Socioeconomic Status Based on Area Deprivation Index Does Not Affect Postoperative Outcomes in Patients Undergoing Endovascular Aortic Aneurysm Repair in the VA Healthcare System.

INTRODUCTION: Living conditions and socioeconomic status are known to impact individual health and access to medical care. Prior research has validated the Area Deprivation Index (ADI) tool as a measure of socioeconomic disadvantage for a given locality. Living in a neighborhood with a higher ADI score has been associated with increased rates of hospital readmission due to complications following surgery. We set forth to identify the possible associations between a patient's ADI score and post-operative endovascular aneurysm repair (EVAR) outcomes in the Veterans Health Care Administration (VHA). METHODS: We retrospectively analyzed the outcomes of patients who underwent EVAR from January 2010 to December 2021 at a Level 1A VHA Hospital. Patient demographics and intra-operative variables were obtained. ADI score was calculated based on home addresses and resulted in a local score on a scale of 1-10 and a national percentile on a scale of 1-100. We then further stratified these patients into local and national quintile groups. Local ADI 1 included scores of 1-2, and local ADI 5 included scores of 9-10. National ADI 1 comprised scores 1-20, and national ADI 5 scored 81-100. The other scores were equally divided into ADI 2, 3, and 4. Higher ADI scores were associated with lower socioeconomic status. We identified clinical outcomes, including wound infection, respiratory failure, urinary tract infection, acute kidney injury, limb stenosis, readmission, length of stay, and subsequent re-intervention rates. RESULTS: 241 patients underwent EVAR over the time period examined. 57.3% (n=138) of patients were in quintiles 4 and 5 for local ADI; when national ADI percentiles organized these same patients, 47.3% (n=114) were in quintiles 4 and 5. Patient demographics did not vary between the local and national groups. We saw no statistically significant difference in intra-operative variables, postoperative complications, readmission, loss to follow-up, or 1-year mortality rates across ADI quintiles at the local or national level. Binary Logistic Regression showed no statistical significance for local and national ADI quintiles for hospital readmission and overall postoperative complications. CONCLUSION: We found that there was no statistical significance between hospital readmission rates or worse surgical outcomes across local and national ADI quintiles. This suggests that the VHA resources and multidisciplinary support may improve care across neighborhoods. This comprehensive care provided at VHA may mitigate post-operative complications in patients undergoing EVARs. Further research is warranted to investigate the role of area deprivation in healthcare and EVAR outcomes in a veteran population.

Diagnosis of mental illness does not affect postoperative outcomes in patients undergoing endovascular aortic aneurysm repair in the VA healthcare system.

OBJECTIVE: Mental illness can be a debilitating chronic disease associated with a higher likelihood of preexisting medical comorbidities and postoperative morbidity and mortality. Given the relative prevalence of mental health disorders among the veteran population, we sought to examine postoperative outcomes in patients undergoing endovascular aortic aneurysm repair (EVAR). METHODS: Retrospective review of a single institution Veterans Administration Hospital operative database was used to identify patients who underwent EVAR from January 2010 to December 2021. Patients' demographics, comorbidities, medications, and intraoperative variables were collected. In addition, mental illness status was evaluated to stratify patients based on preexisting anxiety, depression, posttraumatic stress disorder, substance abuse disorder, or major psychiatric illness. The study's primary outcomes were postoperative complications, mortality, and follow-up rates. Secondary outcomes included hospital length of stay, readmission rates, and intervention rates. RESULTS: A total of 241 patients underwent infrarenal EVARs at our institution. One hundred forty patients (58.1%) were diagnosed with mental illness, whereas 101 (41.9%) had no prior diagnosis of mental illness. Of the 241 patients, 65.7% had a history of substance abuse disorder, 38.6% depression, 29.3% post-traumatic stress disorder, 19.3% anxiety, and 3.6% major psychiatric illness. There was no statistical difference in the number of medical comorbidities, race, smoking status, or medications compared with patients without mental illness. We found no statistical difference in access type, wound infection rates, hypogastric coiling, estimated blood loss, and operating time. χ2 analysis demonstrated a statistically significant lower overall postoperative complication rate (28.6% vs 32.7%; P = .05) and decreased loss to follow-up (8.6% vs 15.8%; P = .05) among patients with a preexisting mental illness diagnosis. There were no statistically significant differences in readmission rate, length of stay, or 30-day mortality. When stratified by type of mental illness, binary logistic regression demonstrated no statistically significant differences in primary outcomes of postoperative complications, readmission rates, loss to follow-up, and 1-year mortality. Cox proportional hazards modeling demonstrated no significant difference in cumulative survival in patients diagnosed with a mental illness (0.56; 95% confidence interval, 0.29-0.107; P = .08). CONCLUSIONS: There was no association between the presence of a prior mental health diagnosis and adverse outcomes following EVAR. Preceding mental illness did not correlate with an increased rate of complications, readmission, length of stay, or 30-day mortality in a veteran population. Lower loss to follow-up rates in patients with mental illness may reflect overall Veterans Health Administration expansion in resources and surveillance of these at-risk individuals. Further research is needed to assess the association between postoperative outcomes and mental illness.

