Postdoctoral National Institutes of Health F32 Grants: Broken Pipeline in the Development of Surgeon-Scientists.

OBJECTIVE: We examined trainees in surgery and internal medicine who received National Institutes of Health (NIH) F32 postdoctoral awards to determine their success rates in obtaining future NIH funding. BACKGROUND: Trainees participate in dedicated research years during residency (surgery) and fellowship (internal medicine). They can obtain an NIH F32 grant to fund their research time and have structured mentorship. METHODS: We collected NIH F32 grants (1992-2021) for Surgery Departments and Internal Medicine Departments from NIH RePORTER, an online database of NIH grants. Nonsurgeons and noninternal medicine physicians were excluded. We collected demographic information on each recipient, including gender, current specialty, leadership positions, graduate degrees, and any future NIH grants they received. A Mann-Whitney U test was used for continuous variables, and a χ 2 test was utilized to analyze categorical variables. An alpha value of 0.05 was used to determine significance. RESULTS: We identified 269 surgeons and 735 internal medicine trainees who received F32 grants. A total of 48 surgeons (17.8%) and 339 internal medicine trainees (50.2%) received future NIH funding ( P < 0.0001). Similarly, 24 surgeons (8.9%) and 145 internal medicine trainees (19.7%) received an R01 in the future ( P < 0.0001). Surgeons who received F32 grants were more likely to be department chair or division chiefs ( P =0.0055 and P < 0.0001). CONCLUSIONS: Surgery trainees who obtain NIH F32 grants during dedicated research years are less likely to receive any form of NIH funding in the future compared with their internal medicine colleagues who received F32 grants.

Adenosine 2A Receptor Activation Attenuates Ischemia Reperfusion Injury During Extracorporeal Cardiopulmonary Resuscitation.

OBJECTIVE: We tested the hypothesis that systemic administration of an A2AR agonist will reduce multiorgan IRI in a porcine model of ECPR. SUMMARY BACKGROUND DATA: Advances in ECPR have decreased mortality after cardiac arrest; however, subsequent IRI contributes to late multisystem organ failure. Attenuation of IRI has been reported with the use of an A2AR agonist. METHODS: Adult swine underwent 20 minutes of circulatory arrest, induced by ventricular fibrillation, followed by 6 hours of reperfusion with ECPR. Animals were randomized to vehicle control, low-dose A2AR agonist, or high-dose A2AR agonist. A perfusion specialist using a goal-directed resuscitation protocol managed all the animals during the reperfusion period. Hourly blood, urine, and tissue samples were collected. Biochemical and microarray analyses were performed to identify differential inflammatory markers and gene expression between groups. RESULTS: Both the treatment groups demonstrated significantly higher percent reduction from peak lactate after reperfusion compared with vehicle controls. Control animals required significantly more fluid, epinephrine, and higher final pump flow while having lower urine output than both the treatment groups. The treatment groups had lower urine NGAL, an early marker of kidney injury (P = 0.01), lower plasma aspartate aminotransferase, and reduced rate of troponin rise (P = 0.01). Pro-inflammatory cytokines were lower while anti-inflammatory cytokines were significantly higher in the treatment groups. CONCLUSIONS: Using a novel and clinically relevant porcine model of circulatory arrest and ECPR, we demonstrated that a selective A2AR agonist significantly attenuated systemic IRI and warrants clinical investigation.

Are You Making Yourself Clear? You Can't Communicate, or Think, Effectively If You Can't Write Clearly.

In the not too distant past, illegible handwriting was considered to be the biggest problem with medical record keeping. Now the primary problem with medical records is that they are disorganized, and usually undigested, data dumps. A solution to at least part of this problem lies in utilizing the principles of the problem-oriented record. When one contemplates the optimal format for progress notes, it is worth considering the purposes of progress notes. While progress notes do, of course, play a role in billing, the primary purposes of a progress note should be to provide efficient and effective communication with all who are caring for that patient and to facilitate efficient and effective contemplation of the condition of and the plans for that patient. Although it is beyond the scope of this treatise on creating progress notes, it is also worth pointing out that all patient care notes will also occasionally have legal implications and lawyers reading clinical notes will pay far more attention to assessments and plans than they will to data and results recorded in progress notes that are always easily available elsewhere in the patient record. In other words, lawyers reviewing medical records want to know what the clinicians caring for a patient were thinking, in addition to what those clinicians actually did for that patient. While all of these issues must be kept in mind, we will focus primarily on the role of clinical notes in providing optimal patient care, particularly in the realm of cardiothoracic surgery, though the principles to be enunciated can apply to most disciplines and to most clinical environments.

