JVS-vascular insights最新文献

Objective

Cutaneous findings are vital for developing differential diagnoses in vascular surgery and are visually distinct based on skin tone. Studies show that non-White patients with vascular disease may be subject to delays in diagnosis, present with more advanced disease, and have worse outcomes. The ability to recognize cutaneous manifestations of vascular disease in various skin tones may contribute to these disparities in care. Thus, we aim to assess if there is equal representation of White vs non-White skin tones in vascular surgery educational materials. To our knowledge, this is the first assessment of racial diversity in vascular surgery resources.

Methods

We included 369 images from 11 commonly utilized vascular surgery resources and assessed for skin tone via the Fitzpatrick scale (ratings 1-3 classified as White, ratings 4-6 classified as non-White). Images without vascular pathology depiction were excluded. One rater examined all the pictures. A subsequent rater rated 60 photos to assess inter-rater reliability.

Results

The Cohen kappa score was 0.86, demonstrating strong inter-rater reliability. Of the photos, 93% (n = 344 photos) were classified as White, and 7% (n = 25) were classified as non-White. The images were then stratified by disease process: arterial (26/28 White), venous, lymphatic, edema (159/169 White), vasculitis (48/50 White), diabetes and ulcers (62/68 White), and other (49/54 White).

Conclusions

Ninety-three percent of images analyzed had a White skin tone, demonstrating unequal racial representation of vascular pathologies in educational resources. A lack of diverse representation of vascular pathology in educational resources may decrease trainee exposure and contribute to delays in diagnosis and disparities in outcomes. Further research is needed to answer this question. Regardless, the disparity should be addressed to provide adequate exposure to trainees and optimize patient care.

Objective

Adherence to peripheral artery disease (PAD) treatment reduces the risk of cardiovascular events and delays disease progression, but patients do not fully adhere to their treatment regimens. This pilot study aimed to identify the adherence levels of patients with PAD and how these are related to sociodemographics, clinical factors, and illness perceptions.

Methods

Patients with PAD were recruited during outpatient appointments at a London teaching hospital between January and May 2022. Data were collected from medical records and questionnaires, including the self-reported Morinsky Medication Adherence Scale (MMAS-8) and the Brief Illness Perceptions Questionnaire (BIPQ). Descriptive statistics, χ², independent sample tests, and one-way analysis were conducted using SPSS.

Results

A total of 105 patients participated and completed the questionnaire. Of these, 73.3% were male, with a mean age of 69.5 years. Of the patients, 41.9% and 36.2% had high antiplatelet and statin adherence, respectively, defined by an MMAS >8 score. One-quarter were current smokers, whereas only 17.1% of patients had previously attended a supervised exercise class. High adherence to antiplatelets and statins was associated with older age (P = .006 and P = .047) and previous vascular interventions (P = .004 and P = .009). Low antiplatelet adherence was linked to lower perceived control (P = .041), treatment control (P = .019), and disease understanding (P = .049). Patients perceiving their medical therapy as less effective showed lower statin adherence (P = .036). Being a current or ex-smoker was related to feeling less in control of care (P = .013). High exercise frequency was associated with lower consequences (P = .041) and identity scores (P = .031). Limited walking distance was linked to higher disease impact on daily quality of life (P < .001), lower perceived treatment effectiveness (P = .002), lower perceived personal control (P = .018), severe claudication symptoms (P < .001), and higher concerns (P = .001) and emotional distress (P < .001).

Conclusions

Treatment adherence among patients with PAD is notably low. Patients’ illness perceptions play a significant role in understanding and explaining this lack of adherence. To improve treatment adherence, interventions should particularly focus on addressing and modifying negative illness perceptions.

Objective

Lower extremity arterial disease (LEAD) is a prevalent condition that produces a significant burden on health care systems. Patients with LEAD have an increased risk of major adverse cardiovascular events as well as major adverse limb events. Despite significant variation in guidance on antiplatelet therapy for LEAD worldwide, many governing bodies recommend clopidogrel as the preferred single anti-platelet agent. Clopidogrel is also used frequently in post-revascularization regimens, either as a single agent or as part of dual antiplatelet therapy. Clopidogrel is a thienopyridine prodrug that is metabolized in the liver by the CYP2C19 enzyme. Genetic variations in CYP2C19 are common and can influence an individual’s ability to metabolize clopidogrel to its active metabolite.

Methods

This work completes a narrative review of the literature to consider whether CYP2C19 genetic testing should be routinely implemented in patients who are to be prescribed clopidogrel to improve outcomes in patients with LEAD.

Results

Recent advances in both cardiac and stroke medicine have demonstrated a role for patient genotyping to identify poor clopidogrel metabolizers and adopt alternative therapeutic strategies in these patient groups. This approach has been shown to improve clinical outcomes and has been incorporated into national and international guidance. Research studies suggest an association between CYP2C19 loss of function alleles and adverse outcomes in patients with LEAD taking clopidogrel.

