Palliative radiotherapy and the introduction of a Rapid Access Palliative Clinic in a national radiation oncology network.

BACKGROUND: Palliative radiotherapy (PRT) is commonly used to treat symptoms of advanced cancer. PRT has been associated with elevated 30-day mortality (30DM). A Rapid Access Palliative Clinic (RAPC) can streamline the treatment process for patients receiving treatment. AIMS: We reviewed the PRT practices in a radiation oncology network in Ireland, and the implementation of a RAPC. Patient outcomes were assessed to inform future treatment decisions. METHODS: A retrospective review of all patients who received PRT over 6 months in 2018 in St. Luke's Radiation Oncology Network (SLRON) was undertaken. We assessed 30DM rates, demographics and referral to specialist palliative care (SPC) services. Subsequently, a retrospective analysis was conducted of a RAPC which ran for 6 months from 2019 to 2020. We assessed treatment data and mortality. RESULTS: Over 6 months, 645 patients commenced PRT in the SLRON. The 30DM for this cohort was 15.8% (n = 102), with most patients having lung primaries. Of the 30DM cohort, only 55% (n = 56) were referred to SPC services and only 26.4% (n = 27) had performance status recorded. Over 6 months, 40 patients attended 28 RAPCs. Of these, 88% (n = 35) received PRT. Single fraction therapy was utilised in 60% and 48% of patients underwent CT simulation and treatment on the same day. Ultimately, 75% of patients received SPC referral. CONCLUSIONS: Referral rates to SPC services and documentation of performance status were low in our 30DM retrospective review cohort. The RAPC facilitated quick treatment turnaround, fewer hospital visits and referral to SPC services.

Artificial intelligence based real-time video ergonomic assessment and training improves resident ergonomics.

BACKGROUND: Surgery demands long hours and intense exertion raising ergonomic concerns. We piloted a sensorless artificial intelligence (AI)-assisted ergonomics analysis app to determine its feasibility for use with residents. METHODS: Surgery residents performed simulated laparoscopic tasks before and after a review of the SCORE ergonomics curriculum while filmed with a sensorless app from Kinetica Labs that calculates joint angles as a metric of ergonomics. A survey was completed before the session and a focus group was conducted after. RESULTS: Thirteen surgical residents participated in the study. The brief intervention took little time and residents improved their ergonomic scores in neck and right shoulder angles. Residents expressed increased awareness of ergonomics based on the session content and AI information. All trainees desired more training in ergonomics. CONCLUSIONS: Ergonomic assessment AI software can provide immediate feedback to surgical trainees to improve ergonomics. Additional studies using sensorless AI technology are needed.

Minimally invasive treatment of mitral valve disease with severe mitral annular calcification: Meeting paper for Mitral Conclave 2022.

Objective: Mitral valve disease in presence of severe mitral annular calcification (MAC) remains a challenge for surgeons to address. Conventional surgical techniques have potential for heightened morbidity and mortality. The advent of transcatheter heart valve technology and transcatheter mitral valve replacement (TMVR) holds promise to treat mitral valve disease with MAC with excellent clinical outcomes. Methods: We review current treatment strategies for MAC and studies in which TMVR techniques were used. Results: Several studies and a global registry describe outcomes of TMVR for mitral valve disease with MAC. We describe our specific technique on how to perform a minimally invasive transatrial approach for TMVR. Conclusions: TMVR demonstrates strong promise as a safe and effective way to treat mitral valve disease with MAC. We advocate for a minimally invasive transatrial approach when performing TMVR for mitral valve disease with MAC.

Strategies for Well-Being in Interventional Radiology.

Interventional radiologists (IRs) have a massive impact on their patients, communities, and healthcare at large. Yet, IRs have physical and emotional challenges that lead to a high rate of burnout compared with other medical specialties. A Medscape survey in 2013 showed a 37% burnout incidence among radiologists, which increased to 49% in 2015. This ranked radiology 7th out of 26 specialties with respect to burnout. Although the survey did not examine IR specifically, with the increasing demands on those in the profession, this number can only be expected to increase. A survey by Bundy et al demonstrated that interventional radiologists are in the upper range of burnout among physicians with 71.9% presenting with at least 1 manifestation of burnout. This is higher than that reported among surgeons or diagnostic radiologists. We must be proactive in addressing wellness in IR if we are to flourish both individually and as a group. The impact of suboptimal well-being in an IR goes beyond that of the individual, influencing patient care with ripple effects to society at large. At worst, severe burnout can lead to an early exit from medicine, with the cost of recruiting a replacement IR estimated at two to three times an annual physician salary. This is to say nothing of the experience, wisdom, and leadership that are lost when physicians burn out and drop out. Particularly in IR, where the work performed often improves the cost-effectiveness and quality of care, burnout is a threat to the physician workforce and healthcare at large. In this article, our goal is to share some elements of physician well-being and highlight opportunities to support well-being in IR.

