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  • The Hispanic Clinic for Pediatric Surgery: A model to improve parent-provider communication for Hispanic pediatric surgery patients JOURNAL OF PEDIATRIC SURGERY Jaramillo, J., Snyder, E., Dunlap, J. L., Wright, R., Mendoza, F., Bruzoni, M. 2016; 51 (4): 670-674

    Abstract

    26 million Americans have limited English proficiency (LEP). It is well established that language barriers adversely affect health and health care. Despite growing awareness of language barriers, there is essentially a void in the medical literature regarding the influence of language disparity on pediatric surgery patients. This study was designed to assess the impact of patient-provider language concordance on question-asking behavior and patient satisfaction for pediatric surgery patients.Participants included families of patients in a General Pediatric Surgery Clinic categorized into 3 groups by patient-provider language concordance: concordant English-speaking, LEP concordant Spanish-speaking, and LEP discordant Spanish-speaking using an interpreter. Clinical visits were audio recorded and the number of patient-initiated questions and the length of clinical encounter were measured. Families were administered a surgery-specific, 5-point Likert scale questionnaire modeled after validated surveys concerning communication, trust, perceived discrimination and patient-provider language concordance. Regression models were performed to analyze associations between language concordance and patient's question-asking behavior and between language concordance and survey results.A total of 156 participants were enrolled including 57 concordant-English, 52 LEP concordant-Spanish and 47 LEP-discordant-Spanish. There was significant variation in the mean number of patient-initiated questions among the groups (p=0.002). Both the English and Spanish concordant groups asked a similar number of questions (p=0.9), and they both asked more questions compared to the Spanish-discordant participants (p=0.002 and p=0.001). Language discordance was associated with fewer questions asked after adjustment for socioeconomic status. Language concordant participants rated higher scores of communication. Both Spanish-concordant and Spanish-discordant patients reported significantly increased preference for, and value of language concordant care. Language discordant participants reported that they desired to ask more questions but were limited by a language barrier (p=0.001).In a pediatric surgery clinic, language concordant care increases the number of patient-asked questions during a clinical visit and improves communication suggesting that discordant care is a potential source of disparities in access to information. Future efforts should focus on expanding access to language concordant providers in other surgery subspecialties as a step towards limiting disparities in surgical care for all patients.

    View details for DOI 10.1016/j.jpedsurg.2015.08.065

    View details for PubMedID 26474548

  • Variability in mortality following caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: a systematic review and analysis of published data LANCET GLOBAL HEALTH Uribe-Leitz, T., Jaramillo, J., Maurer, L., Fu, R., Esquivel, M. M., Gawande, A. A., Haynes, A. B., Weiser, T. G. 2016; 4 (3): E165-E174

    Abstract

    Surgical interventions occur at lower rates in resource-poor settings, and complication and death rates following surgery are probably substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that high quality accompanies increased global access to surgical care. We aimed to assess surgical mortality following three common surgical procedures-caesarean delivery, appendectomy, and groin (inguinal and femoral) hernia repair-to quantify the potential risks of expanding access without simultaneously addressing issues of quality and safety.We collected demographic, health, and economic data for 113 countries classified as low income or lower-middle income by the World Bank in 2005. We did a systematic review of Ovid, MEDLINE, PubMed, and Scopus from Jan 1, 2000, to Jan 15, 2015, to identify studies in these countries reporting all-cause mortality following the three commonly undertaken operations. Reports from governmental and other agencies were also identified and included. We modelled surgical mortality rates for countries without reported data using a two-step multiple imputation method. We first used a fully conditional specification (FCS) multiple imputation method to establish complete datasets for all missing variables that we considered potentially predictive of surgical mortality. We then used regression-based predictive mean matching imputation methods, specified within the multiple imputation FCS method, for selected predictors for each operation using the completed dataset to predict mortality rates along with confidence intervals for countries without reported mortality data. To account for variability in data availability, we aggregated results by subregion and estimated surgical mortality rates.From an initial 1302 articles and reports identified, 247 full-text articles met our inclusion criteria, and 124 provided data for surgical mortality for at least one of the three selected operations. We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality was 7·9 per 1000 operations for caesarean delivery (IQR 2·8-19·9), 2·2 per 1000 operations for appendectomy (0·0-17·2), and 4·9 per 1000 operations for groin hernia (0·0-11·7). Perioperative mortality estimates by subregion ranged from 2·8 (South Asia) to 50·2 (East Asia) per 1000 caesarean deliveries, 2·4 (South Asia) to 54·0 (Central sub-Saharan Africa) per 1000 appendectomies, and 0·3 (Andean Latin America) to 25·5 (Southern sub-Saharan Africa) per 1000 hernia repairs.All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care.None.

