fill prescriptions after transplant have an increased risk of death and graft loss. This study examined the impact of standardized prescriptions on discharge amount and number of outpatient refills.A historical cohort (Group 1) was compared to a cohort without patient-controlled analgesia (Group 2) and a cohort in which providers prescribed no opioids to patients who required none on the day prior to discharge, and 10 pills to those who required opioids on the day prior (Group 3). Demographics, oral morphine equivalents (OMEs) prescribed on the day prior to and at discharge, and outpatient refills were collected.270 recipients were included. There was a nonsignificant trend towards lower OMEs on the day prior to discharge in Groups 2 and 3. Nonopioid adjunct use increased (P < 0.001). Discharge OMEs significantly decreased (mean 87.2 in Group 1, 62.8 in Group 2, 26.6 in Group 3, P< 0.001). The number of patients discharged without opioids increased (23.8% of Group 1, 37.5% of Group 2, 60.6% of Group 3, P < 0.001). Group 3, Asian descent, and lower OMEs on the day prior were factors significantly associated with decreased discharge OMEs on multivariable linear regression. Twelve percent of Group 2 and 2% of Group 3 patients received an outpatient refill (P = 0.02).A protocol targeting discharge opioids significantly reduced the amount of opioids prescribed in kidney transplant recipients; most patients subsequently received no opioids at discharge.
View details for DOI 10.1016/j.jss.2021.03.038
View details for PubMedID 33940238
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Opioid use prior to liver transplant is associated with increased risk of death after transplant.
American journal of surgery
2021; 222 (1): 234-240
Abstract
Opioids are generally discouraged and used sparingly in liver transplant (LT) candidates prior to LT. This study examined the relationship between opioid use at the time of LT and graft and patient survival following transplantation.A retrospective single center cohort study of LT recipients from June 2012 to December 2019 was performed. Primary outcomes were graft and patient survival, analyzed with the Kaplan-Meier method and Cox proportional hazards models; primary predictor was active opioid prescription at LT.751 LT recipients were included; 16% had an opioid prescription at LT. Post-transplant death was significantly greater in opioid users (pvalue<0.001). In a multivariable Cox model examining predictors of death, opioid use remained associated with a significant increase in the risk of death (HR 2.4 CI 1.5-4.0, p < 0.001) even after controlling for other factors.Opioid use at LT is associated with a markedly increased risk of death following transplant.
View details for DOI 10.1016/j.amjsurg.2020.11.039
View details for PubMedID 33384155
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Live Donor Liver Transplantation in the United States: Impact of Share 35 on Live Donor Utilization.
Transplantation
2021; 105 (4): 824-831
Abstract
Share 35 was a policy implemented in 2013 to increase regional sharing of deceased donor livers to patients with model for end-stage liver disease ≥ 35 to decrease waitlist mortality for the sickest patients awaiting liver transplantation (LT). The purpose of this study was to determine whether live donor liver transplantation (LDLT) volume was impacted by the shift in allocation of deceased donor livers to patients with higher model for end-stage liver disease scores.Using Network for Organ Sharing/Organ Procurement and Transplantation Network Standard Transplant Analysis and Research files, we identified all adults who received a primary LT between October 1, 2008, and March 31, 2018. LT from October 1, 2008, through June 30, 2013, was designated as the pre-Share 35 era and July 1, 2013, through March 31, 2018, as the post-Share 35 era. Primary outcomes included transplant volumes, graft survival, and patient survival in both eras.In total, 48 779 primary adult single-organ LT occurred during the study period (22 255 pre-Share 35, 26 524 post). LDLT increased significantly (6.8% post versus 5.7% pre, P < 0.001). LDLT volume varied significantly by region (P < 0.001) with regions 2, 4, 5, and 8 demonstrating significant increases in LDLT volume post-Share 35. The number of centers performing LDLT increased only in regions 4, 6, and 11. Throughout the 2 eras, there was no difference in graft or patient survival for LDLT recipients.Overall, LDLT volume increased following the implementation of Share 35, which was largely due to increased LDLT volume at centers with experience in LDLT, and corresponded to significant geographic variation in LDLT utilization.
