28 results on '"Safford, Shawn D."'
Search Results
2. Routine Repeat Imaging of Pediatric Blunt Solid Organ Injuries Is Not Necessary
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Fletcher, Kelsey L., Meagher, Mitchell, Spencer, Brianna L., Morgan, Madison E., Safford, Shawn D., Armen, Scott B., Hazelton, Joshua P., and Perea, Lindsey L.
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Introduction Nonoperative management of hemodynamically stable patients with blunt splenic and/or hepatic injury has been widely accepted in the pediatric population. However, variability exists in the utilization and timing of repeat imaging to assess for delayed complications during index hospitalization. Recent level-IV evidence suggests that repeat imaging in children should be performed based on a patient’s clinical status rather than on a routine basis. The aim of this study is to examine the rate of delayed complications and interventions in pediatric trauma patients with blunt splenic and/or hepatic injuries who undergo repeat imaging prompted either by a clinical change (CC) or non-clinical change (NCC).Methods A 9-year (2011-2019), retrospective, dual-institution study was performed of children (0-17 years) with blunt splenic and/or hepatic injuries. Patients were grouped based on reason for repeat imaging: CC or NCC. The rate of organ-specific delayed complications and interventions was examined by reason for scan.Results A total of 307 injuries were included in the study period (174 splenic, 113 hepatic, and 20 both). Of 194 splenic injuries, 30(15.5%) underwent repeat imaging (CC = 19; NCC = 11). Of 133 hepatic injuries, 27(20.3%) underwent repeat imaging (CC = 21; NCC = 6). There was no difference in the incidence of organ-specific delayed complications between the CC and NCC groups. Of the 4 patients with complications necessitating intervention, only one was identified based on NCC.Conclusions Our data suggest routine repeat imaging is unnecessary in children with blunt splenic and/or hepatic injuries; therefore, practitioners may rely on a patient’s clinical change.
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- 2023
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3. Predicting Laparoscopic Surgical Skills of Trainees with Eye Metrics Associated with Focused Attention and Workload
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Deng, Shiyu, Wang, Tianzi, Hartman-Kenzler, Jacob, Henrickson Parker, Sarah, Safford, Shawn D., Barnes, Laura E., and Lau, Nathan
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Eye metrics are effective indicators of focused visual attention and perceived workload that have been used to differentiate surgical expertise and task difficulties. However, the change in eye metrics throughout surgical training in a cohort of trainees is under-investigated. This study collected eye-tracking data from 13 medical students practicing the peg transfer task until reaching the passing criteria of the Fundamentals of Laparoscopic Surgery. Six eye metrics measuring focused visual attention and workload were computed and then used in multiple linear regression analysis to predict trial completion time. All predictors were significant in the regression model, collectively explaining 61.7% of the variance in log-transformed completion time. Fixation rates and gaze entropy were the most important metrics at revealing skill acquisition as medical students self-train on the peg-transfer task. The results on these eye metrics demonstrate potential in assessing surgeons-in-training and providing feedback to ensure surgical competency.
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- 2022
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4. Employment search, initial employment experience, and career preferences of recent pediatric surgical fellowship graduates: An APSA survey, part of the right child/right surgeon initiative.
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Martin, Abigail E, McEvoy, Christian S, Lumpkins, Kimberly, Scholz, Stefan, DeRoss, Anthony L, Emami, Claudia, Phillips, Michael R, Qureshi, Faisal, Gray, Brian W, Safford, Shawn D, Healey, Patrick J, Alaish, Samuel M, and Dunn, Stephen P
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APSA's Right Child/Right Surgeon Initiative addresses issues concerning patient access to appropriate pediatric surgical care and workforce distribution. The APSA Workforce Committee sought to understand the experiences and motivations of recent graduates of Pediatric Surgery Training Programs entering the workforce. Using APSA membership databases, we identified members who completed fellowship training from 2010 to 2019. An online survey was created using Survey Monkey, and invitations to participate were sent via email. 144 of 447 invited participants responded (32% response rate). 91% of respondents participated in dedicated research prior to fellowship, but only 64% perform research during their employment. 23% completed an additional clinical fellowship, but only 54% currently practice within the second field. When asked to identify the top three factors used to choose a position, the most common responses were "location or geography" (71%), "available mentorship" (53%), and "compensation and benefits" (37%). Describing their first position, 77% reported working in an academic institution, 78% reported working in a metropolitan/urban area, and 55% reported working in a free-standing children's hospital. 94% participate in General Surgery resident education, and 49% are faculty within a Pediatric Surgery fellowship. Overall, 92% of respondents were able to find the type of employment position that they had wanted. In our survey the overwhelming majority of young pediatric surgeons found the type of job they desired. Most report beginning their practice in more populated, urban areas within academic institutions. Geographic location and work environment played heavily into their employment decisions. These preferences could contribute to continued disparity in access to pediatric surgeons between urban and rural America and to dilution of experience for urban surgeons. Possible solutions include alternative incentive programs for employment in less populated areas or new training models for general surgeons in rural areas to train in fundamentals of Pediatric Surgery. [ABSTRACT FROM AUTHOR]
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- 2022
