Construct validity of multiple mini interviews - Investigating the role of stations, skills, and raters using Bayesian G-theory.

Background: One popular procedure in the medical student selection process are multiple mini-interviews (MMIs), which are designed to assess social skills (e.g., empathy) by means of brief interview and role-play stations. However, it remains unclear whether MMIs reliably measure desired social skills or rather general performance differences that do not depend on specific social skills. Here, we provide a detailed investigation into the construct validity of MMIs, including the identification and quantification of performance facets (social skill-specific performance, station-specific performance, general performance) and their relations with other selection measures.Methods: We used data from three MMI samples (N = 376 applicants, 144 raters) that included six interview and role-play stations and multiple assessed social skills.Results: Bayesian generalizability analyses show that, the largest amount of reliable MMI variance was accounted for by station-specific and general performance differences between applicants. Furthermore, there were low or no correlations with other selection measures.Discussion: Our findings suggest that MMI ratings are less social skill-specific than originally conceptualized and are due more to general performance differences (across and within-stations). Future research should focus on the development of skill-specific MMI stations and on behavioral analyses on the extents to which performance differences are based on desirable skills versus undesired aspects.

Medical doctors' job specification analysis: A qualitative inquiry.

Purpose: A qualitative inquiry was conducted to investigate the qualification requirements of medical doctors in different professional fields and from different perspectives. The inquiry was part of an empirical workplace analysis. Methods: Seventy-four structured interviews were conducted and analyzed to examine critical incidents and behaviors of medical doctors working in different professional fields (clinical theory, clinical practice, practitioner) and disciplines, and from three different perspectives (medical doctors, non-medical staff, and patients). In addition, the National Competency-based Catalogue of Learning Objectives for Medical Education (Nationaler Kompetenzbasierter Lernzielkatalog Medizin / NKLM) was used. Results: The results revealed eleven relevant competencies, which could be categorized into three superordinate competence clusters: interpersonal, work-related, and self-related. The perspectives of medical doctors and non-medical staff included all eleven competencies. However, the perspective of patients did not include one interpersonal and two self-related competencies. Nearly all of the critical behaviors mentioned are included in the NKLM. However, the NKLM also includes behaviors that were not mentioned in the interviews. Conclusions: The behavior-oriented interviews resulted in a requirement profile that is very similar in structure to other competency models in occupational contexts. Comparisons of the different perspectives predominantly revealed similarities. However, the patient perspective also revealed interesting differences compared to the perspectives of medical doctors and non-medical staff. The behavior-related results of the interviews can be directly used for the development of exercises in selection and personnel development contexts and for potential appraisals specific to different medical disciplines. In future steps, the results of this initial qualitative step are to be replicated and extended using quantitative studies and a representative sample. The main overall objective is the definition of relevant competencies both for the selection and development of medical students and for the design of potential appraisals as part of personnel development programs in different medical disciplines.

Results of common femoral artery thromboendarterectomy evaluation of a traditional surgical management in the endovascular era.

