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Gender bias, which contributes to burnout and attrition of female medical trainees, may manifest as disparate workplace evaluations. Here, we explore gender-based differences in perceived competence and professionalism as described in an institutional electronic risk management reporting system.In this retrospective qualitative study, recurring themes were identified from anonymous entries reported to an electronic institutional risk management database from July 2014 to July 2015, and from July 2019 to July 2020 using inductive methods. This electronic system is often used by hospital staff to document complaints against physicians under the pretext of poor patient care, regardless of whether an adverse event occurred. Two individuals independently coded entries. Themes were determined from event indicator codes (EIC) using Delphi methodology and compared between gender and specialty using bivariate statistics.A multi-center integrated healthcare delivery system.Risk management entries pertaining to physician trainees by hospital staff as written submissions to the institution's electronic risk management reporting system. Main outcomes included themes defined as: (1) lack of professionalism (i.e., delay in response, attitude, lack of communication), (2) perceived medical error, (3) breach of institutional protocol.Of the 207 entries included for analysis, 52 entries identified men (25%) and 31 entries identified women (15%). The gender was not available in 124 entries and, therefore, categorized as ambiguous. The most common complaint about men involved a physician-related EIC (n = 12, 23%, EIC TX39) and the most common complaint about women involved a communication-related EIC (n = 7, 23%, EIC TX55). Eighty-eight (43%) entries involved medical trainees; 82 (40%) involved surgical trainees. Women were more often identified by their name only (n = 8, 26% vs. n = 3, 6%; p0.001). This finding was consistent in both medical (n = 0, 0% vs. n = 5, 31%; p0.001) and surgical (n = 2, 7% vs. n = 3, 25%; p = 0.006) specialties. In entries involving women, a lack of professionalism was most frequently cited (n = 29, 94%). Entries identifying medical errors more frequently involved men (n = 25, 48% vs. n = 7, 23%; p = 0.02).Gender-based differences exist in how hospital staff interpret trainees' actions and attitudes. These differences have consequences for training paradigms, perceptions of clinical competence, physician burnout, and ultimately, patient outcomes.

Targeted drug delivery to disease-associated activated neutrophils can provide novel therapeutic opportunities while avoiding systemic effects on immune functions. We created a nanomedicine platform that uniquely utilizes an α(1)-antitrypsin-derived peptide to confer binding specificity to neutrophil elastase on activated neutrophils. Surface decoration with this peptide enabled specific anchorage of nanoparticles to activated neutrophils and platelet–neutrophil aggregates, in vitro and in vivo. Nanoparticle delivery of a model drug, hydroxychloroquine, demonstrated significant reduction of neutrophil activities in vitro and a therapeutic effect on murine venous thrombosis in vivo. This innovative approach of cell-specific and activation-state-specific targeting can be applied to several neutrophil-driven pathologies.

Purpose of Review COVID-19 has rapidly evolved into a global pandemic infecting over two hundred and forty-four million individuals to date. In addition to the respiratory sequelae and systemic infection that ensues, an alarming number of micro and macrovascular thrombotic complications have been observed. This review examines the current understanding of COVID-19-associated thrombotic complications, potential mechanisms, and pathobiological basis for thromboses development. Recent Findings The endothelium plays a major role in the process due to direct and indirect injury. The immune system also contributes to a pro-thrombotic environment with immune cell dysregulation leading to excessive formation of cytokines, also called cytokine storm, and an eventual promotion of a hypercoagulable environment, known as immunothrombosis. Additionally, neutrophils play an important role by forming neutrophil extracellular traps, which are shown to be pro-thrombotic and further enhanced in COVID-19 patients. A disruption of the fibrinolysis system has also been observed. Summary Multiple pathways likely contribute synergistically to form a pro-thrombotic milieu. A better understanding of these factors and the complex interplay between them will lead to the improvement of diagnostic and therapeutic interventions.

Introduction: Intraoperative irrigation, usually with normal saline (NS), aids in bleeding identification and management. We investigated the effect of different irrigation fluids, with additives, on hemostasis using two bleeding models. Methods: C57BL/6 J mice were subjected to a tail bleed model or uncontrolled abdominal hemorrhage via liver laceration followed by abdominal cavity irrigation. We compared NS, lactated Ringer's (LR), and PlasmaLyte. We examined NS and LR at different temperatures. Normal saline or LR with calcium (Ca 2+ ) or tranexamic acid (TXA) was studied. Results: Compared with room temperature (RT), increasing the temperature of the irrigation fluid to 37°C and 42°C reduced tail vein bleeding times substantially in both NS and LR (all P0.001), with no significant differences between the two fluids. At RT, LR, but not PlasmaLyte, substantially reduced bleeding times in comparison to NS ( P0.0001). Liver injury blood loss was lower with LR ( P0.01). Normal saline supplemented with 2.7 mEq/L of Ca 2+ decreased bleeding time and blood loss volume ( P0.001 and P0.01, respectively) to similar levels as LR. Normal saline with 150 mg/mL of TXA markedly reduced bleeding time ( P0.0001), and NS with 62.5 mg/mL TXA decreased blood loss ( P0.01). Conclusion: Whereas Ca 2+ - and TXA-supplemented NS reduced bleeding, LR remained superior to all irrigation fluid compositions. As LR contains Ca 2+ , and Ca 2+ -supplemented NS mirrored LR in response, Ca 2+ presence in the irrigation fluid seems key to improving solution's hemostatic ability. Because warming the fluids normalized the choice of agents, the data also suggest that Ca 2+ -containing fluids such as LR may be more suitable for hemostasis when used at RT.

