Minimal-Access Atrial Septal Defect (ASD) Closure

Progress towards the development and adoption of minimally invasive techniques in cardiac surgery has been slower than that seen in other surgical specialties. Congenital heart disease (CHD) patients represent an important population within cardiac disease, of which atrial septal defect (ASD) is one of the most common diagnoses. Management of ASD encompasses a range of minimal-access and minimally invasive approaches, including transcatheter device closure, mini-sternotomy, thoracotomy, video-assisted, endoscopic, and robotic approaches. In this article, we will discuss the pathophysiology of ASD, along with diagnosis, management, and indications for intervention. We will review the current evidence supporting minimally invasive and minimal-access surgical ASD closure in the adult and paediatric patient, highlighting peri-operative considerations and areas for further research.

Organ Transplants From Deceased Donors With Primary Brain Tumors and Risk of Cancer Transmission

Importance

Cancer transmission is a known risk for recipients of organ transplants. Many people wait a long time for a suitable transplant; some never receive one. Although patients with brain tumors may donate their organs, opinions vary on the risks involved.

Objective

To determine the risk of cancer transmission associated with organ transplants from deceased donors with primary brain tumors. Key secondary objectives were to investigate the association that donor brain tumors have with organ usage and posttransplant survival.

Design, Setting, and Participants

This was a cohort study in England and Scotland, conducted from January 1, 2000, to December 31, 2016, with follow-up to December 31, 2020. This study used linked data on deceased donors and solid organ transplant recipients with valid national patient identifier numbers from the UK Transplant Registry, the National Cancer Registration and Analysis Service (England), and the Scottish Cancer Registry. For secondary analyses, comparators were matched on factors that may influence the likelihood of organ usage or transplant failure. Statistical analysis of study data took place from October 1, 2021, to May 31, 2022.

Exposures

A history of primary brain tumor in the organ donor, identified from all 3 data sources using disease codes.

Main Outcomes and Measures

Transmission of brain tumor from the organ donor into the transplant recipient. Secondary outcomes were organ utilization (ie, transplant of an offered organ) and survival of kidney, liver, heart, and lung transplants and their recipients. Key covariates in donors with brain tumors were tumor grade and treatment history.

Results

This study included a total of 282 donors (median [IQR] age, 42 [33-54] years; 154 females [55%]) with primary brain tumors and 887 transplants from them, 778 (88%) of which were analyzed for the primary outcome. There were 262 transplants from donors with high-grade tumors and 494 from donors with prior neurosurgical intervention or radiotherapy. Median (IQR) recipient age was 48 (35-58) years, and 476 (61%) were male. Among 83 posttransplant malignancies (excluding NMSC) that occurred over a median (IQR) of 6 (3-9) years in 79 recipients of transplants from donors with brain tumors, none were of a histological type matching the donor brain tumor. Transplant survival was equivalent to that of matched controls. Kidney, liver, and lung utilization were lower in donors with high-grade brain tumors compared with matched controls.

Conclusions and Relevance

Results of this cohort study suggest that the risk of cancer transmission in transplants from deceased donors with primary brain tumors was lower than previously thought, even in the context of donors that are considered as higher risk. Long-term transplant outcomes are favorable. These results suggest that it may be possible to safely expand organ usage from this donor group.

The Impact of Same Gender Speed-Mentoring on Women's Perceptions of a Career in Surgery - A Prospective Cohort Study

BACKGROUND

Mentoring is critically important for the personal and professional development of a surgeon. Early career stage mentoring by same-gender role models may help ameliorate the gender imbalance in surgery based on our understanding of barriers for women pursuing surgical careers. A novel method of establishing these relationships is speed mentoring. This study aims to examine the impact of a one-day speed-mentoring session with same gender mentors on a cohort's perceptions of a career in surgery.

DESIGN

This prospective pre-post study compared attitudes and perceptions of a career in surgery before and after a speed-mentoring session with female surgeons. Mentees were assigned into groups of 1 or 2 and were paired with a female surgeon for 8 minutes. Each mentee group then rotated to another mentor for the same amount of time and this process continued for a total of twelve sessions. Mentees completed a 19-point questionnaire before and after the speed mentoring intervention.

SETTING

This multicenter study included participants from across the United Kingdom.

PARTICIPANTS

Inclusion criteria were female gender and medical student or foundation year doctor (internship year 1 or 2) status. Three hundred and forty participants participated in the intervention, 191 were included in the analysis.

RESULTS

Following intervention, the percentage of participants who agreed that having a family would negatively impact a woman's surgical career progression significantly decreased from 46.6% to 23.0%. The percentage of participants who agreed that an "old boys' club" attitude exists in surgery also significantly decreased (73.8%-58.1%). The percentage of participants who agreed it was more difficult for a woman to succeed in her surgical career than a man significantly decreased (73.8%-64.9%). One hundred and eighty-three (96%) participants agreed that mentorship is important for career progression and 153 (71.2%) participants stated that they did not have someone who they considered a mentor.