Key role of mitochondrial mutation Leu107Ser (COX1) in deltamethrin resistance in salmon lice (Lepeophtheirus salmonis).

The pyrethroid deltamethrin (DTM) is used to treat Atlantic salmon (Salmo salar) against salmon louse (Lepeophtheirus salmonis) infestations. However, DTM resistance has evolved in L. salmonis and is currently common in the North Atlantic. This study aimed to re-assess the association between DTM resistance and mitochondrial (mtDNA) mutations demonstrated in previous reports. Among 218 L. salmonis collected in Scotland in 2018-2019, 89.4% showed DTM resistance in bioassays, while 93.6% expressed at least one of four mtDNA single nucleotide polymorphisms (SNPs) previously shown to be resistance associated. Genotyping at further 14 SNP loci allowed to define three resistance-associated mtDNA haplotypes, named 2, 3 and 4, occurring in 72.0%, 14.2% and 7.3% of samples, respectively. L. salmonis strains IoA-02 (haplotype 2) and IoA-10 (haplotype 3) both showed high levels (~ 100-fold) of DTM resistance, which was inherited maternally in crossing experiments. MtDNA haplotypes 2 and 3 differed in genotype for 17 of 18 studied SNPs, but shared one mutation that causes an amino acid change (Leu107Ser) in the cytochrome c oxidase subunit 1 (COX1) and was present in all DTM resistant while lacking in all susceptible parasites. We conclude that Leu107Ser (COX1) is a main genetic determinant of DTM resistance in L. salmonis.

Modern Lower Extremity Bypass Outcomes by Anesthesia Type in the Veteran Population.

