The latest medical research on Endovascular surgery
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Request AccessThe Rationale for Using Fixed-Dose Combination Therapy in the Management of Hypertension in Colombia: A Narrative Review.
Cardiovascular DrugsHypertension is a major risk factor for cardiovascular disease and the leading cause of death in Colombia. While the rate of hypertension awareness...
Collaborative Approach toward Transplant Candidacy for Obese End-Stage Renal Disease Patients.
American College of SurgeonsAn elevated Body Mass Index (BMI) is a major cause of transplant preclusion for patients with End Stage Renal Disease (ESRD). This phenomenon exacerbates existing socioeconomic and racial disparities and increases the economic burden of maintaining patients on dialysis. Metabolic Bariatric Surgery (MBS) in such patients is not widely available. Our center created a collaborative program to undergo weight loss surgery before obtaining a kidney transplant.
We studied the outcomes of these patients post MBS and transplant surgery. One hundred and eighty-three ESRD patients were referred to the bariatric team by the transplant team between Jan 2019 through June 2023. Of these, 36 underwent MBS (20 RYGB, 16 SG), and 10 underwent subsequent transplantation, with another 15 currently waitlisted. Both surgical teams shared resources, including dieticians, social workers, and a common database, for easy transition between teams.
The mean starting BMI for all referrals was 46.4 kg/m2 and was 33.9 kg/m2 at the time of transplant. The average number of hypertension medications decreased from 2.0 (range 2.0 to 4.0) pre-surgery to 1.0 (range 1.0 to 3.0) post-surgery. Similarly, HbA1C levels improved, with pre-operative averages at 6.2 (range 5.4 to 7.6) and postoperative levels at 5.2 (range 4.6 to 5.8) All transplants are currently functioning, with a median creatinine of 1.5 (1.2 - 1.6) mg/dl (GFR 46 (36.3 - 71.0)).
A collaborative approach between bariatric and transplant surgery teams offers a pathway toward transplant for obese ESRD patients, and potentially alleviates existing healthcare disparities. ESRD patients that undergo MBS have unique complications to be aware of. The improvement in comorbidities may lead to superior post-transplant outcomes.
Barriers to Black Medical Students and Residents Pursuing and Completing Surgical Residency in Canada: A Qualitative Analysis.
American College of SurgeonsThe limited available data suggest that the Canadian surgical workforce does not reflect the racial diversity of the patient population it serves, despite the well-established benefits of patient-provider race concordance. There have been no studies to date that characterize the systemic and individual challenges faced by Black medical students in matching to and successfully finishing training in a surgical specialty within a Canadian context that can explain this underrepresentation.
Using critical qualitative inquiry and purposive sampling to ensure gender, geographical, and student/trainee year heterogeneity, we recruited self-identifying Black medical students and surgical residents across Canada. Online in-depth semi-structured interviews were conducted and transcribed verbatim. Transcripts were analyzed through an inductive reflexive narrative thematic process by four analysts.
27 participants including 18 medical students and 9 residents, were interviewed. The results showed three major themes that characterized their experiences: journey to and through medicine, perceptions of the surgical culture, and recommendations to improve the student experience. Medical students identified lack of mentorship and representation, as well as experiences with racism as the main barriers to pursuing surgical training. Surgical trainees cited systemic racism, lack of representation and insufficient safe spaces as the key deterrents to program completion. The intersection with gender exponentially increased these identified barriers.
Except for a few surgical programs, medical schools across Canada do not offer a safe space for Black students and trainees to access and complete surgical training. An urgent change is needed to provide diverse mentorship that is transparent, acknowledges the real challenges related to systemic racism and biases, and is inclusive of different racial and ethnic backgrounds.
New Perspectives on the Role and Therapeutic Potential of Melatonin in Cardiovascular Diseases.
Cardiovascular DrugsCardiovascular diseases (CVDs) are the leading cause of death and disability worldwide. It is essential to develop novel interventions to prevent/d...
