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Objective Surgical frailty and its assessment have become essential considerations in perioperative management for the modern aging surgical population. The risk analysis index is a validated frailty score that has been proven to predict short-term outcomes and long-term mortality in several surgical subspecialties and high-risk procedures. We examined the association of risk analysis index scores with postoperative outcomes in a retrospective nationwide database of patients who underwent lower extremity amputation in the Veterans Health Administration Health Care System. Methods The Veteran Affairs Surgical Quality Improvement Program data was queried across the Veteran Affairs Health Care System with institutional review board approval for lower extremity amputations. Records of above and below knee amputation, Current Procedural Terminology codes 27590, 27591, 27592, 27594, 27596 and 27880, 27881, 27882, 27884, and 27886, respectively, from 1999 to 2018 were obtained. Incomplete and traumatic entries were removed. Risk Analysis Index score was calculated from preoperative variables and patients were separated into five score cohorts (≤15, 16-25, 26-35, 36-45, ≥46). The χ2 test and analysis of variance were used to compare the cohorts. Forward binary logistic regression modeling was used to determine covariate-adjusted odds ratios for outcomes in each cohort (SPSS software; version 25, IBM Corp). Results A total of 47,197 patients (98.9% male) with an average age of 66.4 ± 10.6 years underwent nontraumatic lower extremity amputation, including 27,098 below knee and 20,099 above knee amputations, during the study period. Frailty was associated with increased rates of deep vein thrombosis, sepsis, cardiac arrest, myocardial infarction, pneumonia, intubation for more than 48 hours, pulmonary embolism, reintubation, acute kidney injury, renal failure, increased length of stay, overall complications, and death. Increases in the frailty score were associated with up to three times the likelihood for the occurrence of a postoperative complication and up to 32 times likelihood to perish within 30 days than those with low frailty scores. Conclusions Risk analysis index assessment of frailty was found to be associated with several postoperative outcomes in a dose-dependent manner in patients undergoing lower extremity amputation in the Veterans Health Care System, with higher scores associated with higher rates of death and major cardiac (myocardial infarction, cardiac arrest), pulmonary (pneumonia, failure to wean vent, reintubation), and renal (renal insufficiency, renal failure) complications. We recommend the use of risk analysis index score as a frailty screening tool for patients undergoing lower extremity amputation to enable providers to adequately inform and counsel patients regarding potential significant risks.

Objectives Surgical ethics has been suggested as a distinct field of study apart from clinical ethics due to a unique practice type and treatment dynamic. At our institution, most if not all teaching of clinical ethics is undertaken by nonsurgical faculty. We introduced a novel online Surgical Ethics Program (SEO) in a pilot form (SEO-P) for initial presentation to learners in our environment. The overall goal of our educational intervention was to enhance knowledge, understanding and appreciation for surgical ethics in medical students and to evaluate our curriculum. Setting SEO-P was undertaken over a 4-week period in 2018 with 9 fourth-year medical students enrolled in a surgery elective at our institution. These learners all had career plans in general surgery or a surgical subspecialty. There was 3 weeks of content: (1) background in clinical ethics as it applies to surgical practice, (2) surgical consents and autonomy, and (3) the impaired physician. All pilot learners were evaluated with: (1) postprogram final exam assessment (compared to preprogram knowledge base test), (2) self-reflection essay of ethical practice in surgery, (3) evaluation of 2 case studies, and (4) an assessment of participation in online discussion forums. Postprogram survey of the learners was also undertaken in an anonymous fashion. Results Four of 9 or 44.4% of students scored greater than or equal to 80% on the postprogram knowledge assessment test. A preprogram knowledge-based examination of all learners yielded a mean and standard deviation of 57.1 ± 6.0%. Postprogram knowledge-based test with mean and standard deviation was 78.8 ± 15%. This was a statistically significant increase in scores (p = 0.004; t test). All 9 passed the course with a mean final summative course grade of 95.2 ± 3.2%. From the postprogram evaluation survey, all 7 students who responded felt that the SEO-P would help them become an “ethical” practitioner. Surprisingly, only half of the learners (57.1%) thought “technology used to support the SEO Course (i.e., the chosen curriculum management system) was effective in conducting the course.” Conclusions We set forth to use “web-based” technology to enhance exposure of medical students in our institution to surgical ethics. Hence, we designed our pilot curriculum to be a completely online offering. We feel that the utilization of the surgical voice, that is a surgical ethics curriculum developed by surgeons to explore surgically related clinical ethical issues, is an essential theme and goal of our program. Future challenges will be to present this voice in an effective manner with either an improved curriculum delivery system or by potentially utilizing a blended approach.