BACKGROUND: Lower extremity bypass (LEB) revascularization can be performed under general (GA) or neuraxial anesthesia (NA). Studies show that the use of NA may decrease morbidity, 30-day mortality, and hospital length-of-stay (LOS). The goal of our analysis is to examine the differences in postsurgical outcomes following LEB between patients who undergo GA compared to NA in the Veteran Affairs Surgical Quality Improvement Program (VASQIP) database. METHODS: After IRB approval, the VASQIP database was assessed for patients who underwent LEB between 1998-2018. Only infrainguinal bypass procedures and anesthesia type classified as "general," "epidural," or "spinal" were included. The neuraxial cohort includes both spinal and epidural anesthesia patients. The Risk Analysis Index (RAI), a validated measure of frailty, was additionally calculated for each patient. Chi squared, paired t-test, and binary logistic regression were used to compare the cohorts. RESULTS: During this period, 22,960 veterans underwent LEB recorded in VASQIP. Compared to those who underwent surgery under GA, patients with procedures performed using NA were older (66.4 ± 9.6 years vs. 65.3 ± 9 years respectively; P <0.001) and more frail (average RAI score 25.7 ± 7.0 vs. 24.9 ± 6.7; P < 0.001). Operative time was shorter in the NA group (4.1 ± 1.7 hrs vs. 4.7 ± 3.0 hrs; P < 0.001) and fewer cases were emergent (1.55% vs. 4.13%; P <0.001). Patients in the GA group had higher rates of postoperative prolonged ileus (0.31% vs. 0.00%; P = 0.03), pneumonia (1.60% vs. 1.06%; P = 0.025), deep wound infection (2.67% vs. 2.61%; P = 0.01), sepsis (1.68% vs. 0.79%; P < 0.001), reintubation (1.80% vs. 1.30%) (P = 0.04),and number of packed red blood cell (pRBC) transfused intraoperatively (0.39 ± 1.21 units vs. 0.22 ± 0.79 units; P <0.001). There was no significant difference in rate of graft failure, return to the OR, myocardial infarction, death, or LOS. In regression analysis, those undergoing NA were less likely to require pRBC transfusion intraoperatively (OR: 0.43; 95% CI: 0.31-0.61; P < 0.001), however no other outcomes reached statistical significance. CONCLUSION: Although younger and less frail, veteran patients undergoing GA for lower extremity revascularization had higher rates of postoperative ileus, pneumonia, deep wound infection, sepsis, and need for transfusion as compared to those undergoing NA. There was no significant difference in the rate of other major complications, myocardial infarction, death or LOS. After adjustment, only intraoperative transfusion remained statistically significant, likely reflecting longer and more complex cases for those that undergo general anesthesia rather than the effect of anesthetic choice itself.

Frailty Measurement and Implications for Cerebrovascular Disease Management in a Veteran Based Population.

BACKGROUND: Rapid and objective preoperative assessment of patients undergoing carotid endarterectomy (CEA) remains difficult and variable. The Risk Analysis Index (RAI) is a validated medical record-based assessment of frailty that has been used to predict clinical outcomes for patients undergoing surgical procedures including CEA. We applied RAI to a veteran population following CEA for asymptomatic cerebrovascular disease and examined the factors related to post-operative morbidity and mortality. METHODS: After obtaining IRB approval, Veteran Affairs Surgical Quality Improvement Program data was queried for CEA procedures from 2002 to 2015 for ICD-9 codes indicating asymptomatic patients. RAI was then calculated based on Veteran Affairs Surgical Quality Improvement Program variable medical record extraction. Three groupings of patients were undertaken including non-frail (RAI < 30), frail (RAI 30-34) and very frail (RAI ≥ 35). Chi squared and ANOVA were used to assess cohort differences. Binary logistic regression was used to evaluate predictors of post-operative stroke, myocardial infarction (MI), any complication, and death. RESULTS: Between 2002 and 2015, 37,873 asymptomatic patients underwent CEA. Over 98% (37,266) of the patients were male with an average age of 68.3 ± 8.55 years. The cohorts contained 82.8% (n = 31,362), 12.4% (n = 4,678), and 4.8% (n = 1,833) for the non-frail, frail and very frail groups respectively. Frailty was associated with increased rates of post-operative stroke, MI, any complication, death, and longer hospital length of stay (P< 0.001). Operative time did not significantly differ between the groups. Increasing frailty was associated with having one or more complications (OR 1.69, 95% CI 1.50-1.90 for frail and OR 2.79, 95% CI 2.41-3.24 for very frail, (P< 0.001), post-operative stroke in frail (OR 1.33 95% CI 1.06-1.67) and very frail (OR 1.57 1 95% CI 1.14-2.16) patients, and MI in both frail (OR 1.68, CI 1.17-2.43) and very frail (OR 3.73, CI 2.52-5.51) patients. Frailty was also significantly associated with death with in very frail patients (OR 4.14, 95% CI 3.00-5.71, P< 0.001). CONCLUSION: Increasing frailty as determined by RAI was associated with worse post-operative outcomes in asymptomatic patients undergoing CEA. Higher RAI score cohorts were associated with higher rates of postoperative stroke, MI, complications, and death. We recommend the use of this frailty index as a screening tool to guide risk discussions with asymptomatic patients undergoing CEA.

