Laura Cassidy - Academia.edu (original) (raw)

Papers by Laura Cassidy

The American journal of managed care

Annals of emergency medicine

Study objective: Previous studies disagree about the effect of out-of-hospital endotracheal intub... more Study objective: Previous studies disagree about the effect of out-of-hospital endotracheal intubation on traumatic brain injury. This study compares the effects of out-of-hospital endotracheal intubation versus emergency department (ED) endotracheal intubation on mortality and neurologic and functional outcome after severe traumatic brain injury.

International Journal of Pediatric Otorhinolaryngology, 2015

To implement and review a database for children with a diagnosis of otitis media (OM) to facilita... more To implement and review a database for children with a diagnosis of otitis media (OM) to facilitate comparative outcomes and long-term prospective follow up of surgical outcomes. Specific aim is to review presenting symptoms, risk factors, tympanostomy tube outcomes and complications, and need for further procedures. A web-based customized database was constructed to universally enroll all patients seen in consultation with a diagnosis of OM. Unique database fields include demographics, physical exam findings, risk factors, intervention, and long-term outcomes. Major surgical complications measured include: tympanic membrane perforation, retained tubes, chronic otorrhea, and cholesteatoma formation. Six hundred and thirty four unique patients have been prospectively enrolled. Five hundred and forty four tubes have been followed to extrusion. Outcomes demonstrate high prevalence of OM risk factors associated with surgical patients including: 63% in day care and 26% with a sibling requiring tympanostomy tubes. Complication rates; 1% developed perforations requiring surgical intervention, 2.6% required removal of retained tubes, 1% extruded early (<60 days), and 0.7% were surgically removed for other complications. Cholesteatoma was identified in 0.56%, all had ongoing chronic ear disease. Long-term, outcome driven investigations assessing the surgical management of OM are needed given the prevalence of this disease and the frequency of surgical intervention required. The current database represents the largest prospective cohort of patients enrolled and followed in this fashion and has generated data demonstrating a procedure associated with significant improvement in patient quality of life in the short-term with low complication rates in the long-term. This ongoing prospective investigation is providing data that have the potential to be important in treatment algorithms, procedure justification, and risk factor modification.

Journal of registry management, 2011

The Wisconsin Pediatric Cardiac Registry (WPCR) collects information on infants born in the state... more The Wisconsin Pediatric Cardiac Registry (WPCR) collects information on infants born in the state of Wisconsin with structural congenital heart disease (CHD). The WPCR actively ascertains CHD cases in the state of Wisconsin. Cases must be conceived and born in Wisconsin after January 1, 2000. Once ascertained, subjects are approached to participate in genetic sampling and completion of a questionnaire that assesses family history of CHD, maternal health, and environmental exposures before pregnancy and during the first trimester. In 2009, the WPCR underwent a transition to a new database and from a paper questionnaire to a Web-based questionnaire. The WPCR has screened over 5,100 children and has ascertained 4,919 cases of CHD in the state of Wisconsin during the years 2000 to 2009. During this interval, 1,982 completed questionnaires and 1,062 DNA samples have been obtained from consented subjects. Another 1,774 DNA samples have been obtained from blood relatives of CHD subjects. T...

Journal of Neurosurgery: Pediatrics, 2005

Misdiagnosis of inflicted traumatic brain injury (iTBI) is common. Serum biomarkers may be able t... more Misdiagnosis of inflicted traumatic brain injury (iTBI) is common. Serum biomarkers may be able to assist in the detection of iTBIs that would otherwise be missed. The authors investigated whether serum concentrations of biomarkers were increased after noninflicted (n)TBI and iTBI in pediatric cases of varying severity. This prospective, case-control study involved 100 patients (56 with nTBI, 44 with iTBI) and 64 controls. Blood was collected in patients within 12 hours of injury; a subset had serial samples. A single sample was collected from controls. Serum neuron-specific enolase (NSE), S100B, and myelin basic protein concentrations were measured. Abnormal concentrations were defined using receiver-operator characteristic (ROC) curves. The sensitivity and specificity of initial NSE and S100B and peak myelin basic protein concentrations for identifying TBI at ROC curve-defined cutoffs were 71 and 64% (NSE), 77 and 72% (S100B), and 44 and 96% (myelin basic protein), respectively. Eighty-six percent of patients having suffered iTBI had one or more biomarkers increased, including 82% of children with iTBI and a Glasgow Coma Scale score of 15, and two children with iTBI who were initially misdiagnosed. Children with iTBI had a later peak concentration of all three biomarkers and were more likely to have increased myelin basic protein levels at admission compared with patients with nTBI. Serum NSE, S100B, or myelin basic protein are increased in the majority of children with acute nTBI and iTBI, including well-appearing children with iTBI in whom the diagnosis might otherwise have been missed. Differences in the time course of NSE, S100B, and myelin basic protein after nTBI and iTBI may provide insight into the pathophysiology of iTBI. These serum markers should be prospectively evaluated in a target population of infants.

Clinical Orthopaedics and Related Research®, 2014

Musculoskeletal disease is a major cause of disability in the global burden of disease, yet data ... more Musculoskeletal disease is a major cause of disability in the global burden of disease, yet data regarding the magnitude of this burden in developing countries are lacking. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey was designed to measure the incidence and prevalence of surgically treatable conditions, including musculoskeletal conditions, in patients in low- and middle-income countries, and was administered in the West African nation of Sierra Leone in 2012. We attempted to quantify the burden of potentially treatable musculoskeletal conditions in patients in Sierra Leone. A cross-sectional two-stage cluster-based survey was performed in Sierra Leone using the SOSAS. Two individuals from each randomly selected household underwent a verbal head to toe examination. The musculoskeletal-related questions from the SOSAS survey in Sierra Leone were analyzed to determine the prevalence of musculoskeletal problems in the study population. Prevalence is reported as the number of respondents with a musculoskeletal problem now and number of respondents with a musculoskeletal problem during the past year. Respondents had "no need" for care, they "received care", or they faced a barrier that prevented them from receiving care. One thousand eight hundred seventy-five households were targeted, with 1843 undergoing the survey, which yielded 3645 individual respondents. Of the individual respondents, 462 (n=3645; 12.6% of total; 95% CI, 12%-13%) had a traumatic musculoskeletal problem during the past year, and 236 (n=3645; 6% of total; 95% CI, 5%-7%) respondents had a musculoskeletal problem of nontraumatic etiology. Of respondents with either a traumatic or nontraumatic musculoskeletal problem, 359 (n=562; 63.9% of total; 95% CI, 59.5-68.3%) needed care but were unable to receive it with the major barrier reported as financial. Resource allocation decisions in global health are made based on burden of disease data in low- and middle-income countries. The data provided here for Sierra Leone may offer some generalizable insight into the scope of the burden of musculoskeletal disease for low- and middle-income countries, especially in Sub-Saharan Africa, and provide concrete evidence that musculoskeletal health should be included in the global health discussion. However, there may be important differences across countries in this region, and further study to elucidate these differences seems critical given the large burden of disease and the limited resources available in these regions to manage it.

