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To evaluate the association between genetically determined risk for atopic disease and osteoarthritis (OA). We performed linkage disequilibrium (LD) score regression using 1000 Genomes Project European samples as a reference for patterns of genome-wide LD. Summary statistics for atopic disease traits were obtained from the UK Biobank. We generated a pairwise genetic correlation between OA and traits for atopic disease to estimate the genetic correlation between traits (r g) and heritability for each trait. The association between atopy-related traits and OA was examined using Mendelian randomization (MR) on summary statistics; we reported inverse-variance weighted (IVW), MR-Egger, maximum likelihood estimation, weighted median, and weighted mode. There was a significant positive correlation between the genome-wide genetic architecture of asthma and all OA traits. Using the IVW (random effects), there was a significant association between asthma and knee OA ((odds ratio) OR = 1.04, 95% (confidence interval) CI 1.01–1.08, p = 0.0169). Using IVW (fixed effects), significant associations were identified between knee OA and allergic disease (OR = 1.07, 95% CI 1.01–1.14, p = 0.0342), allergic rhinitis (OR = 1.07, 95% CI 1.00–1.13, p = 0.0368), and asthma (OR = 1.04, 95% CI 1.01–1.07, p = 0.0139), as well as for OA at any site and asthma (OR = 1.02, 95% CI 1.00–1.04, p = 0.0166). We found a significant correlation between the overall genetic architecture of asthma and OA, as well as an increased risk of developing OA in patients with genetic variants associated with asthma and allergic rhinitis; predominately, this risk was for the development of knee OA. These results support a causal relationship between asthma and/or allergic rhinitis and knee OA. [ABSTRACT FROM AUTHOR]

Lower extremity peripheral artery disease and the resultant complications disproportionately affect underrepresented racial and ethnic minority groups, as well as those with low socioeconomic status (SES). Revascularization, including both open surgical and endovascular techniques, is a mainstay of therapy for symptomatic peripheral artery disease; it is required to maximize limb salvage in chronic limb-threatening ischemia and used to improve function and quality of life in patients with claudication. The outcomes of lower extremity revascularization in Black and Hispanic patients, as well as patients with low SES, are not widely known and this knowledge gap formed the basis for this review. The preponderance of evidence suggests that Black, Hispanic, and low-SES patients have inferior limb-related outcomes after revascularization compared with White patients. Based solely on the limited published evidence in the revascularization literature, the specific reasons for these disparities are not clear. The high prevalence of comorbidities and risks factors, as well as the advanced presentation of peripheral artery disease in Black, Hispanic, and low-SES patients, appear to contribute to the inferior limb outcomes post revascularization seen in these groups, but do not account for all of the disparities. Undoubtedly, a complex interplay of social determinants underlies these disparities in care and outcomes at individual, community, and societal levels. Additional understanding of the underpinnings and mechanisms of inferior outcomes in these populations in the specific context of lower extremity revascularization is needed, as this would allow us to identify targets for intervention to improve post-revascularization outcomes in these at-risk populations. [ABSTRACT FROM AUTHOR]

IgG4-related disease (IgG4-RD) is a fibroinflammatory condition involving loss of B-cell tolerance and production of autoantibodies. However, the relevant targets and role of these aberrant humoral immune responses are not defined. Our aim was to identify novel autoantibodies and autoantigen targets that promote pathogenic responses in IgG4-RD. We sequenced plasmablast antibody repertoires in patients with IgG4-RD. Representative mAbs were expressed and their specificities characterized by using cytokine microarrays. The role of anti–IL-1 receptor antagonist (IL-1RA) autoantibodies was investigated by using in vitro assays. We identified strong reactivity against human IL-1RA by using a clonally expanded plasmablast-derived mAb from a patient with IgG4-RD. Plasma from patients with IgG4-RD exhibited elevated levels of reactivity against IL-1RA compared with plasma from the controls and neutralized IL-1RA activity, resulting in inflammatory and fibrotic mediator production in vitro. IL-1RA was detected in lesional tissues from patients with IgG4-RD. Patients with anti–IL-1RA autoantibodies of the IgG4 subclass had greater numbers of organs affected than did those without anti–IL-1RA autoantibodies. Peptide analyses identified IL-1RA epitopes targeted by anti–IL-1RA antibodies at sites near the IL-1RA/IL-1R interface. Serum from patients with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) also had elevated levels of anti–IL-1RA autoantibodies compared with those of the controls. A subset of patients with IgG4-RD have anti–IL-1RA autoantibodies, which promote proinflammatory and profibrotic meditator production via IL-1RA neutralization. These findings support a novel immunologic mechanism underlying the pathogenesis of IgG4-RD. Anti–IL-1RA autoantibodies are also present in a subset of patients with SLE and RA, suggesting a potential common pathway in multiple autoimmune diseases. [ABSTRACT FROM AUTHOR]

● HIV patients were diagnosed with central line–associated bloodstream infections. ● HIV patients were 38% less likely to have a hospital-acquired infection. ● Having at least 1 comorbidity was identified as a significant mediator. Hospital-acquired infections (HAIs) lead to poor health outcomes in hospitalized patients and may be disproportionately affecting the aging population of people living with HIV (PLWH). This study determined the association between HIV and HAIs, and analyzed the potential mediating effects of comorbidities. The Louisiana Hospital Inpatient Discharge Database for the years 2011-2015 was used. All patients with at least 1 HAI diagnosis within this source population were included as cases in the case-control study, and a 1:1 ratio of controls was randomly selected from the same hospitals. Of the 1,852,769 eligible hospital discharges that occurred from 2011 through 2015, there were 7,422 patients with at least 1 HAI. Marginal logistic regressions of the case-control sample showed a strong association between HIV and central line–associated bloodstream infections (CLABSIs), but an inverse association between HIV and any HAI. However, the mediation analyses revealed that having at least 1 comorbidity mediates the association between HIV and CLABSIs. The unexpected inverse association between HIV and HAI could be attributed to the sample size of the exposed group of patients, or it could be explained by the mechanisms of treatment for HIV patients. This study found that people living with HIV are at an increased risk of developing a CLABSI, which is consistent with the published literature. The mediation analyses indicated that having at least 1 comorbidity mediated the association between HIV and CLABSI diagnosis. [ABSTRACT FROM AUTHOR]

Background: Bilateral total knee arthroplasty (TKA) can be performed under a single-anesthetic (SA) or staged under a two-anesthetic (TA) technique. Recently, our institution began piloting a 2-surgeon team SA method for bilateral TKA. The purpose of this study was to compare the inpatient costs and clinical outcomes in the first 90 days after surgery between the team SA, single-surgeon SA, and single-surgeon TA approaches for bilateral TKA.Methods: All primary TKAs performed from 2007 to 2017 by the 2 participating surgeons for each of the 3 groups of interest were identified: team SA (N = 42 patients; 84 knees), single-surgeon SA (N = 146 patients; 292 knees), single-surgeon TA (N = 242 patients; 484 knees). No patients were lost to follow-up.Results: Median hospital cost (per TKA) for the episode(s) of care was as follows: team SA $20,962, single-surgeon SA $22,057, single-surgeon TA $31,145 (P < .001 overall; P = .0905 team SA vs single-surgeon SA). Rate of 90-day complications was 2.4% for team SA, 11.0% for single-surgeon SA, and 8.3% for single-surgeon TA (P = .2090). Discharge to skilled nursing facilities or rehab was as follows: team SA 31%, single-surgeon SA 53%, and single-surgeon TA after the second operation 34% (P < .001).Conclusion: This pilot project suggests that team SA bilateral TKA is a potentially cost-effective option with fewer complications compared to single-surgeon SA bilateral TKA. The less frequent disposition to skilled nursing facilities in the team SA group in conjunction with more efficient operating room utilization may further enhance the financial benefits. [ABSTRACT FROM AUTHOR]

