Jacquelyn A. Quin

An investigation of medical student reactions to feedback: a randomised controlled trial

Background  Medical educators have indicated that feedback is one of the main catalysts required for performance improvement. However, medical students appear to be persistently dissatisfied with the feedback that they receive. The purpose of this study was to evaluate learning outcomes and perceptions in students who received feedback compared to those who received general compliments.

Five-Year Outcomes after On-Pump and Off-Pump Coronary-Artery Bypass

Background Coronary‐artery bypass grafting (CABG) surgery may be performed either with cardiopulmonary bypass (on pump) or without cardiopulmonary bypass (off pump). We report the 5‐year clinical outcomes in patients who had been included in the Veterans Affairs trial of on‐pump versus off‐pump CABG. Methods From February 2002 through June 2007, we randomly assigned 2203 patients at 18 medical centers to undergo either on‐pump or off‐pump CABG, with 1‐year assessments completed by May 2008. The two primary 5‐year outcomes were death from any cause and a composite outcome of major adverse cardiovascular events, defined as death from any cause, repeat revascularization (CABG or percutaneous coronary intervention), or nonfatal myocardial infarction. Secondary 5‐year outcomes included death from cardiac causes, repeat revascularization, and nonfatal myocardial infarction. Primary outcomes were assessed at a P value of 0.05 or less, and secondary outcomes at a P value of 0.01 or less. Results The rate of death at 5 years was 15.2% in the off‐pump group versus 11.9% in the on‐pump group (relative risk, 1.28; 95% confidence interval [CI], 1.03 to 1.58; P=0.02). The rate of major adverse cardiovascular events at 5 years was 31.0% in the off‐pump group versus 27.1% in the on‐pump group (relative risk, 1.14; 95% CI, 1.00 to 1.30; P=0.046). For the 5‐year secondary outcomes, no significant differences were observed: for nonfatal myocardial infarction, the rate was 12.1% in the off‐pump group and 9.6% in the on‐pump group (P=0.05); for death from cardiac causes, the rate was 6.3% and 5.3%, respectively (P=0.29); for repeat revascularization, the rate was 13.1% and 11.9%, respectively (P=0.39); and for repeat CABG, the rate was 1.4% and 0.5%, respectively (P=0.02). Conclusions In this randomized trial, off‐pump CABG led to lower rates of 5‐year survival and event‐free survival than on‐pump CABG. (Funded by the Department of Veterans Affairs Office of Research and Development Cooperative Studies Program and others; ROOBY‐FS ClinicalTrials.gov number, NCT01924442.)

Changes in Health-Related Quality of Life in Off-Pump Versus On-Pump Cardiac Surgery: Veterans Affairs Randomized On/Off Bypass Trial

BACKGROUND The relative benefits of performing coronary artery bypass graft surgery off-pump versus on-pump continue to be debated. A critical, patient-centered outcome is health-related quality of life; yet there has been limited evaluation in large-scale, multicenter trials of the off-pump versus on-pump impact upon quality of life. METHODS The Veterans Affairs Randomized On/Off Bypass trial randomized 2,203 nonemergent patients to off-pump or on-pump from February 2002 to May 2007. Patients completed a general quality of life survey (VR-36) and a disease-specific quality of life survey, the Seattle Angina Questionnaire (SAQ), prior to surgery, then again at 3 and 12 months post-bypass. RESULTS Of the 2,130 1-year survivors, 1,805 patients (85%) completed 1-year surveys. Randomization resulted in comparable baseline patient characteristics, including VR-36 and SAQ scores. At 3 months and 1-year post-procedure, there were no clinically relevant differences between off-pump and on-pump patients in any of the quality of life measures. Both groups had statistically significant, comparable improvements in the physical component scale of the VR-36, and in the SAQ scales. CONCLUSIONS For this trials male, low-to-moderate risk, veteran population, there were no significant differences between off-pump and on-pump with regard to 1-year general and disease-specific quality of life outcomes. Both treatment arms experienced some improvements by 3 months, with continued improvements through 1-year post-bypass.

Resident versus attending surgeon graft patency and clinical outcomes in on- versus off-pump coronary artery bypass surgery

OBJECTIVE Controversy exists regarding ideal approaches in teaching residents complex and/or new surgical techniques in part because consequences on patient outcomes are largely unknown. This study compared patient outcomes for cases in which residents (rather than attending surgeons) performed most of the distal anastomoses as primary surgeons, during on- and off-pump coronary artery bypass grafting (CABG). METHODS This preapproved substudy of the Randomized On/Off Bypass (ROOBY) trial compared clinical outcomes and 1-year graft patency for cases in which residents versus attending surgeons were the primary operator. Comparisons were made between on-pump and off-pump techniques. RESULTS From July 2003 through May 2007, a total of 1272 ROOBY nonemergent CABG patients were randomized at 16 Veterans Affairs centers where residents were active participants. Residents were the primary surgeon (ie, performed ≥50% of the distal anastomoses) more frequently in on-pump (77.9%) than in off-pump (67.4%) cases. Between these 2 techniques, no differences were found [corrected] in baseline patient characteristics; short-term and 1-year morbidity and mortality rates were no different for residents versus attendings in CABG cases. FitzGibbon A graft patency rates were similar for resident versus attendings completed distal anastomoses for on-pump (83.0% vs 82.4%) compared with off-pump (77.2% vs 76.6%) procedures. CONCLUSIONS In the ROOBY trial, short-term and 1-year patient outcomes and graft patency rates did not differ between resident and attending surgeons, demonstrating that with appropriate patient selection and resident supervision, residents can perform advanced, novel surgical techniques with outcomes similar to those of attending surgeons.

