Step 1 of the United States Medical Licensing Examination (USMLE), a historically important factor in the selection of vascular surgery residents and fellows, transitioned to completely pass/fail on ...January 26, 2022. Due to the COVID-19 pandemic, residency and fellowship interviews were conducted virtually during the 2020-21 and 2021-22 application cycles. Given these significant changes in the evaluation of candidates for residency training, we sought to understand vascular surgery program directors' (PDs) perspectives regarding the change in step 1 scoring and use of virtual interviews as well as determine which factors will assume importance when applying to vascular surgery training programs in the future.
A 26-item survey questionnaire was created using Qualtrics survey tools with questions regarding attitudes toward the change in step 1 scoring and virtual interviews, the importance of additional factors utilized by programs in selecting candidates for interviews and ranking applicants for residency/fellowship selection, and programmatic demographics. This was distributed anonymously to all vascular surgery training programs over a 2-week period using a comprehensive list of 249 unique email addresses created by cross-referencing the Accreditation Council for Graduate Medical Education list of certified vascular training programs with email addresses from individual program websites identifying current program leadership. Responses were analyzed with descriptive statistics with values listed as average Likert scale weight ± standard deviation (SD) or percentages.
Sixty-eight of 249 (27.3%) program and associate PDs responded to the survey. Of which, 33.9% of respondents strongly disagreed with step 1 going completely pass/fail. In the absence of a scored USMLE step 1, letters of recommendation (average Likert scale weight ± SD, 4.43 ± 0.92), dedication to specialty (4.14 ± 1.03), and USMLE step 2 CK (4.06 ± 0.92) had the highest average scores for deciding which applicants to interview for integrated vascular surgery residency. For determining which candidates to interview for vascular surgery fellowship, letters of recommendation (4.51 ± 0.84), dedication to specialty (4.12 ± 0.90), and research (4.10 ± 0.80) had the highest average scores. For ranking residency candidates, the interviewee's perceived "fit" (4.61 ± 0.55), letters of recommendation (4.53 ± 0.76), and an overall interview experience (4.47 ± 0.62) had the highest average scores. Similarly, the factors with the highest average Likert scores for ranking fellowship candidates included the interviewee's perceived "fit" (4.69 ± 0.51), letters of recommendation (4.65 ± 0.52), and an overall interview experience (4.51 ± 0.59). The majority (72.2%) of PDs preferred in-person interviews; however, 50% of respondents were at least "somewhat satisfied" with virtual interviews during the 2021-22 application cycle as they could judge applicants' interview skills at least "moderately well." The minority (18.8%) who preferred virtual interviews most commonly noted a "reduction of the financial burden for applicants" as the reason for this preference.
Most vascular surgery program and associate PDs were dissatisfied with USMLE step 1 going pass/fail with most indicating prescreening applicants using both step 1 and step 2 clinical knowledge (CK) during the residency and fellowship selection processes. In the absence of a scored step 1, the top factors for interviewing and ranking integrated vascular surgery residency and fellowship candidates included letters of recommendation, dedication to specialty, research, USMLE step 2 CK, the interviewee's perceived "fit," and overall interview experience. Though most PDs preferred face-to-face interviews, they were overall at least "somewhat satisfied" with the virtual format that took place during the 2021-22 cycle.
Prior research on median arcuate ligament syndrome has been limited to institutional case series, making the optimal approach to median arcuate ligament release (MALR) and resulting outcomes unclear. ...In the present study, we compared the outcomes of different approaches to MALR and determined the predictors of long-term treatment failure.
The Vascular Low Frequency Disease Consortium is an international, multi-institutional research consortium. Data on open, laparoscopic, and robotic MALR performed from 2000 to 2020 were gathered. The primary outcome was treatment failure, defined as no improvement in median arcuate ligament syndrome symptoms after MALR or symptom recurrence between MALR and the last clinical follow-up.