View details for DOI 10.1097/TP.0000000000003318
View details for PubMedID 32433235
View details for PubMedCentralID PMC7980785
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Racial/ethnic disparities among women receiving intrauterine transfusions for alloimmunization at a single fetal treatment center
TRANSFUSION
2021; 61 (7): 2019-2024
Abstract
Disparities are prevalent in numerous areas of healthcare. We sought to investigate whether there were racial/ethnic disparities among pregnant women with the most severe form of alloimmunization who require intrauterine transfusions (IUT). We reviewed patients who underwent IUT for alloimmunization at a single fetal treatment center between 2015 and 2020. This "IUT cohort" was compared to an "Alloimmunization cohort": patients seen at our institution with a diagnosis of alloimmunization during pregnancy, who did not receive IUT. We collected maternal demographics including self-identified race/ethnicity and primary language, transfusion, and antibody characteristics. The cohorts were compared using unpaired t-tests, Mann-Whitney tests, and Fischer's exact tests, as appropriate. The IUT cohort included 43 patients and the alloimmunization cohort included 1049 patients. Compared to the alloimmunization cohort, there were significantly more patients of Latina descent in the IUT cohort (23.3% vs. 3.4%, p < .0001), and more non-English speakers (18.6% vs. 4.6%, p = .001). Twenty-one percent (9/43) of patients had immigrated to the United States, all of whom had pregnancies or miscarriages in their country of origin. A third of patients had new antibodies identified on serial screens during the current pregnancy. Significantly more women of Latina ethnicity and non-English speakers required IUTs compared to the cohort of women with alloimmunization. Insufficient access to care prior to arriving in the United States and among racial and ethnic minorities in the United States may contribute to these findings. Providers should be cognizant of potential, racial, and ethnic inequalities among women receiving intrauterine transfusions.
View details for DOI 10.1111/trf.16379
View details for Web of Science ID 000630881400001
View details for PubMedID 33745158
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The natural history of fetal gallstones: a case series and updated literature review
JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE
2022; 35 (24): 4755-4762
Abstract
The incidence of fetal gallstones is estimated at 0.45% and its clinical relevance after birth remains unknown. This study aimed to describe the natural history of fetal gallstones and their clinical sequelae after birth.We queried a database of fetuses referred for second and third trimester sonograms performed for high-risk pregnancies, and identified cases with fetal gallstones (1996-2019). Demographics, prenatal/postnatal imaging findings, and clinical sequelae were collected. A literature review was performed according to PRISMA guidelines.We screened approximately 200,000 obstetric sonograms; 34 fetuses were found to have cholelithiasis. The median gestational age at the time of sonogram was 35 weeks (range 22-38). Fifty-six percent were female and 11.8% were twin pregnancies with one affected fetus. Median maternal age was 28 years (range 17-42). Eight fetuses underwent postnatal imaging and 4 had persistent cholelithiasis. There was one case of in utero demise. Two patients had structural anomalies (renal and cardiac) by sonogram. A subset of 17 patients was followed long-term (range 3-20 years), and none developed clinical sequelae from cholelithiasis.No child developed postnatal clinical sequelae related to cholelithiasis identified in utero. Fetal cholelithiasis can be managed expectantly without follow-up imaging in asymptomatic patients.
View details for DOI 10.1080/14767058.2020.1863366
View details for Web of Science ID 000599376800001
View details for PubMedID 33327815
View details for PubMedCentralID PMC8206229
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De novo somatic mutations and KRAS amplification are associated with cholangiocarcinoma in a patient with a history of choledochal cyst.
Journal of pediatric surgery
2020; 55 (12): 2657-2661
Abstract
Choledochal cysts are congenital dilations of the bile ducts, and are associated with an increased risk of malignant transformation. The purpose of this study is to report the outcomes of a large series of patients with choledochal cysts and to highlight our analysis of one patient who developed malignancy after cyst resection.We conducted a retrospective review of patients <18 years of age with a choledochal cyst who underwent surgical resection between 1995 and 2018. Molecular testing of resected choledochal cyst specimens using the UCSF500 gene panel was performed on three patients including a 3-month-old boy and a 7-year-old girl who have remained cancer-free, and a 16-year-old girl who subsequently developed cholangiocarcinoma less than two years after resection.One patient of the 48 included in our study developed cholangiocarcinoma after choledochal cyst resection. We observed de novo somatic mutations in TP53 and RBM10, and KRAS amplification in this patient's tumor.In our series, the rate of malignancy after choledochal cyst resection was low. One patient developed de novo mutations in the remnant bile ducts after cyst resection. While it is a rare occurrence, the risk of malignancy following cyst resection supports the need for lifelong surveillance.IV.