Abstract Objective In 2009, the Society for Vascular Surgery (SVS) developed objective performance goals (OPGs) to define the therapeutic benchmarks in critical limb ischemia (CLI) based on outcomes from randomized trials of lower extremity bypass (LEB). Current performance relative to these benchmarks in both LEB and infrainguinal endovascular intervention (IEI) remains unknown. The objective of this study was to determine whether LEB and IEI performed for CLI in a contemporary national cohort met OPG 30-day safety thresholds. Methods SVS OPG criteria were applied to 11,043 revascularizations for CLI performed from 2011 to 2015 in the National Surgical Quality Improvement Program (NSQIP) vascular targeted modules. Primary 30-day safety OPGs including major adverse cardiovascular events (MACEs), major adverse limb events (MALEs), and amputation were calculated for the NSQIP LEB (n = 3833) and IEI (n = 3526) cohorts as well as for subgroups at "high anatomic risk" (infrapopliteal revascularization) and "high clinical risk" (age >80 years and tissue loss). These were compared with SVS OPG benchmarks using χ 2 comparisons. Results Compared with the SVS OPG cohort, both the NSQIP LEB and IEI cohorts had fewer patients at high anatomic risk (LEB, 51%; IEI, 27%; SVS OPG, 60%; both P <.0001). The LEB cohort had fewer patients with high clinical risk than the SVS OPG cohort (LEB, 11%; SVS OPG, 16%; P <.0001). The 30-day MALE was significantly higher in the NSQIP LEB (9.0% [8.7%-9.2%]) and IEI (9.7% [9.4%-10.0%]) cohorts compared with the SVS OPG cohort (6.1% [4.7%-9.0%]; both P ≤.007), including significantly higher rates of amputation. MACE was significantly lower in the NSQIP LEB (4.2% [4.1%-4.3%]) and IEI (3.1% [3.0%-3.2%]) cohorts compared with the SVS OPG cohort (6.1% [4.7%-8.1%]; both P ≤.013). Among patients at high anatomic risk, 30-day MALE was significantly higher after LEB (9.5% [9.1%-9.8%]) and IEI (11.1% [10.4-11.8%]) compared with the SVS OPG cohort (6.1% [4.2%-8.6%]; P ≤.002). Among patients with high clinical risk, IEI was associated with lower MACE compared with the SVS OPG cohort, with similar limb-related outcomes. Conclusions In contemporary real-world practice, LEB and IEI for CLI failed to meet SVS OPG limb-related 30-day safety benchmarks for the entire CLI cohort as well as for the patients at high anatomic risk. Additional investigation using SVS OPGs as consistent end points is required to determine why limb-related outcomes after revascularization for CLI remain suboptimal. LEB and IEI surpassed OPG benchmarks for 30-day cardiovascular morbidity and mortality. OPGs for cardiovascular morbidity in patients undergoing revascularization for CLI deserve re-evaluation using contemporary data. [ABSTRACT FROM AUTHOR]

Abstract Objective Dementia represents a major risk factor for medical complications and has been linked to higher rates of complication after surgery. Given the systemic nature of vascular disease, medical comorbidities significantly increase cost and complications after vascular surgery. We hypothesize that the presence of dementia is an independent predictor of increased postoperative complications and higher health care costs after vascular surgery. Methods The Vascular Quality Initiative database was queried for all patients undergoing vascular surgery at a single academic medical center from 2012 to 2017. All modules were included (open abdominal aortic aneurysm, suprainguinal bypass, lower extremity bypass, amputation, carotid endarterectomy, endovascular aortic aneurysm repair, thoracic endovascular aortic aneurysm repair, and peripheral endovascular intervention). An institutional clinical data repository was queried to identify patients with International Classification of Diseases, Ninth Revision diagnosis codes for dementia as well as total hospital cost and long-term survival using Social Security records from the Virginia Department of Health. Hierarchical logistic and linear regression models were fit to assess risk-adjusted predictors of any complication and inflation-adjusted cost. Kaplan-Meier and Cox proportional hazards models were used for survival analysis. Results A total of 2318 patients underwent vascular surgery and were captured by the Vascular Quality Initiative during the past 5 years, with 88 (3.8%) having a diagnosis of dementia. Patients with dementia were older and had higher rates of medical comorbidities, and the most common procedure was major amputation. In addition, dementia patients had a significantly higher rate of any complication (52% vs 16%; P <.0001) and increased 90-day mortality (14% vs 4.8%; P =.0002). Furthermore, dementia was associated with significant resource utilization, including preoperative length of stay (LOS), postoperative LOS, intensive care unit LOS, and inflation-adjusted total hospital cost (all P <.0001). Hierarchical modeling demonstrated that dementia was the strongest preoperative predictor for any complication (odds ratio, 8.64; P <.0001) and had the largest risk-adjusted impact on total hospital cost ($22,069; P <.0001). Finally, survival analysis demonstrated that dementia is independently associated with reduced survival after vascular surgery (hazard ratio, 1.37; P =.018). Conclusions This study demonstrated that dementia is one of the strongest predictors of any complication and increased hospital cost after vascular surgery. Given the high risk of clinical and financial maladies, patients with dementia should be carefully considered and counseled before undergoing vascular surgery. [ABSTRACT FROM AUTHOR]

Background Studies have demonstrated mixed results after humeral head replacement (HHR) for osteoarthritis at short- and medium-term follow-up intervals. The purpose of this study was to investigate the long-term outcomes (minimum 10 years) of HHR for the treatment of osteoarthritis. Methods This study included 44 shoulders in 42 patients who had been followed up for a minimum of 10 years, at a mean clinical follow-up of 17 years (range, 10-30 years). Of this group, 31 shoulders had radiographic follow-up beyond 5 years, at a mean of 11.1 years (range, 5-21 years). Results Patients experienced significant pain relief postoperatively that was maintained during the long-term follow-up ( P  < .01), with a subgroup of 11 patients reporting persistent moderate or severe pain. Patients maintained increases in shoulder abduction (<.01), external rotation (<.01) and modified Neer scores (<.01). Ten of 44 (22.7%) shoulders underwent revision surgery, predominantly for glenoid arthrosis (n = 9). In the 25 shoulders with 5 years of radiographic follow-up, Kaplan-Meier survival analysis demonstrated moderate to severe glenoid erosion in 50% at 5 years, which increased to 59% at 15 years and 88% at 20 years. Conclusions HHR remains a successful operation for osteoarthritis at long-term follow-up. However, there is a substantive subgroup with continuing pain and a high rate of glenoid bone erosion after 10 years. Surgeons should carefully consider patients' needs and desires when judging the indications for HHR. [ABSTRACT FROM AUTHOR]

