Lab mouse

New research suggests that C-reactive protein (CRP) drives multiple myeloma (MM) to destroy bone.

Researchers found that CRP accelerated the onset of bone destruction and made bone damage more severe in mouse models of MM.

The team also observed an association between elevated serum CRP levels and greater degree of bone damage in newly diagnosed MM patients.

The researchers therefore believe that CRP might be targeted to prevent or treat MM-associated bone disease.

Qing Yi, MD, PhD, of the Lerner Research Institute at the Cleveland Clinic in Ohio, and his colleagues conducted this research and reported the results in Science Translational Medicine.

The researchers noted that high levels of circulating CRP have been associated with poor prognosis in many cancers, including MM.

In a previous study, the team found that CRP enhanced MM cell proliferation under stressed conditions and protected MM cells from chemotherapy-induced apoptosis.

Now, the researchers have found that CRP activates MM cells to promote osteoclastogenesis and bone destruction.

In experiments with mouse models, the team found that CRP promoted MM-cell-mediated lytic bone disease. The researchers said CRP enhanced osteoclast differentiation and bone resorption activity.

In vitro experiments showed that CRP stimulates MM cells to produce osteoclast activators such as RANKL, MCP-1, and MIP-1a.

Further investigation revealed that CRP binds to CD32 on MM cells. This activates a pathway mediated by the kinase p38 MAPK and the transcription factor Twist, which increases MM cells’ production of osteolytic cytokines.

Finally, the researchers analyzed samples from newly diagnosed MM patients.

The team found that serum CRP levels “significantly and positively” correlated with the number of bone lesions patients had. And CRP was abundant in lesion biopsies from individuals with severe skeletal disease.

Lab mouse

New research suggests that C-reactive protein (CRP) drives multiple myeloma (MM) to destroy bone.

Researchers found that CRP accelerated the onset of bone destruction and made bone damage more severe in mouse models of MM.

The team also observed an association between elevated serum CRP levels and greater degree of bone damage in newly diagnosed MM patients.

The researchers therefore believe that CRP might be targeted to prevent or treat MM-associated bone disease.

Qing Yi, MD, PhD, of the Lerner Research Institute at the Cleveland Clinic in Ohio, and his colleagues conducted this research and reported the results in Science Translational Medicine.

The researchers noted that high levels of circulating CRP have been associated with poor prognosis in many cancers, including MM.

In a previous study, the team found that CRP enhanced MM cell proliferation under stressed conditions and protected MM cells from chemotherapy-induced apoptosis.

Now, the researchers have found that CRP activates MM cells to promote osteoclastogenesis and bone destruction.

In experiments with mouse models, the team found that CRP promoted MM-cell-mediated lytic bone disease. The researchers said CRP enhanced osteoclast differentiation and bone resorption activity.

In vitro experiments showed that CRP stimulates MM cells to produce osteoclast activators such as RANKL, MCP-1, and MIP-1a.

Further investigation revealed that CRP binds to CD32 on MM cells. This activates a pathway mediated by the kinase p38 MAPK and the transcription factor Twist, which increases MM cells’ production of osteolytic cytokines.

Finally, the researchers analyzed samples from newly diagnosed MM patients.

The team found that serum CRP levels “significantly and positively” correlated with the number of bone lesions patients had. And CRP was abundant in lesion biopsies from individuals with severe skeletal disease.

Lab mouse

New research suggests that C-reactive protein (CRP) drives multiple myeloma (MM) to destroy bone.

Researchers found that CRP accelerated the onset of bone destruction and made bone damage more severe in mouse models of MM.

The team also observed an association between elevated serum CRP levels and greater degree of bone damage in newly diagnosed MM patients.

The researchers therefore believe that CRP might be targeted to prevent or treat MM-associated bone disease.

Qing Yi, MD, PhD, of the Lerner Research Institute at the Cleveland Clinic in Ohio, and his colleagues conducted this research and reported the results in Science Translational Medicine.

The researchers noted that high levels of circulating CRP have been associated with poor prognosis in many cancers, including MM.

In a previous study, the team found that CRP enhanced MM cell proliferation under stressed conditions and protected MM cells from chemotherapy-induced apoptosis.

Now, the researchers have found that CRP activates MM cells to promote osteoclastogenesis and bone destruction.

In experiments with mouse models, the team found that CRP promoted MM-cell-mediated lytic bone disease. The researchers said CRP enhanced osteoclast differentiation and bone resorption activity.

In vitro experiments showed that CRP stimulates MM cells to produce osteoclast activators such as RANKL, MCP-1, and MIP-1a.

Further investigation revealed that CRP binds to CD32 on MM cells. This activates a pathway mediated by the kinase p38 MAPK and the transcription factor Twist, which increases MM cells’ production of osteolytic cytokines.

Finally, the researchers analyzed samples from newly diagnosed MM patients.

The team found that serum CRP levels “significantly and positively” correlated with the number of bone lesions patients had. And CRP was abundant in lesion biopsies from individuals with severe skeletal disease.

Photo by Bill Branson

A survey of nearly 300 US medical providers revealed that many were open to helping children with cancer access medical marijuana (MM).

However, most of the providers surveyed did not know state-specific regulations pertaining to MM.

