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Introduction: The anti-Müllerian hormone (AMH) produced by the granulosa cells of ovarian follicles has been shown to correlate with ovarian reserve and is often measured for fertility therapies. In this study, we evaluated the relationship between serum AMH values and the clinical pregnancy (CP) rates of female partners with unexplained infertility undergoing intrauterine insemination utilizing varying ovarian simulation protocols., Methods: This is a retrospective cohort study conducted among couples who underwent intrauterine insemination therapy over a period of four years at Charleston Area Medical Center, a tertiary care medical center in West Virginia, USA. Logistic regression was used to determine the best predictor of CP., Results: A total of 509 intrauterine inseminations resulting in 81 (15.9%) Cps were analyzed. The cycles with a CP had higher mean AMH values (3.7+3.5 vs. 2.2+2.1; p<0.001). The majority of patients were nulliparous (77.0%) with a mean age of 33.6+5.0 years. After including only patients with unexplained infertility (the predominate infertility diagnosis; n=255 (50.1% of the cycles)) and stimulation cycles >10, the final sample size for the analysis was 245/509=48.1%. Following a receiver operating characteristic (ROC) curve analysis, the optimal AMH cut-off point was 2.1 ng/mL with an area under the curve (AUC) equal to 0.61 and 95% confidence intervals (CIs) of 0.55- 0.67 (p=0.002). The CP rate was significantly higher with the AMH >2.1 ng/mL (20.0%) compared to <2.1 ng/mL (10.0%; p=0.041). With Clomid/human gonadotropins/human chorionic gonadotropin (hCG) trigger treatment, the CP rate quadrupled (odds ratio (OR): 4.6; 95% CI: 2.1-9.7; p<0.001)., Conclusion: This study indicates that higher AMH levels and a more aggressive ovarian stimulation protocol for intrauterine insemination therapy (IUI) have a better probability of resulting in CP., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Stalzer et al.)

Objective: The aim of this study was to determine the acute impact of baseline serum creatinine, estimated glomerular filtration rate (eGFR), and contrast medium volume (CMV) on the incidence of reduced renal function (RRF) after endovascular abdominal aortic aneurysm repair (EVAR). We aimed to determine if the CMV/eGFR ratio was a predictor of RRF., Methods: This study is a retrospective review of EVAR patients in the Society for Vascular Surgery/Vascular Quality Initiative (SVS/VQI) from January 2015 to August 2020. Reduced renal function was defined as > 0.3 mg/dl (26.5 μmol/L), 50% increase from baseline, and temporary or permanent dialysis. Receiver operator characteristic (ROC) curve analyses were conducted for serum creatinine, eGFR, contrast volume, fluid volume, and CMV/eGFR ratio. Two data sets (training and test) were developed followed by multivariate analyses., Results: SVS/VQI data for EVAR contained 38,701 records, of which 30,539 were divided into training ( n = 18,283; 60%) and test ( n = 12,256; 40%) data sets. RRF rate for the training set was 3.6% ( n = 667) and 3.4% ( n = 420) for the test data. RRF patients included more females (29.4 vs 19.0%, p < 0.001), were older in age (75.6 + 8.4 vs 73.3 + 8.7 years), had more congestive heart failure (22.3 vs 12.2%, p < 0.001), and more COPD (42.0 vs 34.2%, p < 0.001). An ROC analysis revealed that eGRF, creatinine, contrast, intravenous fluid, and contrast medium volume (CMV)/eGFR ratio were all significantly ( p < 0.05) correlated with RRF. The eGFR and CMV/eGFR ratio had the largest area under the curve, (0.26) and (0.65), respectively, while fluid had the lowest (0.54). Negative predictive values were 93.7 (CMV/eGFR), 93.9 (creatinine), 94.2 (eGFR), 92.8 (contrast), and 92.6 (intravenous fluid). Multivariate analysis of the training data set resulted in the CMV/eGFR ratio as an independent predictor of RRF (odds ratio, OR: 1.9 with 95% CI: 1.6, 2.2, p < 0.015). For the test data, the CMV/eGFR ratio was an independent predictor of RRF (OR: 1.8, CI: 1.4 to 2.2, p < 0.001) as well as several other variables., Conclusion: RRF after EVAR is a dreaded and potentially devastating complication. Baseline serum creatinine, eGFR, contrast medium volume, and the ratio (CMV/eGFR) were all significantly associated with RRF. The optimal cut-off value for the CMV/eGFR ratio, ≤ 2, provides an easy-to-use equation to provide a suggested contrast target based on initial renal function with caution applied for high-risk patients.

Intramedullary fixation using a short or long cephalomedullary nail (CMN) for treating hip fractures has gained popularity in recent years. We evaluated reoperation rates requiring device removal of short or long CMNs for patients 65 years and older. A retrospective study was performed at a level I trauma center over a 10-year period (2005-2015). Patients 65 years and older who were treated for intertrochanteric hip fractures with CMNs were included. This study included 893 patients (600 patients treated with a short CMN vs 293 treated with a long CMN). Patients in both cohorts were comparable in age, sex, and Injury Severity Score. There was no significant difference in comorbidities between the short and long CMN groups. Hospital length of stay (7.13 vs 6.88 days, P =.407) and intensive care unit length of stay (4.97 vs 4.63 days, P =.732) were not significantly different between the short and long CMN cohorts, respectively. The in-hospital mortality rate also did not vary between the 2 groups (1.3% for short CMN vs 2.7% for long CMN, P =.139). A significantly higher proportion of patients treated with a long CMN were discharged to a skilled nursing facility (63.4% vs 56.1%, P =.042). The overall reoperation rate was also comparable, 4.7% and 3.4% in the short CMN and long CMN groups, respectively ( P =.367). No difference was found between the 2 treatment modalities (short or long CMN) for the elderly population. Both implants had similar rates of reoperation and implant failure. There is a cost consideration, with increasing length of the nail corresponding to increased cost. [ Orthopedics . 2022;45(5):304-309.].

Introduction Fluid resuscitation is a critical aspect of the sepsis protocol with the usual initial dose being 30 mL per kilogram. Although this dose is well accepted in patients with normal cardiac function, there is some significant variation in clinical practice concerning the optimal fluid resuscitation in septic patients with underlying congestive heart failure (CHF). Many different approaches have been tried to best treat these patients by using lesser volumes of fluid. The purpose of this retrospective study is to attempt to better define optimal fluid resuscitation in congestive heart failure patients and whether standard fluid resuscitation exacerbates CHF in these cases. Methods This was a retrospective study involving patients admitted to the Emergency Department (ED) during the time period of September of 2016 through March of 2019 with a primary diagnosis of sepsis and pre-existing CHF. Data collected from the data warehouse and patient charts included demographics, total amount of fluid received in the ED and outcome data. Evidence of fluid overload (chest X-ray [CXR] evidence, rising B-type natriuretic peptide [BNP], or use of diuretics), was evaluated with respect to in-hospital mortality, white blood cell (WBC) count and comorbidities (chronic obstructive pulmonary disease [COPD], hypertension and coronary artery disease). Results There were 422 patients included in the cohort. Of the 422, 113 (26.8%) patients showed evidence of fluid overload on CXR during hospital stay and received diuretics and therefore considered in the CHF exacerbation group. The patients that experienced CHF exacerbation were significantly older (mean ± SD, 70.9 ± 11.8 years versus 67.4 ± 15.1 years, p=0.014). Patients with exacerbation also received more fluid (median and interquartile range, 3.0, 2:5.5 L versus 2.0, 1:4.3 L, p=0.017). The receiver operating characteristic curve analysis for fluid to predict exacerbation resulted in an area under the curve of 0.59 with a 95% confidence interval (CI) of 0.52 to 0.65, p=0.012. The Youden Index was used to determine an optimal cutoff value of 2.6 L. The percentage of patients in the exacerbation group above the threshold was significantly higher (57.3%) than those without exacerbation (43.3%), p=0.019. Following multivariate analysis, age greater than 60 (odds ratio [OR]: 2.5; CI: 1.4-4.6, p=0.003) and fluid cutoff of 2.6 L (OR: 1.9; CI: 1.2-3.1, p=0.007) were both found to be independent predictors of CHF exacerbation. There was no significant difference in mortality based on the total fluid received in the ED. Conclusion The findings of this study showed that septic patients with pre-existing CHF who received more than 2.6 L of fluid in the ED were 90% more likely to develop symptoms of CHF exacerbation with no evidence of lowering mortality compared to the group that received less than 2.6 L. Our data supports the practice of limiting total fluid resuscitation in CHF to 2.6 L and reconfirms the idea that fluid resuscitation for patients with CHF needs to be individualized., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Payne et al.)

