Prior studies have described the delayed failure of the Endologix AFX Endovascular abdominal aortic aneurysm (AAA) system. Described repair options include relining with a contemporary endograft or graft explant; however, no direct comparisons have been performed between these treatments. The purpose of this study is to compare graft relining and graft explant in order to guide future decision-making for failing AFX devices. A retrospective review of all AFX endografts implanted at our tertiary care center from 2011 to 2019 was performed. Major remediations via endograft relining or graft explant through November 2023 were then identified. The primary composite end point was reintervention-free survival after remediation. Secondary end points included perioperative mortality, all-cause mortality, AAA-related mortality, and major and minor reinterventions. Exclusion criteria included reline with a recalled AFX device or use of additional non-AFX devices during the original aneurysm repair. Of a total of 217 AFX device implants, 52 patients (24%) underwent remediation with 36 devices relined (69%) and 16 grafts explanted (31%) (Table). The original devices were 40 AFX Strata, 8 AFX Duraply, and 4 AFX2. The indications for remediation were endoleak with sac growth (53%), endoleak only (4%), sac growth only (23%), and aneurysm rupture (17%). The devices used for relining were 16 AFX2, 10 Medtronic Endurant, 4 Gore Excluder, 2 Endologix Ovation/Alto, 1 Cook Z-Fen, and 3 that used a combination of devices. At the time of intervention, aneurysms that underwent explant compared with relining were more commonly juxta/pararenal (25% vs 6%, P < .05) and/or ruptured (38% vs 8%, P < .01). There were no significant differences in age, sex, comorbidities, original AFX device, endoleak type, and mean AAA size between the two cohorts. Perioperative mortality was higher after graft explant (25% vs 0%, < .01). However, there was no significant difference in 1-year survival (68% vs 77%, P = .35) or aneurysm-related mortality (27% vs 0%, P = .12). There were higher rates of reintervention following reline (explant: 0% vs reline: 13% at 1 year, P = .03), but there was no difference in reintervention-free survival (reline: 92% vs explant: 67%, P = .66) (Fig). Graft explant is the most durable repair option for failing AFX devices but has a higher risk of early mortality. Relining of failing AFX devices with a second endograft is a safe alternative for treatment but carries a significant risk of continued sac growth requiring additional reinterventions. Elective remediation for the Endologix AFX device should be considered and at minimum enhanced surveillance protocols should be employed.TableCharacteristics of 52 patients who had delayed AFX graft failure requiring remediation by reline or explantCharacteristicAll (n = 52)Reline (n = 36)Explant (n = 1 6)P valueAge, years, mean ± standard deviation76 ± 877 ± 774 ± 9.22Male46 (88)31 (86)15 (94).43Comorbidities Hypertension46 (88)31 (86)15 (94).43 Diabetes14 (27)11 (31)3 (19).38 Congestive heart failure17 (33)11 (31)6 (38).62 Coronary artery disease24 (46)14 (39)10 (63).12 Chronic obstructive pulmonary disease23 (44)16 (44)7 (44).96 Peripheral arterial disease15 (29)11 (31)4 (25).68 Chronic kidney disease28 (54)18 (50)10 (63).40Original graft type AFX Strata40 (77)29 (80)11 (69).35 AFX Duraply8 (15)5 (14)3 (19).65 AFX24 (8)2 (6)2 (12).39Aneurysm extent at remediation Infrarenal46 (88)34 (94)12 (75).04 Juxtarenal4 (8)1 (3)3 (19).05 Pararenal2 (4)1 (3)1 (6).55Indication for remediation Sac growth12 (23)10 (28)2 (13).23 Endoleak2 (4)2 (6)0 (0).34 Endoleak with sac growth28 (53)21 (58)7 (44).33 Rupture9 (17)3 (8)6 (38).01Endoleak type at remediation Type 19 (17)4 (11)5 (31).08 Type 337 (51)28 (78)9 (56).11 Type 2 or unknown5 (10)4 (11)1 (6).58Mean AAA size at intervention, cm, mean ± standard deviation7.2 ± 1.87.0 ± 1.87.7 ± 1.9.22AAA, Abdominal aortic aneurysm.Data are presented as number (%) unless otherwise indicated.Boldface P values represent statistical significance. Open table in a new tab

