A Meta-analysis of Long-term Mortality and Associated Risk Factors following Lower Extremity Amputation.

BACKGROUND: A majority of patients undergoing lower limb amputations have diabetes or peripheral artery disease. Despite improvements in care, there remains a substantial perioperative mortality associated with these procedures. Less well-defined is the mortality risk to these patients going forward, once outside the perioperative period. The aim of this systematic review is to summarize and pool the available data to determine the long-term mortality associated with amputation in the diabetic and peripheral vascular patient, as well as to define specific factors associated with increased mortality risk. METHODS: Four databases were searched from January 2005 through July 2015 using the Medical Subject Headings terms "amputation," "lower extremity," and "mortality." Inclusion criteria were observational and cohort studies where ≥50% of amputations were attributable to diabetic or vascular etiologies. Final article inclusion was approved by reviewer consensus. Bias was assessed with the Joanna Briggs Institute Critical Appraisal Tool for cohort studies. RESULTS: Of the 365 unique records screened, 43 abstracts and 21 full articles were reviewed and 16 studies ultimately included. The overall mortality rate was 47.9%, 61.3%, 70.6%, and 62.2% at 1-, 2-, 3- and 5-year follow-up, respectively. In addition to diabetes and peripheral vascular disease, comorbid factors associated with at least a 2-fold increased mortality were coronary artery disease, cerebrovascular disease, renal dysfunction, American Society of Anesthesiologists class ≥4, dementia, and nonambulatory status. Surgical factors, including higher amputation level and need for staged surgery with up-front guillotine amputation, were also correlated with increased mortality. CONCLUSIONS: The overall mortality rate after primary lower limb amputation in the diabetic and peripheral vascular population is substantial, and should not be underestimated when making decisions regarding limb salvage. Similar to patients undergoing revascularization, comorbid conditions associated with higher mortality should be optimized before surgery whenever possible.

Interhospital transfer for intact abdominal aortic aneurysm repair.

OBJECTIVE: Medically complex patients who need abdominal aortic aneurysm (AAA) repair are at increased risk of mortality. We study the effects of interhospital transfer to high-volume hospitals (HVHs) on postoperative complications and mortality after complications in these patients. METHODS: Data for 491,779 patients undergoing intact AAA surgery were extracted using Medicare files. Patient demographics, comorbidities, hospital volume, repair type, and patient transfer status were collected. Primary outcomes were postoperative complications and failure to rescue within 30 days after surgery. Data were analyzed using multivariable and propensity analysis. RESULTS: From 2000 to 2011, the percentage of patients transferred to another hospital for surgery before starting treatment more than doubled from .7% to 1.9% for endovascular aneurysm repair (EVAR; P < .001) and from 1.2% to 3.7% for open repair (P < .001). At baseline, transferred patients had more congestive heart failure (18.7% vs 11.2%; P < .001), coronary (17.4% vs 15.0%; P < .001), pulmonary (38.3% vs 33.6%; P < .001), and renal failure (8.1% vs 4.6%; P < .001) comorbidities. Transferred patients incurred more complications after EVAR (25.1% vs 12.8%; P < .001) or open repair (42.3% vs 35.5%; P < .001). After propensity matching for comorbidities and demographics, there were fewer complication rates (40.4% vs 47.8%; P < .001) and decreased failure to rescue (5.5% vs 6.5%; P = .04) after open repair in patients transferred to HVHs than in patients who remained at the primary, low-volume hospital for surgery. Complication rates after EVAR for nontransferred patients at low-volume hospitals and transferred patients at HVHs were similar (23.9% vs 24.7%; P = .55). After propensity matching, there was no significant difference in failure to rescue (P = .06) after EVAR between patients transferred to HVHs and nontransferred patients who had procedures at low-volume hospitals. CONCLUSIONS: Transfer of medically complex patients to HVHs for open AAA repair improves outcomes in AAA surgery. Complication rates decrease, and survival of transferred patients increases when they undergo open repair at HVHs.