Effect of Behavioral Health Disorders on Surgical Outcomes in Cancer Patients.
American College of SurgeonsBehavioral health disorders (BHD) can often be exacerbated in the setting of cancer. We sought to define the prevalence of BHD among cancer patients and characterize the association of BHD with surgical outcomes.
Patients diagnosed with lung, esophageal, gastric, liver, pancreatic, and colorectal cancer between 2018-2021 were identified within Medicare Standard Analytic Files. Data on BHD defined as substance abuse, eating disorder, or sleep disorder were obtained. Post-operative textbook outcome (TO)(i.e., no complications, prolonged length of stay, 90-day readmission, or 90-day mortality), as well as in-hospital expenditures and overall survival were assessed.
Among 694,836 cancer patients, 46,719 (6.7%) patients had at least one BHD. Patients with BHD were less likely to undergo resection (no BHD: 23.4% vs. BHD: 20.3%; p<0.001). Among surgical patients, individuals with BHD had higher odds of a complication (OR 1.32 [1.26-1.39]), prolonged length of stay (OR 1.36 [1.29-1.43]), and 90-day readmission (OR 1.57 [1.50-1.65]) independent of social vulnerability or hospital volume status, resulting in lower odds to achieve a TO (OR 0.66 [0.63-0.69]). Surgical patients with BHD also had higher in-hospital expenditures (no BHD: $16,159 vs. BHD: $17,432; p<0.001). Of note, patients with BHD had worse long-term post-operative survival (median, no BHD: 46.6 [45.9-46.7] vs. BHD: 37.1 [35.6-38.7] months) even after controlling for other clinical factors (HR 1.26 [1.22-1.31], p<0.001).
BHD was associated with lower likelihood to achieve a postoperative TO, higher expenditures, as well as worse prognosis. Initiatives to target BHD are needed to improve outcomes of cancer patients undergoing surgery.
Outcomes and Management of Re-Establishing Bariatric Patients.
American College of SurgeonsLifelong follow-up after metabolic/bariatric surgery (MBS) is necessary to monitor for patient outcomes and nutritional status. However, many patients do not routinely follow up with their MBS team. We studied what prompted MBS patients to seek bariatric care after being lost to follow-up and the subsequent treatments they received.
A retrospective cohort study of patients after MBS who had discontinued regular MBS follow-up but represented to the MBS clinic between July 2018 and December 2022 to re-establish care. Patients with a history of a Sleeve Gastrectomy (SG), Roux-En-Y Gastric Bypass (RYGB), and Adjustable Gastric Banding (AGB) were included.
We identified 400 patients (83.5% female, mean age 50.3 ± 12.2 years at the time of RBC), of whom 177 (44.3%) had RYGB, 154 (38.5%) had SG, and 69 (17.2%) had AGB. Overall, recurrent weight gain (RWG) was the most common reason for presentation for all three procedures (81.2% in SG, 62.7% in RYGB, and 65.2% in AGB; p<.001). SG patients were more likely to undergo a revision MBS compared to RYGB patients (16.9% vs. 5.8%, p<.001), while RYGB patients were more likely to undergo an endoscopic intervention than SG patients (17.5% vs. 7.8%, p<.001). The response to AOM agents, specifically GLP-1 drugs, was better in RYGB patients, than SG patients.
This study highlights RWG as the most common reason for patients after MBS seeking to re-establish care with the MBS team. SG had a higher rate of revision MBS than RYGB, whereas endoscopic interventions were performed more frequently in the RYGB group. AOM, especially GLP-1 drugs, were more effective in RYGB patients.
Acetazolamide as an Adjunctive Diuretic Therapy for Patients with Acute Decompensated Heart Failure: A Systematic Review and Meta-Analysis.
Cardiovascular DrugsThis systematic review was prospectively registered on the PROSPERO ( https://www.crd.york.ac.uk/PROSPERO/ ), registration number CRD498330.
