A model for delivery of extracorporeal life support in a stand-alone veterans affairs medical center.

INTRODUCTION: For the Veterans Health Administration (VHA) to continue to perform complex cardiothoracic surgery, there must be an established pathway for providing urgent/emergent extracorporeal life support (ECLS). Partnership with a nearby tertiary care center with such expertise may be the most resource-efficient way to provide ECLS services to patients in post-cardiotomy cardiogenic shock or respiratory failure. The goal of this project was to assess the efficiency, safety, and outcomes of surgical patients who required transfer for perioperative ECLS from a single stand-alone Veterans Affairs Medical Center (VAMC) to a separate ECLS center. METHODS: Cohort consisted of all cardiothoracic surgery patients who experienced cardiogenic shock or refractory respiratory failure at the local VAMC requiring urgent or emergent institution of ECLS between 2019 and 2022. The primary outcomes are the safety and timeliness of transport. RESULTS: Mean time from the initial shock call to arrival at the ECLS center was 2.8 h. There were no complications during transfer. Six patients (86%) survived to decannulation. CONCLUSION: These results suggest that complex cardiothoracic surgery can be performed within the VHA system and when there is an indication for ECLS, those services can be safely and effectively provided at an affiliated, properly equipped center.

Thoracic chordoma in a 36-year-old female.

Chordomas are rare tumors that occur in the bones of the skull base and spine, affecting 1 in 1 000 000 people per year. Thoracic chordomas comprise just 1% of chordomas. A 36-year-old female underwent a right video-assisted thoracoscopic surgical resection for a cystic mass at the level of T2-3 which was well-circumscribed. Despite efforts to achieve an intact resection, there was tumor spillage due to friability, and it was taken off the bony vertebral body with no margin. The final pathologic diagnosis was chordoma. Thoracic chordomas are rare, slow-growing, recurring neoplasms that require proper preoperative diagnostic imaging and ideally preoperative trocar computed tomography-guided biopsy from a posterior approach if anatomic access is possible. They are prone to dissemination and sarcomatous differentiation. The surgical approaches for reported thoracic chordoma tumors vary due to their rarity and the variation in tumor location and presentation.

Multimodal Pain Management Protocol to Decrease Opioid Use and to Improve Pain Control After Thoracic Surgery.

BACKGROUND: Opioid addiction continues to be a devastating problem in our communities, and up to 40% of patients begin their addiction with legally prescribed opioids after injury or surgical procedure. An opioid-free multimodal pain regimen was developed with the goal of decreasing opioid exposure while maintaining adequate pain control. METHODS: A retrospective single-institution study was conducted of 313 consecutive patients undergoing minimally invasive lobectomy before (n = 211) and after (n = 102) implementation of an opioid-free protocol from 2016 to 2020. Data analysis was conducted on preoperative characteristics, postoperative opioid use at set time points (postoperative day 0, postoperative days 1 to 7, and total stay), pain scores, discharge with opioid prescription, and postoperative outcomes. RESULTS: Patients on the opioid-free protocol had significantly lower average total morphine milligram equivalents at all time points. In addition, 56% of patients in the opioid-free group received no oral opioids at all, and 91% did not receive a patient-controlled analgesia pump. Average pain scores were significantly lower in the opioid-free protocol patients along with percentage of time spent with pain scores <3 and <6. With implementation of the protocol, 62% of patients are discharged without an opioid prescription compared with only 7% previously. CONCLUSIONS: Implementation of an opioid-free protocol led to a significant decrease in the use of postoperative opioids at all time points while improving overall management of pain. In addition, most patients are discharged with no home opioid prescription, decreasing a potential source of community opioid spread.

Thromboelastography-Platelet Mapping Allows Safe and Earlier Urgent Coronary Artery Bypass Grafting.

BACKGROUND: The Society of Thoracic Surgeons current (STS) guidelines recommend delaying coronary artery bypass graft surgery (CABG) for several days or performing platelet function testing in stable patients who received P2Y12 inhibitors. Our program routinely uses thromboelastography-platelet mapping (TEG-PM) to expedite CABG in P2Y12 nonresponders. We hypothesize that P2Y12 nonresponders had no difference in length of stay to surgery and blood product transfusion compared with patients undergoing urgent inpatient CABG not treated with a P2Y12 inhibitor. METHODS: A total of 221 patients from 2015 to 2019 were P2Y12 nonresponders based on TEG-PM result of less than 50% adenosine diphosphate inhibition. The control group was 232 consecutive patients who also had urgent inpatient CABG but were not treated preoperatively with a P2Y12 inhibitor. Exclusion criteria were identical between groups. RESULTS: Sixty-seven percent of inpatient CABG patients who were treated preoperatively with a P2Y12 inhibitor were nonresponders. The mean number of days from cardiac surgical consultation to CABG in the TEG-PM nonresponders group was 1.6 ± 0.1 vs 2.1 ± 0.1 in the control group (P < .01). The mean total number of blood product units transfused was 1.6 ± 0.2 in the TEG-PM nonresponders group vs 1.6 ± 0.4 in the control group (P = .91). CONCLUSIONS: Our results demonstrate a very high incidence of P2Y12 nonresponders among patients undergoing urgent CABG at our program. These patients underwent surgery at least 3 days earlier than STS recommendations and common practice with no difference in transfusion requirement. Routine use of TEG-PM to identify P2Y12 nonresponders can safely decrease preoperative hospital length of stay and associated cost and improve resource utilization and patient satisfaction.

