Ryan M. Antiel

Quality of Life After Early Mitral Valve Repair Using Conventional and Robotic Approaches

BACKGROUND Early mitral valve (MV) repair of degenerative mitral regurgitation is associated with superior clinical outcomes compared with prosthetic replacement and restores normal life expectancy, even in those without symptoms. Although current guidelines recommend prompt referral for effective MV repair in those with severe mitral regurgitation, some are reluctant to pursue early correction due to the perception that short-term quality of life (QOL) may be adversely affected by the operation. METHODS Between January 2008 and November 2009, 202 patients underwent conventional transsternotomy or minimally invasive port-access robot-assisted MV repair, with or without patent foramen ovale closure or left Maze, and were mailed a postsurgical QOL survey. RESULTS Unadjusted QOL scores for patients undergoing MV repair were excellent early after the operation using both approaches. Robotic repair was associated with slightly improved scores on the Duke Activity Status Index, the Short Form-12 Item Health Survey Physical domain, and the Linear Analogue Self-Assessment frequency of chest pain and fatigue indices during the first postoperative year; however, differences between treatment groups became indistinguishable after 1 year. Robotic repair patients returned to work slightly quicker (median, 33 vs 54 days, p<0.001). CONCLUSIONS Functional QOL outcomes within the first 2 years after early MV repair are excellent using open and robotic platforms. A robotic approach may be associated with slightly improved early QOL and return to employment-based activities. These results may have implications regarding future evolution of clinical guidelines and economic health care policy.

Surgical Training, Duty-Hour Restrictions, and Implications for Meeting the Accreditation Council for Graduate Medical Education Core Competencies Views of Surgical Interns Compared With Program Directors

OBJECTIVE To describe the perspectives of surgical interns regarding the implications of the new Accreditation Council for Graduate Medical Education (ACGME) duty-hour regulations for their training. DESIGN We compared responses of interns and surgery program directors on a survey about the proposed ACGME mandates. SETTING Eleven general surgery residency programs. PARTICIPANTS Two hundred fifteen interns who were administered the survey during the summer of 2011 and a previously surveyed national sample of 134 surgery program directors. MAIN OUTCOME MEASURES Perceptions of the implications of the new duty-hour restrictions on various aspects of surgical training, including the 6 ACGME core competencies of graduate medical education, measured using 3-point scales (increase, no change, or decrease). RESULTS Of 215 eligible surgical interns, 179 (83.3%) completed the survey. Most interns believed that the new duty-hour regulations will decrease continuity with patients (80.3%), time spent operating (67.4%), and coordination of patient care (57.6%), while approximately half believed that the changes will decrease their acquisition of medical knowledge (48.0%), development of surgical skills (52.8%), and overall educational experience (51.1%). Most believed that the changes will improve or will not alter other aspects of training, and 61.5% believed that the new standards will decrease resident fatigue. Surgical interns were significantly less pessimistic than surgery program directors regarding the implications of the new duty-hour restrictions on all aspects of surgical training (P < .05 for all comparisons). CONCLUSIONS Although less pessimistic than program directors, interns beginning their training under the new paradigm of duty-hour restrictions have significant concerns about the effect of these regulations on the quality of their training.

Orthostatic intolerance and gastrointestinal motility in adolescents with nausea and abdominal pain.

Objective: To describe the relationships between gastric emptying, autonomic function, and postural tachycardia in adolescent patients with nausea and/or abdominal discomfort. It was hypothesized that patients with both gastrointestinal symptoms and symptoms of orthostatic intolerance are more likely to show abnormal tilt table results and delayed gastric emptying. Patients and Methods: A retrospective review was conducted of adolescent patients who came to a pediatric referral center because of nausea and dyspepsia and who subsequently underwent both autonomic reflex screening and gastric emptying testing. Patients with a heart rate change of 30 or more beats per minute on the heads-up tilt table test were assigned to the postural orthostatic tachycardia syndrome (POTS) group (n = 21), and those with a heart rate change of fewer than 30 beats per minute on the heads-up tilt table test were assigned to the non-POTS group (n = 10). Results: There was no significant difference between the POTS and non-POTS groups with regard to presenting symptoms (P > 0.05). Overall, 13 (42%) individuals had abnormal gastric emptying results (delayed in 6, accelerated in 7), but gastric emptying scores were similar between the POTS and non-POTS groups. Furthermore, there was no correlation between an individuals gastric emptying results at 1, 2, and 4 hours and that persons heart rate change on HUT (r = −0.05, −0.15, and −0.19). Conclusions: Although altered gastric emptying and postural tachycardia are common in a referral population of adolescents with nausea and/or abdominal discomfort, the clinical presentation was not predictive of test results. Furthermore, delayed gastric emptying was not correlated with the current definition of postural tachycardia.