Trend, Risk Factors, and Costs of Clostridium difficile Infections in Vascular Surgery.

BACKGROUND: Starting in December 2013, the Hospital Inpatient Quality Reporting Program included Clostridium difficile infection (CDI) rates as a new publically reported quality measure. Our goal was to review the trend, hospital variability in CDI rates, and associated risk factors and costs in vascular surgery. METHODS: The rates of CDI after major vascular procedures including aortic abdominal aneurysm (AAA) repair, carotid endarterectomy or stenting, lower extremity revascularization (LER), and LE amputation were identified using Nationwide Inpatient Sample database for 2000-2011. Risk factors associated with CDI were analyzed with hierarchical multivariate logistic regression. Extra costs, length of stay (LOS), and mortality were assessed for propensity-matched hospitalizations with and without CDI. RESULTS: During the study period, the rates of CDI after vascular procedures had increased by 74% from 0.6 in 2000 to 1.05% in 2011, whereas the case fatality rate was stable at 9-11%. In 2011, the highest rates were after ruptured aortic abdominal aneurysm (rAAA) repair (3.3%), followed by lower extremity amputations (2.3%) and elective open AAA (1.3%). The rates of CDI increased after all vascular procedures during the 12 years. The highest increase was after endovascular LER (151.8%) and open rAAA repair (135.7%). In 2011, patients who had experienced CDI had median LOS of 15 days (interquartile range, 9-25 days) compared with 8.3 days for matched patients without CDI, in-hospital mortality 9.1% (compared with 5.0%), and $13,471 extra cost per hospitalization. The estimated cost associated with CDI in vascular surgery in the United States was ∼$98 million in 2011. Hospital rates of CDI varied from 0 to 50% with 3.5% of hospitals having infection rates ≥5%. Factors associated with CDI included multiple chronic conditions, female gender, surgery type, emergent and weekend hospitalizations, hospital transfers, and urban locations. CONCLUSIONS: Despite potential reduction of infection rates as evidenced by the experience of hospitals with effective interventions, CDI is increasing among vascular surgery patients. It is associated with prolonged LOS, increased mortality, and higher costs.

Failure to rescue trends in elective abdominal aortic aneurysm repair between 1995 and 2011.

OBJECTIVE: Factors affecting mortality after abdominal aortic aneurysm (AAA) repair have been extensively studied, but little is known about the effects of the shift to endovascular aneurysm repair (EVAR) vs open repair on failure to rescue (FTR). This study examines the impact of treatment modalities on FTR for elective AAA surgery during the years 1995 to 2011. METHODS: Data for 491,779 patients undergoing elective AAA surgery were collected from Medicare files. Patient demographics, comorbidities, hospital volume, and repair type were collected. Primary outcome was FTR: the percentage of deaths in patients who had a complication within 30 days of surgery. Data were analyzed by univariate and multivariate analysis. RESULTS: Patients undergoing AAA surgery have become progressively more complex, with 84.96%, 89.33%, 93.76%, and 95.72% presenting with one or more comorbidities in 1995, 2000, 2005, and 2011, respectively. Despite this, overall FTR after AAA surgery was stable from 1995 to 2000 (P = .38) and decreased from 2.68% to 1.58% between 2000 and 2011 (P < .001). In addition, FTR in EVAR decreased from 1.70% to 0.58% from 2000 to 2006 (P = .03) and then stabilized at 0.88% ± 0.9% after 2007 (P = .45). Unlike for EVAR, FTR for open repair remained stable at 3.06% ± 0.17% to 2.74% ± 0.16% from 1995 to 2000 (P = .38) but increased to 4.51% ± 0.21% in 2011 (P < .001). Mortality was highest after transfusion (20.86%), prolonged ventilation (17.37%), and respiratory complications (29.78%) for all AAA surgeries. Of note, high-volume hospitals had lower FTR rates than low-volume hospitals for both open (2.73% vs 5.66%; P < .001) and endovascular (0.7% vs 1.69%; P < .001) repair. Multivariate analysis showed that high annual volume hospital status (odds ratio, 0.6; confidence interval, 0.58-0.63) and endovascular repair (odds ratio, 0.3; confidence interval, 0.28-0.31) were associated with decreased FTR. CONCLUSIONS: The success in AAA surgery of rescuing patients from 30-day mortality after a complication is associated with increased volume of EVAR. This increased success can also be attributed to the improved FTR outcomes and complication rates when surgeries are performed at high-volume hospital centers.

