Mohamad A. Hussain

Prevalence and Causes of Attrition Among Surgical Residents: A Systematic Review and Meta-analysis

Importance Attrition of residents from general surgery training programs is relatively high; however, there are wide discrepancies in the prevalence and causes of attrition reported among surgical residents in previous studies. Objective To summarize the estimate of attrition prevalence among general surgery residents. Data Sources We searched the Medline, EMBASE, Cochrane, PsycINFO, and ERIC databases (January 1, 1946, to October 22, 2015) for studies reporting on the prevalence and causes of attrition in surgical residents, as well as the characteristics and destinations of residents who left general surgery training programs. Database searches were conducted on October 22, 2015. Study Selection Eligibility criteria included all studies reporting on the primary (attrition prevalence) or secondary (causes of attrition and characteristics and destination of residents who leave residency programs) outcomes in peer-reviewed journals. Commentaries, reviews, and studies reporting on preliminary surgery programs were excluded. Of the 41 full-text articles collected from the title/abstract screening, 22 studies (53.7%) met the selection criteria. Data Extraction and Synthesis Two reviewers independently collected and summarized the data. We calculated pooled estimates using random effects meta-analyses where appropriate. Main Outcome and Measure Attrition prevalence of general surgery residents. Results Overall, we included 22 studies that reported on residents (n = 19 821) from general surgery programs. The pooled estimate for the overall attrition prevalence among general surgery residents was 18% (95% CI, 14%-21%), with significant between-study variation (I2 = 96.8%; P < .001). Attrition was significantly higher among female compared with male (25% vs 15%, respectively; P = .008) general surgery residents, and most residents left after their first postgraduate year (48%; 95% CI, 39%-57%). Departing residents often relocated to another general surgery program (20%; 95% CI, 15%-24%) or switched to anesthesia (13%; 95% CI, 11%-16%) and other specialties. The most common reported causes of attrition were uncontrollable lifestyle (range, 12%-87.5%) and transferring to another specialty (range, 19%-38.9%). Conclusions and Relevance General surgery programs have relatively high attrition, with female residents more likely to leave their training programs than male residents. Residents most often relocate or switch to another specialty after the first postgraduate year owing to lifestyle-related issues.

Efficacy of a Guideline-Recommended Risk-Reduction Program to Improve Cardiovascular and Limb Outcomes in Patients With Peripheral Arterial Disease

IMPORTANCE Patients with peripheral arterial disease (PAD) are at a high risk for cardiovascular events, yet, to our knowledge, no studies have examined the effect of a comprehensive risk-reduction program on long-term outcomes for patients with PAD. OBJECTIVE To investigative whether a program that focuses on 8 major guideline-recommended risk-management therapies reduces cardiovascular and limb events in patients with PAD. DESIGN, SETTING AND PARTICIPANTS An observational cohort study with up to 7 years of follow-up was conducted using data from administrative databases from Ontario, Canada, between July 1, 2004, and March 31, 2013. Patients with symptomatic PAD who were enrolled in the Systematic Assessment of Vascular Risk (SAVR) program at a single tertiary vascular center in Ontario between July 2004 and April 2007 were matched with up to 2 (control) patients with PAD from other Ontario tertiary vascular centers not enrolled in the program using propensity score methods. Cox proportional hazards regression analysis was used to compare outcomes. EXPOSURES Program that promoted antiplatelet agents, statins, angiotensin-converting enzyme inhibitors, blood pressure control, lipid control, diabetic glycemic control, smoking cessation, and target body mass index by engaging vascular surgeons, family physicians, and patients with PAD. MAIN OUTCOMES AND MEASURES The primary outcome was a composite risk ratio of death, acute myocardial infarction, or ischemic stroke. Secondary outcomes included rates of lower limb amputations, bypass surgical procedures, and peripheral angioplasties with and without a stent. RESULTS A total of 791 patients were studied after propensity score matching; the mean (SD) age of patients in the SAVR group (n = 290) was 67.9 (10.4) years and 68.2 (11.2) years in the control group (n = 501). During follow-up, the SAVR group experienced the primary outcome at a significantly lower rate than the control group (adjusted hazard ratio [HR], 0.63; 95% CI, 0.52-0.77). Patients in the SAVR group were also less likely to have major amputation (adjusted HR, 0.47; 95% CI, 0.29-0.77), minor amputation (adjusted HR, 0.26; 95% CI, 0.13-0.54), bypass surgery (adjusted HR, 0.47; 95% CI, 0.30-0.73), or hospitalization due to heart failure (adjusted HR, 0.73; 95% CI, 0.53-1.00). The rate of peripheral angioplasty with or without a stent was higher among the SAVR group (adjusted HR, 2.97; 95% CI, 2.15-4.10). CONCLUSIONS AND RELEVANCE A guideline-recommended risk-reduction program targeted at patients with PAD was associated with fewer cardiovascular and limb events over the long-term. This finding emphasizes the need for well-designed prospective studies to develop and examine the effect of such programs on reducing PAD-related morbidity, mortality, and health care costs.