Attracting Students to Surgical Careers: Preclinical Surgical Experience

OBJECTIVES Along with a decline in interest in general surgery among United States medical school graduates, reports indicate a decrease in the amount of time students are spending on their surgical clerkship. In an effort to offer early exposure to general surgery as well as to equip students with the basic surgical skills that will enhance their third-year clerkship experience, we developed a preclinical surgical experience. Students were surveyed to determine whether the surgical selective changed student level of comfort with basic surgical skills. STUDY DESIGN Surveys were administered, preexperience and postexperience to the medical students enrolled in the surgery selective. The students were asked to rate their comfort level with 12 unique surgical skills. Comfort with the task was evaluated using a 10-point Likert scale. Analyses were conducted to evaluate the impact of the surgical experience on student comfort levels with the surgical skills. RESULTS The self-reported comfort levels of students increased significantly after the experience in all 12 areas. The greatest change in comfort level (greater than or equal to mean difference of 4) occurred in the surgical technique categories: knot tying (mean difference: 4.9, p < 0.0001), suturing (mean difference: 4.85, p < 0.0001), correctly making an incision (mean difference: 4.95, p < 0.0001), using a needle driver (mean difference: 5.35, p < 0.0001), holding pickups (mean difference: 4.6, p < 0.0001), use of laparoscopic instruments (mean difference: 4.8, p < 0.0001), and use of surgical simulators (mean difference: 6.0, p < 0.0001). CONCLUSIONS Our preclinical surgical experience serves as a model of an effective modality providing early exposure to general surgery. The experience provides trainees with basic surgical skills well before they begin their third-year clerkships.

Quality of life after videoscopic left cardiac sympathetic denervation in patients with potentially life-threatening cardiac channelopathies/cardiomyopathies

BACKGROUND Left cardiac sympathetic denervation (LCSD) provides an additive or potentially alternative treatment option for patients with life-threatening cardiac channelopathies/cardiomyopathies. OBJECTIVE We sought to examine the effects of LCSD on quality of life (QOL). METHODS From November 2005 to May 2013, 109 patients who underwent LCSD were subsequently sent postoperative QOL surveys. RESULTS Of 109 patients, 8 (7%) could not be contacted. Of the remaining 101 patients, 62 returned surveys (response rate 61%). There were an average of 4.1 ± 1.8 self-reported side effects immediately after LCSD. The most common anticipated side effects included unilateral hand dryness, color or temperature variance between sides of the face, and abnormal sweating. Although parent-reported pediatric physical QOL scores were lower than national norms, there were no differences in psychosocial QOL or disability scores (P = .09 and .33, respectively). QOL scores for adult patients were not significantly different from a US normative sample. Adult LCSD patients reported less disability than a US normative sample (P < .01). There was no correlation between QOL scores and the presence of anticipated side effects. However, among the subset of pediatric patients who continued to receive ventricular fibrillation-terminating implantable cardioverter-defibrillator shocks after LCSD, there was a correlation between their disability scores and the number of reported shocks (Spearman correlation = 0.56). The majority of patients/parents reported that they were very or somewhat satisfied with their surgery (or their childs surgery) and would definitely or probably recommend LCSD to another patient. CONCLUSION Despite the anticipated side effects associated with LCSD, patients are satisfied with their surgery and indicate that they would recommend the surgery to another patient.

Iron insufficiency and hypovitaminosis D in adolescents with chronic fatigue and orthostatic intolerance.

Objectives: More than 10% of adolescents suffer from severe fatigue and/or orthostatic intolerance. Adult studies show correlations between iron insufficiency and fatigue as well as between hypovitaminosis D and non-specific pain. We sought to determine whether there were correlations between nutritional factors (iron status, and serum vitamin D levels) and chronic ill health. Methods: We reviewed records of 188 adolescents with symptoms of fatigue and/or orthostatic intolerance and who underwent autonomic reflex screening. Results: Of the 188 patients, 130 patients (69%) had excessive postural tachycardia (PT) with a heart rate (HR) change of ≥30 bpm. 62 patients (47%, n = 131) had iron insufficiency with low iron stores, and 29 patients (22%, n = 131) were iron deficient. HR change did not correlate to ferritin level (P = 0.15). 21 patients (22%, n = 95) had hypovitaminosis D (25-hydroxyvitamin D ≤20 ng/mL). There was a significant association with hypovitaminosis D and orthostatic intolerance (P = 0.024). Conclusion: In patients presenting with chronic fatigue and/or orthostatic intolerance, low ferritin levels and hypovitaminosis D are common, especially in patients with PT.

