Gender Differences in Authorship and Quality of Anesthesia Clinical Practice Guidelines From 2016 to 2020 Using the Appraisal of Guidelines for Research and Evaluation II Instrument.

INTRODUCTION: Women continue to be underrepresented in academic anesthesiology. This study assessed guidelines in anesthesia journals over the past 5 years, evaluating differences in woman-led versus man-led guidelines in terms of author gender, quality, and changes over time. We hypothesized that anesthesia guidelines would be predominately man-led, and that there would be differences in quality between woman-led versus man-led guidelines. METHODS: All clinical practice guidelines published in the top 10 anesthesia journals were identified as per Clarivate Analytics Impact Factor between 2016 and 2020. Fifty-one guidelines were included for author, gender, and quality analysis using the Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument. Each guideline was assessed across 6 domains and 23 items and given an overall score, overall quality score, and overall rating/recommendation. Stratified and trend analyses were performed for woman-led versus man-led guidelines. RESULTS: Fifty out of 51 guidelines were included: 1 was excluded due to unidentifiable first-author gender. In total, 255 of 1052 (24%) authors were women, and woman-led guidelines (woman-first author) represented 12 of 50 (24%) overall guidelines. Eighteen percent (9 of 50) of guidelines had all-male authors, and a majority (26 of 50, 52%) had less than one-third of female authors. The overall number and percentage of woman-led guidelines did not change over time. There was a significantly higher percentage of female authors in woman-led versus man-led guidelines, median 39% vs 20% (P = .012), as well as a significantly higher number of female coauthors in guidelines that were woman-led median 3.5 vs 1.0, P = .049. For quality, there was no significant difference in the overall rating or objective quality of woman- versus man-led guidelines. However, there was a significant increase in the overall rating of all the guidelines over time (P = .010), driven by the increase in overall rating among man-led guidelines, P = .002. The overall score of guidelines did not increase over time; however, they increased in man-led but not woman-led guidelines. There was no significant correlation between the percentage of female authors per guideline and either overall score or overall rating. CONCLUSIONS: There is a substantial disparity in the number of women leading and contributing to guidelines which has not improved over time. Woman-led guidelines included more women and a higher percentage of women. There was no difference in quality of guidelines by first-author gender or percentage of female authors. Further systematic and quota-driven sponsorship is needed to promote gender equity, diversity, and inclusion in anesthesia guidelines.

Baseline Intraoperative Left Ventricular Diastolic Function Is Associated with Postoperative Atrial Fibrillation after Cardiac Surgery.

BACKGROUND: Detailed understanding of the association between intraoperative left atrial and left ventricular diastolic function and postoperative atrial fibrillation is lacking. In this post hoc analysis of the Posterior Left Pericardiotomy for the Prevention of Atrial Fibrillation after Cardiac Surgery (PALACS) trial, we aimed to evaluate the association of intraoperative left atrial and left ventricular diastolic function as assessed by transesophageal echocardiography (TEE) with postoperative atrial fibrillation. METHODS: PALACS patients with available intraoperative TEE data (n = 402 of 420; 95.7%) were included in this cohort study. We tested the hypotheses that preoperative left atrial size and function, left ventricular diastolic function, and their intraoperative changes were associated with postoperative atrial fibrillation. Normal left ventricular diastolic function was graded as 0 and with lateral e' velocity 10 cm/s or greater. Diastolic dysfunction was defined as lateral e' less than 10 cm/s using E/e' cutoffs of grade 1, E/e' 8 or less; grade, 2 E/e' 9 to 12; and grade 3, E/e' 13 or greater, along with two criteria based on mitral inflow and pulmonary wave flow velocities. RESULTS: A total of 230 of 402 patients (57.2%) had intraoperative diastolic dysfunction. Posterior pericardiotomy intervention was not significantly different between the two groups. A total of 99 of 402 patients (24.6%) developed postoperative atrial fibrillation. Patients who developed postoperative atrial fibrillation more frequently had abnormal left ventricular diastolic function compared to patients who did not develop postoperative atrial fibrillation (75.0% [n = 161 of 303] vs. 57.5% [n = 69 of 99]; P = 0.004). Of the left atrial size and function parameters, only delta left atrial area, defined as presternotomy minus post-chest closure measurement, was significantly different in the no postoperative atrial fibrillation versus postoperative atrial fibrillation groups on univariate analysis (-2.1 cm2 [interquartile range, -5.1 to 1.0] vs. 0.1 [interquartile range, -4.0 to 4.8]; P = 0.028). At multivariable analysis, baseline abnormal left ventricular diastolic function (odds ratio, 2.02; 95% CI, 1.15 to 3.63; P = 0.016) and pericardiotomy intervention (odds ratio, 0.46; 95% CI, 0.27 to 0.78, P = 0.004) were the only covariates independently associated with postoperative atrial fibrillation. CONCLUSIONS: Baseline preoperative left ventricular diastolic dysfunction on TEE, not left atrial size or function, is independently associated with postoperative atrial fibrillation. Further studies are needed to test if interventions aimed at optimizing intraoperative left ventricular diastolic function during cardiac surgery may reduce the risk of postoperative atrial fibrillation.