Stored-value cards, or prepaid cards, are increasingly popular. Like credit cards, their use is vulnerable to fraud, costing merchants and card processors millions of dollars. Prior techniques to automate fraud detection rely on a priori rules or specialized learned models associated with the customer. Mostly, these techniques do not consider fraud sequences or changing behavior, which can lead to false alarms. This study demonstrates how a transaction model can be dynamically created and updated, and fraud can be automatically detected for prepaid cards. A card processing company creates models of the store terminals rather than the customers, in part, because of the anonymous nature of prepaid cards. The technique automatically creates, updates, and compares hidden Markov models (HMM) of merchant terminals. We present fraud detection and experiments on real transactional data, showing the efficiency and effectiveness of the approach. In the fraud test cases, derived from known fraud cases, the technique has a good F-score. The technique can detect fraud in real-time for merchants, as card transactions are processed by a modern transaction processing system. [ABSTRACT FROM AUTHOR]

Background The decision to proceed with vascular surgical interventions requires evaluation of cardiac risk. Recently, several online risk calculators were created to predict outcomes and to lead to a more informed conversation between surgeons and patients. The objective of this study was to compare and further validate these online calculators with actual adverse cardiac outcomes at a single institution. Methods All patients from January 2011 through December 2015 undergoing carotid endarterectomy (CEA), infrainguinal lower extremity bypass, open abdominal aortic aneurysm (AAA) repair, and endovascular aneurysm repair (EVAR) on the vascular surgical service were included using the Society for Vascular Surgery Vascular Quality Initiative database at our health system. Additional information was collected through retrospective chart review. Each patient was entered through three online risk calculators: (1) the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) estimates the risk of cardiac arrest and myocardial infarction (MI); (2) the Revised Cardiac Risk Index (RCRI) estimates risk of MI, pulmonary edema, ventricular fibrillation, primary cardiac arrest, and complete heart block; and (3) the Vascular Study Group of New England (VSGNE) Cardiac Risk Index estimates risk of postoperative MI only. Observed adverse cardiac events (ACEs) were compared with expected values for each calculator using a χ 2 goodness-of-fit test. Institutional Review Board exemption was obtained. Results A total of 856 cases were included: 350 CEAs, 210 infrainguinal bypasses, 77 open AAA repairs, and 219 EVARs. For CEA, no risk calculator showed statistically significant variation from the observed values (NSQIP, P = .45; RCRI, P = .17; VSGNE, P = .24). For infrainguinal bypass, NSQIP slightly underpredicted adverse events ( P = .054), RCRI strongly underpredicted ( P = .002), and VSGNE showed no difference ( P = .42). For open AAA repair, NSQIP ( P = .51) and VSGNE ( P = .98) were adequate predictors, but RCRI strongly underpredicted the adverse events ( P ≤ .0001). Finally, EVAR cardiac outcomes showed greater adverse events than predicted by all three calculators (NSQIP, P = .02; RCRI, P = .0002; and VSGNE, P = .025). Pooled data for the entire group documented that the VSGNE proved an accurate tool for prediction ( P = .34), whereas ACEs were underpredicted by NSQIP ( P = .0055) and RCRI ( P ≤ .001). Conclusions Although online cardiac risk calculators of adverse surgical events are easy to use and to reference in broad surgical decision-making, there is significant variability in their predictability at the procedure and institutional level. Our data suggest that ACEs often occur at a higher rate than expected on the basis of calculated risks profiles, thus creating a platform for future discussion about preoperative evaluation and postoperative care decision-making models. [ABSTRACT FROM AUTHOR]

Background Ruptured abdominal aortic aneurysm is one of the most difficult clinical problems in surgical practice, with extraordinarily high morbidity and mortality. During the past 23 years, the literature has become replete with reports regarding ruptured endovascular aneurysm repair. Methods A variety of study designs and databases have been utilized to compare ruptured endovascular aneurysm repair and open surgical repair for ruptured abdominal aortic aneurysm and studies of various designs from different databases have yielded vastly different conclusions. It therefore remains controversial whether ruptured endovascular aneurysm repair improves outcomes after ruptured abdominal aortic aneurysm in comparison to open surgical repair. Results The purpose of this article is to review the best available evidence comparing ruptured endovascular aneurysm repair and open surgical repair of ruptured abdominal aortic aneurysm, including single institution and multi-institutional retrospective observational studies, large national population-based studies, large national registries of prospectively collected data, and randomized controlled clinical trials. Conclusion This article will analyze the study designs and databases utilized with their attendant strengths and weaknesses to understand the sometimes vastly different conclusions the studies have reached. This article will attempt to integrate the data to distill some of the lessons that have been learned regarding ruptured endovascular aneurysm repair and identify ongoing needs in this field. [ABSTRACT FROM AUTHOR]

Objective Studies from large administrative databases have demonstrated associations between institutional case volume and outcomes after lower extremity bypass (LEB). We hypothesized that increased institutional and surgeon volume would be associated with improved outcomes after LEB. Using a national, prospectively collected clinical database, the objective of this study was to determine the effects of both surgeon and institutional volume on outcomes after LEB. Methods The Vascular Quality Initiative (VQI) was queried to identify all LEBs for critical limb ischemia or claudication between 2004 and 2014. Average annual case volume was calculated by dividing an institution's or surgeon's total LEB volume by the number of years they reported to the VQI. Institutional and surgeon volumes were analyzed as continuous variables to determine the impact of volume on major adverse cardiac events (MACEs), major adverse limb events (MALEs), graft patency, and amputation-free survival. Hierarchical regression models were used with cases clustered by surgeon and center. Time-dependent outcomes were evaluated with multivariable shared frailty Cox proportional hazards models. Results From 2004 to 2014, there were 14,678 LEB operations performed at 114 institutions by 587 surgeons. Average annual institutional volume ranged from 1.0 to 137.5 LEBs per year, with a median of 26.9 (interquartile range, 14-45.3). Average annual surgeon volume ranged from 1 to 52 LEBs per year with a median of 5.7 (interquartile range, 2.5-9.3). Institutional LEB volume was not associated with MACEs or MALEs or with loss of patency. However, average annual surgeon volume was independently associated with reduced MALEs and improved primary patency. Institutional and surgeon volume did not predict MACEs. Conclusions In contradistinction to previous studies, there was no relationship in this study between institutional LEB volume and outcomes after LEB. However, greater average annual surgeon volume was associated with improved primary patency and decreased risk of MALEs. Open LEB remains a safe and effective procedure for limb salvage. Limb-related outcomes in critical limb ischemia and claudication will be optimized if surgeons maintain adequate volume of LEB. [ABSTRACT FROM AUTHOR]

Objective Overweight/obesity and anti-citrullinated protein antibodies (ACPA) increase rheumatoid arthritis (RA) risk. We investigated the relationship between body mass index (BMI) and ACPA, tested for an interaction between BMI and ACPA for RA risk, and examined effects of BMI and ACPA on time to RA diagnosis. Design Within the Nursesʼ Health Studies, blood samples were collected before diagnosis from medical record-confirmed incident RA cases and matched controls. Multiplex assays measured 7 ACPA subtypes (biglycan, clusterin, enolase, fibrinogen, histone 2A, histone 2B, and vimentin). Logistic regression analyses tested the association of BMI and ACPA and for a multiplicative interaction between BMI groups (≥25 vs. <25 kg/m 2 ) and ACPA positivity (≥2 vs. <2 subtypes), adjusting for age, smoking, alcohol use, and HLA -shared epitope. In case-only analyses, log-rank tests compared time from blood draw to RA onset by cross-classified BMI/ACPA status. Results Among 255 pre-RA cases and 778 matched controls, 15.7% vs. 2.1% ( p <0.001) had ≥2 ACPA and 49.4% vs. 40.2% ( p <0.01) were overweight/obese. Continuous BMI was not associated with presence of ≥2 ACPA [OR per kg/m 2 unit BMI: 1.03 (95% CI: 0.97–1.09)]. However, there was a multiplicative interaction between elevated BMI and the presence of ≥2 ACPA for RA risk ( p = 0.027). Women with BMI≥25 kg/m 2 and ≥2 ACPA had OR 22.7 (95% CI: 6.64–77.72) for RA. Median time to RA differed by BMI/ACPA group (overall log-rank p <0.001) and was shortest among women with ≥2 ACPA and BMI≥25 kg/m 2 [45.0 months, IQR: 17.5–72.5] and longest in women with <2 ACPA and BMI<25 kg/m 2 [125.0 months, IQR: 72.0–161.0] (pairwise log-rank p = 0.002). Conclusion Elevated BMI and presence of ACPA interacted to increase RA risk. Time to RA onset was shortest among overweight/obese women with ≥2 ACPA. [ABSTRACT FROM AUTHOR]

