A comprehensive deep venous thrombosis prophylaxis regimen in isolated coronary artery bypass grafting.

Objectives: Deep venous thrombosis (DVT) is a known surgical complication that can lead to pulmonary embolism with subsequent morbidity and mortality. The incidence of DVT following coronary artery bypass grafting is unclear. Prophylaxis regimens vary and some guidelines advocate against use of routine chemoprophylaxis in patients at low-moderate risk for venous thromboembolism. We utilized postoperative lower extremity venous ultrasound to determine the incidence of DVT following coronary artery bypass grafting in patients with low- to moderate-risk of venous thromboembolism receiving aggressive postoperative DVT prophylaxis. Methods: This is a single-center, retrospective study of all patients who underwent coronary artery bypass grafting between April 2022 and January 2023. All patients who completed postoperative venous ultrasound of the bilateral lower extremities were initially included. Patients who underwent concurrent valve or aortic surgery, were at high risk of venous thromboembolism, or were receiving anticoagulation therapy for nonvenous thromboembolism indications were excluded. The primary outcome was in-hospital incidence of DVT. Secondary outcomes were rates of mortality, postoperative bleeding, and thromboembolic events from discharge to 30 days postoperatively and from 30 days to 3 months postoperatively. Results: No DVTs were observed in 211 included patients. In hospital, there were 3 significant bleeding events and 1 stroke. Following discharge there were 3 additional bleeding events, 1 death, 1 transient ischemic attack, and 1 pulmonary embolism. Conclusions: We observed a 0% rate of DVT in low- to moderate-risk patients undergoing isolated coronary artery bypass grafting and receiving a comprehensive DVT prophylaxis regimen. In hospital bleeding and other thromboembolic event rates were 2.84% and 0.47% respectively.

Long-term results of the treatment of aortic graft infection by in situ replacement with femoral popliteal vein grafts.

OBJECTIVE: Graft excision and neo-aortoiliac system (NAIS) reconstruction with large caliber, femoral popliteal vein (FPV) grafts have been reported as successful treatment of aortic graft infection (AGI) in several small series with limited follow-up. The goal of this study was to evaluate long-term outcomes in large cohort of consecutive patients treated with NAIS for AGI. METHODS: From 1990 to 2006, 187 patients (age: 63 +/- 10 years) with AGI were treated with in situ reconstructions using 336 FPV grafts. Data from a prospectively maintained data base were analyzed. RESULTS: NAIS reconstruction was performed for 144 infected aortofemoral bypasses, 21 infected aortic-iliac grafts, and 22 infected axillofemoral bypasses that had been placed to treat AGI. Polymicrobial cultures were present in 37% while 17% showed no growth. There were 55% gram positive, 32% gram negative, 13% anaerobic, and 18% fungal infections. The mean Society for Vascular Surgery run-off resistance score was 4.5 +/- 2.3. Concomitant infrainguinal bypass was necessary in 27 (14%) patients (32 limbs). Major amputations were performed in 14 (7.4%) patients. Out of 14 amputations, five patients had irreversible ischemia and in four, there was no conduit available. Graft disruption from reinfection occurred in 10 patients (5%). While 30-day mortality was 10%, procedure-related mortality was 14%. Independent risk factors for perioperative death on multivariate analysis were: preoperative sepsis (odds ratio [OR] 3.5) ASA class 4 (OR 2.9), Candida species (OR 3.4), Candida glabrata (OR 7.6), Klebsiella pneumoniae (OR 3.5), and Bacteroides fragilis (OR 4.1). Perioperative factors included use of platelets (OR 2.4), blood loss >3.0 liters (OR 9.5). Cumulative primary patency at 72 months was 81%; secondary/assisted primary patency was 91%. Limb salvage at 72 months was 89%. Five-year survival was 52%. CONCLUSIONS: These results compare favorably with other methods of treating AGI, especially in patients with multilevel occlusive disease. Principle advantages include acceptable perioperative mortality, low amputation rate, superior durability with excellent long-term patency, and freedom from secondary interventions and recurrent infections.

Imperfect physician assistant and physical therapist admissions processes in the United States.