PubMed/Medline, Cochrane Library, and Scopus were searched from inception until July 2023, for randomized and nonrandomized studies evaluating acetazolamide as add-on diuretic in patients with acute decompensated HF. Data about natriuresis, urine output, decongestion, and the clinical signs of congestion were extracted, pooled, and analyzed. Data were pooled using a random effects model. Results were presented as risk ratios (RRs), odds ratios (ORs), or weighted mean differences (WMD) with 95% confidence intervals (95% CIs). Certainty of evidence was assessed using the grading of recommendation, assessment, development, and evaluation (GRADE) approach. A P value of < 0.05 was considered significant in all cases.
A total of 5 studies (n = 684 patients) were included with a median follow-up time of 3 months. Pooled analysis demonstrated significantly increased natriuresis (MD 55.07, 95% CI 35.1-77.04, P < 0.00001; I2 = 54%; moderate certainty), urine output (MD 1.04, 95% CI 0.10-1.97, P = 0.03; I2 = 79%; moderate certainty) and decongestion [odds ratio (OR) 1.62, 95% CI 1.14-2.31, P = 0.007; I2 = 0%; high certainty] in the acetazolamide group, as compared with controls. There was no significant difference in ascites (RR 0.56, 95% CI 0.23-1.36, P = 0.20; I2 = 0%; low certainty), edema (RR 1.02, 95% CI 0.52-2.0, P = 0.95; I2 = 45%; very low certainty), raised jugular venous pressure (JVP) (RR 0.86, 95% CI 0.63-1.17, P = 0.35; I2 = 0%; low certainty), and pulmonary rales (RR 0.82, 95% CI 0.44-1.51, P = 0.52; I2 = 25%; low certainty) between the two groups.
Acetazolamide as an adjunctive diuretic significantly improves global surrogate endpoints for decongestion therapy but not all individual signs and symptoms of volume overload.
Eligibility and Cost-Utility Analysis of Dapagliflozin in Patients with Heart Failure Across the Whole Spectrum of Ejection Fraction in South Korea.
Cardiovascular DrugsThe DAPA-HF and DELIVER trials demonstrated the clinical benefits of dapagliflozin in heart failure (HF) patients across the entire ejection fraction (EF) spectrum. However, further investigation is needed for the real-world application of dapagliflozin in HF patients. This study examines the proportion of real-world HF patients eligible for dapagliflozin and evaluates the cost-effectiveness of adding dapagliflozin to current HF therapy.
Data from the nationwide prospective registry, the Korean Acute Heart Failure (KorAHF) registry, were used to determine dapagliflozin eligibility based on the enrollment criteria of the DAPA-HF/DELIVER trials. A cost-utility analysis was conducted using a Markov model to assess the cost-effectiveness of dapagliflozin by comparing it to the standard of care.
Out of 5178 KorAHF patients, 48.7% met the enrollment criteria of the DAPA-HF/DELIVER trials, while 89.5% met the label criteria (US Food and Drug Administration, European Medicines Agency, and Korean Ministry of Food and Drug Safety). Eligibility was highest among HF patients with preserved EF (55.3% vs. HF with mildly reduced EF and HF with reduced EF 46.4%). Dapagliflozin proved to be cost-effective, with an incremental cost-effectiveness ratio (ICER) of 4557 US dollar (US$) per quality-adjusted life year, which falls below the US$18,182 willingness-to-pay threshold. The cost-effectiveness benefit was more pronounced in patients with a left ventricular EF (LVEF) ≤ 40% (ICER US$3279 for LVEF ≤ 40% vs. US$8383 for LVEF > 40%).
Discrepancies in dapagliflozin eligibility were observed between real-world data and clinical trial results. The addition of dapagliflozin to HF therapy proved to be highly cost-effective across the entire EF spectrum.
