Preference heterogeneity for HIV pre-exposure prophylaxis care among gay, bisexual, and other men who have sex with men in the United States: a large discrete choice experiment.

Background: PrEP uptake among Black and Latino gay, bisexual, and other men who have sex with men (GBM) remains low in the United States. The design and implementation of PrEP delivery programs that incorporate the preferences of Black and Latino GBM may overcome barriers to uptake. We aimed to identify preferences for PrEP care among high-priority GBM in the U.S. with a large discrete choice experiment. Methods: We conducted two discreet choice experiments (DCE) to elicit care preferences for (1) Starting PrEP and (2) Continuing PrEP care among GBM clinically indicated for PrEP. The DCE web-based survey was nested in a longitudinal cohort study of GBM in the U.S., implemented with video and audio directions among 16-49 year-old participants, not using PrEP, and verified to be HIV-negative. All participants were presented with 16 choice sets, with choices determined by BLGBM and PrEP implementation stakeholders. We calculated overall utility scores and relative importance and used latent class analyses (LCA) to identify classes within the Starting and Continuing PrEP DCE. Multivariable analysis was performed to identify factors associated with class membership. Findings: Among 1514 participants, mean age was 32 years; 46·5% identified as Latino, 21·4% Black, and 25·2 White; 37·5% had an income less than USD $20,000. Two latent classes were identified for Starting PrEP: Class 1 (n=431 [28·5%]) was driven by preference for more traditional in-person care, and Class 2 (n=1083 [71·5%]) preferred flexible care options and on-demand PrEP. In a multivariable model, having a sexual health doctor (adjusted OR 0·7, CI 0·5, 0·9), having a primary care provider (OR 0·7,CI 0·5, 0·9, p= 0·023), and concerns over PrEP side effects (OR 1·1, CI 1·0,1·2, p= 0·003) were all associated with class membership. Interpretation: The different preferences identified for PrEP care indicate the need for diverse care and formulation choices to improve PrEP uptake and persistence. Addressing these preferences and understanding the factors that shape them can inform the implementation of programs that increase PrEP uptake.

Designing an Observing System to Study the Surface Biology and Geology (SBG) of the Earth in the 2020s.

Observations of planet Earth from space are a critical resource for science and society. Satellite measurements represent very large investments and United States (US) agencies organize their effort to maximize the return on that investment. The US National Research Council conducts a survey of Earth science and applications to prioritize observations for the coming decade. The most recent survey prioritized a visible to shortwave infrared imaging spectrometer and a multispectral thermal infrared imager to meet a range of needs for studying Surface Biology and Geology (SBG). SBG will be the premier integrated observatory for observing the emerging impacts of climate change by characterizing the diversity of plant life and resolving chemical and physiological signatures. It will address wildfire risk, behavior, and recovery as well as responses to hazards such as oil spills, toxic minerals in minelands, harmful algal blooms, landslides, and other geological hazards. The SBG team analyzed needed instrument characteristics (spatial, temporal, and spectral resolutions, measurement uncertainty) and assessed the cost, mass, power, volume, and risk of different architectures. We present an overview of the Research and Applications trade-study analysis of algorithms, calibration and validation needs, and societal applications with specifics of substudies detailed in other articles in this special collection. We provide a value framework to converge from hundreds down to three candidate architectures recommended for development. The analysis identified valuable opportunities for international collaboration to increase the revisit frequency, adding value for all partners, leading to a clear measurement strategy for an observing system architecture.

A pilot study of the use of artificial intelligence with high-fidelity simulations in assessing endovascular procedural competence independent of a human examiner.

BACKGROUND: With increased need for vascular surgery trainees to gain endovascular surgery proficiency, current models of case-numbers and subjective visual assessment are inadequate in capturing the skills required in endovascular surgery. We explored the use of high-fidelity simulators in (1) assessing endovascular surgical competence; (2) clinical decision making; and (3) the reliability of an artificial intelligence (AI) assessor. METHODS: Registrars, fellows and consultants from vascular surgery, interventional radiology and general surgery performed identical procedures on a high-fidelity simulator. Performance was independently assessed using a modified Reznick scale. Scores were compared to raw metric data extracted from the simulator, objective scores extracted from the recordings and analysed by AI. RESULTS: 22 participants were enrolled from vascular surgery (n = 6, 27.3%), interventional radiology (n = 10, 45.5%) and general surgery (n = 6, 27.3%). There were 12 trainees, 2 fellows and 8 consultants. Significant correlations between raw metric data and all categories of the modified Reznick scale except 'respect for tissue' were found. An AI demonstrated positive reliability in all categories, with some predictions being moderately correlated. CONCLUSION: The use of high-fidelity simulators to assess endovascular surgical competence has comparable correlations to the traditional assessment methods with global rating scales, which can be used in formative assessment. AI demonstrates an ability to support assessment but requires further research.