Purpose: To compare the inflammatory profile of hip synovial tissue in those with atraumatic microinstability to patients with femoroacetabular impingement (FAI).Methods: Patients with cam and mixed-type FAI (FAI group) and patients with hip instability underwent sampling of the anterolateral synovium. Demographic data, intraoperative measurements, and functional outcome scores (International Hip Outcomes Tool and Short Form-12) were recorded. Cryosections were stained and examined under light microscopy as well as confocal fluorescent microscopy for anti-CD45 (common leukocyte antigen), anti-CD31 (endothelial), and anti-CD68 (macrophage) cell surface markers. A grading system was used to quantify synovitis under light microscopy whereas digital image analysis was used to quantify immunofluorescence staining area. Comparison were made with Student t test, Mann-Whitney U, χ2, and regression analysis.Results: There were 12 patients in the FAI group and 5 in the instability group. Mean age was not significantly different (P > .05), but there was a significantly greater proportion of females in the instability group versus the FAI group (P < .001). There was a significant correlation (r = 0.653; P = .005) between number of turns needed for 10 mm of distraction and increased synovitis. Synovitis scores also were increased significantly in patients with cam morphology and articular cartilage damage (P = .024) versus those without. Immunohistochemistry did not reveal differences (P > .082) between the instability and FAI groups, but CD68 staining was significantly greater in those with cam morphology and cartilage damage (P < .045). CD45+/CD68- cells were noted in the perivascular area while CD45+/CD68+ cells were noted within the synovial lining in both groups.Conclusions: Increased synovial inflammation was associated with an increased number of turns to achieve joint distraction. Both instability and FAI groups demonstrated baseline levels of synovial inflammation. Synovitis scores also were increased in patients with cartilage damage.Clinical Relevance: An understanding of the molecular and cellular mechanisms behind both hip instability and FAI may lead to novel therapeutic anti-inflammatory therapy, which may serve as an adjunct to treatment of mechanical abnormalities in this conditions. [ABSTRACT FROM AUTHOR]

1) To quantify the association between anti- Porphyromonas gingivalis serum antibody concentrations and the risk of developing rheumatoid arthritis (RA), and 2) to quantify the associations among RA cases between anti- P. gingivalis serum antibody concentrations and RA-specific autoantibodies. Additional anti-bacterial antibodies evaluated included anti- Fusobacterium nucleatum and anti- Prevotella intermedia. Serum samples were acquired pre- and post- RA diagnosis from the U.S. Department of Defense Serum Repository (n = 214 cases, 210 matched controls). Using separate mixed-models, the timing of elevations of anti- P. gingivalis, anti- P. intermedia , and anti- F. nucleatum antibody concentrations relative to RA diagnosis were compared in RA cases versus controls. Associations were determined between serum anti-CCP2, ACPA fine specificities (vimentin, histone, and alpha-enolase), and IgA, IgG, and IgM RF in pre-RA diagnosis samples and anti-bacterial antibodies using mixed-effects linear regression models. No compelling evidence of case-control divergence in serum anti- P. gingivalis, anti -F. nucleatum , and anti- P. intermedia was observed. Among RA cases, including all pre-diagnosis serum samples, anti- P. intermedia was significantly positively associated with anti-CCP2, ACPA fine specificities targeting vimentin, histone, alpha-enolase, and IgA RF (p <0.001), IgG RF (p = 0.049), and IgM RF (p = 0.004), while anti- P. gingivalis and anti- F. nucleatum were not. No longitudinal elevations of anti-bacterial serum antibody concentrations were observed in RA patients prior to RA diagnosis compared to controls. However, anti- P. intermedia displayed significant associations with RA autoantibody concentrations prior to RA diagnosis, suggesting a potential role of this organism in progression towards clinically-detectable RA. [Display omitted] [ABSTRACT FROM AUTHOR]

Objective Both the Vascular Quality Initiative (VQI) and the National Surgical Quality Improvement Program Procedure Targeted (NSQIP-PT) databases aim to track outcomes and to improve quality in vascular surgery. However, both registries are subject to significant selection bias. The objective of this study was to compare the populations and outcomes of a single procedure in VQI and NSQIP-PT and to identify areas of similarity and discrepancy. Methods Deidentified regional data were provided by VQI, and the public use files were provided by NSQIP. Patient characteristics and outcomes were compared between data sets with parametric and nonparametric statistical tests as appropriate. For variables with different definitions between VQI and NSQIP-PT, a standardized definition was created to permit comparison across databases. To account for differences in populations of patients between the data sets, VQI and NSQIP-PT records were propensity matched, allowing a comparison of outcomes between databases adjusted for case mix. Results VQI contained 1358 records from 2011 to 2015, whereas NSQIP-PT contained 5273 complete records from 2011 to 2013. Patients in VQI are younger than those in NSQIP (65 [15] vs 68 [16] years; P < .001) and were less likely to have congestive heart failure (1.7% vs 3.1%; P = .005), to be on dialysis (4.0% vs 6.1%; P = .003), or to be receiving preoperative aspirin (62% vs 79%; P < .001) or statin therapy (63% vs 68%; P < .001). Significant discrepancies were noted in preoperative angina symptoms, prior myocardial infarction, and prior percutaneous coronary intervention, with 0, 1, and 0 NSQIP patients, respectively, having these risk factors compared with 9.4%, 0.7%, and 19.5% of the VQI cohort. Approximately 20% of patients in VQI underwent surgery for acute limb ischemia, which is not a recognized indication in NSQIP-PT. Overall 30-day mortality was equivalent (2.0% vs 1.8%; P = .6), as was composite myocardial infarction/stroke (3.9% vs 3.2%; P = .2). Major amputation (3.3% vs 1.6%; P = .002), return to operating room (16.1% vs 11.5%; P < .001), and wound infection rates (12.8% vs 1.4%; P < .001) were higher in NSQIP relative to VQI. Bleeding rates were higher in VQI (36.5% vs 17.2%; P < .001). Significant differences persisted in the propensity-matched groups. Conclusions This is the first study to compare patient characteristics and outcome reported in the VQI and NSQIP-PT registries. These data documented statistically significant differences in demographics and comorbidities as well as in outcomes between databases. Physicians, payers, and the public should consider differences between these databases when reporting on outcomes and quality. Results from these two registries should not be directly compared. [ABSTRACT FROM AUTHOR]

