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Background: The optimal training program to transform a new resident into a competent and capable surgeon is constantly evolving. Competency-based evaluation represents a change in mindset from quantitative or chronologic metrics for graduate readiness. As surgery becomes more specialized, more dependent on technology, and more public, we must continue to improve our ability to pass on technical skills. Approaching surgery in a component-based fashion enables even the most complex operation to be broken down into smaller sets of steps that range the entire spectrum of complexity. Treating an operation through the lens of its components, emphasizing stepwise forward progression in a trainee's experience, may provide a way to train competent surgeons more efficiently. Current case-logging products do not provide adequate granularity to apply this methodology. Methods: Application design relied on the involvement of local surgeons from all specialties and subspecialties related to general surgical training. Individual interviews with multiple experts in each field were used to generate a list of most commonly performed operations. Once a consensus was reached, the same surgeons were queried on what they felt were the core steps that make up each operation. This information was utilized to create a novel mobile application which enables the user to record cases by date, attending surgeon, specific operation, and which portions of the operation they were able/allowed to perform. Conclusion: Component-based case logging through the Logix application may be a useful adjunct as we continue to implement competency-based surgical training. Future investigation will assess user experience and compare subjective and objective metrics of training progression between the Logix application and currently utilized products. The information provided by the application stands to benefit not just trainees, but educators, training programs, and regulatory bodies. Key message: Component-based case logging via a novel mobile application stands to increase the efficiency of surgical training and more effectively assess trainee competency.
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BACKGROUND: Mechanical circulatory support effectively treats adult cardiogenic shock. Whereas cardiogenic shock confers high mortality, acute limb ischemia is a known complication of mechanical circulatory support that confers significant morbidity. We compared our novel approach to peripheral mechanical circulatory support with a conventional femoral approach, with a focus on the incidence of acute limb ischemia. METHODS: This was a retrospective cohort study of patients treated with mechanical circulatory support between January 1, 2015 and December 5, 2021 at our institution. Patients receiving any femoral peripheral venoarterial extracorporeal membrane oxygenation were compared with those receiving minimally invasive, peripherally inserted, concomitant right and left ventricular assist devices. These included the Impella 5.0 (Abiomed, Danvers, MA) left ventricular assist device and the ProtekDuo (LivaNova, London, UK) right ventricular assist device used concomitantly (Propella) approach. The primary outcome was incidence of acute limb ischemia. The baseline patient characteristics, hemodynamic data, and post-mechanical circulatory support outcomes were collected. Fisher exact test and Wilcoxon rank sum test was used for the categorical and continuous variables, respectively. Kaplan-Meier curves and log-rank test were used to estimate overall survival probabilities and survival experience, respectively. RESULTS: Fifty patients were treated with mechanical circulatory support at our institution for cardiogenic shock, with 13 patients supported with the novel Propella strategy and 37 with peripheral venoarterial extracorporeal membrane oxygenation. The baseline characteristics, including patient organ function and medical comorbidities, were similar among the groups. Nine patients suffered mortality in ≤48 hours of mechanical circulatory support initiation and were excluded. Twenty patients (69%) suffered acute limb ischemia in the peripheral venoarterial extracorporeal membrane oxygenation group; 0 patients receiving Propella suffered acute limb ischemia (P < .001). The percentages of patients surviving to discharge in peripheral venoarterial extracorporeal membrane oxygenation and Propella groups were 24% and 69%, respectively (P = .007). CONCLUSION: Patients treated with the Propella experienced a lower incidence of acute limb ischemia compared with patients treated with peripheral venoarterial extracorporeal membrane oxygenation.