Analysis of racial disparities in acute type A aortic dissection repair at a rural tertiary academic medical center.

BACKGROUND: To determine if racial disparities exist between African Americans (AA) and Non-Hispanic Whites (NHW) for patients undergoing repair of acute type A aortic dissection (ATAAD) at a rural tertiary academic medical center. METHODS: There were 215 consecutive AA and NHW patients who underwent ATAAD repair at our institution from 1999 to 2019 included in a retrospective analysis of our Society of Thoracic Surgeons Adult Cardiac Surgery Database. Statistical analysis was performed with a p value of less than .05 considered statistically significant. RESULTS: Patients undergoing ATAAD repair were 47% AA despite comprising only 27% of the total population in our region. AAs were significantly younger (54.0 vs. 61.2 years), were more likely to be hypertensive (94.1% vs. 79.7%), had higher creatinine levels (1.7 vs. 1.1 mg/dL), and higher body mass index (30.8 vs. 28.1 kg/m2 ) (all p values < .006). There were no significant differences in type of repair or intraoperative variables. A logistic regression analysis showed AAs had an increased rate of postoperative acute renal failure not requiring hemodialysis when compared to NHWs (20.8% vs. 10.6%, p value = .042). Thirty-day mortality was not significantly different (15.7% vs. 13.4%) nor was 1-year survival (78% vs. 79%) in AAs and NHWs, respectively. CONCLUSIONS: Despite AAs having more medical comorbidities at presentation, there were no differences in short- and intermediate-term survival. In our catchment of 1.8 million people, AAs appear to undergo ATAAD repair at a disproportionate rate versus NHWs. These findings may alter strategies for surveillance and prevention of aortic disease in this high-risk population.

Fundic gastropexy for high risk of recurrence laparoscopic hiatal hernia repair and esophageal sphincter augmentation (LINX) improves outcomes without altering perioperative course.

BACKGROUND: The aim of this study is to show that the addition of a fundic gastropexy to a laparoscopic hiatal hernia repair (HHR) and magnetic sphincter augmentation (MSA) with LINX (Johnson and Johnson, New Brunswick, NJ) in patients with high risk for hiatal hernia recurrence improves outcomes without altering perioperative course. METHODS: An IRB approved, single institution retrospective review of patient outcomes after hiatal hernia repair with magnetic sphincter augmentation was performed. Data were obtained from the electronic health record and stored in a REDCap database. Using statistical software, the patient data were analyzed and stratified to assess the specific variables of the perioperative and postoperative course focusing on the high risk of hiatal hernia recurrence group (HRHR) and low risk hiatal hernia of recurrence group (LRHR). The HRHR group received a gastropexy and were defined using the following variables: comorbid state increasing abdominal pressure, gastric herniation > 30%, maximum transverse crural diameter > 4 cm, age 70 years or older, previous hiatal or abdominal wall hernia repair, BMI > 34, heavy weight bearing job/hobby, and/or emergent repair. RESULTS: Hiatal hernia repair with magnetic sphincter augmentation was performed on 137 patients. The HRHR group (N = 86) and the LRHR group (N = 51) were compared and there was a difference observed with acute hernia recurrence, dysphagia (p value = 0.008), and number of post-op EGDs (p value = 0.005) in favor of the HRHR group. Other postoperative variables observed (i.e., length of stay and PPI use) showed no significant difference between the two groups. CONCLUSIONS: Fundic gastropexy for individuals who are considered high risk for recurrence does not appear to alter the perioperative course in our sample of patients. The HRHR group has the same length of stay experience and improved postoperative outcomes with reference to postoperative EGD, dysphagia and a decreasing trend in hiatal hernia recurrence.

Establishment of a per oral endoscopic myotomy program at a rural tertiary care center.

