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

A 72 year-male patient with infrarenal abdominal aortic aneurysms (AAA) of 5.7 cm along with 4 cm right common iliac artery aneurysm presented for repair. The patient had a history of COPD and CAD. After obtaining a medical and cardiac work-up, we elected to pursue an endovascular repair. The central line length as measured from the lowest renal artery to the origin of right internal iliac artery was 157 mm. Therefore, a main aortic device (RLT311413, 31 mm X 14 mm X 13 cm) was deployed via left groin access. Next, a bell-bottom iliac graft (PLC201000, 20 mm X 9.5 cm) to right common iliac artery aneurysm was placed before deploying a right-sided Gore® Excluder® Iliac Branch Endoprosthesis (IBE) (W. L. Gore and Associates, AZ, USA). A through-and-through wire above the follow divider was achieved, and then a 12 Fr. Gore DrySeal Sheath® (W.L. Gore and Associates, AZ, USA) was telescoped without manipulation of the main device. A Gore® Viabahn® VBX balloon (11 mm X 79 mm, W. L. Gore and Associates, AZ, USA) was extended to the right internal iliac artery, and then a right external iliac stent was inserted via right groin access. The final angiogram showed appropriate stents placed without endoleak. The patient was discharged home on postoperative day 1 without any complications.

INTRODUCTION:The anti-Müllerian hormone (AMH) produced by the granulosa cells of ovarian follicles has been shown to correlate with ovarian reserve and is often measured for fertility therapies. In this study, we evaluated the relationship between serum AMH values and the clinical pregnancy (CP) rates of female partners with unexplained infertility undergoing intrauterine insemination utilizing varying ovarian simulation protocols. METHODS:This is a retrospective cohort study conducted among couples who underwent intrauterine insemination therapy over a period of four years at Charleston Area Medical Center, a tertiary care medical center in West Virginia, USA. Logistic regression was used to determine the best predictor of CP. RESULTS:A total of 509 intrauterine inseminations resulting in 81 (15.9%) Cps were analyzed. The cycles with a CP had higher mean AMH values (3.7+3.5 vs. 2.2+2.1; p<0.001). The majority of patients were nulliparous (77.0%) with a mean age of 33.6+5.0 years. After including only patients with unexplained infertility (the predominate infertility diagnosis; n=255 (50.1% of the cycles)) and stimulation cycles >10, the final sample size for the analysis was 245/509=48.1%. Following a receiver operating characteristic (ROC) curve analysis, the optimal AMH cut-off point was 2.1 ng/mL with an area under the curve (AUC) equal to 0.61 and 95% confidence intervals (CIs) of 0.55- 0.67 (p=0.002). The CP rate was significantly higher with the AMH >2.1 ng/mL (20.0%) compared to <2.1 ng/mL (10.0%; p=0.041). With Clomid/human gonadotropins/human chorionic gonadotropin (hCG) trigger treatment, the CP rate quadrupled (odds ratio (OR): 4.6; 95% CI: 2.1-9.7; p<0.001). CONCLUSION:This study indicates that higher AMH levels and a more aggressive ovarian stimulation protocol for intrauterine insemination therapy (IUI) have a better probability of resulting in CP.

Access is an imperative component of endovascular aneurysm repair. The common femoral artery is the most common access site, and the artery is traditionally exposed via open cutdown or, more commonly, via percutaneous access. Access consideration is not limited to femoral arteries only but also includes both the external and the common iliac arteries. We report the case of a 72-year-old female patient who presented with a contained ruptured abdominal aortic aneurysm with small-diameter left common femoral (4 mm) and external iliac (3 mm) arteries. We used an innovative technique without the need for cutdown or the use of an iliac conduit. Balloon expandable covered stents were used that were compatible (in size) to an 8F sheath. The stents were postdilated to a larger diameter to achieve the appropriate seal at the flow divider. Endovascular exclusion of the aneurysm was achieved, and the patient was discharged home on postoperative day 2. At the 6-week office follow-up visit, the abdominal examination findings were benign, and she had positive signals in both feet. Aortic duplex ultrasound showed patent stents and no endoleak.