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5. Scene-dependent, feedforward eye gaze metrics can differentiate technical skill levels of trainees in laparoscopic surgery
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Kulkarni, Chaitanya S., Deng, Shiyu, Wang, Tianzi, Hartman-Kenzler, Jacob, Barnes, Laura E., Parker, Sarah Henrickson, Safford, Shawn D., and Lau, Nathan
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Introduction: In laparoscopic surgery, looking in the target areas is an indicator of proficiency. However, gaze behaviors revealing feedforward control (i.e., looking ahead) and their importance have been under-investigated in surgery. This study aims to establish the sensitivity and relative importance of different scene-dependent gaze and motion metrics for estimating trainee proficiency levels in surgical skills. Methods: Medical students performed the Fundamentals of Laparoscopic Surgery peg transfer task while recording their gaze on the monitor and tool activities inside the trainer box. Using computer vision and fixation algorithms, five scene-dependent gaze metrics and one tool speed metric were computed for 499 practice trials. Cluster analysis on the six metrics was used to group the trials into different clusters/proficiency levels, and ANOVAs were conducted to test differences between proficiency levels. A Random Forest model was trained to study metric importance at predicting proficiency levels. Results: Three clusters were identified, corresponding to three proficiency levels. The correspondence between the clusters and proficiency levels was confirmed by differences between completion times (F
2,488 = 38.94, p< .001). Further, ANOVAs revealed significant differences between the three levels for all six metrics. The Random Forest model predicted proficiency level with 99% out-of-bag accuracy and revealed that scene-dependent gaze metrics reflecting feedforward behaviors were more important for prediction than the ones reflecting feedback behaviors. Conclusion: Scene-dependent gaze metrics revealed skill levels of trainees more precisely than between experts and novices as suggested in the literature. Further, feedforward gaze metrics appeared to be more important than feedback ones at predicting proficiency. Graphical abstract:- Published
- 2022
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6. Differentiating Laparoscopic Skills of Trainees with Computer Vision Based Metrics
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Deng, Shiyu, Kulkarni, Chaitanya, Wang, Tianzi, Hartman-Kenzler, Jacob, Barnes, Laura E., Henrickson Parker, Sarah, Safford, Shawn D., Rajamohan, Srijith, and Lau, Nathan K.
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Context dependent gaze metrics, derived from eye movements explicitly associated with how a task is being performed, are particularly useful for formative assessment that includes feedback on specific behavioral adjustments for skill acquisitions. In laparoscopic surgery, context dependent gaze metrics are under investigated and commonly derived by either qualitatively inspecting the videos frame by frame or mapping the fixations onto a static surgical task field. This study collected eye-tracking and video data from 13 trainees practicing the peg transfer task. Machine learning algorithms in computer vision were employed to derive metrics of tool speed, fixation rate on (moving or stationary) target objects, and fixation rate on tool-object combination. Preliminary results from a clustering analysis on the measurements from 499 practice trials indicated that the metrics were able to differentiate three skill levels amongst the trainees, suggesting high sensitivity and potential of context dependent gaze metrics for surgical assessment.
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- 2021
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7. Timing and volume of crystalloid and blood products in pediatric trauma: An Eastern Association for the Surgery of Trauma multicenter prospective observational study
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Polites, Stephanie F., Moody, Suzanne, Williams, Regan F., Kayton, Mark L., Alberto, Emily C., Burd, Randall S., Schroeppel, Thomas J., Baerg, Joanne E., Munoz, Amanda, Rothstein, William B., Boomer, Laura A., Campion, Eric M., Robinson, Caitlin, Nygaard, Rachel M., Richardson, Chad J., Garcia, Denise I., Streck, Christian J., Gaffley, Michaela, Petty, John K., Greenwell, Cynthia, Pandya, Samir, Waters, Alicia M., Russell, Robert T., Yorkgitis, Brian K., Mull, Jennifer, Pence, Jeffrey, Santore, Matthew T., MacArthur, Taleen, Klinkner, Denise B., Safford, Shawn D., Trevilian, Tanya, Vogel, Adam M., Cunningham, Megan, Black, Christa, Rea, Jessica, Spurrier, Ryan G., Jensen, Aaron R., Farr, Bethany J., Mooney, David P., Ketha, Bavana, Dassinger, Melvin S., Goldenberg-Sandau, Anna, Roman, Janika San, Jenkins, Todd M., and Falcone, Richard A.
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- 2020
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8. Endoscopic biliary stent placement for anastomotic stricture following esophageal atresia repair in infant.
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Gerrish, Ashley W., Kalmar, Christopher L., Yeaton, Paul, and Safford, Shawn D.
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ESOPHAGEAL atresia ,HUMAN abnormalities ,THERAPEUTICS - Abstract
Esophageal atresia is the most common congenital anomaly of the esophagus. Treatment optimally includes primary tension-free anastomosis of the upper and lower aspects of the esophagus. Distance between the upper and lower esophagus predisposes the anastomosis to tension, increasing the risk of anastomotic stricture. Esophageal stricture has historically been managed with repeated endoscopic balloon dilations. Multiple failed attempts at endoscopic balloon dilation requires surgical revision of the anastomosis. Stenting of esophageal stricture has been used in the adult population but has not been described for children. This case report demonstrates the placement of biliary stents in a 2-month-old infant with esophageal stricture following repair of a long gap Type C tracheoesophageal fistula. Successful stenting procedure averted the need for surgical revision. [ABSTRACT FROM AUTHOR]
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- 2018
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9. Insurance status, mortality, and hospital use among pediatric trauma patients over three decades.