To use a nationwide household survey tool to provide an estimate of injury prevalence, mechanisms... more To use a nationwide household survey tool to provide an estimate of injury prevalence, mechanisms of traumatic injuries, and number of injury-related deaths in a low-income country. A randomized, cross-sectional nationwide survey using the Surgeons OverSeas Assessment of Surgical Need tool was conducted in 2012. Sierra Leone, Africa. Three thousand seven hundred fifty randomly selected participants throughout Sierra Leone. Mechanisms of injury based on age, sex, anatomic location, cause, and sociodemographic factors as well as mechanisms of injury-related deaths in the previous year were the primary outcome measures. Data were collected and analyzed from 1843 households and 3645 respondents (98% response rate). Four hundred fifty-two respondents (12%) reported at least 1 traumatic injury in the preceding year. Falls were the most common cause of nonfatal injuries (40%). The extremities were the most common injury site regardless of age or sex. Traffic injuries were the leading cause of injury-related deaths (32% of fatal injuries). This study provides baseline data on the mechanisms of traumatic injuries as well as the sociodemographic factors affecting injury prevalence in one of the world's poorest nations. It is anticipated that these data will provide an impetus for further studies to determine injury severity, associated disability, and barriers to accessing care in these resource-poor areas.

Although great efforts are being undertaken to reduce child morbidity and mortality globally, the... more Although great efforts are being undertaken to reduce child morbidity and mortality globally, there is limited knowledge about the need for pediatric surgical care. Some data on surgical need is available from hospital registries, but it is difficult to interpret for countries with limited surgical capacity. A cross-sectional two-stage cluster-based sample survey was undertaken in Sierra Leone, using the Surgeons OverSeas Assessment of Surgical Need tool. Data were collected and analyzed on numbers of children needing surgical care and pediatric deaths that may have been averted if surgical care had been available. A total of 1,583 children out of 3,645 individuals (43.3 %) were interviewed. Most (64.0 %, n = 1,013) participants lived in rural areas. At the time of interview, 279 (17.6; 95 % confidence interval (95 % CI): 15.7-19.5 %) had a possible surgical condition in need of a consultation. Children in the northern and eastern provinces of Sierra Leone were much more likely to report a surgical problem than those in the urban-west. There is a high need for surgical care in the pediatric population of Sierra Leone. While additional resources should be allocated to address that need, more research is needed. Ideally, questions on surgically treatable conditions should be added to the frequently performed health care surveys on the pediatric population.

Toxicology and Industrial Health, 2002

To assess the possible relationship between formaldehyde exposure and mortality risk from pharyng... more To assess the possible relationship between formaldehyde exposure and mortality risk from pharyngeal cancer (PC), in particular nasopharyngeal cancer (NPC). Subjects were 7328 workers employed at a plastics-producing plant (1941-1984). Vital status for 98% of the cohort and cause of death for 95% of 2872 deaths were determined. Reconstructed exposures to formaldehyde, particulates and pigment were used to compute several exposure measures. Standardized mortality ratios (SMRs) were computed for several demographic, work history and formaldehyde exposure variables. In a nested case-control study, seven cases of NPC and 15 cases of other PC were matched on race, sex, age and year of birth to four controls from the cohort. Among interviewed subjects, lifetime smoking history was determined using respondents or proxies for all but one control subject. Statistically significant 2.23-fold and fivefold excesses for PC and NPC, respectively, were observed. Fivefold range NPC excesses were observed for both short ( < 1 year) and long-term workers and were concentrated among workers hired during 1947-1956. Only three NPC cases were exposed to formaldehyde for longer than one year, and each had low average intensity of formaldehyde exposure (0.03-0.60 ppm). Only a few exposure measures revealed some evidence of an association with all PC or NPC. For all PC combined, adjustment for smoking and year-of-hire in the case-control study generally corroborated findings from the cohort study. Overall, the pattern of findings suggests that the large, persistent nasopharyngeal and other PC excesses observed among the Wallingford workforce are not associated with formaldehyde exposure, and may reflect the influence of nonoccupational risk factors or occupational risk factors associated with employment outside the Wallingford plant.

International Journal of Pediatric Otorhinolaryngology, 2015

To analyze factors associated with progression of an original scientific presentation at the Amer... more To analyze factors associated with progression of an original scientific presentation at the American Society of Pediatric Otolaryngology (ASPO) Annual Meeting to publication in a peer-reviewed journal. A dataset of presenters was created to enable prospective follow-up to assess early impressions regarding publication success with longer-term publication outcomes. Prior to the Annual ASPO meeting in 2013, a survey consisting of 10 questions was e-mailed to all 59 presenters. Questions were designed to assess presenter expectations on publication, barriers to publishing, and experience in presenting, publishing and clinical practice. A second survey was sent 12 months later to those respondents of the first survey who were amenable to follow-up. Overall, 46 of 59 (78%) presenters responded to the initial survey prior to their ASPO 2013 presentation. Of these, 34 agreed to participate in a longer-term follow-up of their presentation to publication experience. Of these 34, there were 17 who participated in the follow-up survey 1 year later. Just under half of the original respondents were residents (46%). All presenters (100%) planned to re-submit a revised manuscript if initially rejected. However, 35% of follow-up respondents did not make initial submission to a peer-reviewed journal. Results of a descriptive analysis suggest that more experienced researchers expect their submitted manuscript to be accepted for publication within a shorter time frame than those that have published fewer papers. Time was ranked as the greatest barrier to publication (60%) of those surveyed both in the initial prospective survey and for those who did not publish a paper in the follow-up survey (83%). This study suggests a strong desire and expectation of publishing ASPO presentations. Despite this expectation, past research and this data set suggest this expectation often does not materialize. "Time constraints" were the most commonly identified barrier to publication. To enhance dissemination of new findings from ASPO meetings, institutions and individuals should examine methods that facilitate and incentivize publication of findings in peer-reviewed publications.