Postoperative pericardial effusion, pericardiotomy, and atrial fibrillation: An explanatory analysis of the PALACS trial.

BACKGROUND: In the Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery (PALACS) trial, posterior pericardiotomy was associated with a significant reduction in postoperative atrial fibrillation (POAF) after cardiac surgery. We aimed to investigate the mechanisms underlying this effect. METHODS: We included PALACS patients with available echocardiographic data (n = 387/420, 92%). We tested the hypotheses that the reduction in POAF with the intervention was associated with 1) a reduction in postoperative pericardial effusion and/or 2) an effect on left atrial size and function. Spline and multivariable logistic regression analyses were used. RESULTS: Most patients (n = 307, 79%) had postoperative pericardial effusions (anterior 68%, postero-lateral 51.9%). The incidence of postero-lateral effusion was significantly lower in patients undergoing pericardiotomy (37% vs 67%; P < .001). The median size of anterior effusion was comparable between patients with and without POAF (5.0 [IQR 3.0-7.0] vs 5.0 [IQR 3.0-7.5] mm; P = .42), but there was a nonsignificant trend towards larger postero-lateral effusion in the POAF group (5.0 [IQR 3.0-9.0] vs 4.0 [IQR 3.0-6.4] mm; P = .06). There was a non-linear association between postero-lateral effusion and POAF at a cut-off at 10 mm (OR 2.70; 95% CI 1.13, 6.47; P = .03) that was confirmed in multivariable analysis (OR 3.5, 95% CI 1.17, 10.58; P = 0.02). Left atrial dimension and function did not change significantly after posterior pericardiotomy. CONCLUSIONS: Reduction in postero-lateral pericardial effusion is a plausible mechanism for the effect of posterior pericardiotomy in reducing POAF. Measures to reduce postoperative pericardial effusion are a promising approach to prevent POAF.

Relative Impact of Surgical Mitral Repair and MitraClip on Annular Remodeling-A Potential Mechanism for Therapeutic Response to Mitral Repair for Degenerative Mitral Regurgitation.

OBJECTIVES: Three-dimensional transesophageal echocardiography (TEE) is widely used to guide decision-making for mitral repair. The relative impact of surgical mitral valve repair (MVr) and MitraClip on annular remodeling is unknown. The aim was to determine the impact of both mitral repair strategies on annular geometry, including the primary outcome of annular circumference and area. DESIGN: This was a retrospective observational study of patients who underwent mitral intervention between 2016 and 2020. SETTING: Weill Cornell Medicine, a single, large, academic medical center. PARTICIPANTS: The population comprised 50 patients with degenerative mitral regurgitation (MR) undergoing MVr. INTERVENTIONS: Elective MVr and TEE. MEASUREMENTS AND MAIN RESULTS: Patients undergoing MitraClip or surgical MVr were matched (1:1) for sex and coronary artery disease. Mitral annular geometry indices were quantified on intraprocedural three-dimensional TEE. Mild or less MR on follow-up transthoracic echocardiography defined optimal response. Patients undergoing MitraClip were older (80 ± eight v 66 ± six years; p < 0.001) but were otherwise similar to surgical patients. Patients undergoing MitraClip had larger baseline left atrial and ventricular sizes, increased tenting height, and volume (p < 0.01), with a trend toward increased annular area (p = 0.23). MitraClip and surgery both induced immediate mitral annular remodeling, including decreased area, circumference, and tenting height (p < 0.001), with greater remodeling with surgical repair. At follow-up (4.1 ± 9.0 months) optimal response (≤ mild MR) was ∼twofold more common with surgery than MitraClip (81% v 46%; p = 0.02). The relative reduction in annular circumference (odds ratio [OR] 1.05 [1.00-1.09] per cm; p = 0.04) and area (OR 1.03 [1.00-1.05] per cm2; p = 0.049) were both associated with optimal response. CONCLUSIONS: Surgical MVr and MitraClip both reduce annular size, but repair-induced remodeling is greater with surgery and associated with an increased likelihood of optimal response.

Left Atrial Strain Quantification by Intraoperative Transesophageal Echocardiography: Validation With Transthoracic Echocardiography.