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Reed, Chistopher R., Hamill, Mark E., and Safford, Shawn D.
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Background We investigated the association between lack of insurance and mortality, resource use, and medical comorbidities among pediatric trauma patients. Methods Our trauma database was queried for patients < 18 years old from 1989 through 2013. Data collected included demographics, injury severity score (ISS), and insurance status. Dependent variables included major medical comorbidities, hospital and ICU lengths of stay (LOS), and mortality. Logistic regression and tests of equivalence were used to analyze the data. Results A total of 3120 patients were included. The mortality among patients with insurance was 3.6% compared to 8.4% among those without insurance ( p = 0.0001, OR = 2.42, 95% CI = 1.53–3.82). This relationship remained statistically significant with adjustment via multivariable logistic regression ( p = 0.0001, OR = 2.83, 95% CI: 1.64–4.74). Hospital and ICU LOS were significantly greater among insured patients in severely and moderately injured samples, respectively. There was no correlation between insurance and medical comorbidities. The uninsured mortality rate was 12.9% from 1989 to 1997 compared to 3.9% in 2006–2013. Conclusion Lack of insurance was associated with mortality but not preexisting comorbidity. This relationship persisted over time despite an overall decline in mortality. Additionally, lack of insurance was associated with decreased hospital stay and ICU utilization. Level of evidence Treatment Study, Level III. [ABSTRACT FROM AUTHOR]
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- 2017
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10. Improving the Intraoperative Educational Experience: Understanding the Role of Confidence in the Resident-Attending Relationship
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Park, Juyeon, Ponnala, Siddarth, Fichtel, Eric, Tehranchi, Kian, Fitzgibbons, Shimae, Parker, Sarah Henrickson, Lau, Nathan, and Safford, Shawn D.
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With recent changes to graduate medical education, the balance between resident autonomy and need for supervision impacts the educational and training experience of residents. The objective of this study was to understand the relationship between the confidence of attendings and residents and their different perspectives of perceived educational experience and autonomy in the operating room (OR). We hypothesized that the attending's confidence in the resident would be an important factor in improving the educational experience and resident's autonomy in the OR.
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- 2019
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11. Endoscopic biliary stent placement for anastomotic stricture following esophageal atresia repair in infant
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Gerrish, Ashley W., Kalmar, Christopher L., Yeaton, Paul, and Safford, Shawn D.
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Esophageal atresia is the most common congenital anomaly of the esophagus. Treatment optimally includes primary tension-free anastomosis of the upper and lower aspects of the esophagus. Distance between the upper and lower esophagus predisposes the anastomosis to tension, increasing the risk of anastomotic stricture. Esophageal stricture has historically been managed with repeated endoscopic balloon dilations. Multiple failed attempts at endoscopic balloon dilation requires surgical revision of the anastomosis. Stenting of esophageal stricture has been used in the adult population but has not been described for children. This case report demonstrates the placement of biliary stents in a 2-month-old infant with esophageal stricture following repair of a long gap Type C tracheoesophageal fistula. Successful stenting procedure averted the need for surgical revision.
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- 2018
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12. Comparing 30-day outcomes between thoracoscopic and open approaches for resection of pediatric congenital lung malformations: Evidence from NSQIP.
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Kulaylat, Afif N., Engbrecht, Brett W., Hollenbeak, Christopher S., Safford, Shawn D., Cilley, Robert E., and Dillon, Peter W.
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Background/Purpose Thoracoscopic surgery has been increasingly utilized in treating pediatric congenital lung malformations (CLM). Comparative studies evaluating 30-day outcomes between thoracoscopic and open resection of CLM are lacking. Methods There were 258 patients identified in pediatric NSQIP with a CLM and pulmonary resection in 2012–2013. Comparisons of patient characteristics and outcomes between surgical approaches were made using standard univariate statistics. In addition, a propensity score match was performed to evaluate outcomes in similar patient cohorts. Results One-hundred twelve patients (43.4%) received thoracoscopic resections and 146 patients (56.6%) received open resections. Patients undergoing open resections were more likely to be less than 5 months of age and have a comorbidity/preoperative condition (47.3% vs. 25.0%, p < 0.001). The extent of resection was a lobectomy in 84.8% of thoracoscopic and 92.5% of open resection patients. Median operative time was similar between both groups (thoracoscopic 172 vs. open 153.5 minutes). On univariate analysis, thoracoscopic resection was associated with decreased postoperative complications (9.8% vs. 25.3%, p = 0.001) and LOS (3 vs. 4 days, p < 0.001). However, after adjusting for similar patient and operative characteristics, no significant differences were encountered between techniques. Conclusions Thoracoscopic and open resection provide comparable 30-day outcomes and safety in the management of congenital lung malformations. [ABSTRACT FROM AUTHOR]
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- 2015
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13. The impact of children's hospital designation on outcomes in children with malrotation.
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Kulaylat, Afif N., Hollenbeak, Christopher S., Engbrecht, Brett W., Dillon, Peter W., and Safford, Shawn D.
