Faculty Bibliography

BACKGROUND:As heart transplant guidelines evolve, the clinical indication for 73% of durable left ventricular assist device (LVAD) implants is now destination therapy. Although completely magnetically levitated LVAD devices have demonstrated improved durability relative to previous models, LVAD replacement procedures are still required for a variety of indications. Thus, the population of patients with a replaced LVAD is growing. There is a paucity of data regarding the outcomes and risk factors for those patients receiving first-time LVAD replacements. METHODS:The study cohort consisted of all consecutive patients between 2006 and 2020 that received a first-time LVAD replacement at a single institution. Preoperative clinical and laboratory variables were collected retrospectively. The primary endpoint was death or need for an additional LVAD replacement. Data were subjected to Kaplan-Meier, univariate, and multivariate Cox hazard ratio analyses. RESULTS:In total, 152 patients were included in the study, of which 101 experienced the primary endpoint. On multivariate analysis, patients receiving HeartMate 3 (HM3) LVADs as the replacement device showed superior outcomes (HR 0.15, 95% CI 0.065-0.35, p < 0.0001). Independent risk factors for death or need for additional replacement included preoperative extracorporeal membrane oxygenation (ECMO) (HR 4.44, 95% CI 1.87-14.45, and p = 0.00042), increased number of sternotomies (HR 5.20, 95% CI 1.87-14.45, and p = 0.0016), and preoperative mechanical ventilation (HR 1.98, 95% CI 1.01-3.86, and p = 0.045). CONCLUSIONS:Replacement with HM3 showed superior outcomes compared to all other pump types when controlling for both initial pump type and other independent predictors of death or LVAD replacement. Preoperative ECMO, mechanical ventilation, and multiple sternotomies also increased the odds for death or the need for subsequent replacement.

(1) Background: Healthcare is a major contributor to global greenhouse gas (GHG) emissions, especially within the surgical suite. Ophthalmologists play a role, since they frequently perform high-volume procedures, such as cataract surgery. This review aims to summarize the current literature on surgical waste and GHG emissions in ophthalmology and proposes a framework to standardize future studies. (2) Methods: Protocol and reporting methods were based on PRISMA guidelines for scoping reviews. Articles that reported any quantitative measurement of waste or GHGs produced from ophthalmic surgeries were eligible for inclusion. Commentaries, opinion papers, reviews and articles in a non-English language were excluded. (3) Results: A total of 713 articles were reviewed, with 10 articles found to meet inclusion criteria. Six studies produced level 3 evidence, two level 4 evidence, and one level 5 evidence. According to studies, most of the GHGs came from procurement of surgical materials, followed by travel emissions and building energy. (4) Conclusions: Research on waste and GHGs produced in ophthalmic surgery is limited, and existing studies utilize varied approaches to quantify this waste. We propose a standardized waste-lifecycle framework for researchers to organize future research. Such standardization will help in comparing studies and may uncover more opportunities to implement impactful waste reduction strategies in ophthalmology.

BACKGROUND:Immediate extubation is becoming more common in liver transplantation. However, limited data exist on how to identify pediatric patients with potential for successful immediate extubation and how this intervention may affect recovery. METHODS:This retrospective review evaluated patients who underwent liver transplantation from 2015 to 2021 at Children's Healthcare of Atlanta. Preoperative status and intraoperative management were evaluated and compared. Outcomes comprised thrombosis, surgical reexploration, retransplantation, as well as reintubation, high flow nasal cannula (HFNC) usage, postoperative infection, the length of stay (LOS), and mortality. RESULTS:A total of 173 patients were analyzed, with 121 patients (69.9%) extubated immediately. The extubation group had older age (median 4.0 vs 1.25 years, p = .048), lower PELD/MELD (28 vs. 34, p = .03), decreased transfusion (10.2 vs. 41.7 mL/kg, p < .001), shorter surgical time (332 vs. 392 min, p < .001), and primary abdominal closure (81% vs. 40.4%, p < .001). Immediate extubation was associated with decreased HFNC (0.21 vs. 0.71 days, p = .02), postoperative infection (9.9% vs. 26.9%, p = .007), mortality (0% vs. 5.8%, p = .036), and pediatric intensive care unit LOS (4.7 vs. 11.4 days, p < .001). The complication rate was lower in the extubation group (24.8% vs. 36.5%), but not statistically significant. CONCLUSIONS:Approximately 70% of patients were able to be successfully extubated immediately, with only 2.5% requiring reintubation. Those immediately extubated had decreased need for HFNC, lower infection rates, shorter LOS, and decreased mortality. Our results show that with proper patient selection and a multidisciplinary approach, immediate extubation allows for improved recovery without increased respiratory complications after pediatric liver transplantation.

