Medical Students' Attitudes Towards Cardiothoracic Surgery in the United Kingdom: A Cross-Sectional Survey of 1675 Students.

OBJECTIVES: The objectives of this study were the following: (i) assess interest levels in cardiothoracic surgery (CTS) among UK-based medical students, (ii) identify potential motivators and barriers to pursuing CTS training, (iii) explore the influence of gender on interest in CTS in greater depth. METHODS: Medical students from all year groups across UK medical schools were invited to participate in a cross-sectional, national online survey. Responses were collected from 02/12/2019 to 08/12/2019. RESULTS: 1675 medical students from 31 UK medical schools responded, with an estimated 5.3% response rate. Of the respondents, 33.7% respondents reported having exposure to CTS, primarily through their medical school or through extracurricular activities (48.4% and 38.8%, respectively). When assessing interest in CTS, 31.4% were interested in undertaking a career in CTS, with a larger proportion of students expressing interest with no exposure to CTS than those with exposure. However, interest in pursuing CTS decreased with exposure as medical students transitioned from pre-clinical to clinical stages. Additionally, male participants were more interested in seeking a CTS post than their female counterparts (38% vs. 27.6%). The length of training (p = 0.0009) and competitive nature (p < 0.0001) of gaining a CTS post were the primary deterring factor for female participants, compared to their male counterparts. CONCLUSIONS: This study shows the importance of quality of exposure and its impact on students' interests in pursuing a career in CTS. The negative relationship between exposure and interest in CTS can be associated with the realisation of the challenges that come with pursuing CTS.

Optimising risk factors for atrial fibrillation post-cardiac surgery.

Postoperative atrial fibrillation (POAF) is an ongoing complication following cardiac surgery, with an incidence of 15%-60%. It is associated with substantial mortality and morbidity, as well increased hospital stays and healthcare costs. The pathogenesis is not fully understood, but the literature suggests that POAF occurs when transient, postoperative triggers act on vulnerable atrial tissue produced by preoperative, procedure-induced and postoperative processes such as inflammation, oxidative stress, autonomic dysfunction and electrophysiological remodelling of the atrial tissues. This sets the stage for arrhythmogenic mechanisms, such as ectopic firing secondary to triggered activity and re-entry mechanisms generating POAF. Preoperative factors include advanced age, sex, ethnicity, cardiovascular risk factors, preoperative drugs, electrocardiogram and echocardiogram abnormalities. Procedural factors include: the use of cardiopulmonary bypass and aortic cross clamp, type of cardiac surgery, use of hypothermia, left ventricular venting, bicaval cannulation and exclusion of the left atrial appendage. Postoperative factors include postoperative drugs, electrolyte and fluid balance and infection. This review explores the pathogenesis of POAF and the contribution of these perioperative factors in the development of POAF. Patients can be risk stratified for targeted treatment and prophylaxis, and how these factors can be attenuated to improve POAF outcomes following cardiac surgery.

A Cost Utility Analysis of Minimally Invasive Surgery with Thrombolysis Compared to Standard Medical Treatment in Spontaneous Intracerebral Haemorrhagic Stroke.

OBJECTIVES: Standard medical management of spontaneous intracerebral haemorrhage (ICH) and surgical hematoma evacuation starkly differ, and whilst landmark randomised control trials report no clinical benefit of early surgical evacuation compared with medical treatment in supratentorial ICH, minimally invasive surgery (MIS) with thrombolysis has been neglected within these studies. However, recent technological advancements in MIS have renewed interest in the surgical treatment of ICH. Several economic evaluations have focused on the benefits of MIS in ischaemic stroke management, but no economic evaluations have yet been performed comparing MIS to standard medical treatment for ICH. MATERIALS AND METHOD: All costs were sourced from the UK in GBP. Where possible, the 2019/2020 NHS reference costs were used. The MISTIE III study was used to analyse the outcomes of patients undergoing either MIS or standard medical treatment in this economic evaluation. RESULTS: The incremental cost-effectiveness ratio (ICER) for MIS was £485,240.26 for every quality-adjusted life year (QALY) gained. Although MIS resulted in a higher QALY compared to medical treatment, the gain was insignificant at 0.011 QALY. Four sensitivity analyses based on combinations of alternative EQ-5D values and categorisation of MIS outcomes, alongside alterations to the cost of significant adverse events, were performed to check the robustness of the ICER calculation. The most realistic sensitivity analysis showed a potential increase in cost effectiveness when clot size is reduced to <15ml, with the ICER falling to £74,335.57. DISCUSSION: From the perspective of the NHS, MIS with thrombolysis is not cost-effective compared to optimal medical treatment. ICER shows that intention-to-treat MIS would require a cost of £485,240.26 to gain one extra QALY, which is significantly above the NHS threshold of £30,000. Further UK studies with ICH survivor utilities, more replicable surgical technique, and the reporting of clot size reduction are indicated as the present sensitivity analysis suggests that MIS is promising. Greater detail about outcomes and complications would ensure improved cost-benefit analyses and support valid and efficient allocation of resources by the NHS.