Providers who were legally eligible to certify (ETC) for MM were less open to endorsing its use.

The lack of standards on formulations, dosing, and potency of MM was identified as the greatest barrier to recommending MM for children with cancer.

Kelly Michelson, MD, of Ann & Robert H. Lurie Children’s Hospital of Chicago in Illinois, and her colleagues reported these findings in Pediatrics.

The researchers used a 32-item survey to assess MM practices, knowledge, attitudes, and barriers for pediatric oncology providers in Illinois, Massachusetts, and Washington.

The survey was sent to providers at Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Seattle Children’s Cancer and Blood Disorders Center, and Lurie Children’s Center for Cancer and Blood Disorders.

There were 288 respondents, and 33% were legally ETC for MM. Eighty-six percent of ETC providers were physicians, and 14% were nurse practitioners or physician assistants.

Of the non-ETC providers, 89% were nurses, 8% were nurse practitioners or physician assistants, 2% were psychosocial providers, and 2% were “other” providers.

Thirty percent of all providers said they had received at least 1 request for MM in the previous month. And 14% of these providers facilitated patient access to MM.

Ninety-two percent of providers said they were willing to help pediatric cancer patients access MM. Fifty-seven percent of providers approved of patients smoking MM, 89% approved of oral formulations, 67% approved of using MM as cancer-directed therapy, and 92% approved of using MM to manage symptoms.

Fifty-nine percent of providers knew that MM is against federal laws, and 86% knew that their state had legalized MM, but only 5% knew state-specific regulations.

ETC providers were less likely to report willingness to help patients access MM. These providers were also less likely to approve of MM use by smoking, oral formulations, as cancer-directed therapy, or to manage symptoms.

“It is not surprising that providers who are eligible to certify for medical marijuana were more cautious about recommending it, given that their licensure could be jeopardized due to federal prohibition,” Dr Michelson said.

“Institutional policies also may have influenced their attitudes. Lurie Children’s, for example, prohibits pediatric providers from facilitating medical marijuana access in accordance with the federal law, even though it is legal in Illinois.”

Most providers considered MM more permissible for use in children with advanced cancer or near the end of life than in earlier stages of cancer treatment. This is consistent with the current American Academy of Pediatrics position that sanctions MM use for “children with life-limiting or seriously debilitating conditions.”

Only 2% of providers reported that MM was never appropriate for a child with cancer.

Most providers (63%) were not concerned about substance abuse in children who receive MM or about being prosecuted for helping patients access MM (80%).

The greatest concern (listed by 46% of providers) was the absence of standards around prescribing MM to children with cancer.

“In addition to unclear dosage guidelines, the lack of high quality scientific data that medical marijuana benefits outweigh possible harm is a huge concern for providers accustomed to evidence-based practice,” Dr Michelson said. “We need rigorously designed clinical trials on the use of medical marijuana in children with cancer.”

Photo by Bill Branson

A survey of nearly 300 US medical providers revealed that many were open to helping children with cancer access medical marijuana (MM).

However, most of the providers surveyed did not know state-specific regulations pertaining to MM.

Providers who were legally eligible to certify (ETC) for MM were less open to endorsing its use.

The lack of standards on formulations, dosing, and potency of MM was identified as the greatest barrier to recommending MM for children with cancer.

Kelly Michelson, MD, of Ann & Robert H. Lurie Children’s Hospital of Chicago in Illinois, and her colleagues reported these findings in Pediatrics.

The researchers used a 32-item survey to assess MM practices, knowledge, attitudes, and barriers for pediatric oncology providers in Illinois, Massachusetts, and Washington.

The survey was sent to providers at Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Seattle Children’s Cancer and Blood Disorders Center, and Lurie Children’s Center for Cancer and Blood Disorders.

There were 288 respondents, and 33% were legally ETC for MM. Eighty-six percent of ETC providers were physicians, and 14% were nurse practitioners or physician assistants.

Of the non-ETC providers, 89% were nurses, 8% were nurse practitioners or physician assistants, 2% were psychosocial providers, and 2% were “other” providers.

Thirty percent of all providers said they had received at least 1 request for MM in the previous month. And 14% of these providers facilitated patient access to MM.

Ninety-two percent of providers said they were willing to help pediatric cancer patients access MM. Fifty-seven percent of providers approved of patients smoking MM, 89% approved of oral formulations, 67% approved of using MM as cancer-directed therapy, and 92% approved of using MM to manage symptoms.

Fifty-nine percent of providers knew that MM is against federal laws, and 86% knew that their state had legalized MM, but only 5% knew state-specific regulations.

ETC providers were less likely to report willingness to help patients access MM. These providers were also less likely to approve of MM use by smoking, oral formulations, as cancer-directed therapy, or to manage symptoms.

“It is not surprising that providers who are eligible to certify for medical marijuana were more cautious about recommending it, given that their licensure could be jeopardized due to federal prohibition,” Dr Michelson said.

“Institutional policies also may have influenced their attitudes. Lurie Children’s, for example, prohibits pediatric providers from facilitating medical marijuana access in accordance with the federal law, even though it is legal in Illinois.”

Most providers considered MM more permissible for use in children with advanced cancer or near the end of life than in earlier stages of cancer treatment. This is consistent with the current American Academy of Pediatrics position that sanctions MM use for “children with life-limiting or seriously debilitating conditions.”