View details for DOI 10.1016/j.jpedsurg.2020.03.008
View details for PubMedID 32295706
View details for PubMedCentralID PMC7942710
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Implementing an opioid reduction protocol in renal transplant recipients.
American journal of surgery
2020; 220 (5): 1284-1289
Abstract
Six percent of opioid-naïve patients develop opioid dependence post-operatively. We implemented a protocol in our renal transplant recipients that eliminated opioid patient-controlled analgesia (PCA) and included a multi-modal non-opioid regimen. The purpose of this study was to examine the impact of PCA elimination on opioid requirements at discharge in renal transplant recipients.We reviewed adult renal transplant recipients for the three months prior to, and following, the protocol's implementation. Patients with an intra-abdominal transplant, pancreas-renal transplant, or chronic pain were excluded. The number of opioid pills prescribed on the day prior to discharge were categorized as A) 0, B) 1-3, and C) ≥4. Discharge opioid prescriptions were then evaluated based on a recent recommendation that group A receive 0 pills, group B 15 pills, and group C 30 pills, to satisfy the outpatient pain needs of 85% of patients. Pre- and post-intervention metrics were compared using independent t-tests and Chi squared tests.150 recipients were included (79 pre-intervention, 71 post; 51% male). PCA use decreased significantly (81% vs. 4.2%, p < 0.001). Post-intervention, gabapentin, topical lidocaine, and acetaminophen increased significantly (6.3%-69%, p < 0.001, 5.1%-66.2%, p < 0.001, 73.4%-93% respectively, p = 0.003.) PCA use did not impact the amount of opioids prescribed at discharge (median 75 OMEs in both groups). Of patients requiring no opioids on the day prior to discharge regardless of PCA use, 51.5% of pre- and 35.5% of post- were prescribed excess opioids at discharge. Of patients prescribed 1-3 pills on the day prior to discharge regardless of PCA use, 24.2% of pre- and 25.8% of post patients were prescribed excessive opioids at discharge.A multidisciplinary approach to developing an opioid-reducing protocol significantly decreased the use of PCAs and increased the use of non-opioid adjunct medications in renal transplant recipients. Patients continued to be prescribed excess opioids at discharge compared to inpatient opioid use the day prior to discharge. Ongoing communication with all providers caring for renal transplant recipients and protocolization of the different stages of a patient's post-operative hospitalization are crucial.
View details for DOI 10.1016/j.amjsurg.2020.06.055
View details for PubMedID 32650975
View details for PubMedCentralID PMC9129056
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Surgical management of middle aortic syndrome in an adult.
Journal of vascular surgery cases and innovative techniques
2020; 6 (1): 38-40
Abstract
Middle aortic syndrome (MAS), a coarctation of the lower thoracic and/or abdominal aorta, is typically diagnosed and treated in the pediatric population. We present a 48-year-old patient with a long-standing history of hypertension who was lost to follow-up owing to a lack of insurance coverage. After two myocardial infarcts owing to severe hypertension, a vascular workup including a computed tomography angiogram revealed a diagnosis of MAS. He underwent open vascular reconstruction with a thoracoabdominal Dacron bypass graft. He was discharged within 1 week with no hypertension or claudication. Adult patients diagnosed with MAS should undergo open or endovascular surgical repair with close follow-up.