Small apolipoprotein(a) isoforms may predict primary patency following peripheral arterial revascularization.

Background: High lipoprotein (a) [Lp(a)] is associated with adverse limb events in patients undergoing lower extremity revascularization. Lp(a) levels are genetically pre-determined, with LPA gene encoding for two apolipoprotein (a) [apo(a)] isoforms. Isoform size variations are driven by the number of kringle IV type 2 (KIV-2) repeats. Lp(a) levels are inversely correlated with isoform size. In this study, we examined the role of Lp(a) levels, apo(a) size and inflammatory markers with lower extremity revascularization outcomes. Methods: 25 subjects with chronic peripheral arterial disease (PAD), underwent open or endovascular lower extremity revascularization (mean age of 66.7±9.7 years; F=12, M=13; Black=8, Hispanic=5, and White=12). Pre- and post-operative medical history, self-reported symptoms, ankle brachial indices (ABIs), and lower extremity duplex ultrasounds were obtained. Plasma Lp(a), apoB100, lipid panel, and pro-inflammatory markers (IL-6, IL-18, hs-CRP, TNFα) were assayed preoperatively. Isoform size was estimated using gel electrophoresis and weighted isoform size ( wIS ) calculated based on % isoform expression. Firth logistic regression was used to examine the relationship between Lp(a) levels, and wIS with procedural outcomes: symptoms (better/worse), primary patency at 2-4 weeks, ABIs, and re-intervention within 3-6 months. We controlled for age, sex, history of diabetes, smoking, statin, antiplatelet and anticoagulation use. Results: Median plasma Lp(a) level was 108 (44, 301) nmol/L. The mean apoB100 level was 168.0 ± 65.8 mg/dL. These values were not statistically different among races. We found no association between Lp(a) levels and w IS with measured plasma pro-inflammatory markers. However, smaller apo(a) wIS was associated with occlusion of the treated lesion(s) in the postoperative period [OR=1.97 (95% CI 1.01 - 3.86, p<0.05)]. The relationship of smaller apo(a) wIS with re-intervention was not as strong [OR=1.57 (95% CI 0.96 - 2.56), p=0.07]. We observed no association between wIS with patient reported symptoms or change in ABIs. Conclusions: In this small study, subjects with smaller apo(a) isoform size undergoing peripheral arterial revascularization were more likely to experience occlusion in the perioperative period and/or require re-intervention. Larger cohort studies identifying the mechanism and validating these preliminary data are needed to improve understanding of long-term peripheral vascular outcomes. Key Findings: 25 subjects with symptomatic PAD underwent open or endovascular lower extremity revascularization in a small cohort. Smaller apo(a) isoforms were associated with occlusion of the treated lesion(s) within 2-4 weeks [OR=1.97 (95% CI 1.01 - 3.86, p<0.05)], suggesting apo(a) isoform size as a predictor of primary patency in the early period after lower extremity intervention. Take Home Message: Subjects with high Lp(a) levels, generally have smaller apo(a) isoform sizes. We find that, in this small cohort, patients undergoing peripheral arterial revascularization subjects with small isoforms are at an increased risk of treated vessel occlusion in the perioperative period. Table of Contents Summary: Subjects with symptomatic PAD requiring lower extremity revascularization have high median Lp(a) levels. Individuals with smaller apo(a) weighted isoform size (wIS) have lower primary patency rates and/or require re-intervention.