Improving physician wellness is increasingly a focus of local and national initiatives. However, the physiologic impact of operating on surgeons has never been evaluated. We sought to quantify the association between surgeon strain and vascular operation. Attendings and residents within one division of vascular surgery wore the Whoop fitness tracker continuously over a 2-month period to measure quantity and quality of sleep, recovery, and overall daily strain (scale, 0-21). All exercise and surgical cases were entered into Whoop as activities, and case-specific information, including assistant level and case difficulty, were recorded in a separate RedCAP database by each surgeon. We compared overall daily strain during operating room (OR) compared with non-OR days and adjusted for demographics, training level, recovery, sleep, and exercise using multivariable linear regression analysis, clustered by surgeon. We performed a separate analysis to assess for predictors of high case strain. We recorded data from seven surgeons over 407 person-days and 284 operations. Surgeons had less sleep (6.5 vs 7.1 hours; P < .001) but a trend towards higher recovery (68% vs 63%; P = .08) preceding OR days. OR days were not associated with higher overall day strain (10.5 vs 9.9; P = .11; coefficient, 1.26; P = .15). However, there was profound variability in the impact of OR days on overall strain among surgeons, with some surgeons having significantly higher daily strain on OR days and others having significantly lower daily strain on OR days (Fig). Operative case strain varied by procedure type, perceived difficulty, and length (Table). On multivariable analysis only poor recovery (coefficient, 0.044; P < .01) and longer case time (coefficient, 0.695; P = .02) was associated with higher OR strain. Operating takes a physiologic toil on surgeons, but the impact of this varies across providers and cases. Further study into this area could potentially improve physician wellness and overall health.TableIntraoperative variables by case typeMedian (range) or n (%)OR strainOR timeAverage heart rateDifficult caseAttending-level assistantOpen aorta (n = 27)4.9 (0-17.3)4.0 (1.0-7.4)88 (57-122)10 (37)15 (56)EVAR (n = 24)4 (0-12.2)1.7 (0.3-4.9)87 (72-123)8 (33)12 (50)Open lower extremity4.1 (0-13.2)2.5 (0.6-7.2)81 (60-107)18 (38)10 (21)Revascularization (n = 48) Peripheral vascular intervention (n = 59)3.7 (0-7.7)1.5 (0.4-3.5)84 (55-135)4 (6.8)0 (0) Carotid endarterectomy (n = 17)2.6 (0-6.3)1.3 (0.7-3.2)82 (59-101)2 (12)0 (0) TCAR (n = 10)2.1 (0-4.7)1.2 (0.9-1.9)87 (76-95)1 (10)1 (10) Rib resection (n = 8)6.0 (0-8.7)1.1 (1.0-2.8)103 (70-119)3 (38)1 (13) Other (n = 91)3.7 (0-7.3)1.1 (0.1-3.4)86 (53-122)16 (18)13 (14) P-value<.001<.001.02.001<.001 Open table in a new tab

OBJECTIVE:The purpose of this study was to measure the efficacy of a novel faculty and resident educational bundle focused on development of faculty-resident behaviors and entrustment in the operating room. SUMMARY BACKGROUND DATA:As surgical training environments are orienting to entrustable professional activities (EPAs), successful transitions to this model will require significant faculty and resident development. Identifying an effective educational initiative which prepares faculty and residents for optimizing assessment, teaching, learning, and interacting in this model is critical. METHODS:From September 2015 to June 2017, an experimental study was conducted in the Department of Surgery at the University of Michigan Health System (UMHS). Case observations took place across general, plastic, thoracic, and vascular surgical specialties. A total of 117 operating room observations were conducted during Phase I of the study and 108 operating room observations were conducted during Phase II following the educational intervention. Entrustment behaviors were rated for 56 faculty and 73 resident participants using OpTrust, a validated intraoperative entrustment instrument. RESULTS:Multiple regression analysis showed a significant increase in faculty entrustment (Phase I = 2.32 vs Phase II = 2.56, P < 0.027) and resident entrustability (Phase I = 2.16 vs Phase II = 2.40, P < 0.029) scores following exposure to the educational intervention. CONCLUSIONS:Our study shows improved intraoperative entrustment following implementation of faculty and resident development, indicating the efficacy of this innovative educational bundle. This represents a crucial component in the implementation of a competency-based assessment framework like EPAs.

