Highlights and Perioperative Implications from the 2022 American College of Cardiology and American Heart Association Guidelines for Diagnosis and Management of Aortic Disease.

As the understanding of aortic diseases and their complications grow, increasing importance of uniformity in diagnosis and management is crucial for optimal care of this patient population. The 2022 American College of Cardiology and American Heart Association Guidelines for Diagnosis and Management of Aortic Disease discusses these considerations in detail. The purpose of this review is to highlight essential recommendations that are of relevance to the perioperative physician who manages these patients. A few notable points include, shared decision-making with patients, creation of multidisciplinary aortic teams, lower diameter thresholds for surgery in certain situations, and increased testing for patients with heritable aortic diseases. In addition to briefly reviewing basics of aortic diseases, the authors discuss changes to guidelines that are especially relevant to perioperative care.

The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2021 Part II: Cardiac Transplantation.

This article spotlights the research highlights of this year that specifically pertain to the specialty of anesthesia for heart transplantation. This includes the research on recent developments in the selection and optimization of donors and recipients, including the use of donation after cardiorespiratory death and extended criteria donors, the use of mechanical circulatory support and nonmechanical circulatory support as bridges to transplantation, the effect of COVID-19 on heart transplantation candidates and recipients, and new advances in the perioperative management of these patients, including the use of echocardiography and postoperative outcomes, focusing on renal and cerebral outcomes.

Determinants of point-of-care ultrasound lung sliding amplitude in mechanically ventilated patients.

BACKGROUND: Although lung sliding seen by point-of-care ultrasound (POCUS) is known to be affected to varying degrees by different physiologic and pathologic processes, it is typically only reported qualitatively in the critical care setting. Lung sliding amplitude quantitatively expresses the amount of pleural movement seen by POCUS but its determinants in mechanically ventilated patients are largely unknown. METHODS: This was a single-center, prospective, observational pilot study examining 40 hemithoraces in 20 adult patients receiving mechanical ventilation. Each subject had lung sliding amplitude measured in both B-mode and by pulsed wave Doppler at their bilateral lung apices and bases. Differences in lung sliding amplitude were correlated with anatomical location (apex vs base) as well as physiologic parameters including positive end expiratory pressure (PEEP), driving pressure, tidal volume and the ratio of arterial partial pressure of oxygen (PaO2) to fraction of inspired oxygen (FiO2). RESULTS: POCUS lung sliding amplitude was significantly lower at the lung apex compared to the lung base in both B-mode (3.6 ± 2.0 mm vs 8.6 ± 4.3 mm; p < 0.001) and the pulsed wave Doppler mode (10.3 ± 4.6 cm/s vs 13.9 ± 5.5 cm/s; p < 0.001) corresponding to expected distribution of ventilation to the lung bases. Inter-rater reliability of B-mode measurements was excellent (ICC = 0.91) and distance traversed in B-mode had a significant positive correlation with pleural line velocity (r2 = 0.32; p < 0.001). There was a non-statistically significant trend towards lower lung sliding amplitude for PEEP ≥ 10 cmH2O, as well as for driving pressure ≥ 15 cmH2O in both ultrasound modes. CONCLUSION: POCUS lung sliding amplitude was significantly lower at the lung apex than the lung base in mechanically ventilated patients. This was true when using both B-mode and pulsed wave Doppler. Lung sliding amplitude did not correlate with PEEP, driving pressure, tidal volume or PaO2:FiO2 ratio. Our findings suggest that lung sliding amplitude can be quantified in mechanically ventilated patients in a physiologically predictable way and with high inter-rater reliability. A better understanding of POCUS derived lung sliding amplitude and its determinants may aid in the more accurate diagnosis of lung pathologies, including pneumothorax, and could serve as a means of further reducing radiation exposure and improving outcomes in critically ill patients.

The Year in Perioperative Echocardiography: Selected Highlights From 2021.

This article is the sixth of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series. In most cases, these were research articles that were targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but, in some cases, these articles targeted the use of perioperative echocardiography in general.

"I might not fit that doctor image": Ideal worker norms and women medical students.

