JVS-vascular insights最新文献

Objective

Multidisciplinary mobile clinics (MMCs) provide a robust venue to provide health care access and peripheral arterial disease (PAD) screening to underserved populations. The ankle-brachial index (ABI) can facilitate PAD diagnosis; however, traditional supine ABI measurements may be challenging technically in a mobile outreach clinic with limited infrastructure, whereas seated ABI offers technical ease. In this study, the usefulness and feasibility of performing supine ABI, seated ABI, and seated ABI with a calculation to account for seated hydrostatic pressure (seated-adjusted ABI) were compared in a mobile outreach setting.

Methods

Prospective data were collected from patients at five independent MMCs focused on diabetic foot and PAD screening with ABI for underserved communities. Three techniques were used to measure the ABI: seated ABI, seated-adjusted ABI using a formula to account for hydrostatic ankle pressure, and traditional supine ABI using a foldable massage table that is 5% of the cost of a medical stretcher. Comparative analysis was performed using the Student t test analysis and one-way analysis of variance. The frequency of completed seated ABI, seated-adjusted ABI, and supine ABI examinations performed at independent MMCs was quantified to determine feasibility.

Results

In 166 individuals experiencing homelessness or housing instability who were screened over the course of five MMCs, 89 underwent PAD screening with ABI. Of the patients screened, 38 patients had seated, seated-adjusted, and supine ABIs measured (43% of total number of patients undergoing any ABI measurement). PAD (ABI < 0.9) was identified in one patient using all three ABI methods. Noncompressible ABI (ABI ≥ 1.3) were identified in 32 patients (32/38 [84%]) screened with seated ABI. Of these 32 patients, 24 (75%) continued to have noncompressible ABIs using seated-adjusted ABI. Of these 24 patients, 4 (17%) continued to have noncompressible ABI using supine ABI. The average seated ABI significantly differed from supine ABI (1.34 vs 1.14; P < .0001). The average seated ABI also significantly differed from seated-adjusted ABI (1.34 vs 1.29; P = .026). The average seated-adjusted ABI significantly differed from supine ABI (1.29 vs 1.14; P = .0204).

Conclusions

We found that seated and seated-adjusted ABI are grossly inaccurate and more often lead to falsely elevated noncompressible ABI (32/38 [84%] and 24/38 [75%], respectively) compared with supine ABI (6/38 [16%]). We recommend using supine ABI on patients for PAD screening. Supine measurement is technically feasible in outreach mobile clinics using a transportable folding massage table and is a more accurate tool for PAD screening.

Background

Vascular surgeons have traditionally been under-represented in various media platforms. Our study aims to characterize vascular surgeon involvement in online news coverage as it relates to vascular pathologies.

Methods

Google news was queried for news articles published between July 31, 2022, and August 1, 2023, using 11 keywords (“carotid stenosis,” “carotid artery disease,” “dialysis fistula,” “abdominal aortic aneurysm,” “aortic dissection,” “varicose vein,” “deep vein thrombosis,” “peripheral vascular disease,” “peripheral arterial disease,” “limb ischemia,” and “claudication). Unrelated articles and medical press under a paywall were excluded. Article and represented physician demographic information were collected. Representation was defined as being the author, interviewed, or involved in the review process of the news article.

Results

One thousand six hundred forty-eight news articles were screened yielding 1257 articles (76%) for analysis. Seven hundred eighty-four (62%) were classified as medical press and 473 (38%) as lay press. Four hundred fifty-seven (36%) news articles had medical professional representation. Vascular surgeons were represented in 186 news articles (14.8%) and medicine doctors in 346 news articles (27.5%). Articles regarding abdominal aortic aneurysm had the highest vascular surgeon representation (28.9%). The most common vascular surgeon involvement type was as an interviewee (67.2%). Most articles represented vascular surgeons from academic centers (80.6%), with varicose vein having the highest private practice representation (37%). Female vascular surgeons were represented in 18.3% of articles, which was proportionate to their workforce representation.

Conclusions

Vascular surgeons are widely under-represented in online news articles regarding common vascular pathologies. Vascular surgeons should focus more efforts on promoting their expertise in news regarding peripheral disease and dialysis.

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Objective

Artificial intelligence (AI) continues to become increasingly integrated with clinical medicine. Generative AI, and particularly large language models (LLMs) like ChatGPT-3.5 and ChatGPT-4, have shown promise in generating human-like text, providing a potential tool for augmenting clinical care. These online AI chatbots have already demonstrated remarkable clinical potential, having passed the US Medical Licensing Exam, for example. The evaluation of these LLMs in the surgical literature, especially as it applies to judgement and decision-making, is sparse. This study aimed to (1) evaluate the efficacy of ChatGPT-4 in providing clinician-level vascular surgery recommendations and (2) compare its performance with its predecessor, ChatGPT-3.5, to gauge the progression of clinical competencies of LLMs.

Methods

A set of 40 clinician-level questions spanning 4 domains of vascular surgery (carotid artery disease, visceral artery aneurysms, abdominal aortic aneurysms, chronic limb-threatening ischemia) were generated by clinical experts. These domains were chosen based on the availability of updated guidelines published before September 2021, which served as the cutoff date for the training dataset of the LLMs. The questions, devoid of additional context or prompts, were input into ChatGPT-3.5 and ChatGPT-4 between March 20 and March 25, 2023. Responses were independently evaluated by two blinded reviewers using a 5-point Likert scale assessing comprehensiveness, accuracy, and consistency with guidelines. The Flesch-Kincaid grade level of each response was also determined. Independent samples t test and Fisher's exact test were used for comparative analysis.