Prehospital Emergency Care, 2004

PEDIATRICS, 2013

Infantile hemangiomas (IHs) are common neoplasms composed of proliferating endothelial-like cells... more Infantile hemangiomas (IHs) are common neoplasms composed of proliferating endothelial-like cells. Despite the relative frequency of IH and the potential severity of complications, there are currently no uniform guidelines for treatment. Although propranolol has rapidly been adopted, there is significant uncertainty and divergence of opinion regarding safety monitoring, dose escalation, and its use in PHACE syndrome (PHACE = posterior fossa, hemangioma, arterial lesions, cardiac abnormalities, eye abnormalities; a cutaneous neurovascular syndrome characterized by large, segmental hemangiomas of the head and neck along with congenital anomalies of the brain, heart, eyes and/or chest wall). A consensus conference was held on December 9, 2011. The multidisciplinary team reviewed existing data on the pharmacologic properties of propranolol and all published reports pertaining to the use of propranolol in pediatric patients. Workgroups were assigned specific topics to propose protocols on the following subjects: contraindications, special populations, pretreatment evaluation, dose escalation, and monitoring. Consensus protocols were recorded during the meeting and refined after the meeting. When appropriate, protocol clarifications and revision were made and agreed upon by the group via teleconference. Because of the absence of high-quality clinical research data, evidence-based recommendations are not possible at present. However, the team agreed on a number of recommendations that arose from a review of existing evidence, including when to treat complicated IH; contraindications and pretreatment evaluation protocols; propranolol use in PHACE syndrome; formulation, target dose, and frequency of propranolol; initiation of propranolol in infants; cardiovascular monitoring; ongoing monitoring; and prevention of hypoglycemia. Where there was considerable controversy, the more conservative approach was selected. We acknowledge that the recommendations are conservative in nature and anticipate that they will be revised as more data are made available.

Pediatric Dermatology, 2010

Outpatient surgical procedures performed in medicine have been increasing, as has the use of gene... more Outpatient surgical procedures performed in medicine have been increasing, as has the use of general anesthesia. Children are more likely to require general anesthesia for procedures because of developmental constraints limiting their cooperation. Dermatology procedures are typically painful and can require time to perform and thus necessitating the use of general anesthesia. Studies evaluating safety and complication rates associated with the use of general anesthesia in children are needed to determine the safety of this practice. The purpose of this investigation was to assess whether the use of general anesthesia to perform pediatric dermatology surgical procedures was associated with any significant adverse events. A retrospective chart review was conducted for eligible patients with a procedure code in the range of 10,040-19,499 for a period of 2 years. Records were reviewed for documentation of any unplanned visits, events or complications. A total of 681 procedures were reported for 226 unique patients with 235 diagnoses. No anesthesia-related adverse events were identified in any of these patients. Eleven patients had documentation of minor complications of the wound. General anesthesia can be used safely in pediatric dermatology surgery patients without associated complications in the appropriate setting, indication, and patient population, using state-of-art technology and equipment, and experienced pediatric-trained anesthesiologists.

Pediatric Anesthesia, 2011

To aggregate data across institutions to identify, characterize, and differentiate potential surv... more To aggregate data across institutions to identify, characterize, and differentiate potential survivors from nonsurvivors based on etiology of event. To evaluate the association of the cardiopulmonary resuscitation (CPR) duration and probability of survival (Ps), stratified by etiology of arrest. In-hospital cardiac arrests occur in 2-6% of pediatric patients with poor survival rates resulting in significant expenditures of time and resources. Retrospective data from six pediatric hospitals on patients suffering from pulseless cardiac arrests receiving CPR for over one minute were analyzed. Data included demographics, reason for code, precardiac arrest diagnosis, devices and treatment, management strategies during cardiac arrest, compression duration, outcome at hospital discharge, and neurologic outcome of survivors at hospital discharge. Results of logistic regression analysis generated predicated probabilities of survival for duration of compression. Patients were stratified by cardiac-induced cardiac arrests (CICA) and respiratory-induced cardiac arrest (RICA). A total of 257 patients were included, and 27% of CICA and 35% of RICA patients survived to hospital discharge. Ps was initially lower for the CICA patients (Ps at 1 min = 29%) and remained constant (Ps at 60 min = 25%). RICA patients'Ps was higher initially (Ps at 1 min = 62%) but demonstrated a dramatic drop within the first 60 min of CPR (Ps at 60 min = 0.2%). Probability of survival curves based on duration of CPR was statistically significantly different for CICA patients compared to RICA patients.

Obstetrics & Gynecology, 2013

To describe the current status of access to maternal care, family planning use, and place of deli... more To describe the current status of access to maternal care, family planning use, and place of delivery in Sierra Leone, one of the poorest countries in the world with one of the highest maternal mortality rates. Data from the Surgeons OverSeas Assessment of Surgical Need, a cross-sectional two-stage cluster-based household survey conducted in Sierra Leone in 2012, were analyzed to determine access to maternal care, family planning use, and location of delivery. Of 3,318 females of reproductive age (12-50 years of age), 1,205 participants were interviewed in depth. Twenty percent (95% confidence interval [CI] 17.9-22.5) of respondents reported using family planning methods; injectables were the most frequently used method. Fifty-nine percent (95% CI 54.0-63.0) of the recalled deliveries took place outside of a health facility. Of the total births, 1.9% (95% CI 1.3-2.5) were reportedly delivered by cesarean and 0.4% (9/2,316) with instrumental delivery. There were 53 reported maternal deaths in the 12 months before the survey, resulting in a maternal mortality rate of 1,600 per 100,000 females per year. Of the maternal deaths, 30 females (56.6%) did not receive any type of modern health care with 53% (16/30) of families citing financial constraints. This study reaffirms a low family planning uptake and very low instrument deliveries and cesarean delivery rates in Sierra Leone. Additionally, financial barriers hinder access to health care and indicate that the free health care initiative for pregnant females is not yet fully covering the reproductive needs of the females of Sierra Leone. III.