CONCLUSIONS

Conducting a speed mentoring program with same-gender role models significantly changed female medical students' and junior doctors' perceptions of women in surgery. The results suggest that such programs may be effective tools for facilitating mentor-mentee relationships and could be employed by surgical organizations to encourage a diverse uptake into surgery.

968 Delivering Human Factors and Non-Technical Skills Training Using Interactive Online Platforms in the COVID Era

Aim

To evaluate the impact and effectiveness of an interactive online human factors (HF) and non-technical skills (NTS) course delivered to Core Surgical Trainees during the COVID-19 pandemic

Method

A 1-day HF and NTS course was conducted online, using the Zoom platform, to Core Surgical Trainees in the North West. The course consisted of interactive lectures, small group teaching sessions, and self-directed learning with written reflections. Pre- and post-course surveys were administered, evaluating the participants’ awareness, knowledge and skills using a 5-part Likert scale, along with a multiple-choice assessment of knowledge. Statistical analysis was undertaken with significance considered at p < 0.05

Results

The course was attended by 63 CT1/2 participants, representing all surgical specialties. In the post-course evaluation, participants’ self-rating of awareness and knowledge for both HF and patient safety increased by between 10-20%. There was a significant increase in the mean post-course test score from 7.54 (SD ± 1.7) to 8.65 (SD ± 1.2) out of 10 (p < 0.0001). The course overall was rated relevant and useful (weighted averages 4.4 and 4.5 respectively)

Conclusions

To our knowledge, this is the first time a video conferencing platform has been used to deliver a live HF/NTS course. This study provides evidence supporting the use of such interactive online platforms in postgraduate surgical education. Training and professional development must continue, despite the evolving pressures from COVID-19. Embracing new methods of education delivery is required, with ongoing reporting and evaluation of education practice, sharing lessons learned and informing the evidence base in postgraduate surgical training during this time

Clinical Practice Guideline for Solid Organ Donation and Transplantation During the COVID-19 Pandemic

The coronavirus 2019 (COVID-19) pandemic has disrupted health systems worldwide, including solid organ donation and transplantation programs. Guidance on how best to screen patients who are potential organ donors to minimize the risks of COVID-19 as well as how best to manage immunosuppression and reduce the risk of COVID-19 and manage infection in solid organ transplant recipients (SOTr) is needed.

METHODS

Iterative literature searches were conducted, the last being January 2021, by a team of 3 information specialists. Stakeholders representing key groups undertook the systematic reviews and generation of recommendations using a rapid response approach that respected the Appraisal of Guidelines for Research and Evaluation II and Grading of Recommendations, Assessment, Development and Evaluations frameworks.

RESULTS

The systematic reviews addressed multiple questions of interest. In this guidance document, we make 4 strong recommendations, 7 weak recommendations, 3 good practice statements, and 3 statements of "no recommendation."

CONCLUSIONS

SOTr and patients on the waitlist are populations of interest in the COVID-19 pandemic. Currently, there is a paucity of high-quality evidence to guide decisions around deceased donation assessments and the management of SOTr and waitlist patients. Inclusion of these populations in clinical trials of therapeutic interventions, including vaccine candidates, is essential to guide best practices.

Heart transplantation in the UK during the first wave of the SARS-CoV-2 pandemic

BACKGROUND

We aim to evaluate practice and understand the impact of the first wave of the SARS-CoV-2 pandemic on heart transplantation in the UK.

METHODS

A retrospective review of the UK Transplant Registry (UKTR) and a national survey of UK heart transplant centers have been performed. The early pandemic period is defined here as 1 March to 31 May 2020.

RESULTS

There was geographic variation in the prevalence of COVID-19 across the UK. All centers reported adaptations to maintain the safety of their staff, candidate, and recipient populations. The number of donors fell by 31% during the early pandemic period. Heart utilization increased to 35%, compared to 26% during the same period of 2019. The number of heart transplants was well maintained, across all centers, with 38 performed, compared to 41 during the same period of 2019, with no change in 30-day survival. Twenty-seven heart transplant recipients with confirmed COVID-19 infection were reported during the study period.

CONCLUSION

All UK heart transplant centers have successfully adapted their programs to overcome the challenges of staff redeployment and ICU and hospital resource limitation, associated with the pandemic, whilst continuing heart transplant activity. On-going evaluation of practice changes, with sharing of lessons learned, is required as the pandemic continues.