Long-Term Outcomes Following Elective Repair of Intact Abdominal Aortic Aneurysms: A Comparison Between Open Surgical and Endovascular Repair Using Linked Administrative and Clinical Registry Data.

OBJECTIVE: Compare long-term mortality, secondary intervention and secondary rupture following elective endovascular aneurysm repair (EVAR) and open surgical repair (OSR). BACKGROUND: EVAR has surpassed OSR as the most common procedure used to repair abdominal aortic aneurysm (AAA), but evidence regarding long-term outcomes is inconclusive. METHODS: We included patients in linked clinical registry and administrative data undergoing EVAR or OSR for intact AAA between January 2010 and June 2019. We used an inverse probability of treatment-weighted survival analysis to compare all-cause mortality, cause-specific mortality, secondary interventions and secondary rupture, and evaluate the impact of secondary interventions and secondary rupture on all-cause mortality. RESULTS: The study included 3460 EVAR and 427 OSR patients. Compared to OSR, the EVAR all-cause mortality rate was lower in the first 30 days [adjusted hazard ratio (HR) = 0.22, 95% confidence interval (CI) 0.140.33], but higher between 1 and 4 years (HR = 1.29, 95% CI 1.12-1.48) and after 4years (HR = 1.41, 95% CI 1.23-1.63). Secondary intervention rates were higher over the first 30 days (HR = 2.26, 95% CI 1.11-4.59), but lower between 1 and 4years (HR = 0.59, 95% CI 0.48-0.74). Secondary aortic intervention rates were higher across the entire follow-up period (HR = 2.52, 95% CI 2.06-3.07). Secondary rupture rates did not differ significantly (HR = 1.06, 95% CI 0.73-1.55). All-cause mortality beyond 1 year remained significantly higher for EVAR after adjusting for any secondary interventions, or secendary rupture. CONCLUSIONS: EVAR has an early survival benefit compared to OSR. However, elevated long-term mortality and higher rates of secondary aortic interventions and subsequent aneurysm repair suggest that EVAR may be a less durable method of aortic aneurysm exclusion.

Editor's Choice - Comparison of Outcomes for Major Contemporary Endograft Devices Used for Endovascular Repair of Intact Abdominal Aortic Aneurysms.

OBJECTIVE: To compare rates of mortality, rupture, and secondary intervention following endovascular repair (EVAR) of intact abdominal aortic aneurysms (AAA) using contemporary endograft devices from three major manufacturers. METHODS: This was a retrospective cohort study using linked clinical registry (Australasian Vascular Audit) and all payer administrative data. Patients undergoing EVAR for intact AAA between 2010 and 2019 in New South Wales, Australia were identified. Rates of all cause death, secondary rupture, and secondary intervention (subsequent aneurysm repair; other secondary aortic intervention) were compared for patients treated with Cook, Medtronic, and Gore standard devices. Inverse probability of treatment weighted proportional hazards and competing risk regression were used to adjust for patient, clinical, and aneurysm characteristics, using Cook as the referent device. RESULTS: This study identified 2 874 eligible EVAR patients, with a median follow up of 4.1 (maximum 9.5) years. Mortality rates were similar for patients receiving different devices (ranging between 7.0 and 7.3 per 100 person years). There was no statistically significant difference between devices in secondary rupture rates, which ranged between 0.4 and 0.5 per 100 person years. Patients receiving Medtronic and Gore devices tended to have higher crude rates of subsequent aneurysm repair (1.5 per 100 person years) than patients receiving Cook devices (0.8 per 100 person years). This finding remained in the adjusted analysis, but was only statistically significant for Medtronic devices (HR 1.57, 95% CI 1.02 - 2.47; HR 1.73, 95% CI 0.94 - 3.18, respectively). CONCLUSION: Major endograft devices have similar overall long term safety profiles. However, there may be differences in rates of secondary intervention for some devices. This may reflect endograft durability, or patient selection for different devices based on aneurysm anatomy. Continuous comparative assessments are needed to guide evidence for treatment decisions across the range of available devices.

