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INTRODUCTION: Deep venous stent placement has developed into a primary treatment modality for venous obstruction in recent decades. Reported rates of complications are low in the literature and are based mainly on case reports and single-centre cohorts. Interventionalists performing these procedures must be aware of the occurrence of complications associated with stent placement to counsel patients adequately and promote avoidance through optimal procedural approach. This study aims to determine the incidence of serious complications associated with iliocaval and iliofemoral stent placement in a cohort of patients from 3 major tertiary deep venous referral centres. METHODS: Data were collated from January 2014 to September 2023. The following major complications were included in the analysis: death, major bleeding requiring transfusion, massive pulmonary embolism, any complication which required endovascular or open surgical intervention, vessel rupture, acute kidney injury requiring dialysis, stent crushing, fracture, migration, involution or erosion. RESULTS: One thousand eight hundred fourteen (1814) patients were treated for acute or chronic deep venous pathology during the 9-year study period. Sixty-one patients (3.3%) experienced a major stent-related complication. The most frequently reported complication was stent crushing (n = 18, 29.5%), followed by stent fracture (n = 10, 16.4%) and erosion of the stent through the vessel wall (n = 8, 13.1%). Death was a rare event (0.2%). CONCLUSION: Deep venous stent placement is a safe procedure with low rates of major complications. It is incumbent upon operators to be aware of the risks associated with these procedures, however, rare, so that they may obtain fully informed consent from patients.

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[This corrects the article DOI: 10.1371/journal.pone.0220480.].

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OBJECTIVES: To determine whether implementation of comprehensive in-school eyecare results in measurable benefits for children and young people in terms of visual status, classroom behaviours and how well their visual needs are met. DESIGN: School-based observational study. PARTICIPANTS & METHODS: 200 pupils [mean age 10 years 9 months, 70% male, majority moderate (40%) or severe (35%) learning difficulty] of a special education school in the UK. A sector-agreed in-school eyecare framework including full eye examination and cycloplegic refraction, dispensing of spectacles (as appropriate) and written reporting of outcomes to parents/teachers was applied. Classroom behaviours were observed and recorded prior to, and after, the in-school eyecare. Surveys were employed to obtain visual histories from parents/teachers. School records and statutory documents were reviewed for diagnostic and learning disability classifications. Visual function and ocular health were profiled at baseline and significant visual deficits identified. Where such deficits were previously unrecognised, untreated or not compensated for (e.g. correction of refractive error, enlargement of educational material) they were recorded as 'unmet visual need'. At follow-up, 2-5 months after initial (baseline) measures, eye examinations, parent/teacher surveys and behaviour observations were repeated. Follow-up measures were used to determine if measurable improvements were evident in visual function, ocular health, the level of unmet need and classroom behaviour following implementation of in-school eyecare. RESULTS: 199 participants completed baseline and follow-up measures. 122 (61%) participants presented with at least one significant visual or ocular health deficit and 90 (45%) participants had at least one unmet visual need. Younger pupils and those with no previous history of eyecare were more likely to demonstrate unmet visual needs at baseline (OR 1.12 95% CI 1.03 to 1.21) p = 0.012; (OR 4.44 95% CI 1.38 to 14.29 p = 0.007 respectively). On follow-up, the number of pupils with unmet visual needs dropped significantly to 36 (18%) (McNemar's test p<0.001). Visual and behavioural metrics of participants without significant visual deficits or whose visual needs were adequately addressed at baseline remained relatively unchanged between baseline and follow-up (Wilcoxon signed rank p>0.05). Where significant refractive deficits were corrected at follow-up, near visual acuity improved significantly (Wilcoxon signed rank p = 0.013), however, poor spectacle compliance was a persistent cause of unmet visual need. Off-task behaviour reduced significantly after actions to address unmet visual needs were communicated to parents and teachers (Wilcoxon signed rank p = 0.035). CONCLUSIONS: The present study demonstrates for the first time measurable visual and behaviour benefits to children in special education settings when they receive comprehensive in-school eye examinations, on-site spectacle dispensing and jargon-free reporting of outcomes to teachers and parents.