Hypercoagulability is common in SARS-CoV-2 and has been associated with arterial thrombosis leading to acute limb ischemia (ALI). Our objective was to determine the outcomes of concurrent COVID-19 infection and ALI, particularly during the Delta variant surge and the impact of vaccination status.A retrospective review was performed of patients treated at a single healthcare system between March 2020 and December 2021 for ALI and recent (14 days) COVID-19 infection or who developed ALI during hospitalization for the same disease. Patients were grouped by year as well as by pre and post Delta variant emergence in 2021 based on WHO timeline (January-May vs. June-December). Baseline demographics, imaging, interventions, and outcomes were evaluated. A control cohort of all ALI patients requiring surgical intervention for a two-year period prior to the pandemic was used for comparison. Primary outcomes were in-hospital mortality and amputation-free survival. Kaplan-Meier survival and Cox proportional hazards analysis were performed.40 acutely ischemic limbs were identified in 36 patients with COVID-19, the majority during the Delta surge (52.8%) and after the wide availability of vaccines. The rate of COVID-19 associated ALI, though low overall, nearly doubled during the Delta surge (0.37% vs. 0.20%, p-value=.09). Baseline demographics and comorbidities are summarized in Table 1. Intervention (open or endovascular revascularization vs. primary amputation) was performed on 31 limbs in 28 individuals with the remaining 8 treated with systemic anti-coagulation. Post-operative mortality was 48% and overall mortality was 50%. Major amputation following revascularization was significantly higher with COVID ALI (25% vs. 3%, p=0.006) compared to the pre-pandemic group. 30-day amputation-free survival was significantly lower (log-rank p0.001). COVID infection (aHR=6.2, p0.001) and age (HR=1.1, p=0.006) were associated with 30-day amputation in multivariate analysis. Severity of COVID infection, defined as vasopressor usage, was not associated with post-revascularization amputation. There was a higher incidence of re-thrombosis in the latter half of 2021 with the Delta surge as reintervention for recurrent ischemia of the same limb was more common than our previous experience (21% vs. 0%, p=0.55). COVID-19 associated limb ischemia occurred almost exclusively in non-vaccinated patients (92%).ALI observed with Delta appears more resistant to standard therapy. Unvaccinated status correlated highly with ALI occurrence in the setting of COVID-19 infection. Information of limb loss as a COVID complication among non-vaccinated may help to increase compliance.

Recent data indicate social determinants of health (SDOH) have a great impact on prevention and treatment outcomes across a broad variety of disease states, especially cardiovascular diseases. The area deprivation index (ADI) is a validated measure of neighborhood level disadvantage capturing key social determinate factors. Abdominal aortic aneurysm rupture (rAAA) is highly morbid, but also preventable through evidence-based screening. However, the association between rAAA and SDOH is poorly characterized. Our objective is to study the association of SDOH with rAAA and screening age.This retrospective study included patients who underwent operative repair of a rAAA at a multihospital healthcare system (2003-2019). Deprivation was measured by the ADI (scale 1-100), grouped into quintiles for simplicity, with higher quintiles indicating greater deprivation. Patients with the highest quintile ADI (89-100) were categorized as the most deprived. We investigated the association between neighborhood deprivation with the odds of (i) undergoing repair for rAAA before screening age 65 and (ii) undergoing endovascular aortic repair (EVAR) using logistic regression, sequentially modeling nonmodifiable then both nonmodifiable and modifiable confounding variables.There were 632 patients who met the inclusion criteria (aged 74.2 ± 9.4 years; 174 women [27.6%]; 564 White [89.2%]; ADI 66.8 ± 22.3). Those from the most deprived neighborhoods (n = 118) were younger (71.7 ± 10.0 years vs 74.8 ± 9.2 years; P = .002), more likely to be female (36% vs 26%; P = .031), more likely to be Black (5.9% vs 0.4%; P = .007), and fewer underwent EVAR (28% vs 39.5%; P = .020) compared with those from other neighborhoods. On sequential modeling, residing in the most deprived neighborhoods was associated with undergoing rAAA repair before age 65 after adjusting for nonmodifiable factors (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.39-2.95; P .001), and nonmodifiable as well as modifiable factors (OR, 2.22; 95% CI, 1.56-3.16; P .001). Those in the most deprived neighborhoods had a lower odds of undergoing EVAR compared with open repair after adjusting for nonmodifiable factors (OR, 0.64; 95% CI, 0.41-0.98; P = .042), and nonmodifiable as well as modifiable factors (OR, 0.61; 95% CI, 0.37-0.99; P = .047).Among patients who underwent rAAA, residing in the most deprived neighborhoods was associated with greater adjusted odds of presenting under age 65 and undergoing an open repair. These neighborhoods represent tangible geographic targets that may benefit from a younger screening age, enhanced education, and access to care. These findings stress the importance of developing strategies for early prevention and diagnosis of cardiovascular diseases among patients with disadvantageous SDOH.

