Objective The primary goal of this study was to determine whether exposure to endovascular simulator training increases interest in vascular surgery among medical students. Secondary goals were to ...determine whether interest in vascular surgery is inversely related to the time after exposure, to identify factors associated with interest, and to identify students' characteristics that positively influence performance metrics. Methods This was a prospective, randomized, crossover study comprising 80 medical students who were randomized into group A (n = 40) and group B (n = 40). Participants completed a survey of their interest in vascular surgery and attitudinal factors using Vascular Surgery Interest Form (VSIF) before exposure to the simulator (pretest). At 1 month after exposure of group A to the simulator, both groups were tested using VSIF (test). Upon completion of testing, group B was exposed to simulator training, whereas group A received no further training. At 2 months after exposure of group B to the simulator, both groups were posttested using VSIF, which asked the students' level of interest in vascular surgery using a 1 to 10 scale. Performance metrics were recorded during each exposure. Differences among cohort demographics were determined using Pearson χ2 analysis. Differences in interest were determined with paired sample correlations. Linear regression and analysis of variance were used to correlate VSIF responses with interest and the performance metrics. Results Both student cohorts had significant increases in interest after exposure to simulation. In group A, test interest (mean ± standard deviation) was significantly higher than pretest and posttest interests (5.51 ± 1.73 vs 4.00 ± 1.88 vs 4.18 ± 1.82; P < .05). In group B, posttest interest was significantly higher than pretest and test interests (5.62 ± 2.03 vs 3.96 ± 1.61 vs 4.08 ± 1.64; P < .05). The increase in interest was reciprocally related to the time passed since the initial exposure. Resident and attending lifestyle, length of training, radiation concerns, gender identification of a mentor, and personality fit with occupation were not correlated with interest. Sex, medical school year, comfort with endovascular procedures, willingness to work long hours, interest in performing percutaneous procedures, and commitment to surgical career did not affect impact performance metrics. Conclusions One exposure of students to endovascular simulator training is associated with an increase in vascular surgery interest. Acquired interest is reciprocally related to the time demonstrating the temporal importance of the exposure.
Background Osteopontin (OPN) is a variably expressed, secreted glycophosphoprotein that mediates the growth and metastases of hepatocellular cancer (HCC). MicroRNAs (miRNAs) may be responsible for ...variant OPN expression, interrupting translation by binding OPN messenger RNA (mRNA) in 3'-untranslated regions (UTRs). Methods A microarray analysis identified miRNAs of interest. Plasmid constructs using a luciferase reporter with variable OPN 3'UTR mutations were transfected into 2 HCC cell lines to determine miRNA regulation of OPN expression. Western blot analyses confirmed variable OPN expression in both cell lines. Invasion, adhesion, and migration evaluated metastatic behavior in Hep G2 and Hep 3B with modified miRNA and OPN expression. Results Hep 3B produces 36 × miRNA 181a compared with Hep G2. Luciferase activity after transfection with miRNA 181a precursor was decreased in both cell lines ( P < .01); luciferase activity increased with miRNA 181a inhibitor transfection in both cell lines ( P < .01). Hep 3B transfected with mutated OPN 3'UTR increased luciferase activity 108% ( P < .01). Hep G2 transfected with miRNA precursor decreased OPN expression 5 × ( P < .01) in Western blot analyses. Hep 3B transfection with miRNA precursor increased OPN expression 3 × ( P < .01) in Western blot analyses. In vitro metastatic correlates increased in Hep 3B lines after transfection with siOPN and/or miRNA 181a inhibitor ( P < .01). Conclusion MiRNA 181a decreases OPN expression in HCC cell lines. This previously undescribed mechanism may confer metastatic characteristics to HCC.
In this report we describe a patient with anterior renal nutcracker syndrome caused by extrinsic compression of the left-sided inferior vena cava between the aorta and the superior mesenteric artery, ...as it crossed the midline, with resultant left renal vein hypertension. The patient was successfully treated by transposition of the right ovarian vein, which created a bypass of the compressed inferior vena cava and resulted in complete resolution of symptoms.