Despite the increasing numbers of women students in medical schools, focused attention on their perceptions about medical school and the medical profession remain underexamined. These perceptions are important to understand, particularly since women students are likely burdened with a host of gender norms related to work, family, and their future roles as physicians. Early experiences in medical school offer important insights into the larger student experience and are tied to academic outcomes and feelings of belonging. To examine early experiences of women medical students, this qualitative study used sensemaking theory to describe the current context and "story" of ideal worker norms. Critical qualitative interviews of 38 women students were performed during their first 2 months of medical school and explored both how the students perceived and experienced ideal worker norms, and how they made sense of the "story" of ideal worker norms. The participants described ways they encountered gendering and ideal worker norms through displays of nurturing behaviour, expectations to balance a future family, and whether they looked or acted the part of a doctor. This article highlights the challenges women medical students are already aware they will face, the opportunities they look forward to, and the strengths they anticipate leaning on to navigate their profession. Results from this study have implications for women medical students' learning experiences and transitions into medical school and for faculty, staff, and scholars concerned with challenging gendering norms that shape medical education.

The Year in Perioperative Echocardiography: Selected Highlights from 2020.

This article is the fifth of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank Editor-in-Chief Dr. Kaplan and the editorial board for the opportunity to continue this series. In most cases, these will be research articles that are targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles will target the use of perioperative echocardiography in general.

The Year in Electrophysiology: Selected Highlights From 2020.

This article is the third in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the Editor-in-Chief Dr. Kaplan, the Associate Editor-in-Chief Dr. Augoustides, and the editorial board for the opportunity to continue this series; namely, the highlights of the year that pertain to electrophysiology in relation to cardiothoracic and vascular anesthesia. This third article focuses on the convergent procedure, His-bundle pacing, a comparison of subcutaneous and transvenous defibrillator therapies, the 2020 practice advisory update for the perioperative management of patients with cardiac implantable electronic devices, and a technology update regarding the Micra AV (Medtronic, Moundsview, MN), the EMPOWER leadless pacemaker (Boston Scientific, Marlborough, MA), WiSE-CRT (EBR Systems, Sunnyvale, CA), the Extravascular Implantable Cardioverter Defibrillator (Medtronic, Moundsview, MN), and the BAROSTIM NEO (CVRx Inc, Minneapolis, MN).

Prevalence, Patterns, and Correlates of Pain in Medically Hospitalized Pediatric Patients With Somatic Symptom and Related Disorders.

BACKGROUND: Somatic symptom and related disorders (SSRDs) and pain are highly comorbid in the pediatric population. Little is known about the prevalence of pain and factors that may predispose and perpetuate pain in hospitalized youth with SSRD. OBJECTIVE: To describe the prevalence of pain and widespread pain symptoms in hospitalized youth with SSRD and describe differences between patients who endorsed limited (1-4 sites) versus widespread (5-8 sites) pain. METHODS: Retrospective chart reviews were conducted of pediatric patients with SSRD seen over a 32-month period at a tertiary pediatric hospital and assessed by the psychiatry consultation service. During admission, patients completed the Childhood Somatization Inventory, which assessed pain and other physical symptoms. Descriptive statistics, one-way analysis of variances, Pearson's χ2, stepwise linear regressions, and internal consistency analyses were used. RESULTS: Of the 219 patients (aged 8-18 y), 97% reported pain symptoms, and of those reporting pain (n = 213), 48% reported widespread pain. Patients with widespread pain had greater rates of comorbid depression (P = 0.012), neglect (P = 0.016), family psychiatric history (P = 0.013), diagnostic tests/procedures (P = 0.012), and prescribed opioid use (P = 0.016), when other medical and demographic factors were considered. When compared dichotomously to youth with limited pain, there was no difference in prevalence of medical conditions; however, patients with widespread pain had higher rates of trauma and stressor-related disorders (P = 0.017), sexual abuse (P = 0.031), emotional abuse (P = 0.041), and prior child protective service involvement (P = 0.011). CONCLUSIONS: Pain symptoms and widespread pain are common in medically hospitalized youth with SSRD, with unique psychiatric and psychosocial factors associated with widespread pain.

Gradually Progressive Dyspnea and Exercise Intolerance in an Otherwise Active Middle-Aged Woman: Why Was the Presentation of Congenital Heart Disease Delayed?