The impact of the SARS-CoV-2 pandemic and COVID-19 on lung transplantation in the UK: Lessons learned from the first wave

Background

Lung transplantation is particularly susceptible to the impact of the severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) pandemic, and evaluation of changes to practice is required to inform future decision‐making.

Methods

A retrospective review of the UK Transplant Registry (UKTR) and national survey of UK lung transplant centers has been performed.

Results

There was geographic variation in the prevalence of COVID‐19 infection across the UK. The number of donors fell by 48% during the early pandemic period. Lung utilization fell to 10% (compared with 24% for the same period of 2019). The number of lung transplants performed fell by 77% from 53, March to May 2019, to 12. Seven (58%) of these were performed in a single‐center, designated “COVID‐light.” The number of patients who died on the lung transplant waiting list increased, compared to the same period of 2019 (p = .0118). Twenty‐six lung transplant recipients with confirmed COVID‐19 infection were reported during the study period.

Conclusion

As the pandemic continues, reviewing practice and implementing the lessons learned during this period, including the use of robust donor testing strategies and the provision of “COVID‐light” hospitals, are vital in ensuring the safe continuation of our lung transplant program.

Mesenteric ischaemia following cardiac surgery: the influence of intraoperative perfusion parameters

OBJECTIVES

Mesenteric ischaemia (MesI) remains a rare but lethal complication following cardiac surgery. Previously identified risk factors for MesI mortality (age, poor left ventricular (LV) function, cardiopulmonary bypass time and blood loss) are non-specific and cannot necessarily be modified. This study aims to identify potentially modifiable risk factors for MesI mortality through analysis of peri- and intraoperative perfusion data.

METHODS

Patients who underwent cardiac surgery between 2006 and 2011 at Papworth Hospital were retrospectively divided into 3 outcome categories: death caused by MesI; death due to other causes and survival to discharge. A published MesI risk calculator was used to estimate risk of MesI for each patient and then to create 3 cohorts of matched patients from each outcome group. Pre-, intra- and postoperative variables were collected and conditional logistic regression methods were used to identify parameters associated specifically with MesI deaths after cardiac surgery.

RESULTS

A total of 10 409 patients underwent cardiac surgery between 2006 and 2011. The incidence of MesI was 0.3% (30 patients). Two hundred and sixty-one patients died of non-MesI causes and 10 118 survived. It was possible to identify 25 patients in each group at equivalent risk of MesI. The following parameters were found to be associated with MesI mortality: recent myocardial infarction [odds ratio (OR) 4.98, 95% confidence interval (CI) 1.58-15.71, P = 0.01], standard EuroSCORE (OR 1.12, 95% CI 1.03-1.21, P = 0.01), vasopressor dose on bypass (OR 1.28, 95% CI 1.04-1.57, P = 0.02), metaraminol dose on bypass (OR 1.52, 95% CI 1.12-2.06, P = 0.01) and lowest documented mean arterial pressure (OR 0.90, 95% CI 0.83-0.97, P = 0.01). No other intraoperative perfusion-related parameters (e.g. flow, average activated clotting time or pressure) were associated with MesI mortality.

CONCLUSIONS

Our study not only confirms previously known predictive factors, but also demonstrates a new association between intraoperative vasopressor use and MesI mortality.

Pulmonary endarterectomy: outcomes in patients aged >70

OBJECTIVES

Advanced age is not a barrier to cardiac surgery, with reports demonstrating excellent outcomes, but the effect of age on more complex surgery has not been studied. We assessed the outcomes of pulmonary endarterectomy (PEA) surgery in patients aged >70.

METHODS

A retrospective review of consecutive patients who underwent PEA between January 2006 and March 2011 at a national referral centre. The total cohort was dichotomized according to age on the day of surgery, either below or above 70 years. Outcomes were in-hospital mortality, overall survival and the length of ICU and hospital stays.

RESULTS

Four hundred and eleven patients underwent PEA during the 5-year period. The mean age was 56.9 years (range, 17-84 years). The in-hospital mortality was 14 of 308 (4.6%) for patients <70 years compared with 8 of 103 (7.8%) for patients ≥70 years (P = 0.21). The overall survival at 1, 2 and 3 years was 91.4, 89.9 and 87.7% in the <70-year old group and 85.9, 84.1 and 84.1% in the >70-year old group (log-rank test, P = 0.07), respectively. The length of ICU and in-hospital stays was longer in the >70-year old group, by 1 and 2 days, respectively (P = 0.005 and 0.001).

CONCLUSIONS

PEA surgery in patients ≥70 years is safe and carries a comparable risk of early mortality in younger patients, but there is an increase in resource use due to longer ICU and hospital stays. Advanced age should be taken into consideration when assessing suitability for PEA, but age per se should not be a contraindication to surgery.