Exploring the barriers and facilitators of psychological safety in primary care teams: a qualitative study.

BACKGROUND: Psychological safety is the concept by which individuals feel comfortable expressing themselves in a work environment, without fear of embarrassment or criticism from others. Psychological safety in healthcare is associated with improved patient safety outcomes, enhanced physician engagement and fostering a creative learning environment. Therefore, it is important to establish the key levers which can act as facilitators or barriers to establishing psychological safety. Existing literature on psychological safety in healthcare teams has focused on secondary care, primarily from an individual profession perspective. In light of the increased focus on multidisciplinary work in primary care and the need for team-based studies, given that psychological safety is a team-based construct, this study sought to investigate the facilitators and barriers to psychological safety in primary care multidisciplinary teams. METHODS: A mono-method qualitative research design was chosen for this study. Healthcare professionals from four primary care teams (n = 20) were recruited using snowball sampling. Data collection was through semi-structured interviews. Thematic analysis was used to generate findings. RESULTS: Three meta themes surfaced: shared beliefs, facilitators and barriers to psychological safety. The shared beliefs offered insights into the teams' background functioning, providing important context to the facilitators and barriers of psychological safety specific to each team. Four barriers to psychological safety were identified: hierarchy, perceived lack of knowledge, personality and authoritarian leadership. Eight facilitators surfaced: leader and leader inclusiveness, open culture, vocal personality, support in silos, boundary spanner, chairing meetings, strong interpersonal relationships and small groups. CONCLUSION: This study emphasises that factors influencing psychological safety can be individualistic, team-based or organisational. Although previous literature has largely focused on the role of leaders in promoting psychological safety, safe environments can be created by all team members. Members can facilitate psychological safety in instances where positive leadership behaviours are lacking - for example, strengthening interpersonal relationships, finding support in silos or rotating the chairperson in team meetings. It is anticipated that these findings will encourage practices to reflect on their team dynamics and adopt strategies to ensure every member's voice is heard.

An economic evaluation for the use of decompressive craniectomy in the treatment of refractory traumatic intracranial hypertension.

Objectives: The management of intracranial hypertension is a primary concern following traumatic brain injury. Data from recent randomized controlled trials have indicated that decompressive craniectomy results in some improved clinical outcomes compared to medical treatment for patients with refractory intracranial hypertension post-traumatic brain injury (TBI). This economic evaluation aims to assess the cost-effectiveness of decompressive craniectomy as a last-tier intervention for refractory intracranial hypertension from the perspective of the National Health Service (NHS).Methods: A Markov model was used to present the results from an international, multicentre, parallel-group, superiority, randomized trial. A cost-utility analysis was then carried out over a 1-year time horizon, measuring benefits in quality adjusted life years (QALYs) and costs in pound sterling.Results: The cost-utility analysis produced an incremental cost-effectiveness ratio (ICER) of £96,155.67 per QALY. This means that for every additional QALY gained by treating patients with decompressive craniectomy, a cost of £96,155.67 is incurred to the NHS.Conclusions: The ICER calculated is above the National Institute for Health and Care Excellence (NICE) threshold of £30,000 per QALY. This indicates that decompressive craniectomy is not a cost-effective first treatment option for refractory intracranial hypertension and maximum medical management is preferable initially.

Thoracic aortic aneurysms in patients with heritable connective tissue disease.

BACKGROUND: Patients with connective tissue diseases are at high lifetime risk of developing thoracic aortic aneurysms (TAAs) due to defects in extracellular matrix composition which compromise the structural integrity of the aortic wall. It is vital to identify and manage aneurysms early to prevent fatal complications such as dissection or rupture. METHOD: This review synthesises information obtained from a thorough literature search regarding the pathophysiology of TAAs in those with heritable connective tissue diseases (HCTDs), the investigations for timely diagnosis and current operative strategies. RESULTS: Major complications of open repair (OR) include pneumonia (32%), haemorrhage (31%) and tracheostomy (18%), with a minor risk of vocal cord paresis (9%). For thoracic endovascular aortic repair (TEVAR), high rates of endoleak were documented (38-66.6%). Reintervention rates for TEVAR are also high at 38-44%. Mortality rates were documented as 25% for open repair and vary from 14% to 44% for TEVAR. CONCLUSION: OR remains the mainstay of surgical management. While TEVAR use is expanding, it remains the alternative choice due to concerns over endograft durability, limited long-term outcome data and the lack of high-quality evidence regarding its use in HCTD patients.