The Lancet, 2012

Surgical care is increasingly recognised as an important part of global health yet data for the b... more Surgical care is increasingly recognised as an important part of global health yet data for the burden of surgical disease are scarce. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) was developed to measure the prevalence of surgical conditions and surgically treatable deaths in low-income and middle-income countries. We administered this survey countrywide in Sierra Leone, which ranks 180 of the 187 nations on the UN Development Index. The study was done between Jan 9 and Feb 3, 2012. 75 of 9671 enumeration areas, the smallest administrative units in Sierra Leone, were randomly selected for the study clusters, with a probability proportional to the population size. In each cluster 25 households were randomly selected to take part in the survey. Data were collected via handheld tablets by trained local medical and nursing students. A household representative was interviewed to establish the number of household members (defined as those who ate from the same pot and slept in the same structure the night before the interview), identify deaths in the household during the previous year, and establish whether any of the deceased household members had a condition needing surgery in the week before death. Two randomly selected household members underwent a head-to-toe verbal examination and need for surgical care was recorded on the basis of the response to whether they had a condition that they believed needed surgical assessment or care. Of the 1875 targeted households, data were analysed for 1843 (98%). 896 of 3645 (25%; 95% CI 22·9-26·2) respondents reported a surgical condition needing attention and 179 of 709 (25%; 95% CI 22·5-27·9) deaths of household members in the previous year might have been averted by timely surgical care. Our results show a large unmet need for surgical consultations in Sierra Leone and provide a baseline against which future surgical programmes can be measured. Additional surveys in other low-income and middle-income countries are needed to document and confirm what seems to be a neglected component of global health. Surgeons OverSeas, Thompson Family Foundation.

The Lancet, 2012

ABSTRACT Background Traumatic injuries are an important cause of disability and mortality worldwi... more ABSTRACT Background Traumatic injuries are an important cause of disability and mortality worldwide and more than 90% of injury-related deaths occur in low-income and middle-income countries. Despite its overall significance, little information exists about the burden of injuries in developing countries. We aim to estimate the prevalence of traumatic injuries, describe injury mechanisms, and assess the degree of associated disability in Sierra Leone.Methods We used the Surgeons OverSeas Assessment of Surgical Need instrument to do a nationwide population-based survey in Sierra Leone in January 2012. We used a two-stage random sampling method to generate a target population of 3750 participants across the 14 districts of Sierra Leone. In the first stage of sampling, 75 clusters were randomly chosen (with a random calculator program on the iPad) with a probability proportional to population stratified for urban and rural settings. In the second stage, 25 households within each cluster were randomly selected. Each participant had a verbal head to toe examination to record information about timing of injuries, mechanism of injury, body regions involved, and injury-related disability. The head of each participating household provided information about injury-related deaths within the household in the preceding year. We used bivariate logistic regression models to test associations between sociodemographic factors (age, sex, residency, occupation, and education) and injury. We did the analyses with SAS OnDemand Enterprise Guide (version 4.3).FindingsWe obtained data from 1843 households and 3645 respondents, yielding a response rate of 97·2%. 1316 injuries were reported in total. 486 respondents (13%) reported at least one traumatic injury in the preceding year. Falls were the most common cause of injury, accounting for 563 cases (43%). Extremities were the most frequently injured body region (n=720, 55%). Of the 57 reported injuries to the groin, 24 (42%) were associated with disability. 14 (25%) of these groin injuries prevented the person from working as they did before the injury. Although injuries related to motor vehicles were uncommon (4th most common overall), they were the leading cause of injury-related deaths, accounting for 13 of 41 deaths (32%). The odds of having a traumatic injury in the previous year were not significantly different between groups when analysed for residency, occupation, or education level. However, women were less likely to have had a traumatic injury in the previous year compared with men (odds ratio [OR] 0·69, 95% CI 0·57–0·83). Also, elderly people were less likely to have had a traumatic injury in the previous year compared with children (OR 0·51, 95% CI 0·31–0·83).InterpretationThis study provides baseline data for the burden of traumatic injuries in a poor country. In addition to injury-prevention measures, strategies to address current injury-related health problems are urgently needed in such resource-poor areas.FundingSurgeons OverSeas, Sierra Leone Ministry of Health & Sanitation, College of Medicine and Allied Health Sciences, Connaught Hospital, Stanford University.

Journal of the American College of Surgeons, 2013

Injury is the leading cause of childhood morbidity and mortality in the US. The associated costs ... more Injury is the leading cause of childhood morbidity and mortality in the US. The associated costs exceed $20 billion annually. This study examined disparities in disadvantaged populations of critically injured pediatric patients admitted to a level 1 pediatric trauma center. A retrospective study was conducted of all trauma patients admitted to the pediatric intensive care unit (PICU) at a level 1 pediatric trauma hospital from 2005 to 2009. Data on 324 patients were analyzed; 45% of patients were Caucasian, 33% were African American, 12% were Hispanic, and 10% were other. There was no difference in age, Glasgow Coma Scale (GCS), or Injury Severity Score (ISS) across ethnic groups. The mortality rate was 12%. A higher percentage of Caucasians were commercially insured and from the highest income quartile than non-Caucasians (p < 0.001). African Americans had the highest rate of penetrating trauma and intentional injury compared with other ethnicities (p < 0.001). Nearly 75% of firearm injuries were clustered in 7 ZIP codes with the lowest median household incomes. The home was the most common location for firearm injuries. Children involved in assaults were more likely to have a single parent (67%) than 2 parents (26%, p < 0.001). Both ethnicity and payer status were significantly associated with mortality. Significant disparities in socioeconomic status exist in severely injured pediatric patients treated in the PICU. Disparities were associated with adverse outcomes. These results should inform community and public health efforts to identify the areas and populations at highest risk for violence-related injuries.