Evaluation of tools to assess operative competence in endovascular procedures: a systematic review.

BACKGROUND: With an increase in the use of endovascular interventions as an alternative to open surgery and the unique technical skills required, current methods for assessing the competence of vascular surgery trainees may not be optimal, suggesting a need for a shift in assessment modalities. We conducted this systematic review to explore current assessment methods used in vascular surgery training to assess competence specific to endovascular procedures. METHODS: A comprehensive literature search was performed with a structured search strategy using terms focusing on endovascular procedures and assessment. Inclusion and exclusion criteria were used in order to screen for suitable articles. RESULTS: We identified 54 articles that satisfied the inclusion criteria. These included a single randomized controlled trial, a single systematic review, a single narrative review and a single literature review, with the vast majority having level 2 evidence. Global rating scales, proficiency assessments and written/oral examinations were described as standard current assessment tools. These modalities lack reproducibility and objectivity, neglecting the needs of assessment of endovascular procedures requiring specialized decision making and finger dexterity. Novel methods such as high fidelity simulation and virtual reality promote reproducible and objective assessment methods in the context of endovascular surgery, and have a promising future. CONCLUSION: While current assessment methods in vascular surgery are widely supported the changing skills required of a vascular surgery trainee warrants a shift in assessment modalities to better align to these requirements. High fidelity simulations show promise, although they require more extensive research to understand their relative merits.

Multicentre Covariate Adjustment Analysis of Short-Term and 5-Year Outcomes after Endovascular Repair according to Sex.

BACKGROUND: Several studies have reported worse outcomes in women compared to men after endovascular aneurysm repair (EVAR). This study aimed to evaluate sex-specific short-term and 5-year outcomes after EVAR. METHODS: A total of 409 consecutive patients underwent elective EVAR from 2004 to 2017 at two tertiary hospitals in Western Australia. Baseline, intraoperative, and postoperative variables were examined retrospectively according to sex. The primary outcome was 30-day mortality (death within 30 days after EVAR). Secondary outcomes were 30-day composite endpoint, length of stay after EVAR, 5-year survival, freedom from reintervention, residual aneurysm size after EVAR, and major adverse event rate at 5-year follow-up. RESULTS: A cohort of 409 patients, comprising 57 women (14%) and 352 men (86%), was analysed. Female patients were older (median age, 76.8 versus 73.5 years, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%. CONCLUSION: This study found no significant differences in 30-day and 5-year outcomes between female and male patients treated with EVAR, implying that EVAR remains a safe treatment choice for female patients.

A Binational Need Assessment to Define the Level of Endovascular Expertise Required by Vascular Surgical Trainees.

BACKGROUND: There has been a shift toward competency-based surgical education programs to improve trainee performance and achieve better patient outcomes. Endovascular procedures comprise a significant volume of vascular surgery, but the current methods for assessing the endovascular competence of vascular trainees in Australia and New Zealand are suboptimal. The objective of this study was to perform a need assessment to define the scope of endovascular expertise required by vascular surgical trainees to later aid in the development of novel surgical training assessment tools. METHODS: A modified Delphi method was used to achieve expert consensus. Fifty-three key stakeholders in vascular surgical education and training (SET) in Australia and New Zealand were invited to take part in the 2-stage survey. Experts were asked which procedures they considered to be requisite for vascular surgery trainees and at which SET level competence should be achieved. The results were reiterated to the expert panel in the second stage, and consensus considered achieved if over 75% of experts were in agreement. RESULTS: In the first stage 25 experts reached consensus that competence in 18 of the 26 procedures should be requisite for SET trainees. Twenty-two experts responded to the second stage and consensus was achieved for 12 out of 14 of the procedural items with mean percentage of experts in agreement being 90%. CONCLUSIONS: A need assessment using a modified Delphi method has achieved consensus among experts in vascular surgery regarding the endovascular procedures considered to be requisite for vascular surgery trainees in Australia and New Zealand.

