Aortoesophageal fistula after thoracic endovascular aortic repair and transthoracic embolization

Endografts are more commonly being used to treat thoracic aortic aneurysms and other vascular lesions. Endoleaks are a potential complication of this treatment modality and can be associated with aneurysmal sac expansion and rupture. This case report presents a patient who developed a type IA endoleak after endograft repair of a descending thoracic aneurysm. The endoleak was successfully treated through computed tomographic-guided transthoracic embolization, although the patient experienced lower extremity paraparesis postprocedurally. The patient’s endovascular repair was complicated by the development of an aortoesophageal fistula and endograft infection necessitating operative débridement and endograft explantation

Evaluation of simulation training in cardiothoracic surgery: The Senior Tour perspective

OBJECTIVE: The study objective was to introduce senior surgeons, referred to as members of the "Senior Tour," to simulation-based learning and evaluate ongoing simulation efforts in cardiothoracic surgery. METHODS: Thirteen senior cardiothoracic surgeons participated in a 2½-day Senior Tour Meeting. Of 12 simulators, each participant focused on 6 cardiac (small vessel anastomosis, aortic cannulation, cardiopulmonary bypass, aortic valve replacement, mitral valve repair, and aortic root replacement) or 6 thoracic surgical simulators (hilar dissection, esophageal anastomosis, rigid bronchoscopy, video-assisted thoracoscopic surgery lobectomy, tracheal resection, and sleeve resection). The participants provided critical feedback regarding the realism and utility of the simulators, which served as the basis for a composite assessment of the simulators. RESULTS: All participants acknowledged that simulation may not provide a wholly immersive experience. For small vessel anastomosis, the portable chest model is less realistic compared with the porcine model, but is valuable in teaching anastomosis mechanics. The aortic cannulation model allows multiple cannulations and can serve as a thoracic aortic surgery model. The cardiopulmonary bypass simulator provides crisis management experience. The porcine aortic valve replacement, mitral valve annuloplasty, and aortic root models are realistic and permit standardized training. The hilar dissection model is subject to variability of porcine anatomy and fragility of the vascular structures. The realistic esophageal anastomosis simulator presents various approaches to esophageal anastomosis. The exercise associated with the rigid bronchoscopy model is brief, and adding additional procedures should be considered. The tracheal resection, sleeve resection, and video-assisted thoracoscopic surgery lobectomy models are highly realistic and simulate advanced maneuvers. CONCLUSIONS: By providing the necessary tools, such as task trainers and assessment instruments, the Senior Tour may be one means to enhance simulation-based learning in cardiothoracic surgery. The Senior Tour members can provide regular programmatic evaluation and critical analyses to ensure that proposed simulators are of educational value

Neighborhood Effects on the Long-Term Well-Being of Low-Income Adults

Nearly 9 million Americans live in extreme-poverty neighborhoods, places that also tend to be racially segregated and dangerous. Yet, the effects on the well-being of residents of moving out of such communities into less distressed areas remain uncertain. Using data from Moving to Opportunity, a unique randomized housing mobility experiment, we found that moving from a high-poverty to lower-poverty neighborhood leads to long-term (10- to 15-year) improvements in adult physical and mental health and subjective well-being, despite not affecting economic self-sufficiency. A 1–standard deviation decline in neighborhood poverty (13 percentage points) increases subjective well-being by an amount equal to the gap in subjective well-being between people whose annual incomes differ by $13,000—a large amount given that the average control group income is$20,000. Subjective well-being is more strongly affected by changes in neighborhood economic disadvantage than racial segregation, which is important because racial segregation has been declining since 1970, but income segregation has been increasing

Experience With the Cardiac Surgery Simulation Curriculum: Results of the Resident and Faculty Survey

BACKGROUND: The Cardiac Surgery Simulation Curriculum was developed at 8 institutions from 2010 to 2013. A total of 27 residents were trained by 18 faculty members. A survey was conducted to gain insight into the initial experience. METHODS: Residents and faculty were sent a 72- and 68-question survey, respectively. In addition to demographic information, participants reported their view of the overall impact of the curriculum. Focused investigation into each of the 6 modules was obtained. Participants evaluated the value of the specific simulators used. Institutional biases regarding implementation of the curriculum were evaluated. RESULTS: Twenty (74%) residents and 14 (78%) faculty responded. The majority (70%) of residents completed this training in their first and second year of traditional-track programs. The modules were well regarded with no respondents having an unfavorable view. Both residents and faculty found low, moderate, and high fidelity simulators to be extremely useful, with particular emphasis on utility of high fidelity components. The vast majority of residents (85%) and faculty (100%) felt more comfortable in the resident skill set and performance in the operating room. Simulation of rare adverse events allowed for development of multidisciplinary teams to address them. At most institutions, the conduct of this curriculum took precedence over clinical obligations (64%). CONCLUSIONS: The Cardiac Surgery Simulation Curriculum was implemented with robust adoption among the investigating centers. Both residents and faculty viewed the modules favorably. Using this curriculum, participants indicated an improvement in resident technical skills and were enthusiastic about training in adverse events and crisis management

