Evaluation of veteran community care outcomes after coronary artery bypass grafting: a retrospective pilot cohort.

For Veterans who cannot be seen in a timely fashion or must travel long distances to be seen, the Veterans Health Administration (VHA) offers funded care in the community. The use of this program has rapidly increased; however, there have been no systematic evaluations of surgery specific metrics such as perioperative complications, mortality and timeliness of care. To evaluate this in cardiac surgery patients, we compared veterans undergoing coronary artery bypass grafting in the community to those remaining within the VHA. We identified 78 patients during calendar year 2018 meeting inclusion criteria. 41 underwent surgery in the community versus 37 in the VHA. There were no significant differences in baseline demographics including age, sex, race, ethnicity, comorbidities and surgical risk scores. With regard to perioperative outcomes, veterans who underwent surgery within the VHA had lower infection rates (17% vs. 0%, p = 0.008) and 30-day emergency department utilization (22% vs. 5%, p = 0.04). A longer median postoperative inpatient stay was also seen within the VHA (8 days vs. 6 days, p < 0.001). These findings suggest that the VHA may better serve Veterans and prevent adverse events after CABG, at the expense of prolonged hospitalization. More study is needed to validate the findings of this pilot study.

Losing weight to achieve joint or hernia surgery: is the intragastric balloon the answer?

BACKGROUND: Obesity is an epidemic, with its accompanying medical conditions putting patients at increased risk of postoperative complications. For patients undergoing elective surgery, preoperative weight loss provides an opportunity to decrease complications. We sought to evaluate the safety and efficacy of an intragastric balloon in achieving a body mass index (BMI) < 35 kg/m2 prior to elective joint replacement or hernia repair. METHODS: Retrospective review of all patients who had intragastric balloon placement at a level 1A VA medical center from 1/2019 to 1/2023. Patients who had a scheduled qualifying procedure (knee/hip replacement or hernia repair) and had a BMI > 35 kg/m2 were offered intragastric balloon placement to achieve 30-50lbs (13-28 kg) weight loss prior to surgery. Participation in a standardized weight loss program for 12 months was required. Balloons were removed 6 months after placement, preferentially concomitant with the qualifying procedure. Baseline demographics, duration of balloon therapy, weight loss and progression to qualifying procedure were recorded. RESULTS: Twenty patients completed intragastric balloon therapy and had balloon removal. Mean age 54 (34-71 years), majority (95%) male. Mean balloon duration was 200 ± 37 days. Mean weight loss was 30.8 ± 17.7lbs (14.0 ± 8.0 kg) with an average BMI reduction of 4.4 ± 2.9. Seventeen (85%) patients were successful, 15 (75%) underwent elective surgery and 2 (10%) were no longer symptomatic after weight loss. Three patients (15%) did not lose sufficient weight to qualify or were too ill to undergo surgery. Nausea was the most frequent side effect. One (5%) patient was readmitted within 30 days for pneumonia. DISCUSSION: Intragastric balloon placement resulted in an average 30lbs (14 kg) weight loss over 6 months allowing more than 75% of patients to undergo joint replacement or hernia repair at an optimal weight. Intragastric balloons should be considered in patients requiring 30-50lbs (13-28 kg) weight loss prior to elective surgery. More study is needed to determine the long-term benefit of preoperative weight loss prior to elective surgery.

Cardiac Surgeons Highlight the Need for Innovation Stewardship: Noteworthy in 2022.

Modern cardiac surgery has rapidly evolved to treat complex cardiovascular disease. This past year boasted noteworthy advances in xenotransplantation, prosthetic cardiac valves, and endovascular thoracic aortic repair. Newer devices often offer incremental design changes while demanding significant cost increases that leave surgeons to decide if the benefit to patients justifies the increased cost. As innovations are introduced, surgeons must continuously aim to harmonize short- and long-term benefits with financial costs). We must also ensure quality patient outcomes while embracing innovations that will advance equitable cardiovascular care.

What Happened and Why: Responding to Racism, Discrimination, and Microaggressions in the Clinical Learning Environment.

Introduction: Within clinical learning environments, medical students are uniquely faced with power differentials that make acts of racism, discrimination, and microaggressions (RDM) challenging to address. Experiences of microaggressions and mistreatment are correlated with higher rates of positive depression screening and lower satisfaction with medical training. We developed a curriculum for medical students beginning clerkship rotations to promote the recognition of and response to RDM. Methods: Guided by generalized and targeted needs assessments, we created a case-based curriculum to practice communication responses to address RDM. The communication framework, a 6Ds approach, was developed through adaptation and expansion of established and previously learned communication upstander frameworks. Cases were collected through volunteer submission and revised to maintain anonymity. Faculty and senior medical students cofacilitated the small-group sessions. During the sessions, students reviewed the communication framework, explored their natural response strategies, and practiced all response strategies. Results: Of 196 workshop participants, 152 (78%) completed the evaluation surveys. Pre- and postsession survey cohort comparison demonstrated a significant increase in students' awareness of instances of RDM (from 34% to 46%), knowledge of communication strategies to mitigate RDM (presession M = 3.4, postsession M = 4.6, p < .01), and confidence to address RDM (presession M = 3.0, postsession M = 4.4, p < .01). Discussion: Students gained valuable communication skills from interactive sessions addressing RDM using empathy, reflection, and relatability. The workshop empowered students to feel prepared to enter professional teams and effectively mitigate harmful discourse.

Understanding the role of placental pathophysiology in the development of bronchopulmonary dysplasia.

The associations between bronchopulmonary dysplasia (BPD) and the gestational pathologies of chorioamnionitis (CA) and hypertensive disorders of pregnancy (HDP) have become increasingly well recognized. However, the mechanisms through which these antenatal conditions cause increased risk of BPD remain less well characterized. The objective of this review is to discuss the role of the placenta in BPD predisposition as a primary driver of intrauterine alterations adversely impacting fetal lung development. We hypothesize that due to similarities in structure and function, placental disorders during pregnancy can uniquely impact the developing fetal lung, creating a unique placental-pulmonary connection. In the current review, we explore this hypothesis through analysis of clinical literature and preclinical model systems evaluating BPD predisposition, discussion of BPD phenotypes, and an overview on strategies to incorporate placental investigation into research on fetal lung development. We also discuss important concepts learned from research on antenatal steroids as a modulator fetal lung development. Finally, we propose that the appropriate selection of animal models and establishment of in vitro lung developmental model systems incorporating primary human placental components are key in continuing to understand and address antenatal predisposition to BPD.