Asunto(s)

Conducta Infantil , Educación Especial , Servicios de Salud Escolar , Selección Visual/métodos , Visión Ocular , Niño , Femenino , Humanos , Discapacidades para el Aprendizaje/complicaciones , Discapacidades para el Aprendizaje/psicología , Masculino , Trastornos de la Visión/complicaciones , Trastornos de la Visión/diagnóstico , Trastornos de la Visión/terapia

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Understanding what drives breast tumor progression is of utmost importance for blocking tumor metastasis; we have identified that semaphorin 7a is a potent driver of ductal carcinoma in situ (DCIS) progression. Semaphorin 7a is a glycophosphatidylinositol membrane-anchored protein that promotes attachment and spreading in multiple cell types. Here, we show that increased expression of SEMA7A occurs in a large percentage of breast cancers and is associated with decreased overall and distant metastasis-free survival. In both in vitro and in vivo models, short hairpin-mediated silencing of SEMA7A reveals roles for semaphorin 7a in the promotion of DCIS growth, motility and invasion as well as lymphangiogenesis in the tumor microenvironment. Our studies also uncover a relationship between COX-2 and semaphorin 7a expression and suggest that semaphorin 7a promotes tumor cell invasion on collagen and lymphangiogenesis via activation of ß1-integrin receptor. Our results suggest that semaphorin 7a may be novel target for blocking breast tumor progression.

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Antígenos CD/genética , Neoplasias de la Mama/genética , Carcinoma Intraductal no Infiltrante/genética , Ciclooxigenasa 2/genética , Neoplasias Mamarias Animales/genética , Semaforinas/genética , Animales , Antígenos CD/administración & dosificación , Neoplasias de la Mama/patología , Carcinoma Intraductal no Infiltrante/patología , Movimiento Celular/genética , Ciclooxigenasa 2/biosíntesis , Progresión de la Enfermedad , Femenino , Proteínas Ligadas a GPI/administración & dosificación , Proteínas Ligadas a GPI/genética , Regulación Neoplásica de la Expresión Génica , Pleiotropía Genética , Humanos , Linfangiogénesis/genética , Neoplasias Mamarias Animales/patología , Ratones , Semaforinas/administración & dosificación , Transducción de Señal

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This study describes how a vascular centre rationalised their blood transfusion policy. A multidisciplinary panel reviewed data for blood transfusion protocols and implemented improvements that were analysed. The number of units cross-matched fell from 272 to 183 over a six month period. Unused blood reduced from 80% to 61%. The study concluded that rationalisation of cross matching policies is safe and provides cost and resource benefits.

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Tipificación y Pruebas Cruzadas Sanguíneas/economía , Tipificación y Pruebas Cruzadas Sanguíneas/normas , Transfusión Sanguínea/economía , Transfusión Sanguínea/normas , Procedimientos Quirúrgicos Vasculares/economía , Procedimientos Quirúrgicos Vasculares/normas , Análisis Costo-Beneficio , Humanos , Guías de Práctica Clínica como Asunto , Estudios Retrospectivos , Reino Unido

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OBJECTIVE: Endoscopic vein harvesting (EVH) for arterial bypass surgery may be associated with lower wound complication rates than open vein harvesting (OVH), but other long-term outcomes remain controversial, and there are concerns that graft patency may be poorer after EVH compared with OVH. We conducted a systematic review of all available evidence for EVH in lower extremity arterial bypass (LEAB). METHODS: A literature search of Medline, Embase, Ovid and Cochrane databases between 1996 and 2013 was performed using the terms "endoscopic vein harvesting", "minimally invasive vein harvest", "peripheral bypass surgery", and "lower extremity bypass surgery", and detailed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Primary outcomes were graft patency and overall wound complication rates. Secondary outcomes were wound infection, length of hospital stay, and cost-effectiveness. Summary estimates were calculated by random effects meta-analysis if sufficient data were available. RESULTS: We identified 18 cohort studies and case series, with considerable clinical heterogeneity, including 2,343 patients. Meta-analysis of six studies revealed a significantly reduced rate of primary patency after EVH (hazard ratio 1.29, 95% confidence interval [CI] 1.03-1.63), with no significant difference between EVH and OVH with respect to wound infection in 12 studies (odds ratio 0.81, 95% CI 0.61-1.08). There was a lack of strong evidence to support the secondary outcomes of EVH. CONCLUSION: EVH reduces primary patency rates after LEAB, but does not demonstrate an advantage with respect to postoperative wound complications. However, the available data are heterogeneous, and uncertainty is introduced by both evolution in technology and increasing technical experience. EVH should be used with caution and in the context of formal research.