Simulation-Based Training in Cardiac Surgery

BACKGROUND: Operating room surgical training has significant limitations. This study hypothesized that some skills could be learned efficiently and safely by using simulation with component task training, deliberate practice, progressive complexity, and experienced coaching to produce safer cardiac surgeons. METHODS: Training modules included cardiopulmonary bypass, coronary artery bypass grafting, aortic valve replacement, massive air embolism, acute intraoperative aortic dissection, and sudden deterioration in cardiac function. Using deliberate practice, first-year cardiothoracic surgical residents at eight institutions were trained and evaluated on component tasks for each module and later on full cardiac operations. Evaluations were based on five-point Likert-scale tools indexed by module, session, task items, and repetitions. Statistical analyses relied on generalized linear model estimation and corresponding confidence intervals. RESULTS: The 27 residents who participated demonstrated improvement with practice repetitions resulting in excellent final scores per module (mean ± two SEs): cardiopulmonary bypass, 4.80 ± 0.12; coronary artery bypass grafting, 4.41 ± 0.19; aortic valve replacement, 4.51 ± 0.20; massive air embolism, 0.68 ± 0.14; acute intraoperative aortic dissection, 4.52 ± 0.17; and sudden deterioration in cardiac function, 4.76 ± 0.16. The transient detrimental effect of time away from training was also evident. CONCLUSIONS: Overall performance in component tasks and complete cardiac surgical procedures improved during simulation-based training. Simulation-based training imparts skill sets for management of adverse events and can help produce safer surgeons

Teaching behaviors in the cardiac surgery simulation environment

OBJECTIVE: To understand how teaching behaviors contribute to simulation-based learning, we used a 7-category educational framework to assess the teaching behaviors used in basic skills training. METHODS: Twenty-four first-year cardiothoracic surgery residents and 20 faculty participated in the Boot Camp vessel anastomosis sessions. A portable chest model with synthetic graft and target vessels and a tissue-based porcine model simulated coronary artery anastomosis. After each 2-hour session on days 1 and 2, residents assessed teaching behaviors of faculty using a 20-item questionnaire based on the 5-point Likert scale. After session on day 1, faculty completed a self-assessment questionnaire. At 3 months, faculty completed self-assessment questionnaires regarding teaching behaviors in simulation and clinical settings. Each questionnaire item represents 1 or more teaching categories: "learning climate," "control of session," "communication of goals," "promoting understanding and retention," "evaluation," "feedback," and "self-directed learning." RESULTS: Generally, resident ratings indicated that faculty showed positive teaching behaviors. Faculty self-assessment ratings were all lower (P < .025) than those assigned to them by the residents except for 1 component representative of "feedback," which approached significance (P = .04); 2 items, representative of "promoting understanding and retention" and "evaluation", had mean scores of less than 3. At 3 months, compared with self-assessment at Boot Camp, faculty ratings suggested improved teaching behaviors in their simulation settings in the following: "learning climate," "control of session," "communication of goals," "promoting understanding and retention," and "evaluation." The simulation environment was perceived as more positive for technical skills training in certain aspects compared with clinical setting: instructor reviewed function and operation of equipment with learner before session (representative of "promoting understanding and retention") and instructor allowed the learner ample time to practice (representative of "control of session" and "promoting understanding and retention") (P < .025). CONCLUSIONS: Simulation-based skills training is perceived by residents to be associated with positive teaching behaviors. Faculty self-ratings indicate that they do not always use many of these teaching behaviors and that their performance can be improved. The simulation setting may provide greater opportunity for positive teaching behaviors compared with the clinical environment

Surgical complications in neuromuscular scoliosis operated with posterior- only approach using pedicle screw fixation