We compared and contrasted physician assistant and physical therapy profession admissions processes based on the similar number of accredited programs in the United States and the co-existence of many programs in the same school of health professions, because both professions conduct similar centralized application procedures administered by the same organization. Many studies are critical of the fallibility and inadequate scientific rigor of the high-stakes nature of health professions admissions decisions, yet typical admission processes remain very similar. Cognitive variables, most notably undergraduate grade point averages, have been shown to be the best predictors of academic achievement in the health professions. The variability of non-cognitive attributes assessed and the methods used to measure them have come under increasing scrutiny in the literature. The variance in health professions students' performance in the classroom and on certifying examinations remains unexplained, and cognitive considerations vary considerably between and among programs that describe them. One uncertainty resulting from this review is whether or not desired candidate attributes highly sought after by individual programs are more student-centered or graduate-centered. Based on the findings from the literature, we suggest that student success in the classroom versus the clinic is based on a different set of variables. Given the range of positions and general lack of reliability and validity in studies of non-cognitive admissions attributes, we think that health professions admissions processes remain imperfect works in progress.

Physician assistant education: an analysis of the Journal of Physician Assistant Education.

PURPOSE: The literature of a profession reflects its vitality, activity, and intellectual temperature. A thorough review of literature can reveal areas of growth and improvement as well as serve as a means to share relevant research accomplishments. As the physician assistant (PA) education profession continues to thrive and expand, it is important for the literature that reflects the profession to also develop and expand its audience. METHODS: A retrospective, systematic analysis of published research articles in the Journal of Physician Assistant Education (JPAE) and its predecessor publication, Perspective on Physician Assistant Education, from 2001-2011 (N = 145) was conducted. Articles were organized by study topic, cohort of interest, and methodology and further analyzed to determine respective response rates and frequency of topics. RESULTS: Nearly one-fourth of all articles considered were dedicated to studying various PA curricula. Methodological approaches used in these studies tended toward Internet-based surveys, but telephone-based surveys retained the highest response rate (97%). Among study subjects (cohorts) examined, the most frequently studied cohort consisted of PA students, who displayed high response rates (74.4%). CONCLUSION: The total number of articles published in JPAE increased annually; study methodology reflects a predominance of survey research approaches. Analysis from this review of 10 years of JPAE content suggests that studies using effective methodology to gain high response rates, those that have more sophisticated designs and use appropriate statistical measures, and those that aim to reach a more diverse pool of cohorts may be future goals.

Predictive ability of the Graduate Record Examination and its usage across physician assistant programs.

PURPOSE: The Graduate Record Examination (GRE) is used by 47% of physician assistant (PA) programs. In the liberal arts education literature, GRE scores have generally correlated with graduate school grade point average (GPA), particularly when used in combination with other admission factors such as undergraduate GPA. In the health professions, data on the predictive ability of the GRE are mixed. The Educational Testing Service (ETS), which administers the GRE, recommends standards for usage of GRE scores, including that they not be used as a stand-alone criterion for denial of admission. We evaluated GRE usage by PA programs to determine score utilization and compliance with ETS guidelines. METHODS: We reviewed the admissions criteria of ARC-PA accredited programs granting master's degrees. Each program's GRE requirements were compared with ETS guidelines. RESULTS: Of 70 master's level PA programs requiring the GRE for admission, 27 programs comply with ETS guidelines; 43 programs use scores incorrectly by requiring or recommending precise minimum scores or by allowing other admissions exams to substitute for the GRE. CONCLUSION: Of the 70 master's degree level PA programs requiring the GRE for admission, only 40% are applying scores in accordance with ETS guidelines. Because the majority of programs are not using GRE scores as recommended, and because current data on the predictive value of the GRE are incongruent, it is important to determine how the GRE relates to the requirements of each program. Further research on the use and predictability of GRE scores by each PA program would be valuable.

Aortic reconstruction with femoral-popliteal vein: graft stenosis incidence, risk and reintervention.