Statins reduce neurologic injury in asymptomatic carotid endarterectomy patients.

BACKGROUND AND PURPOSE: Statins are neuroprotective in a variety of experimental models of cerebral injury. We sought to determine whether patients taking statins before asymptomatic carotid endarterectomy exhibit a lower incidence of neurological injury (clinical stroke and cognitive dysfunction). METHODS: A total of 328 patients with asymptomatic carotid stenosis scheduled for elective carotid endarterectomy consented to participate in this observational study of perioperative neurological injury. RESULTS: Patients taking statins had a lower incidence of clinical stroke (0.0% vs 3.1%; P=0.02) and cognitive dysfunction (11.0% vs 20.2%; P=0.03). In a multivariate regression model, statin use was significantly associated with decreased odds of cognitive dysfunction (odds ratio, 0.51 [95% CI, 0.27-0.96]; P=0.04). CONCLUSIONS: Preoperative statin use was associated with less neurological injury after asymptomatic carotid endarterectomy. These observations suggest that it may be possible to further reduce the perioperative morbidity of carotid endarterectomy. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00597883.

Two-stage hybrid repair of a complex symptomatic celiac aneurysm.

We report the case of a novel 2-stage hybrid repair of a complex celiac artery aneurysm. The patient was a 42-year-old man with a proximal celiac artery aneurysm giving rise to distinct right and left hepatic arterial branches. Repair was performed using a staged approach. First, a bifurcated aortohepatic bypass was constructed to the common and left hepatic arteries. After recovering from surgery, he underwent percutaneous embolization of the aneurysm. Completion angiograms demonstrated flow into all celiac branches with successful thrombosis of the aneurysm. At 12-month follow-up, the patient had remained symptom-free with patent bypass grafts and complete aneurysm exclusion. We describe the treatment option we used, which involves repair of a complex celiac aneurysm using a 2-stage, open, endovascular approach.

Medical Student Assessment in the Time of COVID-19.

BACKGROUND: Medical student education in the era of the COVID-19 outbreak is vastly different than the standard education we have become accustomed to. Medical student assessment is an important aspect of adjusting curriculums in the era of increased virtual learning. METHODS: Students took our previously validated free response clinical skills exam (CSE) at the end of the scheduled clerkship as an open-book exam to eliminate any concern for breaches in the honor code and then grades were adjusted based on historic norms. The National Board of Medical Examiners (NBME) shelf exam was taken with a virtual proctor. Students whose clerkship was affected by the COVID-19 pandemic were compared to the students from a similarly timed surgery block the previous 3 years. Primary outcomes included CSE and NBME exam scores. Secondary outcomes included clinical evaluations and the percentage of students who received grades of Honors, High Pass, and Pass. After the surgery clerkship was completed, we surveyed all students who participated in the surgery clerkship during the COVID-19 crisis. RESULTS: There were 19 students during the COVID-interrupted clerkship and 61 students in similarly timed clerkships between 2017 and 2019. Prior to adjustment and compared to historic scores, the COVID-interrupted clerkship group scored higher on the CSE, NBME exam, and performance evaluations (median, CSE:75.2 vs 68.7, shelf:68.0 vs 64.0, performance evaluation mean: 2.96 vs 2.78). The percentage of students with an honors was marginally higher in the group affected by COVID (42% vs 32%). Out of 19 students surveyed, 9 students responded. Seven students stated they would have preferred a closed-book CSE, citing a few drawbacks of the open-book format such as modifying their exam preparation, being discouraged from thinking prior to searching online during the test, and second guessing their answers. CONCLUSIONS: During the initial outbreak of COVID-19, we found that an open book exam and a virtually proctored shelf exam was a reasonable option. However, to avoid adjustments and student dissatisfaction, we would recommend virtual proctoring if available.

An analysis of the outcomes of a decade of experience with lower extremity revascularization including limb salvage, lengths of stay, and safety.