While recreational escape rooms have gained momentum across education and team training in multiple professions, few published escape room designs have been truly interprofessional. A major obstacle faced by educators and team leaders alike is the lack of any practical design framework for escape room development that is specific to meeting learning objectives. The COMET Framework (Context, Objectives, Materials, Execution, and Team Dynamics) was developed as a step-by-step approach to escape room design using general terminology and piloted in a one-hour workshop at a regional interprofessional conference. Surveys completed by participants suggest that application of the COMET framework increased understanding and confidence regarding escape room design regardless of prior experience with the format. The generality of the COMET framework may allow it to be utilized for team exercise design more broadly in the contexts of interprofessional training and faculty development.

Medical societies such as the Society for Vascular Surgery (SVS) and the Society of Interventional Radiology (SIR) have been encouraging the use of social media at annual meetings by establishing unique meeting hashtags (eg. #VAM19, #SIR19ATX). These two specialties have similar number of active physicians and share procedural interests. We set forth to understand differences in Twitter activity and engagement by analyzing Twitter outputs from the vascular annual meeting (VAM) and the interventional radiology annual meeting (IRAM) in 2019.Tweets with "#VAM19" and "#SIR19ATX" from 30 days before and 30 days after respective meetings were collected. Proportion of distinct Twitter users relative to total number of meeting attendees, number of posts per user, number of hashtags per post, and number of engagement metrics (likes, replies, and retweets) were collected for comparison. As for the top 100 most liked tweets, specialty-related hashtags were categorized into identity, diversity, education, procedure, and medical care, and the authors of these tweets were also identified for comparison. Student's t-test* and Fisher's ExactA total of 362 and 1944 tweets were collected from the VAM and IRAM in 2019. There was no difference in proportion of active Twitter users relative to total number of meeting attendees between the VAM (7.5%) and IRAM (7.7%). Average number of posts per user from the VAM and IRAM showed no significant difference. However, tweets related to IRAM had significantly higher number of hashtags per post (2.67±1.96) than ones related to VAM (1.78±1.26) (P0.0001*). Additionally, these tweets on average received significantly higher number of likes (P0.0001*), retweets (P0.0001*), and replies (P0.0001*) than ones related to the VAM. Specialty-related hashtags from the 100 most liked tweets showed significantly greater proportion of hashtags associated with specialty identity (4% vs 28.6%, P0.0001**), diversity (2.9% vs 8.0%, p=0.0268**), and education (1.1% vs 9.1%, p=0.0004**) in tweets related to the IRAM whereas the proportion of hashtags associated with procedure and medical care was similar between the two meetings. Lastly, the 100 most liked tweets were authored by trainees (p=0.005*) and official societies (p=0.003*) in significantly greater proportion in IRAM whereas academic institutions/training hospitals authored in significantly greater proportion (p=0.004*) from the VAM. Contributions from attending physician users to the 100 most liked tweets were similar between the two meetings.Analysis of Twitter activity centered around #VAM19 and #SIR19ATX indicates that there was no significant difference in proportion of Twitter users relative to meeting attendees and average number of posts per user. However, tweets with #SIR19ATX had significantly higher number of hashtags per post and had greater level of engagement than ones with #VAM19. The top 100 most liked tweets from the two meetings differed in proportion of hashtags related to specialty identity, diversity, and education, as well as proportion of contributing authors identified as trainees, official societies, and academic institutions/training hospitals. These data should help the SVS and its members to establish a more directed social media effort to facilitate its use during national gatherings.

