Fetal bradycardia in open versus fetoscopic prenatal repair of spina bifida.

OBJECTIVE: To compare the occurrence of fetal bradycardia in open versus fetoscopic fetal spina bifida surgery. METHODS: This is a single-institution retrospective cohort study of patients undergoing open (n = 25) or fetoscopic (n = 26) spina bifida repair between 2017 and 2022. From October 2017 to June 2020, spina bifida repairs were performed via an open classical hysterotomy, and from November 2020 to June 2022 fetoscopic repairs were performed following transition to this technique. Fetal heart rate (FHR) in beats per minute (bpm) was recorded via echocardiography every 15 min during the procedure. Cohort characteristics, fetal bradycardia and maternal physiologic parameters were compared between the groups. RESULTS: Fetuses undergoing an open repair more frequently developed bradycardia defined as <110 bpm (32% vs. 3.8%, p = 0.008), and a trend was observed for FHR decreases more than 25 bpm from baseline (20% vs. 3.8%, p = 0.073). Profound bradycardia less than 80 bpm was rare, occurring in only three operations (two in open, one in fetoscopic repair) with two fetuses (one in each group) requiring emergency cesarean delivery. CONCLUSION: When compared to open fetal surgery, fetal bradycardia occurred less frequently in fetoscopic surgery despite a significantly greater anesthetic exposure and the use of the intraamniotic carbon dioxide insufflation.

Needle Fetal Thoracoscopy: A Technique to Assist with Ultrasound-Guided Placement of Challenging Thoracoamniotic Shunts.

INTRODUCTION: Fetal thoracoamniotic shunts are common lifesaving interventions but frequently require replacement. Needle fetal thoracoscopy is a technique that uses standard thoracoamniotic shunt introducer sheaths to permit direct visualization and even instrument manipulation during shunt deployment to facilitate optimal positioning and primary shunt function in the most challenging cases. CASE PRESENTATION: In this study, 5 patients who underwent needle fetal thoracoscopy-assisted thoracoamniotic shunt placement were reviewed. Three patients with large, macrocystic congenital pulmonary airway malformations (CPAMs) with evidence of worsening mediastinal shift and/or hydrops and 2 patients with large chylothorax with fetal hydrops were treated. Four cases had previous shunts that failed due to poor sonographic visualization during initial placement, cyst septations, shunt obstruction, or dislodgment. Needle fetal thoracoscopy was used to disrupt cyst walls and septations, clear hematoma, and confirm the optimal initial position of the shunt. In this series, 1 severe CPAM patient with a short cervix developed preterm labor postoperatively resulting in neonatal demise. The remaining 4 patients experienced resolution of hydrops and progressed to successful delivery with excellent neonatal outcomes. CONCLUSION: Needle fetal thoracoscopy is a procedure that may be selectively deployed in challenging thoracoamniotic shunt cases impacted by recurrent failure, poor sonographic windows, and challenging fetal positioning.

The Demands of Surgery Residency: More Than Just Duty Hours?

INTRODUCTION: Efforts to improve surgical resident well-being could be accelerated with an improved understanding of resident job demands and resources. In this study, we sought to obtain a clearer picture of surgery resident job demands by assessing how residents distribute their time both inside and outside of the hospital. Furthermore, we aimed to elucidate residents' perceptions about current duty hour regulations. METHODS: A cross-sectional survey was sent to 1098 surgical residents at 27 US programs. Responses regarding work hours, demographics, well-being (utilizing the physician well-being index), and perceptions of duty hours in relation to education and rest, were collected. Data were evaluated using descriptive statistics and content analysis. RESULTS: A total of 163 residents (14.8% response rate) were included in the study. Residents reported a median total patient care hours per week of 78.0 h. Trainees spent 12.5 h on other professional activities. Greater than 40% of residents were "at risk" for depression and suicide based on physician well-being index scores. Four major themes associated with education and rest were identified: 1) duty hour definitions and reporting mechanisms do not completely reflect the amount of work residents perform, 2) quality patient care and educational opportunities do not fit neatly within the duty hour framework, 3) resident perceptions of duty hours are impacted the educational environment, and 4) long work hours and lack of adequate rest negatively affect well-being. CONCLUSIONS: The breadth and depth of trainee job demands are not accurately captured by current duty hour reporting mechanisms, and residents do not believe that their current work hours allow for adequate rest or even completion of other clinical or academic tasks outside of the hospital. Many residents are unwell. Duty hour policies and resident well-being may be improved with a more holistic accounting of resident job demands and greater attention to the resources that residents have to offset those demands.