Only 2% of providers reported that MM was never appropriate for a child with cancer.

Most providers (63%) were not concerned about substance abuse in children who receive MM or about being prosecuted for helping patients access MM (80%).

The greatest concern (listed by 46% of providers) was the absence of standards around prescribing MM to children with cancer.

“In addition to unclear dosage guidelines, the lack of high quality scientific data that medical marijuana benefits outweigh possible harm is a huge concern for providers accustomed to evidence-based practice,” Dr Michelson said. “We need rigorously designed clinical trials on the use of medical marijuana in children with cancer.”

Photo by Bill Branson

A survey of nearly 300 US medical providers revealed that many were open to helping children with cancer access medical marijuana (MM).

However, most of the providers surveyed did not know state-specific regulations pertaining to MM.

Providers who were legally eligible to certify (ETC) for MM were less open to endorsing its use.

The lack of standards on formulations, dosing, and potency of MM was identified as the greatest barrier to recommending MM for children with cancer.

Kelly Michelson, MD, of Ann & Robert H. Lurie Children’s Hospital of Chicago in Illinois, and her colleagues reported these findings in Pediatrics.

The researchers used a 32-item survey to assess MM practices, knowledge, attitudes, and barriers for pediatric oncology providers in Illinois, Massachusetts, and Washington.

The survey was sent to providers at Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Seattle Children’s Cancer and Blood Disorders Center, and Lurie Children’s Center for Cancer and Blood Disorders.

There were 288 respondents, and 33% were legally ETC for MM. Eighty-six percent of ETC providers were physicians, and 14% were nurse practitioners or physician assistants.

Of the non-ETC providers, 89% were nurses, 8% were nurse practitioners or physician assistants, 2% were psychosocial providers, and 2% were “other” providers.

Thirty percent of all providers said they had received at least 1 request for MM in the previous month. And 14% of these providers facilitated patient access to MM.

Ninety-two percent of providers said they were willing to help pediatric cancer patients access MM. Fifty-seven percent of providers approved of patients smoking MM, 89% approved of oral formulations, 67% approved of using MM as cancer-directed therapy, and 92% approved of using MM to manage symptoms.

Fifty-nine percent of providers knew that MM is against federal laws, and 86% knew that their state had legalized MM, but only 5% knew state-specific regulations.

ETC providers were less likely to report willingness to help patients access MM. These providers were also less likely to approve of MM use by smoking, oral formulations, as cancer-directed therapy, or to manage symptoms.

“It is not surprising that providers who are eligible to certify for medical marijuana were more cautious about recommending it, given that their licensure could be jeopardized due to federal prohibition,” Dr Michelson said.

“Institutional policies also may have influenced their attitudes. Lurie Children’s, for example, prohibits pediatric providers from facilitating medical marijuana access in accordance with the federal law, even though it is legal in Illinois.”

Most providers considered MM more permissible for use in children with advanced cancer or near the end of life than in earlier stages of cancer treatment. This is consistent with the current American Academy of Pediatrics position that sanctions MM use for “children with life-limiting or seriously debilitating conditions.”

Only 2% of providers reported that MM was never appropriate for a child with cancer.

Most providers (63%) were not concerned about substance abuse in children who receive MM or about being prosecuted for helping patients access MM (80%).

The greatest concern (listed by 46% of providers) was the absence of standards around prescribing MM to children with cancer.

“In addition to unclear dosage guidelines, the lack of high quality scientific data that medical marijuana benefits outweigh possible harm is a huge concern for providers accustomed to evidence-based practice,” Dr Michelson said. “We need rigorously designed clinical trials on the use of medical marijuana in children with cancer.”

Q) My patient has multiple sclerosis and complains of feeling weaker, but denies urinary symptoms. Why have I been told to check for urinary tract infection and not just administer steroids?

Bladder complications are extremely common in patients living with multiple sclerosis (MS), occurring in around 80% of this population.¹ These complications—which include urinary urgency, failure to fully empty the bladder, incontinence, and difficulty getting to a toilet in time—can increase risk for urinary tract infection (UTI). And because many patients with MS also have sensory problems (eg, ­neurogenic bladder), they do not always present with the hallmark UTI symptoms of burning or pain with urination.

Often, presenting symptoms include generalized weakness, increased spasticity, or intensified neurologic issues. These can lead patients to believe they are having a relapse, when in fact, a UTI is causing a pseudoexacerbation of their baseline neurologic issues. In addition, frequent nocturia can disrupt sleep and further contribute to MS-related fatigue. Patients may self-induce dehydration by limiting their daytime fluid intake in an effort to avoid bathroom visits.¹

In partnership with urology colleagues, you can help mitigate bladder complications in patients with MS; this can entail use of medication or interventions such as in-and-out or straight catheterization, timed voids, Botox, or pelvic floor physical therapy. Behavior modifications—ie, minimizing caffeine intake, limiting alcohol consumption, and stopping fluids early in the evening—can also be beneficial.^1,2

Before initiating bladder medication, it is important to review potential adverse effects with the patient. It’s also crucial to ensure that patients are fully emptying their bladders before starting anticholinergic medications, as these can worsen retention.