Mycotic abdominal aortic aneurysms are rare and present unique challenges when potential treatment options are considered. Although aortic resection with in situ grafting techniques or extra-anatomic reconstruction are the treatments of choice, endovascular aortic repair has emerged as a suitable alternative in critically ill patients. We report the successful endovascular repair of a symptomatic, mycotic juxtarenal aortic aneurysm using a physician-modified fenestrated endograft. In this patient, with >6 months of follow-up, the aneurysm has completely regressed, illustrating that in select patients with complex mycotic aneurysms, endovascular repair combined with appropriate medical management is a viable treatment strategy. [ABSTRACT FROM AUTHOR]

Hypothesis We hypothesized that patients with full-thickness rotator cuff tears would have greater synovial inflammation compared with those without rotator cuff tear pathology, with gene expression relating to histologic findings. Methods Synovial sampling was performed in 19 patients with full-thickness rotator cuff tears (RTC group) and in 11 patients without rotator cuff pathology (control group). Cryosections were stained and examined under light microscopy and confocal fluorescent microscopy for anti-cluster CD45 (common leukocyte antigen), anti-CD31 (endothelial), and anti-CD68 (macrophage) cell surface markers. A grading system was used to quantitate synovitis under light microscopy, and digital image analysis was used to quantify the immunofluorescence staining area. Quantitative polymerase chain reaction was performed for validated inflammatory markers. Data were analyzed with analysis of covariance, Mann-Whitney U , and Spearman rank order testing, with significance set at α = .05. Results The synovitis score was significantly increased in the RTC group compared with controls. Immunofluorescence demonstrated significantly increased staining for CD31, CD45, and CD68 in the RTC vs control group. CD45+/68– cells were found perivascularly, with CD45+/68+ cells toward the joint lining edge of the synovium. Levels of matrix metalloproteinase-3 (MMP-3) and interleukin-6 were significantly increased in the RTC group, with a positive correlation between the synovitis score and MMP-3 expression. Conclusions Patients with full-thickness rotator cuff tears have greater levels of synovial inflammation, angiogenesis, and MMP-3 upregulation compared with controls. Gene expression of MMP-3 correlates with the degree of synovitis. [ABSTRACT FROM AUTHOR]

Objective Repeated percutaneous interventions on failing arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) for hemodialysis are common, but the outcomes are largely unknown. We sought to determine the results of the second percutaneous intervention on failing AVGs and AVFs and to identify factors associated with loss of patency. Methods For the purpose of this study, the second percutaneous intervention was identified as the index procedure. We reviewed the second percutaneous interventions on failing AVFs and AVGs at a single institution between 2007 and 2013. Patient comorbidities, graft or fistula configuration, lesion characteristics, and procedural characteristics of the intervention performed were analyzed with respect to technical success, primary patency, primary assisted patency, and secondary patency. Patency was defined per Society for Vascular Surgery recommended reporting standards and was determined from the time of the index procedure. Cox proportional hazards multivariable modeling was performed to identify independent determinants of loss of patency. Results Among 91 patients, 96 second-time percutaneous interventions were performed on 52 AVFs and 44 AVGs. Patients included 56% men and 44% women with a mean age of 64 ± 17 years. The lesions intervened on were primarily located along the accessed portion of the outflow in AVFs and within the length of the graft and at the venous anastomosis in AVGs. Transluminal angioplasty alone was performed in 82 procedures (85%), and uncovered or covered stents were placed in 15 procedures (16%). Pharmacomechanical thrombectomy was performed in 32 patients (34%) and was more commonly performed in AVGs compared with AVFs (53% vs 17%; P = .0002). Technical success was achieved in 90 procedures (97%; n = 92). One-year primary patency, assisted primary patency, and secondary patency rates were 35%, 86%, and 86%, respectively. One-year primary patency did not differ between AVFs and AVGs, but secondary patency was lower for AVG in comparison to AVF ( P = .04). On multivariable analysis, only the need for pharmacomechanical thrombectomy significantly predicted failure of primary patency (hazard ratio, 2.6; 95% confidence interval, 1.6-4.3). The presence of an AVG rather than an AVF independently predicted failure of secondary patency (hazard ratio, 2.9; 95% confidence interval, 1.0-8.2). Conclusions The second percutaneous interventions on AVFs and AVGs are associated with excellent technical success but poor primary patency. The need for pharmacomechanical thrombectomy predicts the need for additional percutaneous intervention to maintain patency. With additional interventions, acceptable secondary patency out to 5 years can be achieved, although AVGs have inferior secondary patency to AVFs. To develop optimal practice management algorithms, the effectiveness of repeated percutaneous interventions for failing AVGs and AVFs vs creation of a new access should be further investigated. [ABSTRACT FROM AUTHOR]

Objective Endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs) reduces in-hospital mortality compared with open repair (OR), but it is unknown whether EVAR reduces long-term mortality. We hypothesized that EVAR of RAAA would independently reduce long-term mortality compared with OR. Methods The Vascular Quality Initiative database (2003-2013) was used to determine Kaplan-Meier 1-year and 5-year mortality after EVAR and OR of RAAA. Multivariate analysis was performed to identify patient and operative characteristics associated with mortality at 1 year and 5 years after RAAA repair. Results Among 590 patients who underwent EVAR and 692 patients who underwent OR of RAAA, the lower mortality seen in the hospital after EVAR (EVAR 23% vs OR 35%; P < .001) persisted at 1 year (EVAR 34% vs OR 42%; P = .001) and 5 years (EVAR 50% vs OR 58%; P = .003) after repair. After adjusting for patient and operative characteristics, EVAR did not independently reduce mortality at 1 year (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.7-1.1) or 5 years (HR, 0.95; 95% CI, 0.77-1.2) compared with OR. Dialysis dependence (HR, 3.9; 95% CI, 1.8-8.6), home oxygen use (HR, 1.9; 95% CI, 1.3-2.7), cardiac ejection fraction <50% (HR, 1.5; 95% CI, 1.03-2.1), female gender (HR, 1.3; 95% CI, 1.04-1.6), and age (HR, 1.06; 95% CI, 1.05-1.08 per 5 years) as well as cardiac arrest (HR, 3.4; 95% CI, 2.5-4.5), loss of consciousness (HR, 1.7; 95% CI, 1.3-2.2), and preoperative systolic blood pressure <90 mm Hg (HR, 1.4; 95% CI, 1.1-1.8) on admission predicted mortality at 1 year and 5 years after RAAA repair. Type I endoleak (HR, 2.2; 95% CI, 1.2-3.8) also predicted mortality at 1 year. Conclusions EVAR does not independently reduce long-term mortality compared with OR. Patient comorbidities and indices of shock on admission are the primary independent determinants of long-term mortality. However, the lower early mortality observed in the Vascular Quality Initiative for patients selected to undergo EVAR of RAAA compared with patients selected for OR is sustained over time, suggesting that EVAR for RAAA is beneficial in appropriate candidates. Better elucidation of the key selection factors, including aneurysm anatomy, is needed to best select patients for EVAR and OR to reduce long-term mortality. [ABSTRACT FROM AUTHOR]

