Are General Surgery Residencies Preparing Graduates for the Practice of Today's General Surgeon? An Analysis of American Board of Surgery Data From Applicants and Re-certifying Surgeons.

OBJECTIVE: To compare the operative experience of general surgery residents and practicing general surgeons. SUMMARY OF BACKGROUND DATA: The scope of general surgery has evolved, yet it remains unknown whether residents are being exposed to the right mix of operations during residency. METHODS: A retrospective review of operative case logs submitted to the American Board of Surgery by US general surgery graduates and practicing general surgeons from 2013 to 2017 was performed. The operative experience of both cohorts was calculated as a proportion of total experience and ranked by frequency. The proportional experience between cohorts was analyzed using factorial analysis of variance. RESULTS: During the 5-year period, 5482 graduates applied for initial American Board of Surgery certification, and 4152 diplomates applied for recertification. Among all operative domains, the graduate experience was similar to that of diplomates in 6 of 12 areas (abdomen, alimentary tract, endoscopy, endocrine, other, skin/soft tissue; all P > 0.05). Residents have a greater experience in subspecialty areas (pediatric, thoracic, trauma, vascular, and plastic) at the expense of fewer breast procedures (all P < 0.05). The 30 operations most commonly performed by graduates comprised 67% of their total operative experience. Among these, residents performed 25 cases ≥10 times, 14 cases ≥20 times, and 7 cases ≥40 times. CONCLUSIONS: The operative experience of graduating US general surgery residents is largely similar to that of practicing general surgeons, particularly for core general surgery domains. These data offer reassurance that surgical training in the modern era appropriately exposes residents to the operations they may perform in practice.

Persistent malperfusion after central aortic repair in acute type I aortic dissections.

OBJECTIVE: Acute dissection involving the ascending aorta and extending beyond the innominate artery (DeBakey type I) may be associated with acute ischemic complications owing to branch artery malperfusion. The purpose of this study was to document the prevalence of noncardiac ischemic complications associated with type I aortic dissections that persisted after initial ascending aortic and hemiarch repair, necessitating vascular surgery intervention. METHODS: Consecutive patients presenting with acute type I aortic dissections between 2007 and 2022 were studied. Patients who underwent initial ascending aortic and hemiarch repair were included in the analysis. Study end points included the need for additional interventions after ascending aortic repair and death. RESULTS: There were 120 patients (70% men; mean age, 58 ± 13 years) who underwent emergent repair for acute type I aortic dissections during the study period. Forty-one patients (34%) presented with acute ischemic complications. These included 22 (18%) with leg ischemia, 9 (8%) with acute strokes, 5 (4%) with mesenteric ischemia, and 5 (4%) with arm ischemia. After proximal aortic repair, 12 patients (10%) had persistent ischemia. Nine patients (8%) required additional interventions for persistent leg ischemia (n = 7), intestinal gangrene (n = 1), or cerebral edema (craniotomy, n = 1). Three other patients with acute stroke had permanent neurologic deficits. All other ischemic complications resolved after the proximal aortic repair despite mean operative times exceeding 6 hours. Comparing patients with persistent ischemia with those whose symptoms resolved after central aortic repair, there were no differences in demographics, distal extent of dissection, mean operative time for aortic repair, or need for venous-arterial extracorporeal bypass support. Overall, 6 of the 120 patients (5%) suffered perioperative deaths. Hospital deaths occurred in 3 of the 12 patients (25%) with persistent ischemia vs none of 29 patients who had resolution of the ischemia after aortic repair (P = .02). Over a mean follow-up of 51 ± 39 months, no patient required an additional intervention for persistent branch artery occlusion. CONCLUSIONS: One-third of patients with acute type I aortic dissections had associated noncardiac ischemia, prompting a vascular surgery consultation. Limb and mesenteric ischemia most often resolved after the proximal aortic repair and did not require further intervention. No vascular interventions were performed in patients with stroke. Although the presence of acute ischemia at presentation did not increase hospital or 5-year mortality rates, persistent ischemia after central aortic repair seems to be a marker for increased hospital mortality after type I dissections.

Risk factors for lower extremity vascular complications in adult patients on veno-arterial extracorporeal membrane oxygenation.

OBJECTIVE: Utilization of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has increased significantly over the last decade. Prior studies have reported worse mortality for patients with vascular complications on VA-ECMO; however, these were limited by small sample size. The purpose of this study is to investigate predictive risk factors for vascular complications in VA-ECMO patients and their potential impact on mortality. METHODS: Patients who underwent peripheral VA-ECMO from January 2011 to December 2021 were identified. Primary outcomes were lower extremity vascular complications and in-hospital mortality. Multivariate stepwise logistic regression models were used to identify predictors of vascular complications and in-hospital mortality. RESULTS: A total of 605 VA-ECMO patients (25% female) were identified. The mean age was 56.3 ± 13 years, and 56 (10.4%) were black. In-hospital mortality was 63.8% (n = 386), and VA-ECMO ipsilateral vascular complications occurred in 72 patients (11.9%). Vascular surgical interventions (thromboembolectomy, fasciotomies, amputation, and surgical management of cannula bleeding) were required in 30 patients (41.7%). Same-side arterial and venous cannulas, cannula size, and absence of distal perfusion cannula did not increase risk of vascular complication. Multivariate analysis identified age (odds ratio, 0.948; 95% confidence interval, 0.909-0.988; P = .0116) and pre-existing peripheral arterial disease (odds ratio, 3.489; 95% confidence inteval, 1.146-10.624; P = .0278) as independent predictors of need for vascular surgery interventions. The mortality rate of patients who developed vascular complications was not significantly different compared with the mortality rate of those who did not develop vascular complications (61% vs 64%; P = .92). CONCLUSIONS: This study represents one of the largest series to date of lower extremity vascular outcomes in patients undergoing VA-ECMO. Our results confirm the high mortality rate associated with VA-ECMO; however, vascular complications did not represent a risk factor for mortality as previously reported. Same-sided VA-ECMO cannulas, cannula size, and the presence or absence of distal perfusion cannula did not predict vascular complications. Increasing age and presence of peripheral arterial disease are independent predictors of need for vascular surgery intervention in patients on VA-ECMO.