View details for DOI 10.1016/j.jvscit.2019.10.008
View details for PubMedID 32072084
View details for PubMedCentralID PMC7016340
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Imaging modalities and management of prenatally diagnosed suprarenal masses: an updated literature review and the experience at a high volume Fetal Treatment Center
JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE
2022; 35 (2): 308-315
Abstract
The differential diagnosis for prenatal suprarenal masses (SRMs) is broad and includes neuroblastoma, adrenal hemorrhage, and subdiaphragmatic extralobar pulmonary sequestration (SEPS). We sought to elucidate the appropriate postnatal management for fetuses found to have an SRM.We conducted a retrospective review of patients prenatally diagnosed with SRM at our institution between 1998 and 2018. Prenatal characteristics, imaging, and neonatal outcomes were collected. We also performed a PubMed literature search and pooled analysis of all patients with a prenatally diagnosed SRM previously described in the literature.The literature review yielded 32 studies, of which 19 were single case reports. In our case series, 12 patients were included. Seven patients were delivered vaginally, one was terminated. Postnatal diagnoses included: SEPS (n = 5), adrenal hemorrhage (n = 3), polycystic kidney (n = 2), splenic cyst (n = 1), and unknown for one patient. All but two of the final diagnoses had been on the initial diagnostic differential. With the exception of the terminated fetus, all remain alive today. On pooled analysis, patients who underwent operative management were diagnosed later 32 versus 24 weeks and had a significant predominance of left-sided lesions (59.5 versus 39.2%). The published literature demonstrates a trend toward observation versus resection over the past 30 years.Patients prenatally diagnosed with an SRM have an excellent prognosis. Our series demonstrates a high incidence of SEPS, which were all resected, and adrenal hemorrhage, which were observed with repeat imaging. These patients can be followed with serial postnatal ultrasounds to determine the diagnosis prior to deciding the appropriate treatment.
View details for DOI 10.1080/14767058.2020.1716719
View details for Web of Science ID 000509429500001
View details for PubMedID 31984817
View details for PubMedCentralID PMC9125789
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The Utility of ECMO After Liver Transplantation: Experience at a High-volume Transplant Center and Review of the Literature.
Transplantation
2019; 103 (8): 1568-1573
Abstract
Extracorporeal membrane oxygenation (ECMO) artificially supports respiratory and cardiac function when conventional techniques fail. ECMO has been described as a treatment modality for acute pulmonary and cardiac failure following orthotopic liver transplantation (OLT). Here, we present a series of adult OLT recipients placed on ECMO after transplantation for both respiratory and cardiac indications and review the literature on the role of ECMO in the setting of OLT.For the patient series, we cross-referenced all patients who underwent OLT at our institution between 2007 and 2018 with the ECMO database of our institution and described these cases. For the literature review, we identified cases and series that described the use of ECMO after liver transplantation in adult recipients.A total of 1792 patients underwent OLT. Eight patients were placed on ECMO (0.4%), 5 men and 3 women aged 28 to 68 years (4 venovenous and 4 venoarterial). Three of (38%) 8 patients survived to discharge and are alive today. In the literature, we identified 3 series and 12 case reports of ECMO following OLT, with the majority of the literature derived from the Asian OLT experience.ECMO following liver transplantation should be considered as a viable rescue strategy in patients with severe cardiopulmonary failure. ECMO is particularly effective if the cause of cardiopulmonary failure is recognized promptly and is thought to be transient. This is the largest series in the United States and demonstrates a 38% survival rate, which is comparable to other reports in the literature from Asia.
View details for DOI 10.1097/TP.0000000000002716
View details for PubMedID 30946214
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Meta-Analysis of Surgeon Burnout Syndrome and Specialty Differences.
Journal of surgical education
2018; 75 (5): 1256-1263
Abstract
Surgeon burnout compromises the quality of life of physicians and the delivery of care to patients. Burnout rates and interpretation of the Maslach Burnout Inventory (MBI) complicates the interpretation of surgeon burnout. The purpose of this study is to apply a standardized interpretation of severe surgeon burnout termed, "burnout syndrome" to analyze inherent variation within surgical specialties.A systematic literature search was performed using MEDLINE, PsycINFO, and EMBASE to identify studies reporting MBI data by surgical specialty. Data extraction was performed to isolate surgeon specific data.A meta-analysis was performed.A total of 16 cross-sectional studies were included in this meta-analysis, totaling 3581 subjects. A random effects model approximated burnout syndrome at 3.0% (95% CI: 2.0%-5.0%; I2 = 78.1%). Subscale analysis of emotional exhaustion, depersonalization, and personal accomplishment indicated subscale burnout in 30.0% (CI: 25.0%-36.0%; I2 = 93.2%), 34.0% (CI: 25.0%-43.0%; I2 = 96.9%), and 25.0% (CI: 18.0%-32.0%; I2 = 96.5%) of surgeons, respectively. Significant differences (p < 0.001) in MBI subscale scoring existed among surgical specialties.Approximately 3% of surgeons suffer from extreme forms of burnout termed "burnout syndrome," although surgeon burnout may occur in up to 34% of surgeons, characterized by high burnout in 1 of 3 subscales. Surgical specialties have significantly different rates of burnout subscales. Future burnout studies should target the specialty-specific level to understand inherent differences in an effort to better understand methods of improving surgeon burnout.
