Variation in Oral Board Examination Accommodations Among Specialties.

Importance: Board certification can have broad implications for candidates' career trajectories, and prior research has found sociodemographic disparities in pass rates. Barriers in the format and administration of the oral board examinations may disproportionately affect certain candidates. Objective: To characterize oral certifying examination policies and practices of the 16 Accreditation Council for Graduate Medical Education (ACGME)-accredited specialties that require oral examinations. Design, Setting, and Participants: This cross-sectional study was conducted from March 1 to April 15, 2023, using data on oral examination practices and policies (examination format, dates, and setting; lactation accommodations; and accommodations for military deployment, family emergency, or medical leave) as well as the gender composition of the specialties' boards of directors obtained from websites, telephone calls and email correspondence with certifying specialists. The percentages of female residents and residents of racial and ethnic backgrounds who are historically underrepresented in medicine (URM) in each specialty as of December 31, 2021, were obtained from the Graduate Medical Education 2021 to 2022 report. Main Outcome and Measures: For each specialty, accommodation scores were measured by a modified objective scoring system (score range: 1-13, with higher scores indicating more accommodations). Poisson regression was used to assess the association between accommodation score and the diversity of residents in that specialty, as measured by the percentages of female and URM residents. Linear regression was used to assess whether gender diversity of a specialty's board of directors was associated with accommodation scores. Results: Included in the analysis were 16 specialties with a total of 46 027 residents (26 533 males [57.6%]) and 233 members of boards of directors (152 males [65.2%]). The mean (SD) total accommodation score was 8.28 (3.79), and the median (IQR) score was 9.25 (5.00-12.00). No association was found between test accommodation score and the percentage of female or URM residents. However, for each 1-point increase in the test accommodation score, the relative risk that a resident was female was 1.05 (95% CI, 0.96-1.16), and the relative risk that an individual was a URM resident was 1.04 (95% CI, 1.00-1.07). An association was found between the percentage of female board members and the accommodation score: for each 10% increase in the percentage of board members who were female, the accommodation score increased by 1.20 points (95% CI, 0.23-2.16 points; P = .03). Conclusions and Relevance: This cross-sectional study found considerable variability in oral board examination accommodations among ACGME-accredited specialties, highlighting opportunities for improvement and standardization. Promoting diversity in leadership bodies may lead to greater accommodations for examinees in extenuating circumstances.

Long-term risk of carotid stenosis and cerebrovascular disease after radiation therapy for head and neck cancer.

BACKGROUND: Recipients of radiation therapy (RT) for head and neck cancer (HNC) are at significantly increased risk for carotid artery stenosis (CAS) and cerebrovascular disease (CVD). We sought to determine (1) cumulative incidences of CAS and CVD among HNC survivors after RT and (2) whether CAS is associated with a RT dose response effect. METHODS: This single-institution retrospective cohort study examined patients with nonmetastatic HNC who completed (chemo)RT from January 2000 through October 2020 and subsequently received carotid imaging surveillance ≤2 years following RT completion and, in the absence of CAS, every 3 years thereafter. Exclusion criteria included history of known CAS/CVD. Asymptomatic CAS was defined as ≥50% reduction of luminal diameter, symptomatic CAS as stroke or transient ischemic attack, and composite CAS as asymptomatic or symptomatic CAS. RESULTS: Of 628 patients undergoing curative intent RT for HNC, median follow-up was 4.8 years (interquartile range, 2.6-8.3), with 97 patients followed ≥10 years. Median age was 61 years and 69% of patients received concurrent chemotherapy and 28% were treated postoperatively. Actuarial 10-year incidences of asymptomatic, symptomatic, and composite CAS were 29.6% (95% CI, 23.9-35.5), 10.1% (95% CI, 7.0-13.9), and 27.2% (95% CI, 22.5-32.1), respectively. Multivariable Cox models significant association between asymptomatic CAS and absolute carotid artery volume receiving ≥10 Gy (per mL: hazard ratio, 1.09; 95% CI, 1.02-1.16). CONCLUSIONS: HNC survivors are at high risk for post-RT CAS. A dose response effect was observed for asymptomatic CAS at doses as low as 10 Gy. PLAIN LANGUAGE SUMMARY: Recipients of radiation therapy for head and neck cancer are at significantly increased risk for carotid artery stenosis and cerebrovascular disease. However, carotid artery screening is not routinely performed among head and neck survivors following radiation therapy. In this single-institution retrospective cohort study, patients with head and neck cancer were initially screened for carotid artery stenosis ≤2 years following radiation therapy completion, then every 3 years thereafter. The 10-year actuarial incidence of carotid artery stenosis was >25% and stroke/transient ischemic attack >10%. Multivariable analysis demonstrated significant associations between asymptomatic carotid artery stenosis and artery volumes receiving ≥10 Gy.