Focus has increased on fatigue mitigation and limiting the number of continuous hours worked among surgical residents in recent years. Although the reported burnout rates are high, little has occurred to address similar concerns among attending surgeons. Diminished productivity has often been cited as a reason to avoid changes in traditional staffing models. In the present study, we compared the operative work relative value unit (wRVU) productivity before and after implementation of a weekly night call model in a single tertiary vascular surgery practice. In 2018, an attending call model, similar to a resident “night float,” was implemented. In this model, one surgeon would provide the weeknight call coverage (Monday through Thursday), with no clinical responsibilities during the day. A separate surgeon covered emergencies and new consultations during the day and provided backup coverage at night. The total case number and operative wRVUs were compared across the year before implementation, the year of implementation, and the year after implementation. A total of 10 attending vascular surgeons participated in the call model during the 3-year study period. Two surgeons left the practice and four were added, although the average total clinical full-time equivalent for the group (6.1) did not change significantly during the study period. The total inpatient wRVUs were stable during the year of implementation compared with the previous year and had increased significantly in the year after implementation. Similar trends were noted in the wRVU/clinical full-time equivalent and total operating room cases (Table). A paradigm shift in attending call staffing with a focus on fatigue mitigation by limiting the number of continuous hours of coverage can be undertaken in a vascular surgery practice without disruption to clinical productivity. Attending wellness should be the aim of further interventions and study.TableStudy findingsVariableBefore implementationAt implementationAfter implementationOR wRVU26,01626,62528,399RVU/FTE426543654618OR cases147417331938FTE, Full-time equivalent; OR, operating room; RVU, relative value unit; wRVU, work relative value unit. Open table in a new tab

Myeloid cells are critical for orchestrating regulated inflammation during wound healing. TLRs, particularly TLR4, and its downstream-signaling MyD88 pathway play an important role in regulating myeloid-mediated inflammation. Because an initial inflammatory phase is vital for tissue repair, we investigated the role of TLR4-regulated, myeloid-mediated inflammation in wound healing. In a cutaneous tissue injury murine model, we found that TLR4 expression is dynamic in wound myeloid cells during the course of normal wound healing. We identified that changes in myeloid TLR4 during tissue repair correlated with increased expression of the histone methyltransferase, mixed-lineage leukemia 1 (MLL1), which specifically trimethylates the histone 3 lysine 4 (H3K4me3) position of the TLR4 promoter. Furthermore, we used a myeloid-specific Mll1 knockout (Mll1f/fLyz2Cre+ ) to determine MLL1 drives Tlr4 expression during wound healing. To understand the critical role of myeloid-specific TLR4 signaling, we used mice deficient in Tlr4 (Tlr4-/- ), Myd88 (Myd88 -/-), and myeloid-specific Tlr4 (Tlr4f/fLyz2Cre+) to demonstrate delayed wound healing at early time points postinjury. Furthermore, in vivo wound myeloid cells isolated from Tlr4-/- and Myd88 -/- wounds demonstrated decreased inflammatory cytokine production. Importantly, adoptive transfer of monocyte/macrophages from wild-type mice trafficked to wounds with restoration of normal healing and myeloid cell function in Tlr4-deficient mice. These results define a role for myeloid-specific, MyD88-dependent TLR4 signaling in the inflammatory response following cutaneous tissue injury and suggest that MLL1 regulates TLR4 expression in wound myeloid cells.