Background Vascular malformations are a rare and complex group of lesions which may present serious pitfalls in diagnosis and management. We sought to evaluate the efficacy and safety of our imaging ...protocol and therapeutic algorithm in the treatment of low-flow and high-flow vascular malformations in a large series of patients. Methods A prospective database of all patients treated by the multidisciplinary vascular malformation team at our institution between 2006 and 2011 was reviewed. Management decisions were based on patients' clinical profile as well as critical lesion characteristics, and included conservative care, sclerotherapy, embolization, surgical resection, or a combination of these modalities. Treatment goals and expectations were established by the patient and physician at the time of initial evaluation. An outcomes grading system based on patient- and physician-derived treatment goals and assessment of response to management was applied (1 = worse; 2 = unchanged, 3 = significantly improved, 4 = completely resolved), and postprocedural complications were identified. Results The 136 vascular malformations in 135 patients included 59 (43.7%) males and 76 (56.3%) females, ranging in age from under 1 year to 68 years (mean, 25.3 ± 17.0 years). In order to facilitate application of the therapeutic algorithm, all patients underwent dynamic contrast-enhanced magnetic resonance imaging to determine critical lesion characteristics, including flow quality and lesion extension. Of the 105 low-flow vascular malformations (LFVM), 23 (21.9%) were managed conservatively, 38 (36.2%) were treated with sclerotherapy (sodium tetradecyl sulfate, polidocanol, and/or ethanol), 18 (17.1%) were surgically resected, and eight (7.6%) were managed with a combination of modalities. Of the 31 high-flow vascular malformations (HFVM), eight (25.8%) were managed conservatively, eight (25.8%) were treated with transcatheter arterial embolization, six (19.4%) required embolization followed by sclerotherapy, and five (16.1%) were primarily resected. Patients in all groups managed conservatively had minimal alteration in status. Response to sclerotherapy in the LFVM group resulted in improvement in 32 (84.2%) patients, surgical resection resulted in improvement in 16 (88.9%) patients, and combination therapy resulted in improvement in eight (100%) patients. Treatment with embolization in the HFVM group resulted in improvement in seven (87.5%) patients, while combination therapy resulted in improvement in six (100%), and surgical resection led to improvement in four (80%). Complications were observed in six (6.8%) patients treated for LFVMs (0 with sodium tetradecyl sulfate or polidocanol, four with ethanol, two with resection), and two (7.4%) patients treated for HFVMs with embolization or combination therapy. Conclusions In this large cohort of vascular malformation patients, implementation of the proposed diagnostic and therapeutic algorithms in a multidisciplinary setting resulted in favorable outcomes with an acceptable complication rate in this challenging patient population.
Congenital vascular malformations (CVMs) are a complex group of lesions that arise by embryologic dysmorphogenesis without increased endothelial proliferation that leads to structural and functional ...anomalies of the vascular system characterized by a wide range of presenting symptoms and often unpredictable clinical course. A recent advancement in the diagnostic and treatment modalities has resulted in a better understanding of the pathophysiology and natural history of CVMs and improved management of these lesions. The multidisciplinary approach and diagnostic algorithm used to distinguish high-flow (HFVM) from low-flow vascular malformations (LFVM) have been validated as clinically applicable for making an accurate anatomic and hemodynamic diagnosis of CVMs; they serve as a basis for proper treatment selection and significantly facilitate communication among different medical specialists. Dynamic contrast-enhanced magnetic resonance imaging is able to definitively distinguish HFVM from LFVM with accuracy of approximately 84%. In inconclusive cases, confirmatory angiography is required. Symptomatic, diffuse, extensive, macrocystic LFVMs and LFVMs that involve multiple tissue planes and vital structures are best treated with foam sclerotherapy. Primary surgical resection is the treatment of choice for localized, septated, and microcystic LFVMs. The management of HFVMs is characterized by multimodal treatment including preoperative embolization followed by complete surgical resection or sclerotherapy of the remaining venous component. Treatment of extensive CVMs is palliative and goal oriented. Implementation of the proposed diagnostic protocols and therapeutic algorithms in a multidisciplinary setting results in favorable outcomes with acceptable complication rates in this challenging patient population.
The use of endovenous procedures to treat superficial venous reflux disease in an exclusively outpatient setting has been growing in popularity during the last decade. Incorporating outpatient venous ...procedures into an existing vascular surgery practice is a logical step and provides optimal patient care by using the combined expertise and knowledge of devoted vascular surgeons and dedicated supporting staff. This affords the opportunity to treat patients comprehensively and to streamline the evaluation and treatment process for patients with virtually all stages of chronic venous insufficiency. Successful establishment of an outpatient vein care clinic involves making well-informed decisions about workspace, staffing, acquisition of equipment, optimization of reimbursement, and patient recruitment. Separation of the venous practice from the arterial practice both geographically and temporally is critical to success because the clinical and operational needs of these two groups of patients are very different and because the vein practice in many situations may become so robust that it erodes physicians' participation in the arterial side of the vascular practice. In addition to favorable clinical results and increased patient demand, procedures performed on an outpatient basis can be expected to significantly increase revenues. With proper strategy and organization, an outpatient vein practice can round out the existing vascular practice and be a profitable adjunct to an already established vascular surgery practice.
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