A minimally invasive approach for management of pancreaticoduodenal artery and gastroduodenal artery aneurysm with celiac artery occlusion.

Management of pancreaticoduodenal artery aneurysms (PDAAs) and gastroduodenal artery aneurysms (GDAAs) with concomitant celiac occlusion represents a challenging clinical scenario. Here, we describe a 62-year-old female with PDAA and GDAA complicated by celiac artery occlusion due to median arcuate ligament syndrome. We used a staged, minimally invasive approach consisting of: (1) a robotic median arcuate ligament release; (2) endovascular celiac artery stenting; and (3) visceral aneurysm coiling. The findings from this case report represent a novel treatment strategy for the management of PDAA/GDAA with celiac artery compression secondary to median arcuate ligament syndrome.

Venous malformations.

The often inexorable growth and expansion of congenital vascular malformations can result in substantial morbidity and, in some cases, premature death of these patients. Despite this, patients suffering from such lesions are often erroneously diagnosed and/or inadequately treated, due to a lack of expertise among primary care practitioners as well as specialists. Venous malformations are the most common type of congenital vascular malformations. Over the last two decades management of these lesions has significantly improved, predominantly due to the introduction and implementation of multidisciplinary team concept as well as improvement in diagnostic and treatment modalities. Relatively recently genetic studies are providing more insights into underlying pathophysiological mechanisms responsible for the development and progression of venous malformations and pharmacotherapy is becoming extensively evaluated for safety and efficacy in the treatment of these often challenging vascular lesions.

Gonadal vein transposition is a safe and effective treatment of nutcracker syndrome.

BACKGROUND: Nutcracker syndrome (NCS) is a pelvic venous disorder that results from outflow obstruction of the left renal vein, most often due to a decreased aortomesenteric angle, leading to gonadal vein reflux, pain, and varices. Although a number of open and minimally invasive procedures to treat NCS have been described, the optimal management of this condition remains uncertain. To the best of our knowledge, we have presented the largest case series to date using gonadal vein transposition (GVT) to treat NCS. METHODS: Patients considered for intervention to treat NCS underwent a rigorous and standardized workup, including axial imaging studies, catheter-based diagnostic procedures, and urinalysis. GVT has been the institutional first-line treatment of NCS for appropriate patients. With institutional review board approval, a retrospective review of patients who had undergone GVT for NCS was conducted. RESULTS: From 2014 to 2019, 18 GVTs had been performed. Of the 18 patients, none had died or required reintervention, although 2 had required readmission. During a median follow-up of 178 days, complete symptom relief was achieved in 11 patients (61.1%), with 4 patients (22.2%) reporting partial symptom relief and 2 (11.1%) reporting transient symptom relief. CONCLUSIONS: GVT is a safe and effective procedure to treat NCS in appropriately selected patients with outcomes that compare favorably with those of other described procedures. Appropriate patient selection for this procedure is critical and requires a rigorous and standardized approach to diagnosis and management.

Cerebral monitoring during transcarotid artery revascularization with flow reversal via transcranial doppler ultrasound examination.