Impact of Clinical Trial Results on the Temporal Trends of Carotid Endarterectomy and Stenting From 2002 to 2014

Background and Purpose— Randomized trials provide conflicting data for the efficacy of carotid-artery stenting compared with endarterectomy. The purpose of this study was to examine the impact of conflicting clinical trial publications on the utilization rates of carotid revascularization procedures. Methods— We conducted a population-level time-series analysis of all individuals who underwent carotid endarterectomy and stenting in Ontario, Canada (2002–2014). The primary analysis examined temporal changes in the rates of carotid revascularization procedures after publications of major randomized trials. Secondary analyses examined changes in overall and age, sex, carotid-artery symptom, and operator specialty–specific procedure rates. Results— A total of 16 772 patients were studied (14 394 endarterectomy [86%]; 2378 stenting [14%]). The overall rate of carotid revascularization decreased from 6.0 procedures per 100 000 individuals ≥40 years old in April 2002 to 4.3 procedures in the first quarter of 2014 (29% decrease; P<0.001). The rate of endarterectomy decreased by 36% (P<0.001), whereas the rate of carotid-artery stenting increased by 72% (P=0.006). We observed a marked increase (P=0.01) in stenting after publication of the SAPPHIRE trial (Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy) in 2004, whereas stenting remained relatively unchanged after subsequent randomized trials published in 2006 (P=0.11) and 2010 (P=0.34). In contrast, endarterectomy decreased after trials published in 2006 (P=0.04) and 2010 (P=0.005). Conclusions— Although the overall rates of carotid revascularization and endarterectomy have fallen since 2002, the rate of carotid-artery stenting has risen since the publication of stenting-favorable SAPPHIRE trial. Subsequent conflicting randomized trials were associated with a decreasing rate of carotid endarterectomy.

Vascular Thoracic Outlet Syndrome.

Two distinct terms are used to describe vascular thoracic outlet syndrome (TOS) depending on which structure is predominantly affected: venous TOS (due to subclavian vein compression) and arterial TOS (due to subclavian artery compression). Although the venous and arterial subtypes of TOS affect only 3% and <1% of all TOS patients respectively, the diagnostic and management approaches to venous and arterial TOS have undergone considerable evolution due to the recent emergence of minimally invasive endovascular techniques such as catheter-directed arterial and venous thrombolysis, and balloon angioplasty. In this review, we discuss the anatomical factors, etiology, pathogenesis and clinical presentation of vascular TOS patients. In addition, we use the most up to date observational evidence available to provide a contemporary approach to the diagnosis and management of venous TOS and arterial TOS patients.

Carotid Artery Revascularization What’s the Best Strategy?

A 64-year-old man with a past medical history of diabetes mellitus, hyperlipidemia, and hypertension presented with acute-onset left hemiparesis, hemisensory loss, and dysarthria. He was diagnosed with a right middle cerebral artery stroke and treated with systemic thrombolysis. His poststroke workup included a carotid duplex ultrasound and computed tomographic angiogram of the carotid arteries (Figure 1), which confirmed a severe (70%–99%) stenosis in the right internal carotid artery (ICA) secondary to a 20-mm-long atherosclerotic plaque extending from the carotid bifurcation to the level of C2-C3 disc space. The left ICA showed moderate (50%–69%) stenosis. Should this patient be recommended for carotid artery revascularization, and, if so, by which method? Figure 1. Computed tomographic angiogram of the 64-year-old patient presented in this case, showing severe right internal carotid artery stenosis (arrow) in coronal ( A ) and sagittal ( B ) views. Stroke, defined as acute development of a focal neurological deficit attributable to the disruption of blood flow to the brain, is caused by 1 of 2 main causes: ischemia or hemorrhage. The majority (>80%) of strokes are of ischemic etiology, of which ≈15% to 20% are attributable to atherosclerosis of the extracranial carotid arteries. The risk of death and recurrent stroke increases following an ischemic stroke. Transient ischemic attacks, or strokelike symptoms that last <24 hours, are also associated with an increased risk of early recurrent stroke, particularly in patients with carotid artery atherosclerosis. The bifurcation point of the common carotid artery, or carotid bulb, is predisposed to the development of atherosclerosis owing to low wall shear stress and resulting flow stagnation. Narrowing or stenosis of the carotid bulb and ICA because of atherosclerosis can lead to ischemic stroke secondary to plaque embolization or hypoperfusion. The prevalence of ICA stenosis is estimated to be 2% to 3% in the general population, with increased prevalence noted …

Sex differences in the outcomes of peripheral arterial disease: a population-based cohort study