Neurodevelopmental outcomes at 5 years of age in congenital diaphragmatic hernia

OBJECTIVE To evaluate neurodevelopmental sequelae in congenital diaphragmatic hernia (CDH) children at 5years of age. MATERIALS AND METHODS The study cohort of 35 CDH patients was enrolled in our follow-up program between 06/2004 and 09/2014. The neurodevelopmental outcomes assessed at a median of 5years (range, 4-6) included cognition (Wechsler Preschool and Primary Scale of Intelligence [WPPSI], n=35), Visual-Motor-Integration (n=35), academic achievement (Woodcock-Johnson Tests of Achievement, n=25), and behavior problems (Child Behavior Check List [CBCL], n=26). Scores were grouped as average, borderline, or extremely low by SD intervals. RESULTS Although mean Full (93.9±19.4), Verbal (93.4±18.4), and Performance (95.2±20.9) IQ were within the expected range, significantly more CDH children had borderline (17%) and extremely low (17%) scores in at least one domain compared to normative cohorts (P<0.02). The Visual-Motor-Integration score was below population average (P<0.001). Academic achievement scores were similar to expected means for those children who were able to complete testing. CBCL scores for the emotionally reactive (23%) and pervasive developmental problems scales (27%) were more likely to be abnormal compared to normal population scores (P=0.02 and P=0.0003, respectively). Autism was diagnosed in 11%, which is significantly higher than the general population (P<0.01). Univariate analysis suggests that prolonged NICU stay, prolonged intubation, tracheostomy placement, pulmonary hypertension, autism, hearing impairment, and developmental delays identified during infancy are associated with worse cognitive outcomes (P<0.05). CONCLUSION The majority of CDH children have neurodevelopmental outcomes within the average range at 5years of age. However, rates of borderline and extremely low IQ scores are significantly higher than in the general population. CDH survivors are also at increased risk for developing symptoms of emotionally reactive and pervasive developmental problems. Risk of autism is significantly elevated. Disease severity and early neurological dysfunction appear to be predictive of longer-term impairments.

Conscientious refusals to refer: findings from a national physician survey

Background Regarding controversial medical services, many have argued that if physicians cannot in good conscience provide a legal medical intervention for which a patient is a candidate, they should refer the requesting patient to an accommodating provider. This study examines what US physicians think a doctor is obligated to do when the doctor thinks it would be immoral to provide a referral. Method The authors conducted a cross-sectional survey of a random sample of 2000 US physicians from all specialties. The primary criterion variable was agreement that physicians have a professional obligation to refer patients for all legal medical services for which the patients are candidates, even if the physician believes that such a referral is immoral. Results Of 1895 eligible physicians, 1032 (55%) responded. 57% of physicians agreed that doctors must refer patients regardless of whether or not the doctor believes the referral itself is immoral. Holding this opinion was independently associated with being more theologically pluralistic, describing oneself as sociopolitically liberal, and indicating that respect for patient autonomy is the most important bioethical principle in ones practice (multivariable ORs, 1.6–2.4). Conclusions Physicians are divided about a professional obligation to refer when the physician believes that referral itself is immoral. These data suggest there is no uncontroversial way to resolve conflicts posed when patients request interventions that their physicians cannot in good conscience provide.

The impact of medical school oaths and other professional codes of ethics: results of a national physician survey.

Most U.S. medical students participate in “white-coat” ceremonies in which they recite an oath, often with reference to the Oath of Hippocrates. Reciting such oaths, or endorsing shared ethical standards such as the AMA Code of Ethics, can nurture professionalism by conveying a sense of gravity and belonging to something greater than oneself (1). Yet historic oaths can sound anachronistic to the modern ear, and the oaths sworn in most medical schools modify the original Hippocratic Oath by excluding significant portions and adding language deemed more fitting (2, 3). Revised oaths, while more relevant to contemporary medicine, may suffer from being arbitrary and self-serving (4, 5).

Professionalism: Etiquette or Habitus?

The past decade has witnessed an outburst of interest and scholarship about medical professionalism. The professionalism movement has a strong presence in medical education, including efforts to define, measure, and instill professionalism as a core competency of medical practice. As these efforts continue, there has been a shift toward emphasizing measurable behaviors while downplaying theinternalizationofvaluesandvirtues.Assuch, wehaveconcernsregardingtheabilityofmedical students and physicians to display outward professional behavior in a sustainable way without actually internalizing the values of the medical profession. Kahn 1 argues for an “etiquette-based medicine,”whichstressesbehaviormasteryovercharacterdevelopment.Heproffersalistofbehaviors that include actions such as shaking hands with a patient, smiling at a patient, and explaining one’s role on the medical team. This emphasis on deportment is attractive for those who wish to approach trainee comportment as a checklist. Just as checklists are used in intensive care units to reduce central catheter infections, Kahn explicitly endorses etiquette checklists for physician trainees in an attempt to reduce negative patient encounters. This raises the question, though,ofhowKahn’saccountdistinguishesthe physician-patient relationship from any other customerserviceprofession.Kahnacknowledges