Objective: The primary purpose of the study was to investigate and to summarize the registered trials that listed COVID-19 as the primary condition., Methods: We performed a search on ClinicalTrials.gov using the independent search terms COVID-19, SARS, and SARS-CoV-2 and then downloaded the data file on March 23, 2020. All trials were downloaded to a csv file and searched for appropriateness., Results: Of 124 registered trials, 56 (45.2%) were listed as recruiting. The majority (85 [68.5%]) were classified as interventional, 37 (29.8%) as observational, and one (0.8%) each as either expanded access: individual patients|treatment investigational new drug/protocol or expanded access: intermediate-size population|treatment investigational new drug/protocol. There were 67 (54.0%) trials that listed drug as the type of study. Immunologic and antiviral trials were the most common, representing approximately 30% and 21%, respectively. When immunologic and antiviral drugs were used alone or in combination, they represented 41.9% and 34.4%, respectively. Antimalarial agents are represented in 7.5% of trials. Approximately 14% of trials involved traditional Chinese medicine. The study agents used solely or in combination represented approximately 80% of therapeutic approaches to COVID-19., Conclusions: There was a large and quick response on ClinicalTrials.gov to the COVID-19 outbreak. Many of the registered trials are currently recruiting new patients, whereas some will begin in the near future. Specific potential experimental therapies, including dosing and monitoring, might be found by reviewing content. Within ClinicalTrials.gov, patients, family members, health care professionals, and researchers can search and find ongoing and future trials for COVID-19., (© 2020 by the Society for Vascular Surgery. Published by Elsevier Inc.)

Introduction: Hydroxychloroquine (HCQ) for coronavirus disease 2019 (COVID-19) is presently being used off-label or within a clinical trial., Objectives: We investigated a multinational database of patients with COVID-19 with real-world data containing outcomes and their relationship to HCQ use. The primary outcome was all-cause mortality within 30 days of follow-up., Methods: This was a retrospective cohort study of patients receiving HCQ within 48 hours of hospital admission. Medications, preexisting conditions, clinical measures on admission, and outcomes were recorded., Results: Among patients with a diagnosis of COVID-19 in our propensity-matched cohort, the mean ages ± SD were 62.3 ± 15.9 years (53.7% male) and 61.9 ± 16.0 years (53.0% male) in the HCQ and no-HCQ groups, respectively. There was no difference in overall 30-day mortality between the HCQ and no-HCQ groups (HCQ 13.1%, n=367; no HCQ 13.6%, n=367; odds ratio 0.95, 95% confidence interval 0.62-1.46) after propensity matching. Although statistically insignificant, the HCQ-azithromycin (AZ) group had an overall mortality rate of 14.6% (n=199) compared with propensity-matched no-HCQ-AZ cohort's rate of 12.1% (n=199, OR 1.24, 95% CI 0.70-2.22). Importantly, however, there was no trend in this cohort's overall mortality/arrhythmogenesis outcome (HCQ-AZ 17.1%, no HCQ-no AZ 17.1%; OR 1.0, 95% CI 0.6-1.7)., Conclusions: We report from a large retrospective multinational database analysis of COVID-19 outcomes with HCQ and overall mortality in hospitalized patients. There was no statistically significant increase in mortality and mortality-arrhythmia with HCQ or HCQ-AZ., (© 2020 Pharmacotherapy Publications, Inc.)

Purpose: Our objective was to determine significant predictors of spinal cord ischemia (SCI) following Thoracic Endovascular Aortic Repair (TEVAR) and to further develop a simple and clinically orientated risk score model., Methods: A retrospective review of data from the Society of Vascular Surgery/Vascular Quality Initiative national data set was performed for all patients undergoing TEVAR from January, 2014 to June 2018. Preoperative demographics, procedure-related variables, and clinical details related to SCI were examined. A SCI risk score was developed utilizing a multivariable logistic regression model., Results: For the 7889 patients in the final analysis who underwent TEVAR during the study period, the mean age was 67.6 ± 13.9, range 18 to 90 years, and the majority was male (65%). Postoperative outcomes included stroke (3.0%), myocardial infarction (2.9%), inhospital mortality (5.4%), transient SCI (1.5%), and permanent SCI (2.1%). Nearly half of the overall cases were performed in high volume centers. Predictors of increased risk for SCI included age by decade (odds ratio [OR]: 1.2), celiac coverage (OR: 1.5), current smoker (OR: 1.6), dialysis (OR: 1.9), 3 or more aortic implanted devices (OR: 1.7), emergent or urgent surgery (OR: 1.5), adjunct aorta-related procedure (OR: 2.5), adjunct not related (OR: 2.6), total estimated length of aortic device (19-31 cm, OR: 1.9 and ≥32 cm, OR: 3.0), ASA class 4 or 5 (OR: 1.6), and procedure time ≥154 minutes (OR: 1.8). Two predictors decreased the risk of SCI, cases from high-volume centers (OR: 0.6) and eGFR ≥ 60 (OR: 0.6). To evaluate the risk score model, probabilities of SCI from the original regression, raw score, and raw score categories resulted in area under the curve statistics of 0.792, 0.786, and 0.738, respectively., Conclusions: Spinal cord ischemia remains one of the most feared complications of TEVAR. Incidence of SCI in this large series of patients with TEVAR was 3.6% with nearly 60% being permanent. The proposed model provides an assessment tool to guide clinical decisions, patient consent process, risk-assessment, and procedural strategy.

Nonoperative treatment has become the standard of care for the majority of humeral shaft fractures. Published studies have mainly come from trauma centers with a young cohort of patients. The purpose of this study was to determine the nonunion rate of humeral shaft fractures in patients older than 55 years. A retrospective study was performed on a group of orthopedic trauma group treated at a level I trauma center during a 10-year period (2007-2017). Patients 55 years or older and treated for a humeral shaft fracture nonoperatively, with or without manipulation, were identified. Nonunion was defined by no bridging callus radiographically or by gross motion at the fracture at least 12 weeks from injury. There were 31 patients identified with humeral shaft fractures who met the inclusion criteria. The cohort included 21 (67.7%) females and 10 (32.3%) males with a mean age of 72.5 years (range, 55-92 years). Twenty-one fractures went on to union, and there were 10 nonunions, with no significant differences in the demographics or comorbidities. There was no correlation between AO/OTA fracture classification or fracture location and union status. There was a tendency toward higher risk of nonunion in proximal third humeral shaft fractures (45%) compared with middle (26%) and distal third (20%) humeral shaft fractures, although this was not statistically significant. The overall nonunion rate for humeral shaft fractures was 32% for patients older than 55 years. The authors found a significant correlation between age and union rate: as age increased, union rate decreased (R=-0.9, P=.045). The incidence of humeral shaft nonunion in patients older than 55 years was significantly higher than that of younger adults. To the authors' knowledge, this study is the first to report a significant correlation between nonunion and increased age. [Orthopedics. 2020;43(3);168-172.]., (Copyright 2020, SLACK Incorporated.)