View details for DOI 10.1016/j.jsurg.2018.02.003
View details for PubMedID 29500145
View details for PubMedCentralID PMC6110990
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Quality of Life and Burnout Rates Across Surgical Specialties: A Systematic Review.
JAMA surgery
2016; 151 (10): 970-978
Abstract
Establishing strategies to minimize the burden of burnout and poor quality of life (QOL) on surgeons relies on a thorough understanding of QOL and burnout among the various surgical specialties.To systematically review the literature across multiple surgical specialties and provide a comprehensive understanding of QOL and burnout among all surgeons, to delineate variation in rates of burnout and poor QOL, and to elucidate factors that are commonly implicated in these outcomes.An OVID electronic search encompassing MEDLINE, PsycInfo, and EMBASE was completed using the following MeSH search terms: quality of life, burnout, surgeon, surgical specialty, and United States. Full articles published in English from January 1, 1980, to June 10, 2015, that evaluated US surgical specialists and included more than 1 question related to QOL were included. Review articles and evaluations that included medical students or nonsurgical health care professionals were excluded. Of 1420 titles, 41 articles met these criteria. The standardized methodologic principles of PRISMA for reporting systematic reviews guided analysis. Primary end points were QOL scores and burnout rates that compared sex, age, level of training (resident vs attending), surgical specialty, and the type of assessment tool. Secondary outcomes included proposed work hours and income as factors contributing to burnout. Owing to the heterogeneity of data reporting among articles, qualitative analysis was also reported.Of the 16 specialties included, pediatric (86% to 96%) and endocrine (96%) surgeons demonstrated the highest career satisfaction, whereas a portion of plastic surgeons (33%) and vascular surgeons (64%) were least satisfied. The effect of sex was variable. Residents demonstrated a significantly higher risk for burnout than attending surgeons across multiple specialties, including obstetrics and gynecology, otolaryngology, and orthopedic surgery. One-third of the studies found hours worked per week to be a statistically significant predictor of burnout, decreased career satisfaction, and poorer QOL.Burnout and QOL vary across all surgical specialties. Whether sex affects burnout rates remains unclear. Residents are at an increased risk for burnout and more likely to report a poor QOL than attending surgeons.
View details for DOI 10.1001/jamasurg.2016.1647
View details for PubMedID 27410167
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The impact of gross anatomy laboratory on first year medical students' interest in a surgical career.
Clinical anatomy (New York, N.Y.)
2016; 29 (6): 691-5
Abstract
This study sought to determine the impact of gross anatomy laboratory (GA) on first year medical students' (M1) interest in a surgical career. Secondary objectives included identifying other influences in M1s' career decision making. This prospective study included surveys before and after GA. All M1s enrolled in GA were invited to participate. Sixty students completed both the pre- and post-test surveys. A 5-point Likert-type scale surveyed participants' interests, specific personality traits, experience during the course of GA, and likelihood of pursuing a surgical career. Statistical analysis included Wilcoxon Signed Rank Test and (Polychotomous) Ordinal Logistic Regression Model. Students' desire to work with their hands increased (50 vs. 33.3%) and enjoyment working with instruments and tools similarly increased (50 vs. 41.7%). Likelihood of pursuing a surgical career after gross anatomy increased in 31.7% of students, decreased in 16.7%, and was unchanged in 51.7%. Over 75% of students with a prior interest in surgery and 21% of those who previously felt neutral agreed that they were likely to pursue a career in surgery at the conclusion of the laboratory. Students with a surgeon family member were 0.1976 times as likely to exhibit a positive change in interest (P values 0.024). Gross anatomy may influence up to a third of the class to consider a surgical career, especially those with a prior interest in surgery and those previously feeling ambivalent. Students with a surgeon family member became less likely to enter a surgical career after gross anatomy. Clin. Anat. 29:691-695, 2016. © 2016 Wiley Periodicals, Inc.
