Targeted muscle reinnervation: A narrative review of a novel tool for the management of neuropathic pathology in major lower extremity amputations

OBJECTIVE

The purpose of this narrative review is to provide the vascular surgery community with updated recommendations and information regarding the use of Targeted Muscle Reinnervation (TMR) for both the prevention and treatment of chronic pain and phantom limb pain occurring in patients after undergoing lower extremity amputation for peripheral artery disease.

METHODS

Current available literature discussing TMR is reviewed and included in the article in order to provide a succinct overview on the indications, clinical applications, and surgical technique for TMR. Additionally, early studies showing favorable long-term results after TMR are discussed. Patient consent for publication was obtained for this investigation.

RESULTS

TMR has been demonstrated to be an effective means of both treating and preventing neuroma-related symptoms including chronic pain and phantom limb pain. It has been proven to be technically feasible, and can help patients to have improved utilization of prostheses for ambulation, which can conceivably lead to a reduction in mortality.

CONCLUSIONS

TMR is an important tool to consider for any patient undergoing lower extremity amputation for a vascular-related indication. A vascular-plastic surgeon dual team approach is an effective means to prevent and reduce neuromas and associated chronic pain in this patient population.

Panel composition and disparities in the topics of presentation in vascular surgery conferences

BACKGROUND

Previous studies identified gender disparities in surgical conference presenters and moderators. We sought to assess disparities in the representation of women in terms of speakers and moderators, but with particular emphasis on panels and topics of discussion at vascular surgery conferences.

METHODS

Data regarding presenters and moderators from the Southern Association of Vascular Surgery, Western Vascular Society, Vascular and Endovascular Surgical Society, Society for Clinical Vascular Surgery, and Society for Vascular Surgery conferences was obtained from online meeting archives and via email correspondence. Scientific session speakers, moderators, and panelists were identified by sex. Specific vascular topics for each discussion were also identified. Keynote speakers or special guests were excluded.

RESULTS

Compared to men, women were less often presenters (18% versus 82%, p < .002) and moderators (16% versus 84%, p < .001) of conference sessions. Women were most likely to present on dialysis access and least likely to present on venous disease overall. Women were more likely to present on aortic (24% vs 19%; p < .013) and cerebrovascular disease (33% vs 27%; p < .021) at regional compared to national conferences. Of panels assessed, 68% were all-male. Subgroup analysis suggests that some improvements have been made over time.

CONCLUSIONS

Significant disparities persist in the topics presented and in panel composition suggesting potential areas for improvement in equity. Further study should focus on evaluating trends in the training level of the presenter and the topics presented, and assessing parity in structural factors that impact research presentation opportunities.

Trends in Ethnicity, Race, and Sex Among Psychiatry and Non-psychiatry Residency Applicants, 2008-2019

OBJECTIVE

The objective of this study was to examine trends in racial/ethnic and gender representation among US psychiatry residency applicants compared with non-psychiatry applicants.

METHODS

Using publicly available applicant data, racial/ethnic and gender distributions of psychiatry residency applicants from 2008 to 2019 were examined and compared with non-psychiatry residency applicants. Both longitudinal trends within both cohorts and cross-sectional, between-group differences were examined.

RESULTS

From 2008 to 2019, the percentage of female, American Indian/Alaskan Native (AIAN), Black, Hispanic, and Native Hawaiian/Other Pacific Islander (NHPI) psychiatry and non-psychiatry residency applicants increased (p<.001). Within each year, Black and Asian applicants comprised a larger percentage of psychiatry applicants compared with non-psychiatry applicants (p<.001). Between 2008 and 2019, Black psychiatry and non-psychiatry applicants increased from 9.1% to 11.6% and 6.6% to 7.6%, respectively; Asian psychiatry and non-psychiatry applicants decreased from 39.5% to 30.5% and 27.5% to 26.6%, respectively; White psychiatry and non-psychiatry applicants increased from 26.7% to 38.2% and 42.7% to 49.2%, respectively.

CONCLUSIONS

Racial/ethnic and gender characteristics of US psychiatry residency applicants represent the future of the US psychiatric workforce. The US psychiatry residency applicant pool has become increasingly diverse from 2008 to 2019. Initiatives should work to enhance representation of psychiatry applicants from historically marginalized backgrounds, and simultaneously to recruit and retain a diverse psychiatric workforce following residency training.