Comparative Effectiveness and Safety of Direct Oral Anticoagulants Compared with Warfarin in Patients with Low Bodyweight who have Atrial Fibrillation: A Systematic Review and Meta-analysis.
Cardiovascular Drugsoral anticoagulant (DOAC) agents are becoming the anticoagulation strategy of choice for most clinical risks for which they are indicated. However, residual uncertainty remains regarding their use in preventing stroke in patients with low bodyweight [< 60 kg or body mass index (BMI) < 18 kg/m2]. We have carried out pooled systematic analyses of published studies to determine the efficacy and safety of these agents compared with warfarin in stroke prevention in patients with low bodyweight.
We carried out a comprehensive search of electronic databases from inception to June 2023 for eligible studies reporting on the efficacy and safety of direct oral anticoagulants versus warfarin in patients with atrial fibrillation who had low bodyweight. These include PubMed, EMBASE, the Cochrane Database of Systematic Reviews, the Science Citation Index, and the Database of Abstracts of Reviews of Effectiveness. Using the random effects model, derived pooled odd ratios (with their corresponding confidence intervals) of mortality outcomes in patient cohorts exposed to direct oral anticoagulants versus warfarin in patients with atrial fibrillation who had low bodyweight.
Nine studies (n = 159,514 patients) were included in our meta-analysis. DOAC analogs were associated with lower stroke recurrence compared with warfarin [odds ratio (OR) 0.66, 95% confidence interval (CI) 0.49-0.9]; however, there was no significant difference in the composite outcome (OR 0.81, 95% CI 0.59-1.09) and mortality (OR 0.82, 95% CI 0.48-1.41). Additionally, DOAC analogs showed a significant reduction in major bleeding events by 30% compared with warfarin (OR 0.70, 95% CI 0.62-0.80).
In this pooled meta-analytical synthesis of studies comprising both real-world and randomized controlled data, the use of DOAC analogs in patients with atrial fibrillation and low bodyweight (< 60 kg or BMI < 18 kg/m2) was associated with a significant reduction in risks of stroke and major bleeding compared with patient cohorts stabilized on warfarin-based therapy. There was uncertainty regarding the composite outcome and mortality point estimate between these two anticoagulation strategies. This finding helps to resolve the uncertainty associated with the use of DOACs in this cohort. Additionally, it suggests the need for confirmatory non-inferiority randomized controlled trials evaluating DOACs versus warfarin in this cohort of patients.
Acute Intraoperative Conversion from Endovascular to Open vs Planned Open Operation for Abdominal Aortic Aneurysm: A Propensity-Score Matched Study from the American College of Surgeons NSQIP Targeted Database.
American College of SurgeonsEvaluating outcomes for acute intraoperative conversion to open surgery during endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) was difficult due to low incidence. This study aimed to compare 30-day outcomes between patients with acute intraoperative conversion during EVAR and planned open surgery, and to identify risk factors associated with acute conversion.
Patients underwent EVAR or planned open AAA repair were identified in ACS-NSQIP targeted databases 2012-2021. Patients with acute intraoperative conversion during EVAR were selected. A 1:3 propensity-score matching was used to match demographics, baseline characteristics, surgical indications, aneurysm size and extent, and emergency cases between the conversion open and planned open groups. Thirty-day postoperative outcomes were assessed.
Out of 20,566 EVAR, 177 (0.86%) had acute intraoperative conversion to open surgery. The conversion open group was matched to 504 out of 5,249 planned open patients. Conversion open and planned open groups had comparable 30-day mortality (23.43% vs 17.46%, p=0.09) and organ system complications including MACE (14.86% vs 10.71%, p=0.17), pulmonary complications (17.71% vs 24.01%, p=0.09), and renal complications (8.57% vs 11.11%, p=0.39). The conversion open group had lower bleeding requiring transfusion (48.57% vs 75.60%, p<0.01), shorter operation time (p<0.01), and shorter length of stay (p<0.01). Other postoperative outcomes did not differ. Risk factors associated with acute intraoperative conversion included ruptured aneurysm with or without hypotension. Protective factors included hypertension and aortic distal aneurysm extent.