How We Do It: Implementing a Virtual, Multi-Institutional Collaborative Education Model for the COVID-19 Pandemic and Beyond.

OBJECTIVE: To describe the implementation of a virtual, multi-institutional educational collaboration involving over 50 general surgery residency programs during the COVID-19 pandemic that enabled enhanced learning for surgical residents despite social-distancing requirements. DESIGN: Description of Virginia Commonwealth University's virtual educational augmentation program and the development of a collaborative teaching network during the coronavirus pandemic. SETTING: This collaboration was initiated by Virginia Commonwealth University's Department of Surgery, Richmond, VA, and grew to include general surgery residency programs from across the nation. PARTICIPANTS: General surgery residents and faculty from Departments of General Surgery were recruited locally via direct emails and nationally via the Association of Program Directors' listserv and Twitter. In total, 52 institutions participated from every part of the country. RESULTS: A virtual, multi-institutional collaborative lecture series was initiated that grew to involve over 50 general surgery residency programs, allowing for daily didactics by experts in their fields during the initial surge of the COVID-19 pandemic, while maintaining social distancing and the provision of essential clinical care. CONCLUSION: A multi-institutional collaboration enabled continued didactic education during the coronavirus pandemic, vastly broadening the expertise, scope and variety available to residents, while decreasing burden on faculty. We believe this can serve as a framework for future multi-institutional collaborations that extend beyond the COVID-19 era.

Investigation of deltamethrin resistance in salmon lice (Lepeophtheirus salmonis) provides no evidence for roles of mutations in voltage-gated sodium channels.

BACKGROUND: The pyrethroid deltamethrin is used to treat infestations of farmed salmon by parasitic salmon lice, Lepeophtheirus salmonis (Krøyer). However, the efficacy of deltamethrin for salmon delousing is threatened by resistance development. In terrestrial arthropods, knockdown resistance (kdr) mutations of the voltage-gated sodium channel (Nav ), the molecular target for pyrethroids, can cause deltamethrin resistance. A putative kdr mutation of an L. salmonis sodium channel homologue (LsNav 1.3 I936V) has been identified previously. At the same time, deltamethrin resistance of L. salmonis has been shown to be inherited maternally and to be associated with mitochondrial DNA (mtDNA) mutations. This study assessed potential roles of the above putative kdr mutation as a determinant of deltamethrin resistance in laboratory strains and field populations of L. salmonis. RESULTS: The deltamethrin-resistant L. salmonis strain IoA-02 expresses the LsNav 1.3 I936V mutation but was susceptible to the non-ester pyrethroid etofenprox, a compound against which pyrethroid-resistant arthropods are usually cross-resistant if resistance is caused by Nav mutations. In a family derived from a cross between an IoA-02 male and a drug-susceptible female lacking the kdr mutation, deltamethrin resistance was not associated with the genotype at the LsNav 1.3 locus (P > 0.05). Similarly, in Scottish field populations of L. salmonis, LsNav 1.3 I936V showed no association with deltamethrin resistance. By contrast, genotypes at the mtDNA loci A14013G and A9030G were significantly associated with deltamethrin resistance (P < 0.001). CONCLUSION: In the studied L. salmonis isolates, deltamethrin resistance was unrelated to the LsNav 1.3 I936V mutation, but showed close association with mtDNA mutations.

Multi-institutional Collaborative Surgery Education Didactics: Virtual Adaptations During a Global Pandemic.