BACKGROUND: Demographic and practice modality changes during the past decade have led to a substantial shift in the management of peripheral vascular disease. This study examined the effect of these changes using large national and regional data sets on procedure type, indications, morbidity, and on the primary target outcome: limb salvage. METHODS: National Inpatient Sample (NIS) data sets and New York (NY) State inpatient hospitalizations and outpatient surgeries discharge databases from 1998 through 2007 were used to identify hospitalizations for lower extremity revascularization (LER) and major amputations. Patients were selected by cross-referencing diagnostic and procedural codes. Proportions were analyzed by chi(2) analysis, continuous variables by t test, and trends by the Poisson regression. RESULTS: The national per capita (100,000 population, age >40 years) volume of major amputations decreased by 38%. The volume for national and regional use of endovascular LER doubled. The volume of open LER decreased by 67% from 1998 through 2007. Ambulatory endovascular LER grew in NY State from 7 per capita in 1998 to 22 in 2007. Interventions declined by 20% (93 to 75) for critical limb ischemia (CLI) but increased by nearly 50% for claudication. Outpatient data analysis revealed a fivefold increase in vascular interventions for CLI and claudication. Nationally, endovascular LER interventions quadrupled (8% to 32%) for CLI and doubled (26% to 61%) for claudication. A parallel reduction occurred in major amputations for patients with CLI (42% to 30%), for other PAD diagnoses (18% to 14%), and for claudication (0.9% to 0.3%). Although surgical interventions for CLI declined significantly for octogenarians from 317 to 240, outpatient interventions increased for CLI, claudication, and other diagnoses in all age groups. Comorbidities for patients treated in 2006 were substantially greater than those of a decade ago. For most procedures, cardiac and bleeding complications have significantly decreased during the last decade. Length of stay (LOS) declined from 9.5 to 7.6 days and the percentage of short (1-2 day) hospitalizations increased from 16% to 35%. CONCLUSION: Although patients today, whether treated for claudication or CLI, have more comorbidities, the rates of amputation, the procedural morbidity and mortality, and LOS have all significantly decreased. Other variables, including changes in medical management and wound care, undoubtedly are important, but this change appears to be largely due to the widespread and successful use of endovascular LER or to earlier intervention, or both, driven by the safety of these techniques.

Surgical Education and the Longitudinal Model at the Columbia-Bassett Program.

OBJECTIVE: The aim of this study is to evaluate a longitudinal medical student surgical curriculum. DESIGN: This is a case-controlled study of students who participated in a longitudinal surgical curriculum compared to students who participated in a standard 12-week surgical clerkship. This study evaluates qualitative data including exam scores as well as qualitative data regarding student experience. SETTING: All students were from Columbia College of Physicians and Surgeons in New York City. A portion of the students completed their clerkship at the main university campus and others performed their clerkship at an affiliate site including Bassett Health Network. The longitudinal curriculum was only at the Bassett Health Network. PARTICIPANTS: All medical students who completed their surgical curriculum from 2012 to 2015 were eligible. The survey response rate was 45% for a total of 128 students. RESULTS: The students receiving the longitudinal curriculum outperformed the block students on the national shelf exam (77 vs 71, p = 0.001). The longitudinal students were also more likely to learn directly from attending surgeons and were more likely to have a greater interest in a surgical career after their surgery experience. CONCLUSIONS: The longitudinal approach to teaching surgery to medical students achieves non-inferior or superior testing outcomes when compared to the block model, and superior outcomes in terms of students' own attitudes and perceptions.

Exploring Medical Students' Perceptions of Organ Procurement: Need for a Formalized Medical Student Curriculum.