For 516 patients treated at 24 institutions, open, laparoscopic, and robotic MALR had been performed in 227 (44.0%), 235 (45.5%), and 54 (10.5%) patients, respectively. Perioperative complications (ileus, cardiac, and wound complications; readmissions; unplanned procedures) occurred in 19.2% (open, 30.0%; laparoscopic, 8.9%; robotic, 18.5%; P < .001). The median follow-up was 1.59 years (interquartile range, 0.38-4.35 years). For the 488 patients with follow-up data available, 287 (58.8%) had had full relief, 119 (24.4%) had had partial relief, and 82 (16.8%) had derived no benefit from MALR. The 1- and 3-year freedom from treatment failure for the overall cohort was 63.8% (95% confidence interval CI, 59.0%-68.3%) and 51.9% (95% CI, 46.1%-57.3%), respectively. The factors associated with an increased hazard of treatment failure on multivariable analysis included robotic MALR (hazard ratio HR, 1.73; 95% CI, 1.16-2.59; P = .007), a history of gastroparesis (HR, 1.83; 95% CI, 1.09-3.09; P = .023), abdominal cancer (HR, 10.3; 95% CI, 3.06-34.6; P < .001), dysphagia and/or odynophagia (HR, 2.44; 95% CI, 1.27-4.69; P = .008), no relief from a celiac plexus block (HR, 2.18; 95% CI, 1.00-4.72; P = .049), and an increasing number of preoperative pain locations (HR, 1.12 per location; 95% CI, 1.00-1.25; P = .042). The factors associated with a lower hazard included increasing age (HR, 0.99 per increasing year; 95% CI, 0.98-1.0; P = .012) and an increasing number of preoperative diagnostic gastrointestinal studies (HR, 0.84 per study; 95% CI, 0.74-0.96; P = .012) Open and laparoscopic MALR resulted in similar long-term freedom from treatment failure. No radiographic parameters were associated with differences in treatment failure.
No difference was found in long-term failure after open vs laparoscopic MALR; however, open release was associated with higher perioperative morbidity. These results support the use of a preoperative celiac plexus block to aid in patient selection. Operative candidates for MALR should be counseled regarding the factors associated with treatment failure and the relatively high overall rate of treatment failure.
The American Board of Surgery In-Training Examination (ABSITE) is used by programs to evaluate the knowledge and readiness of trainees to sit for the general surgery qualifying examination. It is ...often used as a tool for resident promotion and may be used by fellowship programs to evaluate candidates. Burnout has been associated with job performance and satisfaction; however, its presence and effects on surgical trainees' performance are not well studied. We sought to understand factors including burnout and study habits that may contribute to performance on the ABSITE examination.
Anonymous electronic surveys were distributed to all residents at 10 surgical residency programs (n = 326). Questions included demographics as well as study habits, career interests, residency characteristics, and burnout scores using the Oldenburg Burnout Inventory, which assesses burnout because of both exhaustion and disengagement. These surveys were then linked to the individual's 2016 ABSITE and United States Medical Licensing Examination (USMLE) step 1 and 2 scores provided by the programs to determine factors associated with successful ABSITE performance.
In total, 48% (n = 157) of the residents completed the survey. Of those completing the survey, 48 (31%) scored in the highest ABSITE quartile (≥75th percentile) and 109 (69%) scored less than the 75th percentile. In univariate analyses, those in the highest ABSITE quartile had significantly higher USMLE step 1 and step 2 scores (P < 0.001), significantly lower burnout scores (disengagement, P < 0.01; exhaustion, P < 0.04), and held opinions that the ABSITE was important for improving their surgical knowledge (P < 0.01). They also read more frequently to prepare for the ABSITE (P < 0.001), had more disciplined study habits (P < 0.001), were more likely to study at the hospital or other public settings (e.g., library, coffee shop compared with at home; P < 0.04), and used active rather than passive study strategies (P < 0.04). Gender, marital status, having children, and debt burden had no correlation with examination success. Backward stepwise multiple regression analysis identified the following independent predictors of ABSITE scores: study location (P < 0.0001), frequency of reading (P = 0.0001), Oldenburg Burnout Inventory exhaustion (P = 0.02), and USMLE step 1 and 2 scores (P = 0.007 and 0.0001, respectively).
Residents who perform higher on the ABSITE have a regular study schedule throughout the year, report less burnout because of exhaustion, study away from home, and have shown success in prior standardized tests. Further study is needed to determine the effects of burnout on clinical duties, career advancement, and satisfaction.