OBJECTIVE: Transcarotid artery revascularization (TCAR) is a hybrid technique for carotid artery revascularization that relies on proximal carotid occlusion with flow reversal for distal embolic protection. The hemodynamic response of the intracranial circulation to flow reversal is unknown. In addition, the rate and pattern of cerebral embolization during flow reversal has yet to be investigated. The aim of this study was to characterize cerebral hemodynamic and embolization patterns during TCAR. METHODS: A single-institution retrospective study of patients with carotid artery stenosis undergoing TCAR with intraoperative transcranial Doppler (TCD) monitoring of the middle cerebral artery (MCA) was performed. Primary outcomes included changes in MCA velocity and MCA embolic signals observed throughout TCAR. RESULTS: Eleven patients underwent TCAR with TCD monitoring of the ipsilateral MCA. The average MCA velocity at baseline was 50.6 ± 16.4 cm/s. MCA flow decreased significantly upon initiation of flow reversal (50.5 ± 16.4 cm/s vs 19.1 ± 18.4 cm/s; P = .02). The reinitiation of antegrade flow resulted in a significant increase in the number of embolic events compared with baseline (P = .003), and embolic events were observed in two patients during flow reversal. CONCLUSIONS: TCD monitoring of patients undergoing TCAR revealed that the initiation of flow reversal results in a decrement in ipsilateral MCA velocity. Furthermore, embolic events can occur during flow reversal and are significantly associated with the reinitiation of antegrade flow in the internal carotid artery. However, both of these hemodynamic events were well-tolerated in our cohort. These findings suggest that TCAR remains a safe neuroprotective strategy for carotid revascularization.

Safety and Feasibility of Simultaneous Transcarotid Revascularization With Flow Reversal and Coronary Artery Bypass Grafting for Concomitant Carotid Artery Stenosis and Coronary Artery Disease.

OBJECTIVE: The management of patients with combined severe carotid artery and coronary artery disease (CAD) is controversial. Transcarotid stenting with flow reversal (TCAR) is a novel hybrid technique for carotid revascularization. We sought to investigate the safety and feasibility of simultaneous TCAR and coronary artery bypass grafting (CABG) for concomitant carotid and CAD. METHODS: A single-institution, retrospective study of patients with critical carotid artery stenosis and symptomatic CAD who underwent simultaneous TCAR-CABG was completed. The primary outcomes were technical success, perioperative stroke, death, and hemorrhage. RESULTS: Four patients underwent TCAR-CABG. All patients were male with a mean age of 64. Technical success was achieved in all cases. There were no perioperative strokes or deaths. There were no reexplorations for hemorrhage. CONCLUSIONS: Transcarotid stenting with flow reversal-CABG is a technically feasible hybrid approach for simultaneous carotid and coronary revascularization. It should be part of the vascular surgeon's armamentarium for coexisting carotid and coronary disease. Further research focused on patient selection and perioperative antiplatelet management is warranted prior to the widespread adoption of this technique.

Safety and efficacy of foam sclerotherapy for treatment of low-flow vascular malformations in children.

OBJECTIVE: Congenital vascular malformations are a heterogeneous group of lesions with the potential to cause significant lifelong morbidity in children. Diagnosis and treatment of these lesions may be complex and require a multidisciplinary approach. Sclerotherapy is widely used for the treatment of low-flow vascular malformations (LFVMs) as an alternative to surgical resection in adults; however, limited data of its use in a pediatric setting are available. The purpose of this study was to evaluate the efficacy and safety of sclerotherapy for pediatric LFVMs. METHODS: In this retrospective study, we reviewed our multidisciplinary vascular malformations team database for all patients younger than 18 years treated for congenital vascular malformations from 2008 to 2017. Of these, patients with LFVM treated with foam sclerotherapy were included. Dynamic contrast-enhanced magnetic resonance imaging was used to select patients for sclerotherapy by the multidisciplinary team. Foam sclerotherapy was performed with either polidocanol or sodium tetradecyl sulfate. Patients' characteristics, including demographics, presenting symptoms, and anatomic location of malformation, were assessed. Outcomes included treatment response, number of procedures, and postprocedural complications. RESULTS: The 61 patients with 61 LFVMs included 27 boys (44.3%) and 34 girls (55.7%), with mean age of 10.3 years (standard deviation, ± 5.3 years). The cohort included 32 venous (52.5%), 16 lymphatic (26.2%), and 8 mixed venous and lymphatic (13.1%) malformations along with 5 (8.2%) associated with Klippel-Trénaunay syndrome. Primary indications for intervention included pain and swelling (n = 12 [19.6%]), pain alone (n = 23 [37.7%]), swelling alone (n = 15 [24.6%]), functional impairment (n = 8 [13.1%]), and bleeding (n = 3 [4.9%]). Anatomic distributions varied, with 13 head and neck (21.3%), 5 truncal (8.2%), 10 upper extremity (16.4%), 27 lower extremity (44.3%), and 6 diffuse (9.8%). Among the head and neck lesions, 8 (13.1%) extended to the face; and of the extremity lesions, 5 (8.2%) extended to the hand and 17 (27.9%) to the foot. Overall, sclerotherapy resulted in significant improvement or complete resolution of symptoms in 53 patients (86.9%). Complications were observed in seven patients (11.4%); six cases (9.8%) of superficial skin ulceration resolved without intervention, and one infection (1.6%) required antibiotics. No patients experienced adverse hemodynamic consequences or venous thromboembolism. CONCLUSIONS: This series of pediatric LFVMs, the largest of its kind to date, demonstrates that sclerotherapy with foam-based agents effectively reduces symptoms with an acceptable rate of complications. Further study is needed to determine the optimal sclerosing agents for individual subsets of LFVMs in the pediatric population.