Preparing for the Lurch into a Surgery Clerkship.

Over our combined nearly 50 years as surgical educators, we have been asked many times by medical students how they should prepare for and function in a Surgery Clerkship. It is still easy for me (C.G.T.) to recall, as a medical student myself, having the same questions. While I had initially thought that the transition from college to medical school would be challenging, I quickly realized that the first few years of medical school were not as much of a transition as I had imagined. However, as the clerkship year approached for my medical school classmates and me, it was quite clear to us that we were about to enter an educational environment for which our prior years in college and medical school had likely not optimally prepared us. And, when the primary advice we were given about how we should function as medical students rotating through the clerkships was that we should "just live the life of the house officer," we realized that we had little to no idea what we were actually supposed to do once we began the clerkship year.

Can Lung Transplant Surgeons Still Be Scientists? High Productivity Despite Competitive Funding.

BACKGROUND: Today's declining federal budget for scientific research is making it consistently more difficult to become federally funded. We hypothesized that even in this difficult era, surgeon-scientists have remained among the most productive and impactful researchers in lung transplantation. METHODS: Grants awarded by the NIH for the study of lung transplantation between 1985 and 2015 were identified by searching NIH RePORTER for 5 lung transplantation research areas. A grant impact metric was calculated for each grant by dividing the sum of impact factors for all associated manuscripts by the total funding for that grant. We used nonparametric univariate analysis to compare grant impact metrics by department. RESULTS: We identified 109 lung transplantation grants, totaling approximately $300 million, resulting in 2304 papers published in 421 different journals. Surgery has the third highest median grant impact metric (4.2 per $100,000). The department of surgery had a higher median grant impact metric compared to private companies (P <.0001). There was no statistical difference in the grant impact metric compared to all other medical specialties, individual departments with multiple grants, or all basic science departments (all P >.05). CONCLUSIONS: Surgeon-scientists in the field of lung transplantation have received fewer grants and less total funding compared to other researchers but have maintained an equally high level of productivity and impact. The dual-threat academic surgeon-scientist is an important asset to the research community and should continue to be supported by the NIH.

Expanding the donor lung pool: how many donations after circulatory death organs are we missing?

BACKGROUND: The number of patients with end-stage pulmonary disease awaiting lung transplantation is at an all-time high, while the supply of available organs remains stagnant. Utilizing donation after circulatory death (DCD) donors may help to address the supply-demand mismatch. The objective of this study is to determine the potential donor pool expansion with increased procurement of DCD organs from patients who die at hospitals. MATERIAL AND METHODS: The charts of all patients who died at a single, rural, quaternary-care institution between August 2014 and June 2015 were reviewed for lung transplant candidacy. Inclusion criteria were age <65 y, absence of cancer and lung pathology, and cause of death other than respiratory or sepsis. RESULTS: A total of 857 patients died within a 1-year period and were stratified by age: pediatric <15 y (n = 32, 4%), young 15-64 y (n = 328, 38%), and old >65 y (n = 497, 58%). Those without cancer totaled 778 (90.8%) and 512 (59%) did not have lung pathology. This leaves 85 patients qualifying for DCD lung donation (pediatric n = 10, young n = 75, and old n = 0). Potential donors were significantly more likely to have clear chest X-rays (24.3% versus 10.0%, P < 0.0001) and higher mean PaO2/FiO2 (342.1 versus 197.9, P < 0.0001) compared with ineligible patients. CONCLUSIONS: A significant number of DCD lungs are available every year from patients who die within hospitals. We estimate the use of suitable DCD lungs could potentially result in a significant increase in the number of lungs available for transplantation.

On Becoming a Surgical Intern: Navigating the Lurch from Medical School to Internship.

There are three major transitions in the educational trajectory of those heading into a career in surgery. The first transition is from the first year or two of medical school to the clerkships of the third year.  The second is the transition from medical school into the first postgraduate year of residency training. The third, which is widely held to be the toughest transition of all, is from residency into independent practice.  This review, which could be called 'a rookie's survival guide,' will address the second of those 'lurches,' that of the transition from medical school into a surgical internship.

Reoperative Cardiac Surgery - Part II.

The preparation for a reoperative cardiac surgical case was covered in Part I of this two part review [Tribble 2018]. Part II will cover primarily intraoperative strategies and techniques.  As noted in Part I, there has been surprisingly little written about the strategies and techniques of reoperative cardiac surgery. Thus, the goal of this two-part review is to collect and collate some of the lessons, abjurations, and tenets related to reoperative cardiac surgery that may be valuable to cardiac surgeons, especially those in training or early in their careers.Some time-honored admonitions that can apply to all complex operations, often enunciated by "old salts," bear repeating:•  Everything matters. Nothing is neutral.•  Some say that a "life or death" decision is made, on average, every 10 seconds during cardiac surgery. â€¢  If something can go wrong, presume that it will.•  If it seems absolutely impossible for something to go wrong, it will anyway, at least some of the time.•  When something does go wrong, it generally does so all at once.•  If what you are doing is working, keep on doing it. If it ain't working, do something else.