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Endoscopía , Extremidad Inferior/irrigación sanguínea , Enfermedad Arterial Periférica/cirugía , Recolección de Tejidos y Órganos/métodos , Análisis Costo-Beneficio , Endoscopía/efectos adversos , Endoscopía/economía , Costos de la Atención en Salud , Humanos , Tiempo de Internación , Oportunidad Relativa , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/economía , Enfermedad Arterial Periférica/fisiopatología , Factores de Riesgo , Infección de la Herida Quirúrgica/etiología , Factores de Tiempo , Recolección de Tejidos y Órganos/efectos adversos , Recolección de Tejidos y Órganos/economía , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Venas/fisiopatología , Venas/trasplante

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INTRODUCTION: Adoption of endovascular aneurysm repair (EVAR) has led to significant reductions in the short-term morbidity and mortality associated with abdominal aortic aneurysm (AAA) repair. However, EVAR may expose both patient and interventionalist to potentially harmful levels of radiation, particularly as more complex procedures are undertaken. The aim of this study was to assess whether changing from radiographer-controlled imaging to a system of operator-controlled imaging (OCI) would influence radiation exposure, screening time or contrast dose during EVAR. METHOD: Retrospective analysis identified patients that had undergone elective EVAR for infra-renal AAA before or after the change to operator-controlled imaging. Data were collected for radiation dose (measured as dose area product; DAP), screening time, total delivered contrast volume and operative duration. Data were also collected for maximum aneurysm diameter, patient age, gender and body mass index. RESULTS: 122 patients underwent EVAR for infra-renal AAA at a single centre between January 2011 and December 2011. 57 of these were prior to installation of OCI and 65 after installation. Median DAP was significantly lower after installation of OCI (4.9 mGy m(2); range 1.25-13.3) than it had been before installation (6.9 mGy m(2); range 1.91-95.0) (p = 0.005). Median screening times before and after installation of OCI were 20.0 min and 16.2 min respectively (p = 0.027) and median contrast volumes before and after the change to OCI were 100 ml and 90 ml respectively (p = 0.21). CONCLUSION: Introduction of operator-controlled imaging can significantly reduce radiation exposure during EVAR, with particular reduction in the number of 'higher-dose' cases.

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Angiografía/métodos , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Procedimientos Endovasculares/métodos , Fluoroscopía/métodos , Dosis de Radiación , Traumatismos por Radiación/prevención & control , Radiografía Intervencional/métodos , Anciano , Angiografía/efectos adversos , Aneurisma de la Aorta Abdominal/cirugía , Prótesis Vascular , Femenino , Fluoroscopía/efectos adversos , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Traumatismos por Radiación/epidemiología , Traumatismos por Radiación/etiología , Radiografía Intervencional/efectos adversos , Estudios Retrospectivos , Medición de Riesgo , Stents , Factores de Tiempo , Resultado del Tratamiento , Reino Unido/epidemiología

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The use of systemic heparin in patients with ruptured abdominal aortic aneurysms (rAAAs) remains a contentious issue with no clear guidelines. This review reports the current understanding, at a molecular and clinical level, of the possible benefits and risks of heparin in emergency aneurysm repair (both open and endovascular). MEDLINE, EMBASE, AMED, SCOPUS, CINAHL and Cochrane Library were searched for all articles containing the keywords 'rupture', 'abdominal', 'aneurysm' and 'heparin'. Current experience, indications and outcomes were analyzed. Articles were searched for both endovascular and open repair of AAAs. A total of eight studies were included for analysis in the systematic review. Of these, only one paper focused specifically on heparin use in open repair of ruptures and suggested a benefit. Of the remaining seven, two were self-reporting retrospective studies assessing individual surgeons' practice, one was a case report and the remaining four included mention of heparin use but with no outcome data. The evidence available suggests that a pro-coagulable state exists in rAAAs. This may be responsible for the morbidity and mortality postprocedure, which arises predominantly from multiple organ failure and cardiac compromise rather than outright hemorrhage. This diathesis may respond well to heparin administration, suggesting that heparin administration in ruptured aneurysms is appropriate.