OBJECTIVE: The aim of this study was to investigate the long-term outcome of common femoral artery thromboendarterectomy in patients with peripheral arterial occlusive disease. METHODS: The study retrospectively evaluated 713 vessels in 655 patients (75% male; mean age, 69.4 ± 9.5 years) who underwent common femoral thromboendarterectomy from January 2006 until May 2012 in two high-volume vascular centers. Critical limb ischemia was present in 221 patients, and intermittent claudication was present in 434. Three patent tibial arteries, described as runoff vessels, were available in 33% of the cohort, two were present in 28.3%, one runoff vessel was present in 23.4%, and 15.2% (n = 102) showed no runoff option. Hybrid procedures were used to treat 255 limbs (35.8%). The primary end point was primary patency (PP). Secondary patency (SP), limb salvage, and survival were the secondary end points. RESULTS: Survival rates were 93.9%, 83.0%, 74.1%, and 60.1% at 1, 3, 5, and 7 years, respectively. PP was 78.5% and SP was 89.1% at 7 years. Patency rates were 97.3% (PP) and 97.8% (SP) at 6 months and 90.2% (PP) and 98.3% (SP) at 3 years, respectively, with 76 target lesion revascularizations. No significant difference was demonstrated for PP rates stratified for nonhybrid procedures and hybrid procedures (78.1% vs 78.6%; P = .22) and for critical limb ischemia vs intermittent claudication (76.3% vs 79.4%; P = .20) at 7 years. The mean ± standard deviation ankle-brachial index increased from 0.46 ± 0.3 preoperatively to 0.81 ± 0.2 postoperatively and to 0.77 ± 0.3 at 7 years (P < .001). A total of 20 major amputations were performed, achieving a limb salvage rate of 92.6%. Procedure-related complications occurred in 11.5% during 7 years of follow-up. CONCLUSIONS: Open surgery for common femoral artery stenosis is safe and effective in the long-term. Endovascular therapy will need to compete with these excellent results.

Critical appraisal of paclitaxel balloon angioplasty for femoral-popliteal arterial disease.

Peripheral arterial disease, particularly critical limb ischemia, is an area with urgent need for optimized therapies because, to date, vascular interventions often have limited life spans. In spite of initial encouraging technical success after femoropopliteal percutaneous transluminal angioplasty or stenting, postprocedural restenosis remains the major problem. The challenging idea behind the drug-coated balloon (DCB) concept is the biological modification of the injury response after balloon dilatation. Antiproliferative drugs administered via DCBs or drug-eluting stents are able to suppress neointimal hyperplasia, the main cause of restenosis. This article reviews the results of DCB treatments of femoropopliteal and infrapopliteal lesions in comparison to standard angioplasty with uncoated balloons. A systematic literature search was performed in 1) medical journals (ie, MEDLINE), 2) international registers for clinical studies (ie, www.clinicaltrials.gov), and 3) abstracts of scientific sessions. Several controlled randomized trials with follow-up periods of up to 5 years demonstrated the efficacy of paclitaxel -DCB technology. However, calcified lesions seem to affect the efficacy of DCB. Combinations of preconditioning methods with DCBs showed promising results. Although the mechanical abrasion of calcium via atherectomy or laser ablation showed favorable periprocedural results, the long-term impact on restenosis and clinical outcome has to be demonstrated. Major advantages of the DCBs are the rapid delivery of drug at uniform concentrations with a single dose, their efficacy in areas wherein stents have been contraindicated until now (ie, bifurcation, ostial lesions), and in leaving no stent scaffold behind. Reinterventions are easier to perform because DCBs leave no metal behind. Various combinations of DCBs with other treatment modalities may prove to be viable options in future. The follow-up results of clinical studies will evaluate the long-term impact of DCBs.

Results of primary stent therapy for femoropopliteal peripheral arterial disease at 7 years.