Global Makeup of Cardiothoracic Surgeons as Represented by Our Major Societies and Associations.

BACKGROUND: Prior efforts to capture the cardiothoracic surgery community rely on survey data with potentially biased or low response rates. Our goal is to better understand our community by assessing the membership directories from The Society of Thoracic Surgeons (STS), American Association for Thoracic Surgery (AATS), European Association for Cardio-Thoracic Surgery (EACTS), and Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS). METHODS: Membership data were obtained from membership directories. Data for STS and EACTS were supplemented by the associations from their internal databases. The inclusion criterion was active membership; trainees and wholly incomplete profiles were excluded. RESULTS: A total of 12 053 membership profiles were included (STS, 6365; EACTS, 3661; AATS, 1495; ASCVTS, 532). Membership is 7% female overall (EACTS, 9%; STS, 6%; AATS, 5%; ASCVTS, 3%), with a median age of 57 years (STS, 60 years; EACTS, 52 years). All societies had a broad scope of practice including members who practiced both adult cardiac and thoracic (20% overall), but most members practiced adult cardiac (31% overall; ASCVTS, 48%; AATS, 36%; EACTS, 30%; STS, 28%) and were in the late stage of their careers. CONCLUSIONS: We present the makeup of our 4 major societies. We are global with a diversity of careers but concerning factors that require immediate attention. The future of our specialty depends on our ability to evolve, to promote the specialty, to attract trainees, and to include and promote female surgeons. It is crucial that we wake up to these issues, change the narrative, and create action on both individual and leadership levels.

Prevalence of Breast Cancer in Female Physicians Performing Procedures With Significant Fluoroscopy Exposure: Survey.

OBJECTIVE: The aim of this study was to assess self-reported breast cancer prevalence potentially associated with occupational radiation exposure from fluoroscopy-guided procedures in female physicians using current standard protection measures. METHODS: An institutional review board-approved survey was shared as a link to self-identified female physicians. We compared self-reported prevalence of breast cancer among women physicians with longer than 10 years of postfellowship practice in specialties with heavy fluoroscopy exposure versus specialties with low fluoroscopy exposure. We compared the distribution of breast cancer risk factors and personal radiation safety measures. RESULTS: A total of 303 women physicians participated in the survey. There were 8 (16%) of 49 from the first study group and 8 (18%) of 44 from the second study group who self-reported a diagnosis of breast cancer. There were no differences in the distribution of breast cancer risk factors between the 2 groups or prevalence of breast cancer (P = 0.81). CONCLUSIONS: Self-reported breast cancer prevalence is similar between women physicians who are practicing fluoroscopically heavy and light medical specialties.

Improved survival after lung transplantation for adults requiring preoperative invasive mechanical ventilation: A national cohort study.

OBJECTIVE: Early survival after lung transplantation has improved in the last decade. Mechanically ventilated recipients are known to be at greater risk for early post-transplant mortality. We hypothesized that post-transplant survival in mechanically ventilated recipients has improved over time. METHODS: Using a national registry, we compared hazard of death at 30 days, 4 and 14 months, 3 and 5 years, and overall for adults on mechanical ventilation who underwent lung or heart-lung transplantation from May 4, 2011, to April 4, 2018 (modern group) with those undergoing transplantation from May 4, 2005, to May 3, 2011 (early group). We quantified the impact of mechanical ventilation on survival using population-attributable fractions. We also compared mechanically ventilated recipients with nonmechanically ventilated recipients. RESULTS: Mechanically ventilated recipients from the modern group had lower hazard of death than recipients in the early group at all time-points, lowest at 30-days post-transplant (hazard ratio, 0.04; 95% confidence interval, 0.02-0.08). In the modern period, mechanically ventilated recipients had greater hazard of death than nonmechanically ventilated recipients at 30 days' post-transplant (9.53; 4.57-19.86). For mechanically ventilated recipients, the population attributable fraction was lower in the modern group compared to the earlier group (0.6% vs 5.7%). CONCLUSIONS: While mechanically ventilated recipients remain at high risk, survival in this patient population has improved over time. This may reflect improvements in perioperative recipient management.