Conclusions

The introduction of a precision medicine strategy in vascular surgery may have the potential to significantly improve clinical outcomes in this complex group of patients with multiple comorbidities.

Background

Three-dimensional (3D) printing is an additive manufacturing technique capable of the rapid prototyping of objects not feasible by other manufacturing methods. Vascular surgery has welcomed this technology and found it useful in many areas.

Methods

The integration of 3D-printed models in surgical training offers to bridge existing training gaps and increase exposure to complex pathology, while maintaining patient safety, during this time where the surgical education paradigm is shifting. Sterilizable 3D-printed models are being used to aid in the development of physician-modified endografts with excellent results. Rehearsing with patient-specific anatomic models before surgery has demonstrated evidence in improving operator confidence and decreased operative and fluoroscopy times. Research trends have demonstrated that technology such as printed custom implantable devices with tunable chemical and physical properties may be on the horizon.

Results

Despite all of this, the current use of 3D printing in vascular surgery is limited by factors such as materials, time constraints, and initial technical challenges to developing a printing protocol. All of these are areas actively being researched to improve applicability and adaptation of 3D printing. As its use continues to grow, 3D printing may find utility in meeting the global need for safe, timely, and affordable vascular surgical care.

Conclusions

The analysis delves into current uses, challenges, and future visions for this technology, emphasizing its transformative influence in the field of vascular surgery.

Objective

Despite well-established guidelines for the diagnosis and surveillance of abdominal aortic aneurysms (AAAs), many patients are still not discovered until they have already sustained a rupture. It is estimated that as many as 50% of individuals with AAAs are undiagnosed until they present with a life-threatening rupture and hemorrhagic shock. Structured query language (SQL) is a tool that can scan existing electronic medical record (EMR) systems to identify patients with specific characteristics or morbidities. Here we evaluate the use of SQL to determine whether it can identify untreated patients with AAA disease and other vascular comorbidities.

Methods

An SQL disease discovery query code (Medtronic) was developed based on the clinical criteria recommendations of the United States Preventative Services Task Force for AAA screening (male sex; age, 65-75 years; and former/current smoking history). The code was then integrated with 18 International Classification of Diseases, 10th Revision (ICD-10) diagnostic codes for AAA and AAA-related diseases. Over 130 ICD-10 or Current Procedural Terminology (CPT) codes for previous aortic repair were overlaid as an exclusion criterion. The query was applied to 1 year of patient data (June 2021 to June 2022) at our single-center, university-affiliated, regional referral medical center. Manual chart review was performed on identified patients to confirm the incidence of AAA disease (aortic diameter ≥3.0 cm), as well as the incidence of other vascular conditions such as hypertension, coronary artery disease (CAD), peripheral arterial disease (PAD), and/or carotid artery stenosis (CAS).

Results

The SQL code identified a total of 457 patients (449 male, 8 female). Of these patients, 167 (36.5%) had confirmed AAAs with an average diameter of 4.2 cm (range, 3.0-9.7 cm), with a positive predictive value of 28.2%. Prior AAA repair, with either endovascular or open repair, was observed in 39 patients with AAAs (23.4%). Among the remaining untreated 128 patients, six (5 male, 1 female) met the traditional size criteria for repair, and time between last radiological assessment and last clinical follow-up was 4.8 ± 8.8 months. Interestingly, only 71 patients (55.5%) were evaluated by a vascular surgeon. Additionally, we observed that the SQL code identified concomitant PAD in 31 patients (18.5%), and CAS in 17 patients (10.1%). Among patients with treated and untreated AAAs, 26.8% had either PAD or CAS.

Conclusions

An SQL tool can be incorporated in modern healthcare systems to facilitate identification of patients with untreated AAA disease and other vascular comorbidities. Such tools can enhance prompt disease recognition, referral to vascular surgery specialists, and early implementation of appropriate surveillance and/or treatment algorithms.

Objective

The Society for Vascular Surgery (SVS) recently established the Young Surgeons Section (YSS), open to early career vascular surgeons in their first 10 years of practice and dedicated to providing resources and advocacy to foster early career development, and to encourage diversity, equity, and inclusion within the society. Research was identified as a priority area of focus by members of this group of surgeons. This study aims to evaluate the current contribution of early career surgeons to research presented at the Vascular Annual Meeting (VAM).

Methods

Abstracts presented at plenary sessions of the 2021 and 2022 SVS VAM were reviewed. Senior authors for each abstract were identified and categorized as ‘early career’ (EC, first 10 years of practice) or ‘later career’ (LC) and categorized by gender. Information from abstracts including subject matter and subsequent conversion to manuscript publication was collected. Finally, likelihood of abstract presentation on early meeting days compared with the final meeting day was evaluated.