OBJECTIVE: Primary stenting is a well-established treatment option for femoropopliteal arterial disease. However, there is a paucity of data concerning the performance of this modality at ≥5 years. This study evaluated the long-term clinical and radiologic outcomes of primary stent therapy in patients with femoropopliteal arterial disease. METHODS: A prospective data collection and analysis was conducted in patients undergoing primary stent placement in femoropopliteal lesions between September 2006 and September 2007. The EverFlex (Medtronic/Covidien, Plymouth, Minn) bare-metal stent was used. The primary outcome of this study was the primary patency rate. Secondary outcomes were secondary patency rate, amputation-free-survival (AFS), and freedom from target lesion revascularization (TLR). A Cox regression analysis identified risk factors for the primary and the secondary measure outcomes. RESULTS: Included were 89 patients (102 stents). The prevalence of critical limb ischemia was 34% (n = 30). The initial angiography revealed a TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease C/D lesion in 31 patients (35%). Occlusions were present in 49 patients (55%), and the mean lesion length was 116 ± 33 mm. Popliteal artery disease was present in 39 treated limbs (35%). The primary patency rate at 1, 3, 5, and 7 years was 73%, 64%, 47%, and 33% respectively. At 7 years, secondary patency rate was 67%, freedom from TLR was 47%, and the AFS was 73%. Cox regression analysis revealed a decreased AFS among diabetic patients (hazard ratio [HR], 2.6; 95% confidence interval [CI], 1.08-6.28; P = .03), whereas secondary endovascular interventions showed a protective effect for AFS (HR, 0.14; 95% CI, 0.03-0.65; P = .01). Popliteal artery disease was identified as independent risk factor for secondary interventions (HR, 2.07; 95% CI, 1.05-4.06; P = .04) and TLR (HR, 1.99; 95% CI, 1.03-3.83; P = .04). Critical limb ischemia was associated with an increased incidence of surgical conversion owing to endovascular treatment failure (HR, 5.46; 95% CI, 2.44-12.17; P < .001). CONCLUSIONS: This study found primary stenting was associated with acceptable clinical and radiologic long-term outcomes. Diabetes was associated with poor AFS, and popliteal artery involvement correlated with an increased need for reinterventions. AFS was better among patients undergoing secondary procedures.

Gender-related long-term outcome of primary femoropopliteal stent placement for peripheral artery disease.

PURPOSE: To evaluate gender-related long-term outcomes in patients undergoing stent treatment of femoropopliteal peripheral artery disease. METHODS: Between September 2006 and August 2010, all 517 patients (333 men and 184 women; mean age 70.6 years) undergoing primary stent placement in femoropopliteal atherosclerotic lesions at 2 European vascular centers were prospectively enrolled in the study. The main study outcome was primary stent patency. Secondary outcomes included secondary patency, limb salvage, and all-cause mortality. RESULTS: Women had a higher incidence of critical limb ischemia (32.1% vs. 16.9%, p<0.001). Lesion characteristics according to the TransAtlantic Inter-Society Consensus (TASC) classification were comparable in both genders (p=0.52), although total occlusions and popliteal involvement were observed more frequently in female patients (p=0.043 and p=0.001, respectively). Both genders showed similar 5-year primary patency rates (64.3% men vs. 58.1% women, p=0.11). A statistically significant difference was observed concerning the secondary patency rates in favor of men (71.9% vs. 66.8% at 5 years, p=0.005). Limb salvage rates did not vary between the groups (p=0.83). Survival rates were comparable at 5 years (83.3% and 82.6% for men and women, respectively; p=0.63), although female patients were older at their presentation (68.5 vs. 74.3 years, p<0.001). Female gender was an independent risk factor for restenosis for TASC C/D lesions (primary patency rate 39.8% in women vs. 62.0% in men; p=0.002). Finally, critical limb ischemia was an independent risk factor for restenosis in women (odds ratio 1.5). CONCLUSION: Female gender was associated with a higher prevalence of critical limb ischemia, poorer secondary patency, and more frequent restenosis in TASC C/D lesions. Endovascular treatment of femoropopliteal lesions provides equal results between genders in terms of primary stent patency in the long term.

Drug-eluting balloons for femoropopliteal lesions show better performance in de novo stenosis or occlusion than in restenosis.