OBJECTIVES/OBJECTIVE:Right heart failure remains a serious complication of left ventricular assist device therapy. Many patients presenting for left ventricular assist device implantation have significant tricuspid regurgitation. It remains unknown whether concurrent tricuspid valve surgery reduces postoperative right heart failure. The primary aim was to identify whether concurrent tricuspid valve surgery reduced the incidence of moderate or severe right heart failure within the first 6 months after left ventricular assist device implantation. METHODS:Patients with moderate or severe tricuspid regurgitation on preoperative echocardiography were randomized to left ventricular assist device implantation alone (no tricuspid valve surgery) or with concurrent tricuspid valve surgery. Randomization was stratified by preoperative right ventricular dysfunction. The primary end point was the frequency of moderate or severe right heart failure within 6 months after surgery. RESULTS:This report describes a planned interim analysis of the first 60 randomized patients. The tricuspid valve surgery group (n = 32) had mild or no tricuspid regurgitation more frequently on follow-up echocardiography studies compared with the no tricuspid valve surgery group (n = 28). However, at 6 months, the incidence of moderate and severe right heart failure was similar in each group (tricuspid valve surgery: 46.9% vs no tricuspid valve surgery: 50%, P = .81). There was no significant difference in postoperative mortality or requirement for right ventricular assist device between the groups. There were also no significant differences in secondary end points of functional status and adverse events. CONCLUSIONS:The presence of significant tricuspid regurgitation before left ventricular assist device is associated with a high incidence of right heart failure within the first 6 months after surgery. Tricuspid valve surgery was successful in reducing postimplant tricuspid regurgitation compared with no tricuspid valve surgery but was not associated with a lower incidence of right heart failure.

Countertransferential and other types of personal responses to candidates are inevitable among psychoanalytic educators, whether they be supervisors, progression advisors, the progression committee as a whole, or course instructors. Nonetheless many educators remain unaware of these phenomena - despite the robust literature on this subject in supervisors - perhaps because we do not like to think of ourselves as having potentially deleterious personal reactions to younger colleagues with whom we have significant and highly valued relationships. This paper emphasizes the role of such phenomena in progression advisors' deliberations about candidates' development, as well as in the committee as a whole - a subject not addressed in the literature. Especially when unrecognized such responses can compromise the checks and balances function of the progression committee and significantly diminish rich and effective dialogue with candidates about their development. Examples of the potential impact and more or less effective mitigation of such responses are presented. Ensuring that faculty members and candidates alike are familiar with the inevitability of these reactions, their multiple sources and manifestations in those involved in the work of progression enhances the possibility of developing strategies to address these reactions and reduce their effect.