The American journal of managed care

Annals of emergency medicine

Study objective: Previous studies disagree about the effect of out-of-hospital endotracheal intub... more Study objective: Previous studies disagree about the effect of out-of-hospital endotracheal intubation on traumatic brain injury. This study compares the effects of out-of-hospital endotracheal intubation versus emergency department (ED) endotracheal intubation on mortality and neurologic and functional outcome after severe traumatic brain injury.

International Journal of Pediatric Otorhinolaryngology, 2015

To implement and review a database for children with a diagnosis of otitis media (OM) to facilita... more To implement and review a database for children with a diagnosis of otitis media (OM) to facilitate comparative outcomes and long-term prospective follow up of surgical outcomes. Specific aim is to review presenting symptoms, risk factors, tympanostomy tube outcomes and complications, and need for further procedures. A web-based customized database was constructed to universally enroll all patients seen in consultation with a diagnosis of OM. Unique database fields include demographics, physical exam findings, risk factors, intervention, and long-term outcomes. Major surgical complications measured include: tympanic membrane perforation, retained tubes, chronic otorrhea, and cholesteatoma formation. Six hundred and thirty four unique patients have been prospectively enrolled. Five hundred and forty four tubes have been followed to extrusion. Outcomes demonstrate high prevalence of OM risk factors associated with surgical patients including: 63% in day care and 26% with a sibling requiring tympanostomy tubes. Complication rates; 1% developed perforations requiring surgical intervention, 2.6% required removal of retained tubes, 1% extruded early (<60 days), and 0.7% were surgically removed for other complications. Cholesteatoma was identified in 0.56%, all had ongoing chronic ear disease. Long-term, outcome driven investigations assessing the surgical management of OM are needed given the prevalence of this disease and the frequency of surgical intervention required. The current database represents the largest prospective cohort of patients enrolled and followed in this fashion and has generated data demonstrating a procedure associated with significant improvement in patient quality of life in the short-term with low complication rates in the long-term. This ongoing prospective investigation is providing data that have the potential to be important in treatment algorithms, procedure justification, and risk factor modification.

Journal of registry management, 2011

The Wisconsin Pediatric Cardiac Registry (WPCR) collects information on infants born in the state... more The Wisconsin Pediatric Cardiac Registry (WPCR) collects information on infants born in the state of Wisconsin with structural congenital heart disease (CHD). The WPCR actively ascertains CHD cases in the state of Wisconsin. Cases must be conceived and born in Wisconsin after January 1, 2000. Once ascertained, subjects are approached to participate in genetic sampling and completion of a questionnaire that assesses family history of CHD, maternal health, and environmental exposures before pregnancy and during the first trimester. In 2009, the WPCR underwent a transition to a new database and from a paper questionnaire to a Web-based questionnaire. The WPCR has screened over 5,100 children and has ascertained 4,919 cases of CHD in the state of Wisconsin during the years 2000 to 2009. During this interval, 1,982 completed questionnaires and 1,062 DNA samples have been obtained from consented subjects. Another 1,774 DNA samples have been obtained from blood relatives of CHD subjects. T...

Journal of Neurosurgery: Pediatrics, 2005

Misdiagnosis of inflicted traumatic brain injury (iTBI) is common. Serum biomarkers may be able t... more Misdiagnosis of inflicted traumatic brain injury (iTBI) is common. Serum biomarkers may be able to assist in the detection of iTBIs that would otherwise be missed. The authors investigated whether serum concentrations of biomarkers were increased after noninflicted (n)TBI and iTBI in pediatric cases of varying severity. This prospective, case-control study involved 100 patients (56 with nTBI, 44 with iTBI) and 64 controls. Blood was collected in patients within 12 hours of injury; a subset had serial samples. A single sample was collected from controls. Serum neuron-specific enolase (NSE), S100B, and myelin basic protein concentrations were measured. Abnormal concentrations were defined using receiver-operator characteristic (ROC) curves. The sensitivity and specificity of initial NSE and S100B and peak myelin basic protein concentrations for identifying TBI at ROC curve-defined cutoffs were 71 and 64% (NSE), 77 and 72% (S100B), and 44 and 96% (myelin basic protein), respectively. Eighty-six percent of patients having suffered iTBI had one or more biomarkers increased, including 82% of children with iTBI and a Glasgow Coma Scale score of 15, and two children with iTBI who were initially misdiagnosed. Children with iTBI had a later peak concentration of all three biomarkers and were more likely to have increased myelin basic protein levels at admission compared with patients with nTBI. Serum NSE, S100B, or myelin basic protein are increased in the majority of children with acute nTBI and iTBI, including well-appearing children with iTBI in whom the diagnosis might otherwise have been missed. Differences in the time course of NSE, S100B, and myelin basic protein after nTBI and iTBI may provide insight into the pathophysiology of iTBI. These serum markers should be prospectively evaluated in a target population of infants.

Clinical Orthopaedics and Related Research®, 2014

Musculoskeletal disease is a major cause of disability in the global burden of disease, yet data ... more Musculoskeletal disease is a major cause of disability in the global burden of disease, yet data regarding the magnitude of this burden in developing countries are lacking. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey was designed to measure the incidence and prevalence of surgically treatable conditions, including musculoskeletal conditions, in patients in low- and middle-income countries, and was administered in the West African nation of Sierra Leone in 2012. We attempted to quantify the burden of potentially treatable musculoskeletal conditions in patients in Sierra Leone. A cross-sectional two-stage cluster-based survey was performed in Sierra Leone using the SOSAS. Two individuals from each randomly selected household underwent a verbal head to toe examination. The musculoskeletal-related questions from the SOSAS survey in Sierra Leone were analyzed to determine the prevalence of musculoskeletal problems in the study population. Prevalence is reported as the number of respondents with a musculoskeletal problem now and number of respondents with a musculoskeletal problem during the past year. Respondents had "no need" for care, they "received care", or they faced a barrier that prevented them from receiving care. One thousand eight hundred seventy-five households were targeted, with 1843 undergoing the survey, which yielded 3645 individual respondents. Of the individual respondents, 462 (n=3645; 12.6% of total; 95% CI, 12%-13%) had a traumatic musculoskeletal problem during the past year, and 236 (n=3645; 6% of total; 95% CI, 5%-7%) respondents had a musculoskeletal problem of nontraumatic etiology. Of respondents with either a traumatic or nontraumatic musculoskeletal problem, 359 (n=562; 63.9% of total; 95% CI, 59.5-68.3%) needed care but were unable to receive it with the major barrier reported as financial. Resource allocation decisions in global health are made based on burden of disease data in low- and middle-income countries. The data provided here for Sierra Leone may offer some generalizable insight into the scope of the burden of musculoskeletal disease for low- and middle-income countries, especially in Sub-Saharan Africa, and provide concrete evidence that musculoskeletal health should be included in the global health discussion. However, there may be important differences across countries in this region, and further study to elucidate these differences seems critical given the large burden of disease and the limited resources available in these regions to manage it.