Satellite sensor requirements for monitoring essential biodiversity variables of coastal ecosystems.

The biodiversity and high productivity of coastal terrestrial and aquatic habitats are the foundation for important benefits to human societies around the world. These globally distributed habitats need frequent and broad systematic assessments, but field surveys only cover a small fraction of these areas. Satellite-based sensors can repeatedly record the visible and near-infrared reflectance spectra that contain the absorption, scattering, and fluorescence signatures of functional phytoplankton groups, colored dissolved matter, and particulate matter near the surface ocean, and of biologically structured habitats (floating and emergent vegetation, benthic habitats like coral, seagrass, and algae). These measures can be incorporated into Essential Biodiversity Variables (EBVs), including the distribution, abundance, and traits of groups of species populations, and used to evaluate habitat fragmentation. However, current and planned satellites are not designed to observe the EBVs that change rapidly with extreme tides, salinity, temperatures, storms, pollution, or physical habitat destruction over scales relevant to human activity. Making these observations requires a new generation of satellite sensors able to sample with these combined characteristics: (1) spatial resolution on the order of 30 to 100-m pixels or smaller; (2) spectral resolution on the order of 5 nm in the visible and 10 nm in the short-wave infrared spectrum (or at least two or more bands at 1,030, 1,240, 1,630, 2,125, and/or 2,260 nm) for atmospheric correction and aquatic and vegetation assessments; (3) radiometric quality with signal to noise ratios (SNR) above 800 (relative to signal levels typical of the open ocean), 14-bit digitization, absolute radiometric calibration <2%, relative calibration of 0.2%, polarization sensitivity <1%, high radiometric stability and linearity, and operations designed to minimize sunglint; and (4) temporal resolution of hours to days. We refer to these combined specifications as H4 imaging. Enabling H4 imaging is vital for the conservation and management of global biodiversity and ecosystem services, including food provisioning and water security. An agile satellite in a 3-d repeat low-Earth orbit could sample 30-km swath images of several hundred coastal habitats daily. Nine H4 satellites would provide weekly coverage of global coastal zones. Such satellite constellations are now feasible and are used in various applications.

Refractory Arterial Insufficiency Associated with Janus Kinase 2 Positive Essential Thrombocythaemia.

Essential thrombocythaemia (ET) is one of the severe rare clonal haematologic stem cell disorders that encompass myeloproliferative neoplasms. ET has a well-described association with peripheral arterial thrombosis, which presents a challenging clinical presentation. Further understanding into the underlying pathophysiology of thrombosis in ET has been made following the identification of the Janus Kinase 2 (JAK2) mutation, which is thought to confer a prothrombotic phenotype. Here we present a case of refractory arterial insufficiency associated with JAK2-positive ET.

Integrating intervention for substance use disorder in a healthcare setting: practice and outcomes in New York City STD clinics.

OBJECTIVE: This article reports the integration and outcomes of implementing intervention services for substance use disorder (SUD) in three New York City public sexually transmitted disease (STD) clinics. METHODS: The screening, brief intervention, and referral to treatment (SBIRT) service model was implemented in the STD clinics in 2008. A relational database was developed, which included screening results, service dispositions, face-to-face interviews with 6-month follow-ups, and treatment information. RESULTS: From February 2008 to the end of September 2012, 146,657 STD clinic patients 18 years or older were screened for current or past substance use disorders; 15,687 received a brief intervention; 954 received referrals to formal substance abuse treatment; 2082 were referred to substance abuse support services such as Alcoholics Anonymous (AA), and 690 were referred to mental health, social or HIV awareness services. Intervention services delivered through SBIRT resulted in improvements in multiple outcomes at 6 month follow-up. Patients who received interventions had reduced SUD risks, fewer mental health problems, and fewer unprotected sexual contacts. CONCLUSION: Delivery of SUD services in a public health setting represents a significant policy and practice change and benefits many individuals whose SUDs might otherwise be overlooked. Intervention services for substance use disorder were integrated and highly utilized in the STD setting. Further research needs to focus on the long-term impact of SUD interventions in the STD setting, their cost effectiveness, and the extent they are financially sustainable under the new healthcare law.