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Background The benefit of Ladd's procedure for malrotation at a Children's Hospital (CH) has not previously been established. Our aim was to characterize the potential variations in management and outcomes between CH and Non-Children's Hospitals (NCH) in the treatment of malrotation with Ladd's procedure. Methods There were 2827 children identified with malrotation and complete information from the Kids' Inpatient Database (2003, 2006, 2009). Outcomes were compared between CH and NCH and evaluated with logistic and linear regressions. Additional propensity score matching was used to balance covariates between CH and NCH. Results There were 2261 (80.0%) children with malrotation undergoing Ladd's procedures treated at CH; 566 (20.0%) were treated at NCH. In multivariate analysis, CH was associated with a 39% lower odds of resection ( p = 0.004), with no differences observed for mortality, morbidity and LOS. Comparison of a propensity score matched cohort confirmed these findings, as well as demonstrated no significant differences in associated costs. Conclusions The majority of pediatric intestinal malrotation is managed at CH. While measured outcomes of mortality, morbidity, LOS, and costs were not different at NCH, CH was less likely to perform intestinal resection during Ladd's procedure. [ABSTRACT FROM AUTHOR]
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- 2015
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14. A rare case of pulmonary hyalinizing granuloma with calcification in a 5 year old boy.
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Gooty, Vasu, Harris, Charles, Muelenaer, Andre, Watson, Brian, and Safford, Shawn D.
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GRANULOMA ,CALCIFICATION ,COMPUTED tomography - Abstract
Pulmonary hyalinizing granuloma (PHG) is a rare benign pulmonary nodular lesion of unknown etiology. We present a case of a 5-year-old boy who was found to have a chest mass while being evaluated for abdominal pain. He underwent a CXR and CT scan that showed popcorn calcifications in the right posterior mediastinum and within the hilum of right lung. These lesions were suspicious for benign calcified lymph nodes and follow-up chest CT after 3.5 months showed no interval changes in the calcified mediastinal masses. Extensive testing ruled out infectious diseases and malignancies. Given the unknown etiology of the lesions, he underwent VATS biopsy that demonstrated a nodular lesion characterized by a peripheral rim of fibrous tissue and central zone of necrosis and calcification, findings consistent with hyalinizing granuloma. PHG is extremely rare in pediatric age group. Although diagnosis of this condition is made by radiological and histopathological findings, it is important to rule out other causes of chest masses. Most of the patients usually have good prognosis with this rare disorder. [ABSTRACT FROM AUTHOR]
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- 2015
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15. A rare case of pulmonary hyalinizing granuloma with calcification in a 5 year old boy
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Gooty, Vasu, Harris, Charles, Muelenaer, Andre, Watson, Brian, and Safford, Shawn D.
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Pulmonary hyalinizing granuloma (PHG) is a rare benign pulmonary nodular lesion of unknown etiology. We present a case of a 5-year-old boy who was found to have a chest mass while being evaluated for abdominal pain. He underwent a CXR and CT scan that showed popcorn calcifications in the right posterior mediastinum and within the hilum of right lung. These lesions were suspicious for benign calcified lymph nodes and follow-up chest CT after 3.5 months showed no interval changes in the calcified mediastinal masses. Extensive testing ruled out infectious diseases and malignancies. Given the unknown etiology of the lesions, he underwent VATS biopsy that demonstrated a nodular lesion characterized by a peripheral rim of fibrous tissue and central zone of necrosis and calcification, findings consistent with hyalinizing granuloma. PHG is extremely rare in pediatric age group. Although diagnosis of this condition is made by radiological and histopathological findings, it is important to rule out other causes of chest masses. Most of the patients usually have good prognosis with this rare disorder.
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- 2015
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16. Continuing promise 2009—assessment of a recent pediatric surgical humanitarian mission.
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Walk, Ryan M., Glaser, Jacob, Marmon, Louis M., Donahue, Timothy F., Bastien, John, and Safford, Shawn D.
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PEDIATRIC surgery ,POSTOPERATIVE care ,HERNIA ,OPERATIVE surgery ,MEDICAL statistics ,FOLLOW-up studies (Medicine) - Abstract
Abstract: Purpose: Surgical organizations have begun to focus their efforts on providing humanitarian assistance in international communities. Most surgeons do not have previous international experience and lack an understanding of what is expected and what care they can provide. The unknown factors include case types, patient volume, postoperative care, and equipment. This abstract presents humanitarian assistance mission and highlights the importance of preparation, host nation involvement, and understanding the local politics of each country. Methods: In April to July 2009, the USNS (United States Naval Ship) Comfort deployed to provide humanitarian assistance to 7 countries through Central and South America. Data collected included numbers and types of procedures, rate of rejection of patients for operation, patient age, American Society of Anesthesiology (ASA) score, and length of procedure. Results: These data represent the total mission of Continuing Promise 2009 including a total of 1137 surgical procedures of which 340 were pediatric (<18 years old). The average number of pediatric cases for each country in 7 days was 48.3 ± 21.4, with a range of 24 to 84. The average age was 7.5 years (range, 1 month to 18 years). In partnership with host physicians, preoperative screening occurred over 2 to 3 days for every 7 operative days. We maintained a low threshold for rejection (rate of 43%; range, 21%-62%) and average ASA score of 1.3. Including all pediatric subspecialties, the most frequent procedures were inguinal (23%) and umbilical (14%) hernias. Although these were the most frequent procedure, the range and variety of cases varied widely. We had a very low early complication rate (1.2%), including 3 wound infections and 1 early hernia recurrence. Conclusions: Our data represent the largest collection to date on the pediatric surgical care of children in a humanitarian effort. Our experience can be used to identify the most likely types of cases in South and Central America and as a model for the safe and efficient treatment of children in a developing country. [Copyright &y& Elsevier]
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- 2012
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17. Evaluation of intestinal viability using 3–charge coupled device image enhancement technology in a pediatric laparoscopic appendectomy model.