Results

A total of 103 abstracts were presented at plenary sessions of VAM during the two-year study period. Thirty abstracts had EC senior authors (29.1%). The most common topics for EC abstracts were aorta and peripheral artery disease (PAD), whereas the most common for LC abstracts were aorta and cerebrovascular disease, followed by PAD. Sixty abstracts were converted to manuscript publication (58.3%; n = 20 EC, n = 40 LC). The conversion rate for EC authors was higher than that of LC authors (66% EC vs 55% LC). Sixteen LC senior authors had multiple abstracts each that accounted for 41.7% of all plenary abstracts presented, of which 55.8% were converted to publication. Five EC authors had multiple abstracts that contributed 9.7% of the overall abstracts, with a 70% publication rate. Despite a higher rate of publication, manuscripts by EC senior authors were more likely to be presented on the final conference day (odds ratio, 3.06; 95% confidence interval, 1.25-7.45). The proportion of EC abstracts written by women senior authors was 50% as compared with only 8.2% of LC abstracts (P < .0001).

Conclusions

EC surgeon scientists contribute significantly to research presented at VAM with work that is similar in subject matter and publication success in peer-reviewed journals to that of LC senior authors. EC senior authors represent greater membership diversity. EC surgeon-scientists may benefit from recognition by broader audiences at subsequent meetings. SVS efforts to establish a YSS Research Working Group is a productive first step in providing resources and recognition for EC surgeons.

Peripheral artery disease (PAD) is a significant worldwide health burden, yet it remains woefully underdiagnosed and undertreated. By the time PAD manifests symptomatically, patients may already suffer from critical limb ischemia and require invasive surgical intervention. This can be attributed in part to the heterogeneity of PAD pathogenesis as well as shortcomings in current clinical assessment techniques and standards of care. To address these challenges, clinicians need new approaches to prevent, identify, and treat patients at risk for PAD. In this article, we present three clinical cases that exemplify different needs faced by patients with PAD and their providers. These include the need for improved methods of disease detection, more efficient long-term care, and less invasive treatment strategies. The case studies drive our subsequent review and discussion of key areas of translational research that may address each of these needs. The primary objective of this review is to evaluate the current limitations of clinical practice and survey the landscape of emerging research that will hopefully allow clinicians in the near future to better identify and treat patients with PAD. This research encompasses both technological advances in the diagnosis and treatment of the disease, as well as the development of new strategies for optimizing patient management and care delivery. When combined, these different areas of research will address some of the most pressing challenges posed by PAD and will help usher in a new era of holistic, patient-centric care.

Objective

Recently, the use of large language models (LLMs) in medicine has become a prominent topic of discussion due to the rapid improvement of these tools in understanding and responding to natural language. Several models are widely available to the public, both proprietary and open-sourced. We aim to evaluate the possible use of such LLMs in vascular surgery by understanding their abilities to process common consult requests.

Methods

The senior author created 25 fictional vascular surgery consultation queries based on common consultation requests. Five attending surgeons and four LLMs (GPT 3.5, GPT 4, Bard, and Falcon 40B) were asked to answer whether each consult was an emergency that needed immediate attention within an hour. Responders were also asked whether the next best step was an examination, additional imaging, or an urgent operation. GPT 3.5 and 4 also provided free-response answers on the next best step, graded by attending surgeons based on scientific accuracy, possible harm, and content completeness.

Results

The rates of accurate emergency identification were 88%, 100%, 76%, and 88% for GPT 3.5, GPT 4, Falcon 40B, and Bard, respectively. Although they have similar overall accuracy, GPT 3.5 has a high sensitivity at 100%, whereas Bard has a high specificity at 90%. GPT 4.0 had 100% sensitivity and specificity. LLMs agreed with the majority surgeon opinion on the next best step in 64% (GPT 3.5), 32% (GPT 4), 68% (Falcon 40B), and 36% (Bard) of cases. GPT 3.5 and 4 had a collective ratio of 89.5% of answers adhering to the scientific consensus. Only 5% of responses were highly likely to cause clinically significant harm. Although only 4% included incorrect content, 17.5% of answers missed important content. There was no significant difference between GPT 3.5 and 4 regarding the free-response grade.

Conclusions

Existing, widely available LLMs exhibited a solid ability to identify vascular emergencies, with GPT 4.0 agreeing with surgeon attendings in 100% of cases. However, these models continue to have identifiable deficiencies in treatment recommendations, a higher-level task. Future models might help triage incoming consults and provide preliminary management suggestions. The utility of such tools in clinical practice remains to be explored.

Obtaining a career development award from the National Institutes of Health (K award) is often an important step in establishing a career as a vascular surgeon scientist. The application and review process is competitive, involves many steps, and may be confusing to the prospective applicant. Further, there are requirements involving mentors and the applicant's institution. This article, authored completely by vascular surgeons with active K awards, is intended for potential applicants and personnel at their institution and reviews relevant information including strategies for a successful application.