Arin L. Madenci

Prevalence and Predictors of Complications of Radiofrequency Catheter Ablation for Atrial Fibrillation

Complications of Atrial Fibrillation Ablation. Introduction: Up to 6% of patients experience complications after radiofrequency catheter ablation (RFA) of atrial fibrillation (AF). The purpose of this study is to determine the prevalence and predictors of periprocedural complications after RFA for AF.

Predictive factors of 30-day unplanned readmission after lower extremity bypass

BACKGROUND Thirty-day unplanned readmission after lower extremity bypass represents a large cost burden and is a logical target for cost-containment strategies. We undertook this study to evaluate factors associated with unplanned readmission after lower extremity bypass. METHODS This is a retrospective analysis from a prospective institutional registry. All lower extremity bypasses for occlusive disease from January 1995 to July 2011 were included. The primary end point was 30-day unplanned readmission. Secondary end points included graft patency and limb salvage. RESULTS Of 1543 lower extremity bypasses performed, 84.5% were for critical limb ischemia and 15.5% were patients with intermittent claudication. Twenty-seven patients (1.7%) died in-house and were excluded from further analysis. Of 1516 lower extremity bypasses analyzed, 42 (2.8%) were in patients with a planned readmission within 30 days, and 349 (23.0%), in patients with an unplanned readmission. Most unplanned readmissions were wound related (62.9%). By multivariable analysis, preoperative predictive factors for unplanned readmission were dialysis dependence (odds ratio [OR], 1.73; P = .004), tissue loss indication (OR, 1.62; P = .0004), and history of congestive heart failure (OR, 1.43; P = .03). Postoperative predictors included distal inflow source (OR, 1.38; P = .016), in-hospital wound infection (OR, 8.30; P < .0001), in-hospital graft failure (OR, 3.20; P < .0001), and myocardial infarction (OR, 1.96; P < .04). Neither index length of stay nor discharge disposition independently predicted unplanned readmission. Unplanned readmission was associated with loss of assisted primary patency (hazard ratio, 1.39; 95% confidence interval, 1.08-1.80; P = .01) and long-term limb loss (hazard ratio, 1.68; 95% confidence interval, 1.23-2.29; P = .001). CONCLUSIONS Thirty-day unplanned readmission is a frequent occurrence after lower extremity bypass (23.0%). Stratifying patients by risk factors associated with unplanned readmission is essential for quality improvement and equitable resource allocation when disease-specific bundling strategies are being derived.

Believing Is Seeing Using Mindlessness (Mindfully) to Improve Visual Acuity

These experiments show that vision can be improved by manipulating mind-sets. In Study 1, participants were primed with the mind-set that pilots have excellent vision. Vision improved for participants who experientially became pilots (by flying a realistic flight simulator) compared with control participants (who performed the same task in an ostensibly broken flight simulator). Participants in an eye-exercise condition (primed with the mind-set that improvement occurs with practice) and a motivation condition (primed with the mind-set “try and you will succeed”) demonstrated visual improvement relative to the control group. In Study 2, participants were primed with the mind-set that athletes have better vision than nonathletes. Controlling for arousal, doing jumping jacks resulted in greater visual acuity than skipping (perceived to be a less athletic activity than jumping jacks). Study 3 took advantage of the mind-set primed by the traditional eye chart: Because letters get progressively smaller on successive lines, people expect that they will be able to read the first few lines only. When participants viewed a reversed chart and a shifted chart, they were able to see letters they could not see before. Thus, mind-set manipulation can counteract physiological limits imposed on vision.

Central venous access by trainees: a systematic review and meta-analysis of the use of simulation to improve success rate on patients.

Introduction Simulation training for invasive procedures may improve patient safety by enabling efficient training. This study is a meta-analysis with rigorous inclusion and exclusion criteria designed to assess the real patient procedural success of simulation training for central venous access. Methods Published randomized controlled trials and prospective 2-group cohort studies that used simulation for the training of procedures involving central venous access were identified. The quality of each study was assessed. The primary outcome was the proportion of trainees who demonstrated the ability to successfully complete the procedure. Secondary outcomes included the mean number of attempts to procedural success and periprocedural adverse events. Proportions were compared between groups using risk ratios (RRs), whereas continuous variables were compared using weighted mean differences. Random-effects analysis was used to determine pooled effect sizes. Results We identified 550 studies, of which 5 (3 randomized controlled trials, 2 prospective 2-group cohort studies) studies of central venous catheter (CVC) insertion were included in the meta-analysis, composed of 407 medical trainees. The simulation group had a significantly larger proportion of trainees who successfully placed CVCs (RR, 1.09; 95% confidence interval [CI], 1.03–1.16, P < 0.01). In addition, the simulation group had significantly fewer mean attempts to CVC insertion (weighted mean difference, −1.42; 95% CI, −2.34 to −0.49, P < 0.01). There was no significant difference in the rate of adverse events between the groups (RR, 0.50; 95% CI, 0.19–1.29; P = 0.15). Conclusions Training programs should consider adopting simulation training for CVC insertion to improve the real patient procedural success of trainees.

