Patients with heart rhythm disturbances: variables associated with increased psychologic distress

The spectrum of psychologic distress in patients with serious heart rhythm disturbances (HRD) has not been well defined. A survey of personal and clinical background data and general psychologic status was made of 136 patients with serious HRD defined as sustained or symptomatic ventricular tachycardia or fibrillation. Two questionnaires were used: the SCL-90-R, a standard self-report symptom inventory of present psychologic status, and a functional capacity and occupational status questionnaire developed by us. Of the 105 respondents, 89 completed both questionnaires, the results of which form the basis of this report. The patients with HRD were found to have significantly elevated SCL-90-R scores reflective of an increase in overall psychologic distress (Global Severity Index, Positive Symptom Distress Index, and Positive Symptom Total) as well as significantly higher scores on the specific constructs. Within the HRD population, univariate analysis revealed three variables significantly correlated with increased psychologic distress: (1) requiring long-term antiarrhythmic medication, (2) being forced to modify work status, and (3) having more advanced cardiac impairment. Patients who had two or more of these variables, termed risk factors, reported significantly more symptoms and greater psychologic distress than those with zero or one risk factor. We conclude that patients with serious HRD have greater psychologic distress than do normal subjects. Within the HRD group, patients requiring long-term medical treatment for their arrhythmia, those forced to modify work status, and those with more advanced cardiac impairment are at greater risk for emotional sequelae, and patients with two or more of the identified risk factors are more likely to have elevated psychologic distress.(ABSTRACT TRUNCATED AT 250 WORDS)     

Who are the surgery clerkship directors and what are their educational needs?

BACKGROUND: The surgery clerkship director is a key individual in the surgery department's educational mission and yet there has been no prior effort to describe this group or identify their learning needs. The purpose of this study was to develop a demographic profile and an educational needs assessment for surgery clerkship directors. METHODS: A survey instrument was designed based on existing literature and distributed to surgery clerkship directors in the United States and Canada. RESULTS: Surveys were returned from 108 subjects (77%). The majority of clerkship directors strongly agree that directing is a positive experience but express concern that the job demands may impede their professional careers. The perceived educational needs identified related primarily to the development and management of the student education curriculum. CONCLUSIONS: Surgery clerkship directors are experienced academic surgeons who report high levels of satisfaction. They identify a number of important educational needs of the position and express concern about the requirements of the position on their academic careers.     

Exploring social cognitive theory constructs for promoting exercise among breast cancer patients

Physical activity during breast cancer treatment can significantly reduce treatment-related fatigue and improve quality of life. Unfortunately, the majority of women with breast cancer either do not exercise at all or exercise below recommended levels. Little is known about how to enhance physical activity among breast cancer patients. The social cognitive theory, a useful framework for the design of physical activity interventions, has not been studied among breast cancer patients. Our study purpose was to explore physical activity knowledge, attitudes, and behaviors among breast cancer patients during adjuvant therapy utilizing social cognitive theory constructs in preparation for a larger, survey study and future intervention research. Twelve breast cancer patients attended 1 of 3 focus group sessions. Focus group questions were based on the social cognitive theory constructs of self-efficacy, environment, behavioral capability, expectations, expectancies, self-control and performance, observational learning, and reinforcement. The focus group participants generally felt confident in their ability to exercise during treatment if fatigue, time management, and social networking were addressed. The majority of participants had not been given information related to exercise by their physicians during treatment. The participants felt that exercise was more beneficial than harmful during treatment, with the 2 most important benefits identified as reduced fatigue and the potential for improved survival. The use of reinforcements by participants was minimal. The participants consistently expressed the desire for education and guidance by knowledgeable staff during an exercise program. Walking was the most acceptable exercise modality. Social cognitive theory may be a useful framework for future study of exercise behavior among breast cancer patients and measurement of constructs related to this theory should be included in such studies. Future exercise intervention studies should consider the unique barriers and program preferences of breast cancer patients while focusing on self-efficacy, outcome expectations/ expectancies, observational learning, and reinforcements.     

Novel Multiphase Assessment for Predicting Left Ventricular Outflow Tract Obstruction Before Transcatheter Mitral Valve Replacement

ObjectivesThis study proposes a physiologic assessment of left ventricular outflow tract obstruction (LVOTO) that accommodates changes in systolic flow and accounts for the dynamic neo–left ventricular outflow tract (LVOT).BackgroundPatients considered for transcatheter mitral valve replacement trials often screen-fail because of the perceived risk of LVOTO. In the Intrepid Global Pilot Study, assumed risk of LVOTO was based on computed tomography estimates of the neo-LVOT area computed at end-systole. However, this may overestimate actual risk.MethodsRetrospective analyses were performed for screen-failed patients for potential LVOTO (n = 33) and treated patients (n = 29) with available dynamic computed tomography. A multiphase assessment of the neo-LVOT area was performed and represented as: 1) multiphase average; and 2) early systolic value. Prospective evaluation was performed in 9 patients approved for enrollment with multiphase and early systole methods that would have previously screen-failed with the end-systolic approach.ResultsOf 166 patients screened for possible inclusion; 32 were screen-failed for nonanatomical reasons. Screen failure for assumed LVOTO risk occurred in 37 of 134 (27.6%) patients. Retrospective analysis indicated a potential enrollment increase of 11 of 33 (33.3%) and 18 of 33 (54.5%) patients using multiphase and early systolic assessment methods. In the prospective cohort, there were no clinical observations of LVOTO 30 days post-procedure, despite assumed risk based on end-systolic estimates.ConclusionsMultiphase, and specifically early systolic, assessment of the neo-LVOT may better determine risk of LVOTO with transcatheter mitral valve replacement compared with end-systolic estimates. This novel approach has the potential to significantly increase patient eligibility, with over one-half of patients previously screen-failed now eligible for treatment.     

A Novel BMPR2 Mutation Associated with Pulmonary Arterial Hypertension in an Octogenarian

We describe the case of an 83-year-old man with a family history of pulmonary hypertension (PH) who presented with severe pulmonary arterial hypertension (PAH) and later tested positive for a novel bone morphogenetic protein receptor 2 (BMPR2) gene mutation. To our knowledge, this may be the oldest reported patient with PAH in whom a BMPR2 mutation was initially identified.     

Development of a peer review of operative teaching process and assessment tool

BackgroundWhile teaching evaluation systems are common in academia, very little information is available regarding formal coaching and peer review of teaching performance in surgery. This article is a report on the development and implementation of a peer review of operative teaching program.MethodsOur process was designed using a multistep sequential model which included developing a peer review of teaching instrument that was piloted to study the efficacy and utility of the tool.ResultsThirty-nine peer reviews of teaching were conducted. Among the most frequent challenges that faculty identified were allowing residents to struggle/give autonomy, judging when to take over the case, communicating effectively, being patient, balancing education and patient safety, and giving feedback.ConclusionsOur peer review of teaching program is systematic, feasible, and can be adopted by other surgery departments. Faculty’s identified strengths and challenges have been incorporated into our faculty development curricula.