Emergency department visits after acute aortic syndromes.

OBJECTIVE: Recent reports document a high rate of readmission after hospitalization for acute aortic syndromes (AAS) that include acute aortic dissections, intramural hematomas, or penetrating aortic ulcers. We examined the rate of return to the emergency department (ED) to better understand the utilization of emergent health care services after AAS. METHODS: Consecutive patients with AAS admitted to the vascular surgery service from 2004 to 2020 were included. Patients with type A dissections, arch involvement, or chronic aortic pathology were excluded. The primary outcome was ED visits within 90 days of the original hospitalization. RESULTS: The study included 79 subjects (62% men, 38% women; mean age: 64 ± 14 years) with AAS (82% aortic dissections, 11% intramural hematomas, and 6% penetrating aortic ulcers). A total of 54 ED visits related to the AAS occurred within 90 days of the original discharge, each of which incurred a computed tomography angiogram. Twenty-eight (35%) subjects had a mean of 2 ± 2 ED visits, whereas 51 (65%) subjects had no ED visits. Ninety percent (25 of 28) of the first ED visits occurred within 1 month of discharge and 53% (15 of 28) within 1 week. A total of 17 (61%) subjects were readmitted to the hospital from the ED. Four subjects were found to have progression of AAS on imaging studies and underwent thoracic endovascular aortic repair during readmission. Comparing subjects who returned to the ED with those who did not, there were no significant differences in demographics, atherosclerotic risk factors except coronary artery disease, type of AAS, number of antihypertensive medications at admission or discharge, operative intervention, length of initial hospital stay, or discharge status. The chief complaints at the first ED visit were pain (n = 17), uncontrolled hypertension (n = 5), syncope (n = 3), and other (n = 3). CONCLUSIONS: These data show that one in three patients with AAS returned to the ED within 90 days of initial discharge. Although returning subjects had a higher number of readmissions, few had progression of AAS that required intervention. Because the vast majority were readmitted for medical therapy, early and frequent clinic follow-up may help decrease ED visits and readmissions after AAS.

Ankle-brachial index use in peripheral vascular interventions for claudication.

OBJECTIVE: The ankle-brachial index (ABI) has been recommended as the first-line noninvasive test to establish a diagnosis of peripheral arterial disease in patients with claudication (grade 1, level A evidence). The ABI can also be used to monitor disease progression and assess the benefits of treatment after peripheral vascular intervention (PVI). The Upper Midwest Region of the Vascular Quality Initiative has a unique balance of participation from vascular surgeons, interventional radiologists, and cardiologists performing PVI. We sought to identify the use of ABI and assess the functional outcomes of patients who had undergone PVI for claudication. METHODS: We conducted a review of the Upper Midwest Region of the Vascular Quality Initiative to identify PVI performed for claudication from native artery atherosclerotic occlusive disease in nondiabetic patients from 2010 to 2020. Patients who had undergone PVI with infection, tissue loss, rest pain, bypass graft stenosis, or aneurysmal disease were excluded. The primary outcomes included the ABI, ambulation status, and functional status before and after PVI. RESULTS: A total of 3787 patients (58.0% male, 42.0% female; mean age, 68.4 years) who had undergone 3830 procedures were identified. Of the 3787 patients, 2665 (69.5%) had had the ABI measured: 1803 (47.1%) before PVI only, 190 (4.9%) after PVI only, and 862 (22.5%) before and after PVI. In addition, 975 patients (25.5%) had never had the ABI performed. Statistical analysis of the entire cohort found no change in ambulation status (P = .33-.95 for all comparisons) or functional status (P = .42-.61 for all comparisons) regardless of the use of the ABI. However, a significant number of patients who had never had the ABI measured had decreased from full functional status before PVI to only being functional with light work after PVI (P = .015). CONCLUSIONS: Despite the grade 1, level A evidence, ABI had been used before and after PVI for only 22.5% of the patients who had undergone PVI for claudication. In addition, we found overall functional status had decreased significantly after PVI for those patients who had never had an ABI performed. Accurately identifying patients with claudication due to PAD using the ABI remains critically important before PVI. Given the lack of overall improvement in ambulation after PVI found in the present study, identifying the patients who will benefit from PVI to treat claudication remains elusive.