Rapid and objective preoperative assessment of patients undergoing carotid endarterectomy (CEA) remains difficult and variable. The Risk Analysis Index (RAI) is a validated medical record-based assessment of frailty that has been used to predict clinical outcomes for patients undergoing surgical procedures including CEA. We applied RAI to a veteran population following CEA for asymptomatic cerebrovascular disease and examined the factors related to post-operative morbidity and mortality.After obtaining IRB approval, Veteran Affairs Surgical Quality Improvement Program data was queried for CEA procedures from 2002 to 2015 for ICD-9 codes indicating asymptomatic patients. RAI was then calculated based on Veteran Affairs Surgical Quality Improvement Program variable medical record extraction. Three groupings of patients were undertaken including non-frail (RAI30), frail (RAI 30-34) and very frail (RAI ≥ 35). Chi squared and ANOVA were used to assess cohort differences. Binary logistic regression was used to evaluate predictors of post-operative stroke, myocardial infarction (MI), any complication, and death.Between 2002 and 2015, 37,873 asymptomatic patients underwent CEA. Over 98% (37,266) of the patients were male with an average age of 68.3 ± 8.55 years. The cohorts contained 82.8% (n = 31,362), 12.4% (n = 4,678), and 4.8% (n = 1,833) for the non-frail, frail and very frail groups respectively. Frailty was associated with increased rates of post-operative stroke, MI, any complication, death, and longer hospital length of stay (P0.001). Operative time did not significantly differ between the groups. Increasing frailty was associated with having one or more complications (OR 1.69, 95% CI 1.50-1.90 for frail and OR 2.79, 95% CI 2.41-3.24 for very frail, (P0.001), post-operative stroke in frail (OR 1.33 95% CI 1.06-1.67) and very frail (OR 1.57 1 95% CI 1.14-2.16) patients, and MI in both frail (OR 1.68, CI 1.17-2.43) and very frail (OR 3.73, CI 2.52-5.51) patients. Frailty was also significantly associated with death with in very frail patients (OR 4.14, 95% CI 3.00-5.71, P0.001).Increasing frailty as determined by RAI was associated with worse post-operative outcomes in asymptomatic patients undergoing CEA. Higher RAI score cohorts were associated with higher rates of postoperative stroke, MI, complications, and death. We recommend the use of this frailty index as a screening tool to guide risk discussions with asymptomatic patients undergoing CEA.

INTRODUCTION Radiocephalic arteriovenous fistula (RCAVF) creation is the preferred first line hemodialysis access procedure. Analysis of diabetic rat arteriovenous fistula model indicates improved vascular function with HMG-CoA-Reductase Inhibitor (statin) use. We predict similar outcomes in diabetic patients undergoing primary RCAVF placement. METHODS A Veterans Administration Hospital dialysis access database over a fifteen-year period was queried identifying all RCAVF placements in diabetic patients. Patients were stratified into statin medication usage or not at RCAVF creation. Outcomes examined include rate of successful cannulation, functional patency duration, interventions per access, and rates of access thrombosis. Thrombosis-free survival of cannulated RCAVFs were compared using Kaplan-Meier method with log-rank analysis followed by univariate, stepwise logistic regression and ROC curve analysis. RESULTS Total number of 123 RCAVF cases were performed in 122 diabetic male patients. At the time of RCAVF placement, 92 cases were performed on patients that were taking statin medication and 31 cases were performed on patients that were not taking statin medication. There was no difference in terms of rate of successful cannulation, functional patency duration, and number of interventions per access between the statin and non-statin groups. However, rate of RCAVF thrombosis once accessed was significantly lower in the statin group compared to the non-statin group (p=0.0005). Kaplan-Meier survival curve for each group were compared using log-rank test to reveal that diabetic patients who were on statin therapy at the time of operation had significantly higher access survival over time against thrombosis once it was cannulated for dialysis treatment compared to those who were not on statin therapy (p=0.0003). Univariate, stepwise logistic regression model indicated statin use as the only significant factor associated with lack of thrombosis (p=0.05). CONCLUSIONS Statins appear to have protective effects against RCAVF thrombosis as predicted in animal models for diabetic patients undergoing primary RCAVF placements. There were similar functional outcomes in terms of rate of successful cannulation, functional patency duration, and number of interventions per access. These data should encourage further investigation of statins and their role in hemodialysis access.

