A Novel Use of a Not So "EZ-Blocker" For Lung Isolation During a Direct Transaortic Transcatheter Aortic Valve Replacement

Alternate access transcatheter aortic valve replacement presents unique challenges for anesthesiologists, including the possible need for lung isolation while working with space constraints around the patient's airway. Troubleshooting lung isolation in these cases can be challenging, requiring quick thinking and adaptability while maintaining patient safety. We present a case of direct transaortic transcatheter aortic valve replacement with an endobronchial blocker ("EZ-blocker") used for lung isolation that required a novel use of the "EZ-blocker" to achieve adequate lung isolation.

The Impact of a New Anesthesiology Residency Program on the Number of Medical Students Matching Into Anesthesiology at a Single Institution: A Retrospective Longitudinal Study

Introduction There are projected workforce shortages within anesthesiology exacerbated by an increase in demand for anesthesia services and an aging anesthesia workforce. Given this mismatch, it is critical for the specialty to recruit the next generation of anesthesiologists and understand the factors affecting medical students' decision to apply to anesthesiology. This study aims to evaluate the impact of establishing a new anesthesiology residency program at a single institution on the number of medical students that match into anesthesiology in the subsequent years. Methods A single-center, retrospective longitudinal study examined the number of medical students matching into anesthesiology at a single institution between 2013 and 2023, five years before and after the establishment of an accredited anesthesiology residency program. The data were compared to aggregated data on all US medical student applicants through the National Resident Matching Program. Results The pre-anesthesiology residency match rate (2013-2018) of medical students from Alpert Medical School (AMS) was 2.47% while the post-anesthesiology residency match rate (2019-2023) was 4.30%. This represents a 74% increase in the average proportion of medical students matching into anesthesiology after the start of the residency program compared to a 20% increase nationally over the same time period. The rate of change of AMS matched applicants after the implementation of the AMS anesthesia residency program increased compared to the national applicant pool (p= 0.002). Conclusion The establishment of a new accredited anesthesiology residency program increased the proportion of medical students matching into anesthesiology at the affiliated medical school in the subsequent five years. Exposure to an academic anesthesiology program improves medical student interest and ultimately matches rates in anesthesiology, a vital tool to address the projected shortages in the anesthesiology workforce.

Effect of concurrent mitral valve surgery for secondary mitral regurgitation upon mortality after aortic valve replacement or coronary artery bypass surgery

Objectives

It is uncertain whether concurrent mitral valve repair or replacement for moderate or greater secondary mitral regurgitation at the time of coronary artery bypass graft or aortic valve replacement surgery improves long-term survival.

Methods

Patients undergoing coronary artery bypass graft and/or aortic valve replacement surgery with moderate or greater secondary mitral regurgitation were reviewed. The effect of concurrent mitral valve repair or replacement upon long-term mortality was assessed while accounting for patient and operative characteristics and mitral regurgitation severity.

Results

Of 1,515 patients, 938 underwent coronary artery bypass graft or aortic valve replacement surgery alone and 577 underwent concurrent mitral valve repair or replacement. Concurrent mitral valve repair or replacement did not alter the risk of postoperative mortality for patients with moderate mitral regurgitation (hazard ratio = 0.93; 0.75-1.17) or more-than-moderate mitral regurgitation (hazard ratio = 1.09; 0.74-1.60) in multivariable regression. Patients with more-than-moderate mitral regurgitation undergoing coronary artery bypass graft-only surgery had a survival advantage from concurrent mitral valve repair or replacement in the first two postoperative years (P = 0.028) that did not persist beyond that time. Patients who underwent concurrent mitral valve repair or replacement had a higher rate of later mitral valve operation or reoperation over the five subsequent years (1.9% vs. 0.2%; P = 0.0014) than those who did not.

Conclusions

These observations suggest that mitral valve repair or replacement for more-than-moderate mitral regurgitation at the time of coronary artery bypass grafting may be reasonable in a suitably selected coronary artery bypass graft population but not for aortic valve replacement, with or without coronary artery bypass grafting. Our findings are supportive of 2021 European guidelines that severe secondary mitral regurgitation "should" or be "reasonabl[y]" intervened upon at the time of coronary artery bypass grafting but do not support 2020 American guidelines for performing mitral valve repair or replacement concurrent with aortic valve replacement, with or without coronary artery bypass grafting.

Joint preoperative transthoracic and intraoperative transoesophageal echocardiographic assessment of functional mitral regurgitation severity provides better association with long-term mortality

OBJECTIVES

Functional mitral regurgitation (MR) is observed with ischaemic heart disease or aortic valve disease. Assessing the value of mitral valve repair or replacement (MVR/P) is complicated by frequent discordance between preoperative transthoracic echocardiographic (pTTE) and intraoperative transoesophageal echocardiographic (iTOE) assessment of MR severity. We examined the association of pTTE and iTOE with postoperative mortality in patients with or without MR, at the time of coronary artery bypass grafting (CABG) and/or aortic valve replacement without MVR/P.

METHODS

Medical records of 6629 patients undergoing CABG and/or aortic valve replacement surgery with or without functional MR and who did not undergo MVR/P were reviewed. MR severity assessed by pTTE and iTOE were examined for association with postoperative mortality using proportional hazards regression while accounting for patient and operative characteristics.