BACKGROUND The role of sex in the outcomes of patients with peripheral arterial disease (PAD) has been poorly studied. We sought to investigate differences in the long-term adverse cardiovascular and limb outcomes between men and women with PAD. METHODS We conducted a population-based cohort study with up to 7 years of follow-up using linked administrative databases in Ontario, Canada. Patients aged 40 years or older who visited a vascular surgeon between Apr. 1, 2004, and Mar. 31, 2007 (index date), and carried a diagnosis of PAD comprised the study cohort. The primary outcome was a composite of death or hospital admission for stroke or myocardial infarction. Secondary outcomes included lower limb amputation or revascularization. We used Cox proportional hazards modelling to compute unadjusted hazard ratios (HRs) and HRs adjusted for baseline covariates. RESULTS A total of 6915 patients were studied, of whom 2461 (35.6%) were women. No significant differences in the risk of the primary outcome were observed between men and women (adjusted HR 0.99 [95% confidence interval (CI) 0.92-1.05]). Women were less likely than men to undergo minor amputation (adjusted HR 0.73 [95% CI 0.62-0.85]) and arterial bypass surgery (adjusted HR 0.82 [95% CI 0.71-0.94]) but were more likely to be admitted to hospital for acute myocardial infarction (adjusted HR 1.15 [95% CI 1.00-1.31]). There were no sex differences in the rates of major amputation or transluminal percutaneous angioplasty. INTERPRETATION We identified no significant differences in the composite risk of major adverse cardiovascular events between women and men with PAD, although our findings suggest men may be at increased risk for adverse limb events compared with women. Cardiovascular health campaigns should focus on both women and men to promote early diagnosis and management of PAD.

Coil embolization of the false lumen in complicated type B aortic dissection.

A patent false lumen with persistent flow after endovascular repair of type B aortic dissection (TBAD) is associated with an ongoing risk of aortic dilation and rupture. We describe the case of a 64-year-old man who initially underwent thoracic endovascular aortic repair for acute complicated TBAD, but continued to have symptomatic retrograde aneurysm filling and dilatation because of a patent false lumen. Coil embolization of the patent false lumen successfully excluded the aneurysmal thoracic aorta from further perfusion, and led to a decease in aneurysm size on follow-up. Our case report is followed by a discussion on this management strategy and a review of literature.

Antithrombotic Therapy for Peripheral Artery Disease: Recent Advances

Peripheral artery disease (PAD) affects over 200 million people globally and is a cause of significant morbidity, mortality, and disability due to limb loss. Although secondary prevention with antithrombotic therapy is a mainstay of treatment to prevent adverse cardiovascular events, PAD patients are often undertreated with antithrombotic agents. Furthermore, there is a paucity of high-quality data from randomized controlled trials of PAD patients, leading to wide variations in clinical practice and guideline recommendations. Recently, there have been important advances that have further increased the number of antiplatelet and anticoagulant choices potentially available for patients with PAD. In this context, this paper aims to summarize the current available evidence for the safety and efficacy of various antithrombotic agents in PAD, and discuss how to integrate this emerging evidence into actual clinical practice. An evidenced-based approach to PAD patients is essential to achieve optimal outcomes, weighing cardiovascular and limb benefits against bleeding risks.

Poor knowledge of peripheral arterial disease among the Saudi population: A cross-sectional study

Peripheral arterial disease is a marker of severe atherosclerosis with a significantly higher risk of cardiovascular morbidity and mortality. It is often underdiagnosed and undertreated. Public and patients’ perception of peripheral arterial disease is influenced by their knowledge of the condition. In this study, we aimed to evaluate the Saudi public’s knowledge of peripheral arterial disease and its specific characteristics. We conducted an interview-based cross-sectional survey, and collected data on basic demographics, self-reported peripheral arterial disease awareness, and knowledge of clinical features, risk factors, preventative measures, management strategies, and potential complications of peripheral arterial disease. A total of 866 participants completed the survey (response rate, 94%); two-thirds were females. Only 295 (34%) of the surveyed participants indicated awareness of peripheral arterial disease. Overall peripheral arterial disease knowledge was low among the “peripheral arterial disease aware” group, particularly in the clinical features domain. Age > 40 years, female gender, and higher education were predictors of self-reported awareness of peripheral arterial disease. In conclusion, the Saudi public is largely unaware of peripheral arterial disease. Educational programs are important to address this critical knowledge gap.

Blunt traumatic subclavian vein pseudoaneurysm

Subclavian and upper extremity venous pseudoaneurysms are rare and poorly understood. We present the case of a 45-year-old woman with a right subclavian vein pseudoaneurysm that formed after blunt trauma to the upper chest and shoulder. The patient was managed successfully with surgical excision through a supraclavicular approach. The case report is followed by a discussion on the etiology, clinical presentation, and management of venous pseudoaneurysms.