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Millendez, Maridelle B., Crane, Nicole J., Elster, Eric A., and Safford, Shawn D.
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CCD cameras ,PEDIATRIC surgery ,LAPAROSCOPIC surgery ,APPENDECTOMY ,THREE-dimensional imaging ,APPENDICITIS ,INTESTINAL ischemia - Abstract
Abstract: Background: Intraoperative laparoscopic determination of intestinal viability is currently limited to subjective visible cues. Adjunctive modalities are neither widely available nor practical. Three–charge coupled device (3-CCD) imaging directly correlates the amount of light detected by CCDs to tissue oxygenation. We hypothesize that application of 3-CCD image enhancement detects bowel ischemia in a pediatric laparoscopic appendectomy model. Methods: We recorded 10 laparoscopic appendectomies for appendicitis. Offline analysis involved selecting regions of interest (ROIs) in the appendix, adjacent colon, and nonappendiceal fat and calculating mean intensity values in selected images before and after division of the mesoappendix. The colon was used as a control, and the intensity values were normalized to fat. Results: As an indicator of decreased perfusion, the mean appendix ROI intensity values decreased over time (R
2 = 0.92) compared with the colon mean ROI intensity values, which remained stable. There was a statistically significant difference between fat-normalized intensity values for ischemic and nonischemic appendix after 1 minute. Conclusion: We have demonstrated proof of principle for the determination of bowel ischemia using 3-CCD image enhancement. By quantitatively identifying areas of ischemia, this technique has the potential to significantly change the management of ischemic bowel in the future. [Copyright &y& Elsevier]- Published
- 2012
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18. Three phases of disaster relief in Haiti—pediatric surgical care on board the United States Naval Ship Comfort.
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Walk, Ryan M., Donahue, Timothy F., Sharpe, Richard P., and Safford, Shawn D.
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DISASTER relief ,NATURAL disasters ,WARSHIPS ,PEDIATRIC surgery ,ORTHOPEDIC surgery - Abstract
Abstract: Background: On January 12, 2010, Haiti experienced the western hemisphere''s worst-ever natural disaster. Within 24 hours, the United States Naval Ship Comfort received orders to respond, and a group of more than 500 physicians, nurses, and staff undertook the largest and most rapid triage and treatment since the inception of hospital ships. Methods: These data represent pediatric surgical patients treated aboard the United States Naval Ship Comfort between January 19 and February 27, 2010. Prospective databases managed by patient administration, radiology, blood bank, laboratory services, and surgical services were combined to create an overall patient care database that was retrospectively reviewed for this analysis. Results: Two hundred thirty-seven pediatric surgical patients were treated, representing 27% of the total patient population. These patients underwent a total of 213 operations composed of 243 unique procedures. Orthopedic procedures represented 71% of the total caseload. Patients returned to the operating room up to 11 times and required up to 28 days for completion of surgical management. Conclusions: This represents the largest cohort of pediatric surgical patients in an earthquake response. Our analysis provides a model for anticipating surgical caseload, injury patterns, and duration of surgical course in preparing for future disaster response missions. Moreover, we propose a 3-phased response to disaster medicine that has not been previously described. [Copyright &y& Elsevier]
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- 2011
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19. Thyroid and parathyroid disease in children.
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Safford, Shawn D. and Skinner, Michael A.
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PARATHYROID gland diseases ,PEDIATRIC diagnosis ,GOITER ,EMBRYOLOGY - Abstract
Although diseases of the thyroid and parathyroid glands are relatively uncommon in children, the implications of missed diagnoses can be severe. This review describes the embryology, anatomy, and physiology of the thyroid and parathyroid glands, and focuses on significant benign and malignant pathologies of these glands. [Copyright &y& Elsevier]
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- 2006
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20. A study of 11,003 patients with hypertrophic pyloric stenosis and the association between surgeon and hospital volume and outcomes.
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Safford, Shawn D., Pietrobon, Ricardo, Safford, Kristine M., Martins, Henrique, Skinner, Michael A., and Rice, Henry E.