Background: Post-surgical discharge complications result in increased hospital readmissions, cost, and patient dissatisfaction. Telehealth technology to monitor patients, especially those in geographically isolated areas, may reduce post-operative complications and improve health and financial outcomes. The primary objective of this study was to compare outcomes between patients who received TeleHealth Electronic Monitoring (THEM) and those with routine discharge instructions and no monitoring, Standard Of Care (SOC)., Methods: This is a prospective randomized study of vascular surgery patients with infrainguinal incisions. THEM patients received a tablet and home monitoring devices that transmitted information to care managers. Monitoring tools included image capture, weight scales, blood pressure cuffs, thermometers, and oxygen saturation monitors. Care managers used the TeleMed 2020 Enform™ platform to review alerts, real-time patient data, and dialogue with the care team., Results: Eighty patients were screened and 30 enrolled, of which 16 (53.3%) were randomized to the THEM group and 14 (46.7%) to the control group. Average age and body mass index for THEM and control patients were similar (62.5 ± 7.2 vs. 65.7 ± 7.3, P = 0.234; and 27.7 ± 4.3 vs. 29.1 7.1, P = 0.487), respectively. There was a similar number of male participants in each group (THEM 62.5% vs. SOC 42.9%, P = 0.464). There were no significant differences in wound or 30-day readmissions (THEM 6.3% vs. SOC 7.1%, P = 1.000). Interestingly, 30-day infection rates indicated that care managers identified marginally more superficial wound problems in the THEM group (31.3% vs. 7.1%, P = 0.175). Both groups reported an increase in short-form-8 physical summary scores, but was more pronounced in THEM patients (P = 0.076). THEM patients reported a significantly greater improvement in quality of life on 3 of the short-form-8 quality subscales (physical function, role-physical, and role-emotional; THEM delta 7.5 versus Control delta 1.1; THEM delta 8.7 versus Control delta 1.1; and THEM delta 6.3 versus Control delta -0.5; all P < 0.05). THEM patients reported trends for higher satisfaction in terms of general satisfaction, technical quality, and accessibility for Patient Satisfaction Questionnaire-18 survey questions (4.2 vs. 3.7, P = 0.072; 4.5 vs. 4.1, P = 0.081; and 4.2 vs. 3.8, P = 0.063), respectively., Conclusions: THEM was technically feasible and provided some benefit to patients in geographically disparate areas. THEM was associated with increased patient satisfaction. Additional findings suggested that THEM patients embraced telehealth technology and took advantage of increased access to healthcare professionals. Telehealth successfully merged remotely generated information with care manager interaction. Presently, a larger study, preferably multi-center, is warranted and under consideration., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: Emergent cricothyroidotomy (EC) is a rarely used yet lifesaving procedure that is important for an emergency physician to master throughout his or her training. We evaluated the difference in utilization of a manikin or porcine model among emergency medicine (EM) residents when teaching EC. We also evaluated the difference in the models using two different commonly utilized and taught techniques: "scalpel-finger-bougie" (SFB) technique and the Melker technique (MT)., Methods: This was a prospective crossover design. Instructions about the procedure were provided; study participants were randomly assigned to one of two groups and performed cricothyrotomy on both manikin and porcine simulators using both the Melker and the SFB techniques. Each group was started with the technique on the second simulator opposite what they started with on the first simulator. After the procedures, study participants completed a questionnaire that used the same format for both groups. All survey questions required a 7-point Likert scale response. Confidence, difficulty, reality of the anatomy, and landmarks were compared., Results: Fifteen EM residents participated in the study. Compared to the porcine-first group, the manikin-first group rated the anatomy more realistic (question 5) after their first attempt (6.29 vs. 5.87) than their second attempt (using the porcine model; 4.29 vs. 5.62; main effect for attempts [first vs. second] p = 0.027; interaction p = 0.074). Interestingly, the porcine model-first group rated the landmarks (question 6) significantly easier to find in both attempts (6.87 vs. 5.86 on the first attempt and 6.50 vs. 5.57 on the second attempt; p = 0.012). Twelve participants (80%) chose SFB as their preferred technique to use in real-life scenario., Conclusion: The Manikin model tends to be more realistic in cricothyrotomy simulation than the porcine model. The influence of fresh pig skin overlying the porcine model may require further research. Landmark identification during the procedure was easier on both models when participants start with the porcine model. Participants prefer the SFB over MT if faced with a real-life scenario.

Background: The D-dimer (DD) level combined with the pretest Wells criteria probability (WCP) score can safely exclude deep venous thrombosis (DVT). The objective of this study was to examine the correlation between DD results alongside WCP score with findings on venous duplex ultrasound (VDU). The hypothesis is that VDU remains overutilized in low-risk patients with negative DD and that higher DD levels may correlate with thrombus burden and location., Methods: Patients who presented to a high-volume tertiary care center with lower limb swelling with or without associated pain were retrospectively examined through June and July for 4 consecutive years (2012 to 2015). After calculating WCP, patients were divided into low-, moderate-, and high-risk categories. Electronic DD results utilizing enzyme linked immunosorbent assay, WCP data, and VDU analysis data were merged and analyzed based on receiver operator characteristic curve to determine the DD cutoff point for each WCP. Abnormal DD with an average value ≥ 0.6 mg/L fibrinogen equivalent units (FEUs) was correlated to positive DVT to differentiate proximal DVT (above popliteal vein) from distal DVT (below popliteal vein)., Results: Data of 1,909 patients were analyzed, and 239 (12.5%) patients were excluded secondary to serial repeat visits or follow-ups, surveillance screens, and if they had a previous history of DVT. The average age was 62.1 ± 16.3 years with more women (55.7%) and the majority presented with limb pain and edema (87%). DD studies were ordered and completed in 202 patients and correlated with all positive and negative DVT patients (100% sensitivity and negative predictive value, with specificity and positive predictive value of 14.9% and 15.9%, respectively). Twenty-six of 202 patients had DD that were in the normal range 0.1-0.59 mg/L (FEU), all of which were negative for DVT (100% sensitive). Fifty one of 202 patients had DD values of 0.6-1.2 mg/L FEU, of which only 3 DVTs were recorded, and all of them were distal DVTs. In addition, 685 patients with WCP <1 and negative DD were sent for VDU. Thus, 762 patients had an unnecessary immediate VDU (Wells ≤1 and -DD) study during their initial presentation. Potential charge savings for VDU for all patients are 762 × $1,557 = $1,186,434 and DD for all patients are 762 × $182 = $138,684, with total potential savings of $1,047,750 (USD 2016)., Conclusions: This study suggests that DD is still underutilized, and DD in conjunction with WCP could significantly reduce the number of unnecessary immediate VDUs. Higher value of DD (>1.2 mg/L FEU) may raise concern for proximal DVT. Concern on cost-effectiveness exists and raises the demand for a proposed algorithm to be followed., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to examine birth outcomes in women treated or untreated for thrombophilia during pregnancies affected or not by tobacco exposure., Methods: This was a retrospective cohort study of consecutive women from a single maternal fetal medicine clinic who delivered between January 2009 and December 2013. We compared birth outcomes by four groups of thrombophilia and smoking combinations and then by treated or untreated groups., Results: Of the 8889 pregnant women in this study, 113 had thrombophilia and 97 received treatment. Thromboprophylaxis included: low molecular weight heparin, aspirin, unfractionated heparin, folic acid, and combinations of these. Smokers with thrombophilia had significantly higher rates of preeclampsia, intrauterine growth restriction, preterm birth (<37 weeks gestation) and low birth weight (all p ≤ .001). Conversely, this group had significantly lower rates of hemolysis, elevated liver enzymes, low platelet count (HELLP syndrome) and placental abruption. Women with thrombophilia who received thromboprophylaxis had lower rates of adverse birth outcomes, reaching significance for preterm birth <32 weeks gestation (4.3% versus 21.1%, p = .026)., Conclusion: Pregnant women who smoke and have thrombophilia may be more likely to experience adverse birth outcomes and receive more benefit from thromboprophylaxis than their nonsmoking counterparts.