Objective This study compared the performance of the Aorfix endograft (Lombard Medical, Oxfordshire, United Kingdom) in standard (<60°), highly angled (60°-90°), and severely angled (>90°) aortic necks in the PYTHAGORAS study and evaluated changes in neck morphology over time. Methods PYTHAGORAS is a prospective nonrandomized clinical trial of the Aorfix endograft. We divided the endovascular aneurysm repair (EVAR) cohort into groups by standard, high, and severe neck angle. The primary control group was patients concurrently undergoing open repair. Mortality at 30 days, 1 year, and 2 years and 30-day freedom from Society for Vascular Surgery major adverse events for the EVAR groups was compared with the open control. Aneurysm sac change, type I and III endoleaks, graft migration, and the reintervention rate at 1 and 2 years was compared between the standard, highly, and severely angled populations. The relative risk of graft complications with a neck diameter increase >10% was also calculated. At predetermined anatomic points, the effect of oversizing on aortic diameter was evaluated by calculating oversize percentage ([1 − outer aortic diameter measured at a given time/stent graft diameter] × 100%) preoperatively and at 3 years. In addition, the average oversizing percentage at 30 days and annually at 1 to 5 years was compared with the preoperative oversizing percentage. Finally, complication rates with ≥30% vs <30% planned oversizing were compared. Results The adverse event rate was lower for every EVAR group than the open control. In addition, the mortality rates at 30 days, 1 year, and 2 years were similar between the standard-angle (1.5%, 3.0%, 4.5%), high-angle (0.9%, 7.3%, 13.8%), and severe-angle (4.8%, 9.5%, 14.3%) EVAR groups and the open control groups (1.3, 6.6%, 10.5%). At 1 and 2 years, there was no difference in graft complications among the EVAR groups. However, with neck dilatation of >10% at 5 mm above the proximal renal and 1 mm below the distal renal, there was an increased risk of graft migration (relative risk, 4.38 [ P = .01] and 4.33 [ P = .002], respectively). For all predetermined anatomic points, the oversizing percentage decreased over time. The rate of oversize percentage decrease was faster at more distal aortic locations, reaching <10% at 30 days 15 mm below the renal, at 2 years 7 mm below the renal, and at 5 years 1 mm below the renal ( P < .001 for all). Half the oversize percentage achieved at the index procedure remained at 3 years (Pearson correlation coefficient = 0.5). However, there was no difference in complications between the ≥30% and <30% planned oversize groups. Conclusions The Aorfix endograft has performed well in excluding aneurysms with standard and highly angled aortic neck anatomy. [ABSTRACT FROM AUTHOR]

Vascular surgery training programs face multiple pressures, including attracting and retaining trainees. Current knowledge of trainees' views with respect to diversity and equity in vascular training programs is limited. We sought to understand United States vascular surgery trainees' perceptions and expectations regarding diversity, equity, and inclusion (DEI). The Association of Program Directors in Vascular Surgery designed and administered the Annual Training Survey to specifically address DEI and administered it to all trainees (Integrated Residents/Fellows; n = 637) at 122 institutions in August 2020. Of the 637 vascular trainees, 227 (35%) responded. The respondents included 115 male and 62 female trainees, with 50 not disclosing or not answering the question. The majority of respondents (96.9%) believed their programs incorporated a diverse background of trainees. Of the trainees, 89.8% felt that the faculty were similarly comprised of a diverse background. The majority of respondents (63.6%) felt that their training program was both more diverse and focused on inclusion compared with other training programs at their institution. However, 20% of respondents had experienced discrimination. Seventy-three percent (n = 143) of trainees felt empowered to disagree or engage in a discussion should they observe a faculty member make a disparaging remark about a patient's background/race/gender, although 27% (n = 35) trainees expressed fear of retaliation as a reason to not engage. Trainees view their program director (82.6%), faculty mentor (60.9%), and Graduate Medical Education office (52.7%) as potential resources for support. Overall, 83.7% (n = 160) of trainees believe that their program has been open to discussion of race relations within the medical community. Trainees are committed to multifaceted diversity and inclusion. The perception of trainees regarding DEI issues within vascular surgery training programs appears to be positive; however, trainees did describe discrimination and gender biases in their institutions. This data has the potential to improve institutional education of faculty and trainees about the multidimensional levels of diversity and increased awareness and incorporation of this philosophy can assist in the recruitment of diverse vascular surgeons. [ABSTRACT FROM AUTHOR]

Objective Previous studies have reported that endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs) has lower postoperative mortality than open repair (OR). However, comparisons involved heterogeneous populations that lacked adjustment for preoperative risk. We hypothesize that for RAAA patients stratified by a validated measure of preoperative mortality risk, EVAR has a lower in-hospital mortality and morbidity than does OR. Methods In-hospital mortality and morbidity after EVAR and OR of RAAA were compared in patients from the Vascular Quality Initiative (2003-2013) stratified by the validated Vascular Study Group of New England RAAA risk score into low-risk (score 0-1), medium-risk (score 2-3), and high-risk (score 4-6) groups. Results Among 514 patients who underwent EVAR and 651 patients who underwent OR of RAAA, EVAR had lower in-hospital mortality (25% vs 33%, P = .001). In risk-stratified patients, EVAR trended toward a lower mortality in the low-risk group (n = 626; EVAR, 10% vs OR, 15%; P = .07), had a significantly lower mortality in the medium-risk group (n = 457; EVAR, 37% vs OR, 48%; P = .02), and no advantage in the high-risk group (n = 82; EVAR, 95% vs OR, 79%; P = .17). Across all risk groups, cardiac complications (EVAR, 29% vs OR, 38%; P = .001), respiratory complications (EVAR, 28% vs OR, 46%; P < .0001), renal insufficiency (EVAR, 24% vs OR, 38%; P < .0001), lower extremity ischemia (EVAR, 2.7% vs OR, 8.1%; P < .0001), and bowel ischemia (EVAR, 3.9% vs OR, 10%; P < .0001) were significantly lower after EVAR than after OR. Across all risk groups, median (interquartile range) intensive care unit length of stay (EVAR, 2 [1-5] days vs OR, 6 [3-13] days; P < .0001) and hospital length of stay (EVAR, 6 [4-12] days vs OR, 13 [8-22] days; P < .0001) were lower after EVAR. Conclusions This novel risk-stratified comparison using a national clinical database showed that EVAR of RAAA has a lower mortality and morbidity compared with OR in low-risk and medium-risk patients and that EVAR should be used to treat these patients when anatomically feasible. For RAAA patients at the highest preoperative risk, there is no benefit to using EVAR compared with OR. [ABSTRACT FROM AUTHOR]

Objective The Agency for Healthcare Research and Quality (AHRQ) Inpatient Quality Indicator (IQI) #11, abdominal aortic aneurysm (AAA) repair mortality rate, is a measure of hospital quality that is publically reported but has not been externally validated. Because the IQI #11 overall mortality rate includes both intact and ruptured aneurysms and open and endovascular repair, we hypothesized that IQI #11 overall mortality rate does not provide accurate assessment of mortality risk after AAA repair and that AAA mortality cannot be accurately assessed by a single quality measure. Methods Using AHRQ IQI software version 4.2, we calculated observed (O) and expected (E) mortality rates for IQI #11 for all hospitals performing more than 10 AAA repairs per year in the Nationwide Inpatient Sample for the years 2007 to 2011. We used Spearman correlation coefficient to compare expected rates as determined by IQI #11 overall mortality rate risk adjustment methodology and observed rates for all AAA repairs in four cohorts stratified by aneurysm stability (ruptured vs intact) and method of repair (open vs endovascular). Results Among 187,773 AAA repairs performed at 1268 U.S. hospitals, hospitals' IQI #11 overall expected rates correlated poorly with their observed rates (E: 5.0% ± 4.4% vs O: 6.0% ± 9.8%; r = .49). For ruptured AAAs, IQI #11 overall mortality rate methodology underestimated the mortality risk of open repair (E: 34% ± 7.2% vs O: 40.1% ± 38.2%; r = 0.20) and endovascular repair (E: 24.8% ± 9% vs O: 27.3% ± 37.9%; r = 0.08). For intact AAA repair, IQI #11 overall mortality rate methodology underestimated the mortality risk of open repair (E: 4.3% ± 2.4% vs O: 6.3% ± 16.1%; r = .24) but overestimated the mortality risk of endovascular repair (E: 1.3% ± 0.8% vs O: 1.1% ± 3.7%; r = 0.25). Hospitals' observed mortality rates after intact AAA repair were not correlated with their mortality rates after ruptured AAA repair ( r = 0.03). Conclusions IQI #11 overall mortality rate fails to provide accurate assessment of inpatient mortality risk after AAA repair. Thus, it is inappropriate to use IQI #11 overall mortality rate for quality reporting. The accuracy of separate quality measures that assess mortality risk after repair of ruptured and intact AAAs, stratified by the use of open or endovascular repair, should be examined. [ABSTRACT FROM AUTHOR]