Enhancing crystalline properties of a cardiovascular active pharmaceutical ingredient using a process analytical technology based crystallization feedback control strategy.

Pharmaceutical regulatory bodies require minimal presence of solvent in an active pharmaceutical ingredient (API) after crystallization. From a processing point of view bigger crystals with minimal agglomeration and uniform size distribution are preferred to avoid solvent inclusion and for improved downstream processing. The current work addresses these issues encountered during the production of the potential anti-arrhythmic cardiovascular drug, AZD7009. This paper demonstrates that by applying the automated direct nucleation control (ADNC) approach problems with agglomeration and solvent inclusion were resolved. This model free approach automatically induces temperature cycles in the system, with the number of cycles, temperature range and adaptive heating and cooling rates determined to maintain the number of particles in the system, as measured by a focused beam reflectance measurement (FBRM) probe, within a constant range during the crystallization. The ADNC approach was able to produce larger and more uniform crystals and also removed the residual solvent trapped between the crystals compared to the typical crystallization operation using linear cooling profile. The results illustrate the application of process analytical technologies, such as FBRM and ATR-UV-vis spectroscopy, for the design of optimal crystallization operating conditions for the production of pharmaceuticals, and demonstrate that the ADNC approach can be used for rapid crystallization development for APIs exhibiting problems with agglomeration and solvent inclusion.

Marked reduction of effective radiation dose in patients undergoing CT coronary angiography using prospective ECG gating.

Coronary CT angiography (CCTA) is a rapidly evolving technology which can characterise and image sub clinical atherosclerotic plaque and visualise anatomy and quantitate stenosis. Concern about radiation exposure has limited the uptake of this technology. The aim of this study was to review the radiation dose data in 2298 consecutive patients referred to a single centre in an Australian outpatient setting over 27 months using all available radiation dose reduction strategies. Prospective ECG gating ("step and shoot") was used preferentially in 2025 patients with a mean effective dose of 3.39 ± 1.84 mSv (range 0.86-12.6 mSv). For clinical reasons only 273 patients required retrospective ECG gating, mean dose 19.21 ± 5.58 mSv (range 2.4-34.9 mSv) resulting in an 85.7% reduction in dose for the majority of patients with the low dose technique. In conclusion, most patients referred for routine CCTA can be studied with a radiation dose comparable to invasive X-ray angiography and less than radionuclide myocardial perfusion imaging.

A secure semi-field system for the study of Aedes aegypti.

BACKGROUND: New contained semi-field cages are being developed and used to test novel vector control strategies of dengue and malaria vectors. We herein describe a new Quarantine Insectary Level-2 (QIC-2) laboratory and field cages (James Cook University Mosquito Research Facility Semi-Field System; MRF SFS) that are being used to measure the impact of the endosymbiont Wolbachia pipientis on populations of Aedes aegypti in Cairns Australia. METHODOLOGY/PRINCIPAL FINDINGS: The MRF consists of a single QIC-2 laboratory/insectary that connects through a central corridor to two identical QIC-2 semi-field cages. The semi-field cages are constructed of two layers of 0.25 mm stainless steel wire mesh to prevent escape of mosquitoes and ingress of other insects. The cages are covered by an aluminum security mesh to prevent penetration of the cages by branches and other missiles in the advent of a tropical cyclone. Parts of the cage are protected from UV light and rainfall by 90% shade cloth and a vinyl cover. A wooden structure simulating the understory of a Queenslander-style house is also situated at one end of each cage. The remainder of the internal aspect of the cage is covered with mulch and potted plants to emulate a typical yard. An air conditioning system comprised of two external ACs that feed cooled, moistened air into the cage units. The air is released from the central ceiling beam from a long cloth tube that disperses the airflow and also prevents mosquitoes from escaping the cage via the AC system. Sensors located inside and outside the cage monitor ambient temperature and relative humidity, with AC controlled to match ambient conditions. Data loggers set in the cages and outside found a <2 °C temperature difference. Additional security features include air curtains over exit doors, sticky traps to monitor for escaping mosquitoes between layers of the mesh, a lockable vestibule leading from the connecting corridor to the cage and from inside to outside of the insectary, and screened (0.25 mm mesh) drains within the insectary and the cage. A set of standard operating procedures (SOP) has been developed to ensure that security is maintained and for enhanced surveillance for escaping mosquitoes on the JCU campus where the MRF is located. A cohort of male and female Aedes aegypti mosquitoes were released in the cage and sampled every 3-4 days to determine daily survival within the cage; log linear regression from BG-sentinel trapping collections produced an estimated daily survival of 0.93 and 0.78 for females and males, respectively. CONCLUSIONS/SIGNIFICANCE: The MRF SFS allows us to test novel control strategies within a secure, contained environment. The air-conditioning system maintains conditions within the MRF cages comparable to outside ambient conditions. This cage provides a realistic transitional platform between the laboratory and the field in which to test novel control measures on quarantine level insects.