RESULTS

In 72% of 709 patients with clinically significant (moderate or greater) functional MR detected by pTTE, iTOE performed after induction of anaesthesia demonstrated a reduction in MR severity, while 2% of patients had increased severity of MR by iTOE. iTOE assessment of MR was better associated with long-term postoperative mortality than pTTE in patients with moderate MR [hazard ratio (HR) 1.31 (1.11-1.55) vs 1.02 (0.89-1.17), P-value for comparison of HR 0.025] but was not different for more than moderate MR [1.43 (0.96-2.14) vs 1.27 (0.80-2.02)].

CONCLUSIONS

In patients undergoing CABG and/or aortic valve replacement without MVR/P, these findings support intraoperative reassessment of MR severity by iTOE as an adjunct to pTTE in the prediction of mortality. Alone, these findings do not yet provide evidence for an operative strategy.

Children's goals and strategies in response to conflicts within a friendship

Little is known about the skills required for friendship, as distinct from those required for peer acceptance. The present study examined whether children's goals and strategies in friendship conflict situations are predictive of their friendship adjustment, after accounting for level of peer acceptance. Fourth- and 5th-grade children (N = 696) responded to 30 hypothetical situations in which they were having a conflict with a friend. Results indicated that children's goals were highly related to their strategies and that children's goals and strategies were predictive of their real-life friendship adjustment. Pursuing the goal of revenge toward a friend was the goal or strategy most strongly associated with lacking friends and having poor-quality friendships. Gender differences were also found for each goal and strategy, with girls displaying a more prosocial goal and strategy orientation than boys.

Children's social goals and self-efficacy perceptions as influences on their responses to ambiguous provocation

This study examined whether children who vary in their behavioral responses (aggression vs. withdrawal vs. problem solving) to ambiguous provocation but who are similar in their attributional processes differ in their social goals and self-efficacy perceptions. In response to 10 hypothetical situations involving ambiguous provocation, fourth- and fifth-grade students (n = 781) indicated whether or not the protagonist intended to cause the harm and reported how they would respond to the protagonist's action. Newly developed measures assessed children's situated social goals and self-efficacy perceptions. Results indicated that the aggressive, withdrawn, and problem-solving responders differed in their social goals and self-efficacy perceptions. The strength of the findings, compared to earlier work on children's goals and self-efficacy perceptions, suggests the importance of a situated social-cognitive assessment in which children's thoughts are measured in a specific kind of social situation and are related to their reported behavior in the same type of situation.

The academic lives of neglected, rejected, popular, and controversial children

The purposes of this study were to examine academically relevant characteristics of different sociometric status groups and to learn about the academic orientations of behavioral subgroups of rejected children. Results from a sample of 423 sixth and seventh graders (ages 11-13) suggested that sociometrically neglected children have quite positive academic profiles. When compared with average status children, these students reported higher levels of motivation, were described by teachers as more self-regulated learners, as more prosocial and compliant, and as being better liked by teachers. Analyses of two behavioral subgroups of rejected children indicated that aggressive-rejected but not submissive-rejected children have problematic academic profiles. Relations of neglected and aggressive-rejected status to academic adjustment in young adolescents' lives is discussed.

Loneliness and peer relations in young children

Recent studies indicate that feelings of loneliness and social dissatisfaction can be reliably assessed with third- through sixth-grade children, and that children who are sociometrically rejected by their peers are significantly more lonely than other children. The present research was designed (a) to examine whether loneliness could be reliably assessed in a population younger than previously studied, (b) to learn whether young children who are poorly accepted by peers report elevated levels of loneliness and social dissatisfaction, (c) to assess whether young children understand the concept of loneliness, and (d) to examine the behavioral characteristics of lonely young children. Kindergarten and first-grade children (N = 440) responded to a questionnaire about feelings of loneliness and social dissatisfaction in school. A subset of children (N = 46) were individually interviewed to assess their understanding of loneliness. To assess sociometric status and behavior, peers were asked to respond to various sociometric measures and behavioral assessment items. Teachers also provided behavioral information about children using a newly developed instrument. Results indicated that nearly all children understood loneliness, that loneliness was reliably assessed in young children, and that poorly accepted children were more lonely than other children. In addition, children who reported the most loneliness were found to differ from others on several behavioral dimensions.

Assessment of loneliness at school among children with mild mental retardation

This study was designed to determine whether children with mild mental retardation understand the concept of loneliness, whether their feelings of loneliness at school can be reliably assessed, and whether there are differences in loneliness between children with and without mental retardation. Results from a sample of 62 students with mild mental retardation and 62 students without retardation, ages 8 through 13, indicated that (a) high percentages of both groups understood what loneliness means, (b) a loneliness questionnaire yielded satisfactory internal reliability with both groups, and (c) boys but not girls with mental retardation reported significantly more loneliness than did children without mental retardation. Suggestions were made for future research on loneliness in school settings.

The social adaptation of mainstreamed mildly retarded children

The purpose of the present study was to assess the social adaptation of mainstreamed mildly retarded children, comparing them to a matched sample of regular education students. Results indicated that mildly retarded children were quite rejected by their peers, and, compared to nonretarded classmates, they reported significantly more dissatisfaction and anxiety about their peer relations. With respect to behavioral style, there were no group differences in peer- or teacher-reported aggressiveness or disruptiveness. However, retarded children were perceived as more shy and avoidant, as less cooperative, and as less likely to exhibit leadership skills. Further analysis of the behavioral assessment data, via cluster analysis, revealed 2 subtypes of rejected retarded children: an internalizing group perceived as displaying high levels of shy/avoidant behavior and an externalizing group perceived as high in aggressive and/or disruptive behavior. In addition, the internalizing group reported higher social anxiety than did the externalizing group. Implications for school-based intervention research with mildly retarded children are discussed.