Unawane A.,Providence Surgery Centers |
Kamyab A.,Providence Surgery Centers |
Patel M.,Providence Surgery Centers |
Flynn J.C.,Providence Hospital and Medical Centers |
Mittal V.K.,Providence Surgery Centers
American Journal of Surgery | Year: 2013
Background: Realizing the trends toward minimally invasive procedures, the Accreditation Council for Graduate Medical Education (ACGME) increased the requirements for laparoscopic procedures effective 2007 to 2008. Our purpose was to analyze the trend of laparoscopic versus open cases. Methods: We analyzed national ACGME general surgery operative log program data for basic and advanced open and laparoscopic procedures performed by graduating surgical residents between academic years 1996 to 1997 and 2009 to 2010. Results: From 1997 to 2010, the average number of procedures performed by graduating residents increased for appendectomies (36.5 to 59.3), cholecystectomies (90.9 to 112), hernia repairs (58.9 to 67.4), and colectomies (40.1 to 60.2). These increases have been accompanied by decreases in the percentage of open procedures for appendectomies (84% to 30%), cholecystectomies (24% to 9%), hernia repairs (90% to 70%), and colectomies (97% to 71%), which have resulted primarily from a decrease in open procedures (basic) or an increase in laparoscopic procedures (advanced). Conclusions: The rising number of laparoscopic procedures performed by surgical residents is associated with a drastic decrease in the number of basic open procedures. Although the number of open procedures is sufficient to meet ACGME requirements for now, this is an area of concern for the adequacy of training in the future. © 2013 Elsevier Inc. All rights reserved.
Hasan R.A.,Pediatric Critical Care Medicine |
Thomas J.,Providence Hospital and Medical Centers |
Davidson B.,University of Toledo |
Barnes J.,Providence Hospital and Medical Center |
Reddy R.,Mercy Childrens Hospital
Pediatric Critical Care Medicine | Year: 2011
Objective: To evaluate the safety and feasibility of exhaled breath condensate (EBC) collection in children recovering from status asthmaticus (SA) in a pediatric intensive care unit (PICU); and to investigate whether 8-isoprostane (8-Iso) could be detected in the EBC of these children and to compare its concentration with that in the EBC collected from healthy children. Design: Prospective study. Setting: Multidisciplinary PICU in a teaching hospital. Patients: Sixteen consecutive patients (7-18 yrs of age) with SA and 16 age- and sex-matched controls. Interventions: The Wood clinical asthma score and the pulmonary index were used to assess the clinical severity of patients with SA upon admission to the PICU. EBC samples were collected within 24 hrs of admission to the PICU and were analyzed for the concentration of 8-Iso. Measurements and Main Results: Data are presented as mean ± sd values. There were no differences in age (12 ± 3.3 yrs vs.12 ± 2 yrs, p > .05) or sex (n = 10 males and n = 6 females in each group), between SA patients and controls. All patients with SA and the controls completed the EBC collection without complications. There was no statistically significant difference in the pulmonary index (3.2 ± 2.7 vs. 3.1 ± 2.8, p 0.9) post collection of EBC compared with the baseline values. There was a statistically significant correlation between Wood score and pulmonary index at the time of admission to the PICU in children with SA (r = .7, p < .01). The concentration of 8-Iso was significantly higher in the EBC of children with SA compared with controls (14.3 ± 1.8 pg/mL vs. 5.2 ± 0.7 pg/mL, p < .001). The correlation between the concentration 8-Iso and either the pulmonary index or Wood score at the time admission to the PICU was not statistically significant. Conclusions: EBC collection is well tolerated by children aged 7-18 yrs who are recovering from SA in a PICU. 8-Iso is elevated in the EBC from children with SA and may provide insight into the biochemical changes of oxidative stress in children in this clinical setting. Copyright © 2011 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Hasan R.A.,Providence Hospital and Medical Centers |
O'Brien E.,University of Michigan |
Mancuso P.,University of Michigan
Pediatric Critical Care Medicine | Year: 2012
OBJECTIVE: To measure levels of 8-isoprostane and Lipoxin A4 in the exhaled breath condensate of children (7-17 yrs old) recovering from status asthmaticus in a pediatric intensive care unit and to compare their respective levels in the exhaled breath condensate collected from age-matched "healthy" children enrolled from an ambulatory pediatric clinic during well-child visits. DESIGN: Prospective case-controlled study. SETTING: Teaching hospitals and a research laboratory. PATIENTS: Children recovering from status asthmaticus and age-matched controls. INTERVENTIONS: Collection of exhaled breath condensate from patients recovering from status asthmaticus and controls for purpose of measurement of 8-isoprostane and Lipoxin A4. MEASUREMENTS AND MAIN RESULTS: There was no difference in age (11.9 ± 3.0 