Kristy L. Rialon

Handoffs in the era of duty hours reform: A focused review and strategy to address changes in the accreditation council for graduate medical education common program requirements

With changes in the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements related to transitions in care effective July 1, 2011, sponsoring institutions and training programs must develop a common structure for transitions in care as well as comprehensive curricula to teach and evaluate patient handoffs. In response to these changes, within the Duke University Health System, the resident-led Graduate Medical Education Patient Safety and Quality Council performed a focused review of the handoffs literature and developed a plan for comprehensive handoff education and evaluation for residents and fellows at Duke. The authors present the results of their focused review, concentrating on the three areas of new ACGME expectations--structure, education, and evaluation--and describe how their findings informed the broader initiative to comprehensively address transitions in care managed by residents and fellows. The process of developing both institution-level and program-level initiatives is reviewed, including the development of an interdisciplinary minimal data set for handoff core content, training and education programs, and an evaluation strategy. The authors believe the final plan fully addresses both Dukes internal goals and the revised ACGME Common Program Requirements and may serve as a model for other institutions to comprehensively address transitions in care and to incorporate resident and fellow leadership into a broad, health-system-level quality improvement initiative.

Endoscopic versus surgical ampullectomy: an algorithm to treat disease of the ampulla of Vater.

Objective: The objective of this study was to compare the effectiveness, morbidity, and mortality associated with endoscopic ampullectomy (EA) and surgical ampullectomy (SA). Background: The proposed management of benign ampullary lesions includes local resection (EA or SA) and en bloc resection (pancreaticoduodenectomy). Most agree that en bloc resection entails a significant morbidity and mortality. No study has previously compared EA and SA for the treatment of benign ampullary lesions. Methods: Medical records of patients selected for ampullectomy at Duke University Medical Center from 1991 to 2010 were reviewed. Results: After review, 109 patients were confirmed to have undergone ampullectomy for a suspected benign ampullary lesion. Sixty-eight patients underwent EA, whereas 41 patients underwent SA. Patients in each group were identical in terms of age, sex, race, and comorbid conditions, except that EA had a higher rate of severe obesity (body mass index >35). Endoscopic ampullectomy was found to have a significantly reduced length of stay, lower morbidity, and readmission rates, but it had similar rates of mortality, margin-positive excisions, and reinterventions. Conclusions: In patients selected for ampullectomy for benign ampullary lesions, EA was found to have equivalent efficacy when compared with SA. Moreover, EA had lower morbidity and identical mortality. These findings suggest that patients would likely benefit from an aggressive endoscopic approach before consideration for surgery.

Value of surgical resection in children with high-risk neuroblastoma

The value of gross total resection (GTR) for children with high‐risk neuroblastoma (NB) is controversial. We hypothesized that patients undergoing GTR would demonstrate improved overall survival (OS) compared those having

Factors associated with survival in pediatric adrenocortical carcinoma: An analysis of the National Cancer Data Base (NCDB)

PURPOSE Adrenocortical carcinoma (ACC) is a rare tumor in children with important distinctions from the adult disease. We reviewed the National Cancer Data Base (NCDB) to determine factors associated with long-term survival. METHODS The NCDB was queried for patients less than 18 years of age who were diagnosed with ACC between 1998 and 2011. Kaplan-Meier analysis was utilized to determine factors significantly associated with overall survival. RESULTS A total of 111 patients were included (median age: 4 years, 69% female). ACC was more common in the youngest cohort, with 48% of cases occurring in children younger than the age of 3. Median tumor size was 9.5 cm (IQR: 6.5-13.0), and 87% of patients underwent some form of surgical resection. Among children with available data, 19 of 62 presented with metastases. Overall 1- and 3-year survival was 70% and 64%, respectively. Age, tumor size, extension of tumor into surrounding tissue, and metastatic disease were all found to be significantly associated with survival. Among patients who underwent a surgical procedure, margin status was also found to be significantly associated with survival. CONCLUSION Age, tumor size, extension of tumor, metastatic disease, and margin status are significantly associated with long-term survival in children with adrenocortical carcinoma.