OBJECTIVE: We evaluated the medical student experience with a deceased-donor multiorgan procurement program at a single center. The program provided the opportunity to assist with organ procurement, but no formal curriculum was offered. DESIGN, SETTING, PARTICIPANTS: In 2018, medical students who registered for the program between 2014 and 2017 completed a voluntary survey about the experience and its impact on surgery interest and organ donation knowledge and advocacy. RESULTS: Of 139 respondents, 53.3% (N = 74) of students participated in at least one procurement. The experience was resoundingly positive: 81.7% (N = 58) believed it exceeded expectations, with less than one-third missing class and only 4.3% (N = 3) reporting a negative impact on academics. Although 60.6% (N = 43) students studied prior to procurement, 57.8% (N = 41) expressed the need for increased preparation. Preferred learning modalities included videos, discussion with the transplant fellows, and focused anatomy overview. Following participation, 53.5% (N = 38) of students had increased interest in pursuing an acting internship and career in surgery. However, participation was not associated with improved familiarity with organ donation concepts or advocacy. CONCLUSIONS: Adding a structured curriculum may turn medical students from passive observers into active learners, maximizing the educational value of procurement and better equipping future providers to promote organ donation.

Anti-receptor for advanced glycation end products therapies as novel treatment for abdominal aortic aneurysm.

OBJECTIVE: Rupture of abdominal aortic aneurysms (AAA) is a devastating event potentially preventable by therapies that inhibit growth of small aneurysms. Receptor of advanced glycation end products (RAGE) has been implicated in age related diseases including atherosclerosis and Alzheimer. Consequently, we explored whether RAGE may also contribute to the formation of AAAs. RESULTS: Implicating a role for RAGE in AAA, we found the expression of RAGE and its ligand AGE were highly elevated in human aneurysm specimens as compared with normal aortic tissue. In a mouse model of AAA, RAGE gene deletion (knockout) dramatically reduced the incidence of AAA to 1/3 of control (AAAs in 75.0% of controls vs. 25.0% knockouts). Moreover, aortic diameter was markedly reduced in RAGE knockout animals versus controls. As to mechanism, we found that RAGE was coexpressed in AAA macrophages with MMP-9, a promoter of matrix degradation, which is known to induce AAA. In vitro, AGE induced the production of MMP-9 in macrophages in a dose-dependent manner while blocking RAGE signaling with a soluble AGE inhibitor prevented MMP-9 expression. In vivo, RAGE gene deficiency eliminated MMP-9 activity that was prevalent in aneurismal wall of the wild-type mice. CONCLUSIONS: RAGE promotes the development of AAA by inducing MMP-9 expression. Blocking RAGE in a mouse aneurysm model has a dramatic inhibitory effect on the formation of aneurysms. These data suggest that larger animal and eventually human trials should be designed to test oral RAGE inhibitors and their potential to prevent progression of small aneurysms.

Bilateral carotid endarterectomy as treatment of vascular pulsatile tinnitus.

Atherosclerotic carotid artery disease (ACAD) is a rare but recognized cause of pulsatile tinnitus. Existing literature of reported cure for pulsatile tinnitus is reviewed. We found: (1) a male preponderance exists; (2) ipsilateral carotid endarterectomy (CEA) for tinnitus is 92% (12 of 13) effective; (3) proximal lesions lend themselves to CEA whereas distal lesions have been treated by stenting; (4) overall 68% (15 of 22) are cured by intervention; and (5) 89% (17 of 19) can expect immediate relief. We now present a case of bilateral pulsatile tinnitus relieved by bilateral carotid endarterectomy.

Insurance status predicts access to care and outcomes of vascular disease.