Is laparoscopic sleeve gastrectomy safer than laparoscopic gastric bypass? a comparison of 30-day complications using the MBSAQIP data registry.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become popular due to its technical ease and excellent short-term results. Understanding the risk profile of LSG compared with the gold standard laparoscopic Roux-en-Y gastric bypass (LRYGB) is critical for patient selection. OBJECTIVES: To use traditional regression techniques and random forest classification algorithms to compare LSG with LRYGB using the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Data Registry. SETTING: United States. METHODS: Outcomes were leak, morbidity, and mortality within 30 days. Variable importance was assessed using random forest algorithms. Multivariate models were created in a training set and evaluated on the testing set with receiver operating characteristic curves. The adjusted odds of each outcome were compared. RESULTS: Of 134,142 patients, 93,062 (69%) underwent LSG and 41,080 (31%) underwent LRYGB. One hundred seventy-eight deaths occurred in 96 (.1%) of LSG patients compared with 82 (.2%) of LRYGB patients (P<.001). Morbidity occurred in 8% (5.8% in LSG versus 11.7% in LRYGB, P<.001). Leaks occurred in 1% (.8% in LSG versus 1.6% in LRYGB, P<.001). The most important predictors of all outcomes were body mass index, albumin, and age. In the adjusted multivariate models, LRYGB had higher odds of all complications (leak: odds ratio 2.10, P<.001; morbidity: odds ratio 2.02, P<.001; death: odds ratio 1.64, P<.01). CONCLUSION: In the Metabolic and Bariatric Surgery Accreditation and Quality Improvements data registry for 2015, LSG had half the risk-adjusted odds of death, serious morbidity, and leak in the first 30 days compared with LRYGB.

Elevated donor plasminogen activator inhibitor-1 levels and the risk of primary graft dysfunction.

Primary graft dysfunction (PGD) following lung transplantation is associated with elevated recipient plasma levels of plasminogen activator inhibitor-1 (PAI-1) and the receptor for advanced glycation end products (RAGE). However, the significance of these biomarkers in the donor plasma is uncertain. We hypothesized that elevated donor plasma levels of PAI-1 and RAGE would be associated with recipient PGD. We carried out a prospective unmatched case-control study of double-lung transplant recipients between May 2014 and September 2015. We compared donor plasma levels of PAI-1 and RAGE using rank-sum tests and t tests, in 12 recipients who developed PGD grade 2 or 3 within 72 hours postoperatively with 13 recipients who did not. Recipients who developed PGD had higher donor plasma levels of PAI-1 than recipients who did not (median 2.7 ng/mL vs 1.4; P = .03). Recipients with PGD also had numerically higher donor plasma levels of RAGE than recipients without PGD, although this difference did not achieve statistical significance (median 1061 pg/mL vs 679; P = .12). Systemic inflammatory responses in the donor, as reflected by elevated plasma levels of PAI-1, may contribute to the risk of developing PGD. Rapid biomarker assessment of easily available plasma samples may assist in donor lung selection and risk stratification.

Efficacy of Evolving Early-Extubation Strategy on Early Postoperative Functional Recovery in Pediatric Open-Heart Surgery: A Matched Case-Control Study.

There has been a paradigm shift toward "fast-track" management with early extubation (EE) in cardiac surgery. Our retrospective, matched case-control study wishes to define the benefits of EE in pediatric congenital heart surgery. We examined 50 consecutive pediatric cardiac surgery patients extubated in the operating room (February 2009 to July 2009) against a control group of delayed-extubation patients. No significant differences were found in preoperative variables except heart failure medication. Significant intraoperative variables included the following: blood products (363 vs 487 mL, P = .023), morphine (62% vs 6%, P < .0001), and inotropes (16% vs 60%, P < .0001) given. Postoperatively significant differences included hospital stay and lower inotrope scores in the early-extubation group (14.89 vs 31.68, P < .0001). The reintubation rate was not significant. EE patients have equivalent hemodynamic profiles shown by a decreased necessity for inotropic support. We conclude that EE is feasible in low-/medium-risk pediatric congenital heart surgery patients.

Predictors of adherence to secondary preventive medication in stroke patients.

OBJECTIVE: The purpose of this study is to identify factors which predict adherence in stroke survivors. DESIGN: This is a longitudinal study where 180 stroke survivors were assessed 1 year after their first ischaemic stroke. The relationship between adherence and illness and medication beliefs was tested at baseline (time 1) and again 5-6 weeks later (time 2). MAIN OUTCOME MEASURES: The main outcome measures used in this study are Medication Adherence Report Scale and urinary salicylate levels. RESULTS: Four variables predicted time 1 poor adherence: (1) younger age, (2) increased specific concerns about medications, (3) reduced cognitive functioning and (4) low perceived benefit of medication. Three out of these four variables were again predictive of time 2 adherence and accounted for 24% of the variance: (1) younger age, (2) increased specific concerns about medications and (3) low perceived benefit of medication. The urinary salicylate assay failed to differentiate between patients taking and not taking aspirin. CONCLUSION: Interventions to improve adherence should target patients' beliefs about their medication.