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Anticoagulantes/uso terapéutico , Aneurisma de la Aorta Abdominal/tratamiento farmacológico , Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/tratamiento farmacológico , Coagulación Sanguínea/efectos de los fármacos , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Heparina/uso terapéutico , Anticoagulantes/efectos adversos , Aneurisma de la Aorta Abdominal/sangre , Aneurisma de la Aorta Abdominal/mortalidad , Rotura de la Aorta/sangre , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Medicina Basada en la Evidencia , Heparina/efectos adversos , Humanos , Guías de Práctica Clínica como Asunto , Medición de Riesgo , Factores de Riesgo , Resultado del Tratamiento

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INTRODUCTION: The effectiveness of percutaneous access with large vessel closure (pEVR) in non-selective groups of patients undergoing endovascular aneurysm repair (EVR) remains unclear. This study aims to identify factors that predict success in pEVR, performed using percutaneous access and the Prostar XL (Abbott Vascular, Redwood City, Calif) closure device. METHOD: Consecutive patients who underwent pEVR between April 2010 and March 2011 were identified from a prospectively maintained database. Procedural and postoperative outcomes were compared with consecutive patients who underwent endovascular aneurysm repair using standard open femoral access between April 2008 and March 2009. To determine the predictors of technical success of pEVR, the association between clinical, anatomical and procedural variables with technical success, were examined in a multiple logistic regression model. RESULTS: pEVR was attempted in 186 common femoral arteries (CFAs) with a technical success rate of 95.2% (177/186). Conventional open femoral access in the historic control group was performed in 208 CFAs. pEVR was associated with a reduced operation length (131 min [105-152] versus 150 min [124-195], p≤0.001) and length of stay (2 days [2-5] versus 4 days [2-7], p = 0.01) in patients undergoing infrarenal EVR. In secondary analysis of outcomes following percutaneous access in 91 CFAs, pre-operative renal failure, CFA depth (min and max), CFA diameter (min and max) and operator experience predicted success of percutaneous access in univariate analysis. Operator experience was the only independent predictor of technical success (p = 0.05) after adjustment for all confounding variables. CONCLUSION: pEVR using the Prostar XL device is effective in the majority of patients. In this study there were benefits in terms of reduced postoperative complications, shorter procedures and decreased lengths of stay. Operator experience is a predictor of technical success for pEVR, irrespective of clinical and morphological characteristics at baseline.

Asunto(s)

Aneurisma de la Aorta/cirugía , Procedimientos Endovasculares/métodos , Anciano , Femenino , Humanos , Masculino , Pronóstico , Estudios Prospectivos

RESUMEN

Hybrid procedures for the repair of thoracoabdominal aneurysms have become more widely reported in the literature in the past few years. This procedure was developed as an alternative to the traditional method of open thoracoabdominal repair in the absence of a viable total endovascular solution for all cases. The early results of the procedure encouraged more centers to use a hybrid solution in the treatment of complex aortic pathology. This article evaluates the current status of this procedure and future developments.

Asunto(s)

Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Stents , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aortografía/métodos , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/efectos adversos , Humanos , Selección de Paciente , Diseño de Prótesis , Tomografía Computarizada por Rayos X , Resultado del Tratamiento

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Cholinergic neurons rely on the sodium-dependent choline transporter CHT to provide choline for synthesis of acetylcholine. CHT cycles between cell surface and subcellular organelles, but little is known about regulation of this trafficking. We hypothesized that activation of protein kinase C with phorbol ester modulates choline uptake by altering the rate of CHT internalization from or delivery to the plasma membrane. Using SH-SY5Y cells that stably express rat CHT, we found that exposure of cells to phorbol ester for 2 or 5 min significantly increased choline uptake, whereas longer treatment had no effect. Kinetic analysis revealed that 5 min phorbol ester treatment significantly enhanced V(max) of choline uptake, but had no effect on K(m) for solute binding. Cell-surface biotinylation assays showed that plasma membrane levels of CHT protein were enhanced following 5 min phorbol ester treatment; this was blocked by protein kinase C inhibitor bisindolylmaleimide-I. Moreover, CHT internalization was decreased and delivery of CHT to plasma membrane was increased by phorbol ester. Our results suggest that treatment of neural cells with the protein kinase C activator phorbol ester rapidly and transiently increases cell surface CHT levels and this corresponds with enhanced choline uptake activity which may play an important role in replenishing acetylcholine stores following its release by depolarization.