Surgery Provider Perceptions on Telehealth Visits During the COVID-19 Pandemic: Room for Improvement.

BACKGROUND: COVID-19 has mandated rapid adoption of telehealth for surgical care. However, many surgical providers may be unfamiliar with telehealth. This study evaluates the perspectives of surgical providers practicing telehealth care during COVID-19 to help identify targets for surgical telehealth optimization. MATERIALS AND METHODS: At a single tertiary care center with telehealth capabilities, all department of surgery providers (attending surgeons, residents, fellows, and advanced practice providers) were emailed a voluntary survey focused on telehealth during the pandemic. Descriptive statistics and Mann-Whitney U analyses were performed as appropriate on responses. Text responses were thematically coded to identify key concepts. RESULTS: The completion rate was 41.3% (145/351). Providers reported increased telehealth usage relative to the pandemic (P < 0.001). Of respondents, 80% (116/145) had no formal telehealth training. Providers estimated that new patient video visits required less time than traditional visits (P = 0.001). Satisfaction was high for several aspects of video visits. Comparatively lower satisfaction scores were reported for the ability to perform physical exams (sensitive and nonsensitive) and to break bad news. The largest barriers to effective video visits were limited physical exams (55.6%; 45/81) and lack of provider or patient internet access/equipment/connection (34.6%; 28/81). Other barriers included ineffective communication and difficulty with fostering rapport. Concerns regarding video-to-telephone visit conversion were loss of physical exam/visual cues (34.3%; 24/70), less personal interactions (18.6%; 13/70), and reduced efficiency (18.6%; 13/70). CONCLUSIONS: Telehealth remains a new experience for surgical providers despite its expansion. Optimization strategies should target technology barriers and include specialized virtual exam and communication training.

Twelve tips for the integration of medical students into telemedicine visits.

The use of telemedicine in clinical care has grown significantly in the last few years and has only increased during the COVID-19 pandemic. Given that many physicians will be expected to deliver virtual care moving forward, it is important for medical students to gain exposure via this modality during their clinical training. Many medical schools are actively working to integrate students into telemedicine. This article aims to provide guidance for readers incorporating medical students in telemedicine visits at an institutional or departmental level. This article covers essential topics such as coordinating key stakeholders, conducting needs assessments, addressing technological or software considerations, and creating appropriate workflows for students and physicians.

Rare germline mutations in African American men diagnosed with early-onset prostate cancer.

BACKGROUND: African Americans have both a higher incidence of prostate cancer and greater disease-specific mortality compared with non-Hispanic whites. Historically, the investigation of the contribution of rare genetic variants to prostate cancer in African American men has been hampered by low participation in large genetic studies, particularly those focused on early-onset and familial disease. METHODS: We sequenced 160 genes purported to be involved in carcinogenic pathways in germline DNA samples collected from 96 African American men diagnosed with early-onset prostate cancer (≤55 years at diagnosis). REVEL software was used to determine the pathogenic potential of observed missense variants. RESULTS: We observed three protein-truncating mutations, one in BRCA2 and two in BRIP1 in three African American men diagnosed with early-onset prostate cancer. Furthermore, we observed five rare, mostly private, missense variants among four genes (BRCA1, BRCA2, PMS2, and ATM) that were predicted to be deleterious and hence likely pathogenic in our patient sample. CONCLUSIONS: Protein-truncating mutations in BRCA2 and BRIP1 were discovered in African American men diagnosed with early-onset prostate cancer. Further study is necessary to determine the role of rare, missense variants to prostate cancer incidence, and progression in this group of high-risk men.