It is intuitive that postdischarge surgical complications are associated with increased patient dissatisfaction, and are directly associated with an increase in medical expenditures. It is also easy to make the connection that many post-hospital discharge surgical complications, including surgical site infections (SSIs), could be influenced or exacerbated by patient comorbidities. The authors of a recent study reported that female gender, obesity, diabetes, smoking, hypertension, coronary artery disease, critical limb ischemia, chronic obstructive pulmonary disease, dyspnea, and neurologic disease were significant predictors of SSIs after vascular reconstruction was performed. The main concern for optimal patient care, especially in geographically isolated areas of West Virginia, is to have early, expeditious, and prompt diagnosis of complications and SSI. This adjunct to existing approaches could lead to improved outcomes and patient satisfaction, minimizing third-party interventions and decreasing the total cost of care. It seems reasonable to believe that monitoring using telehealth technology and managing the general health care of patients after a hospital vascular intervention will improve overall health and reduce 30-day readmissions and SSIs., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Renal artery stenosis may play a significant role in the pathogenesis of secondary hypertension, renal dysfunction, and flash pulmonary edema. Currently correction of renal arterial inflow stenosis is reserved for resistant hypertension patients who have failed maximal medical therapy, have worsening renal function and/or unexplained proximal congestive failure. With the recent advances in minimally invasive percutaneous stent placement techniques, open surgical revascularization has been largely replaced by renal artery stenting. The potential benefit of revascularization seemed intuitive; however, the initial enthusiasm and rise in the number of percutaneous interventions have been tempered by many subsequent negative randomized clinical trials that failed to prove the proposed benefits of the percutaneous intervention. The negative randomized trial results have fallen under scrutiny due to trial design concerns and inconsistent outcomes of these studies compared to pivotal trials undertaken under US Food and Drug Administration scrutiny. Treatment of atherosclerotic renal artery occlusive disease has become one of the most debatable topics in the field of vascular disease. The results from recent randomized clinical trials of renal artery stenting have basically limited the utilization of the procedure in many centers, but not every clinical scenario was covered in those trials. There are potential areas for improvement focusing mainly on procedural details and patient selection with respect to catheter based treatment of atherosclerotic renal artery stenosis. We believe, limiting patient selection, enrollment criteria and outcomes measured functioned to reduce the benefit of renal artery stenosis stenting by not enrolling patients likely to benefit. Future studies incorporating potential procedural improvements and that include patients more likely to benefit from renal stenting than were included in ASTRAL and CORAL are needed to more carefully examine specific patient subgroups so that "the baby is not thrown out with the bath water." We also discuss several other concerns related to renal artery stenting which include diagnostic, procedure, indication, and reimbursement issues.

Objective: The study objective was to compare rates of alcohol use between urine ethanol testing and self- reporting (Method: 1) and Phosphatidylethanol (PEth) dried blood spot testing and self-reporting (Method: 2)., Methods: This was a prospective observational study in an obstetric clinic with universal alcohol screening., Results: Method: 1 identified 11 patients with alcohol use (5 urine and 6 self-reported); Method: 2 identified 28 (22 PEth and 6 self-reported) out of 315 patients (one patient positive for both urine and PEth). The six patients with self-reported use had negative urine and PEth testing. We had fair agreement between the two methods (282 negative and 7 positive; 289/314=92.0%; Kappa 0.32, p<0.001); method 2 identified significantly more women (McNemar, p<0.001). Combining methods: resulted in an alcohol detection rate of 10.2% (32/314)., Conclusion: Method: 2 identified more alcohol users than Method: 1. Combining both methods: identified the most alcohol consumption., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: High-degree stenosis of both innominate (IA) or left common carotid artery (CCA) and carotid bifurcation is uncommon but still represents a significant challenge to interventionists in many aspects including techniques, timing, and priority. There are several strategies for intervention that have been reported in the literature. A well-described, less-invasive strategy for extracranial tandem carotid lesions is concomitant carotid endarterectomy (CEA) with retrograde carotid angioplasty and stenting (CAS). In this study, we examine intermediate-term outcomes of this hybrid procedure and review other described treatments., Methods: Electronic medical records of all patients who underwent hybrid (ostial CAS and CEA) procedures in a tertiary center over the last 10 years were reviewed. High-degree stenosis of the IA or CCA was defined according to North American Symptomatic Carotid Endarterectomy Trial criteria., Results: A total of 6 patients were identified. The population included 4 males and 2 females with a median age of 65 years. Five patients were symptomatic and all had stenosis >75% by angiography. Five of the patients underwent left CEA with proximal stenting and one patient underwent right-sided CEA with proximal stenting. Combined 30-day mortality and stroke rate was 0%. No restenosis, stroke, heart attack, or death occurred during a follow-up range of 1 to 36 months (mean 12.8 months, median 7.8 months)., Conclusion: The combined CEA with retrograde stenting for tandem extracranial lesion procedure is safe and feasible, with adequate intermediate-term outcomes consistent with the recent literature.

Purpose: To report on the implementation and clinical outcomes of a community-based pulmonary rehabilitation program in rural Appalachia., Methods: Three rural health centers and a large referral hospital worked together to establish pulmonary rehabilitation services based on AACVPR guidelines. Each site hired at least 1 respiratory therapist. To measure clinical outcomes, a retrospective medical record study compared pre- and post-program values for the modified Medical Research Council dyspnea level, 6-minute walk test (6MWT), negative inspiratory force (NIF), respiratory disease knowledge, St George Respiratory Questionnaire (SGRQ), BODE index (body mass index, airflow obstruction, dyspnea and exercise capacity), and smoking status. The percentages of persons completing the program and participating in maintenance exercise after the program were recorded., Results: During the first 20 months of the program, 195 unduplicated persons with qualifying chronic lung diseases started the program. Of these, 111 (57%) completed the program. Mean improvements for all 6 measures were highly significant (P < .001) and compared favorably with published results from hospital-based programs: dyspnea level, -1.2; 6MWT, +259 ft; NIF, +11.3 cm H2O; knowledge test, +1.9; SGRQ, -6.2; BODE index, -1.1. Of the 23 smokers, 5 quit by the end of the program., Conclusions: Community-based pulmonary rehabilitation in rural health centers is feasible and achieves clinical outcomes similar to programs in large hospitals and academic centers. Furthermore, the addition of respiratory therapists to these primary care teams provides important collateral benefits for the evidence-based care of patients with chronic lung diseases.