In this video, we describe the technique of popliteal venous aneurysm repair by venous plication and discuss the advantages, disadvantages, and contraindications. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJkMGQyZDczODE4ZmJjZmQyNzBjMDNkMTNiMjZlMWVkYyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc5MzIyMzc4fQ.mcojJbLxMR9_Sqj2j7sVzgOEqtIsBxh4V4zqwHpjtA7fBOnN-pJbzoS1C-bEF6CaYW6gcO87PJhP9YP_ziWJBq507B6nbLAAqXEL7gkJBkVlXFRcPTmuQPWKPZTA5n2lo4pB4bEsUztuynl-JDwedQeVbWgjkKJl5VGNOXZ3TNiX9UxfxLyCsgwQaR_nYkUTrTkzJDO_aZZj0KhYuTWXbI3KAnuusIloWLo1m73V8VRjs4XAK_tmAdbIgOvSI4AG1ZrtCvoFB2kF0e9sugok1FwtPuwH3dTlS54bd-BzoXRGL5B-9tVA4wjeVlERBKpapkJUYY4iGXoDTtZLAXp9Cg Download .mp4 (83.46 MB) Help with .mp4 files Video

Macrophage (Mφ) plasticity, allowing the transition of Mφs from an inflammatory to a reparative phenotype, is critical for normal wound healing. In pathologic conditions, such as type 2 diabetes (T2D), wounds fail to heal due to impaired resolution of Mφ inflammation. Although the mechanisms responsible for the persistent inflammatory phenotype in T2D wounds are unknown, recent investigations have revealed that cellular metabolites can alter Mφ function providing a link between metabolism and innate immunity. Further, there is increasing evidence that epigenetic mechanisms control Mφ function. The purpose of this study was to investigate if altered Mφ metabolism in T2D induces epigenetic modifications resulting in derangements in Mφ inflammation and impaired wound healing. Using the murine diet induce obesity (DIO) wound model, we demonstrate that diabetic bone marrow derived macrophages (BMDM) and wound Mφs display a hyperinflammatory phenotype following injury with increased expression of toll-like receptor (TLR) 4 signaling and proinflammatory cytokines (IL-1β and TNFα). Given that histone methylation has previously been shown by our group to influence Mφ phenotype, we examined H3K4 trimethylation on the TLR4 promoter and found a significant increase in DIO BMDMs and wound Mφs. To evaluate the impact of Mφ metabolites on inflammation we performed a LC-MS metabolite expression analysis demonstrating significant upregulation of the methyl donor, S-adenosyl methionine (SAM), which participates in histone methylation, and its rate limiting enzyme, MAT2a, in diabetic BMDMs. In summary, these results suggest that increased levels of the metabolite SAM in diabetic Mφs contribute to an inflammatory Mφ phenotype via increased H3K4 methylation at the TLR4 promoter. Disclosure F.M. Davis: None. A.D. denDekker: None. A.S. Kimball: None. A. Boniakowski: None. A. Joshi: None. M. ElAzzouny: Employee; Self; Agilent Technologies. C. Burant: Stock/Shareholder; Self; Metabolic Solutions Development Company. K. Gallagher: None. Funding National Institutes of Health