Choice of Vein‐Harvest Technique for Coronary Artery Bypass Grafting: Rationale and Design of the REGROUP Trial

The Randomized Endo‐vein Graft Prospective (REGROUP) trial (ClinicalTrials.gov NCT01850082) is a randomized, intent‐to‐treat, 2‐arm, parallel‐design, multicenter study funded by the Cooperative Studies Program (CSP No. 588) of the US Department of Veterans Affairs. Cardiac surgeons at 16 Veterans Affairs (VA) medical centers with technical expertise in performing both endoscopic vein harvesting (EVH) and open vein harvesting (OVH) were recruited as the REGROUP surgeon participants. Subjects requiring elective or urgent coronary artery bypass grafting using cardiopulmonary bypass with use of ≥1 saphenous vein graft will be screened for enrollment using pre‐established inclusion/exclusion criteria. Enrolled subjects (planned N = 1150) will be randomized to 1 of the 2 arms (EVH or OVH) after an experienced vein harvester has been assigned. The primary outcomes measure is the rate of major adverse cardiac events (MACE), including death, myocardial infarction, or revascularization. Subject assessments will be performed at multiple times, including at baseline, intraoperatively, postoperatively, and at discharge (or 30 days after surgery, if still hospitalized). Assessment of leg‐wound complications will be completed at 6 weeks after surgery. Telephone follow‐ups will occur at 3‐month intervals after surgery until the participating sites are decommissioned after the trials completion (approximately 4.5 years after the full study startup). To assess long‐term outcomes, centralized follow‐up of MACE for 2 additional years will be centrally performed using VA and non‐VA clinical and administrative databases. The primary MACE outcome will be compared between the 2 arms, EVH and OVH, at the end of the trial duration.

Thoracotomy for correction of a kinked right internal mammary artery graft.

DOI:€10.1016/S0003-4975(02)04175-9 Ann Thorac Surg 2003;75:1655 Ibrahim B. Cetindag, Jacquelyn A. Quin, Anthony L. Grasch and Stephen R. Hazelrigg Thoracotomy for correction of a kinked right internal mammary artery graft http://ats.ctsnetjournals.org/cgi/content/full/75/5/1655 located on the World Wide Web at: The online version of this article, along with updated information and services, is

Key referencesDiaphragm pacing

Diaphragm pacing is an established mode of ventilation for patients with upper motor neuron injury and preserved phrenic nerve function. Careful patient evaluation with regard to phrenic nerve function, motivation, and adequate psychosocial support is paramount for successful pacing. In properly selected individuals, full-time continuous bilateral pacing for several years has been demonstrated with advantages of increased independence and productivity, fewer tracheal tube complications, and improved phonation. Ongoing research in the field of diaphragm pacing includes refinements in electrode placement and continued testing of totally implantable devices.

Surgeon Judgment and Utility of Transit Time Flow Probes in Coronary Artery Bypass Grafting Surgery

IMPORTANCE Transit time flow (TTF) probes may be useful for predicting long-term graft patency and assessing grafts intraoperatively in patients undergoing coronary artery bypass grafting (CABG); however, studies of TTF probe use are limited. OBJECTIVE To examine 1-year graft patency and intraoperative revision rates in patients undergoing CABG based on intraoperative TTF assessment. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of a multicenter randomized clinical trial conducted at 18 Veterans Affairs hospitals using the Randomized On/Off Bypass (ROOBY) Trial data set. Of the original 2203 patients undergoing CABG surgery with or without cardiopulmonary bypass from February 1, 2002, through May 31, 2008, we studied a subset of 1607 who underwent TTF probe analysis of 1 or more grafts during surgery. EXPOSURES Use of TTF probes to assess graft flow and pulsatility index (PI) values. The decision to revise a graft was based on the judgment of the attending surgeon. MAIN OUTCOMES AND MEASURES Rates of 1-year FitzGibbon grade A patency and intraoperative revision were compared based on TTF measurements (<20 [low flow] vs ≥20 mL/min [normal flow]) and PI values (<3, 3-5, and >5). RESULTS We measured TTF and/or PI in 2738 grafts, and 1-year patency was determined in 1710 (62.5%) of these grafts. FitzGibbon grade A patency occurred significantly less often in grafts with a TTF with low flow (259 of 363 [71.3%]) than in those with normal flow (1174 of 1347 [87.2%]; P < .01). FitzGibbon grade A patency was also inversely correlated with increasing PI values, as found in 936 of 1093 grafts (85.6%) with a PI less than 3, 136 of 182 grafts (74.7%) with a PI of 3 to 5, and 91 of 134 grafts (67.9%) with a PI greater than 5 (P ≤ .01). Intraoperative graft revision was more frequent in grafts with low flow (44 of 568 [7.7%]) than in those with normal flow (8 of 2170 [0.4%]; P < .01). Graft revision was also more frequent as PI increased (12 of 1827 [0.7%] with a PI <3, 9 of 307 [2.9%] with a PI 3-5, and 9 of 155 [5.8%] with a PI >5; P < .01). CONCLUSIONS AND RELEVANCE Intraoperative TTF probe data may be helpful in predicting long-term patency and in the decision of whether to revise a questionable graft for patients undergoing CABG surgery.

LONG-TERM PATENCY OF CORONARY ARTERY BYPASS VEIN GRAFTS HARVESTED ENDOSCOPICALLY: A META-ANALYSIS

Failure of saphenous vein grafts (SVG) used in CABG is associated with increased rates of late major adverse cardiac events: these include death, myocardial infarction and need for revascularization. In the last 10 years endoscopic vein harvest (EVH) has become the preferred method of venous conduit

Concordance between administrative data and clinical review for mortality in the randomized on/off bypass follow-up study (ROOBY-FS)

The optimal methodology to identify cardiac versus non‐cardiac cause of death following cardiac surgery has not been determined.