Which treatment should you choose? Insurance companies tend to prefer generic, older-generation anticholinergics, but bear in mind that these can cause or contribute to cognitive issues (which many patients with MS already have).³ Another medication, such as mirabegron, may be preferable; it’s less likely than anticholinergics to cause dry mouth, which may help with compliance. Also, be aware that anticholinergics can cause blurred vision, which might lead patients to believe they are having optic neuritis or another MS-related visual change.⁴

That said, it is possible for patients to have a relapse and a UTI simultaneously. Due to potential adverse effects, it is essential to balance the risks and benefits of steroid therapy. Steroids could worsen an untreated infection and may not be appropriate for the patient’s symptoms or chief complaint.

Addressing bladder symptoms can not only help prevent UTIs but can also improve skin integrity, sleep quality, independence, and overall quality of life. A thorough exam and history-taking can alleviate secondary and tertiary urinary complications, as well as avoid unnecessary use of corticosteroids. -DRB

Denise R. Bruen, MSN, APRN-BC, MSCN
University of Virgina, Charlottesville

Q) My patient has multiple sclerosis and complains of feeling weaker, but denies urinary symptoms. Why have I been told to check for urinary tract infection and not just administer steroids?

Bladder complications are extremely common in patients living with multiple sclerosis (MS), occurring in around 80% of this population.¹ These complications—which include urinary urgency, failure to fully empty the bladder, incontinence, and difficulty getting to a toilet in time—can increase risk for urinary tract infection (UTI). And because many patients with MS also have sensory problems (eg, ­neurogenic bladder), they do not always present with the hallmark UTI symptoms of burning or pain with urination.

Often, presenting symptoms include generalized weakness, increased spasticity, or intensified neurologic issues. These can lead patients to believe they are having a relapse, when in fact, a UTI is causing a pseudoexacerbation of their baseline neurologic issues. In addition, frequent nocturia can disrupt sleep and further contribute to MS-related fatigue. Patients may self-induce dehydration by limiting their daytime fluid intake in an effort to avoid bathroom visits.¹

In partnership with urology colleagues, you can help mitigate bladder complications in patients with MS; this can entail use of medication or interventions such as in-and-out or straight catheterization, timed voids, Botox, or pelvic floor physical therapy. Behavior modifications—ie, minimizing caffeine intake, limiting alcohol consumption, and stopping fluids early in the evening—can also be beneficial.^1,2

Before initiating bladder medication, it is important to review potential adverse effects with the patient. It’s also crucial to ensure that patients are fully emptying their bladders before starting anticholinergic medications, as these can worsen retention.

Which treatment should you choose? Insurance companies tend to prefer generic, older-generation anticholinergics, but bear in mind that these can cause or contribute to cognitive issues (which many patients with MS already have).³ Another medication, such as mirabegron, may be preferable; it’s less likely than anticholinergics to cause dry mouth, which may help with compliance. Also, be aware that anticholinergics can cause blurred vision, which might lead patients to believe they are having optic neuritis or another MS-related visual change.⁴

That said, it is possible for patients to have a relapse and a UTI simultaneously. Due to potential adverse effects, it is essential to balance the risks and benefits of steroid therapy. Steroids could worsen an untreated infection and may not be appropriate for the patient’s symptoms or chief complaint.

Addressing bladder symptoms can not only help prevent UTIs but can also improve skin integrity, sleep quality, independence, and overall quality of life. A thorough exam and history-taking can alleviate secondary and tertiary urinary complications, as well as avoid unnecessary use of corticosteroids. -DRB

Denise R. Bruen, MSN, APRN-BC, MSCN
University of Virgina, Charlottesville

Q) My patient has multiple sclerosis and complains of feeling weaker, but denies urinary symptoms. Why have I been told to check for urinary tract infection and not just administer steroids?

Bladder complications are extremely common in patients living with multiple sclerosis (MS), occurring in around 80% of this population.¹ These complications—which include urinary urgency, failure to fully empty the bladder, incontinence, and difficulty getting to a toilet in time—can increase risk for urinary tract infection (UTI). And because many patients with MS also have sensory problems (eg, ­neurogenic bladder), they do not always present with the hallmark UTI symptoms of burning or pain with urination.

Often, presenting symptoms include generalized weakness, increased spasticity, or intensified neurologic issues. These can lead patients to believe they are having a relapse, when in fact, a UTI is causing a pseudoexacerbation of their baseline neurologic issues. In addition, frequent nocturia can disrupt sleep and further contribute to MS-related fatigue. Patients may self-induce dehydration by limiting their daytime fluid intake in an effort to avoid bathroom visits.¹

In partnership with urology colleagues, you can help mitigate bladder complications in patients with MS; this can entail use of medication or interventions such as in-and-out or straight catheterization, timed voids, Botox, or pelvic floor physical therapy. Behavior modifications—ie, minimizing caffeine intake, limiting alcohol consumption, and stopping fluids early in the evening—can also be beneficial.^1,2

Before initiating bladder medication, it is important to review potential adverse effects with the patient. It’s also crucial to ensure that patients are fully emptying their bladders before starting anticholinergic medications, as these can worsen retention.