OBJECTIVE: Whereas left atrial (LA) strain has been well-validated using transthoracic echocardiography (TTE), its detection using transesophageal echocardiography (TEE) has not been studied. Conventional transesophageal views are known to be limited due to the posterior location of the LA. Here, the feasibility and accuracy of the deep transgastric long-axis LA focused view for peak atrial longitudinal strain (PALS) quantification was tested. DESIGN: This was a retrospective study of patients who underwent elective cardiac surgery between 2018 and 2020. TEE deep transgastric long-axis view was compared to TTE 4-chamber atrial focused view as the reference standard. LA area, volume, and PALS were quantified independently. SETTING: At Weill Cornell Medicine, a single, large academic medical center. PARTICIPANTS: The population comprised 42 patients undergoing cardiac surgery who had a TTE and TEE within 14.9 ± 20.8 days. INTERVENTIONS: TTE, TEE, and cardiac surgery. MEASUREMENTS AND MAIN RESULTS: TEE-derived PALS strongly correlated with TTE- derived PALS (r = 0.92, p < 0.001), though absolute PALS were lower (20.7 ± 6.0% v 25.7 ± 6.8%; p < 0.001). Mean TEE-derived atrial length was similar to TTE-derived length (5.18 ± 0.61 cm v 5.24 ± 0.61 cm; p = 0.38), but mean LA area was significantly smaller (16.7 ± 3.5 cm2v 18.9 ± 3.7 cm2; p < 0.001), with significant correlations between the 2 modalities for both (r = 0.74, 0.74, respectively; all p < 0.001). CONCLUSION: This exploratory study supported the feasibility of TEE for assessing LA longitudinal strain. There was an excellent correlation between atrial strain derived via TEE versus TTE, although values tended to be smaller on TEE, and bias between values was highly variable, suggesting that the values were not interchangeable.

Examining the correlation between Altmetric Attention Score and citation count in the gynecologic oncology literature: Does it have an impact?

We sought to determine the correlation between Altmetric Attention Score and traditional bibliometrics in the gynecologic oncology literature. We identified the 10 most-cited gynecologic oncology articles from 5 major gynecology journals and 10 major "oncology" journals that publish on gynecologic oncology during 2014, 2016, and 2018. Article citation count and Altmetric Attention Score (AAS), as well as journal impact factor (IF) and date of Twitter account development were recorded. Pearson's correlation coefficient was used to describe the relationship between AAS, tweets, IF, and citation count. While the median citation counts significantly decreased for the top-cited gynecologic oncology articles from 2014 to 2018 (p < 0.001), the corresponding median AAS continuously increased during this period (p = 0.008). For articles published in 2014 and 2018, there was a strong positive relationship between the median citation count and the median AAS (2014: r = 0.92; 2018: r = 0.97), as well as between the IF (r = 0.78 and r = 0.89, respectively); these correlations were moderate to weak in 2016 (r = 0.5 and r = 0.41, respectively). There was a continuously increasing strong positive correlation from 2014 to 2018 between journal IF and median AAS (2014: r = 0.75; 2016: r = 0.82; 2018: r = 0.92). Gynecologic oncology articles published in higher impact journals are associated with increased social media visibility and attention. Our data support the idea that early online attention scores, like the AAS, might be useful for predicting future citation counts for oncology publications in general and gynecologic oncology specifically.

Descending aortic strain quantification by intra-operative transesophageal echocardiography: Multimodality validation via cardiovascular magnetic resonance.

BACKGROUND: Whereas cardiac magnetic resonance (CMR) imaging provides high temporal resolution imaging of aortic distensibility (strain), transesophageal echocardiography (TEE) is widely used for intra-operative aortic imaging and provides a clinical alternative for aortic assessment. We tested intra-operative global circumferential aortic strain (GCS) measured on TEE in relation to the reference of CMR-derived strain among patients undergoing surgical graft repair of ascending aortic aneurysms. METHODS: CMR (3T) was prospectively performed in patients scheduled for aortic repair. TEE was performed intra-operatively; images were co-localized with MRI. GCS on CMR and TEE was quantified independently, blinded to results of the other modality. RESULTS: 25 patients (54 ± 10 year-old, 88% male) were studied, inclusive of 13 genetically mediated and 12 degenerative aneurysms: CMR and TEE were performed within 12 ± 9 days. Pulse pressure (PP)-adjusted descending aortic TEE-derived GCS strongly correlated with cine-CMR-derived GCS (r = .75, P = .002) though absolute GCS and PP-adjusted values were slightly lower (5.40 ± 1.11 vs 6.49 ± 1.43% and 11.55 ± 3.04 vs 13.99 ± 4.53%, respectively). Similarly, TEE yielded slightly lower end-diastolic area (EDA [5.1 ± 1.7 cm2 vs 5.8 ± 1.3 cm2 , P = .004]) and end-systolic area (ESA [6.1 ± 1.9 cm2 vs 6.5 ± 1.7 cm2 , P = .10]), with significant correlations between the two modalities (r = .73, .76, P < .05 for all). CONCLUSIONS: This exploratory study supports feasibility of TEE for assessing aortic GCS in a surgical at-risk population, as well as magnitude of agreement between intra-operative TEE and preoperative CMR. We found that there is a significant correlation between GCS and EDA and ESA aortic areas, but that TEE-derived parameters underestimated CMR values by a small but significant amount.