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MEDICAL care costs ,PYLORIC stenosis ,PYLORUS diseases ,PEDIATRIC epidemiology - Abstract
Abstract: Aim: The availability of large clinical databases allows for careful evaluation of surgical practices, indicators of quality improvement, and cost. We used a large clinical database to compare the effect of surgeon and hospital volume for the care of children with hypertrophic pyloric stenosis (HPS). Methods: Patients with International Classification of Diseases-9 codes for HPS and pyloromyotomy were selected from the 1994 to 2000 National Inpatient Samples database. Multiple and logistic regression models were used to evaluate the risk-adjusted association between provider volume and outcomes. Results: Postoperative complications occurred in 2.71% of patients. Patients operated on by low- and intermediate-volume surgeons were more likely to have complications compared with those operated on by high-volume surgeons (95% confidence interval [CI], 1.25-3.78 and 95% CI, 1.25-2.69, respectively). Patients operated at low-volume hospitals were 1.6 times more likely to have complications compared with those operated at intermediate- or high-volume hospitals (95% CI, 1.19-2.20). Procedures performed at high-volume hospitals were less expensive than those at intermediate-volume hospitals by a margin of $910 (95% CI, $443-$1377). Conclusions: These data represent the largest study to date on the epidemiology, complication rate, and cost for care for HPS. Patients treated by both high-volume surgeons and at high-volume hospitals have improved outcomes at less cost. [Copyright &y& Elsevier]
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- 2005
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21. Decreased E-cadherin expression correlates with higher stage of Wilms' tumors.
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Safford, Shawn D., Freemerman, Alex J., Langdon, Scott, Bentley, Rex, Goyeau, Dominique, Grundy, Paul E., and Skinner, Michael A.
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NEPHROBLASTOMA ,CADHERINS ,GENE expression ,METASTASIS ,CANCER relapse ,IMMUNOHISTOCHEMISTRY ,GENETIC polymorphisms ,REVERSE transcriptase polymerase chain reaction - Abstract
Abstract: Purpose: The aim of this study was to examine the association between E-cadherin expression and markers of Wilms'' tumor aggression, including metastasis and recurrence. Methods: Forty Wilms'' tumor samples from the National Wilms'' Tumor Study Group underwent immunohistochemical staining for E-cadherin. Tumor stage at diagnosis, recurrence, and loss of heterozygosity at 16q status was known for each of the tumor samples. E-Cadherin cell staining was defined as high (>33%) or low (<33%), and values were assigned by a pathologist blinded to the tumor characteristics. Five stage IV tumors were ineligible for assay because of lack of a tubular component. To identify a mechanism of downregulation, we screened tumor DNA for genetic mutations in exons 1-16 using a combination of WAVE and sequence analysis. To assess the functional significance of the identified mutations, the authors compared amino acid homology across multiple species. Finally, they performed reverse transcriptase–polymerase chain reaction for those tumors with intronic single nucleotide polymorphisms (SNPs) to evaluate for mRNA splice variants. Results: Wilms'' tumors presenting with metastatic (stage IV) disease demonstrated decreased levels of E-cadherin expression compared with localized tumors (stage I) (Fisher''s Exact test, P < .01). In a search for the mechanism of the downregulation of E-cadherin, we identified 5 different mutations in 7 high stage tumors (7/15) and 1 mutation in a low stage tumor (1/20). The mutations occurred in amino acids that were conserved across multiple species. Additionally, 11 of 15 high stage tumors contained an intronic SNP located within 6 bp of the 5′ intronic splice junction immediately downstream of exon 1. However, examination of 5 of these tumors using reverse transcriptase–polymerase chain reaction showed that this intronic SNP does not appear to disrupt the assembly of full-length E-cadherin transcripts. Lastly, no correlation was identified between E-cadherin expression and recurrence of disease. Conclusions: In this study, the authors have found an association between decreased E-cadherin expression and metastatic Wilms'' tumor. Mutations identified may help identify a mechanism for downregulation. The functional significance of these mutations is supported by the conserved nature of the amino acids across multiple species. The authors believe these findings support the involvement of E-cadherin in the evolution of Wilms'' tumor. [Copyright &y& Elsevier]
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- 2005
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22. Haitian Earthquake Relief: Disaster Response Aboard the USNS Comfort
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Walk, Ryan M., Donahue, Timothy F., Stockinger, Zsolt, Knudson, M. Margaret, Cubano, Miguel, Sharpe, Richard P., and Safford, Shawn D.
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ABSTRACTObjective:The Haitian earthquake of January 12, 2010, was a disaster essentially unprecedented in the Western Hemisphere's recorded history. The USNS Comfortdeparted from Baltimore, Maryland, within 72 hours of the earthquake and arrived in Port-au-Prince harbor on January 19. During the subsequent 40 days, the ship provided one of the largest relief efforts in the US Navy's history.Methods:The data analyzed included all patients evaluated and treated by the USNS Comfortbetween January 19 and February 27, 2010. A medical chart with a unique identifier was created for each patient on admission. A patient database was created from these records and used for this analysis.Results:A total of 872 patients and 185 patient escorts were processed aboard the ship. Ages ranged from younger than 1 day to 89 years: 635 were adults and 237 were children. Of those admitted, 817 of the patients were admitted for longer than 24 hours; the average length of stay was 8.0 days. The need for surgery was substantial: 454 patients went to the operating room (OR) 843 times for 927 cumulative procedures. A total of 58 patients underwent amputations.Conclusions:Haiti was almost completely reliant on foreign medical teams for trauma care. Analysis of the data illustrates the challenges of triage and treatment in a humanitarian mass-casualty response. The remarkable coordination and cooperation among the Haitian Ministry of Health, nongovernmental humanitarian aid organizations, and the US military highlighted the responders' respective capabilities and demonstrated the importance of collaboration in future disaster response efforts.(Disaster Med Public Health Preparedness. 2012;6:370–377)
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- 2012
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23. Effects of age and size in the ears of gekkonomorph lizards: Middle-ear morphology with evolutionary implications
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Werner, Yehudah L., Safford, Shawn D., Seifan, Merav, and Saunders, James C.