Which treatment should you choose? Insurance companies tend to prefer generic, older-generation anticholinergics, but bear in mind that these can cause or contribute to cognitive issues (which many patients with MS already have).³ Another medication, such as mirabegron, may be preferable; it’s less likely than anticholinergics to cause dry mouth, which may help with compliance. Also, be aware that anticholinergics can cause blurred vision, which might lead patients to believe they are having optic neuritis or another MS-related visual change.⁴

That said, it is possible for patients to have a relapse and a UTI simultaneously. Due to potential adverse effects, it is essential to balance the risks and benefits of steroid therapy. Steroids could worsen an untreated infection and may not be appropriate for the patient’s symptoms or chief complaint.

Addressing bladder symptoms can not only help prevent UTIs but can also improve skin integrity, sleep quality, independence, and overall quality of life. A thorough exam and history-taking can alleviate secondary and tertiary urinary complications, as well as avoid unnecessary use of corticosteroids. -DRB

Denise R. Bruen, MSN, APRN-BC, MSCN
University of Virgina, Charlottesville

Clinical question: Does exposure to a patient with a multidrug-resistant organism result in colonization of a health care provider?

Background: Multidrug-resistant organisms (MDROs) are growing threats in our hospitals, particularly vancomycin-resistant enterococci (VRE) and resistant gram-negative bacteria. The role of the health care team in preventing infection transmission is paramount. If a team member who is caring for a patient with an MDRO or handling lab specimens becomes colonized with these bacteria, he or she could potentially transmit them to the next patient.

Dr. Sata is a medical instructor, Duke University Hospital.

Clinical question: Does exposure to a patient with a multidrug-resistant organism result in colonization of a health care provider?

Background: Multidrug-resistant organisms (MDROs) are growing threats in our hospitals, particularly vancomycin-resistant enterococci (VRE) and resistant gram-negative bacteria. The role of the health care team in preventing infection transmission is paramount. If a team member who is caring for a patient with an MDRO or handling lab specimens becomes colonized with these bacteria, he or she could potentially transmit them to the next patient.

Dr. Sata is a medical instructor, Duke University Hospital.

Clinical question: Does exposure to a patient with a multidrug-resistant organism result in colonization of a health care provider?

Background: Multidrug-resistant organisms (MDROs) are growing threats in our hospitals, particularly vancomycin-resistant enterococci (VRE) and resistant gram-negative bacteria. The role of the health care team in preventing infection transmission is paramount. If a team member who is caring for a patient with an MDRO or handling lab specimens becomes colonized with these bacteria, he or she could potentially transmit them to the next patient.

Dr. Sata is a medical instructor, Duke University Hospital.

The total number of health insurance plans selected on HealthCare.gov increased by 68% during weeks 5 and 6 of the 2018 open season, compared with the total at the end of week 4, according to the Centers for Medicare & Medicaid Services.

The 1.89 million plans that consumers selected over the 2-week period ending Dec. 9 brought this year’s total to 4.68 million after 6 weeks. That’s 16.5% higher than last year’s 6-week total of 4.02 million, but the difference has been getting smaller: After week 2 (enrollment figures were released only biweekly last year), the 2018 open season’s tally was higher than the 2017 open season’s week 2 tally by almost 47%, but after 4 weeks, the difference was only 30%, the CMS data show.

[email protected]

The total number of health insurance plans selected on HealthCare.gov increased by 68% during weeks 5 and 6 of the 2018 open season, compared with the total at the end of week 4, according to the Centers for Medicare & Medicaid Services.

The 1.89 million plans that consumers selected over the 2-week period ending Dec. 9 brought this year’s total to 4.68 million after 6 weeks. That’s 16.5% higher than last year’s 6-week total of 4.02 million, but the difference has been getting smaller: After week 2 (enrollment figures were released only biweekly last year), the 2018 open season’s tally was higher than the 2017 open season’s week 2 tally by almost 47%, but after 4 weeks, the difference was only 30%, the CMS data show.

[email protected]

The total number of health insurance plans selected on HealthCare.gov increased by 68% during weeks 5 and 6 of the 2018 open season, compared with the total at the end of week 4, according to the Centers for Medicare & Medicaid Services.

The 1.89 million plans that consumers selected over the 2-week period ending Dec. 9 brought this year’s total to 4.68 million after 6 weeks. That’s 16.5% higher than last year’s 6-week total of 4.02 million, but the difference has been getting smaller: After week 2 (enrollment figures were released only biweekly last year), the 2018 open season’s tally was higher than the 2017 open season’s week 2 tally by almost 47%, but after 4 weeks, the difference was only 30%, the CMS data show.