Review of Malpractice Lawsuits in the Diagnosis and Management of Aortic Aneurysms and Aortic Dissections

OBJECTIVE

Aortic aneurysms and dissections are prevalent causes of morbidity and mortality. The management of aortic pathologies may be called into question in malpractice suits. Malpractice claims were analyzed to understand common reasons for litigation, medical specialties involved, patient injuries, and outcomes.

METHODS

Litigation cases in the Westlaw database from September 1st, 1987 to October 23 rd, 2019 were analyzed. Search terms included "aortic aneurysm" and "aortic dissection." Data on plaintiff, defendant, litigation claims, patient injuries, misdiagnoses, and case outcomes were collected and compared for aortic aneurysms, aortic dissections, and overall cases.

RESULTS

A total of 346 cases were identified, 196 involving aortic aneurysms and 150 aortic dissections. Physician defendants were emergency medicine (29%), cardiology (20%), internal medicine (14%), radiology (11%), cardiothoracic (10%) and vascular surgery (10%). Litigation claims included "failure to diagnose and treat" (61%), "delayed diagnosis and treatment" (21%), "post-operative complications after open repair" (10%) and "negligent post-operative care" (10%). Patients with aneurysms presented with abdominal (63%) and back pain (37%), while dissections presented with chest pain (78%), abdominal pain (15%), and shortness of breath (14%). Misdiagnoses included gastrointestinal (12%), other cardiovascular (9%), and musculoskeletal conditions (9%), but many were not specified (58%). Overall, 83% of cases were wrongful death suits. Injuries included loss of consortium (23%), emotional distress (19%), and bleeding (17%). In 53% of the cases, the jury ruled in favor of the defendant. 25% of cases ruled for the plaintiff. 22% of cases resulted in a settlement. The mean rewarded for each case was $1,644,590.66 (SD: $5,939,134.58; Range: $17,500-$68,035,462).

CONCLUSION

For aortic pathologies, post-operative complications were not prominent among the reasons why suits were brought forth. This suggests improvements in education across all involved medical specialties may allow for improved diagnostic accuracy and efficient treatment, which could then translate to a decrease in associated litigation cases.

Clinical characteristics of acute lower extremity deep venous thrombosis diagnosed by duplex in patients hospitalized for coronavirus disease 2019

OBJECTIVE

Little is known about coronavirus disease 2019 (COVID-19)-associated hypercoagulability. We sought to characterize patients with deep venous thrombosis (DVT) identified after admission for COVID-19.

METHODS

All adult patients admitted to Montefiore Medical Center from March 1, 2020, to April 10, 2020, and undergoing lower extremity venous duplex for DVT evaluation were included. Patients admitted with suspicion of COVID-19 were divided into severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive and SARS-CoV-2 negative groups based on in-hospital test results. Patients without clinical suspicion for COVID-19 were not tested. A retrospective case-control study design was used to identify potential risk factors for DVT in patients with COVID-19. Demographic, radiographic, and laboratory values were abstracted and analyzed.

RESULTS

During the study period, 3404 patients with confirmed COVID-19 were admitted to the hospital. Of the 135 SARS-CoV-2 patients who underwent duplex scanning, there were 18 (13.3%) noted to have DVT compared with 72 of the 711 patients (10.1%) who were either SARS-CoV-2 negative or untested. The odds ratio for DVT in COVID-19 was 1.35 (95% confidence interval, 0.78-2.34; P = .289). Baseline characteristics for COVID-19 patients with and without DVT were overall similar. COVID-19 patients with DVT had an elevated median first d-dimer (18.88 μg/mL [interquartile range (IQR), 7.79-20.00] vs 2.55 μg/mL [IQR, 1.45-6.28]; P = .002; reference value, <0.5 μg/mL), average in-hospital d-dimer (median, 11.93 μg/mL [IQR, 8.25-16.97] vs 3.54 μg/mL [IQR, 2.05-8.53]; P < .001) and median fibrinogen level (501.0 [IQR, 440.0-629.0] vs 654.5 [IQR, 535.8-780.0]; P = .002; reference range, 187-502 mg/dL). There was a trend to significance for COVID-19 patients with DVT compared with without DVT in median d-dimer levels at the time of the duplex (13.61 μg/mL [IQR, 4.04-19.97] vs 3.58 μg/mL [IQR, 2.51-9.62]; P = .055) and median ferritin levels (1679.0 ng/mL [IQR, 1168.0-2577.0] vs 1103.0 ng/mL [IQR, 703.5-2076.5]; P = .055; reference range, 25-270 ng/mL). Twelve of the 18 patients with COVID who developed DVT did so despite chemical thromboprophylaxis, and 2 developed DVT despite therapeutic anticoagulation CONCLUSIONS: We found only a modestly increased risk of DVT in patients with COVID-19, likely underestimated owing to limitations in duplex testing early in the epidemic. Elevated d-dimer and a less elevated fibrinogen are associated with DVT in patients with COVID-19 who seem to form thrombus despite conventional chemical thromboprophylaxis. Additionally, an increasing d-dimer over time may be a reflection of the development of DVT in patients with COVID-19.