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The function of the ear depends in part on its absolute size and internal proportions. Thus, in both young individuals and small species, the middle ear is expected to be allometrically enlarged despite its smaller absolute size. Here we aim to compare the ontogenetic allometry of relevant middle-ear structures as observed within gecko (gekkonomorph lizards) species, with the evolutionary allometry observed interspecifically. These observations also provide middle-ear data for future evaluation of variation in auditory sensitivity. The material comprised 84 museum specimens of geckos, representing nine species of three gekkonomorph subfamilies. The results of dissections and measurements show that different reports notwithstanding, the middle-ear ossicular chain is indeed structured as described for geckos by Werner and Wever (J Exp Zool 1972;179:1–16) and Wever (The reptile ear, 1978). Some sexual dimorphism is indicated, but this requires further study. During postnatal ontogeny, the allometric growth in the ratio of the columellar footplate area to body length differed between the intraspecific and interspecific levels, hence species differences in the middle ear do not merely result from animal size. The ratio of the tympanic membrane area to the columellar footplate area increased during ontogeny. In this, geckos resemble birds and probably also mammals. Similarly, when the comparison was among adults representing different species, the ratio of the tympanic membrane area to the columellar footplate area increased with body size. In this, however, the geckos differed from birds and mammals, in which this ratio varied taxonomically, irrespective of body size. It would thus seem that middle-ear proportions have evolved among geckos to produce small interspecific differences, but among amniote tetrapods they have evolved according to different principles in the classes reptiles, birds, and mammals. © 2005 Wiley-Liss, Inc.
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- 2005
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24. A Human Yeast Artificial Chromosome Containing the Multiple Endocrine Neoplasia Type 2B RetMutation Does Not Induce Medullary Thyroid Carcinoma but Does Support the Growth of Kidneys and Partially Rescues Enteric Nervous System Development in Ret-Deficient Mice
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Skinner, Michael A., Kalyanaraman, Somasundaram, Safford, Shawn D., Heuckeroth, Robert O., Tourtellotte, Warren, Goyeau, Dominique, Goodfellow, Paul, Milbrandt, Jeffrey D., and Freemerman, Alex
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We generated a line of transgenic mice using a yeast artificial chromosome containing the Retmutation responsible for the multiple endocrine neoplasia type 2B syndrome (MEN 2B). The resulting animals did not develop any of the expected neoplasms associated with MEN 2B. Transgenic animals were then bred with animals lacking murine Ret(RetM) to further evaluate the function of human mutated Ret(RetH2B) in the murine context. Whereas mice lacking RetMexhibit intestinal aganglionosis and the absence of kidneys with other genitourinary anomalies, expression of the RetH2Btransgene in RetM-deficient mice allowed significant renal development with a partial rescue of the enteric nervous system. These RetH2B-positive/RetM-deficient mice exhibit normal Retexpression and survive longer than RetM-deficient mice, but still die at 3 to 5 days of age with evidence of enterocolitis. We conclude that the normal expression of a human Retproto-oncogene with the MEN 2B mutation does not cause any features of MEN 2B in mice. Although the gene is normally expressed in the appropriate target tissues, there is incomplete phenotypic rescue in mice lacking murine Ret. These results suggest important interspecies differences between humans and mice in the function of the Retoncogene.
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- 2005
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25. Iodine‐131 metaiodobenzylguanidine treatment for metastatic carcinoid: Results in 98 patients
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Safford, Shawn D., Coleman, R. Edward, Gockerman, Jon P., Moore, Joseph, Feldman, Jerome, Onaitis, Mark W., Tyler, Douglas S., and Olson, John A.
- Abstract
Iodine‐131 metaiodobenzylguanidine (131I‐MIBG) is useful for imaging carcinoid tumors and recently has been applied to the palliative treatment of metastatic carcinoid in small studies. The authors now report their results on the therapeutic utility of high‐dose 131I‐MIBG treatment in a large group of patients with metastatic carcinoid tumors.The authors performed a retrospective review of 98 patients with metastatic carcinoid who were treated at their institution with 131I‐MIBG over a 15‐year period. Endpoints examined included the World Health Organization criteria for treatment response: symptoms, hormone (5‐hydroxyindoleacetic acid [5‐HIAA]) production, and clinical tumor response.Patients received a median dose of 401 ± 202 millicuries (mCi) 131I‐MIBG. The median survival after treatment was 2.3 years. Patients who experienced a symptomatic response had improved survival (5.76 years vs. 2.09 years; P < 0.01). For the 56 patients who had 5‐HIAA levels monitored, the mean urine 5‐HIAA levels decreased significantly after 131I‐MIBG treatment (126 ± 122 ng/mL vs. 91 ± 125 ng/mL; P < 0.01); however, the patients with reduced 5‐HIAA levels did not experience improved survival (4.11 years vs. 3.42 years; P = 0.2). Patients who received an initial 131I‐MIBG dose > 400 mCi lived longer than patients who received < 400 mCi (4.69 years vs. 1.86 years; P = 0.05). Radiographic tumor response did not predict survival. Toxicity included pancytopenia, thrombocytopenia, nausea, and emesis.The current data support 131I‐MIBG treatment in select patients with metastatic carcinoid who progress despite optimal medical management. Improved survival was predicted best by symptomatic response to 131I‐MIBG treatment, but not by hormone or radiographic response. Cancer 2004. © 2004 American Cancer Society.