Adherence to medication in stroke survivors: a qualitative comparison of low and high adherers.

OBJECTIVES: The aim of this study was to investigate factors that may explain variance in adherence to medication in stroke patients. Design. A qualitative comparison of high and low adherers to medication. METHODS: Thirteen participants, selected from a sample of 180 stroke survivors because they self-reported the lowest adherence to medication regimes, were matched with 13 reporting maximal adherence. All took part in semi-structured qualitative interviews. RESULTS: Thematic analysis revealed that those with poor adherence to medication reported both intentional and non-intentional non-adherence. Two main themes emerged: the importance of stability of a medication routine and beliefs about medication and treatment. High adherers reported remembering to take their medication and seeking support from both family and health professionals. They also had a realistic understanding of the consequences of non-adherence, and believed their medicine did them more good than harm. Low adherers reported forgetting their medication, sometimes intentionally not taking their medication and receiving poor support from medical staff. They disliked taking their medication, had limited knowledge about the medication rationale or intentions, and often disputed its benefits. CONCLUSIONS: Our findings suggest that appropriate medication and illness beliefs coupled with a stable medication routine are helpful in achieving optimal medication adherence in stroke patients. Interventions designed to target both intentional and non-intentional adherence may help maximize medication adherence in stroke patients.

Primary sutureless repair for infants with mixed total anomalous pulmonary venous drainage.

BACKGROUND: Mixed type total anomalous pulmonary venous drainage (TAPVD) poses technical challenges and high mortality owing to diminutive size and remote location of the pulmonary vein (PV) confluences. We hypothesized that primary application of sutureless repair may better incorporate small and remote confluences, thereby minimizing PV stenosis and improving outcomes. METHODS: Twenty-two consecutive infants (1985 to 2009; median age 27 days; body weight 3.7 kg) with mixed type TAPVD were retrospectively reviewed. Survival and reintervention were compared between the sutureless group (n = 8) and the conventional group (n = 14). Predictors for death and reintervention were identified by an univariate analysis using a chi(2) test. RESULTS: No differences were noted on preoperative and intraoperative variables between the groups. There were 5 early deaths in the conventional group and no deaths in the sutureless group (p = 0.05). There were trends toward improved survival (100% versus 57% at 1 year, p = 0.07) and freedom from reintervention (100% versus 67% at 1 year, p = 0.09) in the sutureless group. The univariate analysis showed that preoperative PV obstruction (p = 0.05), conventional repair (p = 0.05), palliative surgery (p = 0.001), and residual PV obstruction (p = 0.002) were the risk factors for death. Preoperative PV obstruction, palliative surgery, and residual PV obstruction were the predictors for reintervention (p < 0.05 for all). CONCLUSIONS: The primary sutureless repair for the patients with mixed type TAPVD appeared to be safe and effective, resulting in no mortality and reintervention. There were nonsignificant trends toward improving survival and reintervention in the sutureless group. The patients who had sutureless repair and partially unrepaired PV revealed reasonable early and medium-term physiologic tolerance without need for reinterventions.

Early extubation after pediatric cardiac surgery: systematic review, meta-analysis, and evidence-based recommendations.

OBJECTIVE: To derive evidence-based recommendations regarding early extubation strategy after congenital cardiac surgery. OUTCOMES: Incidence of total mortality, morbidity, reintubation, length, and costs of intensive care unit and hospital stay. EVIDENCE: Medline, Embase, and the Cochrane-controlled trial register on the Cochrane library were searched from the earliest achievable date of each database to present. No language restrictions were applied. Retrieved reprints were evaluated according to a priori inclusion criteria, and those included were critically appraised using established internal validity criteria. BENEFITS AND HARMS: Early extubation (in the operating room or ≤6 hours after surgery) was associated with a lower early mortality. There was a trend toward lower ICU and hospital length of stays, lower hospital costs, and less respiratory morbidity. There was no difference in the rate of reintubation in those extubated early versus late. CONCLUSION: Early extubation appears safe and is associated with reduction in length of ICU and hospital stay without adverse effects on mortality or morbidity. However, studies to date are poor, heterogeneous, and not suitable to determine a causal effect. Therefore, there is need for a well-designed randomized clinical trial to demonstrate the potential significant benefits of early extubation.