OBJECTIVE: To determine if insurance status predicts severity of vascular disease at the time of treatment or outcomes following intervention. METHODS: Hospital discharge databases from Florida and New York from 2000-2005 were analyzed for lower extremity revascularization (LER, n = 73,532), carotid revascularization (CR, n = 116,578), or abdominal aortic aneurysm repair (AAA, n = 35,593), using ICD-9 codes for diagnosis and procedure. The indications for intervention as well as the post-operative outcomes were examined assigning insurance status as the independent variable. Patients covered under a variety of commercial insurers, as well as Medicare, were compared to those who either had no insurance or were covered by Medicaid. RESULTS: Patients without insurance or with Medicaid were at significantly greater risk of presenting with a ruptured AAA compared to insured (non-Medicaid) patients; while insurance status did not seem to impact post-operative mortality rates for elective and ruptured AAA repair. The uninsured or Medicaid recipients presented with symptomatic carotid disease nearly twice as often as the insured, but stroke rates after CR did not differ significantly based on insurance status. Patients with Medicaid or without insurance were more likely to present with limb threatening ischemia than claudication. In contrast to AAA repair and CR, the outcomes of LER were worse in the uninsured and Medicaid beneficiaries who had higher rates of post-revascularization amputation compared to the insured (non-Medicaid) group. CONCLUSION: Insurance status predicts disease severity at the time of treatment, but once treated, the outcomes are similar among insurance categories, with the exception of lower extremity revascularization. This data suggests inferior access to preventative vascular care in the Medicaid and the uninsured populations.

Watch what happens: using a web-based multimedia platform to enhance intraoperative learning and development of clinical reasoning.

BACKGROUND: We aim to determine whether observed operations or internet-based video review predict improved performance in the surgery clerkship. METHODS: A retrospective review of students' usage of surgical videos, observed operations, evaluations, and examination scores were used to construct an exploratory principal component analysis. Multivariate regression was used to determine factors predictive of clerkship performance. RESULTS: Case log data for 231 students revealed a median of 25 observed cases. Students accessed the web-based video platform a median of 15 times. Principal component analysis yielded 4 factors contributing 74% of the variability with a Kaiser-Meyer-Olkin coefficient of .83. Multivariate regression predicted shelf score (P < .0001), internal clinical skills examination score (P < .0001), subjective evaluations (P < .001), and video website utilization (P < .001) but not observed cases to be significantly associated with overall performance. CONCLUSIONS: Utilization of a web-based operative video platform during a surgical clerkship is an independently associated with improved clinical reasoning, fund of knowledge, and overall evaluation. Thus, this modality can serve as a useful adjunct to live observation.

Off-pump right atrial thrombectomy for heparin-induced thrombocytopenia with thrombosis.

This report describes a 72-year-old woman with atrial fibrillation who presented with lower extremity ischemia secondary to thromboembolism. After lower extremity thrombectomy, the patient developed heparin-induced thrombocytopenia with thrombosis (HITT). Her postoperative course was complicated by recurrent supraventricular and ventricular tachycardia, secondary to a mobile thrombus in the right atrium extending into the right ventricle. Because administration of heparin was contraindicated, the patient underwent off-pump right atrial thrombectomy during a brief period of inflow occlusion. Postoperatively, she was placed on lepirudin. Her platelet count normalized without any further thrombotic episodes, and she was discharged on warfarin.

Validity and reliability of a novel written examination to assess knowledge and clinical decision making skills of medical students on the surgery clerkship.

BACKGROUND: The Surgery Clerkship Clinical Skills Examination (CSE) is a novel written examination developed to assess the surgical knowledge, clinical decision making, communication skills, and professionalism of medical students on the surgery clerkship. This study was undertaken to determine its validity. METHODS: Data were prospectively collected from July 2011 through February 2013. Multivariate linear and logistic regression analyses were used to assess score trend; convergent validity with National Board of Medical Examiners surgery and medicine subject scores, United States Medical Licensing Examination Step 1 and Step 2 Clinical Knowledge scores, and evaluation of clinical reasoning and fund of knowledge; and the effect of clerkship order. Exam reliability was assessed using a modified Cronbach's α statistic. RESULTS: During the study period, 262 students completed the CSE, with a normal distribution of performance. United States Medical Licensing Examination Step 2 Clinical Knowledge score and end-of-clerkship evaluations of fund of knowledge and clinical reasoning predicted CSE score. Performance on the CSE was independent of clerkship order or prior clerkships. The modified Cronbach's α value for the exam was .67. CONCLUSIONS: The CSE is an objective, valid, reliable instrument for assessing students on the surgery clerkship, independent of clerkship order.