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Oxigenação por Membrana Extracorpórea , Coração Auxiliar , Adulto , Humanos , Choque Cardiogênico/etiologia , Choque Cardiogênico/terapia , Estudos Retrospectivos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Isquemia/etiologia , Isquemia/terapia , Coração Auxiliar/efeitos adversosRESUMO
BACKGROUND: Body mass index (BMI) is an important consideration for transplant-eligible left ventricular assist device (LVAD) recipients. LVAD therapy's impact on BMI is unclear. We evaluated BMI changes in patients who underwent LVAD implantation. The association between these patients' BMI and the transplant was studied. METHODS: This was a retrospective cohort study of patients who underwent LVAD implantation between January 1, 2012 and December 31, 2018 at our institution. Patients were stratified by preoperative BMI (kg/m2 ) into four groups: <30, 30-34.9, 34.9-39.9, and ≥40. BMI data were collected at 12 and 6 months prior to implantation, time of implantation, and 3- and 6- months postimplantation. RESULTS: A total of 107 patients underwent LVAD implantation at our institution. Data were available for 80 patients. Baseline characteristics included a mean age of 56.0 years, 69% male, and a mean implant BMI of 29.9 ± 6.8 kg/m2 . The mean BMI (kg/m2 ) for each of the BMI (kg/m2 ) groups <30, 30-34.9, 35-39.9, and ≥40 (n = 60, 25, 12, and 10, respectively) was 25.1, 32.5, 36.8, and 43.8, respectively. There was no consistent pattern with weight change across differing implant BMIs. No patient with a BMI of <30 gained sufficient weight to impact transplant candidacy. Twenty-three percent of patients with a BMI of 30-34.9 kg/m2 , 60% of patients with a BMI of 35-39.9 kg/m2 , and 87.5% of patients with a BMI of ≥40 kg/m2 had a 6-month BMI potentially affecting transplant. CONCLUSIONS: Associated weight changes during LVAD support may significantly impact transplant candidacy. Higher BMI groups may benefit from multimodal and multidisciplinary targeted weight-loss interventions.
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Insuficiência Cardíaca , Transplante de Coração , Coração Auxiliar , Índice de Massa Corporal , Feminino , Insuficiência Cardíaca/cirurgia , Coração Auxiliar/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Extracorporeal membrane oxygenation (ECMO) has diverse applications. In the present report, we have described a case of tracheomalacia from a thoracic aortic aneurysm causing respiratory failure. Total arch replacement with reverse frozen elephant trunk grafting was performed. Perioperative ECMO support was accomplished with venopulmonary artery ECMO. This strategy allowed for preoperative oxygenation support, venous drainage during cardiopulmonary bypass, and postoperative support without cannula exchanges. Our patient required ECMO support for 12 days postoperatively. We have illustrated a unique case of acquired tracheomalacia but also an ECMO cannulation strategy allowing for preoperative oxygenation, seamless transition to cardiopulmonary bypass, and postoperative support.
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Despite the widespread belief that donor organ availability varies around holidays and seasons, there is little empirical data supporting this long-held belief. Variations in donor heart availability may be of interest to patients and clinicians. The UNOS/OPTN registry was queried for all heart donations from October 1987 through March 2017. Daily heart donation rates were modeled nationally using Poisson regression including splines for year and day of the year. Seasonality was assessed using a likelihood ratio test for the spine terms for day of the year. The holiday effect was assessed using conditional logistic regression. Seasonal plots suggest a significant, although modest, increase in organ availability during the summer months, except for region 1. The regions with the highest amplitude were region 7 (peak: June 21, amplitude: 16.63%) and region 6 (peak: July 5, amplitude: 11.29%). There was no significant difference in the odds of heart donation when comparing holidays vs. non-holidays using national data (odds ratio [95% CI]: 1.01 [0.98, 1.03], P = 0.560) or any regional subsets. There was no observable correlation between donor heart availability and holidays. However, a significant seasonality effect was observed with higher donation rates occurring during warmer months.
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Transplante de Coração , Bases de Dados Factuais , Férias e Feriados , Humanos , Estações do Ano , Doadores de TecidosRESUMO
â¢Early use of extracorporeal membrane oxygenation (ECMO) is valuable when pulmonary tumor burden from GTN is high.â¢Induction chemotherapy of cisplatin and etoposide was administered during ECMO successfully.â¢The induction chemotherapy regimen led to exponential decline in beta-HCG after 1 cycle.â¢Collaboration of subspecialists is necessary to treat coexisting malignancy and cardiopulmonary failure associated with GTN.