Introduction: Post-operative urinary retention (POUR) is a frequent surgical complication that can require repeated urethral catheterization or indwelling catheter placement. These procedures may increase the risk of catheter-associated urinary tract infection (UTI), increase length of stay, and lead to lower patient satisfaction.1 Although POUR has been well characterized in other surgical specialties, to date there is limited data on POUR in vascular surgery patients. The purpose of this study was to analyze the occurrence of POUR after uncomplicated carotid endarterectomy (CEA). Methods: A retrospective chart review was performed examining patients who underwent elective CEA from 2014-2016 at the University of Michigan. Patient demographics, comorbidities, intraoperative parameters, and inpatient nursing data were collected. Pearson χ2 was used to compare categorical variables, while Mann Whitney U was used to compare continuous variables. Binary logistic regression was performed to identify risk factors associated with POUR. Results: A total of 150 patients met inclusion criteria for this study. The incidence of POUR, defined as intermittent catheterization or indwelling catheter placement after surgery, was 34%. Overall, 13% of CEA patients continued to require catheterization at discharge. Male gender (P=0.034), preoperative tamsulosin (P=0.046), age (71.0 with POUR vs 68.9 without POUR, P=0.036) and BMI (28.6 with POUR vs 30.9 without POUR, P=0.031) were significantly associated with POUR. After logistic regression, BMI (Odds Ratio 0.906, 95% confidence interval 0.830-0.988) and preoperative tamsulosin maintained significance (Odds Ratio 26.96, 95% confidence interval 3.444-210.4). POUR was not associated with an increased length of stay (1.09 days with POUR vs 1.21 days without POUR, P=0.199) or postoperative UTI (4.1% with POUR vs 4.1 without POUR, P=0.605). Conclusion: POUR occurred frequently after CEA but was not associated with increased risk of UTI or length of stay. Preoperative tamsulosin use and BMI were associated with POUR after CEA, but no modifiable risk factors for POUR were identified. Strict catheterization guidelines may be needed to minimize unnecessary postoperative urinary tract instrumentation. References 1. Wu AK, Auerbach AD, Aaronson DS. National incidence and outcomes of postoperative urinary retention in the Surgical Care Improvement Project. Am J Surg. 2012;204(2):167-171.

Macrophage (Mϕ) plasticity allows transition of Mϕs from an inflammatory to a reparative phenotype and is critical for wound healing. In pathologic conditions, such as type 2 diabetes (T2D), wounds fail to heal because of impaired resolution of inflammation. Although the mechanisms responsible for persistent T2D inflammation are unknown, growing evidence indicates that the Toll-like receptor (TLR) 4 and saturated fatty acids (SFAs) drive Mϕ-mediated inflammation. Given the excess SFAs in T2D, we hypothesized that SFAs induce epigenetic alterations in wound Mϕs and drive Mϕ inflammation that impairs diabetic wound healing. Using a murine model of diet-induced obesity (DIO) and wound healing, tissue repair was analyzed between control and Tlr4-deficient (Tlr4−/−) mice (n = 10/group). Bone marrow-derived Mϕs (BMDMs) were isolated in standard fashion. BMDMs were stimulated with control or DIO serum, lipopolysaccharide, or palmitate. Expression of inflammatory genes and JMJD3 was determined by quantitative polymerase chain reaction. Statistical significance was determined using t-tests or analysis of variance. We demonstrate that DIO BMDMs display a hyperinflammatory phenotype with increased expression of Tlr4 (P < .05) and proinflammatory cytokines (interleukin 1β and tumor necrosis factor α). To determine whether altered metabolites in the diabetic environment have an impact on Mφ phenotype, BMDMs were incubated in DIO or control serum. BMDMs incubated with DIO serum displayed a hyperinflammatory response. Furthermore, stimulation with only the SFA palmitate produced increased interleukin 1β expression (P < .05) in BMDMs, suggesting that palmitate stimulation may prime Mϕs toward an inflammatory response. To determine the mechanism, we examined several epigenetic enzymes and found that palmitate stimulation increased expression of JMJD3, a histone demethylase, which alters inflammatory gene expression. Last, to uncover whether this inflammatory response has an impact on wound healing, wounds were created in Tlr4−/− and control mice on a high-fat diet. Tlr4−/− mice demonstrated improved wound healing at all time points after injury (P < .05; Fig). These studies suggest that T2D, specifically increased levels of the SFA palmitate and its interaction with the TLR4 pathway, induces expression of the epigenetic enzyme JMJD3, and this regulates Mφ-mediated inflammation.