Spontaneous recanalization of a total occlusion of an infrarenal abdominal aorta after left axillary-bifemoral bypass

Acute aortic occlusion is an infrequent clinical event with high morbidity and mortality. Management is determined by the cause of the occlusion, with thromboembolectomy used for embolic events and bypass for thrombotic events. After bypass, recanalization of a total aortic occlusion has been sparsely reported. We present a case of a total occlusion of an infrarenal abdominal aorta that was managed surgically with a left axillary-bifemoral bypass. Imaging performed 6 months postoperatively revealed a spontaneously recanalized aorta and occluded bypass graft.

Transplant surgery enters a new era: Increasing immunosuppressive medication adherence through mobile apps and smart watches

The high rate of immunosuppressive medication non-adherence in transplant recipients demands the search for a solution that targets modifiable risk factors and incorporates mobile health technology to better engage and educate patients. Kidney transplant recipients (kidneys alone or multi-organ) were randomized to receive a mobile app known as Transplant Hero, both the app and a smart watch, or neither. The coefficient of variability (CV) of tacrolimus levels was measured at one and three months. No statistically significant differences in CV levels were observed between the three groups at either one or three months. Although mobile health apps are a promising strategy for increasing medication adherence, further research is required to determine how to best use this technology.

The Pancreas Can Take the Cold: Lower Waitlist Times Through Importation

BACKGROUND

Our center has used a strategy of pancreas importation owing to long regional waitlist times. Here we assess the clinical outcomes and financial considerations of this strategy.

METHODS

This was a retrospective observational cohort study of patients who received a pancreas transplant at Montefiore Medical Center (MMC) from 2014 to 2017 (n = 28). Clinical parameters, including hemoglobin A_1c and complications, were analyzed. The cohort was compared with United Network for Organ Sharing (UNOS) Region 9 with the use of the UNOS/Organ Procurement and Transplantation Network database. Cost analysis of length of stay (LOS), standard acquisition (SAC) fees, and transportation was performed with the use of internal financial data.

RESULTS

Pancreas importation resulted in significantly shorter simultaneous pancreas kidney transplant waitlist times compared with Region 9: 518 days vs 1001 days (P = .038). In addition, postoperative complications and 1-year HbA_1c did not differ between groups: local 6.30% vs import 6.17% (P = .87). Patients receiving local pancreata stayed an average of 9.2 days compared with 11 days for the import group (P = .36). As such, pancreas importation was associated with higher mean charges ($445,968) compared with local pancreas recipients ($325,470).

CONCLUSIONS

Long waitlist times in Region 9 have encouraged our center's adoption of pancreas importation to address the needs of our patient population. This practice has resulted in a reduction of waitlist times by an average of 483 days. Understandably, centers have long been wary of importation owing to perceived risk in clinical outcomes. In our single-center experience, we have demonstrated equivalent postoperative glucose control and graft survival. Importantly, there does appear to be increased costs associated with importation, which are mainly driven by LOS. Curiously, importation from regions with lower SAC fees has the potential to offset costs related to transportation expenses. Notwithstanding these findings, pancreas importation does have the potential to lessen the financial societal burden through reduction in waitlist times.