Patients with congenital heart disease (CHD) increasingly are surviving into adulthood. In the United States alone, there are more than one million adult patients living with CHD with the number increasing about 5% each year. With more than 85% of infants with CHD surviving into adulthood with their disease, encounters with these patients in the operating room for cardiac and noncardiac operative procedures is becoming more commonplace. Most of these patients receive corrective surgery early in life, although some may live with uncorrected CHD with no-to-relatively mild symptoms and present at a later time in life with symptoms of heart failure or pulmonary hypertension. The authors present an adult patient with uncorrected CHD presenting with late onset of heart failure symptoms. The authors also review the patient's complex congenital heart lesion, transesophageal echocardiography findings, and intraoperative management.

The Year in Perioperative Echocardiography: Selected Highlights from 2018.

This article is the third of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series. In most cases, these will be research articles targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles will target the use of perioperative echocardiography in general.

Emergent Colon Resections: Does Surgeon Specialization Influence Outcomes?

BACKGROUND: Relationships between high-volume surgeons and improved postoperative outcomes have been well documented. Colorectal procedures are often performed by general surgeons, particularly in emergent settings, and may form a large component of their practice. The influence of subspecialized training on outcomes after emergent colon surgery, however, is not well described. OBJECTIVE: The purpose of this study was to determine whether subspecialty training in colorectal surgery is associated with differences in postoperative outcomes after emergency colectomy. DESIGN: This was a retrospective cohort study. SETTINGS: Three tertiary care hospitals participating in the National Surgical Quality Improvement Project were included. PATIENTS: Patients undergoing emergent colon resections were identified at each institution and stratified by involvement of either a colorectal surgeon or a general or acute care surgeon. MAIN OUTCOME MEASURES: Propensity score matching was used to isolate the effect of surgeon specialty on the primary outcomes, including postoperative morbidity, mortality, length of stay, and the need for unplanned major reoperation, in comparable cohorts of patients. RESULTS: A total of 889 cases were identified, including 592 by colorectal and 297 by general/acute care surgeons. After propensity score matching, cases performed by colorectal surgeons were associated with significantly lower rates of 30-day mortality (6.7% vs 16.4%; p = 0.001), postoperative morbidity (45.0% vs 56.7%; p = 0.009), and unplanned major reoperation (9.7% vs 16.4%; p = 0.04). In addition, length of stay was ≈4.4 days longer among patients undergoing surgery by general/acute care surgeons (p < 0.001). LIMITATIONS: This study was limited by its retrospective design, with potential selection bias attributed to referral patterns. CONCLUSIONS: After controlling for underlying disease states and illness severity, emergent colon resections performed by colorectal surgeons were associated with significantly lower rates of postoperative morbidity and mortality when compared with noncolorectal surgeons. These findings may have implications for referral patterns for institutions. See Video Abstract at http://links.lww.com/DCR/A767.

Multifocal Versus Conventional Unifocal Diverticulitis: A Comparison of Clinical and Transcriptomic Characteristics.

BACKGROUND: The management of diverticulitis is compromised by difficulty in identifying patients who require surgery for recurrent or persistent disease. Here, we introduce the concept of multifocal diverticulitis (MFD), characterized by multiple episodes of diverticulitis occurring at different locations within the colon. AIMS: To compare clinical characteristics, success of surgical management, and colonic transcriptomes of MFD patients to patients with conventional unifocal diverticulitis (UFD). METHODS: This retrospective study included 404 patients with CT-confirmed diverticulitis episodes. Patients with diverticulitis seen in at least two different colonic locations were classified as the MFD group and compared to the UFD group based on number of episodes, sites of disease, family history, surgeries performed, and postoperative recurrence. RNA-seq was conducted on full-thickness colonic tissues of ten MFD and 11 UFD patients. RESULTS: Twenty-eight patients (6.9%) with MFD were identified. MFD patients had more diverticulitis episodes and were more likely to have positive family history, have right-sided disease, require surgery, and have recurrence after surgery. All MFD patients treated with segmental resection had recurrence, while recurrence was less common in patients undergoing more extensive surgery (P < 0.001). Using RNA-seq, we identified 69 genes that were differentially expressed between MFD and UFD patients. Significantly down-regulated genes were associated with immune response pathways. CONCLUSIONS: MFD appears to be a more severe subset of diverticulitis with a possible genetic component. Transcriptomic data suggest that MFD may be associated with alteration of the immune response.