The association of intraoperative and early postoperative events with risk of pneumonia following cardiac surgery.

BACKGROUND: Pneumonia, the most common infection following cardiac surgery, is associated with major morbidity and mortality. Although prior work has identified preoperative risk factors for pneumonia, the present study evaluated the role and associated impact of intraoperative and postoperative risk factors on pneumonia after cardiac surgery. METHODS: This observational cohort study evaluated 71,165 patients undergoing coronary and/or aortic valve surgery across 33 institutions between 2011 and 2021. Terciles of estimated pneumonia risk were compared between a validated preoperative model (Model One) and a model additionally accounting for significant intraoperative (eg, bypass duration) and postoperative (eg, extubation time) factors (Model Two). Logistic regression was used to develop and validate Model Two. RESULTS: Postoperative pneumonia occurred in 2.62% of the patients. A total of 9 significant intraoperative and early postoperative risk factors were identified. The absolute risk of pneumonia increased across Model One terciles: low (≤1.04%), medium (1.04%-2.40%), and high (>2.40%). Model two performed well (c-statistic = 0.771). Most patients (60.1%) had no change in their preoperative versus intraoperative/postoperative risk tercile. The 19.6% of patients who increased their risk tercile with Model Two accounted for 18.6% of all pneumonia events. CONCLUSIONS: This study identified 9 significant perioperative risk factors for pneumonia. Nearly 1 of every 5 patients moved into a higher pneumonia risk category based on their intraoperative and postoperative course. These findings may serve as the focus of future quality improvement efforts to reduce a patient's risk of postoperative pneumonia.

Laser aortic septotomy during thoracic endovascular aortic repair for chronic type B aortic dissection.

OBJECTIVE: Persistent false lumen perfusion due to the presence of a thick aortic septum is a significant obstacle to successful thoracic endovascular aortic repair for chronic type B aortic dissection (cTBAD). We describe our new approach of laser aortic septotomy to optimize the landing zone. METHODS: Between 2019 and 2020, 11 patients with cTBAD with degenerative aneurysm underwent laser aortic septotomy during thoracic endovascular aortic repair. A prospectively maintained database was retrospectively reviewed. RESULTS: The median age was 70.0 years, and 10 (91%) were men. Six (55%) were de novo type B aortic dissection and 5 (45%) were residual type B aortic dissection. The age of aortic dissection was 2.9 years (interquartile range, 1.1-12.1). Technical success was achieved in 91% (10/11). In 1 case (9%), laser aortic septotomy was not feasible due to extremely tortuous aorta. Among successful cases, the median extents of proximal and distal laser fenestrations were Th7.5 and Th11.0, respectively and distal landing zones included zone 4 (40%) and zone 5 (60%). Two (18%) underwent a continuous longitudinal laser fenestration, and 8 (73%) had longitudinal spot laser fenestrations with immediate balloon dilatations. Apposition of the stent-graft to the outer aortic wall of the newly created common aortic lumen with elimination of retrograde false lumen flow was achieved in all cases. CONCLUSIONS: This is the first description using the laser technology to optimize the distal landing zone for cTBAD. This new technique is safe and reproducible, with excellent controllability to achieve aortic septotomy at the desired target aorta segment.

Perspectives From Rising Fourth Year Medical Students Regarding Strategies to Counteract the Effects of COVID-19 on Medical Education.

The COVID-19 pandemic has put those who oversee medical education in a challenging position. Medical school administrators, students, and national governing bodies have been forced to make difficult decision as a result of public health concerns and government-enforced restrictions. We, as rising fourth-year medical students, would like to shed light upon the hard work that many of those in leadership positions have done as well as lay out some concerns that medical students who are preparing to apply to residency have. Additionally, we would like to suggest several potential approaches that attempt to address some of the problems arising from the pandemic. Continuing to balance education with the hurdles presented by COVID-19 will require a multi-faceted and coordinated approach. We believe that implementing virtual rotations, delaying the opening of the application, decentralizing clinical skills evaluations, and modifying graduation requirements are possible options among many that could aid in addressing some of the current challenges presented by COVID-19.