The impact of pre-existing blood pressure control in patients with acute aortic dissections.

OBJECTIVES: Arterial hypertension (HTN) is considered a seminal risk factor for aortic dissection (AD). The purpose of this study is to evaluate whether pre-existing blood pressure (BP) control lessens the extent of dissection and has a favorable impact on outcome of patients with acute AD. METHODS: Consecutive acute AD patients who had at least two BPs recorded within the 12 months preceding the AD were retrospectively analyzed. The two most recent BPs were averaged and defined per published guidelines as normal (BP≤ 130/80), Stage I HTN (BP >130/80 and <139/89), or Stage 2 or greater HTN (BP > 140/90). The number of hypertensive medications (MEDs) was also used as a surrogate marker of HTN severity. Patients with known genetic causes of AD were excluded. RESULTS: 89 subjects (55% men, 45% women; mean age, 64±14 years) with acute AD (58% Stanford type A and 42% Stanford type B) were included. Two most recent BPs were recorded a mean of 5±3 and 3±2.7 months before the AD, respectively. Twenty-nine (33%) subjects had normal BP, including nine subjects with no history of HTN and on no MEDs. Sixty (67%) subjects had elevated BP, including 21 (35%) with Stage I HTN and 39 (65%) with Stage 2 HTN. Compared to subjects with normal BP, subjects with Stage 1 and Stage 2 HTN were younger (70±13 years vs 62±1 year, p = 0.01), but there were no differences in other demographics, risk factors, comorbidities, or history of drug use. There were no group differences in the distal extent of the dissections, complications requiring thoracic endograft repair, mean length of hospital stay, final discharge status, or 30-day mortality. Compared to the number of MEDs before AD, all three groups had a higher mean number of MEDs to achieve normal BP at discharge that persisted at a mean follow-up of 18±15 months. CONCLUSIONS: These data show that approximately one-third of patients with acute AD had well controlled or no antecedent history of HTN. The degree of pre-existing HTN control had no bearing on the type or extent of AD, length of stay, or early outcome. Regardless of the state of HTN control before AD, the consistent and sustained increase in the severity of HTN after AD suggests that the dissection process has a profound and lasting effect on BP regulation. Further studies are indicated to elucidate the pathologic mechanisms involved in AD.

Pre-emptive thoracic endovascular aortic repair is unnecessary in extended type A (DeBakey type I) aortic dissections.

OBJECTIVE: Pre-emptive thoracic endovascular aortic repair (TEVAR) improves late survival and limits progression of disease after type B aortic dissection, but the potential value of pre-emptive TEVAR has not been evaluated after type A dissection extending beyond the aortic arch (DeBakey type I). The purpose of this study was to compare disease progression and need for aortic intervention in survivors of acute, extended type A (ExTA) dissections after initial repair of the ascending aorta versus acute type B aortic dissections. METHODS: Consecutive patients presenting with ExTA or type B dissections between 2011 and 2018 were studied. Forty-three patients with ExTA and 44 with type B dissections who survived to discharge and had follow-up imaging studies were included in the analysis. Study end points included progression of aortic disease (>5 mm growth or extension), need for intervention, and death. RESULTS: The groups were not different for age, sex, atherosclerotic risk factors, or extent of dissection distal to the left subclavian artery. Following emergent ascending aortic repair, five ExTA patients (12%) underwent TEVAR within 4 months after discharge. Despite optimal medical treatment, 29 type B patients (66%) underwent early or late TEVAR (P < .001). During a mean follow-up of 38 ± 30 months, 38 ExTA patients (88%) did not require intervention-23 (53%) of whom showed no disease progression. In comparison, during a mean follow-up of 18 ± 6 months, 14 type B patients (32%) did not require intervention-nine (20%) of whom showed no disease progression (P = .003). There was one aortic-related late death in the ExTA group and two in the type B group. Compared with ExTA patients, type B patients had significantly worse intervention-free survival and intervention/growth-free survival (log rank, P < .001). CONCLUSIONS: In contrast with type B dissections, these midterm results demonstrate that one-half of ExTA aortic dissections show no disease progression in the thoracic or abdominal aorta, and few require additional interventions. After initial repair of the ascending aorta, pre-emptive TEVAR does not seem to be justified in patients with acute, ExTA dissections.

Follow-up imaging of traumatic vertebral artery dissections is unnecessary in asymptomatic patients.