Background: Validation of subclavian duplex ultrasound velocity criteria (SDUS VC) to grade the severity of subclavian artery stenosis has not been established or systematically studied. Currently, there is a paucity of published literature and lack of practitioner consensus for how subclavian duplex velocity findings should be interpreted in patients with subclavian artery stenosis., Objective: The objective of the present study was to validate SDUS measurements using subclavian conventional or computed tomography angiogram (subclavian angiogram [SA])-derived measurements. Secondary objectives included measuring the correlation between SDUS peak systolic velocities and SA measurements, and to determine the optimal cutoff value for predicting significant stenosis (>70%)., Methods: This is a retrospective review of all patients with suspected subclavian artery stenosis and a convenience sample of carotid artery patients who underwent SDUS and SA from May 1999 to July 2013. SA reference vessel and intralesion minimal lumen diameters were measured and compared with SDUS velocities obtained within 3 months of the imaging study. Percent stenosis was calculated using the North American Symptomatic Carotid Endarterectomy Trial method for detecting stenosis in a sufficiently large cohort. Receiver operating characteristic curves was generated for SDUS VC to predict >70% stenosis. Velocity cutoff points were determined with equal weighting of sensitivity and specificity., Results: We examined 268 arteries for 177 patients. The majority of the arteries were for female patients (52.5%) with a mean age of 66.7 ± 11.1 years. Twenty-three arteries had retrograde vertebral artery flow and excluded from further analysis. For the remaining 245 arteries, the average peak systolic velocity was 212.6 ± 110.7 cm/s, with a range of 45-626 cm/s. Average stenosis was 25.8% ± 28.2%, with a range of 0% to 100%. Following receiver operating characteristic analysis, we found a cutoff value of >240 cm/s to be most predictive of >70%. Area under the curve was 0.94 with 95% confidence intervals of 0.91 to 0.97. The sensitivity and specificity for predicting >70% stenosis was 90.9 and 82.5%, respectively., Conclusions: In patients with known or suspected disease involving the great vessels, a subclavian artery flow velocity exceeding 240 cm/s seems to be predictive of significant subclavian stenosis. Thus, we propose new SDUS VC, for predicting subclavian artery stenosis. However, because of the use of a convenience sample, it is possible that the current proposed cutoff point might need to be adjusted for other populations., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to investigate associations between Doppler measurements and adverse outcomes in an obstetric population with high tobacco use., Methods: This retrospective study included patients with Doppler data (umbilical systolic/diastolic velocity ratios (S/D), uterine S/D, uterine left/right ratio index (RI)). Receiver operator characteristic curve analysis determined cut-off elevated Doppler indices. Stepwise logistic regression was used to predict adverse outcomes., Results: 338 of 745 patients (45.4%) had adverse outcomes. Doppler artery indices identified significant associations with IUGR, preeclampsia, low birth weight, pre-term birth and composite adverse outcome variable. An elevated Umbilical S/D was 2.1 (95% Confidence Interval (CI): 1.5-2.9; p<0.001) times was more likely to have an adverse outcome. For left uterine artery S/D and nulliparity, the odds ratios were 1.8 (95% CI: 1.3-2.5) and 1.4 (95% CI: 1.0-1.9), respectively., Conclusion: Umbilical and uterine left S/D indices and nulliparity are significant independent predictors of adverse outcomes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To compare incidence and severity of neo- natal abstinence syndrome (NAS) in neonates exposed to methadone and selective serotonin reuptake inhibitors (SSRIs) with neonates ex- posed to methadone alone., Study Design: Retro- spective cohort study of women on methadone main- tenance with live births be- tween January 1, 2003, and December 31, 2009, at a tertiary care hospital. Data were abstracted from electronic medical records, exclud- ing cases of multiple gestations and lack of neonatal abstinence score documentation. Data analysis included Mann-Whitney U, Fisher's exact test, a receiver operat- ing characteristic curve, and a scatter diagram., Results: A total of 91 cases comprised our study population, with 85 (93.4%) assigned to the methadone- only group and 6 (6.6%) assigned to the methadone and SSRIs group. NAS incidence was not significantly different between the methadone/SSRI group and the methadone group (5/6 [83.3%] vs. 43/85 [50.6%], p=0.21). However, severity of NAS (median 14.0 vs. 10.0, p=0.04) and neonatal intensive care unit stay were significantly higher and longer in the methadone/ SSRI group., Conclusion: While currently neonates exposed to SSRIs are not screened for NAS, health care providers may need to pay closer attention to the effects of SSRIs on neonates.

Objective: Chronic venous ulcer (CVU) is a potentially debilitating condition that remains the most common etiology for leg ulcers. The condition has significant associated costs and effect on patient quality of life. That truncal reflux can be worsened by iliac vein occlusive disease is well known. However, there has not been systematic investigation of venous duplex ultrasound (VDUS) criteria to correlate common femoral vein (CFV) reflux with iliac vein stenosis. We sought to correlate VDUS criteria for predicting iliac vein stenosis and to investigate venous outflow factors associated with CVU recurrence., Methods: We conducted a systematic retrospective review of a consecutive series of 36 patients who received standard therapies, including compression therapy along with ablation of incompetent great saphenous veins for treating CVU, but in whom the treatment failed. Elevated CVF reflux was considered as reflux duration (RD) measured by VDUS to last >1 second. A receiver operator characteristic curve analysis was performed to determine the optimal CFV threshold value to predict 50% iliac vein stenosis measured by intravascular ultrasound., Results: The 36 patients presented with 54 CVUs on 38 limbs. The median (25th-75th quartiles) age was 61.2 (57.6-68.8) years, body mass index was 36.8 (25.2-52.3) kg/m(2), CFV RD was 2.7 (1.6-3.5) seconds, ulcer diameter was 4.2 (3.0-4.0) cm, and ulcer depth was 2.5 (2.0-3.0) mm. The optimal cutoff RD value was >2.5 seconds by receiver operator characteristic curve analysis, with an area under the curve of 0.77 (P = .001). CVUs associated with an RD >2.5 seconds had significantly more iliac vein stenosis >50% by intravascular ultrasound (24 of 30; 80%) than those with an RD <2.5 seconds (6 of 24; 25%; P < .001). Likewise, >50% stenosis for those above and below an RD >1 second was 61.4% vs 30%, respectively (P = .089). Significantly less recurrence of CVU was found for patients taking pentoxifylline (43.6% vs 80.0%; P = .031) and those with stents placed (40.0% vs 70.8%; P = .031). A nonsignificant trend was found for iliac vein interrogation (44.4% vs 72.2%; P = .082)., Conclusions: This study highlights the utility of VDUS in diagnosing iliac vein stenosis with 2.5 seconds to predict ≥50% iliac vein stenosis. Stent placement and pentoxifylline were associated with ulcer healing and reduced risk of venous ulcer recurrence., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Treatment of venous ulcers is demanding for patients, as well as clinicians, and the investigation of underlying venous hypertension is the cornerstone of therapy. We propose that occult iliac vein stenosis should be ruled out by iliac vein interrogation (IVI) in patients with advanced venous stasis., Methods: We conducted a systematic retrospective analysis of a consecutive series of patients who presented with CEAP (clinical, etiological, anatomical, and pathophysiological) 6 venous disease. All patients had great saphenous vein ablation, compressive treatment, wound care (including Unna boot compression), and perforator closure using ablation therapy. Iliac vein stenosis was defined as ≥50% stenosis in cross-sectional surface area on intravascular ultrasound. Primary outcomes include time of venous ulcer healing and/or measurable change in the Venous Clinical Severity Score., Results: Twenty-two patients with CEAP 6 venous disease met the inclusion criteria (active ulcers >1.5 cm in diameter). The average age and body mass index were 62.2 ± 9.2 years and 41.7 ± 16.7, respectively. The majority were female (72.7%) with common comorbidities, such as hyperlipidemia (54.5%), hypertension (36.4%), and diabetes mellitus (27.3%). Twenty-nine ulcers with an average diameter of 3.4 ± 1.9 cm and a depth of 2.2 ± 0.5 mm were treated. The majority of the ulcers occurred on the left limb (n = 17, 58.6%). Average perforator venous reflux was 3.6 ± 0.8 sec, while common femoral reflux was 1.8 ± 1.6. The majority (n = 19, 64.5%) of the perforator veins were located at the base of the ulcer, while the remainder (n = 10, 34.5%) were within 2 cm from the base. Of the 13 patients who underwent IVI, 8 patients (61.5%) had stenosis >50% that was corrected with iliac vein angioplasty and stenting (IVAS). There was a strong trend toward shorter healing time in the IVI group (7.9 ± 9.5 weeks) than for patients in the no iliac vein interrogation (NIVI) group (20.2 ± 15.3 weeks, P = 0.055). The final VCCS score was not significantly different (IVI = 7.9 ± 9.5 vs. NIVI = 10.0 ± 6.5, P = 0.578). However, compared with the NIVI group, the healing time for patients who actually received IVAS was marginally lower (5.8 ± 3.6 weeks, P = 0.075) and final VCCS was significantly lower (2.4 ± 2.9, P = 0.031). Veins that received IVI and IVAS remained patent and the associated ulcers were healed (100%)., Conclusion: The small sample size and retrospective design limit the strength of the conclusions but the findings suggest that further studies are needed to define the exact role of IVI including angioplasty/stenting for patients with chronic venous ulcers., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To test the hypothesis that morphology is the best predictor of clinical pregnancy (CP) when employing intrauterine insemination (IUI)., Study Design: We retrospectively reviewed a registry of 527 couples who collectively underwent 1,027 IUI cycles, testing sperm parameters and other variables with univariate and multivariate analyses for association with CP. With the literature scant regarding the impact of sperm morphology on IUI outcome, we determined semen parameter threshold values in our patient population and compared them to published reference range values. A logistic regression model was used to determine predictors of CP., Results: Fecundity was 12.9% per cycle and fertility was 23.3% by the third attempted cycle. Morphology was the most significant parameter predicting CP with IUI. Motility was also significant when employing our new threshold values. Using receiver operator characteristic curve analysis, values 16% morphology and 69% motility were found to be the optimal threshold values for achieving CP., Conclusion: Morphology was the best predictor of CP. When considering IUI, the best chance of clinical pregnancy occurs when both motility and morphology values are above normal thresholds.