Cultivation of Enterobacter hormaechei from human atherosclerotic tissue.

AIM: To determine whether culturable bacterial strains are present in human atheromatous tissue and to investigate their properties using culture, quantitative PCR, metagenomic screening, genomic and biochemical methods. METHODS: We analyzed femoral atherosclerotic plaque and five pairs of diseased and healthy arterial tissue for the presence of culturable bacteria using cell cultures and genomic analysis. RESULTS: Gram negative aerobic bacilli were cultivated from the plaque tissue. Ribosomal 16S DNA amplification and sequencing identified the isolates as Enterobacter hormaechei. The isolate was resistant to ampicillin, cefazolin, and erythromycin. A circular 10 kb plasmid was isolated from the strain. Antibiotic protection assays of the isolate demonstrated invasive ability in a human monocytic cell line. To extend the study, five matched pairs of diseased and healthy aortic tissue were analyzed via quantitative PCR. Eubacterial 16S rDNA was detected in all specimens, however, E. hormaechei DNA was detected in surprisingly high numbers in two of the diseased tissues only. CONCLUSIONS: While it is well documented that inflammation is an important risk factor for vascular pathophysiology, the association of bacteria with atherosclerosis has not been clearly established, in large part due to the inability to isolate live bacteria from atheromatous tissue. This is the first study providing direct evidence of Enterobacter spp. associated with atheromatous tissues. The data suggest that chronic infection with bacteria may be an under-reported etiologic factor in vascular pathogenesis. Importantly, characterization of the clinical isolate supports a model of atherogenesis where systemic dissemination of bacteria to atherosclerotic sites may occur via internalization in phagocytic cells.

Shifting paradigms in the treatment of lower extremity vascular disease: a report of 1000 percutaneous interventions.

OBJECTIVES: Catheter-based revascularization has emerged as an alternative to surgical bypass for lower extremity vascular disease and is a frequently used tool in the armamentarium of the vascular surgeon. In this study we report contemporary outcomes of 1000 percutaneous infra-inguinal interventions performed by a single vascular surgery division. METHODS: We evaluated a prospectively maintained database of 1000 consecutive percutaneous infra-inguinal interventions between 2001 and 2006 performed for claudication (46.3%) or limb-threatening ischemia (52.7%; rest pain in 27.7% and tissue loss in 72.3%). Treatments included angioplasty with or without stenting, laser angioplasty, and atherectomy of the femoral, popliteal, and tibial vessels. RESULTS: Mean age was 71.4 years and 57.3% were male; comorbidities included hypertension (84%), coronary artery disease (51%), diabetes (58%), tobacco use (52%), and chronic renal insufficiency (39%). Overall 30-day mortality was 0.5%. Two-year primary and secondary patencies and rate of amputation were 62.4%, 79.3%, and 0.5%, respectively, for patients with claudication. Two-year primary and secondary patencies and limb salvage rates were 37.4%, 55.4%, and 79.3% for patients with limb-threatening ischemia. By multivariable Cox PH modeling, limb-threat as procedural indication (P < 0.0001), diabetes (P = 0.003), hypercholesterolemia (P = 0.001), coronary artery disease (P = 0.047), and Transatlantic Inter-Society Consensus D lesion complexity (P = 0.050) were independent predictors of recurrent disease. For patients that developed recurrent disease, 7.5% required no further intervention, 60.3% underwent successful percutaneous reintervention, 11.7% underwent bypass and 20.5% underwent amputation. Patency rates were identical for the initial procedure and subsequent reinterventions (P = 0.97). CONCLUSION: Percutaneous therapy for peripheral vascular disease is associated with minimal mortality and can achieve 2-year secondary patency rates of nearly 80% in patients with claudication. Although patency is diminished in patients with limb-threat, limb-salvage rates remain reasonable at close to 80% at 2 years. Percutaneous infra-inguinal revascularization carries a low risk of morbidity and mortality, and should be considered first-line therapy in patients with chronic lower extremity ischemia.