<p>Abstract</p> <p>Background</p> <p>There are no reports describing complications with posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI) using pedicle screw fixation in patients with neuromuscular scoliosis.</p> <p>Methods</p> <p>Fifty neuromuscular patients (18 cerebral palsy, 18 Duchenne muscular dystrophy, 8 spinal muscular atrophy and 6 others) were divided in two groups according to severity of curves; group I (< 90°) and group II (> 90°). All underwent PSF and SSI with pedicle screw fixation. There were no anterior procedures. Perioperative (within three months of surgery) and postoperative (after three months of surgery) complications were retrospectively reviewed.</p> <p>Results</p> <p>There were fifty (37 perioperative, 13 postoperative) complications. Hemo/pneumothorax, pleural effusion, pulmonary edema requiring ICU care, complete spinal cord injury, deep wound infection and death were major complications; while atelectesis, pneumonia, mild pleural effusion, UTI, ileus, vomiting, gastritis, tingling sensation or radiating pain in lower limb, superficial infection and wound dehiscence were minor complications. Regarding perioperative complications, 34(68%) patients had at least one major or one minor complication. There were 16 patients with pulmonary, 14 with abdominal, 3 with wound related, 2 with neurological and 1 cardiovascular complications, respectively. There were two deaths, one due to cardiac arrest and other due to hypovolemic shock. Regarding postoperative complications 7 patients had coccygodynia, 3 had screw head prominence, 2 had bed sore and 1 had implant loosening, respectively. There was a significant relationship between age and increased intraoperative blood loss (p = 0.024). However it did not increased complications or need for ICU care. Similarly intraoperative blood loss > 3500 ml, severity of curve or need of pelvic fixation did not increase the complication rate or need for ICU. DMD patients had higher chances of coccygodynia postoperatively.</p> <p>Conclusion</p> <p>Although posterior-only approach using pedicle screw fixation had good correction rate, complications were similar to previous reports. There were few unusual complications like coccygodynia.</p

Radiotherapy plus chemotherapy with or without surgical resection for stage III non-small-cell lung cancer: a phase III randomised controlled trial

Concurrent chemotherapy plus radiation therapy (chemoRT) is the standard treatment for stage IIIA(N2) non-small cell lung cancer (NSCLC), a common disease entity. Phase II studies demonstrated feasibility of resection after chemoRT with encouraging survival rates. This phase III trial compared both approaches

Spectral reflectance properties of zeolites and remote sensing implications

The 0.3- to 26-μm reflectance spectra of a suite of 28 zeolites were measured and analyzed to derive spectral-compositional-structural relationships. Below ~7 μm, the spectra are largely dominated by absorption features associated with zeolitic water. At longer wavelengths, the spectra are dominated by absorption features associated with the aluminosilicate framework. The spectra exhibit a number of systematic variations which can be used for both structurl and compositional determinations. These include: (1) distinguishing different structural groups on the basis of wavelength position variations associated with absorption features in the 8.5- to 26-μm region that are related to differences in the structure of the aluminosilicate framework; (2) determining the major cation which is present (Ca, Na, K) and the associated electronic environment of the zeolitic water on the basis of how these cations hydrogen bond to the water molecules in the void spaces and consequently affect water-related absorption band positions, particularly in the 1.4, 1.9, and 2.0- to 2.5-μm regions; (3) determining the Al:(Al + Si) ratio and SCFM chemical index on the basis of absorption features in the 7- to 26-μm region which are most sensitive to these compositional variations; and (4) identifying ironbearing zeolites on the basis of absorption features in the 0.35- to 0.9-μm region. The wavelength position and number of H2O-associated absorption bands are sensitive to factors such as the type of major cation, degree of hydrogen bonding, and size of the void space, all of which are somewhat interrelated.This study was supported by a research grant from the Natural Sciences and Engineering Research Council of Canada, a contract from the Canadian Space Agency Space Science Program, a discretionary grant from the University of Winnipeg (to E.A.C.), and the Louise McBee Scholarship of the Georgia Association for Women in Education, University of Georgia (to P.M.A.).This study was supported by a research grant from the Natural Sciences and Engineering Research Council of Canada, a contract from the Canadian Space Agency Space Science Program, a discretionary grant from the University of Winnipeg (to E.A.C.), and the Louise McBee Scholarship of the Georgia Association for Women in Education, University of Georgia (to P.M.A.).https://agupubs.onlinelibrary.wiley.com/doi/abs/10.1029/2000JE00146