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

There is mounting evidence that COVID-19 patients may possess a hypercoagulable profile that increases their risk for thromboembolic complications, including pulmonary embolism (PE). PE has been associated with an increase in morbidity, mortality, prolonged ventilation, and extended ICU admissions. Intervention is warranted in some patients who develop acute massive and submassive PEs. However, the development of PE in COVID-19 patients is often complicated by such factors as delay of diagnosis, confounding medical conditions, and strict isolation precautions. In addition, depleted cardiopulmonary reserve and prone positioning can make management of PE in these patients especially challenging for the physician. In this article, we review current understanding of PE in COVID-19 patients, summarize consensus data regarding the treatment of PE, and propose an algorithm to guide the management of COVID-19 patients with PE.

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

Objective: The primary purpose of the study was to investigate and to summarize the registered trials that listed COVID-19 as the primary condition. Methods: We performed a search on ClinicalTrials.gov using the independent search terms COVID-19, SARS, and SARS-CoV-2 and then downloaded the data file on March 23, 2020. All trials were downloaded to a csv file and searched for appropriateness. Results: Of 124 registered trials, 56 (45.2%) were listed as recruiting. The majority (85 [68.5%]) were classified as interventional, 37 (29.8%) as observational, and one (0.8%) each as either expanded access: individual patients|treatment investigational new drug/protocol or expanded access: intermediate-size population|treatment investigational new drug/protocol. There were 67 (54.0%) trials that listed drug as the type of study. Immunologic and antiviral trials were the most common, representing approximately 30% and 21%, respectively. When immunologic and antiviral drugs were used alone or in combination, they represented 41.9% and 34.4%, respectively. Antimalarial agents are represented in 7.5% of trials. Approximately 14% of trials involved traditional Chinese medicine. The study agents used solely or in combination represented approximately 80% of therapeutic approaches to COVID-19. Conclusions: There was a large and quick response on ClinicalTrials.gov to the COVID-19 outbreak. Many of the registered trials are currently recruiting new patients, whereas some will begin in the near future. Specific potential experimental therapies, including dosing and monitoring, might be found by reviewing content. Within ClinicalTrials.gov, patients, family members, health care professionals, and researchers can search and find ongoing and future trials for COVID-19. (J Vasc Surg 2021;73:13-7.)

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

Peritoneal dialysis (PD) is a primary mode of renal replacement that has gained popularity in the United States as a viable option for renal replacement therapy. It seems intuitive that a less invasive option that also allows a visual inspection of the peritoneal cavity would result in better placement and outcomes. To date, there is no consensus guideline favoring laparoscopic over open surgery. The objective of this study was to compare the immediate outcomes after laparoscopic PD catheter (LPDC) placement to historical controls who received open surgical PD catheter (OPDC) placement. A retrospective review of patients who had a PD catheter placed for dialysis. The primary end point was immediate success, defined as a functional PD catheter. Catheter survival was estimated using the Kaplan-Meier method. One hundred thirty-five laparoscopic catheters were placed in 121 patients (mean of 1.1 ± 0.34 attempts). Demographics indicated more patients were female (53.3%) with an average age of 59.8 ± 14.0 years and body mass index of 31.5 ± 9.1 kg/m2. The majority were in renal failure (n = 82 [60.7%]). Diabetes was associated with a higher, but not significantly, rate of catheter related peritonitis (19.0 vs 9.8%; P = .221). Eighty-four patients (62.2%) had previous abdominal surgery, while 22 (16.3%) a previous PD catheter placed. The LPDC group had significantly more previous abdominal surgeries (62.2 vs 13.3%; P < .001) than OPDC. Immediate success was significantly higher in the LPDC group compared to OPDC (100 vs 80%; P = .001). The median survival time for a functioning PD catheter was 18.4 ± 5.9 months. The 3-year cumulative catheter patency rate for LPDC (41%) was as good as or perhaps slightly better than published rates for OPDC (36%). Nearly one-third of the catheters (30%) were functioning at 5 years (Figure). This study demonstrates the feasibility and the immediate success benefit of LPDC placement over open surgery. Thirty-percent of the catheters were functioning at 5 years. This technique has the potential to be the preferred modality for PD placement. Larger studies or randomized control trials are warranted to accurately assess outcomes for laparoscopy versus open surgery.