OBJECTIVE: Routine computed tomography (CT) imaging in trauma patients has led to increased recognition of blunt vertebral artery injuries (BVIs). We sought to determine the prevalence of strokes, injury progression, and need for intervention in patients with BVI. METHODS: Consecutive patients presenting with BVI during 2 years were identified from the institutional trauma registry. Inpatient records, imaging studies, and follow-up data were reviewed in detail from the electronic medical record. RESULTS: There were 76 BVIs identified in 70 patients (64% male; mean age, 47 ± 19 years); bilateral injuries occurred in 6 patients. Five patients who arrived at the hospital intubated had evidence of posterior circulation infarcts on admission CT, whereas one additional patient had evidence of a posterior circulation infarct attributed to complications of late spinal surgery. Four of the five patients with infarcts on admission CT survived to discharge, but only one had residual stroke symptoms. Minor (grade 1 or grade 2) injuries occurred in 25 (36%) patients; severe (grade 3 or grade 4) injuries occurred in 45 (64%). Twelve patients died of associated injuries (eight with severe BVI, four with minor BVI). Stepwise logistic regression analysis selected age (odds ratio, 1.14; confidence interval, 1.04-1.25; P < .001) and intubation on arrival (odds ratio, 450.4; confidence interval, 17.41-1645.51; P < .001) as independent predictors of hospital stroke and death. Of the 58 surviving to discharge, 31 (53%) returned for follow-up CT scans. Six of 10 (60%) patients with minor injuries had resolution or improvement compared with 3 of 21 (14%) with severe injuries (P = .027). One patient (10%) with a minor BVI and two patients (10%) with severe BVI had radiologic progression, but none were clinically significant. During a mean follow-up of 15 ± 13 months, none of the study patients had treatment (surgical or interventional) for BVI, and there were no delayed strokes. Only five patients in this series had vertebral pseudoaneurysms, which limits conclusions about this type of BVI. CONCLUSIONS: These data suggest that BVI-related strokes are present at the time of admission and do not have clinical sequelae. No late strokes occurred in this series, and no surgical or interventional treatments were required even in the presence of radiographic worsening. The relatively few cases of vertebral pseudoaneurysms in this series limit any conclusions about these specific lesions. However, these data indicate that follow-up imaging of nonaneurysmal BVI is not necessary in adults who are found to be asymptomatic on follow-up.

Regioselective addition of Grignard reagents to N-acylpyrazinium salts: synthesis of substituted 1,2-dihydropyrazines and Δ5-2-oxopiperazines.

The regioselective addition of Grignard reagents to mono- and disubstituted N-acylpyrazinium salts affording substituted 1,2-dihydropyrazines in modest to excellent yields (45-100%) is described. Under acidic conditions, these 1,2-dihydropyrazines can be converted to substituted Δ5-2-oxopiperazines providing a simple and efficient approach towards their preparation.

Declining Resident Experience in Open Vascular Operations Threatens the Status of Vascular Surgery as an Essential Content Area of General Surgery Training.

OBJECTIVE: The objective of this study was to document trends in the performance of open arterial vascular surgery procedures (OAVP) by general surgery residents (GSR). BACKGROUND: The ACGME Review Committee for Surgery considers vascular surgery (VS) to be an "essential content area." However, the operative experience in VS for GSRs is threatened by 1) increasing numbers of GSRs, 2) increasing numbers of VS trainees, and 3) the proliferation of endovascular surgery. METHODS: The last 16 years of ACGME national reports of case logs for completing GSRs were reviewed. Total vascular operations and OAVPs performed as "surgeon" were recorded and analyzed. The number of individuals completing ACGME programs in general and vascular surgery annually over that period were also recorded and analyzed. To better understand long-term and more recent trends, trends were analyzed for the 15-year period spanned by the 16 years of data as well as the most recent 10- and 5-year periods. RESULTS: The number of individuals completing both general and vascular surgery programs increased significantly. Over 15 years, the total vascular operations performed by GSRs significantly declined as did the total OAVPs and the OAVPs in 7 of 9 categories. In just the last 5 years, significant declines occurred in 5 OAVP categories. CONCLUSIONS: Operative experience in OAVPs for GSRs has significantly declined. Because fundamental VS skills are necessary for operative general surgery, VS should remain an essential content area. However, programs cannot solely depend on operative experience to teach fundamental VS skills.

Discovery and characterization of an iminocoumarin scaffold as an inhibitor of MEKK2 (MAP3K2).

The kinase MEKK2 (MAP3K2) activates the MEK5/ERK5 cell signaling pathway and may play an important role in tumor growth and metastasis. Thus, MEKK2 may represent a novel kinase target for cancer. In order to identify inhibitors of MEKK2, we screened a library of compounds using a high throughput MEKK2 intrinsic ATPase enzyme assay. We identified two hits with validated structures and confirmed activity in the primary assay (IC50 values = 322 nM and 7.7 µM) and two orthogonal MEKK2 biochemical assays. Compound 1, the more potent hit, was the subject of further investigation. Limited structure-activity relationship (SAR) studies were performed on this iminocoumarin hit which resulted in ≥20-fold more potent analogs (e.g. 8 and 16 nM IC50). Two analogs had improved selectivity in a 50-member kinase profiling panel compared to the hit. These studies suggested that substitutions around the phenoxy ring of this scaffold can impart improved potency and selectivity for MEKK2. Analog Compound 1s (16 nM IC50) was further verified by external testing to inhibit MEKK2 and MEKK3 with similar potencies. Compound 1s displayed activity in cell-based assays in which it inhibited ERK5 pathway activation in cells and inhibited cell migration in a scratch assay. Thus, we have identified a scaffold that has promising potential to be developed into a highly selective and potent inhibitor of MEKK2. Information from these SAR studies provides specific guidance for the future design of MEKK2 inhibitor probes.

Initial and intermediate-term treatment of the phantom thrombus (primary non-occlusive mural thrombus on normal arteries).