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Encéfalo/metabolismo , Proteínas del Tejido Nervioso/efectos de los fármacos , Neuronas/efectos de los fármacos , Proteínas de Transporte de Neurotransmisores en la Membrana Plasmática/efectos de los fármacos , Proteína Quinasa C/efectos de los fármacos , Acetato de Tetradecanoilforbol/análogos & derivados , Acetilcolina/biosíntesis , Animales , Línea Celular Tumoral , Membrana Celular/efectos de los fármacos , Membrana Celular/metabolismo , Endocitosis/efectos de los fármacos , Endocitosis/fisiología , Activación Enzimática/efectos de los fármacos , Activación Enzimática/fisiología , Inhibidores Enzimáticos/farmacología , Cinética , Potenciales de la Membrana/efectos de los fármacos , Potenciales de la Membrana/fisiología , Proteínas del Tejido Nervioso/metabolismo , Neuronas/metabolismo , Fosforilación/efectos de los fármacos , Fosforilación/fisiología , Proteínas de Transporte de Neurotransmisores en la Membrana Plasmática/metabolismo , Proteína Quinasa C/metabolismo , Transporte de Proteínas/efectos de los fármacos , Transporte de Proteínas/fisiología , Ratas , Acetato de Tetradecanoilforbol/farmacología

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BACKGROUND: Methods of surgical training that do not put patients at risk are desirable. A high-fidelity simulation of carotid endarterectomy under local anaesthesia was tested as a tool for assessment of vascular surgical competence, as an adjunct to training. METHODS: Sixty procedures were performed by 30 vascular surgeons (ten junior trainees, ten senior trainees and ten consultants) in a simulated operating theatre. Each performed in a non-crisis scenario followed by a crisis scenario. Performance was assessed live by means of rating scales for technical and non-technical skills. RESULTS: There was a significant difference in technical skills with ascending grade for both generic and procedure-specific technical skill scores in both scenarios (P < 0.001 for all comparisons). Similarly, there was also a significant difference in non-technical skill with ascending grade for both scenarios (P < 0.001). There was a highly significant correlation between technical and non-technical performance in both scenarios (non-crisis: r(s) = 0.80, P < 0.001; crisis: r(s) = 0.85, P < 0.001). Inter-rater reliability was high (alpha > or = 0.80 for all scales). CONCLUSION: High-fidelity simulation offers competency-based assessment for all grades and may provide a useful training environment for junior trainees and more experienced surgeons.

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Anestesia Local/normas , Competencia Clínica/normas , Simulación por Computador/normas , Educación de Postgrado en Medicina/métodos , Endarterectomía Carotidea/normas , Cirugía General/educación , Educación Basada en Competencias , Consultores , Cirugía General/normas , Humanos , Cuerpo Médico de Hospitales/normas , Variaciones Dependientes del Observador , Quirófanos , Simulación de Paciente , Autoevaluación (Psicología)

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BACKGROUND: There is a common perception that a large number of secondary interventions are needed following endovascular aortic aneurysm repair. METHODS: Prospective data were collected for a cohort of 417 consecutive elective patients undergoing infrarenal aortic endograft repair between April 2000 and May 2008. The rate of secondary interventions, associated morbidity and need for reintervention following surveillance imaging were analysed. RESULTS: The male : female ratio was 11 : 1, median age 76 (range 40-93) years and median aneurysm diameter 6.1 (5.3-11) cm. The overall 30-day mortality rate was 1.7 per cent (seven of 417). Secondary interventions were performed in 31 patients (7.4 per cent), of which six (1.4 per cent) were detected by surveillance. Endoleaks requiring reintervention occurred in 12 patients (2.9 per cent; ten type I and two type III endoleaks). Limb ischaemia secondary to graft occlusion occurred in 17 patients (4.1 per cent); extra-anatomical bypass was needed in 15 patients (3.6 per cent) and the remaining two had an amputation. Graft explantation following late infection was required in two patients (0.5 per cent). CONCLUSION: Endoluminal repair of infrarenal aortic aneurysms can be performed with a low reintervention rate. The value of prolonged surveillance seems limited and current surveillance protocols may require revision.