Objective: The purpose of this study was to identify significant predictors of long-term mortality after elective endovascular abdominal aortic aneurysm repair (EVAR)., Methods: We included all cases with elective EVAR based on a national data set from the Society for Vascular Surgery Patient Safety Organization. Clinical and anatomic variables were analyzed with a Kaplan-Meier and Cox-regression model to determine predictors of mortality and develop a score equation to categorize patients into low, medium, and high long-term mortality risk., Results: A total of 5678 patients with EVAR were included with an average age of 73.6 ± 8.2 years. The majority were male (81.6%) with a history of smoking (86.1%). There were 3 deaths within 30 days (0.1%). Several factors were associated with poor survival: unstable angina (hazard ratio [HR], 2.8; P = .008), dialysis (HR, 3.7; P < .001), estimated glomerular filtration rate (eGFR) <30 (HR, 1.7; P = .044), eGFR 30 to 59 (HR, 1.4; P = .002), age >80 (HR, 3.2; P < .001), age 75 to 79 (HR, 2.2; P < .001), chronic obstructive pulmonary disease on oxygen (HR, 3.3; P < .001), aortic diameter >5.8 cm (HR, 1.2; P = .043), and high risk for surgery (HR, 1.4; P = .043). Preoperative aspirin use and body mass index 25 to 35 were both found to be protective (HR, 0.78; P = .017 and HR, 0.8; P = .024, respectively). With our scoring model, 5- and 10-year survival rates for patients with low, medium, and high risk were 89.2%, 80.7%, and 64.1% and 77.2%, 60.1%, and 40.1%, respectively (P < .001)., Conclusion: Ten-year survival following EVAR in patients with a high-risk score utilizing the model provided was 40.1%. Patients with multiple comorbidities at risk for decreased long-term survival can be identified with our model, which is more applicable for high-volume contemporary institutions., (© The Author(s) 2016.)

Objective: This study was conducted to determine long-term predictors of target lesion reintervention (TLR) after subclavian artery stenting (SAS)., Methods: This was a single-center retrospective review of patients with symptomatic atherosclerotic subclavian artery disease who underwent SAS between January 1999 and December 2013. Repeat intervention was only performed in patients with recurrent symptoms and ≥70% in-stent restenosis (ISR). TLR was defined as need for a repeat percutaneous intervention involving a previously stented area. Freedom from events (ISR and TLR) was analyzed using Kaplan-Meier curves. Cox regression analysis was used to determine the significant predictors of TLR and ISR., Results: Index procedures were performed on 139 arteries in 138 patients (69.6% female). Patients were an average age of 64.5 years, with major comorbidities of hypertension (80.4%), hyperlipidemia (72.5%), and tobacco use (60.1%). Also performed during the study period were 24 TLR procedures, resulting 166 SAS interventions attempted for patients with subclavian atherosclerotic disease during a 15-year span. Of 166 procedures, 163 (98.2%) were treated successfully. Stents were placed in all but two index arteries. The main indications for SAS were subclavian steal syndrome (48.9%), arm claudication (21.6%), and coronary steal syndrome (28.8%). The average preprocedure stenosis was 87.2% ± 11.2%. For index procedures (139 arteries), duplex follow-up was available for 134 arteries (96.4%), with an overall ISR rate of 18.7% (25 of 134). Primary patency for the index procedures was 84.7% at 10 years. The overall TLR rate for the index procedures was 12.7% (17 cases). Seven patients required more than one secondary procedure. For all cases, the freedom from ISR was 91%, 77%, and 68% at 1, 5, and 10 years, respectively, and freedom from TLR was 94%, 85%, and 82% at 1, 5, and 10 years, respectively. Multivariate analysis showed the significant predictors of ISR were smoking/chronic obstructive pulmonary disease (hazard ratio [HR], 3.2; P = .001), age by decade (HR, 0.5; P < .001), discharged with statin therapy (HR, 0.3; P = .001), vessel diameter ≤7 mm (HR, 2.3; P = .028), and right-sided intervention (HR, 0.3; P = .040). The sole significant predictor of TLR was age by decade (HR, 0.6; P = .008)., Conclusions: SAS has a high primary success and durability with satisfactory outcomes well beyond 10 years. ISR was more likely to develop in patients who were smokers with chronic obstructive disease or had a baseline vessel size of ≤7 mm. Younger age could be an independent risk factor for secondary intervention., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the long-term outcomes of patients who underwent carotid artery stenting (CAS) for de novo carotid stenosis vs patients treated for restenosis after carotid endarterectomy (CEA)., Methods: A retrospective review was conducted of all 385 patients (mean age 68.6±9.6 years; 231 men) who underwent 435 CAS procedures at a large tertiary care center between January 1999 and December 2013. For analysis, patients were stratified based on their lesion type [de novo (dn) vs post-CEA restenosis (res)] and subclassified by symptoms status [symptomatic (Sx) or asymptomatic (Asx)], creating 4 groups: (1) CAS-dn Asx, (2) CAS-dn Sx, (3) CAS-res Asx, and (4) CAS-res Sx. For the CAS-res group, the mean elapsed time from CEA to CAS was 72.4±63.6 months. Outcomes included target vessel reintervention (TVR) and in-stent restenosis (ISR), the latter defined by a carotid duplex ultrasound velocity >275 cm/s., Results: The main indication for initial carotid angiography with possible revascularization was severe carotid stenosis (≥70%-99% on duplex) in both CAS-dn and CAS-res groups (83.6% vs 83.7%, p=0.999). There were no significant differences in the percentage of patients with postintervention residual stenosis (<30%; 100% each arm) or complications between CAS-res vs CAS-dn: in-hospital stroke (1.4% vs 1.8%, respectively), myocardial infarction (0.9% vs 0%), or death (0.9% vs 0%). Mean follow-up was 62.4±45.6 months (median 53.5, range 1-180). Average clinical/TVR follow-up was greater for the CAS-res group (71.9±48.6 months) compared with 53.3±40.5 months for the CAS-dn group (p<0.001). Across the 4 study groups, there were no differences in freedom from ISR (p=0.174) or TVR (p=0.856). Multivariate analysis found peripheral vascular disease (PVD) as the sole ISR independent predictor [hazard ratio (HR) 1.92, 95% confidence interval (CI) 1.03 to 3.62, p=0.041], while significant predictors for TVR were age <65 years at the time of the procedure (HR 2.55, 95% CI 1.05 to 6.18, p=0.039) and PVD (HR 2.46, 95% CI 1.03 to 5.87, p=0.043)., Conclusion: The current study suggests that CAS is a feasible and durable therapeutic option for recurrent restenosis after CEA. Long-term outcomes were similar for patients treated for de novo lesions or post-CEA restenosis. Age and PVD appear to influence long-term CAS durability., (© The Author(s) 2015.)