[email protected]

Stent-graft coverage of the left subclavian artery (LSA) is often performed during TEVAR treatment of thoracic aortic pathologies and, consequently, debranching of the LSA is frequently performed in such settings. The carotid-subclavian bypass (CSB) is undoubtedly the cervical bypass option preferred by most surgeons for this purpose.^1,2 The technique was first described by Lyons and Galbraith in 1957,³ and popularized by Diethrich et al. who reported their large experience in a well-known article published 10 years later.⁴ In the ensuing decades, CSB became the overwhelming favorite of surgeons everywhere performing LSA revascularization for management of arterial occlusive disease and, more recently, in the context of zone-2 TEVAR. Well- documented good results would seem to justify such preference,⁵ but some level of concern has been voiced consistently over the years about some technical complexities and potential complications such as phrenic nerve and thoracic duct injuries.⁶ My own personal experience substantiated these reservations early on, prompting adoption of an alternative operative solution with use of the carotid-axillary bypass (CAB),⁷ an operation first reported by Shumacker in 1973.⁸ In my hands, it has produced equivalent results to the carotid-subclavian technique in terms of efficacy and durability, and with the additional appeal of distinct practical advantages – mainly because the axillary artery tends to be an easier vessel to expose and handle, and through the avoidance of complications resulting from damage to anatomical structures that are often in harm’s way when exposing the LSA.

Technical aspects

Courtesy of Dr. Criado

End-to-side anastomoses proximally and distally are constructed in routine manner (Fig. 2). We do not use carotid shunting for this procedure.

Occasionally one may want to combine a carotid endarterectomy with the cervical bypass, in which case the proximal vascular graft anastomosis is constructed at the endarterectomy site (Fig. 3). Close attention must be paid to careful length-tailoring the conduit to achieve the desirable gently curving course without undue tension or redundancy.

Proximal ligation of the LSA, often performed during the CSB, cannot be a component of the carotid-axillary operation because of inaccessibility. Some experts look upon this as a disadvantage, but I tend to view such limitation as advantageous because it eliminates the potential for a misplaced ligation distal to the left vertebral artery origin which present-day CTA studies show it to be the case more frequently than previously suspected. If interruption of the LSA is deemed necessary, it is arguably best to use an endovascular (retrograde trans-brachial) approach with precise deployment of a vascular plug device under angiographic guidance (Fig. 4). ■

Dr. Criado is at MedStar Union Memorial Hospital, Baltimore.

References

1. J Endovasc Ther 2002;9(suppl 2):1132-1138.

2. Ann Cardiothorac Surg 2013;2:247-260.

3. Ann Surg 1957;146:487-494.

4. Am J Surg 1967;114:800-808.

5. J Vasc Surg 2008;48:555-560.

6. Ann Vasc Surg 2008;22:70-78.

7. J Vasc Surg 1995;22:717-723.

8. Surg Gynecol Obstet 1973;136:447-8.

9. J Vasc Surg 1999;30:1106-1112.

Stent-graft coverage of the left subclavian artery (LSA) is often performed during TEVAR treatment of thoracic aortic pathologies and, consequently, debranching of the LSA is frequently performed in such settings. The carotid-subclavian bypass (CSB) is undoubtedly the cervical bypass option preferred by most surgeons for this purpose.^1,2 The technique was first described by Lyons and Galbraith in 1957,³ and popularized by Diethrich et al. who reported their large experience in a well-known article published 10 years later.⁴ In the ensuing decades, CSB became the overwhelming favorite of surgeons everywhere performing LSA revascularization for management of arterial occlusive disease and, more recently, in the context of zone-2 TEVAR. Well- documented good results would seem to justify such preference,⁵ but some level of concern has been voiced consistently over the years about some technical complexities and potential complications such as phrenic nerve and thoracic duct injuries.⁶ My own personal experience substantiated these reservations early on, prompting adoption of an alternative operative solution with use of the carotid-axillary bypass (CAB),⁷ an operation first reported by Shumacker in 1973.⁸ In my hands, it has produced equivalent results to the carotid-subclavian technique in terms of efficacy and durability, and with the additional appeal of distinct practical advantages – mainly because the axillary artery tends to be an easier vessel to expose and handle, and through the avoidance of complications resulting from damage to anatomical structures that are often in harm’s way when exposing the LSA.

Technical aspects

Courtesy of Dr. Criado

End-to-side anastomoses proximally and distally are constructed in routine manner (Fig. 2). We do not use carotid shunting for this procedure.

Occasionally one may want to combine a carotid endarterectomy with the cervical bypass, in which case the proximal vascular graft anastomosis is constructed at the endarterectomy site (Fig. 3). Close attention must be paid to careful length-tailoring the conduit to achieve the desirable gently curving course without undue tension or redundancy.

Proximal ligation of the LSA, often performed during the CSB, cannot be a component of the carotid-axillary operation because of inaccessibility. Some experts look upon this as a disadvantage, but I tend to view such limitation as advantageous because it eliminates the potential for a misplaced ligation distal to the left vertebral artery origin which present-day CTA studies show it to be the case more frequently than previously suspected. If interruption of the LSA is deemed necessary, it is arguably best to use an endovascular (retrograde trans-brachial) approach with precise deployment of a vascular plug device under angiographic guidance (Fig. 4). ■

Dr. Criado is at MedStar Union Memorial Hospital, Baltimore.