To use a nationwide household survey tool to provide an estimate of injury prevalence, mechanisms... more To use a nationwide household survey tool to provide an estimate of injury prevalence, mechanisms of traumatic injuries, and number of injury-related deaths in a low-income country. A randomized, cross-sectional nationwide survey using the Surgeons OverSeas Assessment of Surgical Need tool was conducted in 2012. Sierra Leone, Africa. Three thousand seven hundred fifty randomly selected participants throughout Sierra Leone. Mechanisms of injury based on age, sex, anatomic location, cause, and sociodemographic factors as well as mechanisms of injury-related deaths in the previous year were the primary outcome measures. Data were collected and analyzed from 1843 households and 3645 respondents (98% response rate). Four hundred fifty-two respondents (12%) reported at least 1 traumatic injury in the preceding year. Falls were the most common cause of nonfatal injuries (40%). The extremities were the most common injury site regardless of age or sex. Traffic injuries were the leading cause of injury-related deaths (32% of fatal injuries). This study provides baseline data on the mechanisms of traumatic injuries as well as the sociodemographic factors affecting injury prevalence in one of the world's poorest nations. It is anticipated that these data will provide an impetus for further studies to determine injury severity, associated disability, and barriers to accessing care in these resource-poor areas.

Although great efforts are being undertaken to reduce child morbidity and mortality globally, the... more Although great efforts are being undertaken to reduce child morbidity and mortality globally, there is limited knowledge about the need for pediatric surgical care. Some data on surgical need is available from hospital registries, but it is difficult to interpret for countries with limited surgical capacity. A cross-sectional two-stage cluster-based sample survey was undertaken in Sierra Leone, using the Surgeons OverSeas Assessment of Surgical Need tool. Data were collected and analyzed on numbers of children needing surgical care and pediatric deaths that may have been averted if surgical care had been available. A total of 1,583 children out of 3,645 individuals (43.3 %) were interviewed. Most (64.0 %, n = 1,013) participants lived in rural areas. At the time of interview, 279 (17.6; 95 % confidence interval (95 % CI): 15.7-19.5 %) had a possible surgical condition in need of a consultation. Children in the northern and eastern provinces of Sierra Leone were much more likely to report a surgical problem than those in the urban-west. There is a high need for surgical care in the pediatric population of Sierra Leone. While additional resources should be allocated to address that need, more research is needed. Ideally, questions on surgically treatable conditions should be added to the frequently performed health care surveys on the pediatric population.

Toxicology and Industrial Health, 2002

To assess the possible relationship between formaldehyde exposure and mortality risk from pharyng... more To assess the possible relationship between formaldehyde exposure and mortality risk from pharyngeal cancer (PC), in particular nasopharyngeal cancer (NPC). Subjects were 7328 workers employed at a plastics-producing plant (1941-1984). Vital status for 98% of the cohort and cause of death for 95% of 2872 deaths were determined. Reconstructed exposures to formaldehyde, particulates and pigment were used to compute several exposure measures. Standardized mortality ratios (SMRs) were computed for several demographic, work history and formaldehyde exposure variables. In a nested case-control study, seven cases of NPC and 15 cases of other PC were matched on race, sex, age and year of birth to four controls from the cohort. Among interviewed subjects, lifetime smoking history was determined using respondents or proxies for all but one control subject. Statistically significant 2.23-fold and fivefold excesses for PC and NPC, respectively, were observed. Fivefold range NPC excesses were observed for both short ( < 1 year) and long-term workers and were concentrated among workers hired during 1947-1956. Only three NPC cases were exposed to formaldehyde for longer than one year, and each had low average intensity of formaldehyde exposure (0.03-0.60 ppm). Only a few exposure measures revealed some evidence of an association with all PC or NPC. For all PC combined, adjustment for smoking and year-of-hire in the case-control study generally corroborated findings from the cohort study. Overall, the pattern of findings suggests that the large, persistent nasopharyngeal and other PC excesses observed among the Wallingford workforce are not associated with formaldehyde exposure, and may reflect the influence of nonoccupational risk factors or occupational risk factors associated with employment outside the Wallingford plant.

International Journal of Pediatric Otorhinolaryngology, 2015

To analyze factors associated with progression of an original scientific presentation at the Amer... more To analyze factors associated with progression of an original scientific presentation at the American Society of Pediatric Otolaryngology (ASPO) Annual Meeting to publication in a peer-reviewed journal. A dataset of presenters was created to enable prospective follow-up to assess early impressions regarding publication success with longer-term publication outcomes. Prior to the Annual ASPO meeting in 2013, a survey consisting of 10 questions was e-mailed to all 59 presenters. Questions were designed to assess presenter expectations on publication, barriers to publishing, and experience in presenting, publishing and clinical practice. A second survey was sent 12 months later to those respondents of the first survey who were amenable to follow-up. Overall, 46 of 59 (78%) presenters responded to the initial survey prior to their ASPO 2013 presentation. Of these, 34 agreed to participate in a longer-term follow-up of their presentation to publication experience. Of these 34, there were 17 who participated in the follow-up survey 1 year later. Just under half of the original respondents were residents (46%). All presenters (100%) planned to re-submit a revised manuscript if initially rejected. However, 35% of follow-up respondents did not make initial submission to a peer-reviewed journal. Results of a descriptive analysis suggest that more experienced researchers expect their submitted manuscript to be accepted for publication within a shorter time frame than those that have published fewer papers. Time was ranked as the greatest barrier to publication (60%) of those surveyed both in the initial prospective survey and for those who did not publish a paper in the follow-up survey (83%). This study suggests a strong desire and expectation of publishing ASPO presentations. Despite this expectation, past research and this data set suggest this expectation often does not materialize. "Time constraints" were the most commonly identified barrier to publication. To enhance dissemination of new findings from ASPO meetings, institutions and individuals should examine methods that facilitate and incentivize publication of findings in peer-reviewed publications.