Marine biomonitoring programs in the U.S. and Europe have historically relied on monitoring tissue concentrations of bivalves to monitor contaminant levels and ecosystem health. By integrating 'omic methods with these tissue residue approaches we can uncover mechanistic insight to link tissue concentrations to potential toxic effects. In an effort to identify novel biomarkers and better understand the molecular toxicology of metal bioaccumulation in bivalves, we exposed the blue mussel, Mytilus edulis L., to sub-lethal concentrations (0.54 µM) of cadmium, lead, and a Cd + Pb mixture. Metal concentrations were measured in gill tissues at 1, 2, and 4 weeks, and increased linearly over the 4 week duration. In addition, there was evidence that Pb interfered with Cd uptake in the mixture treatment. Using a 3025 sequence microarray for M. edulis, we performed transcriptomic analysis, identifying 57 differentially expressed sequences. Hierarchical clustering of these sequences successfully distinguished the different treatment groups demonstrating that the expression profiles were reproducible among the treatments. Enrichment analysis of gene ontology terms identified several biological processes that were perturbed by the treatments, including nucleoside phosphate biosynthetic processes, mRNA metabolic processes, and response to stress. To identify transcripts whose expression level correlated with metal bioaccumulation, we performed Pearson correlation analysis. Several transcripts correlated with gill metal concentrations including mt10, mt20, and contig 48, an unknown transcript containing a wsc domain. In addition, three transcripts directly involved in the unfolded protein response (UPR) were induced in the metal treatments at 2 weeks and were further up-regulated at 4 weeks. Overall, correlation of tissue concentrations and gene expression responses indicates that as mussels accumulate higher concentrations of metals, initial stress responses are mobilized to protect tissues. However, given the role of UPR in apoptosis, it serves as an early indicator of stress, which once overwhelmed will result in adverse physiological effects. [ABSTRACT FROM AUTHOR]

Introduction: The impact of a postoperative troponin elevation on long-term survival after vascular surgery is not well-defined. We hypothesize that a postoperative troponin elevation is associated with significantly reduced long-term survival. Methods: The Vascular Study Group of New England registry identified all patients who underwent carotid revascularization, open abdominal aortic aneurysm repair (AAA), endovascular AAA repair, or infrainguinal lower extremity bypass (2003-2011). The association of postoperative troponin elevation and myocardial infarction (MI) with 5-year survival was evaluated. Multivariable models identified predictors of survival and of postoperative myocardial ischemia. Results: In the entire cohort (n = 16,363), the incidence of postoperative troponin elevation was 1.3% (n = 211) and for MI was 1.6% (n = 264). Incidences differed across procedures (P < .0001) with the highest incidences after open AAA: troponin elevation, 3.9% (n = 74); MI, 5.1% (n = 96). On Kaplan-Meier analysis, any postoperative myocardial ischemia predicted reduced survival over 5 years postoperatively: no ischemia, 73% (standard error [SE], 0.5%); troponin elevation, 54% (SE, 4%); MI, 33% (SE, 4%) (P < .0001). This pattern was observed for each procedure subgroup analysis (P < .0001). Troponin elevation (hazard ratio, 1.45; 95% confidence interval, 1.1-2.0; P = .02) and MI (hazard ratio, 2.9; 95% confidence interval, 2.3-3.8; P < .0001) were independent predictors of reduced survival at 5 years. Conclusions: Postoperative troponin elevation and MI predict a 26% or a 55% relatively lower survival in the 5 years following a vascular surgical procedure, respectively, compared with patients who do not experience myocardial ischemia. This highlights the need to better characterize factors leading to postoperative myocardial ischemia. Postoperative troponin elevation, either alone, or in combination with an MI, may be a useful marker for identifying high-risk patients who might benefit from more aggressive optimization in hopes of reducing adverse long-term outcomes. [Copyright &y& Elsevier]

Mollusks, especially bivalves, exhibit a great diversity of sex determining mechanisms, including both genetic and environmental sex determination. Some bivalve species can be gonochoristic (separate sexes), while others are hermaphroditic (sequential or simultaneous). Several models have been proposed for specific bivalve species, utilizing information gained from gene expression data, as well as limited RAD-seq data (e.g., from Crassostrea gigas). However, these mechanisms are not as well studied as those in model organisms (e.g., Mus musculus , Drosophila melanogaster , Caenorhabditis elegans) and many genes involved in sex differentiation are not well characterized. We used phylotranscriptomics to better understand which possible sex differentiating genes are in bivalves and how these genes relate to similar genes in diverse phyla. We collected RNAseq data from eight phylogenetically diverse bivalve species: Argopecten irradians , Ensis directus , Geukensia demissa , Macoma tenta , Mercenaria mercenaria , Mya arenaria , Mytilus edulis , and Solemya velum. Using these data, we assembled representative transcriptomes for each species. We then searched for candidate sex differentiating genes using BLAST and confirmed the identity of nine genes using phylogenetics analyses from nine phyla. To increase the confidence of identification, we included ten bivalve genomes in our analyses. From the analysis of doublesex and mab-3 related transcription factor (DMRT) genes, we confirmed the identify of a Mollusk-specific sex determining DMRT gene: DMRT1L. Based on gene expression data from M. edulis and previous research, DMRT1L and FoxL2 are key genes for male and female development, respectively. [Display omitted] • Phylotranscriptomics identified nine candidate sex differentiating genes • DMRT1L is a mollusk-specific gene, with a possible role in sex differentiation • We propose FoxL2 and DMRT1L are two important genes for bivalve sex differentiation [ABSTRACT FROM AUTHOR]

Objective: Elective abdominal aortic aneurysm (AAA) repair is beneficial when rupture is likely during a patient's expected lifetime. The purpose of this study was to identify predictors of long-term mortality after elective AAA repair for moderately sized AAAs (<6.5-cm diameter) to identify patients unlikely to benefit from surgery. Methods: We analyzed 2367 elective infrarenal AAA (<6.5 cm) repairs across 21 centers in New England from 2003 to 2011. Our main outcome measure was 5-year life-table survival. Cox proportional hazards analysis was used to describe associations between patient characteristics and 5-year survival. Results: During the study period, 1653 endovascular AAA repairs and 714 open AAA repairs were performed. Overall, 5-year survival rates were similar by procedure type (75% endovascular repair, 80% open repair; P = .14). Advanced age ≥75 years (hazard ratio [HR], 2.0; P < .01) and age >80 years (HR, 2.6; P < .01), coronary artery disease (HR, 1.4; P < .04), unstable angina or recent myocardial infarction (HR, 4.6; P < .01), oxygen-dependent chronic obstructive pulmonary disease (HR, 2.7; P < .01), and estimated glomerular filtration rate <30 mL/min/1.73 m2 (HR, 2.8; P < .01) were associated with poor survival. Aspirin (HR, 0.8; P < .03) and statin (HR, 0.7; P < .01) use were associated with improved survival. We used these risk factors to develop risk strata for low-risk, medium-risk, and high-risk groups with survival, respectively, of 85%, 69%, and 43% at 5 years (P < .001). Conclusions: More than 75% of patients with moderately sized AAAs who underwent elective repair in our region survived 5 years, but 4% were at high risk for 5-year mortality. Patients with multiple risk factors, especially age >80 years, unstable angina, oxygen-dependent chronic obstructive pulmonary disease, and estimated glomerular filtration rate <30 mL/min/1.73 m2, are unlikely to achieve sufficient long-term survival to benefit from surgery, unless their AAA rupture risk is very high. [Copyright &y& Elsevier]