References

1. J Endovasc Ther 2002;9(suppl 2):1132-1138.

2. Ann Cardiothorac Surg 2013;2:247-260.

3. Ann Surg 1957;146:487-494.

4. Am J Surg 1967;114:800-808.

5. J Vasc Surg 2008;48:555-560.

6. Ann Vasc Surg 2008;22:70-78.

7. J Vasc Surg 1995;22:717-723.

8. Surg Gynecol Obstet 1973;136:447-8.

9. J Vasc Surg 1999;30:1106-1112.

Stent-graft coverage of the left subclavian artery (LSA) is often performed during TEVAR treatment of thoracic aortic pathologies and, consequently, debranching of the LSA is frequently performed in such settings. The carotid-subclavian bypass (CSB) is undoubtedly the cervical bypass option preferred by most surgeons for this purpose.^1,2 The technique was first described by Lyons and Galbraith in 1957,³ and popularized by Diethrich et al. who reported their large experience in a well-known article published 10 years later.⁴ In the ensuing decades, CSB became the overwhelming favorite of surgeons everywhere performing LSA revascularization for management of arterial occlusive disease and, more recently, in the context of zone-2 TEVAR. Well- documented good results would seem to justify such preference,⁵ but some level of concern has been voiced consistently over the years about some technical complexities and potential complications such as phrenic nerve and thoracic duct injuries.⁶ My own personal experience substantiated these reservations early on, prompting adoption of an alternative operative solution with use of the carotid-axillary bypass (CAB),⁷ an operation first reported by Shumacker in 1973.⁸ In my hands, it has produced equivalent results to the carotid-subclavian technique in terms of efficacy and durability, and with the additional appeal of distinct practical advantages – mainly because the axillary artery tends to be an easier vessel to expose and handle, and through the avoidance of complications resulting from damage to anatomical structures that are often in harm’s way when exposing the LSA.

Technical aspects

Courtesy of Dr. Criado

End-to-side anastomoses proximally and distally are constructed in routine manner (Fig. 2). We do not use carotid shunting for this procedure.

Occasionally one may want to combine a carotid endarterectomy with the cervical bypass, in which case the proximal vascular graft anastomosis is constructed at the endarterectomy site (Fig. 3). Close attention must be paid to careful length-tailoring the conduit to achieve the desirable gently curving course without undue tension or redundancy.

Proximal ligation of the LSA, often performed during the CSB, cannot be a component of the carotid-axillary operation because of inaccessibility. Some experts look upon this as a disadvantage, but I tend to view such limitation as advantageous because it eliminates the potential for a misplaced ligation distal to the left vertebral artery origin which present-day CTA studies show it to be the case more frequently than previously suspected. If interruption of the LSA is deemed necessary, it is arguably best to use an endovascular (retrograde trans-brachial) approach with precise deployment of a vascular plug device under angiographic guidance (Fig. 4). ■

Dr. Criado is at MedStar Union Memorial Hospital, Baltimore.

References

1. J Endovasc Ther 2002;9(suppl 2):1132-1138.

2. Ann Cardiothorac Surg 2013;2:247-260.

3. Ann Surg 1957;146:487-494.

4. Am J Surg 1967;114:800-808.

5. J Vasc Surg 2008;48:555-560.

6. Ann Vasc Surg 2008;22:70-78.

7. J Vasc Surg 1995;22:717-723.

8. Surg Gynecol Obstet 1973;136:447-8.

9. J Vasc Surg 1999;30:1106-1112.

When faced with a poorly performing or nonfunctional peritoneal dialysis catheter, there is a very simple trick to make laparoscopic exploration easier. Prep the catheter into the field and take extra care to prep the cover of the catheter. It is usually easier to remove the extended portion of the catheter (A) and just leave the shorter piece (B).

Courtesy Dr. Rigberg

Dr. Rigberg is Clinical Professor of Surgery and Program Director, University of California, Los Angeles, Division of Vascular Surgery, and an associate medical editor for Vascular Specialist.

When faced with a poorly performing or nonfunctional peritoneal dialysis catheter, there is a very simple trick to make laparoscopic exploration easier. Prep the catheter into the field and take extra care to prep the cover of the catheter. It is usually easier to remove the extended portion of the catheter (A) and just leave the shorter piece (B).

Courtesy Dr. Rigberg

Dr. Rigberg is Clinical Professor of Surgery and Program Director, University of California, Los Angeles, Division of Vascular Surgery, and an associate medical editor for Vascular Specialist.

When faced with a poorly performing or nonfunctional peritoneal dialysis catheter, there is a very simple trick to make laparoscopic exploration easier. Prep the catheter into the field and take extra care to prep the cover of the catheter. It is usually easier to remove the extended portion of the catheter (A) and just leave the shorter piece (B).

Courtesy Dr. Rigberg

Dr. Rigberg is Clinical Professor of Surgery and Program Director, University of California, Los Angeles, Division of Vascular Surgery, and an associate medical editor for Vascular Specialist.

From the Editor

Recent news events have detailed the many humiliations and abuses, both verbal and physical, that women, and some men, have to endure in the workforce. It would not surprise me if some vascular surgeons admit that they have heard of similar instances of egregious behavior occurring in our workplaces. The people that have been impacted have predominantly been women and have come from all walks of life. They have been patients, colleagues, our employees or those of the many institutions in which we work. Unfortunately, the demands of our profession and the pace of our lives may diminish our relationships with these persons. This facelessness and disconnection may allow some surgeons to justify their poor behavior whereas others may not realize that they are negatively impacting these individuals’ lives. The fact that these injustices persist is made more upsetting because we are so indebted for all that these nurses, technologists, office personnel, and even patients, do for us.