An embolic event originating from thrombus on an otherwise un-diseased or minimally diseased proximal artery (Phantom Thrombus) is a rare but significant clinical challenge. All patients from a single center with an imaging defined luminal thrombus with a focal mural attachment site on an artery were evaluated retrospectively. We excluded all patients with underlying anatomic abnormalities of the vessel at the attachment site. Six patients with a mean age of 62.5 years were identified over a 2.5-year period. All patients had completed treatment for or had a current diagnosis of malignancy and none were on antiplatelets or other anticoagulants. Four thrombi originated in the aorta proximal to the renal arteries and one originated distal. One thrombus was found in the common carotid artery and one was in an arterialized vein graft. Mean follow-up was 22 months. None of the patients underwent removal or exclusion of the embolic source. With systemic anticoagulation, four of the phantom thrombi were resolved on imaging within 8 weeks, one resolved after 72 weeks. One phantom thrombus reoccurred after 6 months on reduced anticoagulant dosing. There was one acute and one death in follow-up (26 months). One patient required a partial foot amputation secondary to tissue necrosis from the initial thromboembolic event. Arterial thrombi forming on otherwise normal vessels are a distinct clinical entity. In patients with a phantom thrombus, a strategy of therapeutic anticoagulation for management of the embolic source seems to be safe and effective over both the short and intermediate-term.

Arteriographic Patterns of Atherosclerosis and the Association between Diabetes Mellitus and Ethnicity in Chronic Critical Limb Ischemia.

BACKGROUND: Disparate outcomes in critical limb ischemia (CLI) persist between ethnicities. The contribution of modifiable factors versus intrinsic biologic differences remains unclear. Hence, we aimed to quantify the associations between ethnicity and anatomic patterns of arterial occlusive disease in CLI, adjusting for known atherosclerotic risk factors. METHODS: We performed a retrospective, single-center review of consecutive patients presenting to the vascular surgery service with CLI. Arterial lesions were defined by location (aortoiliac = aorta and iliac arteries; femoral = common, profunda, and superficial femoral arteries; and popliteal-tibial = infrapopliteal and tibial arteries). Stenoses ≥50% were deemed hemodynamically significant. Associations between the patients' baseline arteriographic patterns, demographics, and medical comorbidities were defined using Kruskal-Wallis, χ2, and Mantel-Haenszel χ2 tests. RESULTS: Between August 2010 and January 2014, 286 CLI patients (n = 172 male, n = 176 tissue loss) were evaluated by the Vascular Surgery service. Two hundred seventy subjects had baseline arteriograms for analysis (black n = 134, 50%; Hispanic n = 78, 29%; Caucasian n = 58, 21%.) All ethnicities presented most frequently with simultaneous disease in all infrainguinal segments (n = 124, 46%). Of Hispanics, 30% (n = 23) presented with isolated infrapopliteal disease, which was higher than any other ethnic group (P = 0.02, χ2). Caucasians (n = 8, 14%) presented more frequently with isolated aortoiliac occlusive disease than either Hispanics (n = 0, 0%) or blacks (n = 2, 1%; P = 0.06). Diabetes mellitus was most prevalent among Hispanics (n = 72, 85%) relative to blacks (n = 77, 55%) and Caucasians (n = 32, 52%; P < 0.001, χ2). Median hemoglobin A1c (HbA1c) was also highest among Hispanics (7.3%, interquartile range [IQR] 6.2-9.9) versus blacks and Caucasians (6.6%, IQR 5.8-8.2 and 6.0%, IQR 5.6-7.6; P = 0.002, Kruskal-Wallis). Tobacco abuse was most frequent among Caucasians (n = 53, 87%) and blacks (n = 113, 81%). Forty-eight (57%) of Hispanics abused tobacco (P = 0.001, χ2.) Subgroup analysis of subjects stratified by baseline HbA1c revealed that there was no relationship between ethnicity and isolated infrapopliteal disease among subjects with HbA1c ≤8.8% (P = 0.58, Mantel-Haenszel χ2). Conversely, patients with poorer glycemic control (HbA1c ≥ 8.9%) were more frequently Hispanic and had a higher probability of having isolated infrapopliteal disease (P = 0.005, Mantel-Haenszel χ2). CONCLUSIONS: Hispanic patients present more frequently with isolated infrapopliteal arterial disease relative to other ethnicities, which may contribute to disparate CLI outcomes. Isolated infrapopliteal disease appears to be driven mostly be poorer glycemic control rather than inherent biologic differences between ethnicities. Future studies aimed at understanding disparate outcomes due to race after lower extremity revascularization may benefit from stratification by the severity of diabetes mellitus. Understanding the distribution of atherosclerotic disease may improve the ability to predict outcomes in limb-threatening ischemia.

Does a selection interview predict year 1 performance in dental school?

It is important for dental schools to select students who will complete their degree and progress on to become the dentists of the future. The process should be transparent, fair and ethical and utilise selection tools that select appropriate students. The interview is an integral part of UK dental schools student selection procedures. OBJECTIVE: This study was undertaken in order to determine whether different interview methods (Cardiff with a multiple mini interview and Newcastle with a more traditional interview process) along with other components used in selection predicted academic performance in students. METHODS: The admissions selection data for two dental schools (Cardiff and Newcastle) were collected and analysed alongside student performance in academic examinations in Year 1 of the respective schools. Correlation statistics were used to determine whether selection tools had any relevance to academic performance once students were admitted to their respective Universities. RESULTS: Data was available for a total of 177 students (77 Cardiff and 100 Newcastle). Examination performance did not correlate with admission interview scores at either school; however UKCAT score was linked to poor academic performance. DISCUSSION: Although interview methodology does not appear to correlate with academic performance it remains an integral and very necessary part of the admissions process. Ultimately schools need to be comfortable with their admissions procedures in attracting and selecting the calibre of students they desire.