vs. 12.0 ± 3.3 yrs, p = .9) between patients and control subjects. All participants completed the exhaled breath condensate collection without complications. There was no difference in the pulmonary index (3.3 ± 2.2 vs. 3.1 ± 1.9, p = 1.0) after collection of exhaled breath condensate compared with baseline values in patients with status asthmaticus. The level of 8-isoprostane was significantly higher (63 ± 9 vs. 41 ± 13 pg/mL, p < .001), whereas the level of Lipoxin A4 was significantly lower (5.6 ± 2.9 vs. 10.5 ± 3.1 ng/mL, p < .001) in the exhaled breath condensate from children recovering from status asthmaticus compared with control subjects. CONCLUSIONS: 8-Isoprostane was elevated and Lipoxin A4 is decreased in the exhaled breath condensate of children recovering from status asthmaticus in a pediatric intensive care unit. These data may provide new insight into the pathophysiology of asthma in children in this clinical setting. © 2012 The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Ronco C.,International Renal Research Institute IRRIV |
Stacul F.,Science Radiologia Ospedale Maggiore |
McCullough P.A.,St John Providence Health System |
McCullough P.A.,Medical Center |
McCullough P.A.,Providence Hospital and Medical Centers
European Radiology | Year: 2013
Abstract: Contrast-induced acute kidney injury (CI-AKI), previously known as contrast-induced nephropathy (CIN), is a syndrome in which an acute renal dysfunction is diagnosed after the intravascular injection of contrast media. AKI implies an injury or damage but not necessarily a reduction in overall renal filtration function. The renal damage becomes evident only when more than 50 % of the renal mass is compromised. This typically occurs when AKI is diagnosed using creatinine as a marker; in fact, creatinine is a surrogate of glomerular filtration and it does not describe the whole spectrum of kidney function. Recent AKI classifications include even slight changes in serum creatinine (as low as 0.3 mg/dl), which are associated with worse outcomes. An early diagnosis of AKI using novel biomarkers has now become possible. These new biomarkers provide additional value, not only because they facilitate earlier diagnosis but also because they can diagnose AKI even in the absence of a change in subsequent filtration function. Thus, in this situation, these new criteria can reveal subclinical AKI. A new domain of AKI diagnosis could then include functional and structural criteria as indicated by laboratory testing. Key Points: • There is continuing concern about renal damage caused by radiological contrast agents • Acute kidney injury may be associated with minor changes in serum creatinine • AKI implies damage but not necessarily a reduction in overall renal filtration function. • Novel biomarkers facilitate earlier diagnosis, even if subsequent filtration function is unaltered. • AKI diagnosis could include functional and structural criteria as indicated by laboratory testing © 2012 European Society of Radiology.
Daee S.S.,Providence Surgery Centers |
Flynn J.C.,Providence Hospital and Medical Centers |
Jacobs M.J.,Providence Surgery Centers |
Mittal V.K.,Providence Surgery Centers
HPB | Year: 2013
Objective This study was conducted to determine whether residents are receiving enough hepatopancreatobiliary (HPB) training during general surgery residencies to exclude the necessity of pursuing formal fellowships in HPB surgery. Methods Trends in HPB surgery training were examined using Accreditation Council for Graduate Medical Education (ACGME) operative log data for the academic years 1999/2000 to 2009/2010. Results Of 800 000 HPB operations performed annually in the USA, the proportion of HPB procedures performed by general surgery residents increased from 15% (122 007) to 18% (143 000) between the periods under study. Numbers of pancreatic, liver and biliary procedures performed by graduating general surgery residents increased by 47% (from 8185 to 12 006), 31% (from 7468 to 9765), and 14% (from 106 354 to 121 239), respectively. The mean number of operations undertaken by a graduating resident increased from 8.3 to 11.5 (38% increase) for pancreatic surgeries, from 7.6 to 9.4 (24% increase) for liver surgeries, and from 107.5 to 116.6 (8% increase) for biliary surgeries. Total numbers of complex pancreatic, liver and biliary procedures increased by 91% (from 4768 to 9129) and 24% (from 6649 to 8233), and decreased by 29% (from 6581 to 4648), respectively. Conclusions The overall trend shows an increase in the number of HPB procedures undertaken by graduating general surgery residents. The mean number of procedures exceeds ACGME requirements, but falls short of association guidelines. However, certain residents exceed International Hepato-Pancreato-Biliary Association (IHPBA) fellowship requirements for total and complex procedures during residency. Consideration should be given to those residents to allow them to bypass fellowship training provided that they meet other IHPBA standards. © 2013 International Hepato-Pancreato-Biliary Association.