String Music: Creating Coronary Artery and other Vascular Anastomoses.

The initial version of this treatise was written as I (Curt Tribble) was learning to do coronary anastomoses over 30 years ago, and I worried that I was not being taught very well how to go about doing them. It seemed to me that my teachers were channeling Dr. Alain Carpentier, who often answered questions about his mitral valve repair techniques by saying, "Oh, you just know." These frustrations were compounded by the fact that the best cardiovascular techniques books, including even those texts dedicated to coronary artery bypass techniques, did not describe these anastomotic techniques in detail, which remains the case to the present day [Kaiser 2007; Copeland 1986].

The Skeleton in the Closet: Harvesting a Skeletonized IMA.

There is a considerable amount of data that using more than one arterial graft provides a survival advantage for patients undergoing coronary bypass operations. The Society of Thoracic Surgeons has a set of official guidelines for the use of arterial grafts which include the following recommendations:Internal mammary arteries (IMA's) should be used to bypass the left anterior descending (LAD) artery when bypass of the LAD is indicated.As an adjunct to left internal mammary artery (LIMA), a second arterial graft (right IMA or radial artery [RA]) should be considered in appropriate patients.Use of bilateral IMA's (BIMA's) should be considered in patients who do not have an excessive risk of sternal complications.To reduce the risk of sternal infection with bilateral IMA's, skeletonized grafts should be considered, smoking cessation is recommended, glycemic control should be considered, and enhanced sternal stabilization may be considered.Use of arterial grafts should be a part of the discussion of the heart team in determining the optimal approach for each patient.         [Ann Thorac Surg 2016; 101: 801-9].

Give My Poor Heart Ease.

We came to The University of Virginia (UVA) within a year of each other nearly four decades ago: one (DN) to join the UVA basketball team during four of the best years of UVA basketball, and to earn 2 degrees, first in English and then in Sports Psychology; and the other (CT) to begin 7 years of training in general, vascular, thoracic, and cardiac surgery, which culminated with a faculty appointment in the UVA Department of Surgery, with part of the charge being to organize most of the Department's educational programs. Realizing that the education and training of medical students and surgical residents would require knowledge, skills, and understanding above and beyond the usual training of a resident in surgery, I (CT) started an informal, though enriching, attempt to find those on the grounds of the University who might share ideas and insights that could enhance the educational programs in the Department. This process embodied the vision of the founders of the University to create an "academical village."

Median Sternotomy for Lung Transplantation: Techniques and Advantages.

Lung transplantation is traditionally performed with a clamshell thoracotomy or bilateral anterior thoracotomy incisions. We have performed 121 lung transplants with a median sternotomy incision from 2013-2017. We present our technique for lung transplantation utilizing cardiopulmonary bypass with a median sternotomy, and discuss the potential advantages of this technique.

Failing to Prepare is Preparing to Fail: The Known, The Known Unknown, and The Unknown Unknown.

Cardiothoracic surgery residents often enter their training with fairly limited prior exposure to the field. Obviously, they need to master the essential knowledge and skills of the discipline during their training. In addition to following a didactic curriculum of one sort or another, much of the necessary knowledge and understanding will accrue from their experiences caring for and operating on the patients who will be under their auspices, not only during their formal training but also after they finish their training.  Some of these cases and situations, such as elective cases, allow for careful preparation, while some more urgent or emergent cases require generic, advance preparation in order to be ready to perform optimally in these cases when they arise. And then there will always be cases for which one will not be able to prepare in any meaningful way, and these types of cases will require creativity and innovation "on the fly."  I will describe three cases, which are examples of each of these situations, with suggestions on how to handle each type of situation optimally. I will describe the preparation, such as it was for each, in some detail to help the reader understand how it felt to deal with each of these cases. The technical details of each of these cases resulted in a publication, which will be cited in the references, should the reader want to learn more about them.

Always Keep Your Clothes in the Car.

In helping to organize many different educational environments in the School of Medicine and the Department of Surgery at the University of Virginia over the last 30 years, my colleagues and I have long recognized that our students and trainees, while uniformly well prepared academically for their respective missions, often take inadequate care of themselves. Everyone who has flown on a plane will recall that the flight attendants always tell passengers that, if oxygen is needed, one must put one's own mask on first, before helping others put their masks on. And the obvious reason for that admonition is that you cannot help others if you, yourself, are impaired. This admonition applies equally to those who have committed their lives to helping others, which, in the case of our protégés and ourselves, is through medicine and surgery.