Aortic arch involvement worsens the prognosis of type B aortic dissections.

OBJECTIVE: Medical management of acute aortic dissections limited to the descending thoracic aorta (AD-desc) is associated with acceptable outcomes. Uncertainty remains about whether acute type B aortic dissections involving the aortic arch (AD-arch) have an increased risk of retrograde extension into the ascending aorta or other dissection-related complications. This study compared outcomes of AD-arch with AD-desc managed medically. METHODS: Consecutive patients admitted from 2005 to 2014 with acute aortic dissections not involving the ascending aorta were retrospectively analyzed. Primary end points included dissection-related death and operative intervention. RESULTS: The study included 99 patients (63% men; mean age, 60 ± 14 years) with acute aortic dissections. Dissections were limited to the aorta distal to the left subclavian artery (AD-desc) in 79 patients (80%), and 20 (20%) had involvement of the left subclavian (n = 16), left common carotid (n = 1), or innominate (n = 3) arteries (AD-arch). Dissections ended proximal to the celiac artery in 30 patients (30%), between the celiac artery and aortic bifurcation in 36 (36%), and distal to the aortic bifurcation in 33 (33%). During medical management, further proximal extension into the arch occurred in two AD-arch patients and one AD-desc patient (P < .05), but proximal dissection into the ascending aorta occurred in only one AD-arch patient with Marfan disease. Compared with patients with AD-desc, those with AD-arch were younger (53 ± 12.5 vs 62 ± 16 years; P < .01) and had more frequent early interventions (40% vs 19%; P = .047), cardiac complications (35% vs 11%; P < .01), and neurologic events (25% vs 6%; P < .01). Seven AD-arch patients (35%) and nine AD-desc patients (11%) died of dissection-related causes (P < .01). Among survivors, late interventions were performed in four of eight AD-arch patients (50%) and in six of 58 AD-desc patients (10%; P = .02). Medical treatment without intervention was successful in four AD-arch patients (20%) and in 52 AD-desc patients (66%; P < .001). Multivariate logistic regression retained arch involvement as the sole predictor of dissection-related death (odds ratio, 4.2; 95% confidence interval, 1.3-13.4) and failure of medical treatment (odds ratio, 7.7; 95% confidence interval, 2.5-29). The distal extent of dissection had no bearing on outcome. CONCLUSIONS: AD-arch dissections are associated with a higher risk of cardiac and neurologic events, need for early intervention, and dissection-related death than AD-desc dissections. Because further proximal dissections into the ascending aorta were rare in this study, medical management appears to be safe as the initial treatment of AD-arch dissections. However, surgeons should be aware of the increased risk of complications and the potential need for urgent interventions in these patients.

Multidisciplinary care improves amputation-free survival in patients with chronic critical limb ischemia.

BACKGROUND: This study was conducted to quantify the effect of multidisciplinary care (MDC) on amputation-free survival (AFS) and wound healing within a chronic critical limb ischemia (CLI) population. METHODS: We performed a retrospective, single-center cohort study of consecutive CLI patients presenting to the Vascular Surgery Service. Patients who received initial and follow-up wound care from the MDC were compared with patients who received standard wound care (SWC). The MDC team consisted of vascular, plastic, and podiatric surgeons who jointly managed wound care and directed any other consults or services as deemed necessary. SWC consisted of an inconsistent mix of providers without a defined manager, including nurses, wound care midlevel providers, general surgeons, internists, or the patients themselves. The referring physician determined the allocation of patients. The primary outcome variable was AFS, with a secondary evaluation of wound healing. The effects of baseline demographics, comorbid medical conditions, laboratory values, ischemic lesion severity and location, Rutherford classification, and participation in MDC were assessed. Significant univariate predictors (P < .10) of AFS were entered into a multivariate Cox regression model and assessed at an α = .05. RESULTS: Between August 2010 and June 2012, 146 CLI patients (91 male [63%]) were evaluated by the Vascular Surgery Service and were followed up for a median of 539 days (interquartile range 314-679 days). Ischemic tissue loss was present in 85 patients (38 at Rutherford category 5, and 47 at Rutherford category 6). Within this cohort, 51 (60%) had MDC, and 34 (40%) had SWC. Fifty-eight patients (68%) underwent revascularization (open in 17, endovascular in 35, and hybrid in 6), 14 (8%) were managed with primary major amputation, and 13 (15%) declined revascularization. AFS was superior for patients in the MDC arm vs the SWC arm (593.3 ± 53.5 days vs 281.0 ± 38.2 days; log-rank, P = .02). Wound-healing times favored the MDC arm over the SWC arm (444.5 ± 33.2 days vs 625.2 ± 126.5 days), although this was not statistically significant (log-rank, P = .74). Multivariate modelling revealed that independent predictors of major amputation or death, or both, were nonrevascularized patients (hazard ratio [HR], 3.76; 95% confidence interval [CI], 1.78-8.02; χ(2), P < .01), treatment by SWC (HR, 2.664; 95% CI, 1.23-5.77; χ(2), P = .012), and baseline nonambulatory status (HR, 1.89; 95% CI, 1.17-2.85; χ(2), P < .01). CONCLUSIONS: MDC pathways for the management of a population of CLI patients improved AFS by greater than twofold and should be the standard of care for the CLI population. Baseline nonambulatory status and unrevascularized patients also predict worse AFS. Wound healing remains prolonged regardless of preoperative or postoperative wound care. Future study is required to evaluate the costs and functional outcomes for MDC in the management of CLI.