Transcarotid artery revascularization (TCAR) has received its U.S. Food and Drug Administration approval, has garnered additional substantiation by the study of Kashyap et al,1Kashyap V.S. King A.H. Foteh M.I. Janko M. Jim J. Motaganahalli R.L. et al.A multi-institutional analysis of transcarotid artery revascularization compared to carotid endarterectomy.J Vasc Surg. 2019; 70: 123-129Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar and thus is moving from its infancy to childhood phase with real-world results on the horizon. The authors are to be congratulated on expanding our present knowledge in the area of carotid intervention. However, there is concern that the safety and effectiveness outcomes associated with TCAR could decline as it moves into the real world. Some of these concerns center on the strict inclusion and exclusion criteria, medication adherence, and device learning curve. Importantly, the low event rates for the Kashyap study are comparable to those found in the pivotal Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER)2Kwolek C.J. Jaff M.R. Leal J.I. Hopkins L.N. Shah R.M. Hanover T.M. et al.Results of the ROADSTER multicenter trial of transcarotid stenting with dynamic flow reversal.J Vasc Surg. 2015; 62: 1227-1234Abstract Full Text Full Text PDF PubMed Scopus (169) Google Scholar and also for a much larger Society for Vascular Surgery Vascular Quality Initiative containing 1182 TCAR cases.3Schermerhorn M.L. Liang P. Dakour-Aridi H. Kashyap V.S. Wang G.J. Nolan B.W. et al.In-hospital outcomes of transcarotid artery revascularization and carotid endarterectomy in the Society for Vascular Surgery Vascular Quality Initiative.J Vasc Surg. 2019 Jun 18; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (58) Google Scholar The early results shared by Kashyap and colleagues suggest that the TCAR procedure is a carotid intervention that can be mastered in a very short time (ie, five or fewer training cases), and it has been found to lower the risk of cranial nerve injury. As we move forward and the news of the device begins to fade and less attention is paid to trial adherence, will the low event rates remain? Indeed, Paraskevas et al4Paraskevas K.I. de Borst G.J. Veith F.J. Why randomized controlled trials do not always reflect reality.J Vasc Surg. 2019; 70: 607-614Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar likewise have proclaimed a similar concern regarding the discordance between randomized trials and real-world results within the field of vascular surgery. Moreover, there are ongoing concerns about the appropriateness of TCAR interventions in patients with severe or occluded contralateral lesions, whereas these patients were excluded in the experimental trials.2Kwolek C.J. Jaff M.R. Leal J.I. Hopkins L.N. Shah R.M. Hanover T.M. et al.Results of the ROADSTER multicenter trial of transcarotid stenting with dynamic flow reversal.J Vasc Surg. 2015; 62: 1227-1234Abstract Full Text Full Text PDF PubMed Scopus (169) Google Scholar Although cranial nerve injury was lower than the 6% reported by the Carotid Stenting Trialists' Collaboration,5Bonati L.H. Dobson J. Algra A. Branchereau A. Chatellier G. Fraedrich G. et al.Carotid Stenting Trialists' Collaboration. Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a preplanned meta-analysis of individual patient data.Lancet. 2010; 376: 1062-1073Abstract Full Text Full Text PDF PubMed Scopus (351) Google Scholar there remains the possibility of lymphatic leak on the left side from injury to the thoracic duct or vagus nerve injury. So, despite TCAR's having successfully survived infancy, awareness, caution, and expertly deployed mitigating countermeasures will enhance this promising therapy's likelihood of a promising childhood. A multi-institutional analysis of transcarotid artery revascularization compared to carotid endarterectomyJournal of Vascular SurgeryVol. 70Issue 1PreviewTranscarotid artery revascularization (TCAR) is a novel approach to carotid intervention that uses a direct carotid cut-down approach coupled with cerebral blood flow reversal to minimize embolic potential. The initial positive data with TCAR indicates that it may be an attractive alternative to trans-femoral carotid artery stenting and possibly carotid endarterectomy (CEA) for high-risk patients. The purpose of this study was to present 30-day and 1-year outcomes after treatment by TCAR and to compare these outcomes against a matched control group undergoing CEA at the same institutions. Full-Text PDF Open ArchiveReplyJournal of Vascular SurgeryVol. 71Issue 1Preview“What is now proved was once only imagined.”–William Blake Full-Text PDF Open Archive