OBJECTIVE: Although drug-eluting balloons (DEBs) have shown promising results treating de novo (DN) atherosclerotic lesions and appear to have been widely adopted in Europe, their long-term efficacy in the broad spectrum of femoropopliteal restenosis (RE) remains to be proven. The purpose of the study was to assess the efficacy of paclitaxel-DEBs in restenotic (stented and nonstented) vs DN stenotic femoropopliteal arteries. METHODS: The study prospectively enrolled 100 patients undergoing femoropopliteal endovascular intervention by DEB for RE or DN stenosis. Patients who received additive atherectomy were excluded. The primary end point was the primary patency (PP) rate at 12 months. Secondary end points were sustained clinical improvement and clinically driven target lesion revascularization. RESULTS: DEBs were used to treat 105 limbs for intermittent claudication (82 [78%]) or critical limb ischemia (23 [22%]) in 100 patients. Of these, 111 lesions were DN stenosis (46 [41%]) or RE (65 [59%]). The overall PP was 86% at 6 months and 74% at 12 months. PP of DN stenosis was higher at 6 months (93% vs 81%) and was significantly (P = .021) better than RE at 12 months (85% vs 68%). Sustained clinical improvement based on Rutherford classification was significant in both groups (P < .001). Target lesion revascularization was significantly lower in DN stenosis compared with RE at 12 months (15% vs 32%; P = .021). CONCLUSIONS: DEB angioplasty is an effective therapy for DN femoropopliteal lesions. The results of DEB angioplasty for RE are inferior compared with DN stenosis after 12 months. Nevertheless, results of DEB angioplasty for RE seem comparable with technically more demanding literature-derived strategies.

Early outcomes for fenestrated and chimney endografts in the treatment of pararenal aortic pathologies are not significantly different: a systematic review with pooled data analysis.

PURPOSE: To compare short-term outcomes between fenestrated and chimney endografts for pararenal aortic pathologies. METHODS: An English-language literature search up to January 2012 found 129 articles evaluating the immediate outcomes of endovascular repair of degenerative juxta-/suprarenal aortic aneurysms, type I endoleaks, and para-anastomotic aneurysms using the chimney technique or fenestrated endografts. Data concerning thoracoabdominal aortic aneurysms, ruptured aneurysms, and reports with <5 cases were excluded (n=84). An additional 28 articles were excluded for insufficient data, leaving 17 articles for review: 5 dealing with chimney grafts in 123 patients with pararenal aortic pathologies and 12 presenting data on 660 [corrected] patients undergoing fenestrated stent-grafting. The composite endpoints were 30-day mortality, deterioration of renal function, new postoperative dialysis dependence, and endoleak rate. RESULTS: Cumulative 30-day procedure-related mortality was 0.58% (95% CI 0.0% to 2.93%) for the chimney group (n=3) and 1.17% (95% CI 0.26% to 2.09%, p=0.645) for the f-EVAR group (n=9). In the f-EVAR group, 86 (9.67%; 95% CI 4.77% to 14.57%) patients suffered from postoperative renal impairment vs. 16 (12.43%) patients in the chimney group (95% CI 2.39% to 22.48%, p=0.628). In the chimney group, 4 (0.57%; 95% CI 0.0% to 2.94%) patients required persistent postoperative dialysis in contrast to the 1.33% (95% CI 0.29% to 2.37%, p=0.567) rate (n=9) in patients undergoing f-EVAR. There were also no significant differences recorded in the endoleak rate: 1.93% (95% CI 0.0% to 4.82%) of the chimney patients had a persistent type Ia endoleak vs. 2.06% (95% CI 0.69% to 3.43%) for the f-EVAR group (p=0.939). For type II endoleaks, the rates were 2.16% (95% CI 0.0% to 10.77%) for the chimney group vs. 6.88% (95% CI 1.92% to 11.83%) for the f-EVAR group (p=0.352). No patient in the chimney group had a type III endoleak, and the rate was low in the f-EVAR group (0.32%, 95% CI 0.0% to 0.91%, p=0.079). CONCLUSION: No statistically significant differences were found between the two endovascular approaches for pararenal aortic pathologies in terms of 30-day mortality, renal impairment, or endoleak. These findings support the assumption that chimney grafts may be a reliable alternative in the treatment of pararenal aortic pathologies.

Endovascular treatment of common iliac artery aneurysms using the bell-bottom technique: long-term results.