Clinical Level of Evidence Presented at the Cervical Spine Research Society (CSRS) Annual Meeting Over 10 Years (2008-2017): A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: We systematically reviewed the level of clinical evidence presented at Cervical Spine Research Society annual meetings from 2008 through 2017. SUMMARY OF BACKGROUND DATA: The Cervical Spine Research Society is dedicated to advancing knowledge of the cervical spine to promote evidence-based care. Research presented at these meetings impacts clinical practice. METHODS: A total of 774 paper abstracts presented at Cervical Spine Research Society (CSRS) annual meetings were independently assessed by two reviewers. Reviewers designated a clinical level of evidence (LOE) to each included abstract from level I to level IV based on criteria set forth by the Oxford Centre for Evidence-Based Medicine. Reviewer agreement was assessed using Cohens Kappa coefficient (k) and disagreements were discussed until a consensus was reached. Wilcoxon rank sum test was used to assess for differences in LOE grades. Chi-squared testing was used to assess nonrandom changes in level of evidence and in excluded studies. RESULTS: A total of 583 abstracts were included. Over the last 10 CSRS meetings, 5.15% of presentations were level I, 27.8% level II, 27.4% level III, and 39.6% level IV. The average LOE from 2008 to 2017 was 3.02 (median = 3). Additionally, 49.7% were therapeutic studies, 37.6% prognostic studies, and 12.7% diagnostic studies. When comparing the first 5 years (2008-2012) to the last 5 years (2013-2017), we observed a significant increase in Level II (P = 0.007) evidence and a corresponding decrease in level IV evidence (P < 0.001). The average LOE improved from 3.14 (2008-2012) to 2.91 (2013-2017); there was a significant improvement in LOE between the two periods (P = 0.001). CONCLUSION: Emphasis on evidence-based medicine within cervical spine research has positively influenced the clinical level of evidence disseminated at CSRS annual meetings between 2008 and 2017. Continued focus on higher quality Level I studies is warranted. LEVEL OF EVIDENCE: 4.

Factors Associated with Increased Risk of Patient No-Show in Telehealth and Traditional Surgery Clinics.

BACKGROUND: With the growing use of telehealth, understanding factors affecting patient follow-up in traditional and telehealth settings is important. Few data exist examining the use of telehealth compared with traditional settings. Bridging this gap is critical to optimizing telehealth use and reducing barriers. STUDY DESIGN: This is a retrospective cohort study of return and postoperative (electronic video [eClinic] and traditional) visits from January 2018 to March 2020 at single tertiary care center. There were 12,359 unique first-encounter patients with 903 eClinic and 11,456 traditional visits; 11,547 patients completed visits, while 812 patients did not show up. Multivariable logistic regression modeling was performed to identify factors associated with no-show. County-level mapping was used to identify patterns in no-show rates. RESULTS: Patients from the eClinic had twice the odds of no-show compared with those from a traditional clinic (p < 0.001). Age was inversely proportional to odds of no-show, with each additional decade associated with a 16% decrease in these odds (p < 0.001). African-American patients had greater odds of no-show compared to Caucasian patients (odds ratio [OR] 2.47; 95% CI 1.95-3.13, p < 0.001). Marital statuses of single and legal separation were associated with higher odds of no-show compared with married marital status (p < 0.001 and p = 0.04, respectively). Minimally invasive and endocrine surgery clinics had lower odds of no-show compared with acute care surgery clinic (p < 0.001 for both). County-level no-show rates demonstrate similar patterns between clinic settings. CONCLUSIONS: Several factors are associated with increased odds of no-show, including the visit being in eClinic. County-level analysis suggests no-show variation is not dependent on geographic location. Understanding these patterns allows for prospective identification of barriers and development of interventions to optimize access and patient care.