Asunto(s)

Aneurisma de la Aorta Abdominal/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Angioplastia/métodos , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Prótesis Vascular , Implantación de Prótesis Vascular , Femenino , Humanos , Isquemia/etiología , Pierna/irrigación sanguínea , Masculino , Persona de Mediana Edad , Infecciones Relacionadas con Prótesis , Stents , Dehiscencia de la Herida Operatoria/etiología , Tomografía Computarizada por Rayos X

RESUMEN

OBJECTIVE: Endovascular repair for degenerative aortic aneurysms is well established, but its role in those with infective pathology remains controversial. This study aims to assess the durability of endovascular repair with a review of our midterm results. METHOD: A retrospective analysis of a prospectively maintained endovascular database (1998-2008) was conducted, which identified 673 consecutive patients with aortic aneurysms. RESULTS: Nineteen patients (2.8%) were identified with infected aortic aneurysms, in which there were a total of 23 separate aneurysms (16 thoracic and seven abdominal). Six patients (32%) presented with rupture. Eleven patients (58%) had received antibiotics preoperatively for a median duration of 11 days (1-54 days). Fifteen of the 19 (79%) had positive blood cultures, with Staphylococcus aureus being the most common organism. All 19 patients underwent endovascular repair. There were three Type I endoleaks (one requiring conversion to open repair) and two Type II endoleaks. One patient developed transient paraplegia, resolved by cerebrovascular fluid (CSF) drainage, and one patient had a stroke. The 30-day mortality was 11%, and survival at median follow-up of 20 months (0-83 months) was 73%. All eight deaths in the series were related to aneurysm. CONCLUSION: Endovascular treatment of infective aortic pathology provides an early survival benefit; however, concerns over on-going graft infection remain.

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Aneurisma Infectado/cirugía , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Torácica/cirugía , Prótesis Vascular , Stents , Adulto , Anciano , Aneurisma Infectado/diagnóstico por imagen , Aneurisma Infectado/microbiología , Aneurisma Infectado/mortalidad , Antibacterianos/uso terapéutico , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/mortalidad , Rotura de la Aorta/cirugía , Femenino , Fístula/diagnóstico por imagen , Fístula/cirugía , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Prospectivos , Radiografía , Estudios Retrospectivos , Staphylococcus aureus/aislamiento & purificación , Resultado del Tratamiento

RESUMEN

AIM: Despite no formal training in consenting patients, surgeons are assumed to be competent if they are able to perform an operation. We tested this assumption for carotid endarterectomy (CEA). METHODS: Thirty-two surgeons [Group 1: junior surgical trainees--performed 0 CEA's (n=11); 2: senior vascular trainees--1-50 CEA's (n=11); 3: consultant vascular surgeons - > 50 CEA's (n=10)] consented two patients (trained actors) for a local anaesthetic CEA. The performance was assessed at post hoc video review by two independent assessors using a validated rating scale and checklist of risk factors. RESULTS: There was no difference in performance between the junior and senior trainees (1: median 91 range 64-121; 2: median 100.5 range 66-125; p=0.118 1 vs. 2 Mann-Whitney). There was a significant improvement between senior trainees and consultant surgeons (3: median 120 range 89-1 142; p=0.001 2 vs. 3). Few junior (1/11) and senior (2/11) trainees, and most (8/11) consultants, were competent. Inter-rater reliability was high (alpha=0.832). Consultant surgeons were significantly more likely to discuss cranial nerve injuries (p<0.0001 Chi-square test) as well as personal or hospital specific stroke risk (p<0.0001) than their junior counterparts. They were less likely to discuss infection (p<0.0001). CONCLUSION: Senior trainees, despite being able to perform a CEA, were not competent in consent. The majority of consultant surgeons had developed competence in consenting even though they had no formal training.

Asunto(s)

Competencia Clínica , Educación de Postgrado en Medicina , Endarterectomía Carotidea , Consentimiento Informado , Simulación de Paciente , Anestesia Local , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/educación , Femenino , Humanos , Internado y Residencia , Masculino , Variaciones Dependientes del Observador , Derivación y Consulta , Reproducibilidad de los Resultados , Medición de Riesgo , Análisis y Desempeño de Tareas , Factores de Tiempo , Grabación en Video