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BACKGROUND: Primary pediatric lung malignancies are rare tumors. We provide an updated analysis of the epidemiology and prognosis of these tumors since the last SEER series published in 2009. METHODS: The SEER 18 database from 1975 to 2016 was analyzed for patients ages 0-19 years with primary lung and/or bronchus neoplasms. RESULTS: 348 patients met inclusion criteria. The majority were white and ≥12 years of age. The most common histologies were neuroendocrine (41.4%) and blastoma (16.4%). 75.4% of patients had local-regional disease and 81.4% underwent surgery. Significant differences between histologies were seen for age, year at diagnosis, tumor laterality and location, stage, and treatment type. Median survival was 36.6 years (95% CI 33.3-37.4). Blastoma (HR 3.47) and squamous cell (HR 6.26) carried a significantly higher risk of death than neuroendocrine cancer diagnosis. CONCLUSION: Primary pediatric lung malignancies are rare, long-term survival is favorable but histology-dependent. Surgery continues to be an important treatment modality.
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Neoplasias Pulmonares/epidemiologia , Neoplasias Pulmonares/terapia , Adolescente , Criança , Pré-Escolar , Demografia , Feminino , Humanos , Neoplasias Pulmonares/patologia , Masculino , Estadiamento de Neoplasias , Prognóstico , Programa de SEER , Taxa de Sobrevida , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Coronary artery bypass grafting (CABG) is a durable treatment for coronary artery disease. Left ventricular dysfunction (LVD) (a division of cardiothoracic surgery) (ejection fraction < 35%) significantly elevates perioperative risk for patients pursuing surgical revascularization. Periprocedural support with temporary mechanical circulatory support (tMCS) has shown benefit in this patient population. METHODS: Four patients with ischemic cardiomyopathy and LVD underwent CABG at our institution between 2017 and 2018. Each patient received perioperative ventricular support using a microaxial tMCS device (Impella 5.0®). The occurrence of a postoperative low-output state (LOS) was assessed for as well as postoperative morbidity and mortality, device-specific complications, and tMCS support duration. RESULTS: All patients survived to device explant without device-related complications. Two patients required reoperation for nondevice-related bleeding. All patients were without an LOS at 24 h postoperatively with cardiac indices of 2.9-3.6 L/min/m2 , normalized serum lactate, and vasoactive-inotrope scores of 0-12.0. There was a notably high incidence of acute renal failure (50%), which was observed in patients with preoperative cardiogenic shock. One patient died 10 days after the device explant. Of the three patients that survived to discharge, two were alive at the most recent follow-up. Postoperative device support varied widely (0-500 h). CONCLUSION: Perioperative tMCS may be a viable strategy for preventing postoperative LOS in high-risk CABG patients with a low complication rate and acceptable morbidity. The application of microaxial tMCS devices in CABG is an area that warrants further investigation to delineate its impact on perioperative outcomes and potentially expand the indications for such devices.
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Doença da Artéria Coronariana , Disfunção Ventricular Esquerda , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Humanos , Choque Cardiogênico , Resultado do TratamentoRESUMO
BACKGROUND: Coronary artery bypass grafting (CABG) can be performed through a variety of approaches. Minimally-invasive CABG (MICABG) may reduce perioperative morbidity. Previous results demonstrate improved perioperative outcomes; however, adoption has been limited. METHODS: The Society of Thoracic Surgeons (STS) database and electronic medical record at a single institution were reviewed for isolated left internal mammary to left anterior descending artery (LIMA-LAD) bypass procedures performed between 2011 and 2018. Patients were grouped on the basis of operative approach, comparing sternotomy to non-sternotomy (minimally-invasive). Patient characteristics, perioperative variables, and short- and long-term outcomes were compared. Primary outcomes included mortality and major adverse cardiac events (MACE). Secondary outcomes were morbidity. RESULTS: A total of 42 MICABG and 54 conventional LIMA-LAD procedures were performed with 95.2% of MICABG procedures performed by two surgeons. MICABG were more often elective (83.3 vs 38.9%, P < .001). STS risk scores predicted equitable mortality and morbidity for MICABG dependent on operative indication. MICABG was associated with fewer pulmonary complications (0.0 vs 11.1%, P = .033), in-hospital events (11.9 vs 37.0%, P = .005), and shorter intensive care unit (34.1 vs 66.0 hours, P = .022) and total length of stay (3.7 vs 6.5 days, P = .002). There were no observed strokes, myocardial infarctions, or reoperations. MICABG patients demonstrated reduced thirty-day mortality (0.0 vs 10.9%, P = .036) and improved Kaplan-Meier 5-year (95.2 vs 77.9%, P = .016) and MACE-free survival (89.2 vs 63.9%, P = .010). CONCLUSIONS: Minimally-invasive LIMA-LAD CABG demonstrates improved early postoperative morbidity and a long-term mortality benefit. In select patients, minimally-invasive approaches to single-vessel grafting may be beneficial when performed by experienced surgeons in the elective setting.