Outcomes following splenectomy in patients with myeloid neoplasms

Myeloid neoplasms are classified into five major categories. These patients may develop splenomegaly and require splenectomy to alleviate mechanical symptoms, to ameliorate transfusion‐dependent cytopenias, or to enhance stem cell transplantation. The objective of this study was to determine which clinical variables significantly impacted morbidity, mortality, and survival in patients with myeloid neoplasms undergoing splenectomy, and to determine if operative outcomes have improved over time.

Factors impacting survival in children with renal cell carcinoma

PURPOSE Renal cell carcinoma (RCC) is an uncommon tumor in the pediatric population. We examined a large national cancer database to determine outcomes for children with RCC and to identify variables affecting long-term survival. METHODS The National Cancer Data Base (NCDB) was queried for patients age 0 to 17 years diagnosed with RCC from 1998-2011. Patient demographics, tumor stage and characteristics, management, and outcomes were evaluated. RESULTS A total of 304 children met inclusion criteria. Overall, 39% of children had stage I disease, 16% stage II, 33% stage III, and 12% stage IV. One-year and five-year survival for all children was 87% and 70%, respectively. Eighty-six percent of patients underwent surgical resection. In comparison to children who underwent complete nephrectomy, patients undergoing partial nephrectomy had smaller tumors and were of lower clinical stages. Survival following partial resection was 100% at one and five years. Age and gender had no significant impact on survival. Survival was negatively impacted by increasing tumor size (P<0.001), positive nodal status (P=0.001), and higher pathologic stage (P<0.001). CONCLUSION Children with renal cell carcinoma who undergo surgical resection have excellent one-year and five-year survival. Overall survival is significantly affected by pathologic stage, tumor size, and nodal status.

US-Guided, Direct Puncture Retrograde Thoracic Duct Access, Lymphangiography, and Embolization: Feasibility and Efficacy.

PURPOSE To describe technical details, success rate, and advantages of direct puncture of the thoracic duct (TD) under direct ultrasound (US) guidance at venous insertion in the left neck. MATERIALS AND METHODS All patients who underwent attempted thoracic duct embolization (TDE) via US-guided retrograde TD access in the left neck were retrospectively reviewed. Indications for lymphangiography were iatrogenic chyle leak, pulmonary lymphangiectasia, and plastic bronchitis. Ten patients with mean age 41.4 years (range, 21 d to 72 y) underwent US-guided TD access via the left neck. Technical details, procedural times, and clinical outcomes were evaluated. TD access time was defined as time from start of procedure to successful access of TD, and total procedural time was defined from start of procedure until TDE. RESULTS All attempts at TD access via the neck were successful. Technical and clinical success of TDE was 60%. There were no complications. Mean TD access time was 17 minutes (range, 2-47 min), and mean total procedure time was 49 minutes (range, 25-69 min). Mean follow-up time was 5.4 months (range, 3-10 months). CONCLUSIONS TDE via US-guided access in the left neck is technically feasible and safe with a potential decrease in procedure time and elimination of oil-based contrast material.

Influence of weight at enterostomy reversal on surgical outcomes in infants after emergent neonatal stoma creation