Atherosclerotic renal artery stenosis is known to be one of the most common causes of secondary hypertension, and early nonrandomized studies suggested that renal artery stenting (RASt) improved outcomes. The vascular community embraced this less invasive treatment alternative to surgery, and RASt increased in popularity during the late 1990s. However, recent randomized studies have failed to show a benefit regarding blood pressure or renal function when RASt was compared with best medical therapy, creating significant concerns about procedural efficacy. In the wake of these randomized trial results, hypertension and renal disease experts along with vascular interventional specialists now struggle with how to best manage atherosclerotic renal artery stenosis. This review objectively analyzes the current literature and highlights each trial's design weaknesses and strengths. We have provided our recommendations for contemporary treatment guidelines based on our interpretation of the available empirical data., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Currently ACOG recommends that a mid-term screening strategy may be considered to identify short cervix in low risk populations in an effort to prevent preterm birth. Vaginal progesterone is recommended for women with a cervical length ≤20 mm. Cerclage is recommended for women with prior spontaneous preterm birth who are already receiving progesterone supplementition and CL is <25 mm. This study examined risk factors for spontaneous preterm birth (SPB) <35 weeks among a general obstetrical population prior to these ACOG recommendations. However, cervical cerclage was a possible intervention. Study population included 1,074 patients from 1 Jan 2007-30 Jun 2008 receiving mid-trimester transvaginal ultrasounds during prenatal care at a tertiary medical center clinic. Receiver operator characteristic (ROC) curve cutoff optimal value was ≤34 mm, (n=224), corresponding to 8.9% SPB with shortened cervices compared to 1.4% in patients with normal cervices (>34 mm; n=850; p<0.001 (Area Under the Curve (AUC) 76.6, p<0.001). Cervical lengths <30 mm had 12 times the risk of SPB (p<0.001) while 30-34 mm had 5 times (p=0.005). Tobacco use (≥10 cigarettes per day), p=0.030, and low BMI, p=0.034, had additive effect. Shortened cervical length during routine screening independently predicted SPB while heavy smoking with shortened cervix during pregnancy doubled risk compared to shortened cervix alone.

Background: The sensitivity of d-dimer (DD) in detecting deep venous thrombosis (DVT) is remarkably high; however, many institutions send patients immediately for a venous duplex ultrasound (VDU). This study was designed to examine the appropriate utilization of DD and VDU in a high-volume hospital., Methods: A retrospective study was conducted on consecutive patients who presented to a high-volume emergency department (ED) with lower extremity limb swelling/pain over a 30-day period, who were sent for VDU during an evaluation for DVT. VDU data were merged with electronic DD laboratory results. The enzyme-linked immunosorbent assay method was used to provide DD values and thresholds. Values above 0.60 mg/fibrinogen equivalent unit (FEU) were considered abnormal., Results: We reviewed the medical records of 517 ED patients in the month of June 2013. After applying the Wells criteria, 157 patients (30.4%) were excluded because of a history of DVT or pulmonary embolism, having been screened for shortness of breath, or sent for surveillance-leaving 360 for analysis. The average age was 59.3 ± 16.5 years with more women (210, 58.3%) and the majority reported limb pain or swelling (73.9%). DD was performed on 51 patients with an average value of 3.6 ± 5.4 mg/FEU, of which 43 (84.3%) were positive. DD identified all positive and negative DVT patients (100% sensitivity and negative predictive value), but also included 40 false positives (16.7% specificity). On the other hand, 309 patients were sent directly to VDU without DD; of those, 43 (13.9%) were positive for DVT. However, 266 (86.1%) patients were negative for DVT by VDU without DD and these were deemed improper by our current study protocol. Potential charge savings were calculated as VDU for all (360 × $1000 = $360,000), DD for all (360 × $145 = $52,200), and VDU for both true and false positives (estimated to be about 25% of the cases; 90 × $1000 = $90,000); this equals a charge savings of $217,800 and would avoid unnecessary VDUs., Conclusions: Based on the results of our study, we suggest that the DD test be utilized during the initial work-up for patients with limb swelling/pain in the emergency room. Appropriate utilization of DD, as well as other clinical criteria, may limit the over-utilization and added cost of VDU, without a negative impact on patient care. The results of DD tests should be utilized to limit the number of patients sent for VDU to only those patients with a positive DD or other significant underlying concerns., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Amyloid light-chain (AL) amyloidosis is a multi-organ disease due to deposition of misfolded monoclonal immunoglobulin light chains. IgM AL amyloidosis is a rare variant, about 6% of AL amyloidosis cases, and more data are needed for treatment guidance. In IgM AL amyloidosis, the clonal cell of origin may be a plasma or lymphoplasmacytic cell, and treatments targeting each are employed. We describe presenting clinical and laboratory features of 95 patients with IgM AL amyloidosis treated at Boston University Amyloidosis Center from 1996 to 2012. The median diagnosis age was 66 years (range: 38-89) with 56% males. Organ involvement rates were: kidney (51%); heart (40%); lymph nodes (25%) and gastrointestinal tract (17%). Treatment responses were analyzed for 46 patients seen after 2003. Five treatment regimens were assigned by bone marrow pathology and patient-specific factors. Overall hematologic response rates and very good partial or complete hematologic response rates, respectively, were: high-dose melphalan/stem cell transplant (HDM/SCT) 100%;80%, Bortezomib 82%;27%, Rituximab 80%;27%, immunomodulatory agents (IMids) 75%;0%, and standard dose alkylating agents (Melphalan or cyclophosphamide) 63%;19%. Overall, 5-year survival rates were significantly higher in patients with a hematological response: 79.2 ± 8.5% versus 41 ± 14.9% in non-responders, which is more favorable than typically expected in AL amyloidosis.

Serum anti-endometrial antibodies (AEA) have been studied as a marker for endometriosis and implantation failure. We sought to determine if the presence of AEA in the serum of pregnant patients is associated with first trimester pregnancy loss including complete abortion. This is a prospective pilot case control study of 30 patients presenting with first trimester pregnancy loss compared to a control group of 30 first trimester pregnant patients with a normal course for the presence of serum AEA. The control group was selected using propensity matching of patient characteristics. AEA assays were performed by a single operator blinded to clinical status of patients. The mean maternal age in the study and control groups was not statistically significant (26.1 +/- 5.7 vs. 24.2 +/- 4.5 years, p < 0.155). A history of pregnancy loss was not significantly greater in the study group (12/30 = 40.0%) as compared to the control group (8/30 = 26.7%, p < 0.412). In both study and control groups, 40% of the samples tested positive for AEA; therefore, we found no evidence of an association between the presence of AEA and pregnancy loss. These findings in our pilot study suggest that presence of serum AEA does not appear to be a marker for early pregnancy loss.