View details for DOI 10.1002/ca.22730
View details for PubMedID 27071498
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Laparoscopic Excision of Congenital Hepatic Cysts in the Pediatric Population: A Case Series and Literature Review.
Journal of laparoendoscopic & advanced surgical techniques. Part A
2016; 26 (6): 493-7
Abstract
Congenital hepatic cysts are rare. Surgical excision is indicated for symptoms, complications, and to rule out malignancy. Laparoscopic management in the pediatric population has not been extensively documented. We present a series involving laparoscopic excision of pediatric congenital hepatic cysts and review the literature.Data were collected over 15 years from two pediatric surgeons at three medical centers. Presence of a hepatic cyst excised laparoscopically was the only inclusion criterion. Data were collected on the cyst size, type, pathology, and location, as well as on length of hospital stay, complications, and 1 year recurrence rate.Four patients were identified: a 7-week-old male presenting with feeding intolerance due to a hepatic cyst; a 6-year-old male presenting with a hepatic cyst identified by ultrasound during evaluation for appendicitis; a male neonate diagnosed at birth with a left thoracic cyst that communicated through the diaphragm with a hepatic cystic lesion; and a 14-year-old male presenting with a 25 cm × 11 cm hepatic cyst. All lesions were excised laparoscopically.Our series is the largest documenting complete laparoscopic excision of congenital solitary hepatic cysts in the pediatric population. Laparoscopic excision is a safe and effective approach for the pediatric population.
View details for DOI 10.1089/lap.2016.0115
View details for PubMedID 27149195
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Putting residents in the office: an effective method to teach the systems-based practice competency.
Journal of surgical education
2015; 72 (2): 286-90
Abstract
Systems-based practice (SBP) was 1 of 6 core competencies established by the Accreditation Council for Graduate Medical Education and has proven to be one of the most difficult to effectively implement. This pilot study presents an immersion workshop as an effective tool to teach the SBP competency in a way that could easily be integrated into a residency curriculum.In 2006, 16 surgical residents rotated through 3 stations for 30 minutes each: coding and billing, scheduling operations and return appointments, and patient check-in. Participants were administered a pretest and posttest questionnaire evaluating their knowledge of SBP, and were asked to evaluate the workshop.Outpatient clinic at MedStar Georgetown University Hospital, Washington, DC.Residents in the general surgery residency training program at MedStar Georgetown University Hospital.Most residents (62.5%) improved their score after the workshop, whereas 31.25% showed no change and 6.25% demonstrated a decrease in score. Overall within their training levels, all groups demonstrated an increase in mean test score. Postgraduate year-2 residents demonstrated the greatest change in mean score (20%), whereas postgraduate year-4 residents demonstrated the smallest change in mean score (3.3%).An immersion workshop where general surgery residents gained direct exposure to SBP concepts in situ was an effective and practical method of integrating this core competency into the residency curriculum. Such a workshop could complement more formal didactic teaching and be easily incorporated into the curriculum. For example, this workshop could be integrated into the ambulatory care requirement that each resident must fulfill as part of their clinical training.
View details for DOI 10.1016/j.jsurg.2014.09.001
View details for PubMedID 25312297
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Giant juvenile fibroadenoma: a systematic review with diagnostic and treatment recommendations.
Gland surgery
2015; 4 (4): 312-21
Abstract
Currently, there is a lack of clear guidelines regarding evaluation and management of giant juvenile fibroadenomas. The purpose of this study was to conduct a systematic review of giant juvenile fibroadenomas and to evaluate the most common diagnostic and therapeutic modalities.A systematic literature search of PubMed and MEDLINE databases was conducted in February 2014 to identify articles related to giant juvenile fibroadenomas. Pooled outcomes are reported.Fifty-two articles (153 patients) met inclusion criteria. Mean age was 16.7 years old, with a mean lesion size of 11.2 cm. Most patients (86%) presented with a single breast mass. Imaging modalities included ultrasound in 72.5% and mammography in 26.1% of cases. Tissue diagnosis was obtained using a core needle biopsy in 18.3% of cases, fine-needle aspiration (FNA) in 25.5%, and excisional biopsy in 11.1% of patients. Surgical treatment was implemented in 98.7% of patients (mean time to treatment of 9.5 months, range, 3 days to 7 years). Surgical intervention included excision in all cases, of which four were mastectomies. Breast reconstruction was completed in 17.6% of cases. There were no postoperative complications.Diagnosis and treatment of giant juvenile fibroadenoma is heterogeneous. There is a paucity of data to support observation and non-operative treatment. The most common diagnostic modalities include core needle or excisional biopsy. The mainstay of treatment is complete excision with an emphasis on preserving the developing breast parenchyma and nipple areolar complex. Breast reconstruction is uncommon, but may be necessary in certain cases.