Deterministic effects after fenestrated endovascular aortic aneurysm repair.

BACKGROUND: Endovascular aortic aneurysm repairs (EVARs) with fenestrated (FEVAR) stent grafts are high radiation dose cases, yet no skin injuries were found retrospectively in our 61 cases with a mean peak skin dose (PSD) of 6.8 Gy. We hypothesize that skin injury is under-reported. This study examined deterministic effects in FEVARs after procedural changes implemented to detect skin injury. METHODS: All FEVARs during a 6-month period with a radiation dose of 5 Gy reference air kerma (RAK; National Council on Radiation Protection and Measurements threshold for substantial radiation dose level [SRDL]) were included. Patients were questioned about skin erythema, epilation, and necrosis, with a physical examination of the back completed daily until discharge and then at 2 and 4 weeks and at 3 and 6 months. PSD distributions were calculated with custom software using input data from fluoroscopic machine logs. These calculations have been validated against Gafchromic (Ashland Inc, Covington, Ky) film measurements. Dose was summed for the subset of patients with multiple procedures ≤6 months of the SRDL event, consistent with the joint commission recommendations. RESULTS: Twenty-two patients, 21 FEVARs and one embolization, reached an RAK of 5 Gy. The embolization procedure was excluded from review. The average RAK was 7.6 ± 2.0 Gy (range, 5.1-11.4 Gy), with a mean PSD of 4.8 ± 2.0 Gy (range, 2.3-10.4 Gy). Fifty-two percent of patients had multiple endovascular procedures ≤6 months of the SRDL event. The mean RAK for this subset was 10.0 ± 2.9 Gy (range, 5.5-15.1 Gy), with a mean PSD of 6.6 ± 1.9 Gy (range, 3.4-9.4 Gy). One patient died before the first postoperative visit. No radiation skin injuries were found. Putative risk factors for skin injury were evaluated and included smoking (32%), diabetes (14%), cytotoxic drugs (9%), and fair skin type (91%). No other risk factors were present (hyperthyroidism, collagen vascular disorders). CONCLUSIONS: Deterministic skin injuries are uncommon after FEVAR, even at high RAK levels, regardless of cumulative dose effects. This study addresses the concern of missed injuries based on the retrospective clinical examination findings that were published in our previous work. Even with more comprehensive postoperative skin examinations and patient questioning, the fact that no skin injuries were found suggests that radiation-induced skin injuries are multifactorial and not solely dose dependent.

Surgeon radiation dose during complex endovascular procedures.

BACKGROUND: Surgeon radiation dose during complex fluoroscopically guided interventions (FGIs) has not been well studied. We sought to characterize radiation exposure to surgeons during FGIs based on procedure type, operator position, level of operator training, upper vs lower body exposure, and addition of protective shielding. METHODS: Optically stimulable, luminescent nanoDot (Landauer, Inc, Glenwood, Ill) detectors were used to measure radiation dose prospectively to surgeons during FGIs. The nanoDot dosimeters were placed outside the lead apron of the primary and assistant operators at the left upper chest and left lower pelvis positions. For each case, the procedure type, the reference air kerma, the kerma-area product, the relative position of the operator, the level of training of the fellow, and the presence or absence of external additional shielding devices were recorded. Three positions were assigned on the right-hand side of the patient in decreasing relative proximity to the flat panel detector (A, B, and C, respectively). Position A (main operator) was closest to the flat panel detector. Position D was on the left side of the patient at the brachial access site. The nanoDots were read using a microSTARii medical dosimetry system (Landauer, Inc) after every procedure. The nanoDot dosimetry system was calibrated for scattered radiation in an endovascular suite with a National Institute of Standards and Technology traceable solid-state radiation detector (Piranha T20; RTI Electronics, Fairfield, NJ). Comparative statistical analysis of nanoDot dose levels between categories was performed by analysis of variance with Tukey pairwise comparisons. Bonferroni correction was used for multiple comparisons. RESULTS: There were 415 nanoDot measurements with the following case distribution: 16 thoracic endovascular aortic repairs/endovascular aneurysm repairs, 18 fenestrated endovascular aneurysm repairs (FEVARs), 13 embolizations, 41 lower extremity interventions, 10 fistulograms, 13 visceral interventions, and 3 cerebrovascular procedures. The mean operator effective dose for FEVARs was higher than for other case types (P < .03), 20 µSv at position A and 9 µSv at position B. For all case types, position A (9.0 µSv) and position D (20 µSv) received statistically higher effective doses than position B (4 µSv) or position C (0.4 µSv) (P < .001). However, the mean operator effective dose for position D was not statistically different from that for position A. The addition of the lead skirt significantly decreased the lower body dose (33 ± 3.4 µSv to 6.3 ± 3.3 µSv) but not the upper body dose (6.5 ± 3.3 µSv to 5.7 ± 2.2 µSv). Neither ceiling-mounted shielding nor level of fellow training affected operator dose. CONCLUSIONS: Surgeon radiation dose during FGIs depends on case type, operator position, and table skirt use but not on the level of fellow training. On the basis of these data, the primary operator could perform approximately 12 FEVARs/wk and have an annual dose <10 mSv, which would not exceed lifetime occupational dose limits during a 35-year career. With practical case loads, operator doses are relatively low and unlikely to exceed occupational limits.