BACKGROUND/UNASSIGNED:Older adults treated in emergency departments (EDs) are at higher risk for adverse outcomes. Using multiple facilities can worsen this issue through service duplication and poor care transitions. Veterans with dual insurance coverage can access both Veterans Health Administration (VHA) and non-VHA EDs. This study aimed to identify factors associated with non-VHA ED use among veterans. METHODS/UNASSIGNED:We conducted a retrospective observational study of patients aged ≥ 65 who had primary care at the James J Peters VA Medical Center and at least one VHA or non-VHA ED visit between October 2017 and February 2020. Data were collected from the Veterans Affairs Corporate Data Warehouse and the Bronx Regional Health Information Exchange Organization. Generalized linear mixed models were used to examine factors influencing non-VHA ED use. RESULTS/UNASSIGNED:The study sample consisted of 3,897 veterans and a total of 13,312 ED visits. Compared to VHA-exclusive ED users, non-VHA ED users were more likely to live farther away (OR 1.04, CI 1.02 - 1.06) and seek care outside regular hours, including mornings (OR 1.61, CI 1.39 - 1.87), nights (OR 1.49, CI 1.33 - 1.66), weekends (OR 1.28, CI 1.16 - 1.42), and holidays (OR 1.32, CI 1.04 - 1.68). They were also more likely to present with emergency care sensitive conditions (OR 2.13, CI 1.90 - 2.37) and recent inpatient hospitalizations (OR 1.22, CI 1.05 - 1.41). CONCLUSION/UNASSIGNED:These findings suggested that distance and acuity are important predictors of non-VHA ED use in urban areas such as the Bronx, NY. Identifying veterans with key risk factors could improve care coordination and potentially reduce non-VHA ED use.

While the emergency department (ED) is an important setting for identifying youth with psychiatric symptoms and connecting them to services, the demands of the ED make efficient and accurate measurement essential in the implementation of mental health screening. The Kiddie-Computerized Adaptive Test (K-CAT) scales, a new electronically administered measure that offers quick and comprehensive assessment across several mental health domains, may be particularly useful in this setting. Given current recommendations for youth suicide risk screening in EDs, this study compared the K-CAT-Suicide Scale (K-CAT-SS) and the Ask Suicide-screening Questions (ASQ), a widely used measure in EDs, in a sample of participants presenting to a pediatric, psychiatric emergency setting. The measures agreed on the presence of suicide risk in over 85% of cases (κ=0.59), and the characteristics of youth who screened at risk on both were similar. Cases of disagreement were more often male and more often had educational accommodations. They had lower symptom levels of and were less often diagnosed with internalizing disorders and were less often identified as high risk by ED psychiatrists and psychologists. Examination of item endorsement patterns in cases of disagreement revealed important areas of future study, including the role of caregiver report in suicide risk screening, item comprehension concerns, and the validity of assessing youth with neurodevelopmental disabilities. While additional research would be beneficial into its psychometrics when deployed in real-world settings, the K-CAT-SS should be considered a viable alternative for suicide risk screening in EDs.

INTRODUCTION/UNASSIGNED:Despite the effectiveness of Diabetes Prevention Programmes (DPP) in reducing diabetes risk, primary care provider (PCP) referrals remain low, especially among men and racial/ethnic minorities, exacerbating their under-representation in DPPs. Understanding PCPs' perspectives on referrals is crucial for enhancing the intervention's reach and effectiveness. RESEARCH DESIGN AND METHODS/UNASSIGNED:We conducted a qualitative study to explore PCPs' experiences, perspectives and engagement with DPP referrals, focusing on factors influencing variations in referral rates. Based on electronic record data, high and low-referring PCPs from a large integrated health system in the Bronx, NY, participated in interviews conducted between February and September 2023. Interviews were conducted and recorded on Zoom, anonymised, transcribed and analysed using the constant comparative method. RESULTS/UNASSIGNED:From 22 PCP interviews, 4 themes emerged representing factors that influenced referrals: (1) perceived barriers to the patient engagement with the DPP, including infrastructure gaps, programme accessibility issues and unmet social needs, particularly affecting low-referring PCPs; (2) perceived effectiveness of the DPP, with concerns raised about its efficacy, especially for male and socioeconomically disadvantaged patients; (3) perceived self-efficacy in referring patients, driven by knowledge gaps and limited opportunities, especially among low-referrers and (4) recommendations to facilitate and strengthen referrals, highlighting areas for PCP and patient support. The perspectives of high-referring/low-referring PCPs often differed across these themes and associated subthemes. CONCLUSIONS/UNASSIGNED:Our research illuminates the challenges PCPs face in treating prediabetic patients and factors influencing DPP referrals in underserved populations. This understanding can guide interventions to enhance equitable DPP referrals and engagement, thereby reducing diabetes risk in vulnerable populations.