National Analysis of Sternal Wound Complications and Readmissions After Coronary Bypass Surgery.

BACKGROUND: Wound complications are a cause for readmission after cardiac surgery. Health insurance status has been associated with poor postoperative outcomes. We investigate the association between health insurance status and post-CABG wound dehiscence or infection along with 30-day wound-related readmission using a national database. METHODS: We queried the National Readmissions Database for the year 2018 for patients aged 18 years or more undergoing multivessel coronary artery bypass graft surgery (CABG). Patients were subcategorized by health insurance status (private, Medicaid, Medicare, uninsured). Our primary outcomes were wound dehiscence or infection during the index admission and 30-day readmission after discharge for wound-related complications. RESULTS: In all, 131,976 patients met inclusion criteria: 32.7% private, 7.6% Medicaid, 59.3% Medicare, and 0.4% uninsured. Compared with patients having private insurance, Medicaid patients had greater odds of readmission for superficial wound dehiscence (odds ratio [OR] 2.11; 1.11-4.00; P = .022) and deep wound dehiscence (OR 2.11; 95% CI, 1.09-4.10; P = .026), as did Medicare patients (OR 2.34; 95% CI, 1.29-3.88; P = .004; and OR 3.23; 95% CI, 1.76-5.90; P = .001, respectively). Medicaid patients additionally had higher odds of readmission for superficial wound infection (OR 1.59; 95% CI, 1.11-4.00; P = .014). Compared with patients with private insurance, Medicaid patients had higher odds of deep wound dehiscence on index admission (OR 1.97; 95% CI, 1.02-3.83; P = .044), and Medicare patients had higher odds of superficial wound dehiscence (OR 2.55; 95% CI, 1.28-5.06; P = .001). CONCLUSIONS: Patients with Medicaid and Medicare had greater odds of readmission for wound complications and higher rates of wound dehiscence in their index admission. Further research is warranted to characterize factors driving readmission due to postsurgical wound complications in low socioeconomic status populations.

Update on Plant-Based Diets and Cardiometabolic Risk.

PURPOSE OF REVIEW: The number of published studies on the health effects of plant-based diets has increased dramatically in the last decade. The purpose of this narrative review is to update the most recent evidence from large prospective cohort studies and meta-analyses on the effects of plant-based dietary patterns on cardiovascular outcomes and risk factors and total mortality. RECENT FINDINGS: Most new data from large prospective cohort studies carried out in the USA, Europe, and Asia continue to show inverse associations between plant-based diets and the incidence of ischemic heart disease and stroke, while less data exist for heart failure incidence. New analyses suggest that only some components of plant-based diets are associated with cardiovascular benefit. Recent meta-analyses show inverse associations between plant-protein intake and all-cause mortality, although heterogeneity exists, and small mortality risks from some animal proteins, notably processed meats. New studies continue to demonstrate small but favorable effects of plant-based diets on traditional risk factors and suggest other emerging mechanisms by which plant-based diets exert cardiovascular benefits. The recommendation to consume a plant-based diet to reduce cardiovascular risk remains an evidence-based strategy based on observational studies. New data highlight the importance of ensuring that these diets are nutrient-rich and low in plant foods associated with signals of harm. For this reason, assessment of diet quality is important even in patients who report adherence to plant-based diets. Large randomized trials with hard cardiovascular endpoints might strengthen this evidence-base, but feasibility is limited.

Methylome of skeletal muscle tissue in patients with hypertension and diabetes undergoing cardiopulmonary bypass.

Background: Epigenomic changes occurring during surgery have been neglected in research; diabetes and hypertension can affect the epigenome but little is known about the epigenetics of skeletal muscle (SKM). Methods: DNA methylation was profiled via Illumina MethylationEPIC arrays in SKM samples obtained at the beginning and end of heart surgery with cardiopulmonary bypass. Results: Methylation in patients with hypertension and diabetes was significantly different, more so for uncontrolled diabetes; hypertension alone produced minimal effect. The affected pathways involved IL-1, IL-12, IL-18, TNF-α, IFN-γ, VEGF, NF-κB and Wnt signaling, apoptosis and DNA damage response. Significant changes occurred during surgery and included loci in the Hippo-YAP/TAZ pathway. Conclusion: Cardiopulmonary bypass surgery affects the SKM methylome, and the combination of hypertension and diabetes induces changes in the SKM epigenome in contrast to hypertension alone.

The Past, Present, and Future of the United States Medical Licensing Examination Step 2 Clinical Skills Examination.

In January 2021, the United States Medical Licensing Examination (USMLE) announced the permanent suspension of their Step 2 Clinical Skills (CS) examination. Launched in 2004, the Step 2 CS examination was intended to ensure that physicians entering graduate medical education possess the necessary information gathering, clinical reasoning, and communication skills necessary to provide patient care. Although the requirement that doctors pass a clinical skills examination as a condition of licensure likely improved some elements of medical education and physician practice, the Step 2 CS examination was deeply unpopular among many medical students since its inception. The demise of USMLE Step 2 CS provides an opportunity to re-examine the test's value and incorporate improvements in future iterations. However, doing so requires a clear understanding of why the test was so vigorously challenged. Here, we review the history of clinical skills examinations used for medical licensure in the United States and highlight the persistent concerns regarding Step 2 CS's cost, value, validity, and lack of examinee feedback before proposing future improvements to address each concern.