Negative pressure wound therapy reduces surgical site infections.

OBJECTIVE: Surgical site infection (SSI) with lower extremity incisions represents a modifiable source of major morbidity. Our institutional bundled care protocol to decrease SSI includes optimization of perioperative risk factors, dedicated wound closure tray, and voluntary use of a closed surface negative pressure wound therapy (cNPWT) device applied over closed incisions in the operating room. This study examined the individual effect of cNPWT on SSI reduction and other perioperative outcomes. METHODS: All patients with lower extremity or infrainguinal incisions between January 2016 and December 2017 were prospectively identified and tracked for infectious complications. All patients were treated with the same perioperative care bundle to reduce SSI. cNPWT was applied over closed incisions at the discretion of the surgeon. The 90-day outcomes regarding SSI, return to operating room, death, and readmission were tracked. Univariate and multivariate analysis using binary logistic regression for factors associated with SSI was performed for patients with and without cNPWT devices, with P < .05 determined to be significant. RESULTS: There were 504 patients included, 225 with cNPWT and 279 with standard dressings. Between the groups, there were no major differences in mean age, mean body mass index, perioperative transfusions, use of prosthetic, reoperative field, dialysis status, and presence of diabetes. There were significantly more women (39.6% vs 27.2% female; P < .01) and active smokers (47.1% vs 30.2%; P < .01) in the cNPWT group along with increased mean operative times (238.3 vs 189.0 minutes; P < .01). Univariate analysis revealed significantly fewer SSIs with cNPWT (9.8% vs 19.0% in standard dressings; P < .01) along with decreased perioperative mortality (5.8% vs 11.2%; P = .04). There were no differences in return to operating room (27.6% cNPWT vs 27.7% standard; P = .97) or readmissions (29.8% cNPWT vs 26.5%; P = .43), but more returns to the operating room were for wound-related problems in the standard dressings group (48.3% vs 26.2%; P < .01). Binary logistic regression using an SSI end point demonstrated that female sex increases SSI (odds ratio, 2.43; confidence interval, 1.37-4.30; P < .01), whereas cNPWT reduces SSI (odds ratio, 0.32; confidence interval, 0.17-0.63; P < .01). CONCLUSIONS: The use of negative pressure wound therapy devices decreases the incidence of infrainguinal wound infections. This occurs as an independent factor as part of a patient care bundle targeting modifiable variables in perioperative care.

An analysis of the vascular injuries and attempted resuscitation surrounding the assassination of Martin Luther King Jr.

Martin Luther King Jr was the most prominent civil rights leader in the United States in the 1960s. He was shot by an assassin in Memphis, Tennessee, on April 4, 1968. After the shooting he was taken to a local hospital where he had an unsuccessful resuscitation for a right subclavian artery transection. Despite the fact that the circumstances around the assassination have been frequently reported and reviewed in the past 50 years, the specific vascular care of the traumatic injury has not been analyzed. This paper reviews the medical aspects of the King assassination and the management of his subclavian injury.

Carotid stenting and endarterectomy and contralateral carotid occlusion.