Upper extremity access for fenestrated endovascular aortic aneurysm repair is not associated with increased morbidity.

OBJECTIVE: Fenestrated endovascular aortic aneurysm repair (FEVAR) is an alternative to open repair in patients with complex abdominal aortic aneurysms who are neither fit nor suitable for standard open or endovascular repair. Chimney and snorkel grafts are other endovascular alternatives but frequently require bilateral upper extremity access that has been associated with a 3% to 10% risk of stroke. However, upper extremity access is also frequently required for FEVAR because of the caudal orientation of the visceral vessels. The purpose of this study was to assess the use of upper extremity access for FEVAR and the associated morbidity. METHODS: During a 5-year period, 148 patients underwent FEVAR, and upper extremity access for FEVAR was used in 98 (66%). Outcomes were compared between those who underwent upper extremity access and those who underwent femoral access alone. The primary end point was a cerebrovascular accident or transient ischemic attack, and the secondary end point was local access site complications. The mean number of fenestrated vessels was 3.07 ± 0.81 (median, 3) for a total of 457 vessels stented. Percutaneous upper extremity access was used in 12 patients (12%) and open access in 86 (88%). All patients who required a sheath size >7F underwent high brachial open access, with the exception of one patient who underwent percutaneous axillary access with a 12F sheath. The mean sheath size was 10.59F ± 2.51F (median, 12F), which was advanced into the descending thoracic aorta, allowing multiple wire and catheter exchanges. RESULTS: One hemorrhagic stroke (one of 98 [1%]) occurred in the upper extremity access group, and one ischemic stroke (one of 54 [2%]) occurred in the femoral-only access group (P = .67). The stroke in the upper extremity access group occurred 5 days after FEVAR and was related to uncontrolled hypertension, whereas the stroke in the femoral group occurred on postoperative day 3. Neither patient had signs or symptoms of a stroke immediately after FEVAR. The right upper extremity was accessed six times without a stroke (0%) compared with the left being accessed 92 times with one stroke (1%; P = .8). Four patients (4%) had local complications related to upper extremity access. One (1%) required exploration for an expanding hematoma after manual compression for a 7F sheath, one (1%) required exploration for hematoma and neurologic symptoms after open access for a 12F sheath, and two patients (2%) with small hematomas did not require intervention. Two (two of 12 [17%]) of these complications were in the percutaneous access group, which were significantly more frequent than in the open group (two of 86 [2%]; P = .02). CONCLUSIONS: Upper extremity access appears to be a safe and feasible approach for patients undergoing FEVAR. Open exposure in the upper extremity may be safer than percutaneous access during FEVAR. Unlike chimney and snorkel grafts, upper extremity access during FEVAR is not associated with an increased risk of stroke, despite the need for multiple visceral vessel stenting.

The need for improved risk stratification in chronic critical limb ischemia.

Vascular surgeons are well acquainted with chronic critical limb ischemia (CLI), the most severe manifestation of peripheral arterial disease, with patients presenting with ischemic rest pain or ulcerations, or both. Epidemiologic data predict a burgeoning epidemic of CLI within the United States, commensurate with the increasing incidence and prevalence of atherosclerotic risk factors, especially age and diabetes. Untreated, the risk of major amputation (above the ankle) or death, or both, ranges between 20% and 40% at 1 year. Current open and endovascular therapies have imperfect results, diverse treatment options, and recommendations that are often conflicting and confuse physicians, industry, and patients alike. The best treatment options are ideally evaluated by prospective, randomized controlled trials. However, these have proven impractical in CLI because the rapid evolution of devices and techniques has outstripped the ability to measure outcomes and compare treatment options. Alternatively, risk-stratifying models have been proposed to allow physicians, patients, and industry to objectively evaluate new therapeutics and devices as they evolve. These models are developed from prospective cohorts to identify and quantify variables that can subsequently predict outcome in individual patients. The risk stratification models can also compare CLI outcomes between physicians and institutions, supporting quality assessments, and compensation decisions within Accountable Care Organizations under the Affordable Health Care Act (ACA). Widespread adoption of risk-stratification schemes has yet to occur, despite the critical need for such a tool in CLI, because present models lack optimal predictive ability and generalizability. The passage of the ACA amplifies the importance of developing an improved risk-stratification tool to ensure equitable quality assessments and compensation. This review presents current risk-stratification models for CLI with a summary of the respective strengths and limitations of each. Future research is needed to simplify and improve the accuracy and generalizability of risk stratification in CLI.