Surgical practice to reduce dialysis access insufficiency.

BACKGROUND: Patients who are dependant on a percutaneous central venous catheter for dialysis have an excess morbidity and mortality compared with patients with an autologous arteriovenous fistula. METHODS: In an effort to improve outcomes related to episodes of permanent access insufficiency, defined as a patient requiring a venous catheter for haemodialysis, a 12-month prospective audit of surgery carried out to establish and maintain dialysis access was carried out at our institution. RESULTS: Effective measures that reduced the period of time that patients required a venous catheter for dialysis included regular communication between dialysis staff, the surgical service and patients attending for treatment in the dialysis unit, liberal use of duplex ultrasound imaging, pursuing autologous access in the majority of patients, early intervention to correct failing vascular access before conduit thrombosis, using both traditional open surgical and endovascular solutions in establishing and maintaining vascular access, using peritoneal dialysis as a long-term or temporary alternative to haemodialysis and, in cases of arteriovenous polytetrafluoroethylene graft occlusion, early thrombectomy and mandatory revision to provide a conduit immediately available for effective dialysis. CONCLUSION: Conducting an audit of surgical practice contributed to an improvement in outcomes for dialysis-dependant patients. Establishing an arteriovenous fistula in a greater proportion of cases before initiating renal replacement therapy may further address the problem of dialysis access insufficiency.

An investigation of religiosity and the Gastaut-Geschwind syndrome in patients with temporal lobe epilepsy.

We examined the religious experiences of 28 patients with epilepsy and religiosity, 22 patients with epilepsy and no expressed interest in religion, and 30 volunteer regular churchgoers. We profiled the experiences of the first group, revealing more of their phenomenology, but also their bipolarity, and demonstrated that members of the religious group were significantly more likely to have had past episodes of postictal psychosis, and to have bilateral cerebral dysfunction. We added further data to support the validity of the Bear-Fedio Inventory, and noted that although the experiences of patients with epilepsy are different in content and intensity from the experiences of regular churchgoers, the patients with epilepsy and religiosity conform to those who William James referred to as having, with respect to religion, "an acute fever."

Damage control surgery and angiography in cases of acute mesenteric ischaemia.

BACKGROUND: Acute mesenteric arterial occlusion typically presents late and has an estimated mortality of 60-80%. This report examines the evolution of a novel management approach to this difficult surgical problem at a teaching hospital in rural Australia. METHODS: A retrospective review of 20 consecutive cases that presented to Lismore Base Hospital, Lismore, New South Wales, between 1995 and 2003 was performed. RESULTS: Of the 16 patients who were actively treated, 10 survived. Mortality was associated with attempting an emergency operative revascularisation and not performing a second-look laparotomy. All three patients who had a damage control approach at the initial operation survived and in four cases endovascular intervention successfully achieved reperfusion of acutely ischaemic bowel. CONCLUSIONS: Evidence from the series of patients described suggests that damage control surgery and early angiography improve survival in patients suffering acute mesenteric ischaemia. A damage control approach involves emergency resection of ischaemic bowel with no attempt to restore gastrointestinal continuity and formation of a laparostomy. Patients are stabilised in the intensive care unit (ICU) and angiography can be arranged to either plan a definitive bypass procedure or alternatively endovascular therapies can be carried out in an attempt to arrest gastrointestinal infarction. Definitive surgery is then considered after 2-3 days. This approach is particularly attractive if immediate specialist vascular expertise is not available.