    View details for Web of Science ID 000370675000019

    View details for PubMedID 26916818

  • Long-term follow-up of laparoscopic transcutaneous inguinal herniorraphy with high transfixation suture ligature of the hernia sac. Journal of pediatric surgery Bruzoni, M., Jaramillo, J. D., Kastenberg, Z. J., Wall, J. K., Wright, R., Dutta, S. 2015; 50 (10): 1767-1771

    Abstract

    Laparoscopic transcutaneous inguinal hernia repair in children may reduce postoperative pain, improve cosmesis, allow for less manipulation of the cord structures, and offer easy access to the contralateral groin. However, there is concern for unacceptably high recurrence rates when the procedure is generalized. To address this increase in recurrence, in 2011 we described in this journal a modification of the laparoscopic transcutaneous technique that replicates high transfixation ligature of the hernia sac with the aim of inducing more secure healing, preventing suture slippage, and distributing tension across two suture passes. We now describe our long-term follow-up of this novel repair.After obtaining IRB approval, a retrospective chart review and phone follow-up were performed on all patients who underwent laparoscopic transfixation ligature hernia repair between October 2009 and August 2014 (including further follow-up of the 21 patients reviewed in the 2011 report of this technique). Data collection included demographics, laterality of hernia, evidence of recurrence, complications, and time to follow-up.Median follow-up was 24months (range 2-52months). Three pediatric surgeons performed 216 laparoscopic transfixation ligature repairs on 166 patients. Demographics: mean age 29.5months (range 1-192months); male 67.2% and female 32.8%; 4.2% of patients were premature at operation. Repairs were bilateral in 42% of patients, right sided in 34%, and left sided in 24%. Three patients together experienced 4 recurrences, for an overall recurrence rate of 1.8%. Two of the recurrences occurred in a 2-month old syndromic patient with severe congenital heart disease who recurred twice after laparoscopic transfixation ligature repair then subsequently failed an attempt at open repair. Excluding this one outlier patient, the recurrence rate was 0.9%. The complication rate was 1.7% (3 hydroceles and 1 inguinal hematoma; all resolved spontaneously).Laparoscopic high transfixation ligature hernia repair can be adopted by surgeons with basic laparoscopic skills, and result in excellent outcomes with acceptable recurrence rates.

    View details for DOI 10.1016/j.jpedsurg.2015.06.006

    View details for PubMedID 26201542

  • Sutureless vs Sutured Gastroschisis Closure: A Prospective Randomized Controlled Trial. Journal of the American College of Surgeons Bruzoni, M., Jaramillo, J. D., Dunlap, J. L., Abrajano, C., Stack, S. W., Hintz, S. R., Hernandez-Boussard, T., Dutta, S. 2017; 224 (6): 1091-1096 e1

    Abstract

    Sutureless gastroschisis repair involves covering the abdominal wall defect with the umbilical cord or a synthetic dressing to allow closure by secondary intention. No randomized studies have described the outcomes of this technique. Our objective was to prospectively compare short-term outcomes of sutureless vs sutured closure in a randomized fashion.We recruited patients who presented with gastroschisis between 2009 and 2014 and were randomized into either sutureless or sutured treatment groups. Patients with complicated gastroschisis (stricture, perforation, and ischemia) were excluded. Predefined ventilation, feeding, and dressing change protocols were instituted. Primary outcomes were time to extubation and time to full feeds. Secondary outcomes included time to discharge and rate of complications. Data were analyzed using Fisher's exact or t-tests using a p value ≤ 0.05. Factors associated with increased time to discharge were estimated using multivariate analyses.Thirty-nine patients were enrolled, 19 to sutureless and 20 to sutured repair. There was no statistical difference in time to extubation (sutureless 1.89 vs sutured 3.15 days; p = 0.061). The sutureless group had a significant increase in mean time to full feeds (45.1 vs 27.8 days; p = 0.031) and mean time to discharge (49.3 vs 31.4 days; p = 0.016). Complication rates were similar in both groups. Multivariate regression modeling showed that an increase in time to discharge was independently associated with sutureless repair, feeding complications, and sepsis.Sutureless repair of uncomplicated gastroschisis can be performed safely, however, it is associated with a significant increase in time to full feeds and time to discharge.

    View details for DOI 10.1016/j.jamcollsurg.2017.02.014

    View details for PubMedID 28279777

  • Variability in mortality after caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: implications for expanding surgical services. Lancet Weiser, T. G., Uribe-Leitz, T., Fu, R., Jaramillo, J., Maurer, L., Esquivel, M. M., Gawande, A. A., Haynes, A. B. 2015; 385: S34-?