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Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Vasos Coronários/cirurgia , Artéria Torácica Interna/transplante , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Esternotomia/métodos , Doença da Artéria Coronariana/diagnóstico , Vasos Coronários/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Anastomose de Artéria Torácica Interna-Coronária/métodos , Masculino , Pessoa de Meia-Idade , Morbidade/tendências , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
Toll-like receptor 2 (TLR2) and TLR4 belong to a family of highly conserved pattern recognition receptors and are well-known upstream sensors of signaling pathways of innate immunity. TLR2 and TLR4 upregulation is thought to be associated with poor outcome in stroke patients. We currently show that transient focal ischemia in adult rats induces TLR2 and TLR4 expression within hours and shRNA-mediated knockdown of TLR2 and TLR4 alone and in combination decreases the infarct size and swelling. We further show that TLR2 and TLR4 knockdown also prevented the induction of their downstream signaling molecules MyD88, IRAK1, and NFκB p65 as well as the pro-inflammatory cytokines IL-1ß, IL-6, and TNFα. This study thus shows that attenuation of the severity of TLR2- and TLR4-mediated post-stroke inflammation ameliorates ischemic brain damage.
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Isquemia Encefálica/metabolismo , Isquemia Encefálica/terapia , Inflamação/metabolismo , Inflamação/prevenção & controle , Receptor 2 Toll-Like/genética , Receptor 4 Toll-Like/genética , Animais , Edema Encefálico/etiologia , Edema Encefálico/metabolismo , Edema Encefálico/prevenção & controle , Isquemia Encefálica/complicações , Modelos Animais de Doenças , Escherichia coli , Técnicas de Silenciamento de Genes , Inflamação/etiologia , Quinases Associadas a Receptores de Interleucina-1/metabolismo , Interleucina-1beta/metabolismo , Interleucina-6/metabolismo , Masculino , Fator 88 de Diferenciação Mieloide/metabolismo , Proteínas de Neoplasias/metabolismo , Neuroproteção/fisiologia , Proteínas de Transporte Nucleocitoplasmático/metabolismo , RNA Mensageiro/metabolismo , RNA Interferente Pequeno/administração & dosagem , Distribuição Aleatória , Ratos Sprague-Dawley , Fator de Necrose Tumoral alfa/metabolismoRESUMO
We describe a functional profiling strategy to identify and characterize subtypes of neurons present in a peripheral ganglion, which should be extendable to neurons in the CNS. In this study, dissociated dorsal-root ganglion neurons from mice were exposed to various pharmacological agents (challenge compounds), while at the same time the individual responses of >100 neurons were simultaneously monitored by calcium imaging. Each challenge compound elicited responses in only a subset of dorsal-root ganglion neurons. Two general types of challenge compounds were used: agonists of receptors (ionotropic and metabotropic) that alter cytoplasmic calcium concentration (receptor-agonist challenges) and compounds that affect voltage-gated ion channels (membrane-potential challenges). Notably, among the latter are K-channel antagonists, which elicited unexpectedly diverse types of calcium responses in different cells (i.e., phenotypes). We used various challenge compounds to identify several putative neuronal subtypes on the basis of their shared and/or divergent functional, phenotypic profiles. Our results indicate that multiple receptor-agonist and membrane-potential challenges may be applied to a neuronal population to identify, characterize, and discriminate among neuronal subtypes. This experimental approach can uncover constellations of plasma membrane macromolecules that are functionally coupled to confer a specific phenotypic profile on each neuronal subtype. This experimental platform has the potential to bridge a gap between systems and molecular neuroscience with a cellular-focused neuropharmacology, ultimately leading to the identification and functional characterization of all neuronal subtypes at a given locus in the nervous system.