Objective: To determine predictors of percutaneous (PEVAR) access failure requiring conversion to an open approach (OEVAR) during endovascular aortic aneurysm repair (EVAR)., Methods: A single-center retrospective review of all EVAR patients from January 2009 through June 2011 with multivariate analysis of clinical and anatomic variables that could impact access outcome was conducted. Target vessel calcification was categorized as mild, moderate, or severe based on circumferential calcium arc (<⅓, ⅓ to ½, and >½ respectively), dyslipidemia (defined as low-density lipoprotein >130 mg/dL or receiving lipid lowering medication), and obesity (defined as body mass index [BMI] >30)., Results: We investigated 400 access sites for 200 patients who underwent EVAR. The study cohort's characteristics included an average age of 72.8 ± 9.0 years, vessel size of 9.6 ± 1.8 mm, sheath size of 17.1 ± 3.0 Fr, BMI of 27.6 ± 5.3, and estimated glomular filtration rate of 68.5 ± 24.2 mL/min. Comorbidities included dyslipidemia in 129 patients (64.5%) and diabetes in 54 patients (27%). There were 132 OEVAR (66 patients), two mixed OEVAR with contralateral PEVAR (one patient), and 266 (133 patients) PEVAR approaches. Use of PEVAR increased over time (45.5% [2009], 77.8% [2010], and up to 88.5% [2011]; P = .001) while conversions decreased (24.3% [2009], 8.7% [2010], and 4.3% [2011]; P = .001]. More OEVAR patients (35.8%) stayed longer than 3 days compared with 21.1% for PEVAR (P = .028). For the 266 PEVAR approaches, 32 access sites (12.0%) had to be converted. Severely calcified arteries were most predictive of conversion (odds ratio [OR], 36.4; P < .001). Year of procedure (2010; OR, 0.17; P = .001; 2011, OR, 0.20; P = .049), female gender (OR, 3.1; P = .017), moderately calcified arteries (OR, 2.5; P = .085), and age (OR, 2.3 [per decade]; P = .002) were all also significant. Vessel size, sheath size, and BMI were found to be nonsignificant predictors of conversion., Conclusions: PEVAR was found to be safe, reliable, and feasible. Several factors, including learning curve, vessel calcification, age, and female gender predicted conversion of PEVAR to OEVAR., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Introduction: Current guidelines based on clinical trials may have inadvertently excluded a representative cohort of older adults. As a result, little is known about the predictors of stroke among elderly patients undergoing coronary artery bypass surgery (CABG). The purpose of this study was to determine how a lower than normal ejection fraction (EF) predicted post surgery stroke among elderly patients undergoing CABG when compared with younger populations., Methods: Retrospective cross-sectional cohort analysis. setting: Charleston Area Medical Center, a tertiary medical center., Participants: 8661 consecutive CABG cases between 2003 and 2009. measurements: PARTICIPANTS were divided into three different age groups: < 65 years old (Group 1), between 65 and 79 years old (Group 2), and > or = 80 years old (Group 3). We calculated the rate of overall neurological complications after CABG for patients with ejection fraction values: < 40%, between 40% and 59%, and > or = 60., Result: Group 3 (age > = 80) with EF < = 39 had the highest odds of developing post CABG stroke (Odds Ratio (OR): 5.6) followed by Group 3 (age > = 80) with EF 40-59 (OR: 3.9). In addition, Group 2 (age 65-79) with EF < = 39 had the next highest odds of developing post CABG stroke (OR: 2.3) followed by Group 2 (age 65-79) with EF 40-59 (OR: 1.9)., Conclusion: Contrary to current guidelines, in our study population, mildly affected EF increased the overall risk of neurological complications among elderly patients undergoing CABG.

Objective: Contrary to coronary artery literature, the effect of preprocedural clopidogrel on renal artery restenosis (RAR) has not been characterized. This study was designed to evaluate the effect of preprocedural clopidogrel on target vessel revascularization (TVR), reintervention, and restenosis for patients who underwent recurrent renal artery angioplasty., Methods: A retrospective analysis of patients treated for RAR in a single tertiary center from January 1999 to December 2009 was conducted. Patients were divided into preadmission use of (1) clopidogrel or (2) aspirin only (acetylsalicylic acid [ASA]) for the initial procedure. TVR was defined as occurrence of a tertiary procedure for symptomatic RAR. Rate of freedom from event (ie, tertiary restenosis and TVR) was analyzed using Kaplan-Meier method., Results: Eighty-eight interventions were performed on 77 patients with RAR; 66% were females with average (mean ± SEM) age and body mass index of 68.8 ± 1.1 and 28.6 ± 0.8, respectively. Comorbidities included 96% chronic hypertension, 33% diabetes, 76% hyperlipidemia, 20% renal insufficiency, 39% tobacco use, 58% coronary artery disease, and 51% peripheral vascular disease. Clopidogrel use increased significantly during the index procedure from admission 35.2% to discharge 97.7% (P < .001, McNemar test). There was a trend toward risk reduction of a tertiary intervention (23%) for patients admitted on clopidogrel compared with ASA (P = .052). Likewise, there was a trend (P = .051) toward increased freedom from a tertiary intervention, with cumulative freedom at 8 years 93.5% for clopidogrel vs 61% for ASA. No differences were found for restenosis., Conclusions: The use of preprocedural clopidogrel was associated with a possible risk reduction of TVR reintervention, but this finding needs to be validated in randomized clinical trial., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: The purpose of this study was to evaluate short and long-term outcomes of percutaneous transluminal intervention in patients with symptomatic renal artery stenosis due to fibromuscular dysplasia (RAFMD) and/or the combination of RAFMD with aorto-ostial atherosclerotic disease., Methods: A retrospective analysis of all patients with renal artery RAFMD who underwent transcatheter therapy between January 1999 and December 2009 was performed. Blood pressure (BP) measurement, number of BP medications, and hypertension defined by a systolic BP >140 ± diastolic BP >90 were recorded. Renal function was defined by estimated glomerular filtration rate (eGFR). Restenosis was defined by stenosis >60% and was determined by renal artery duplex and/or angiography. Freedom from event (restenosis, renal failure, or recurrent hypertension) was performed using life table analysis., Results: Forty-three procedures were performed on 35 patients with RAFMD. Thirty-two patients (91%) were women, with mean age of 61.9 years old. Technical success was 100% with adjunctive stent placement required in the FMD segment for dissection in 1 patient (2.3%) and in the non-FMD aorto-ostial atherosclerotic lesion in 4 patients (9.3%). Short-term outcomes: the majority (69%) had an immediate clinical benefit for hypertension, 6% were cured without BP medications, and 63% improved with less than or equal to preoperative BP medications. Postintervention, 17% remained at moderately reduced renal function (<60), whereas the percent above >60 mL/minute eGFR increased significantly (from 51% to 69%; P = .002). For the entire cohort, renal function (mean eGFR) significantly increased from 71.9 mL/minute + 5.8 to 80.8 mL/minute + 5.2 (P = .007). Long-term outcomes: freedom from recurrent or worsening hypertension (>140 systolic blood pressure [SBP] and >90 diastolic blood pressure [DBP]) was (93%, 75%, and 41%) and freedom from reduced renal function (eGFR <30 mL/minute) was (100%, 95%, and 64%) at 1, 5, and 8 years, respectively. Patients with reduced baseline renal function (<60 mL/minute) and combined atherosclerotic disease were more likely to experience long-term reduced renal function (eGFR <30 mL/minute; P = .003). Primary and assisted primary patency was (95%, 71%, and 50%) and (100%, 100%, and 100%) at 1, 5, and 9 years, respectively., Conclusion: Renal angioplasty is a safe and durable modality for treating RAFMD with favorable short and long-term clinical outcomes. Patients with combined atherosclerotic disease and FMD were older and were more likely to have declining renal function over time. Early intervention may be imperative to achieve possible cure of hypertension., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)