The current manuscript contains a protocol proposal for a prospective research trial comparing virtual vascular clinic visits to actual physical clinic visits. Patient dissatisfaction can increase because of the complexities associated with navigating modern health care systems. It is easy to speculate that some of this dissatisfaction is associated with travel, wait times and other issues that arise during routine clinic visits. The authors of recent studies have demonstrated that it is possible and feasible to conduct many routine visits remotely. It is our belief that virtual health assessments and treatment plans (VHAT) conducted remotely can be as effective, perhaps be more efficient and increase patient satisfaction when compared to regular physical health assessments and treatment plans (PHAT). Physicians want to provide optimal health care; however, in geographically isolated areas such as some locations in West Virginia that can be a challenge. It seems reasonable to believe that monitoring patients with telehealth technology, collecting on-going real time data and conducting VHAT can provide high-quality health care for patients. It can also help to classify health risk, increase patient and medical staff satisfaction, decrease staff time for visits, while at the same time increase the efficiency of the follow-up process. We plan to compare the physician assessments and future treatment plans made using VHAT to those made after PHAT. It is believed that VHAT will be in agreement with those made with PHAT. Aims/objectives: The primary objective of the current project is to compare assessment and future treatment plans for low-risk patients made via VHAT and PHAT visits. A secondary objective is to measure patient and physician satisfaction. Methods Study hypotheses: 1. There will be good agreement (kappa coefficient ≥ 0.80) between VHAT and PHAT assessments and treatment plans. More specifically, VHAT and PHAT assessments will be used to classify patients into low, moderate and high risk for intervention and there will be good agreement between the two methods. 2. Patient satisfaction will be greater for VHAT as compared to PHAT visits.