BACKGROUND:Longitudinal contact between faculty and residents facilitates greater faculty entrustment. The purpose of this study is to assess the relationship between faculty familiarity with residents and faculty entrustment. MATERIALS AND METHODS:Researchers observed and rated entrustment behaviors using OpTrust, September 2015-June 2017 at Michigan Medicine. Faculty familiarity with resident was measured on a 1-4 scale (1 = not familiar, 4 = extremely familiar). ANOVA and Sidak adjusted multiple comparisons were used to assess the relationship between faculty familiarity and faculty entrustment. RESULTS:56 faculty and 73 residents were observed across 225 surgical cases. Faculty entrustment scores increased to 2.48 when resident familiarity was reported as "slightly familiar". Faculty entrustment scores for "moderately familiar" increased to 2.57. Faculty entrustment scores for "extremely familiar" increased to 2.84. CONCLUSIONS:We found a positive relationship between faculty familiarity and entrustment. These findings support greater continuity in faculty/resident relationships. Longitudinal contact allows learners to be granted progressive entrustment. SUMMARY:This study demonstrates a positive relationship between faculty familiarity with residents and an increase in intraoperative entrustment. These findings support greater continuity in faculty/resident relationships.

Objective— Wound monocyte-derived macrophage plasticity controls the initiation and resolution of inflammation that is critical for proper healing, however, in diabetes mellitus, the resolution of inflammation fails to occur. In diabetic wounds, the kinetics of blood monocyte recruitment and the mechanisms that control in vivo monocyte/macrophage differentiation remain unknown. Approach and Results— Here, we characterized the kinetics and function of Ly6C Hi [Lin − (CD3 − CD19 − NK1.1 − Ter-119 − ) Ly6G − CD11b + ] and Ly6C Lo [Lin − (CD3 − CD19 − NK1.1 − Ter-119 − ) Ly6G − CD11b + ] monocyte/macrophage subsets in normal and diabetic wounds. Using flow-sorted tdTomato -labeled Ly6C Hi monocyte/macrophages, we show Ly6C Hi cells transition to a Ly6C Lo phenotype in normal wounds, whereas in diabetic wounds, there is a late, second influx of Ly6C Hi cells that fail transition to Ly6C Lo . The second wave of Ly6C Hi cells in diabetic wounds corresponded to a spike in MCP-1 (monocyte chemoattractant protein-1) and selective administration of anti-MCP-1 reversed the second Ly6C Hi influx and improved wound healing. To examine the in vivo phenotype of wound monocyte/macrophages, RNA-seq–based transcriptome profiling was performed on flow-sorted Ly6C Hi [Lin − Ly6G − CD11b + ] and Ly6C Lo [Lin − Ly6G − CD11b + ] cells from normal and diabetic wounds. Gene transcriptome profiling of diabetic wound Ly6C Hi cells demonstrated differences in proinflammatory and profibrotic genes compared with controls. Conclusions— Collectively, these data identify kinetic and functional differences in diabetic wound monocyte/macrophages and demonstrate that selective targeting of CD11b + Ly6C Hi monocyte/macrophages is a viable therapeutic strategy for inflammation in diabetic wounds.

Background Mentoring relationships have been encouraged for medical students interested in surgical specialties. We investigated the role of mentoring relationships of integrated vascular surgery residents, while in medical school. We hypothesized that mentoring relationships between medical students and vascular surgeons would have a positive effect on match outcome in the integrated vascular surgery residency match. Methods We used an online survey that respondents completed on a smartphone, tablet, or computer. This was created with Qualtrics Software. The survey was circulated to all North American Integrated Vascular Surgery residents, with the support of the Association of Program Directors in Vascular Surgery Recruitment Committee and the Society for Vascular Surgery Resident/Student Outreach Committee. Questions were posed either as Likert Scale or as multiple choice. Data were analyzed in Stata. Results Response rate (67 total responses of 241 polled residents) was 28%. Earlier postgraduate year residents were more likely to have had vascular surgeon mentors (P = 0.033). There was no association between having a mentor and match rank; however, those with vascular surgeon mentors matched higher on their rank list (P = 0.022). 50% of respondents indicated that mentoring was influential in the choice of integrated residency. Respondents with nonvascular surgeon mentors were more likely to answer negatively regarding their mentor's knowledge about other integrated (P < 0.0001) and traditional programs (P < 0.0001) while residents with a vascular surgeon mentor were more likely to respond positively to this question (P < 0.0001). Regarding the effectiveness of mentorship, 81% indicated their mentor was accessible, 92% responded that their mentor demonstrated professional integrity, and 76% responded that their mentor prioritized their success. Conclusions Integrated vascular surgery residents were generally positive about their medical school mentors. Our data indicate that surgical mentorship in medical school is effective, both in influencing medical students to choose the vascular surgery specialty and in improving match rank—vascular surgeons were more knowledgeable and mentees with vascular surgeon mentors tended to be more successful in the match.

