Mehul Raval Mentees to Present at PAPS

March 2016

Two Emory post-graduates under the research mentorship of Emory pediatric surgeon Mehul Raval, MD, MS, will present abstracts at the 49th Annual Meeting of the Pacific Association of Pediatric Surgeons (PAPS) in Kaui, Hawaii, April 24-28. General surgery resident Heather Short, MD, and MPH student Mitali Thakore of the Rollins School of Public Health, are contributing to components of Dr. Raval's quality, safety, and outcomes studies involving pediatric surgical care.

"PAPS is one of only a handful of pediatric surgical societies that has fast track meeting publications in the Journal of Pediatric Surgery," says Dr. Raval, who was senior author of both abstracts. "The meeting will be a great opportunity for Heather and Mitali's work to be exposed to many of the west coast surgical groups."

Dr. Short will present "Increased Morbidity and Mortality in Cardiac Patients Undergoing Nissen Fundoplication: Evidence from NSQIP-P." For the study, she and her co-investigators evaluated risk factors and compared morbidity/mortality rates among infants with congenital cardiac disease (CCD) that underwent gastrostotomy tube placement (GT), fundoplication, or both surgeries to treat their inability to swallow or take adequate oral nutrition.

Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, the team identified 4070 patients less-than one year old who underwent GT and/or fundoplication from 2012-2014. Of these infants, 2346 had CCD and were categorized as minor, major, or severe as defined by NSQIP-P. Regression models were used to estimate the association of cardiac comorbidities with morbidity/mortality.  

Dr. Short's team found that fundoplication done alone and with GT was associated with increased odds of morbidity in infants with CCD compared to GT alone. Risk decreased when these procedures were performed later in the first year of life and when they were done laparoscopically. Increased risk persisted after accounting for surgical approach and stratifying by severity of CCD. The investigators, who included Emory pediatric surgery chief Mark Wulkan, MD, and Emory pediatric surgeon Matthew Clifton, MD, concluded that the timing of these interventions for patients with CCD and the surgical method used required further investigation.

Dr. Short, Emory general surgery chief resident Jeremy Fisher, MD, and Emory pediatric surgeon Kurt Heiss, MD, were among Ms. Thakore's collaborators on "Cost Efficiency of Lobectomy Versus Fine Needle Aspiration for Diagnostic Workup of Thyroid Nodules in Children." The team examined the cost efficiency of ultrasound guided fine needle aspiration (FNA) versus initial diagnostic lobectomy (DL) in children with ultrasound-confirmed thyroid nodules. The DL procedure removes the section of the thyroid that has the nodule, while FNA only removes a few cells from the nodule itself.   

Despite the fact that current guidelines recommend FNA as the initial diagnostic study of choice for these nodules, the procedure is not widely available.

Decision investigation was conducted using costs and probabilities identified through literature searches. A tornado diagram was created that indicated the most influential variables in the model, and Monte Carlo probability simulation and sensitivity analyses were performed.   

Costs for FNA were estimated at $2577, DL costs at $5680. The probability of the initial FNA yielding an indeterminate result was the primary contributor to variance in cost outcomes. However, the team found that even though cost increased with the heightened probability of an indeterminate initial FNA, the procedure remained more cost efficient than proceeding directly to lobectomy. In fact, Monte Carlo simulation supported the cost efficiency of FNA in 74% of 10,000 simulations, leading Ms. Thakore and her co-investigators to conclude that mobilizing resources to perform FNA may be more financially beneficial to hospitals aiming to provide high quality, guideline-compliant care.

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