While this study does not endorse a universal "EVAR first" strategy for all patients with AAA, EVAR can be attempted first in eligible AAA patients. Even when EVAR is unsuccessful, intraoperative conversion to open surgery still appears to be safe compared to planned open repair.
Remission of Obesity-Related Sleep Apnea and Its Effect on Mortality and Cardiovascular Events After Metabolic and Bariatric Surgery: A Propensity Matched Cohort Study.
American College of SurgeonsWhile obstructive sleep apnea (OSA) is common among patients with obesity and linked to cardiovascular disease, there is a lack of studies evaluating the effects of reaching remission from OSA after metabolic and bariatric surgery (MBS).
A registry-based nationwide study including patients operated with sleeve gastrectomy or Roux-en-Y gastric bypass from 2007 until 2019 in Sweden. Patients who reached remission of OSA were compared to those who did not reach remission, and a propensity score matched control group of patients without OSA at the time of operation. Main outcome was overall mortality, secondary outcome was major cardiovascular events (MACE).
In total, 5892 patients with OSA and 11,552 matched patients without OSA completed a 1-year follow-up and were followed for a median of 6.8 years. Remission of OSA was seen for 4334 patients (74%). Patients in remission had a lower risk for overall mortality (cumulative incidence 6.0% v. 9.1%;p<0.001) and MACE (cumulative incidence 3.4% vs 5.8%;p<0.001) at 10-years after operation compared to those who did not reach remission. The risk was similar to that of the control group without OSA at baseline (cumulative incidence for mortality 6.0%, p=0.493, for MACE 3.7%, p=0.251).
The remission rate of OSA was high after MBS. This was in turn associated with reduced risk for death and MACE compared to patients who did not achieve remission reaching a similar risk seen among patients without OSA at baseline. A diligent follow-up of patients who do not reach remission remains important.
Refractory and Recurrent Idiopathic Granulomatous Mastitis Treatment: Adaptive, Randomized Clinical Trial.
American College of SurgeonsIdiopathic Granulomatous Mastitis (IGM) is mostly described as an autoimmune disease with high prevalence among Middle Eastern childbearing-age women. The current study aimed to evaluate the best treatment of choice in patients with resistant or recurrent IGM.
Patients with established recurrent or resistant IGM who were referred to the breast cancer research center from 2017 to 2020 were randomly assigned to either one of the following treatment groups: A (Best supportive care), B (corticosteroids: prednisolone), and C (methotrexate and low dose corticosteroids). This adaptive clinical trial evaluated radiological and clinical responses, as well as the possible side effects, on a regular basis in each group, with patients followed up for a minimum of 2 years.
A total of 318 participants, with a mean age of 33.52 ± 6.77 years, were divided into groups A (10 patients), B (78 patients), and C (230 patients). In group A, no therapeutic response was observed; group B exhibited a mixed response, with 14.1% experiencing complete or partial responses, 7.7% maintaining stability, and 78.2% experiencing disease progression. Accordingly, groups A and B were terminated due to inadequate response. In group C, 94.3% achieved complete response, 3% partial remission, and 2.7% no response. Among the entire patient cohort, 11.6% tested positive for anti-nuclear antibodies (ANA), 3.5% for angiotensin-converting enzyme (ACE), and 12.3% for erythema nodosum (EN). Notably, hypothyroidism was a prevalent condition among the patients, affecting 7.2% of the cohort. Furthermore, the incidence of common side effects was consistent across all groups.
The most effective treatment option for patients with recurrent or resistant idiopathic granulomatous mastitis is a combination therapy involving steroids and disease-modifying antirheumatic drugs such as methotrexate.