Results

ChatGPT-4 significantly outperformed ChatGPT-3.5 by providing appropriate recommendations in 38 of 40 questions (95%) as compared with 13 of 40 (32.5%) by ChatGPT-3.5 (Fisher's exact test P < .001). Despite longer response lengths (chatGPT-4 mean 317 ± 58 words vs chatGPT-3.5 mean 265 ± 74 words; P < .001), the reading ease of both models remained similar, corresponding with college-level graduate texts.

Conclusions

ChatGPT-4 can consistently respond accurately to complex clinician-level vascular surgery questions. This also represents a substantial advancement in performance compared with its predecessor, which was released only a few months prior, highlighting the progress of performance of LLMs in clinical medicine. Several limitations persist with the use of LLMs, including hallucinations, data privacy issues, and the black box problem, However, these findings suggest that, with further refinements, LLMs like ChatGPT-4 have the potential to become indispensable tools in clinical decision-making, thereby marking an exciting frontier in the fusion of AI with clinical medicine and vascular surgery.

Background

Carotid endarterectomy reduces the risk of recurrent stroke in symptomatic carotid stenosis. In patients with a history of heparin-induced thrombocytopenia, heparin is contraindicated, and these patients require an alternative parenteral anticoagulant during carotid endarterectomy. The aim of this review was to review the literature for evidence of the use of parenteral direct thrombin inhibitors (DTIs) (hirudin, hirudin derivatives [lepirudin, desirudin, and bivalirudin], and argatroban) in carotid endarterectomy.

Methods

A literature search was conducted using MEDLINE through PubMed on October 14, 2023. All reports that described treatment with parenteral direct thrombin inhibitors in carotid endarterectomy were included. Two authors independently screened abstract and titles according to the predefined criteria, and nonagreement was discussed with a third author for the final decision.

Results

46 publications were identified, and 39 were excluded based on predefined criteria. Seven case reports were included, identifying seven patients who underwent carotid endarterectomy with intraoperative parenteral DTI use. There were four reports of the use of argatroban, two of bivalirudin, and one report of hirudin in a case of concurrent carotid endarterectomy and coronary artery bypass grafting. Argatroban was the preferred agent in patients with renal insufficiency. DTIs were administered parenterally through bolus and infusion and were monitored through activated clotting times or plasma-modified activated clotting times. There were no significant bleeding events, and all procedures were successfully performed. The pharmacology of DTIs and the use of DTIs in other peripheral vascular and cardiac procedures will also be reviewed.

Conclusions

Overall, the use of DTIs for anticoagulation in vascular surgery appears to be safe and effective. The DTIs with the most evidence supporting their use in carotid endarterectomy are bivalirudin and argatroban.

Background

Specialty board certification is an important indicator of surgeon competence and necessary for residency and fellowship programs to maintain accreditation by the Accreditation Council for Graduate Medical Education. Thus, identification of trainees at risk of board certification failure is important for both vascular surgery graduates and their parent program. We sought to examine the correlation of Vascular Qualifying Examination (VQE) performance on first-time pass achievement of the Vascular Certifying Examination (VCE).

Methods

We used American Board of Surgery data to examine predictive associations of a national longitudinal cohort of all vascular surgery integrated residents (VIRs) and vascular surgery fellows (VSFs) who completed the VQE and VCE from 2016 through 2021. Descriptive statistics were used to examine trends. We used χ² tests to examine proportional group differences. Predictive associations between VQE scaled score performance and first-time pass achievement on subsequent VCE attempts were examined using logistic regression.

Results

VQE scaled score performance and VCE pass rates were obtained for all VIRs and VSFs (n = 579; 175 residents and 404 fellows) from 151 programs (48 residency and 103 fellowship) during the study period. First-attempt pass rate for the VQE was 96% in the study cohort, and first-attempt pass rate for the VCE was 94%. There were no significant differences in pass-fail rates in VQE and VCE for VIR and VSF candidates (P = .210 and P = .116, respectively). Trainee scaled score performance on the VQE was not predictive of subsequent first-attempt pass achievement on VCE (odds ratio, 1.00; 95% confidence interval, 1.00-1.01; P = .077). Stratified subgroup analyses by VIR and VSF cohorts also showed no significant predictive first-attempt VCE pass achievement (P = .190 and P = .094, respectively).

Conclusions

In this national cohort of vascular trainees taking the VQE and VCE, VQE performance was not predictive of subsequent VCE first-time pass achievement. This finding highlights the necessity to identify other measures of trainee competence to indicate the preparedness of trainees for board certification examinations. Furthermore, this may be reflective of the ability to assess distinctive competencies between the two examinations, with the VQE focused on medical knowledge and the VCE on clinical judgment and interpersonal communication skills, thus broadening assessment of the Accreditation Council for Graduate Medical Education core competencies to ensure certification of vascular surgeons possessing both the knowledge and judgment necessary to maintain high-quality standards within our specialty.

Objective

The impact of medical errors on patient outcomes has been well-described. Multiple avenues for documenting and addressing patient safety events have been created, including quality outcome registries and adverse event databases.

Methods

This paper summarizes key data and definitions related to medical errors, as well as systems for monitoring them. We also offer considerations for how to interpret and act on these reports, at the hospital- or vascular surgery division-specific level.

Results

Several methods and systems exist for characterizing, cataloging, and addressing medical errors and quality of care.

Conclusions

Safety report review and adjudication should be timely and conducted according to principles of root cause analysis. Strategies to address systems-level factors should follow a defined improvement model. Division-level quality officers should meet as a group with hospital-level safety officers on a routine basis to discuss themes of safety that may resonate across the institution.