Macrophage (Mϕ) plasticity is essential for the repair and remodeling of wounds. However, under pathologic conditions such as type 2 diabetes (T2D), Mϕs exist in a chronic inflammatory state that drives continued tissue destruction and results in impaired wound healing. We have previously shown that Mϕs isolated from wounds in a murine model that mimics physiologic development of T2D (diet-induced obese mice; DIO) display increased levels of inflammatory cytokines at both a gene expression and protein level. Although the underlying mechanisms remain unclear, we and others have shown that Mϕ phenotype can be controlled by epigenetic modifications that alter gene expression. Our recent work provides evidence that the diabetic milieu alters gene expression and sets an “epigenetic signature” in myeloid cells that result in an exaggerated inflammatory phenotype and delayed wound healing in a murine model. Further, our recent work has found that the histone acetyl transferase, Males absent on the first (MOF), responsible for acetylation of lysine 16 on histone H4 (H4K16), was critical for expression of genes involved in fatty acid metabolism. In the present study, we find that wound Mϕs from DIO mice have increased expression of MOF at day 5, when Mϕs shift from a pro-inflammatory to an anti-inflammatory state within wound tissue. This change in MOF was accompanied by increased expression of components of MOF regulatory complexes, MSL1/2 and KANSL1. Our findings reveal a previously unreported role for MOF in promoting a pro-inflammatory state in innate immune cells. Moreover, our data suggest that the diabetic milieu promotes increased expression of MOF which, in turn, may contribute to maintaining the persistent inflammatory state in wound Mϕs.

This video demonstrates a step-by-step approach to a complex case of pediatric midaortic syndrome in a 7-year-old child with severe renovascular hypertension. It highlights key steps in the surgical management of this pathology, including exposure, aortic reconstruction, and renal artery revascularization. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3YjVhMjQ0ZGE2YWVhZDcwNTE5Zjk0OTA1OGFiNWVlNCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NTI4NzkxfQ.edqWNfppdNOVGuqldeGT5oMLD98mwgGgfs6EB1fbgRwpwYa5b-SZPHRlFYvipx799xNNZo4MWa--Xz3IcBmXD-2K7QIRySJqL3YJrmU27P2PKkkSXZkivxfRtRQLwmWpDHTvq5mq1e7OjdtgV-0r-seXhRFwRukdsWrcM9yQa9ZQ2o9TnQtf5mYJlW147_03e8L6mKAHZIBW5KItmQvBWdwNqiG5IRJHspXmCZ959n-91LuG9qYA-HPkhS7D1GWRugkPpgjjghAvqoUSh7BFe0d-_9-XGMYE6Kqn29ahpudnrXF73uHDpGrVeCK4kW1jzmsALWvUGXMRqWMvOpaY6w Download .mp4 (167.3 MB) Help with .mp4 files Video