Introduction In response to the Coronavirus 2019 (COVID-19) pandemic, vascular surgeons in the Veteran Affairs Health Care System have been undertaking only essential cases, such as advanced critical limb ischemia. Surgical risk assessment in these patients is often complex, considers all factors known to impact short- and long-term outcomes, and the additional risk that COVID-19 infection could convey in this patient population is unknown. The European Centre for Disease Prevention and Control (ECDC) published risk factors (ECDC-RF) implicated in increased COVID-19 hospitalization and case-fatality which have been further evidenced by initial reports from the United States Centers for Disease Control and Prevention. CDC reports additionally indicate that African American (AA) patients have incurred disparate infection outcomes in the United States. We set forth to survey the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database over a nearly 20 year span to inform ongoing risk assessment with an estimation of the prevalence of ECDC-RF in our veteran critical limb ischemia population and investigate whether an increased COVID-19 comorbidity burden exists for AA veterans presenting for major non-traumatic amputation. Materials and Methods The VASQIP database was queried for all above knee amputation (AKA) and below knee amputation (BKA) completed 1999–2018 after IRB approval (MIRB:#02507). Patient race and ECDC-RF including male gender, age > 60 years, smoking status, hypertension, diabetes, chronic obstructive pulmonary disease, cancer, and cardiovascular disease were recorded from preoperative patient history. AKA and BKA cohorts were compared via χ2-test with Yates correction or unpaired t-test and a subgroup analysis was conducted between AA and all other race patients for COVID-19 comorbidities in each cohort. Results VASQIP query returned 50,083 total entries. Average age was 65.1 ± 10.4 years and 68.2 ± 10.5 years for BKA and AKA cohorts, respectively, (P Conclusions According to a large national Veterans Affairs database, there are high rates of ECDC-RF in veteran amputees. During the present crisis, management of these patients should incorporate telehealth, expedient discharge, and ongoing COVID-19 transmission precautions.

The Food and Drug Administration recently approved two percutaneous arteriovenous fistula creation systems: the Ellipsys vascular access (EL) system and WavelinQ EndoAVF (WQ) system. Although the initial clinical trials of each system have demonstrated a high success rate, little detail on anatomic suitability was provided. We sought to determine the real-world applicability of the EL and WQ systems by studying them in a single representative cohort.All patients receiving a first-time arteriovenous access consultation at a single Veterans Affairs institution underwent extensive vein mapping of the bilateral upper extremities. Anatomic suitability was assessed in accordance with the manufacturer's instructions for use (IFU), and clinical usability was determined using additional published anatomic guidelines. The suitability for radiocephalic fistula (RCF) creation was also assessed. To estimate how often these systems would be used in practice, a clinical algorithm was created, with a preference for RCF creation, followed by percutaneous arteriovenous fistula (pAVF) creation, surgical fistula creation at the elbow, and, finally, graft placement.During the study period, 116 upper extremities were measured in 58 male patients. Per the IFU, the rate of extremity suitability was 93% and 52% for the WQ and EL systems, respectively (P .0001). In the same population, 32% of the extremities had acceptable anatomy for RCF creation. The overall clinical usability of these systems using more recent published guidelines was 55% for the WQ system and 44% for the EL system (P = .09). The usability of both pAVF systems was most limited by the size of the deep perforating cubital vein. The proximity of the antecubital perforator vein and proximal radial artery additionally limited EL usability. Based on the clinical algorithm, initial access creation would have been RCF creation for 31% of the cohort, followed by the WQ (32%), the EL (23%), surgical fistula creation at the elbow (18%), and graft placement (17%).Anatomic suitability was greater for WQ than for EL when considering only the IFU. Once the full requirements for pAVF creation were considered, we found no significant differences in usability between the two systems. Anatomic analysis showed that pAVF creation can constitute a substantial part of a hemodialysis access practice.