PURPOSE: To retrospectively evaluate the long-term outcome of the bell-bottom technique for the endovascular repair of common iliac artery (CIA) aneurysms. METHODS: Between September 2003 and September 2008, 89 patients (84 men; mean age 73.7+/-8.4 years) with aortic and CIA aneurysms were treated at 2 European centers with aortic extension cuffs or large iliac limbs that gave a bell-bottom configuration to the iliac portion of an aortoiliac stent-graft. The mean maximum aortic diameter was 65.7+/-12.3 mm (range 42-98), and the mean diameter of the treated CIA aneurysms was 22.1+/-3.0 mm (range 20-30). RESULTS: Technical success was achieved in 97.8% (87/89). There was no early (<30-day) mortality, but 8 (8.9%) patients died (none aneurysm-related) during follow-up. Cumulative survival by Kaplan-Meier analysis was 96.3% at 1 year, 85.5% at 3 years, and 83.1% at 5 years. After a mean follow-up of 56.5 months, computed tomography documented 3 (3.4%) type I endoleaks: one proximal leak was treated by conversion to open repair, and the other 2 distal type I endoleaks were treated by implantation of an iliac extension. Two (2.2%) type II endoleaks were accompanied by an increase in the aneurysm diameter; one was treated by coil embolization of the inferior mesenteric artery and the other by conversion to open repair after repeated coil embolization. One patient underwent thrombectomy for iliac limb occlusion. The freedom from secondary intervention was 91.6% at 5 years. The mean maximum diameter of the CIA aneurysms showed no significant change over time (24.1+/-3 mm at 30 days and 23.4+/-4 mm at latest follow-up). CONCLUSION: Moderate-size CIA aneurysms (<30 mm) can be safely and effectively treated using the bell-bottom technique. The risk of distal type I endoleak is low. Iliac-related complications can be successfully treated by endovascular techniques.

Below knee bare nitinol stent placement in high-risk patients with critical limb ischemia is still durable after 24 months of follow-up.

BACKGROUND: This study evaluated the durability of nitinol stent placement in high-risk patients with chronic critical limb ischemia (CLI) and infrapopliteal lesions after suboptimal balloon angioplasty. METHODS: Between January 2006 and January 2009, 53 high-risk patients (24 women; mean age, 71.8 +/- 5.1 years) with CLI underwent infragenicular stent placement with a 4F sheath-compatible self-expanding nitinol stent. Patients had three or more serious cardiopulmonary comorbidities, including chronic obstructive pulmonary disease, congestive heart failure, coronary artery occlusive disease, American Society of Anesthesiologists score >/=3, previous myocardial infarction, coronary stent or bypass, or infection after peripheral revascularization. Endovascular therapy was performed in 30 stenoses and 23 occlusions in 53 patients. The mean stenosis length was 5.5 +/- 1.9 cm. The mean occlusion length was 6.5 +/- 2.9 cm. The mean follow-up was 24.1 +/- 7.3 months and consisted of clinical examination, ankle-brachial index (ABI) measurements, and duplex ultrasound imaging. Digital subtraction angiography was performed if restenosis or reocclusion was suspected. RESULTS: The technical success rate was 98.1%. The 24-month cumulative primary patency rate was 75.5%. During the follow-up, two patients underwent successful repeat angioplasty, and four patients required crural bypass. The 24-month secondary patency and freedom from amputation rates were 88.7% and 88.7%, respectively. The mean ABI increased significantly at 12 and 24 months (P < .001). Risk stratification to detect predictors that influenced the patency rate showed that proximal lesions had significant better patency than distal crural lesions (83.3% vs 65.2%, P = .04). The morphology of the lesions (stenoses vs occlusions, P = .88) did not seem to influence primary patency. Four patients died from nonprocedure-related causes during the follow-up, including lung cancer, myocardial infarction, and glioblastoma multiforme. No procedure-related deaths were recorded. CONCLUSIONS: The 2-year outcome of our series underscores the value of infrapopliteal nitinol stent placement as a durable bailout treatment option in high-risk CLI patients with suboptimal angioplasty.