Prehospital Emergency Care, 2004

PEDIATRICS, 2013

Infantile hemangiomas (IHs) are common neoplasms composed of proliferating endothelial-like cells... more Infantile hemangiomas (IHs) are common neoplasms composed of proliferating endothelial-like cells. Despite the relative frequency of IH and the potential severity of complications, there are currently no uniform guidelines for treatment. Although propranolol has rapidly been adopted, there is significant uncertainty and divergence of opinion regarding safety monitoring, dose escalation, and its use in PHACE syndrome (PHACE = posterior fossa, hemangioma, arterial lesions, cardiac abnormalities, eye abnormalities; a cutaneous neurovascular syndrome characterized by large, segmental hemangiomas of the head and neck along with congenital anomalies of the brain, heart, eyes and/or chest wall). A consensus conference was held on December 9, 2011. The multidisciplinary team reviewed existing data on the pharmacologic properties of propranolol and all published reports pertaining to the use of propranolol in pediatric patients. Workgroups were assigned specific topics to propose protocols on the following subjects: contraindications, special populations, pretreatment evaluation, dose escalation, and monitoring. Consensus protocols were recorded during the meeting and refined after the meeting. When appropriate, protocol clarifications and revision were made and agreed upon by the group via teleconference. Because of the absence of high-quality clinical research data, evidence-based recommendations are not possible at present. However, the team agreed on a number of recommendations that arose from a review of existing evidence, including when to treat complicated IH; contraindications and pretreatment evaluation protocols; propranolol use in PHACE syndrome; formulation, target dose, and frequency of propranolol; initiation of propranolol in infants; cardiovascular monitoring; ongoing monitoring; and prevention of hypoglycemia. Where there was considerable controversy, the more conservative approach was selected. We acknowledge that the recommendations are conservative in nature and anticipate that they will be revised as more data are made available.

Pediatric Dermatology, 2010

Outpatient surgical procedures performed in medicine have been increasing, as has the use of gene... more Outpatient surgical procedures performed in medicine have been increasing, as has the use of general anesthesia. Children are more likely to require general anesthesia for procedures because of developmental constraints limiting their cooperation. Dermatology procedures are typically painful and can require time to perform and thus necessitating the use of general anesthesia. Studies evaluating safety and complication rates associated with the use of general anesthesia in children are needed to determine the safety of this practice. The purpose of this investigation was to assess whether the use of general anesthesia to perform pediatric dermatology surgical procedures was associated with any significant adverse events. A retrospective chart review was conducted for eligible patients with a procedure code in the range of 10,040-19,499 for a period of 2 years. Records were reviewed for documentation of any unplanned visits, events or complications. A total of 681 procedures were reported for 226 unique patients with 235 diagnoses. No anesthesia-related adverse events were identified in any of these patients. Eleven patients had documentation of minor complications of the wound. General anesthesia can be used safely in pediatric dermatology surgery patients without associated complications in the appropriate setting, indication, and patient population, using state-of-art technology and equipment, and experienced pediatric-trained anesthesiologists.

Pediatric Anesthesia, 2011

To aggregate data across institutions to identify, characterize, and differentiate potential surv... more To aggregate data across institutions to identify, characterize, and differentiate potential survivors from nonsurvivors based on etiology of event. To evaluate the association of the cardiopulmonary resuscitation (CPR) duration and probability of survival (Ps), stratified by etiology of arrest. In-hospital cardiac arrests occur in 2-6% of pediatric patients with poor survival rates resulting in significant expenditures of time and resources. Retrospective data from six pediatric hospitals on patients suffering from pulseless cardiac arrests receiving CPR for over one minute were analyzed. Data included demographics, reason for code, precardiac arrest diagnosis, devices and treatment, management strategies during cardiac arrest, compression duration, outcome at hospital discharge, and neurologic outcome of survivors at hospital discharge. Results of logistic regression analysis generated predicated probabilities of survival for duration of compression. Patients were stratified by cardiac-induced cardiac arrests (CICA) and respiratory-induced cardiac arrest (RICA). A total of 257 patients were included, and 27% of CICA and 35% of RICA patients survived to hospital discharge. Ps was initially lower for the CICA patients (Ps at 1 min = 29%) and remained constant (Ps at 60 min = 25%). RICA patients'Ps was higher initially (Ps at 1 min = 62%) but demonstrated a dramatic drop within the first 60 min of CPR (Ps at 60 min = 0.2%). Probability of survival curves based on duration of CPR was statistically significantly different for CICA patients compared to RICA patients.

Obstetrics & Gynecology, 2013

To describe the current status of access to maternal care, family planning use, and place of deli... more To describe the current status of access to maternal care, family planning use, and place of delivery in Sierra Leone, one of the poorest countries in the world with one of the highest maternal mortality rates. Data from the Surgeons OverSeas Assessment of Surgical Need, a cross-sectional two-stage cluster-based household survey conducted in Sierra Leone in 2012, were analyzed to determine access to maternal care, family planning use, and location of delivery. Of 3,318 females of reproductive age (12-50 years of age), 1,205 participants were interviewed in depth. Twenty percent (95% confidence interval [CI] 17.9-22.5) of respondents reported using family planning methods; injectables were the most frequently used method. Fifty-nine percent (95% CI 54.0-63.0) of the recalled deliveries took place outside of a health facility. Of the total births, 1.9% (95% CI 1.3-2.5) were reportedly delivered by cesarean and 0.4% (9/2,316) with instrumental delivery. There were 53 reported maternal deaths in the 12 months before the survey, resulting in a maternal mortality rate of 1,600 per 100,000 females per year. Of the maternal deaths, 30 females (56.6%) did not receive any type of modern health care with 53% (16/30) of families citing financial constraints. This study reaffirms a low family planning uptake and very low instrument deliveries and cesarean delivery rates in Sierra Leone. Additionally, financial barriers hinder access to health care and indicate that the free health care initiative for pregnant females is not yet fully covering the reproductive needs of the females of Sierra Leone. III.