RESUMEN

INTRODUCTION: Technical skill has been formally assessed in the Fellow of the European Board of Vascular Surgery Examinations (FEBVS) since 2002. The aim of this study was to examine the relationship between expert assessment and trainee self-assessment. MATERIALS AND METHODS: Forty-two examination candidates performed a saphenofemoral junction (SFJ) ligation and an anterior tibial anastomosis on a synthetic simulation. Each candidate was rated by two examiners using a validated rating scale for their generic surgical skill for both procedures. Candidates then anonymously rated their own performance using the same scale. Parametric tests were used in the statistical analysis; a P-value < 0.05 was considered significant. RESULTS: The maximum mark in each assessment was 40; 24 was considered a competent score. The interobserver correlation for examiners marks were high (SFJ ligation, alpha = 0.68; distal anastomosis, alpha = 0.76). Examiners' marks were averaged. The mean examiner score for the SFJ ligation station was 27.8 (SD = 4.1) with 36 candidates (85.8%) attaining a competent score. The mean self-assessment score for this station was 30.7 (SD = 4.66). The mean examiners' marks for the distal anastomosis station was 29.2 (SD = 4.2); 39 candidates (92.8%) attained a competent score. The mean self-assessment score was 32.1 (SD = 4.0). There was no correlation between examiner and self-assessment scores in either station (Pearson's correlation coefficient: SFJ, r = 0.045, P = NS); distal anastomosis, r = 0.089, P = NS). Bland and Altman plots assessed the agreement between examiner and self-assessment. These showed candidates marked themselves higher than examiners with a mean difference of 2.9 marks in each station. CONCLUSIONS: Candidates' self-assessment and expert independent assessment correlate poorly. Trainees overestimate their ability according to independent assessment; regular technical feedback during training is, therefore, essential.

Asunto(s)

Competencia Clínica/normas , Educación de Postgrado en Medicina/normas , Retroalimentación , Procedimientos Quirúrgicos Vasculares/normas , Humanos , Variaciones Dependientes del Observador , Simulación de Paciente , Autoevaluación (Psicología) , Reino Unido , Procedimientos Quirúrgicos Vasculares/educación

RESUMEN

INTRODUCTION: Thorascopic sympathectomy is accepted as an effective treatment for palmar hyperhidrosis, facial blushing and to a lesser extent for digital ischaemia and axillary hyperhidrosis. PATIENTS AND METHODS: Data were collected retrospectively on patients undergoing thorascopic sympathectomy at St Peter's Hospital between 1987 and 2006. Patients were followed up by telephone interview. RESULTS: A total of 233 thorascopic sympathectomy procedures were performed by a single operator in 123 patients. Ages ranged from 9-71 years and 75 were women. In patients, 105 had a bilateral and 13 a unilateral procedure, 5 patients had a bilateral procedure performed in two stages. In 6 upper limbs, the procedure could not be done. Overall, 110 patients (90%) had the procedure performed for palmar hyperhidrosis, 8 (6%) for facial blushing and in 5 (4%) patients the operation was performed for digital ischaemia with tissue loss. There were no deaths and all patients were discharged on day 1 following the procedure. Complications included bleeding (2), pulmonary oedema (1) and failed procedure (2); however, no incidences of Horner's syndrome occurred. Only 40 of 123 (32.5%) patients gave follow-up information. Of this small group, 33 of 40 (83%) were cured, 4 of 40 (10%) were better, 2 of 40 (5%) were unchanged and 1 patient was worse. Only 22 out of 40 (55%) of these patients were troubled by compensatory sweating, with only 4 of 40 (10%) reporting this as a major problem. CONCLUSIONS: Thorascopic sympathectomy is safe and can be carried out as a single bilateral procedure in the majority of cases. The laser allows the use of a single port, requires less dissection than surgical or clipping techniques, is more precise than diathermy and may be less likely to cause a Horner's syndrome.

Asunto(s)

Sonrojo , Rubor/cirugía , Hiperhidrosis/cirugía , Isquemia/cirugía , Simpatectomía/instrumentación , Adolescente , Adulto , Anciano , Niño , Inglaterra , Femenino , Dedos/irrigación sanguínea , Humanos , Terapia por Láser/métodos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Simpatectomía/métodos , Toracoscopía , Dedos del Pie/irrigación sanguínea , Resultado del Tratamiento

