Disparities in heart transplantation.

PURPOSE OF REVIEW: Heart transplantation remains the gold standard therapy for end stage heart failure, but barriers remain, preventing equitable access to and affecting outcomes following transplantation. The objective of this review is to summarize current and historical literature on the disparities that persist, and to highlight the gaps in evidence for further investigation. RECENT FINDINGS: Although progress has been made to increase the rates of advanced heart failure therapies to racial/ethnic minority populations and those with lower socioeconomic status, differential access and outcomes remain. The disparities that persist are categorized by patient demographics, social influences, geopolitical factors, and provider bias. SUMMARY: Disparities in heart transplantation exist, which span a wide spectrum. Healthcare professionals need to be cognizant of these disparities that patients face in terms of access to and outcomes for heart transplantation. Further research and system changes are needed to make heart transplantation a fairer option for patients of varying backgrounds with end stage heart failure.

Impact of Trauma Hospital Ransomware Attack on Surgical Residency Training.

BACKGROUND: A recent ransomware attack led to the shutdown of the electronic health information system (HIS) at our trauma center for 2 mo. We investigated its impact on residency training during the downtime. MATERIAL AND METHODS: General and orthopedic surgical residents who rotated at the hospital were invited to participate in a survey regarding their patient care and residency training experiences during the downtime. Attending surgeons from both the specialties were invited to participate in a semistructured interview regarding their attitude toward residency training during the downtime. RESULTS: Twenty-nine residents responded to the survey with a response rate of 78.4%. Residents acknowledged significant increases in face-to-face communication and decreases in use of online educational resources during the downtime (P < 0.01). Residents were significantly stressed by the dearth of online resources (P < 0.0001) and by paper-based orders and outpatient clinic (P < 0.05). A multivariate analysis demonstrated an inverse relationship between postgraduate year and stress from paper orders (P = 0.003). Attending surgeon's interviews revealed that they recognized residents' unpreparedness and strove harder to teach more effectively. CONCLUSIONS: Our study demonstrated that an unexpected shutdown of the hospital HIS imposed significant stress upon surgical residents providing trauma patient care and made attending surgeons take greater efforts to be more effective teachers. Residents who are digital natives lack adaptability to handle a paper-based workflow. With cyber security threats increasing in health care, preparedness should be included in the graduate medical education curriculum.

Skeletal muscle regeneration by extracellular matrix biological scaffold: a case report.

A case report of a 17-year-old female with a complex, non-healing, two-month-old wound, wherein exposed fibula was evident. On assessment, the wound measured 35cm in length, 3cm in width, and was 1cm deep, along the lateral aspect of the left lower leg. A rim of granulation tissue was visible along the wound edge. The exposed bone measured 20cm in length, and was 3cm wide. Porcine-derived, extracellular matrix (ECM) biological scaffold was placed on the wound bed to facilitate regeneration of the patient's skeletal muscle. The patient healed without incident postoperatively and was able to regain her ambulatory ability. This technique has, in the authors' experience, proved successful and without complication in complex non-healing wound cases, particularly in patients who have lost a large volume of skeletal muscle. The authors believe that patients and surgeons would benefit from early consideration of ECM biological scaffolds in similar types of large, open, and complex wounds.

Prehabilitation for Older Adults Undergoing Lung Cancer Surgery: A Literature Review and Needs Assessment.

Early-stage lung cancer patients are increasingly considered for preoperative systemic therapy. Older adults in particular are among the most vulnerable patients, with little known on how preoperative therapies affect the risk-benefit of surgery. We sought to summarize the current literature and elucidate existing evidence gaps on the effects of prehabilitation interventions relative to age-related functional impairments and the unique needs of older patients undergoing lung cancer surgery. A literature review was performed using PubMed and Google Scholar databases, of all scientific articles published through April 2022 which report on the effects of prehabilitation on patients undergoing lung cancer surgery. We extracted current prehabilitation protocols and their impact on physical functioning, resilience, and patient-reported outcomes of older patients. Emerging evidence suggests that prehabilitation may enhance functional capacity and minimize the untoward effects of surgery for patients following lung resection similar to, or potentially even better than, traditional postoperative rehabilitation. The impact of preoperative interventions on surgical risk due to frailty remains ill-defined. Most studies evaluating prehabilitation include older patients, but few studies report on activities of daily living, self-care, mobility activities, and psychological resilience in older individuals. Preliminary data suggest the feasibility of physical therapy and resilience interventions in older individuals concurrent with systemic therapy. Future research is needed to determine best prehabilitation strategies for older lung cancer patients aimed to optimize age-related impairments and minimize surgical risk.