BACKGROUND: This study's purpose is to determine the application and effectiveness of a POEM program in the rural healthcare setting. Achalasia has a substantial impact on the lives of afflicted patients. Traditionally, a Heller myotomy with fundoplication has been the standard of care for treatment. In 2008, the first per oral endoscopic myotomy (POEM) was performed in Japan. Since 2017, our rural healthcare institution has performed approximately 60 POEMs. METHODS: An IRB approved, single-institution retrospective review of patient outcomes after POEM was performed along with prospective analysis of post-operative surveys. An institutional cost analysis was also performed. Demographic and qualitative variables were measured and included PPI use, a Likert scale of 0-5 for progressively worsening symptoms of heartburn, dysphagia, and regurgitation. In addition, we included a Dysphagia Outcome and Severity Scale. RESULTS: The number of myotomy operations increased from 4.5 per year to 28.8 per year after initiation of the POEM program. Mean Likert scale scores were 0.91, 0.73, and 1 for heartburn, dysphagia, and regurgitation, respectively. 72.5% percent of patients were satisfied with their present condition. 87.5% of patients reported minimal or no dysphagia on the Dysphagia Severity Scale. Intraoperative costs were $2477 for laparoscopic myotomy and $1650 for POEM. The capital expense of the equipment required to perform POEM was $110,232. Average contribution margin per case was $6024. The procedure pays off capital outlay upon completion of the 19th case. CONCLUSIONS: This study shows that patients have excellent symptom control after POEM. When compared to the institution's laparoscopic myotomy volume, POEM far surpasses in terms of operative volume and monetary benefit. Examination of these data shows that a rural hospital can successfully employ a state-of-the-art intervention when there is a population in need and an infrastructure in place.

Prevalence of pediatric epilepsy in low-income rural Midwestern counties.

Epilepsy is one of the most common disabling neurological disorders, but significant gaps exist in our knowledge about childhood epilepsy in rural populations. The present study assessed the prevalence of pediatric epilepsy in nine low-income rural counties in the Midwestern United States overall and by gender, age, etiology, seizure type, and syndrome. Multiple sources of case identification were used, including medical records, schools, community agencies, and family interviews. The prevalence of active epilepsy was 5.0/1000. Prevalence was 5.1/1000 in males and 5.0/1000 in females. Differences by age group and gender were not statistically significant. Future research should focus on methods of increasing study participation in rural communities, particularly those in which research studies are rare.

Patient-provider discussions about lung cancer screening: Results from the 2012/2013 Kansas Adult Tobacco Survey.

OBJECTIVE: Prior to the 2013 US Preventive Services Task Force (USPSTF) guidelines for lung cancer screening, the American Cancer Society released interim guidance recommending physicians discuss lung cancer screening with high risk patients. We included a question on patient-provider discussions about lung cancer screening on a statewide population-based survey to establish baseline prevalence for surveillance and to identify subpopulation disparities. METHODS: We analyzed the 2012/2013 Kansas Adult Tobacco Survey to assess patient-provider discussions about lung cancer screening. Weighted prevalence estimates and adjusted odds ratios were calculated to examine characteristics associated with discussing screening. RESULTS: The prevalence of patient-provider discussions about lung cancer screening among current and former smokers aged 55 to 74 years was 31.0% (95% CI 27.0-35.0). The adjusted prevalence odds of having these discussions was higher among males, adults aged 65 to 74 years, adults living with a disability, as well as those who saw a health professional in the past year and had their smoking status assessed or were advised to quit. CONCLUSIONS: The current study is unique as it is the first to assess patient-provider discussions about lung cancer screening using a statewide survey. These results may inform strategies to increase patient-provider discussions about lung cancer screening among high risk Kansans.

Development and mineralization of embryonic avian scleral ossicles.

PURPOSE: To investigate the development and mineralization of avian scleral ossicles using fluorescence microscopy in combination with field emission scanning electron microscopy (FESEM) and energy dispersive spectroscopy (EDS). METHODS: The anterior halves of whole eyeballs from chickens on embryonic (E) days E10 to E21 and Japanese quail on embryonic days E8 to E17 were fixed in 100% methanol for 1 min, stained with Giemsa solution for 5 min, destained with distilled water for 30 min, and then viewed by epifluorescence. Propidium iodide (PI) was used to detect the nuclei of osteocytes in scleral ossicles. FESEM and EDS were then used to show areas of mineralization and to identify differences in the elemental composition of different regions of the ossicles. RESULTS: Using Giemsa as a fluorescence stain, it was possible to observe the detailed morphology and development of both chicken and quail scleral ossicles. In chickens, bone microporosities first became visible at E15. Each microporosity contained a single nucleus, likely that of an osteocyte. The amount of carbon in ossicles steadily decreased during embryogenesis and post-hatching, while the concentration of oxygen showed a distinct increase over this time period. Calcium and phosphate levels in the ossicles increased gradually during embryonic and post-hatching stages. CONCLUSIONS: A novel approach to study the development and mineralization of avian scleral ossicles during embryogenesis is presented. This methodology was validated by studying two different species, both important models for avian developmental research.