The Risk Analysis Index (RAI) has been used to evaluate preoperative frailty, which is associated with poor short- and long-term outcomes. We assessed this tool's ability to predict postoperative outcomes after endovascular aortic aneurysm repair.Institutional Review Board approval was obtained for this retrospective study. All patients who underwent elective endovascular aneurysm repair at a single Veterans Affairs Medical Center from December 2010 to March 2016 were included. Patients' characteristics and clinical data were retrospectively collected and analyzed. The RAI score was calculated from preoperative data, and a standard cutoff value (RAI ≥30) was used to determine frailty. Outcomes including postoperative complications, delayed discharge, and survival were compared between frail and nonfrail groups. Multivariate analysis was performed to evaluate preoperative factors associated with these outcomes.There were 134 patients who met inclusion criteria. There were 44 frail patients (RAI ≥30) and 90 nonfrail patients (RAI 30). Frail patients had a longer hospital stay (3.9 ± 4.0 days vs 2.3 ± 1.6 days; P = .02), increased operative time (155 ± 30 minutes vs 138 ± 30 minutes; P = .002), and increased postoperative complications (43% vs 21%; P = .02) compared with nonfrail patients. Kaplan-Meier average survival for frail patients and nonfrail patients was 60 ± 4 months and 84 ± 3 months (P .001), respectively. In multivariate analyses, frailty was associated with worse overall survival (hazard ratio, 3.7; 95% confidence interval [CI], 1.8-7.3) and higher odds of complications (odds ratio, 1.1; 95% CI, 1.0-1.14) and delayed discharge (odds ratio, 1.1; 95% CI, 1.05-1.2).Preoperative frailty as evaluated by the RAI is associated with worse short-term postoperative outcomes and long-term mortality. The RAI can be used to inform risk-benefit discussions with patients and their families.

Objective Sarcopenia measured by decreased psoas muscle size has been used as a surrogate for frailty and correlates with adverse outcomes in both the short and long term after many major operations. Our aim was to evaluate this measure as a predictor of outcomes in patients undergoing endovascular aortic aneurysm repair (EVAR). Methods Once Institutional Review Board approval was obtained, all patients who underwent EVAR from December 2010 to March 2016 at a Veterans Affairs hospital were assessed for sarcopenia by total psoas muscle area (TPA) measured on axial computed tomography scan immediately inferior to the fourth lumbar (L4) superior end plate. Outcomes including length of stay and mortality were collected from the medical record. Results There were 135 patients who underwent EVAR at a median age of 70 years. Median aneurysm size was 5.5 cm. Length of stay was >2 days in 25% of patients (n = 33), with the most common reasons for delayed discharge including respiratory complications (8.9% [n = 12]) and urinary retention (4.0% [n = 9]). Low TPA was not associated with extended length of stay ( P = .40). Patients with lowest tertile TPA had 42% 5-year survival compared with 93% survival observed for the remaining two-thirds of patients ( P = .01). Multivariate analysis revealed increased likelihood of mortality at 5 years for patients in the lowest tertile for TPA (odds ratio, 3.9; 95% confidence interval, 1.2-12.9) as well as for patients with chronic kidney disease (odds ratio, 5.2; 95% confidence interval, 1.5-18.0). Conclusions Preoperative sarcopenia does not appear to affect length of stay but does portend worse long-term survival. This simple preoperative measurement may help vascular surgeons tailor repair thresholds and avoid nonbeneficial procedures.