PURPOSE Neonates after emergent enterostomy creation frequently require reversal at low weight because of complications including cholestasis, dehydration, dumping, failure to thrive, and failure to achieve enteral independence. We investigated whether stoma reversal at low weight (< 2.5kg) is associated with poor surgical outcomes. METHODS Patients who underwent enterostomy reversal from 2005 to 2013 at less than 6months old were identified in our institutional database. Only patients who underwent emergent enterostomy creation (i.e. for necrotizing enterocolitis or spontaneous perforation) were included. Demographics, disease process, comorbidities, stoma type, reversal indication, operative details, and complications were examined. Patients were categorized by weight at reversal of less than 2kg, 2.01-2.5kg, 2.51-3.5kg, and greater than 3.5kg. Data were analyzed using univariable and multivariable regression with significance level of p<0.05. The primary outcome examined was major morbidity, defined as the presence of anastomotic leak, obstruction, hernia, EC fistula, perforation, wound infection, sepsis, or death. RESULTS Eighty-nine patients met inclusion criteria. Demographics (sex, ethnicity, surgical disease process, reversal indication, and ASA score) were similar. The lowest weight group had lower gestational age (p<0.001) and birth weight (p=0.005), and contained a higher proportion of jejunostomies to ileostomies (p=0.013). On univariable analysis, only incisional hernia was significantly different as a complication between weight groups. On multivariable analysis controlling for gestational age and ASA, there was no significant difference in odds of major operative morbidity between groups. CONCLUSIONS Enterostomy reversal at lower weight may not be associated with increased risk of perioperative complications. Early stoma reversal may be acceptable when required for progression of neonatal care. LEVEL OF EVIDENCE Level III, Treatment Study (Retrospective comparative study).

Current use and outcomes of helicopter transport in pediatric trauma: a review of 18,291 transports☆☆☆★

PURPOSE The role of helicopter emergency medical services (HEMS) in pediatric trauma remains controversial. We examined its use in pediatric trauma and its effectiveness in children with moderate/severe injuries. METHODS All blunt/penetrating trauma patients ≤18years old in the National Trauma Data Bank were evaluated for use of HEMS and in-hospital mortality. In a comparative effectiveness study, only patients treated at level I/II pediatric centers with injury severity score (ISS)≥9 were included. RESULTS Of 127,489 included patients, 18,291 (14%) arrived via HEMS, compared to 56% by ground ambulance and 29% by private vehicle/walk-in. HEMS patients had more severe injuries (ISS≥25; 28% vs. 14%) and altered mental status (GCS≤8; 29% vs. 11%), but also contained many patients with only minor injuries or no major physiologic derangements. In unadjusted analysis, HEMS was associated with increased mortality (OR: 1.6; 95% CI: 1.4-1.7). However, it had decreased mortality by regression (0.5; 0.4-0.6) and propensity analysis (0.7; 0.6-0.8) to adjust for confounders. CONCLUSION We found multiple indicators for overuse of HEMS, with nearly 40% of children having only minor injuries. In moderate/severe injuries, HEMS is associated with decreased mortality, potentially saving one life for every 47 flights. Research is needed to determine appropriate criteria for helicopter triage. COMPARATIVE STUDY/LEVEL OF EVIDENCE III.

Inequalities in the use of helmets by race and payer status among pediatric cyclists

BACKGROUND Despite nationwide campaigns to increase the use of helmets among pediatric cyclists, many children continue to be injured while riding without a helmet. To determine where programs and policies intended to promote helmet use should be directed, we surveyed a large national dataset to identify variables associated with helmet use. METHODS The National Trauma Data Bank was queried during the years 2007, 2010, and 2011 for children younger than the age of 16 years who were involved in a bicycle accident. Children were grouped based on whether they had a helmet on during the accident. A multivariable logistic mixed-effects model was utilized to determine factors associated with helmet use. RESULTS Of the 7,678 children included in the analysis, 1,695 (22.1%) were wearing a helmet during their accident. On unadjusted analysis, nonhelmeted riders were more likely to be older (median age 11 years vs 10 years, P < .001), black (10.1% vs 3.7%, P < .001) or insured by Medicaid (32.8% vs 14.3%, P < .001). After adjustment, black children were still less likely to have had worn a helmet compared with white children (adjusted odds ratio 0.38, 95% confidence interval 0.28-0.50). Children on Medicaid were also less likely to have been wearing a helmet compared to children with private insurance (adjusted odds ratio 0.33, 95% confidence interval 0.28-0.39). CONCLUSION Children who are black or who are on Medicaid are less likely to be wearing a helmet when involved in a bicycle accident than white children or children with private insurance, respectively. Future efforts to promote helmet use should be directed towards these groups.