    Abstract

    While surgical interventions occur at lower rates in resource-poor settings, rates of complication and death after surgery are substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that quality accompanies increased global access to surgical care. We aimed to assess mortality following surgery to assess the risks of such interventions in these environments.We collected the most recent demographic, health, and economic data from WHO for 114 countries classified as low-income or lower-middle-income according to the World Bank in 2005. We searched OVID, MedLine, PubMed, and SCOPUS to identify studies in these countries reporting all-cause mortality after three commonly performed operations: caesarean delivery, appendectomy, and groin hernia repair. Reports from governmental and other agencies were also identified. We modelled surgical mortality rates for countries without reported data with the lasso technique that performs continuous variable subset selection to avoid model overfitting. We validated our model against known case fatality rates for caesarean delivery. We aggregated mortality results by subregion to account for variability in data availability. We then created collective surgical case fatality rates by WHO region.We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality rates were 7·7 per 1000 operations for caesarean delivery (IQR 3-14), 4·0 per 1000 operations for appendectomy (IQR 0-17), and 4·7 per 1000 operations for hernia groin (IQR 0-13); all recorded deaths occurred during the same admission to hospital as the operation. Based on our model, case fatality rate estimates by subregion ranged from 0·7 (central Europe) to 13·9 (central sub-Saharan Africa) per 1000 caesarean deliveries, 5·6 (central Asia) to 6·4 (central sub-Saharan Africa) per 1000 appendectomies, and 3·5 (tropical Latin America) to 33·9 (central sub-Saharan Africa) per 1000 hernia repairs.All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments, and substantially higher than those in middle-income and high-income settings. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care.None.

    View details for DOI 10.1016/S0140-6736(15)60829-7

    View details for PubMedID 26313082

  • Reduced Bone Density and Vertebral Fractures in Smokers: Men and COPD Patients at Increased Risk. Annals of the American Thoracic Society Jaramillo, J. D., Wilson, C., Stinson, D. J., Lynch, D. A., Bowler, R. P., Lutz, S., Bon, J. M., Arnold, B., McDonald, M. N., Washko, G. R., Wan, E. S., DeMeo, D. L., Foreman, M. G., Soler, X., Lindsay, S. E., Lane, N. E., Genant, H. K., Silverman, E. K., Hokanson, J. E., Make, B. J., Crapo, J. D., Regan, E. A. 2015

    Abstract

    Rationale: Former smoking history and Chronic Obstructive Pulmonary Disease (COPD) are potential risk factors for osteoporosis and fractures. Under existing guidelines for osteoporosis screening, women are included but men are not, and only current smoking is considered. Objectives: To demonstrate the impact of COPD and smoking history on the risk of osteoporosis and vertebral fracture in men and women. Measurements: Volumetric bone mineral density (vBMD) by calibrated quantitative CT (QCT), visually scored vertebral fractures and severity of lung disease were determined from chest CT scans of 3321 current and ex-smokers in COPDGene study. Low volumetric bone mineral density as a surrogate for osteoporosis was calculated from young adult normal values. Methods: Characteristics of participants with low volumetric bone mineral density were identified and associated to COPD and other risk factors. We tested associations of gender and COPD to both volumetric bone mineral density and fractures adjusting for age, race, BMI, smoking and glucocorticoid use. Main Results: Male smokers had a small but significantly greater risk of low volumetric bone mineral density (- 2.5 SD below young adult mean by calibrated quantitative CT) and more fractures than female smokers. Low volumetric bone mineral density was present in 58% of all subjects, was more frequent with worse COPD and rose to 84% of very severe COPD subjects. Vertebral fractures were present in 37% of all subjects and were associated with lower volumetric bone mineral density at each GOLD stage. Vertebral fractures were most common in the mid-thoracic region. COPD and specifically emphysema were associated with both low volumetric bone mineral density and vertebral fractures after adjustment for steroid use, age, pack years, current smoking and exacerbations. Airway disease was associated with higher bone density after adjustment for other variables. Calibrated quantitative CT identified more abnormal subjects than the standard DXA in a subset of subjects and correlated well with prevalent fractures. Conclusion: Male smokers with and without COPD, have a significant risk of low bone mineral density and vertebral fractures. COPD was associated with low volumetric bone mineral density after adjusting for race, gender, BMI, smoking, steroid use, exacerbations and increasing age. Screening for low bone mineral density in men and women smokers using quantitative CT scanning will increase opportunities to identify and treat osteoporosis in this at-risk population.

    View details for DOI 10.1513/AnnalsATS.201412-591OC

    View details for PubMedID 25719895

  • The Hispanic Clinic for Pediatric Surgery: A model to improve parent-provider communication for Hispanic pediatric surgery patients Journal of Pediatric Surgery Jaramillo, J., Snyder, E., Dunlap, J., Wright, R., Mendoza, F., Bruzoni, M. 2015
  • The effects of language concordant care on patient satisfaction and clinical understanding for Hispanic pediatric surgery patients Journal of Pediatric Surgery Dunlap, J. L., Jaramillo, J. D., Koppolu, R., Wright, R., Mendoza, F., Bruzoni, M. 2015; 50 (9): 1586-1589
  • It's the Fracture that Matters - Bone Disease in COPD Patients COPD-JOURNAL OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE Regan, E., Jaramillo, J. 2012; 9 (4): 319-321

    View details for DOI 10.3109/15412555.2012.708544

    View details for Web of Science ID 000307360300001

    View details for PubMedID 22876916