OBJECTIVE: The COVID-19 pandemic has disrupted graduate medical education, impacting Accreditation Council for Graduate Medical Education (ACGME)-mandated didactics. We aimed to study the utility of 2 methods of virtual learning: the daily National Surgery Resident Lecture Series (NSRLS), and weekly "SCORE School" educational webinars designed around the Surgical Council on Resident Education (SCORE) curriculum. DESIGN AND SETTING: NSRLS: The National Surgery Resident Lecture Series was a daily virtual educational session initially led by faculty at an individual surgical residency program. Thirty-eight lectures were assessed for number of live viewings (March 23, 2020-May 15, 2020). SCORE SCHOOL: Attendance at eleven weekly SCORE educational webinars was characterized into live and asynchronous viewings (May 13, 2020-August 5, 2020). Each 1-hour live webinar was produced by SCORE on a Wednesday evening and featured nationally recognized surgeon educators using an online platform that allowed for audience interaction. RESULTS: NSRLS: There were a mean of 71 live viewers per NSRLS session (range 19-118). Participation began to decline in the final 2 weeks as elective case volumes increased, but sessions remained well-attended. SCORE SCHOOL: There were a range of 164-3889 live viewers per SCORE School session. Sessions have most commonly been viewed asynchronously (89.8% of viewings). Live viewership decreased as the academic year ended and then rebounded with the start of the new academic year (range 4.9%-27%). Overall, the eight webinars were viewed 11,135 times. Each webinar continues to be viewed a mean of 43 times a day (range 0-102). Overall, the eleven webinars have been viewed a total of 22,722 times. CONCLUSIONS: Virtual didactics aimed at surgical residents are feasible, well-attended (both live and recorded), and have high levels of viewer engagement. We have observed that careful coordination of timing and topics is ideal. The ability for asynchronous viewing is particularly important for attendance. As the COVID-19 pandemic continues to disrupt healthcare systems, training programs must continue to adapt to education via virtual platforms.

Maternal inheritance of deltamethrin resistance in the salmon louse Lepeophtheirus salmonis (Krøyer) is associated with unique mtDNA haplotypes.

Parasitic infections by the salmon louse, Lepeophtheirus salmonis (Krøyer), cause huge economic damage in salmon farming in the northern hemisphere, with combined treatment costs and production losses in 2014 having been estimated at US$ 350 million for Norway (annual production 1.25 million tonnes). The control of L. salmonis relies significantly on medicinal treatments, supplemented by non-pharmacological approaches. However, efficacy losses have been reported for several delousing agents, including the pyrethroid deltamethrin. The aim of the present study was to analyse the genetic basis of deltamethrin resistance in L. salmonis. Deltamethrin median effective concentrations (EC50) were 0.28 µg L-1 in the drug susceptible L. salmonis strain IoA-00 and 40.1 µg L-1 in the pyrethroid resistant strain IoA-02. IoA-00 and IoA-02 were crossed to produce families spanning one parental and three filial generations (P0, F1-F3). In three families derived from P0 crosses between an IoA-00 sire and an IoA-02 dam, 98.8% of F2 parasites (n = 173) were resistant, i.e. remained unaffected after exposure to 2.0 µg L-1 deltamethrin. F3 parasites from these crosses showed a deltamethrin EC50 of 9.66 µg L-1. In two families of the inverse orientation at P0 (IoA-02 sire x IoA-00 dam), 16.7% of F2 parasites were resistant (n = 84), while the deltamethrin EC50 in F3 animals was 0.26 µg L-1. The results revealed a predominantly maternal inheritance of deltamethrin resistance. The 15,947-nt mitochondrial genome was sequenced and compared among six unrelated L. salmonis strains and parasites sampled from wild salmon in 2010. IoA-02 and three further deltamethrin resistant strains, established from isolates originating from different regions of Scotland, showed almost identical mitochondrial haplotypes. In contrast, the mitochondrial genome was variable among susceptible strains and L. salmonis from wild hosts. Deltamethrin caused toxicity and depletion of whole body ATP levels in IoA-00 but not IoA-02 parasites. The maternal inheritance of deltamethrin resistance and its association with mitochondrial haplotypes suggests that pyrethroid toxicity in L. salmonis may involve molecular targets encoded by mitochondrial genes.