Plain Chest Film Versus Computed Tomography of the Chest as the Initial Imaging Modality for Blunt Thoracic Injury.

BACKGROUND: While chest X-ray (CXR) is an efficient tool for expeditious detection of life-threatening injury, chest computed tomography (CCT) is more sensitive albeit with added time, cost, and radiation. Thus far, there is limited evidence and lack of consensus on the best imaging practices. We sought to determine the association between imaging modality and outcomes in isolated blunt thoracic trauma. METHODS: The 2017-2020 TQIP database was queried for adult patients who sustained isolated blunt chest trauma and underwent chest imaging within 24 hours of admission. Patients who underwent CCT were 2:1 propensity-score-matched to those who underwent CXR. The primary outcome was mortality, and the secondary outcomes were hospital and ICU length of stay (LOS), ICU admission, need for and days requiring mechanical ventilation, complications, and discharge location. RESULTS: Propensity score matching yielded 17 716 patients with CCT and 8861 with CXR. While bivariate analysis showed lower 24-hr (CCT .2% vs CXR .4%, P = .0015) and in-hospital mortality (CCT 1.2% vs CXR 1.5%, P = .0454) in the CCT group, there was no difference in survival probability between groups (P = .1045). A higher percentage of CCT patients were admitted to the ICU (CCT 26.9% vs CXR 21.9%, P < .0001) and discharged to rehab (CCT .8% vs CXR .5%, P = .0178). DISCUSSION: CT offers no survival benefit over CXR in isolated blunt thoracic trauma. While CCT should be considered if clinically unclear, CXR likely suffices as an initial screening tool. These findings facilitate optimal resource allocation in constrained environments.

The surgical blog: An important supplement to traditional scientific literature.

BACKGROUND: Blogging is a new and innovative means of information exchange in the surgical community. We examined the Association of Women Surgeons (AWS) blog to understand its audience and most read content. METHODS: Google Analytics was used to assess the AWS blog site data. A search was performed from February 2018 to February 2019. Demographic data, blog posts, and tags sorted by unique pageviews were recorded. RESULTS: There were 31,221 unique pageviews during the search period. The AWS Blog readership was mostly women (75%), ages 25-44 years (70.3%). The three tags that elicited the most pageviews were "residency (16.95%)," "medical students (12.12%)," and "family life (10.38%)." The most read blog post was responsible for 9.7% of total pageviews. DISCUSSION & CONCLUSION: Most of the AWS Blog readership are young, women, and interested in content related to graduate and postgraduate medical education or family life. Blogging may be a good vehicle for topics not covered in traditional scientific literature.

Interprofessional Communication Goes Up When the Electronic Health Record Goes Down.

OBJECTIVE: The electronic health record (EHR) has been faulted for the erosion of interprofessional communication and the patient-physician relationship. Surgical residents may be susceptible to communication workarounds facilitated by the EHR, but the full extent is not well understood. A recent ransomware attack with the abrupt return to paper charting provided a unique opportunity to investigate the impact of the EHR on surgical residents' interprofessional communication. We sought to explore how surgical residents perceived communications during the 2-month period when the EHR was inaccessible. DESIGN: General surgery residents who rotated through the regional tertiary referral medical center and level I trauma center were invited to participate in a semistructured interview about communication with one another, faculty, staff, and patients during the downtime. A grounded theory approach was used to analyze the data. SETTING: Regional tertiary referral medical center and level I trauma center. PARTICIPANTS: General surgery residents who rotated through the affected site. RESULTS: Ten general surgery residents were interviewed. Interviews revealed that the abrupt loss of the EHR impacted communication in three major ways: (1) engendered more professional courtesy and collegiality, (2) prioritized bedside patient care over documentation demands, and (3) encouraged more explicit and deliberate communications. CONCLUSIONS: Our study demonstrates that the loss of the EHR encourages surgery residents interprofessional communication. With healthcare becoming increasingly digital, active efforts should be made to preserve the communication benefits by optimizing existing and emerging technology to facilitate direct face-to-face interactions.