BACKGROUND: The presence of contralateral carotid occlusion (CCO) has been controversial throughout the history of carotid intervention. Some studies cite a higher stroke risk in the setting of CCO, whereas other studies document no difference in stroke risk. We investigated the risk of stroke after intervention in the setting of CCO in a large, national, validated dataset. METHODS: Data were obtained from the 2011-2014 American College of Surgeons National Surgical Quality Initiative Project files using targeted carotid endarterectomy (CEA), carotid angioplasty, and carotid artery stenting (CAS) data. Patient and procedural characteristics, and 30-day postoperative outcomes were compared using Pearson χ2 tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. Logistic regression was used for multivariable analysis. The primary outcome measure was the stroke rate, with a secondary outcome of major adverse cardiovascular events. RESULTS: During the study period, 11,948 CEA and 422 CAS procedures were available for study, with significantly fewer CEA (4.73% of all CEA) than CAS (9.95%; P < .0001) occurring in the setting of CCO. CAS was associated with more severe degree of stenosis than CEA (P = .045). Multivariable logistic regression showed that stroke after procedures was higher in patients with CCO than without CCO (odds ratio, 1.73; 95% confidence interval, 1.08-2.76; P = .02), but specific procedure (CEA vs CAS) was not associated with stroke while controlling for confounders. However, when evaluating our secondary composite outcome, CCO was not associated with the outcome while controlling for confounders. CONCLUSIONS: There is currently a bias that CCO confers a higher risk on patients undergoing carotid procedures and this notion is manifest in the proportion of CEA and CAS procedures done in the setting of CCO. Our study observes that CCO provides only a minor influence on periprocedural stroke risk and that other factors are more closely tied to outcomes of CEA and CAS.

Emergency General Surgery-A Misnomer?

Emergency general surgery (EGS) is defined as the urgent assessment and treatment of nontrauma, general surgical emergencies involving adults. Acute surgical emergencies often represent the most common reason for hospital admission with diagnoses, including bowel obstruction and appendicitis. EGS is a growing surgical subspecialty that includes both operative and nonoperative management of acutely ill patients. We sought to assess the burden of nonoperative care in EGS patients at our academic medical center. This study was conducted by retrospective analysis of prospectively collected data from patients entered into the Duke EGS Registry between July 1, 2016 and September 10, 2017. Fifty-six per cent (n = 771) of patients in the Duke EGS Registry (n = 1377) were managed nonoperatively as compared with 44 per cent (n = 606) who were managed operatively. Nonoperative management of disease represents a large subset of EGS and, therefore, needs further investigation to improve processes, outcomes, and standardization of care.

The risk of carotid stenosis in head and neck cancer patients after radiation therapy.

OBJECTIVES: Head and neck radiotherapy (RT) is a risk factor for cerebrovascular disease. We performed a retrospective cohort study to evaluate carotid artery stenosis (CAS) incidence in head and neck cancer (HNC) patients undergoing RT, characterizing associated risk factors. MATERIALS AND METHODS: Records were retrospectively reviewed for HNC patients undergoing carotid ultrasound screening after definitive or adjuvant RT between January 2000 and May 2016. CAS was defined as ≥50% stenosis on imaging, stroke, or transient ischemic attack. Actuarial CAS rates were calculated by Kaplan-Meier method. Univariate and multivariate analyses predicted CAS risk based on carotid dosimetric and clinical parameters. RESULTS: 366 patients met inclusion criteria. Median time from RT completion to last follow-up was 4.1 yr. Actuarial risk for CAS was 29% (95% CI 22-36%) at 8 years. Univariate analysis showed that smoking (HR 1.7; 95% CI 1.1-2.7), hyperlipidemia (HR 1.6; 95% CI 1.03-2.6), diabetes (HR 2.8; 95% CI 1.6-4.8), coronary artery disease (HR 2.4; 95% CI 1.4-4.2), and peripheral artery disease (HR 3.6; 95% CI 1.1-11.6) were significantly associated with increased CAS. In multivariate analysis, diabetes was predictive of time to CAS (HR 1.9; 95% CI 1.1-3.4). Carotid dose parameters were not significantly associated with CAS. CONCLUSIONS: CAS incidence is high after head and neck radiotherapy, gradually rising over time. No clear dose-response effect between carotid dose and CAS was identified for HNC patients. Carotid artery screening and preventative strategies should be employed in this high-risk patient population.