Dania Daye

Exploring intentions of physician-scientist trainees: factors influencing MD and MD/PhD interest in research careers

BackgroundPrior studies have described the career paths of physician-scientist candidates after graduation, but the factors that influence career choices at the candidate stage remain unclear. Additionally, previous work has focused on MD/PhDs, despite many physician-scientists being MDs. This study sought to identify career sector intentions, important factors in career selection, and experienced and predicted obstacles to career success that influence the career choices of MD candidates, MD candidates with research-intense career intentions (MD-RI), and MD/PhD candidates.MethodsA 70-question survey was administered to students at 5 academic medical centers with Medical Scientist Training Programs (MSTPs) and Clinical and Translational Science Awards (CTSA) from the NIH. Data were analyzed using bivariate or multivariate analyses.ResultsMore MD/PhD and MD-RI candidates anticipated or had experienced obstacles related to balancing academic and family responsibilities and to balancing clinical, research, and education responsibilities, whereas more MD candidates indicated experienced and predicted obstacles related to loan repayment. MD/PhD candidates expressed higher interest in basic and translational research compared to MD-RI candidates, who indicated more interest in clinical research. Overall, MD-RI candidates displayed a profile distinct from both MD/PhD and MD candidates.ConclusionsMD/PhD and MD-RI candidates experience obstacles that influence their intentions to pursue academic medical careers from the earliest training stage, obstacles which differ from those of their MD peers. The differences between the aspirations of and challenges facing MD, MD-RI and MD/PhD candidates present opportunities for training programs to target curricula and support services to ensure the career development of successful physician-scientists.

Novel and Advanced Techniques for Complex IVC Filter Retrieval

Opinion statementInferior vena cava (IVC) filter placement is indicated for the treatment of venous thromboembolism (VTE) in patients with a contraindication to or a failure of anticoagulation. With the advent of retrievable IVC filters and their ease of placement, an increasing number of such filters are being inserted for prophylaxis in patients at high risk for VTE. Available data show that only a small number of these filters are retrieved within the recommended period, if at all, prompting the FDA to issue a statement on the need for their timely removal. With prolonged dwell times, advanced techniques may be needed for filter retrieval in up to 60% of the cases. In this article, we review standard and advanced IVC filter retrieval techniques including single-access, dual-access, and dissection techniques. Complicated filter retrievals carry a non-negligible risk for complications such as filter fragmentation and resultant embolization of filter components, venous pseudoaneurysms or stenoses, and breach of the integrity of the caval wall. Careful pre-retrieval assessment of IVC filter position, any significant degree of filter tilting or of hook, and/or strut epithelialization and caval wall penetration by filter components should be considered using dedicated cross-sectional imaging for procedural planning. In complex cases, the risk for retrieval complications should be carefully weighed against the risks of leaving the filter permanently indwelling. The decision to remove an embedded IVC filter using advanced techniques should be individualized to each patient and made with caution, based on the patient’s age and existing comorbidities.

Complications of endovascular aneurysm repair of the thoracic and abdominal aorta: evaluation and management

In recent decades, endovascular aneurysm repair or endovascular aortic repair (EVAR) has become an acceptable alternative to open surgery for the treatment of thoracic and abdominal aortic aneurysms and other aortic pathologies such as the acute aortic syndromes (e.g., penetrating aortic ulcer, intramural hematoma, dissection). Available data suggest that endovascular repair is associated with lower perioperative 30-day all-cause mortality as well as a significant reduction in perioperative morbidity when compared to open surgery. Additionally, EVAR leads to decreased blood loss, eliminates the need for cross-clamping the aorta and has shorter recovery periods than traditional surgery. It is currently the preferred mode of treatment of thoracic and abdominal aortic aneurysms in a subset of patients who meet certain anatomic criteria conducive to endovascular repair. The main disadvantage of EVAR procedures is the high rate of post-procedural complications that often require secondary re-intervention. As a result, most authorities recommend lifelong imaging surveillance following repair. Available surveillance modalities include conventional radiography, computed tomography, magnetic resonance angiography, ultrasonography, nuclear imaging and conventional angiography, with computed tomography currently considered to be the gold standard for surveillance by most experts. Following endovascular abdominal aortic aneurysm (AAA) repair, the rate of complications is estimated to range between 16% and 30%. The complication rate is higher following thoracic EVAR (TEVAR) and is estimated to be as high as 38%. Common complications include both those related to the endograft device and systemic complications. Device-related complications include endoleaks, endograft migration or collapse, kinking and/or stenosis of an endograft limb and graft infection. Post-procedural systemic complications include end-organ ischemia, cerebrovascular and cardiovascular events and post-implantation syndrome. Secondary re-interventions are required in approximately 19% to 24% of cases following endovascular abdominal and thoracic aortic aneurysm repair respectively. Typically, most secondary reinterventions involve the use of percutaneous techniques such as placement of cuff extension devices, additional endograft components or stents, enhancement of endograft fixation, treatment of certain endoleaks using various embolization techniques and embolic agents and thrombolysis of occluded endograft components. Less commonly, surgical conversion and/or open surgical modification are required. In this article, we provide an overview of the most common complications that may occur following endovascular repair of thoracic and AAAs. We also summarize the current surveillance recommendations for detecting and evaluating these complications and discuss various current secondary re-intervention approaches that may typically be employed for treatment.

Impact of Delayed Time to Advanced Imaging on Missed Appointments Across Different Demographic and Socioeconomic Factors

PURPOSE The aim of this study was to investigate the impact of wait days (WDs) on missed outpatient MRI appointments across different demographic and socioeconomic factors. METHODS An institutional review board-approved retrospective study was conducted among adult patients scheduled for outpatient MRI during a 12-month period. Scheduling data and demographic information were obtained. Imaging missed appointments were defined as missed scheduled imaging encounters. WDs were defined as the number of days from study order to appointment. Multivariate logistic regression was applied to assess the contribution of race and socioeconomic factors to missed appointments. Linear regression was performed to assess the relationship between missed appointment rates and WDs stratified by race, income, and patient insurance groups with analysis of covariance statistics. RESULTS A total of 42,727 patients met the inclusion criteria. Mean WDs were 7.95 days. Multivariate regression showed increased odds ratio for missed appointments for patients with increased WDs (7-21 days: odds ratio [OR], 1.39; >21 days: OR, 1.77), African American patients (OR, 1.71), Hispanic patients (OR, 1.30), patients with noncommercial insurance (OR, 2.00-2.55), and those with imaging performed at the main hospital campus (OR, 1.51). Missed appointment rate linearly increased with WDs, with analysis of covariance revealing underrepresented minorities and Medicaid insurance as significant effect modifiers. CONCLUSIONS Increased WDs for advanced imaging significantly increases the likelihood of missed appointments. This effect is most pronounced among underrepresented minorities and patients with lower socioeconomic status. Efforts to reduce WDs may improve equity in access to and utilization of advanced diagnostic imaging for all patients.

MR Imaging for Incidental Adnexal Mass Characterization

Incidentally detected adnexal masses are common, and the overwhelming majority of them are benign. As many of these adnexal masses are considered indeterminate at CT or US, a large number of benign oophorectomies occur. Of the malignant adnexal masses, high-grade primary ovarian neoplasms with fast doubling times and early dissemination are the most common. Due to their aggressive behavior, diagnosis of malignancy by interval growth on surveillance imaging represents an undesirable option. Immediate MR characterization allows for a decreased rate of benign oophorectomies and expedited triage of patients to definitive treatment when malignancy is suspected.