Barriers, Facilitators, and Solutions to Optimal Patient Portal and Personal Health Record Use: A Systematic Review of the Literature.

Patient portal and personal health record adoption and usage rates have been suboptimal. A systematic review of the literature was performed to capture all published studies that specifically addressed barriers, facilitators, and solutions to optimal patient portal and personal health record enrollment and use. Consistent themes emerged from the review. Patient attitudes were critical as either barrier or facilitator. Institutional buy-in, information technology support, and aggressive tailored marketing were important facilitators. Interface redesign was a popular solution. Quantitative studies identified many barriers to optimal patient portal and personal health record enrollment and use, and qualitative and mixed methods research revealed thoughtful explanations for why they existed. Our study demonstrated the value of qualitative and mixed research methodologies in understanding the adoption of consumer health technologies. Results from the systematic review should be used to guide the design and implementation of future patient portals and personal health records, and ultimately, close the digital divide.

Beyond surgical care improvement program compliance: antibiotic prophylaxis implementation gaps.

BACKGROUND: Despite increased compliance with Surgical Care Improvement Project infection measures, surgical-site infections are not decreasing. The aim of this study was to test the hypothesis that documented compliance with antibiotic prophylaxis guidelines on a pediatric surgery service does not reflect implementation fidelity or adherence to guidelines as intended. METHODS: A 7-week observational study of elective pediatric surgical cases was conducted. Adherence was evaluated for appropriate administration, type, timing, weight-based dosing, and redosing of antibiotics. RESULTS: Prophylactic antibiotics were administered appropriately in 141 of 143 cases (99%). Of 100 cases (70%) in which antibiotic prophylaxis was indicated, compliance was documented in 100% cases in the electronic medical record, but only 48% of cases adhered to all 5 guidelines. Lack of adherence was due primarily to dosing or timing errors. CONCLUSIONS: Lack of implementation fidelity in antibiotic prophylaxis guidelines may partly explain the lack of expected reduction in surgical-site infections. Future studies of Surgical Care Improvement Project effectiveness should measure adherence and implementation fidelity rather than just documented compliance.

Implementing a surgical checklist: more than checking a box.

BACKGROUND: Perioperative checklists are mandated by many hospitals as determined by the reduction in morbidity and mortality seen with the use of the World Health Organization's Surgical Safety Checklist. An adapted perioperative checklist was implemented within our hospital system, and compliance with the checklist was reported to be 100%. We hypothesized that compliance does not measure the fidelity of implementation. METHODS: During a 7-week period, a prospective study was performed to evaluate the completion of all preincision components of the surgical checklist. Pediatric surgical operations were selected for direct observation. In addition, a poststudy survey was used to assess perception and understanding of the checklist process. RESULTS: A total of 142 pediatric surgical cases were observed. Hospital reported data demonstrated 100% compliance with the preincision phase of the checklist for these cases. None of the cases completely executed all items on the checklist, and the average number of checklist items performed in the observed cases was 4 of 13. The most commonly performed checkpoint were the confirmation of patient name and procedure (99%) and the "timeout" at the start of the checklist (97%). The rest of the checkpoints were performed in less than 60% of cases. Adherence did not increase during the observation period. CONCLUSION: These data show that despite the 100% documented completion of the preincision phase of the checklist; most of the individual checkpoints are either not executed as designed or not executed at all. These findings demonstrate lack of checklist implementation fidelity, which may be a reflection a poor implementation and dissemination strategy.