We sought to determine the risk factors for subsequent bleeding and recurrent venous thromboembolism (VTE) events following isolated noncatheter-associated upper extremity deep venous thrombosis (non-CA-UEDVT) to better inform future treatment decisions for this group of patients.The RIETE registry (Registro Informatizado de Enfermedad TromboEmbólica [Computerized Registry of Patients with Venous Thromboembolism]) is a prospective international registry of patients with objectively confirmed symptomatic VTE. Patients with a symptomatic, isolated, proximal UEDVT from March 2001 through March 2015 were analyzed. Any patient with an indwelling catheter or pacemaker lead at the DVT site and at the time of thrombosis was considered to have a CA-UEDVT and was excluded. Patient and treatment characteristics such as age, gender, comorbidities, VTE risk factors, treatment drug, and duration were collected. Outcomes examined included recurrent DVT, subsequent pulmonary embolism (PE), and hemorrhage. Multivariate analysis was performed using stepwise logistic regression.Of the 1100 patients who met the study criteria, 580 (53%) were male. The mean age of the patients was 50 ± 20 years, and overall patient survival at 1 year was 85%. Recurrent VTE occurred in 59 patients (5.4%). Of these, 46 patients (4%) had recurrent DVT, 10 (0.9%) had a PE following UEDVT diagnosis, and 3 (0.3%) had both. PE was fatal in three patients (0.3%). Bleeding occurred in 50 patients (4.5%), major bleeding in 19 patients (1.7%), and fatal bleeding in 6 patients (0.5%). On multivariate analysis, malignant disease was associated with VTE recurrence (odds ratio [OR], 2.00; 95% confidence interval [CI], 1.04-3.45; P .04), whereas hemorrhage was associated with age (OR, 1.03; 95% CI, 1.01-1.05; P = .002) and malignant disease (OR, 2.53; 95% CI, 1.34-4.76; P .005). Hemorrhage and recurrent VTE were also significantly associated (OR, 2.79; 95% CI, 1.16-6.76; P .03).PE following non-CA-UEDVT is rare. Malignant disease was associated with VTE recurrence. Age and malignant disease were associated with hemorrhage, and VTE recurrence was associated with hemorrhage. Further prospective studies should be undertaken to best determine length of anticoagulation treatment for the varied populations of patients with UEDVT.

Organizational effects on job satisfaction, burnout, work-life balance, and perceived support have not been studied in the context of the clinical learning environment. We evaluated the relationship between academic resources and resident well-being, the clinical learning environment, and in-service examination performance of surgical residents.Residents of general surgery and surgical specialty programs were recruited from March 2016 through June 2016 across the Southeast, Mid-Atlantic, and Northeast regions. Program directors were asked to allow distribution of a paper survey or to forward an electronic survey link onto residents. Five dichotomous questions were asked regarding access to academic resources. Validated measures were obtained assessing resident well-being and perceived clinical learning environment. Data were analyzed through t-tests and chi-squared test of independence.We received 276 respondents across 50 programs. Residents perceiving adequate support to succeed had less burnout (P = 0.008), better resilience (P = 0.009), better job satisfaction (P 0.001), less work/life strain (P = 0.001), better workplace climate (P 0.001), better organizational support (P 0.001), and were more likely to have high performance on the in-service examination (P = 0.001). Specific resources including educational stipends, review questions, in-service board prep, and support for poor performers correlated with improved well-being and perceived clinical learning environment.Provision of academic resources has implications beyond in-service examination performance, correlating with improved resident well-being and perceptions of the clinical learning environment.

Novice learners are increasingly turning to YouTube as a learning resource for surgical procedures. One example of such a procedure is common femoral artery puncture and sheath placement. Practitioners in several specialties perform this procedure to access the arterial system for angiography and intervention. We set forth to compare the techniques demonstrated on YouTube by the various specialists, as well as compare each specialty׳s prevalence on this website.YouTube (www.youtube.com) was accessed in December 2015 at multiple time points with a cleared-cache web browser for the keyword search categories: "femoral artery access," "femoral access," and "angiography access." The top 500 videos from each of these keyword searches were analyzed. Videos were categorized by practitioner specialty, technique, duration of video, age of video, and total views. Videos with clear demonstration of femoral artery access were included in the analysis. All industry videos were excluded from the analysis. Categorical variables were compared using Fisher׳s exact test, and continuous variables were compared with the Student׳s t-test.A total of 2460, 4680 and 1800 videos were found for each keyword search, respectively. Of these, 33 videos clearly demonstrated femoral artery access technique. Vascular specialists, compared to interventional cardiology and radiology, had fewer videos (n = 4 vs. 14) and older videos (3.5 ± 2.1y vs. 2.25 ± 0.5y, p0.05). The vascular specialists demonstrated ultrasound-guided access, while interventional cardiology predominantly demonstrated landmark-guided access (p0.05).Although YouTube and other online resources are being used by novice learners, vascular specialists are underrepresented for femoral artery access, a foundational vascular procedure. Other practitioners demonstrate videos with landmark-guided access and rarely demonstrate ultrasound use. As recognized vascular experts, vascular surgeons should improve their visibility in online learning resources.