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- 2004
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26. Antisense basic fibroblast growth factor gene transfer reduces neointimal thickening after arterial injury
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Hanna, Abigail K., Fox, Jonathan C., Neschis, David G., Safford, Shawn D., Swain, Judith L., and Golden, Michael A.
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Purpose:To determine whether synthesis of endogenous basic fibroblast growth factor (bFGF) after arterial injury is critical to the intimal thickening response, intraluminal adenoviral gene transfer of an antisense bFGF (Ad.ASbFGF) transgene was used to inhibit the subsequent synthesis of bFGF protein after injury.
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- 1997
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27. Helmet use among Alaskan children involved in off-road motorized vehicle crashes
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Snyder, Christopher W., Muensterer, Oliver J., Sacco, Frank, and Safford, Shawn D.
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BackgroundOff-road motorized vehicle crashes are a common source of trauma among Alaska children. Injury morbidity is worse in Alaska Native children than non-Native children, but the reasons are unclear.ObjectiveTo evaluate the differences in helmet use between the Native and the non-Native children, and to assess the impact of helmet use on injury patterns and outcomes.DesignThis retrospective cohort study identified patients aged 17 or younger admitted after all-terrain vehicle, snowmobile or motorbike injury between 2001 and 2011 from the Alaska Trauma Registry. Helmeted and non-helmeted patients were compared with respect to demographics, central nervous system (CNS) injury and the overall risk of death or permanent disability. Logistic regression was used to evaluate predictors of helmet use and the effects of ethnicity and helmet use on outcomes.ResultsOf the 921 injured children, 51% were Alaska Native and 49% were non-Native. Helmet use was lower among Native versus non-Native patients on unadjusted comparison (24% vs. 71%) and multivariable logistic regression (OR 0.17, 95% CI 0.11–0.27, p<0.0001). Prevalence of CNS injury was higher among Native children (39.7% vs. 30.4%, p=0.016). However, on logistic regression with adjustment for helmet use, Native ethnicity was not a significant predictor of CNS injury (OR 1.07, 95% CI 0.68–1.68, p=0.78), whereas helmet use was strongly protective against CNS injury (OR 0.28, 95% CI 0.18–0.44, p<0.0001) as well as death or permanent disability (OR 0.26, 95% CI 0.10–0.67, p=0.006).ConclusionsHelmet use is lower among Alaska Native children involved in off-road motorized vehicle crashes. These ethnic disparities in helmet use contribute to higher rates of CNS injury among Native children. Helmet use significantly improves overall outcome. Helmet promotion efforts should be expanded, especially in Native communities.
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- 2014
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28. Paediatric trauma on the Last Frontier: an 11-year review of injury mechanisms, high-risk injury patterns and outcomes in Alaskan children
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Snyder, Christopher W., Muensterer, Oliver J., Sacco, Frank, and Safford, Shawn D.
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BackgroundPaediatric trauma system development in Alaska is complicated by a vast geographic coverage area, wide regional variations in environment and culture, and a lack of available published data.ObjectiveTo provide a detailed description of paediatric trauma mechanisms, high-risk injury patterns and outcomes in Alaska.DesignThis retrospective study included all children aged 17 years or younger in the State of Alaska Trauma Registry database admitted with traumatic injury between 2001 and 2011. Each injury record was reviewed individually and assigned a mechanism based on Centers for Disease Control E-codes. Geographic definitions were based on existing Emergency Medical Services regions. Mechanisms were compared by geographic region, patient demographics, injury characteristics and outcome. Subgroup analysis of fatal injuries was performed to identify causes of death.ResultsOf 5,547 patients meeting inclusion criteria, the most common mechanisms of injury were falls (39%), motor vehicle collisions (10%) and all-terrain vehicle (ATV) accidents (9%). The overall case fatality rate was 2%. Mechanisms with the greatest risk of death were gunshot wounds (21%), pedestrians struck by motorized vehicles (9%) and motor vehicle collisions (5%). These 3 mechanisms accounted for 15% of injuries but 60% of deaths in the overall cohort. Injury patterns involving combined central nervous system (CNS) and torso injuries were unusual but especially lethal, occurring in 3% of patients but carrying a case fatality rate of 18%. Although the distribution of mechanisms was generally similar for each geographic region, ATV and snowmobile injuries were significantly more common in remote areas (23% remote vs. 7% non-remote, p < 0.0001).ConclusionsMechanisms of paediatric trauma in Alaska have widely varying impacts on outcome and show some variation by region. Highest-risk mechanisms include gunshot wounds and motorized vehicle-related accidents. Prevention efforts should give special attention to CNS injury prevention, ATV and snowmobile safety in remote areas, and optimization of management of multisystem trauma. Further studies should investigate predictors of outcome in greater detail.
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- 2014
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