The objective of the present study was to categorize the presentation and treatment of acute limb ischemia (ALI) in young patients and compare the adverse outcomes after revascularization compared with that of older patients.All the patients who had presented to a multi-institution healthcare system with ALI from 2016 to 2020 were identified. The presenting features, operative details, and outcomes were included in the present analysis. Patients with existing peripheral arterial disease (acute on chronic) were analyzed separately from those without (de novo thrombosis or embolus). Within these groups, younger patients (age, ≤50 years) were compared with older patients (age,50 years). The 3-month major adverse limb event-free survival was the primary outcome.A total of 232 patients (age, 60 ± 16 years; 44% female sex, 87% white race) were included in the analysis. Of the 232 patients, 119 were in the acute on chronic cohort and 113 were in the de novo thrombosis/embolism cohort. Age did not affect the overall outcomes (P = .45) or the outcomes for the acute on chronic group (P = .17). However, in the de novo thrombosis/embolism cohort, patients aged ≤50 years had worse major adverse limb event-free survival compared with patients aged50 years (hazard ratio, 2.47; 95% confidence interval, 1.08-5.68; P = .03) after adjustment for Rutherford class, interval from presentation to the operating room, and smoking status. In the de novo thrombosis/embolism group, the operative approach was similar across the age groups (endovascular, 12% vs 14%; open, 48% vs 41%; hybrid, 41% vs 45%; P = .78). In the younger patients, embolism was more likely from a proximal arterial source (71%). In contrast, in the older patients, the source of embolism was more often a cardiac source (86%). The rates of hypercoagulable disease were equal across the age groups (10% vs 10%; P = .95). The In-hospital mortality was 3% overall (acute on chronic, 5%; de novo, 3%).Despite advances in interventional options, for patients with ALI due to de novo thrombosis or embolus, younger age was associated with worse short-term limb-related outcomes.

Abdominal aortic aneurysm (AAA) shrinkage after endovascular aortic aneurysm repair (EVAR) is a surrogate marker for successful exclusion. Our study characterized aneurysm sac remodeling after EVAR to identify a pattern that may be associated with benign AAA behavior and would safely allow a less rigorous follow-up regimen after EVAR.Elective infrarenal EVARs performed between 2008 and 2011 at our institution were retrospectively reviewed. AAA sac diameters using the minor axis measurement from ultrasound imaging or computer tomography angiogram imaging were compared with the baseline diameter from the 1-month postoperative computer tomography angiogram. The primary outcome was a composite of freedom from postoperative reintervention or rupture. We compared those with AAA sacs who regressed to predefined minimum diameter thresholds with those who did not. Outcomes were plotted with Kaplan-Meier curves and compared using log-rank testing and Fine-Gray regression using death as a competing risk, clustered on graft type. For patients whose AAA reached the minimum sac diameter, landmark analysis evaluated ongoing size changes including further regression and sac re-expansion.A total of 540 patients (aged 75.1 ± 8.2 years; 82.0% male) underwent EVAR with an average preoperative AAA size of 55.2 ± 11.5 mm. The median postoperative follow-up was 5.3 years (interquartile range, 1.4-8.7 years) during which 64 patients underwent reintervention and 4 ruptured. AAA sac regression to ≤40 mm in diameter was associated with improved freedom from reintervention or rupture overall (log-rank, P .01), which was maintained after controlling for the competing risk of death (P .01). In 376 patients (70%) whose aneurysm sac remained40 mm, 99 reinterventions were performed on 63 patients. Of 166 (31%) patients whose sac regressed to ≤40 mm, only 1 patient required a reintervention, and no one ruptured. The mean time to a diameter of ≤40 mm was 2.3 ± 1.9 years. Only eight patients (5%) developed sac re-expansion to45 mm; all but two occurred at least 3 years after initially regressing to ≤40 mm.In long-term follow-up, patients whose minimum AAA sac diameter regressed ≤40 mm after EVAR experienced a very low rate of reintervention, rupture, or sac re-expansion. Most sac re-expansion occurred at least 3 years after reaching this threshold and did not result in clinical events. Increasing follow-up frequency up to 3-year intervals once the AAA sac regresses to 40 mm would carry minimal risk of aneurysm-related morbidity.

Targeted drug delivery to disease-associated activated neutrophils can provide novel therapeutic opportunities while avoiding systemic effects on immune functions. We created a nanomedicine platform that uniquely utilizes an α