Massive Pulmonary Embolism Treated with Catheter Therapy and Extracorporeal Membrane Oxygenation.

Massive pulmonary embolism (PE) is associated with significant morbidity and mortality.  Treatment for massive PE can include systemic thrombolysis and catheter-directed therapy. We present the case of a patient with massive PE successfully treated with catheter-directed therapy, using extracorporeal membrane oxygenation for hemodynamic support, and discuss some of the potential complications associated with this therapy.

Medical student education in the Department of Surgery at the University of Mississippi Medical Center in the 21st Century.

The approach of the Department of Surgery at the University of Mississippi to the education of medical students is considerably different from that of earlier eras. An overview of the current strategies for medical student education adopted by the Department in recent years and the philosophies behind them is presented.

Nitroglycerin and sodium nitroprusside: potential contributors to postoperative bleeding?

Postoperative bleeding is common in patients undergoing cardiac surgery with cardiopulmonary bypass. Most cases of severe postoperative bleeding not due to incomplete surgical hemostasis are related to acquired transient platelet dysfunction mediated by platelet activation during contact with the synthetic surfaces of the cardiopulmonary bypass equipment. Antihypertensive agents nitroglycerin and sodium nitroprusside have been shown to have platelet inhibitory properties, yet the clinical consequence in terms of postoperative bleeding has been little studied. Knowing that cardiopulmonary bypass causes platelet dysfunction, it is prudent for physicians to be aware of the additional platelet inhibition caused by these commonly used antihypertensive agents.

Current use of intrapleural tissue plasminogen activator in the treatment of complex pleural processes: a review of the literature and report of 9 cases.

Intrapleural tissue plasminogen activator is increasingly being utilized to treat complex pleural processes, such as complicated pleural effusions and empyemas, without surgical intervention. This technique is especially useful for patients with numerous co-morbidities or who are poor surgical candidates. We present our experience in treating nine adult patients with intrapleural tissue plasminogen activator for complex pleural processes. Patients were treated with one to eight doses until their condition resolved or surgical intervention was necessary. Seven patients had complete resolution, two patients required surgical intervention, and there were no complications from therapy. A review of all available literature on the use of intrapleural tissue plasminogen activator in adults is presented, comparing the various methods and techniques used by others.

Early blood biomarkers predict organ injury and resource utilization following complex cardiac surgery.

BACKGROUND: Patients undergoing complex cardiac surgery (thoracic aorta and valve) are at risk for organ failure and increased resource utilization. Neutrophil gelatinase-associated lipocalin (NGAL) has been found to be an early biomarker for renal injury. Multiplex cytokine immunoassays allow the evaluation of the early inflammatory response. We examined the relationship between early biomarker appearance (NGAL and multiplex cytokines) and organ injury and resource utilization. MATERIALS AND METHODS: NGAL and multiplex cytokine immunoassays were performed at baseline, 1, 6, and 24 h following surgery on 38 patients undergoing thoracic aorta and valve operations. The mean age was 65 y with 26 males and 12 females. Acute kidney injury (AKIN definition), pulmonary failure (>24 h ventilation), and intensive care unit and hospital stays were examined. RESULTS: One hour following complex cardiac surgery, the quartile of patients with the greatest IL-6 response had higher serum NGAL levels compared with the lowest quartile (347 versus 145 ng/mL, P=0.002), and 70% of these patients progressed to clinical kidney injury. Six hours following surgery, the quartile of patients with the greatest IL-10 response had higher serum NGAL compared with the lowest quartile (271 versus 160, P =0.04), more pulmonary failure (60% versus 10%, P =0.01), and longer ICU and hospital stays (P =0.001). CONCLUSIONS: Patients with early elevated biomarkers of inflammation exhibited higher NGAL, more pulmonary failure, and greater resource utilization. Earlier identification of patients at risk for organ injury may allow for earlier intervention and reduce resource utilization.

Benefit of 3D volume rendered CT scans in the diagnosis and treatment of cardiac anomalies: a report of 3 cases.

3D volume rendered computed tomography (3D-CT) produces detailed, three-dimensional models that can be rotated and viewed in any orientation to provide a more natural and functional view of the patient's anatomy. This technology is especially beneficial in diagnosing and repairing cardiovascular anomalies. Three cases are presented where 3D-CT was used to diagnose and plan a course of treatment for patients with cardiac anomalies.