Carotid-subclavian bypass and subclavian-carotid transposition in the thoracic endovascular aortic repair era

OBJECTIVE Beyond traditional indications, subclavian revascularization is increasingly performed to allow for aortic arch debranching in the setting of thoracic endovascular aortic repair (TEVAR). Endovascular treatment options for subclavian disease have emerged, perhaps altering the patient population undergoing open revascularization. We leveraged prospectively collected American College of Surgeons (ACS)-National Surgical Quality Improvement Program (NSQIP) data to delineate evolving stroke and mortality rates after carotid-subclavian bypass (CSB) and subclavian-carotid transposition (SCT) in this dynamic context. METHODS The ACS-NSQIP database (2005 to 2010) was used to examine patients who underwent CSB or SCT. Patients admitted for emergency cases were excluded. Factors associated with 30-day postoperative cerebrovascular accident (CVA) or death (CVA/D) were defined using univariable and multivariable analyses. RESULTS CSB comprised 41% of revascularizations associated with TEVAR and 89% of isolated revascularizations. A greater proportion of TEVARs were performed in the SCT group (37.4% vs 4.9%; P < .01). The groups were similar in demographic characteristics and prevalence of comorbidities. Overall stroke, mortality, and combined CVA/D rates were 3.5% (n = 31), 3.3% (n = 29), and 5.8% (n = 51), respectively. Surgical approach did not affect outcome. The CVA/D rate was 10.2% (n = 9) for revascularization in conjunction with TEVAR and 5.3% (n = 42) for isolated reconstruction (P = .06). For patients undergoing isolated revascularization, increasing age (adjusted odds ratio, 1.06; 95% confidence interval, 1.03-1.10; P < .01), and nonindependent functional status (odds ratio, 3.49; 95% confidence interval, 1.41-8.68; P < .01) were significantly associated with CVA/D. CONCLUSIONS In this contemporary data set, there was no significant difference in CVA/D by surgical approach. TEVAR trended toward an association with CVA/D compared with isolated subclavian reconstruction. CVA/D continues to complicate contemporary CSB and SCT, especially among elderly and nonindependent patient subsets.

Another dimension to survival: predicting outcomes with fetal MRI versus prenatal ultrasound in patients with congenital diaphragmatic hernia.

PURPOSE A major determinant of survival in patients with congenital diaphragmatic hernia (CDH) is severity of pulmonary hypoplasia. This study addresses the comparative effectiveness of prenatal methods of lung assessment in predicting mortality, extracorporeal membrane oxygenation (ECMO), and ventilator dependency. METHODS We retrospectively reviewed all patients born with isolated CDH between 2004 and 2008. Lung-to-head ratio (LHR) and observed-to-expected LHR (OELHR) were obtained from prenatal ultrasounds. Percent-predicted lung volume (PPLV) was obtained from fetal MRI (fMRI). Postnatal data included in-hospital mortality, need for ECMO, and ventilator dependency at day-of-life 30. RESULTS Thirty-seven patients underwent 81 prenatal ultrasounds, while 26 of this sub-cohort underwent fMRI. Gestational age during imaging study was associated with LHR (p=0.02), but not OELHR (p=0.12) or PPLV (p=0.72). PPLV, min-LHR, and min-OELHR were each associated with mortality (p=0.03, p=0.02, p=0.01), ECMO (p<0.01, p<0.01, p=0.03), and ventilator dependency (p<0.01, p<0.01, p=0.02). For each outcome, PPLV was a more discriminative measure, based on Akaikes information criterion. Using longitudinal analysis techniques for patients with multiple ultrasounds, OELHR remained associated with mortality (p=0.04), ECMO (p=0.03), and ventilator dependency (p=0.02), while LHR was associated with ECMO (p=0.01) and ventilator dependency (p=0.02) but not mortality (p=0.06). CONCLUSION When assessing fetuses with CDH, OELHR and PPLV may be most helpful for counseling regarding postnatal outcomes.

Use of simulated electronic mail (e-mail) to assess medical student knowledge, professionalism, and communication skills.

Background Physicians communicate with patients using electronic mail (e-mail) with increasing frequency. Communication skills specific to e-mail do not appear to be taught explicitly in medical school. Therefore, the effect of an instructive session on effective e-mail communication was examined. Method Four simulated e-mails from a parent were developed. Students responded to an initial e-mail and then participated in a session on effective e-mail communication. Responses to a final e-mail were assessed using a rubric with subscores for medical knowledge, communication, and professionalism. Results Performance improved from the first to final e-mail response in the overall score and in each subscore. Improvement was sustained over the course of the academic year. Interrater reliability revealed good agreement. Conclusions Communicating effectively with patients via e-mail is not intuitive but can be taught. It is feasible to introduce responses to a simulated e-mail case in a clinical clerkship as an assessment tool.