View details for DOI 10.3978/j.issn.2227-684X.2015.06.04
View details for PubMedID 26312217
View details for PubMedCentralID PMC4523628
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Transcartilaginous ear piercing and infectious complications: a systematic review and critical analysis of outcomes.
The Laryngoscope
2015; 125 (8): 1827-34
Abstract
The purpose of this systematic review was to critically analyze infectious complications and treatment following transcartilaginous ear piercing.MEDLINE Pubmed database.A MEDLINE PubMed database search using free text, including "ear chondritis," "ear perichondritis," "ear cartilage piercing," and "auricle piercing," yielded 483 titles. Based on set inclusion and exclusion criteria, the titles, abstracts, and full text articles were reviewed for inclusion and underwent data extraction. Pooled outcomes are reported.A total of 29 articles met inclusion criteria, including 66 patients. The mean age of the patients was 18.7 ± 7.6 years (range: 11-49), 87.5% female. Ear deformity was more likely to occur following postpiercing perichondritis of the scapha 100% versus the helix 43% (P = 0.003). Mean duration of symptoms prior to patients seeking medical attention was 6.1 ± 4.1 days. Greater than 5 days of symptoms prior to seeking treatment was significantly more likely to result in hospitalization. Pseudomonas aeruginosa accounted for 87.2% infections. Of the patients with Pseudomonas, 92.3% were hospitalized versus 75% of the patients infected with Staphylococcus aureus. Initial oral antibiotics prescribed did not target the cultured bacterium in 53.3% of cases; of these, 87.5% were hospitalized.Transcartilaginous postpiercing infection may lead to ear deformity and hospitalization. Patients (customers) and practitioners must be aware of optimal treatment strategies to minimize associated morbidity. Scapha piercing and delay in presentation are associated with poorer outcomes. Pseudomonas is the most common bacterial infection. Initial antibiotic selection must be optimized accordingly.
View details for DOI 10.1002/lary.25238
View details for PubMedID 25825232
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Affiliations between bacteria and marine fish leeches (Piscicolidae), with emphasis on a deep-sea species from Monterey Canyon, CA.
Environmental microbiology
2012; 14 (9): 2429-44
Abstract
Leeches within the Piscicolidae are of great numerical and taxonomic importance, yet little is known about bacteria that associate with this diverse group of blood-feeding marine parasites of fish and elasmobranchs. We focused primarily on the bacteria from a deep-sea leech species of unknown identity, collected at ∼ 600 m depth in Monterey Canyon, CA, along with two shallow-living leech genera, Austrobdella and Branchellion, from Los Angeles Harbor, CA. Molecular analysis of all five leech species revealed a dominance of gammaproteobacteria, which were distinct from each other and from previously reported freshwater leech symbionts. Bacteria related to members of the genus Psychromonas (99% similarity in 16S rRNA) were dominant in the deep-sea leech species (80-94% of recovered ribotypes) collected over 19 months from two different locations. Psychromonas was not detected in cocoons or 2-16 week-old juveniles, suggesting that acquisition is via the environment at a later stage. Transmission electron microscopy did, however, reveal abundant bacteria-like cells near areas of thinning of the juvenile epithelial surface, as well as Psychromonas sparsely distributed internally. Electron and fluorescence in situ microscopy of adults also showed Psychromonas-like bacteria concentrated within the crop. Despite the apparent non-transient nature of the association between Psychromonas and the deep-sea leech, their functional role, if any, is not known. The prevalence, however, of an abundant bacterial genus in one piscicolid leech species, as well as the presence of a dominant bacterial species in singular observations of four additional marine species, suggests that members of the Piscicolidae, possibly basal within the class Hirudinea, form specific alliances with microbes.
View details for DOI 10.1111/j.1462-2920.2012.02798.x
View details for PubMedID 22681178