Objective: We assessed the impact of abdominal aortic aneurysm (AAA)-specific simulation training on resident performance in simulated open AAA repair (SOAAAR) and determined whether simulation training required dedicated faculty instruction. Methods: We randomized 18 residents (postgraduate years 3-5) to an AAA simulation course consisting of two mandatory practice sessions proctored either by a surgical skills lab coordinator (Group A, n = 8) or by a vascular surgery faculty instructor (Group B, n = 10). All residents received a detailed manual and video demonstrating the technique of open AAA repair. Using a validated tool, vascular faculty who were blinded to resident identity, level of training, and randomization status graded SOAAAR performance via videos that were recorded before and after the course. Results: Characteristics and baseline scores between Groups A and B were not different. Postcourse, there was a no significant improvement in performance in Group A. Group B performance was improved significantly from baseline with regard to task-specific checklist scores (44.1 ± 6.3 vs 34.9 ± .5; P = .02), global rating scores (28.4 ± .6 vs 25.3 ± 5.0; P = .049), and overall assessment of operative competence (P = .02). Time to complete SOAAAR improved in both groups (P = .02). Baseline performance varied significantly with year of training as measured by task-specific checklist scores, global rating scores, final product analysis, time to complete repair, and overall operative competence. Improvement varied inversely with year of training (P < .05) and postcourse scores were equivalent for postgraduate year 3-5 residents. Conclusions: An AAA-specific simulation training course improved resident performance in simulated open AAA repair. Dedicated faculty instruction during the simulation training was required for significant improvement in resident performance. The impact of simulation training was greatest in more junior residents. Procedure-specific simulation training with dedicated faculty can be used to effectively teach simulated open AAA repair. [ABSTRACT FROM AUTHOR]

Objective: Scoring systems for predicting mortality after repair of ruptured abdominal aortic aneurysms (RAAAs) have not been developed or tested in a United States population and may not be accurate in the endovascular era. Using prospectively collected data from the Vascular Study Group of New England (VSGNE), we developed a practical risk score for in-hospital mortality after open repair of RAAAs and compared its performance to that of the Glasgow aneurysm score, Hardman index, Vancouver score, and Edinburg ruptured aneurysm score. Methods: Univariate analysis followed by multivariable analysis of patient, prehospital, anatomic, and procedural characteristics identified significant predictors of in-hospital mortality. Integer points were derived from the odds ratio (OR) for mortality based on each independent predictor in order to generate a VSGNE RAAA risk score, which was internally validated using bootstrapping methodology. Discrimination and calibration of all models were assessed by calculating the area under the receiver-operating characteristic curve (C-statistic) and applying the Hosmer-Lemeshow test. Results: From 2003 to 2009, 242 patients underwent open repair of RAAAs at 10 centers. In-hospital mortality was 38% (n = 91). Independent predictors of mortality included age >76 years (OR, 5.3; 95% confidence interval [CI], 2.8-10.1), preoperative cardiac arrest (OR, 4.3; 95% CI, 1.6-12), loss of consciousness (OR, 2.6; 95% CI, 1.2-6), and suprarenal aortic clamp (OR, 2.4; 95% CI, 1.3-4.6). Patient stratification according to the VSGNE RAAA risk score (range, 0-6) accurately predicted mortality and identified those at low and high risk for death (8%, 25%, 37%, 60%, 80%, and 87% for scores of 0, 1, 2, 3, 4, and ≥5, respectively). Discrimination (C = .79) and calibration (χ 2 = 1.96; P = .85) were excellent in the derivation and bootstrap samples and superior to that of existing scoring systems. The Glasgow aneurysm score, Hardman index, Vancouver score, and Edinburg ruptured aneurysm score correlated with mortality in the VSGNE cohort but failed to identify accurately patients with a risk of mortality >65%. Conclusions: Existing scoring systems predict mortality after RAAA repair in this cohort but do not identify patients at highest risk. This parsimonious VSGNE RAAA risk score based on four variables readily assessed at the time of presentation allows accurate prediction of in-hospital mortality after open repair of RAAAs, including identification of those patients at highest risk for postoperative mortality. [Copyright &y& Elsevier]

Objective: We assessed the effect of an open vascular simulation course on the surgical skill of junior surgical residents in performing a vascular end-to-side anastomosis and determined the course length required for effectiveness. We hypothesized that a 6-week course would significantly increase the surgical skill of junior residents in performing an end-to-side anastomosis, while a 3-week course would not. Methods: We randomized 37 junior residents (postgraduate year 1 to 3) to a course consisting of three (short course, n = 18) or six (long course, n = 19) consecutive weekly 1-hour teaching sessions. Content focused on instrument recognition and performance of an end-to-side vascular anastomosis using a simulation model. A standardized 50-point vascular skills assessment (SVSA) measured knowledge and technical proficiency. Senior residents (postgraduate year 4 to 5) were tested at baseline. Junior residents were tested at baseline and at 1 and 16 weeks after course completion, and their scores were compared with baseline and senior resident scores. Residents and faculty completed a standardized anonymous evaluation of the course. Results: Baseline scores between short-course and long-course participants were not different. At baseline, junior residents had significantly lower SVSA scores than senior residents (36 ± 7 vs 41.4 ± 2.5; P = .002). One week after course completion, SVSA scores for short-course (43.5 ± 2.9 vs 34.2 ± 7.5; P = .008) and long-course (43.9 ± 5.6 vs 38.3 ± 5.9; P = .006) participants were significantly improved from baseline. SVSA scores decreased slightly at 16 weeks but remained above baseline in short-course (39 ± 6.2 vs 34.2 ± 7.5; P = .03) and long-course (40 ± 4.5 vs 38.3 ± 5.9; P = .08) participants. Long vs short course length didnot affect improvement in SVSA scores at 1 or 16 weeks. In short-course and long-course participants, SVSA scores at 1 and 16 weeks were not significantly different from senior resident scores. Course ratings were high, and 95% of residents indicated the course “made them a better surgeon.” Residents and faculty felt the educational benefit of the course merited the investment of resources. Conclusions: An open vascular simulation course consisting of three weekly 1-hour sessions increased the surgical skill of junior residents in performing a vascular end-to-side anastomosis to that of senior residents on a standardized assessment. A 6-week course provided no additional benefit. This study supports the use of an open vascular simulation course to teach vascular surgical skills to junior residents. A course consisting of three 1-hour sessions is an effective and efficient component of a simulation program for junior surgical residents in a busy surgical center. [Copyright &y& Elsevier]