Major depression is associated with increased morbidity and mortality in vascular surgery patients. The US Preventive Services Task Force and American Heart Association recommend routine depression ...screening for adults, especially those with cardiovascular disease. Since routine depression screening has not been implemented in most vascular surgery clinics across the nation, we sought to determine the feasibility of depression screening and understand the prevalence and predictors of depression in patients presenting to a single institution's vascular surgery clinic over a 4 month period.
From June to September 2020, vascular surgery clinic patients were administered a 26-item survey that included validated scales for depression (PHQ-9), pain, frailty, alcohol dependence, and nicotine dependence. Although not validated, the Rosenberg Self-Esteem Scale was also administered. Patient charts were reviewed for demographic information and medical history. 9-digit patient zip codes were used to determine Area Deprivation Index, a measure of socioeconomic status. Univariate and multivariate analyses were performed to understand the factors associated with increased depression prevalence in the study population.
A total of 140 (36.4%) of 385 patients met study inclusion criteria. 35.7% of them screened positive for mild to severe depression (PHQ-9 scores ≥5). On univariate analysis, major depression was significantly associated with lower socioeconomic status (
= 0.007), higher frailty (
< 0.001), lower self-esteem (
< 0.001), higher daily pain (
< 0.001), health problems that interfere with social activities (
< 0.001), fatigue (
< 0.001), unmarried status (
= 0.031), and lack of primary care provider (
= 0.048). Multivariate analyses significantly predicted higher frailty (B= 0.487,
= 0.007) and lower self-esteem (B= -0.413,
< 0.001) in patients with depression. Depression was not associated with gender, age, employment status, smoking status, alcohol use, or type of vascular disease.
More than one-third of vascular surgery clinic patients have comorbid depression. Higher frailty and lower self-esteem are significant risk factors for depression. Prevention and early identification of frailty may improve outcomes. Depression screening in vascular surgery clinics is feasible and could be useful in determining which patients may benefit from more frequent follow-up and monitoring for associated comorbidities. Vascular surgeons may play an important role in screening for depression and referring patients for psychotherapy and/or pharmacotherapy.
The acute technical failure of endovascular treatment of chronic total occlusions (CTOs) is most often due to the inability to re-enter the true lumen after occlusion is crossed in a subintimal ...plane. This study reports our initial experience with true lumen re-entry devices in the treatment of CTOs.
Patients with treatment of CTOs were identified from our vascular registry. All patients in whom the Pioneer catheter or the Outback catheter were used were also identified from a prospectively maintained separate database of cases in which true lumen re-entry devices were used. We used procedural data from the prospective database and reviewed the medical records. Lesion character and location, access type, location of true lumen re-entry, stent usage, procedural times, and complications, were tabulated.
From August 2003 to December 2004, endovascular techniques were used to treat 87 CTOs in 58 iliac and 29 superficial femoral arteries. In 24 (26%), the true lumen could not be re-entered by using standard catheter and wire techniques. The true lumen was not initially re-entered in 20 (34%) of 58 of treated iliac CTOs and four (13%) of 29 of treated superficial femoral artery CTOs (73% TASC C and D lesions). Intravascular ultrasound-guided true lumen re-entry using the Pioneer catheter (21 CTOs), or fluoroscopic-guided true lumen re-entry using the Outback catheter (3 CTOs) was successful in achieving true lumen re-entry in all cases at the location desired. Total time of re-entry catheter manipulation required to achieve re-entry was <10 minutes and was routinely accomplished in <3 minutes. All occlusions were stented. No cases were converted to open repair. Bleeding from the recanalization and angioplasty site occurred in four patients (15%). It was controlled with use of covered stents in two cases, and resolved after placement of uncovered stents in the other two. No significant bleeding occurred at the sites of true lumen re-entry needle deployment. All occlusions treated with true lumen re-entry devices remain clinically patent at a mean follow-up of 5.8 months.
Endovascular treatment of chronic total occlusions is often limited by the inability to re-enter the true lumen after subintimal crossing of the occluded segment. This occurs more commonly with treatment of iliac occlusions than in superficial femoral artery occlusions. True lumen re-entry catheters are very effective at gaining wire passage back to the true lumen and facilitating successful endovascular treatment of chronic total occlusions that would otherwise require open bypass.