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

The global impact of COVID-19 has affected everyone, including healthcare providers caring for the surge in critically ill patients.1Sterpetti A.V. Lessons learned during the COVID-19 virus pandemic [published online ahead of print March 27, 2020].doi.org/10.1016/j.jamcollsurg.2020.03.018Google Scholar,2Park M. Cook A.R. Lim J.T. Sun Y. Dickens B.L. A systematic review of COVID-19 epidemiology based on current evidence.J Clin Med. 2020; 9: E967Crossref PubMed Scopus (378) Google Scholar Vascular interventionists have always been involved with direct patient care. The effect has been compounded for teaching physicians and vascular trainees.3Potts 3rd., J.R. Residency and fellowship program accreditation: effects of the novel coronavirus (COVID-19) pandemic [published online ahead of print April 3, 2020].doi.org/10.1016/j.jamcollsurg.2020.03.026Google Scholar,4Guo J. Huang Z. Lin L. Lv J. Coronavirus disease 2019 (COVID-19) and cardiovascular disease: a viewpoint on the potential influence of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers on onset and severity of severe acute respiratory syndrome coronavirus 2 infection.J Am Heart Assoc. 2020; 9: e016219PubMed Google Scholar The rotations for many third- and fourth-year medical students have been suspended, often because of a shortage of medical supplies. New quarantine policies have limited surgeries to urgent and emergent cases.5Adams J.G. Walls R.M. Supporting the health care workforce during the COVID-19 global epidemic.JAMA. 2020; 323: 1439-1440Crossref PubMed Scopus (1019) Google Scholar However, students could perform other medically related tasks such as triage or patient assessments to free up clinicians' time or could possibly assist in some administrative tasks. Final semester students could help create surge capacity.6Rose S. Medical student education in the time of COVID-19 [published online ahead of print March 31, 2020].doi.org/10.1001/jama.2020.5227Google Scholar Education conferences have been conducted virtually at the institutional and regional levels. Virtual clinic visits have been used to reach out to desperate patients.7Villani A. Scalvenzi M. Fabbrocini G. Teledermatology: a useful tool to fight COVID-19 [published online ahead of print April 13, 2020].doi.org/10.1080/09546634.2020.1750557Google Scholar, 8Khairat S. Meng C. Xu Y. Edson B. Gianforcaro R. Interpreting COVID-19 and virtual care trends: a call for action.JMIR Public Health Surveill. 2020; 6: e18811Crossref PubMed Scopus (80) Google Scholar, 9Kandeel M. Al-Nazawi M. Virtual screening and repurposing of FDA approved drugs against COVID-19 main protease.Life Sci. 2020; 251: 117627Crossref PubMed Scopus (273) Google Scholar Many institutions have been teaching their vascular fellows and residents about ventilators, respiratory therapy, intubations, and triaging patients. They can also perform many bedside procedures for critically ill patients such as placement of central intravenous catheters and temporary vascular access. The Society for Vascular Surgery recently published new regulations for vascular trainees, which includes accepting 44 weeks of clinical time, including any nonvoluntary time for the 2019-2020 academic year without preapproval, and a 10% decrease in the total number of reported cases. Nonvoluntary time off used for clinical or education purposes can be counted as clinical time. Trainees are learning about "check-ins" and "E-visits," with the newly introduced Healthcare Common Procedure Coding System codes G2010 and G2012 and about remote patient monitoring services such as a patient's oxygen saturation levels using pulse oximetry (Current Procedural Terminology codes 99091, 99457-99458, 99473-99474, 99493-99494). Medicare physician supervision no longer requires direct physician supervision for outpatient or critical cases. However, team segregation policies to limit the risk of intercircle cross-contamination is extremely important, as is complying with the new Medicare telehealth update (ie, available at: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes). In conclusion, the COVID-19 pandemic has posed unprecedented challenges to our healthcare system. Although we are often restricted by the aspects of accreditation, the pandemic has opened the door for many potential areas of training. The main goal is to manage the surge, but maintain patient and provider safety.

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

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

OBJECTIVE: To determine if prenatal ultrasound measurements of dividing membrane thickness (DMT) can predict spontaneous preterm birth (sPTB) and histologically-confirmed chorionicity in twin pregnancies. STUDY DESIGN: Prospective cohort in which DMT was measured by transabdominal ultrasound, both parallel and perpendicular to the transducer. RESULTS: A total of 73 twin pregnancies were included: 54 dichorionic-diamniotic (DCDA) and 19 monochorionic-diamniotic (MCDA). Overall, 75.9% of DCDA and 100% of MCDA gestations delivered preterm (p<0.02); these were categorized as spontaneous in 78.0% of DCDA and 84.2% of MCDA gestations. Ultimately, no association between DMT and sPTB was identified. However, DMT was associated with overall PTB at <37 weeks, with receiver operating characteristic curve analyses resulting in an area under the curve (AUC) of 0.756 for parallel (p<0.006) and 0.725 for perpendicular (p<0.016) measurements with cutoff values of 2.6 and 2.7 mm, respectively. The AUC to predict monochorionicity was 0.950 (p<0.001) for parallel measurements and 0.883 (p<0.001) for perpendicular measurements, with cutoff values of 1.9 and 1.8 mm, respectively. CONCLUSION: Ultrasound-measured DMT is not associated with sPTB in twin pregnancies. DMT <2.6 mm is associated with an increased risk of overall PTB, though the etiology is uncertain. Monochorionicity can be determined by DMT <1.9 mm.

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