Chronic thromboembolic pulmonary hypertension: an underdiagnosed entity?

Chronic thromboembolic pulmonary hypertension (CTEPH) is the only cause of pulmonary hypertension for which there is a potential cure, which is in the form of pulmonary endarterectomy. There is a strong link between pulmonary embolism (PE) and the development of CTEPH. Although CTEPH was initially believed to be a rare complication, this belief has been reconsidered following several studies suggesting that up to 8.8% of patients develop CTEPH within the 2 years after PE. However, considering the incidence of PE, there is a significant discrepancy in the number of patients who are diagnosed, referred, and treated for CTEPH. Potential reasons for this include its often vague clinical presentation, the variable association of CTEPH with PE, and discrepancies when interpreting imaging studies. Underdiagnosis of CTEPH is preventing patients from accessing potentially curative therapy. Increased awareness about this condition is an important initial step to improving diagnostic rates and treatment.

Access to the evidence base from general practice: a survey of general practice staff in Northern and Yorkshire Region

AIM

To identify and describe current methods of making health related research evidence accessible to general practice staff in the Northern and Yorkshire Region.

METHOD

A postal survey questionnaire of general practice staff in the Northern and Yorkshire Region.

RESULTS

At least one completed questionnaire was obtained from 70% of the general practices surveyed, and the individual response rate to the survey was 45%. Just under 60% of all respondents reported having no access to the NHS internet and just under 50% also reported having no access to the internet. All respondents in this survey reported greater access to paper based information than to electronic databases. However, this research provides evidence of differential access to information resources between different professions in general practice with GPs clearly having easier access than other professions to both paper based resources and electronic databases. 70% of all respondents said that they would need to be trained to use either a computer, the internet, or to search databases if the opportunity for easy access to any of these information services was available.

CONCLUSIONS

At the time of this survey, general practices seemed to be struggling to set up the infrastructure and develop the skills that are necessary to make best use of available research evidence. In addition, there is a need for further investigation into the reasons why different professions working in the same practice setting have differential access to information resources available in primary care.

Costing substance misuse services

AIMS

To develop a methodology for obtaining the detailed costs of different substance misuse services and illustrate some of the specific problems by means of a case study.

DESIGN

Data on the resources required, clinical activity, and patient characteristics for one year were combined to provide detailed costs for different types of clinical events and patients.

SETTING

The clinical services of a publicly funded addiction unit in a large industrial city in the UK. The unit provides for alcohol and other drug misusers mainly on an outpatient basis but with inpatient care.

PARTICIPANTS

Over 1500 patients were included in the analysis with 75 per cent being male, and 80 per cent aged between 20 and 49. Nearly half of the clients had alcohol as their main drug of misuse with opiate users being the next largest group.

MEASUREMENT

Detailed costing by event and patient was possible as the staff type and time taken for each event were routinely recorded. A cost for each individual event was estimated and summed for each individual patient to give a cost estimate by patient for the financial year 1992/3.

FINDINGS

Core treatment outpatient events had an average cost of Pounds 48, with new assessments costing Pounds 87 but these averages hid high variations. The average cost per year for those receiving only outpatient care was Pounds 358; it was Pounds 1857 for those receiving both outpatient and inpatient care. Opiate misusers were on average more costly than alcohol misusers. The costs were skewed with 10 per cent of patients accounting for 56 per cent of the total annual costs.

CONCLUSIONS

Dealing with costs of non attendance, including all resource use, and coping with large individual variations in costs across individuals and intervention types are the main problems in devising cost figures. Cost data are useful but need to be combined with outcome data if they are to be used to improve patient services.

Allocating resources to health authorities: development of method for small area analysis of use of inpatient services

Every year about 22 billion pounds is allocated to health authorities for hospital and community services in England. The distribution of most of these funds is based on a formula developed to reflect the population's needs, but the existing formula has been criticised on several grounds. This paper describes the development of a method to determine the health needs for small geographical areas. Data from the hospital episodes statistics and 1991 census together with information on vital statistics and supply of health care facilities were used in the model. Two stage least squares regression was used to identify true indicators of need, and these were entered into a multilevel model to take account of variations in practice in different health authorities. The resulting formula should be more statistically robust and more sensitive to needs than previous approaches.

Allocating resources to health authorities: results and policy implications of small area analysis of use of inpatient services

A study designed to identify the principal determinants of use of inpatient facilities in NHS hospitals in England used the data and methods outlined in the previous paper. The model for the psychiatric sector contains mortality, self reported morbidity, and social variables indicating deprivation and the level of care at home. The non-acute model contains mortality and several socioeconomic variables. The models lay less weight on age than the current formula, and a national formula based on these models would, in the acute sector, redistribute resources to poorer areas compared with the current formula.