Background: Free digital platforms are smartphone-compatible and permit self-directed curriculum development based on learners' interests and educational needs. We developed a free mobile vascular surgery handbook initiated, authored, and edited by surgical house officers and surveyed on the content and users. Methods: Using a free digital platform, house officers developed a vascular surgery handbook. Initiated by a single user for conference preparation and clinical care, the use expanded through sharing among residents. The handbook was then deployed at a second medical center, with free access granted to users after completing a survey. Handbook and content use were evaluated based on user ratings >= 4 on a Likert scale from 1 to 5, where 1 - "strongly disagree'' and 5 = "completely agree.'' Domains assessed included handbook ease of use, content, and relevance to a variety of learning environments and goals (e.g., preparation for the operating room, rounds, clinic, teaching conferences, and examinations). Analytic methods included qualitative analysis, graphical evaluation, and categorical tests. Results: The handbook is organized into sections, with each consisting of multiple pages and/or posts related to the section topic. Sections with the most content included lower extremity arterial disease, endovascular aneurysm repair/thoracic endovascular aortic repair, venous disease, anticoagulation, and anatomy/exposures. Fifty-four users participated in the evaluation phase, including different types of surgical residents (35%), medical students (30%), and anesthesia residents (22%). Sixty-nine percent of participants were in their position for <2 years. The average age was 29.1 years, and 57% were women. Preferred learning styles among users at the time of enrollment primarily included question banks (52%), followed by slide-based lectures (15%) and "chalk talk'' lectures (13%). Of the users who participated in the presurvey, 43 users participated in the postsurvey with a general agreement on the handbook being an easy-to-use resource that was useful for gaining overall knowledge and contained accurate information. Users generally agreed they would recommend the handbook to a colleague. Conclusions: References customized to user needs can be developed through crowdsourcing and published with free digital resources. These approaches allow mobile access to useful information during conferences and clinical care. House officers' self-perceived educational needs can be targeted for tailored educational initiatives.

Macrophages play a critical role in the establishment of a regulated inflammatory response following tissue injury. Following injury, CCR2(+) monocytes are recruited from peripheral blood to wound tissue, and direct the initiation and resolution of inflammation that is essential for tissue repair. In pathologic states where chronic inflammation prevents healing, macrophages fail to transition to a reparative phenotype. Using a murine model of cutaneous wound healing, we found that CCR2-deficient mice (CCR2(-/-)) demonstrate significantly impaired wound healing at all time points postinjury. Flow cytometry analysis of wounds from CCR2(-/-) and WT mice revealed a significant decrease in inflammatory, Ly6C(Hi) recruited monocyte/macrophages in CCR2(-/-) wounds. We further show that wound macrophage inflammatory cytokine production is decreased in CCR2(-/-) wounds. Adoptive transfer of mT/mG monocyte/macrophages into CCR2(+/+) and CCR2(-/-) mice demonstrated that labeled cells on days 2 and 4 traveled to wounds in both CCR2(+/+) and CCR2(-/-) mice. Further, adoptive transfer of monocyte/macrophages from WT mice restored normal healing, likely through a restored inflammatory response in the CCR2-deficient mice. Taken together, these data suggest that CCR2 plays a critical role in the recruitment and inflammatory response following injury, and that wound repair may be therapeutically manipulated through modulation of CCR2.

OBJECTIVE To determine the association between intraoperative entrustment and personality alignment. SUMMARY BACKGROUND DATA For surgical residents, achieving operative autonomy has become increasingly difficult. The impact of faculty-resident operative interactions in accomplishing this goal is not well understood. We hypothesized that if operative dyads (faculty and resident) had personality alignment or congruency, then resident entrustment in the operating room would increase. METHODS We completed a retrospective analysis of 63 operations performed from September 2015 to August 2016. Operations were scored using OpTrust, a validated tool that assesses progressive entrustment of responsibility to surgical residents in the operating room. All dyads were classified as having congruent or incongruent personality alignment as measured by promotion or prevention orientation using the regulatory focus questionnaire. The association between personality congruence and OpTrust scores was identified using multivariable linear regression. RESULTS A total of 35 congruent dyads and 28 incongruent dyads were identified. Congruent dyads had a higher percentage of "very difficult" cases (33.3 vs. 7.4%, P = 0.017), female residents (37.1 vs. 14.3%, P = 0.042) and faculty with fewer years of experience (10.4 vs. 14.8%, P = 0.028) than incongruent dyads. In addition to post-graduate year level, dyad congruency was independently associated with a 0.88 increase (95% CI [0.27-1.49], P = 0.006) in OpTrust scores (overall range 2-8), after adjusting for case difficulty, faculty experience, and post-graduate year. CONCLUSIONS Congruent operative dyads are associated with increased operative entrustment as demonstrated by increased OpTrust scores. Developing awareness and strategies for addressing incongruence in personality in the operative dyad is needed.