Cannabinoid type 1 (CB1) receptor antagonists have been developed for the treatment of obesity, but a major disadvantage is that they cause unwanted psychiatric effects. Selective targeting of ...peripheral CB1 receptors might be an option to circumvent these side effects. Multidrug resistance-associated proteins (MRPs) can influence the pharmacokinetics of drugs and thereby affect their disposition in the body. In this study, we investigated the interaction of the prototypic CB1 receptor antagonist rimonabant and a series of 3,4-diarylpyrazoline CB1 receptor antagonists with MRP1, MRP2, MRP3, and MRP4 in vitro. Their effect on ATP-dependent transport of estradiol 17-β-D-glucuronide (E(2)17βG) was measured in inside-out membrane vesicles isolated from transporter-overexpressing human embryonic kidney 293 cells. Rimonabant inhibited MRP1 transport activity more potently than MRP4 (K(i) of 1.4 and 4 μM, respectively), whereas the 3,4-diarylpyrazolines were stronger inhibitors of MRP4- than MRP1-mediated transport. A number of CB1 receptor antagonists, including rimonabant, stimulated MRP2 and MRP3 transport activity at low substrate concentrations but inhibited E(2)17βG transport at high substrate concentrations. The interaction of 3,4-diarylpyrazolines and rimonabant with MRP1-4 indicates their potential for drug-drug interactions. Preliminary in vivo data suggested that for some 3,4-diarylpyrazolines the relatively lower brain efficacy may be related to their inhibitory potency against MRP4 activity. Furthermore, this study shows that the modulatory effects of the 3,4-diarylpyrazolines were influenced by their chemical properties and that small variations in structure can determine the affinity of these compounds for efflux transporters and thereby affect their pharmacokinetic behavior.
Background Women with peripheral vascular disease requiring vascular operations are less well studied than their male counterparts. The surgical outcomes of female vascular patients in the Department ...of Veterans Affairs (VA) and private sector hospitals have not previously been compared, and their preoperative risk profile, postoperative morbidity, and mortality need to be better elucidated. Study Design Patients undergoing vascular operations at 14 private sector and 128 VA hospitals, from October 2001 through September 2004, had their preoperative characteristics, operative data, and 30-day postoperative morbidity and mortality compared, as part of the Patient Safety in Surgery (PSS) Study. Logistic regression analysis was performed to develop predictive models for morbidity and mortality, which allowed for a comparison of risk-adjusted outcomes between the two hospital groups. Results There were 458 vascular surgical operations performed in women in the VA, and 3,535 vascular operations were performed in women in the private sector. Eighteen of 45 preoperative comorbidities and laboratory variables differed considerably between the institutions, and 16 of 18 were adverse among the private sector patients. The unadjusted 30-day mortality rate was higher in the private sector compared with the VA (5.2% versus 2.4%, p = 0.008); the unadjusted morbidity rate was higher in the private sector compared with the VA sector (23.4% versus 13.3%, p < 0.0001). After risk adjustment, there was no marked difference between the VA and the private sector in mortality (p = 0.12), but the difference in morbidity rates remained pronounced, with an odds ratio of 0.60 for VA versus private sector (95% CI = 0.44, 0.81). Conclusions Compared with their VA counterparts, women undergoing vascular operations at private sector hospitals had a higher incidence of preoperative comorbidities; after risk adjustment, mortality did not differ substantially. Despite risk adjustment, the incidence of postoperative morbidity in the VA patients was considerably lower, suggesting unidentified differences in the hospital populations, their processes of care, or both.
Based on the full BABAR data sample, we report improved measurements of the ratios R(D(*))=B(B̄→D(*)τ⁻ν¯τ)/B(B̄→D(*)ll¯ν¯l), where l is either e or μ. These ratios are sensitive to new physics ...contributions in the form of a charged Higgs boson. We measure R(D)=0.440±0.058±0.042 and R(D*)=0.332±0.024±0.018, which exceed the standard model expectations by 2.0σ and 2.7σ, respectively. Taken together, our results disagree with these expectations at the 3.4σ level. This excess cannot be explained by a charged Higgs boson in the type II two-Higgs-doublet model.
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