BACKGROUND: Management using femoral-popliteal vein (FPV) of aortic graft infections, failing aortofemoral bypass, and aortoiliac occlusive disease in young patients with a small aorta is now an accepted therapeutic method and is performed frequently at our institution. A high reintervention rate for FPV graft stenosis has recently been reported. The purpose of this study was to determine the incidence of FPV graft failure due to stenosis after neoaortoiliac system (NAIS) reconstruction, and to identify risk factors for this complication. METHODS: A review was performed of 240 patients who underwent NAIS reconstruction at our institution between January 1991 and December 2005. All patients were entered into a prospective database and were evaluated for the incidence of vein graft stenosis requiring reintervention, risk factors for stenosis, and the rate and type of reintervention required to assist patency. Patients with occlusion are evaluated and reported, but excluded from detailed analysis. Risk factors assessed included gender, operative features, FPV size (diameter), smoking history, and medical comorbidities. RESULTS: Of the 240 NAIS procedures performed during this time period, 11 (4.6%) patients have required 12 graft revisions (one patient required a second intervention) for stenosis using open and endovascular techniques. Over the same time period, graft occlusion occurred in nine patients (3.8%). This provided a primary patency at 2 and 5 years of 87% and 82%, and an assisted primary patency rate of 96% and 94%. Mean time to revision was 23.5 months (range 5.5 to 83.5 months). Median FPV graft size in the nonrevised patients was 7.8 mm (range 4.0 to 11.4 mm), and 6.4 mm (range 4.7 to 8.7 mm) in the revised group (P = .006). Survival analysis revealed small vein graft size (<7.2 mm), coronary artery disease (CAD), and extensive smoking history as independent predictors of time to stenosis (P = .002, .02, .01, respectively), with multivariable analysis confirming these results (P = .002, .06, .012). Patients with CAD combined with small graft size were found to be at especially high risk for stenosis, with 8/36 (22.2%) requiring revision vs 3/184 (1.6%) of patients without both factors (P < .0001). CONCLUSIONS: FPV graft stenosis requiring revision after NAIS reconstruction is uncommon. Risk factors for stenosis include small graft size, history of CAD, and smoking. All patients merit aggressive counseling for smoking cessation, and patients exhibiting multiple risk factors should undergo close postoperative surveillance for graft stenosis.

Late incidence of chronic venous insufficiency after deep vein harvest.

BACKGROUND: The deep veins (DV) of the thigh have proven to be versatile autogenous conduits for arterial reconstruction. Harvesting DV poses a theoretical risk of compromising venous outflow of the limb, which could predispose to chronic venous morbidity. The purpose of this study was to define the late incidence of chronic venous insufficiency (CVI) and to characterize the long-term alterations in venous physiology after DV harvest. METHODS: Since 1991, 269 patients have undergone arterial reconstructions using DV at our facility. Patients with DV harvest at least 43 months prior to the study (n = 151) were eligible for inclusion. Eighty-nine patients were excluded (deceased = 70; lost to follow-up = 19). Forty-six patients who declined formal testing were queried by phone for signs and symptoms of CVI. The current study presents a case-control series of 16 patients (27 limbs) after DV harvest and six age- and gender-matched control patients (12 limbs) who underwent examination and venous testing. RESULTS: At a mean follow-up of 70.1 +/- 5.6 months, 23 of 27 limbs (85.2%) had no significant CVI (CEAP C(0) to C(2)). Four limbs (14.8%) had significant venous morbidity (C(3) to C(6)), including edema alone (C(3); n = 2 limbs), edema with skin changes (C(4); n = 1 limb), and a healed venous ulceration (C(5); n = 1 limb). APG testing confirmed relative venous outflow obstruction after DV harvest (mean outflow fraction: harvested limbs = 38.4 +/- 3.9% vs control limbs = 51.7 +/- 4.3%; P = .04). Despite the relative outflow obstruction, the mean VFI was not significantly different between harvested and control limbs (harvested limbs = 1.08 +/- 0.15% vs control limbs = 0.77 +/- 0.16%; P = .19). DV harvest resulted in no significant changes in calf ejection fraction (harvested limbs = 67.4 +/- 6.4% vs control limbs = 86.8 +/- 9.5%; P = .09) or residual volume fraction measured (harvested limbs = 32.3 +/- 6.4% vs control limbs = 47.7 +/- 11.6%; P = .22). Of the 46 patients interviewed by phone, five (10.9%) reported bilateral amputations, seven (15.2%) reported chronic edema in their harvested limbs (C(3)), and 34 (73.9%) reported no signs of CVI in their harvested limbs (C(0)). CONCLUSIONS: Deep vein harvest produces few symptoms of chronic venous insufficiency, and venous ulceration is infrequent. Despite relative venous outflow obstruction, noninvasive indices of chronic venous insufficiency on APG are often normal, suggesting that the risk of developing venous ulceration is low in the majority of patients after DV harvest.