The Lancet, 2012

Surgical care is increasingly recognised as an important part of global health yet data for the b... more Surgical care is increasingly recognised as an important part of global health yet data for the burden of surgical disease are scarce. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) was developed to measure the prevalence of surgical conditions and surgically treatable deaths in low-income and middle-income countries. We administered this survey countrywide in Sierra Leone, which ranks 180 of the 187 nations on the UN Development Index. The study was done between Jan 9 and Feb 3, 2012. 75 of 9671 enumeration areas, the smallest administrative units in Sierra Leone, were randomly selected for the study clusters, with a probability proportional to the population size. In each cluster 25 households were randomly selected to take part in the survey. Data were collected via handheld tablets by trained local medical and nursing students. A household representative was interviewed to establish the number of household members (defined as those who ate from the same pot and slept in the same structure the night before the interview), identify deaths in the household during the previous year, and establish whether any of the deceased household members had a condition needing surgery in the week before death. Two randomly selected household members underwent a head-to-toe verbal examination and need for surgical care was recorded on the basis of the response to whether they had a condition that they believed needed surgical assessment or care. Of the 1875 targeted households, data were analysed for 1843 (98%). 896 of 3645 (25%; 95% CI 22·9-26·2) respondents reported a surgical condition needing attention and 179 of 709 (25%; 95% CI 22·5-27·9) deaths of household members in the previous year might have been averted by timely surgical care. Our results show a large unmet need for surgical consultations in Sierra Leone and provide a baseline against which future surgical programmes can be measured. Additional surveys in other low-income and middle-income countries are needed to document and confirm what seems to be a neglected component of global health. Surgeons OverSeas, Thompson Family Foundation.

The Lancet, 2012

ABSTRACT Background Traumatic injuries are an important cause of disability and mortality worldwi... more ABSTRACT Background Traumatic injuries are an important cause of disability and mortality worldwide and more than 90% of injury-related deaths occur in low-income and middle-income countries. Despite its overall significance, little information exists about the burden of injuries in developing countries. We aim to estimate the prevalence of traumatic injuries, describe injury mechanisms, and assess the degree of associated disability in Sierra Leone.Methods We used the Surgeons OverSeas Assessment of Surgical Need instrument to do a nationwide population-based survey in Sierra Leone in January 2012. We used a two-stage random sampling method to generate a target population of 3750 participants across the 14 districts of Sierra Leone. In the first stage of sampling, 75 clusters were randomly chosen (with a random calculator program on the iPad) with a probability proportional to population stratified for urban and rural settings. In the second stage, 25 households within each cluster were randomly selected. Each participant had a verbal head to toe examination to record information about timing of injuries, mechanism of injury, body regions involved, and injury-related disability. The head of each participating household provided information about injury-related deaths within the household in the preceding year. We used bivariate logistic regression models to test associations between sociodemographic factors (age, sex, residency, occupation, and education) and injury. We did the analyses with SAS OnDemand Enterprise Guide (version 4.3).FindingsWe obtained data from 1843 households and 3645 respondents, yielding a response rate of 97·2%. 1316 injuries were reported in total. 486 respondents (13%) reported at least one traumatic injury in the preceding year. Falls were the most common cause of injury, accounting for 563 cases (43%). Extremities were the most frequently injured body region (n=720, 55%). Of the 57 reported injuries to the groin, 24 (42%) were associated with disability. 14 (25%) of these groin injuries prevented the person from working as they did before the injury. Although injuries related to motor vehicles were uncommon (4th most common overall), they were the leading cause of injury-related deaths, accounting for 13 of 41 deaths (32%). The odds of having a traumatic injury in the previous year were not significantly different between groups when analysed for residency, occupation, or education level. However, women were less likely to have had a traumatic injury in the previous year compared with men (odds ratio [OR] 0·69, 95% CI 0·57–0·83). Also, elderly people were less likely to have had a traumatic injury in the previous year compared with children (OR 0·51, 95% CI 0·31–0·83).InterpretationThis study provides baseline data for the burden of traumatic injuries in a poor country. In addition to injury-prevention measures, strategies to address current injury-related health problems are urgently needed in such resource-poor areas.FundingSurgeons OverSeas, Sierra Leone Ministry of Health & Sanitation, College of Medicine and Allied Health Sciences, Connaught Hospital, Stanford University.

Journal of the American College of Surgeons, 2013

Injury is the leading cause of childhood morbidity and mortality in the US. The associated costs ... more Injury is the leading cause of childhood morbidity and mortality in the US. The associated costs exceed $20 billion annually. This study examined disparities in disadvantaged populations of critically injured pediatric patients admitted to a level 1 pediatric trauma center. A retrospective study was conducted of all trauma patients admitted to the pediatric intensive care unit (PICU) at a level 1 pediatric trauma hospital from 2005 to 2009. Data on 324 patients were analyzed; 45% of patients were Caucasian, 33% were African American, 12% were Hispanic, and 10% were other. There was no difference in age, Glasgow Coma Scale (GCS), or Injury Severity Score (ISS) across ethnic groups. The mortality rate was 12%. A higher percentage of Caucasians were commercially insured and from the highest income quartile than non-Caucasians (p < 0.001). African Americans had the highest rate of penetrating trauma and intentional injury compared with other ethnicities (p < 0.001). Nearly 75% of firearm injuries were clustered in 7 ZIP codes with the lowest median household incomes. The home was the most common location for firearm injuries. Children involved in assaults were more likely to have a single parent (67%) than 2 parents (26%, p < 0.001). Both ethnicity and payer status were significantly associated with mortality. Significant disparities in socioeconomic status exist in severely injured pediatric patients treated in the PICU. Disparities were associated with adverse outcomes. These results should inform community and public health efforts to identify the areas and populations at highest risk for violence-related injuries.