A contemporary series of patients undergoing open debridement for necrotizing pancreatitis

BACKGROUND For patients with acute pancreatitis complicated by infected necrosis, minimally invasive techniques have taken hold without substantial comparison with open surgery. We present a contemporary series of open necrosectomies as a benchmark for newer techniques. METHODS Using a prospective database, we retrospectively identified consecutive patients undergoing debridement for necrotizing pancreatitis (2006 to 2009). The primary endpoint was in-hospital mortality. RESULTS Sixty-eight patients underwent debridement for pancreatic/peripancreatic necrosis. In-hospital mortality was 8.8% (n = 6). Infection (n = 43, 63%) and failure-to-thrive (n = 13, 19%) comprised the most common indications for necrosectomy. The false negative rate (FNR) for infection of percutaneous aspirate was 20.0%. Older age (P = .02), Acute Physiology and Chronic Health Evaluation II score upon admission (P = .03) or preoperatively (P < .01), preoperative intensive care unit admission (P = .01), and postoperative organ failure (P = .03) were associated with mortality. CONCLUSIONS Open debridement for necrotizing pancreatitis results in a low mortality, providing a useful comparator for other interventions. Given the high FNR of percutaneous aspirate, debridement should not be predicated on proven infection.

Factors Associated with Rapid Progression to Esophagectomy for Benign Disease

BACKGROUND The reasons why some patients with benign esophageal diseases require esophagectomy remain poorly understood. In this study we sought to define the rate of progression to esophagectomy and the postesophagectomy outcomes of patients with benign esophageal conditions in whom 1 or more previous interventions failed. STUDY DESIGN Using a prospective database, we retrospectively identified patients who had esophagectomies for benign disease between 1978 and 2010. Patients who underwent 1 or more esophageal interventions before resection met inclusion criteria. We examined factors associated with progression to esophagectomy and with postesophagectomy complications. RESULTS One hundred eleven patients underwent 1 or more esophageal interventions before esophagectomy. The most common indications for initial intervention were achalasia (37%, n = 41) and gastroesophageal reflux (33%, n = 37). More rapid progression to esophagectomy was associated with acquired esophageal disease (p < 0.01), initial esophageal intervention at age ≥ 18 (p < 0.01), and previous fundoplication (p = 0.03). Complications of esophagectomy included 30-day mortality (n = 2, 1%), chylothorax (n = 4, 3%), anastomotic leak (n = 17, 11%), and reoperation (n = 17, 11%). CONCLUSIONS These findings highlight the importance of increased awareness of the potential progression to esophagectomy during repeated procedural interventions for benign esophageal disease. A subset of the patients who progress more rapidly, including adult patients and those with acquired disease and/or previous fundoplication, may benefit from counseling about potential esophagectomy.

Intestinal Obstruction in Survivors of Childhood Cancer: A Report From the Childhood Cancer Survivor Study

PURPOSE For adult survivors of childhood cancer, knowledge about the long-term risk of intestinal obstruction from surgery, chemotherapy, and radiotherapy is limited. METHODS Intestinal obstruction requiring surgery (IOS) occurring 5 or more years after cancer diagnosis was evaluated in 12,316 5-year survivors in the Childhood Cancer Survivor Study (2,002 with and 10,314 without abdominopelvic tumors) and 4,023 sibling participants. Cumulative incidence of IOS was calculated with second malignant neoplasm, late recurrence, and death as competing risks. Using piecewise exponential models, we assessed the associations of clinical and demographic factors with rate of IOS. RESULTS Late IOS was reported by 165 survivors (median age at IOS, 19 years; range, 5 to 50 years; median time from diagnosis to IOS, 13 years) and 14 siblings. The cumulative incidence of late IOS at 35 years was 5.8% (95% CI, 4.4% to 7.3%) among survivors with abdominopelvic tumors, 1.0% (95% CI, 0.7% to 1.4%) among those without abdominopelvic tumors, and 0.3% (95% CI, 0.1% to 0.5%) among siblings. Among survivors, abdominopelvic tumor (adjusted rate ratio [ARR], 3.6; 95% CI, 1.9 to 6.8; P < .001) and abdominal/pelvic radiotherapy within 5 years of cancer diagnosis (ARR, 2.4; 95% CI, 1.6 to 3.7; P < .001) increased the rate of late IOS, adjusting for diagnosis year; sex; race/ethnicity; age at diagnosis; age during follow-up (as natural cubic spline); cancer type; and chemotherapy, radiotherapy, and surgery within 5 years of cancer diagnosis. Developing late IOS increased subsequent mortality among survivors (ARR, 1.8; 95% CI, 1.1 to 2.9; P = .016), adjusting for the same factors. CONCLUSION The long-term risk of IOS and its association with subsequent mortality underscore the need to promote awareness of this complication among patients and providers.