RESUMEN

Drug-eluting stents are a recommended treatment for lesions in the coronary arteries. Stent insertion requires the patient remain on anti-platelet medication for a minimum of six months after insertion. A serious consequence of ceasing anti-platelet medication is late stent thrombosis leading to myocardial infarction in the territory of the drug-eluting stent. Continuing anti-platelet medication can lead to excessive bleeding at the time of surgery. Understanding the risk of complications attributable to bleeding or myocardial ischaemia will help in defining the optimal management of these patients at the time of non-cardiac surgery. This study is a retrospective database analysis and case note review of all patients with drug-eluting stents presenting for non-cardiac surgical procedures over a three-year period in one centre. Twenty-four patients with drug-eluting stents inserted presented for 43 non-cardiac surgical procedures. Severe bleeding problems were encountered in one case. Three of 15 patients (20%) who ceased clopidogrel prior to surgery without alternative anti-thrombotic prophylaxis suffered myocardial infarction due to stent thrombosis. Four patients who received alternative anti-thrombotic prophylaxis did not suffer complications. All 19 patients who ceased clopidogrel remained on aspirin prior to surgery. Patients treated with drug-eluting stents for coronary artery stenosis represent a challenging group of patients for subsequent perioperative management. The risk of myocardial infarction when clopidogrel is stopped prior to surgery is 20%, if alternative anti-thrombotic prophylaxis is not used. This risk persists beyond one year after insertion of drug-eluting stents. Some treatments appear to be effective in reducing the risk of myocardial infarction.

Asunto(s)

Trombosis Coronaria/etiología , Stents Liberadores de Fármacos/efectos adversos , Complicaciones Intraoperatorias/etiología , Infarto del Miocardio/etiología , Clopidogrel , Trombosis Coronaria/complicaciones , Trombosis Coronaria/prevención & control , Humanos , Complicaciones Intraoperatorias/prevención & control , Masculino , Auditoría Médica , Persona de Mediana Edad , Infarto del Miocardio/prevención & control , Inhibidores de Agregación Plaquetaria/uso terapéutico , Estudios Retrospectivos , Ticlopidina/análogos & derivados , Ticlopidina/uso terapéutico

RESUMEN

BACKGROUND: Competency-based assessment is being introduced to surgical training. The value of bench-top technical skills assessment using a synthetic carotid endarterectomy (CEA) model was evaluated in vascular trainees and consultants. METHODS: Forty-one surgeons (13 junior trainees, 15 senior trainees and 13 experienced consultants with experience of more than 50 CEAs) performed a three-throw knot-tying exercise on a jig and a CEA on the bench model. A composite score for knot-tying was calculated, incorporating electromagnetic motion analysis. CEA technical skill was assessed using validated rating scales by blinded video analysis. RESULTS: Senior trainees performed better than junior trainees in knot-tying (P = 0.025) as well as generic (P < 0.001) and procedural (P < 0.001) skills on CEA model assessment. There was no difference between senior trainees and consultants on any of these measures. The CEA model interobserver reliability was high for all rating scales (generic alpha = 0.974, procedural alpha = 0.952, end-product alpha = 0.976). CONCLUSION: Senior trainees achieved the same score as consultants, suggesting a similar level of basic technical skill and knowledge required to perform CEA, and were significantly better than junior trainees. Performance on the bench model could provide an early assessment for suitability to proceed to operative training in a competency-based training and assessment programme.

Asunto(s)

Competencia Clínica/normas , Educación de Postgrado en Medicina , Procedimientos Quirúrgicos Vasculares/educación , Endarterectomía Carotidea , Humanos , Cuerpo Médico de Hospitales/educación , Modelos Biológicos , Autoevaluación (Psicología) , Técnicas de Sutura , Procedimientos Quirúrgicos Vasculares/normas

RESUMEN

BACKGROUND: Carotid interventions are performed to reduce the cumulative risk of stroke. The success of the procedure is dependent upon maintaining low operative risk. This article reviews the current state of training for both carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS). METHODS: Medline searches were performed to identify articles with the combination of the following key words: carotid, endarterectomy, stent, training, assessment and simulation. Manual searches of the reference lists and related papers was conducted. RESULTS: Training and assessment for CEA and CAS follows the traditional apprenticeship model. There is no formal training protocol or objective means of assessment for either carotid endarterectomy or stenting. Models and simulators to allow for training and assessment away from the operative theatre have been developed, and exist for both CEA and CAS. CONCLUSION: The technology exists to allow for both training and assessment of competency to take place in a controlled and objective environment for both CEA and CAS. The use of simulation needs to be robustly evaluated and assessed to both complement and augment existing training programs to ensure that the highest standards of care are maintained for treatment of carotid territory disease. Objective competency based training and assessment is no longer unattainable. Simulators augment this process and without them operative exposure is sporadic and crisis management infrequent.

Asunto(s)

Angioplastia de Balón/educación , Endarterectomía Carotidea/educación , Cirugía General/educación , Competencia Clínica , Humanos , Simulación de Paciente , Stents