Just think how much we owe the nurses on the hospital floors. It is to nurses that we entrust the postoperative care of our patients. They make sure to call us when they detect that a pulse is weakening or suddenly absent, or that a neck is expanding as a hematoma threatens breathing. They timely diagnose a retroperitoneal bleed that may endanger the patient’s life. Dialysis nurses notify us that a puncture looks like it may suddenly bleed out. Our patients’ lives are often entirely dependent on the astute observation of an accomplished nurse.

And what about the operating nurses and scrub technicians? They lay out our surgical tray perfectly with all the tools that we are wont to use. They are there to assist when a sudden event requires the steady hand of an observant nurse who knows just what instrument we need without us having to ask. When you are in a difficult area, an encouraging word will often inspire the confidence required to accomplish a successful outcome. When a procedure is going poorly and tension mounts, their silence accepts our sometimes curt requests. There is a bond that develops between two professionals who recognize each other’s expertise.

Vascular technologists work tirelessly, often in darkened rooms, frequently under challenging positions straining eyes and limbs to detect pathology that may be life or limb saving. Their diagnostic acumen can be the difference between a subsequent procedure’s success or failure. Indeed, the vascular surgeon has to make the final interpretation, but if the technologist fails to show the pathology, even the most erudite physician may miss the diagnosis.

Front-desk personnel who sit at check-in and check-out in an office are the face of our practice. Their friendly attitude welcomes our patients and reassures them that they have come to a well-run, professional workplace. A smiling, personal greeting will calm even the most worried patient. Of course, their attention to detail assures that collections will not be misplaced.

Our office nurses exude compassion for the many patients who face immense hurdles in living with vascular disease. They assist in teaching wound care, explain medications, and help in arranging social services. They cry with those that have recently lost a spouse or child and get excited to hear of the birth of a patient’s grandchild. Without their organizational skills, office hours would be interminable, and patients who are kept waiting would complain, or worse, leave the practice. They have learned to laugh at the same joke that they have heard us tell innumerable times, and to ignore the sometimes lousy mood we may bring into the office after a brutal night on call.

The spouses or significant others of our patients also play an important role since it is often from them that we get the most accurate history. They will ask to speak to us privately to make sure we do not cause despair when we discuss treatment options or to ensure that we firmly admonish their loved one to stop smoking, exercise or watch their weight. Unfortunately, they will sometimes have to accept a disparaging remark or gesture from their “spouse” to make sure that we are supplied all the necessary information to come to an appropriate diagnosis.

I can go on about other medical personnel that contribute to our success, but I believe I have made the point. The men and women with whom we interact as vascular surgeons deserve the same respect we grant ourselves. Any insult to them demeans not only the recipient but more so the abuser and those of us who stand by silently.

Finally, there are many female colleagues whose interest and drive has allowed them to not only break into but achieve leadership positions in a specialty that was almost uniformly male and unwelcoming. Their aptitudes and attitudes have broadened the specialty’s ability to help our patients. However, recently the news has been replete with evidence that women have been abused as they tried to enter other male-dominated professions and so it is likely that this has happened in ours.

Other recent news items suggest that these physical and emotional abuses are inflicted not only on women but also men. We may never know the scope of this mistreatment, but we must assure that it stops immediately.

Ethical behavior must be gender neutral. Further, condescending attitudes, cruel language, and a lack of appreciation sometimes can be as damaging as physical or sexual abuse and must be abolished from our workplace. ■

From the Editor

Recent news events have detailed the many humiliations and abuses, both verbal and physical, that women, and some men, have to endure in the workforce. It would not surprise me if some vascular surgeons admit that they have heard of similar instances of egregious behavior occurring in our workplaces. The people that have been impacted have predominantly been women and have come from all walks of life. They have been patients, colleagues, our employees or those of the many institutions in which we work. Unfortunately, the demands of our profession and the pace of our lives may diminish our relationships with these persons. This facelessness and disconnection may allow some surgeons to justify their poor behavior whereas others may not realize that they are negatively impacting these individuals’ lives. The fact that these injustices persist is made more upsetting because we are so indebted for all that these nurses, technologists, office personnel, and even patients, do for us.

Just think how much we owe the nurses on the hospital floors. It is to nurses that we entrust the postoperative care of our patients. They make sure to call us when they detect that a pulse is weakening or suddenly absent, or that a neck is expanding as a hematoma threatens breathing. They timely diagnose a retroperitoneal bleed that may endanger the patient’s life. Dialysis nurses notify us that a puncture looks like it may suddenly bleed out. Our patients’ lives are often entirely dependent on the astute observation of an accomplished nurse.

And what about the operating nurses and scrub technicians? They lay out our surgical tray perfectly with all the tools that we are wont to use. They are there to assist when a sudden event requires the steady hand of an observant nurse who knows just what instrument we need without us having to ask. When you are in a difficult area, an encouraging word will often inspire the confidence required to accomplish a successful outcome. When a procedure is going poorly and tension mounts, their silence accepts our sometimes curt requests. There is a bond that develops between two professionals who recognize each other’s expertise.

Vascular technologists work tirelessly, often in darkened rooms, frequently under challenging positions straining eyes and limbs to detect pathology that may be life or limb saving. Their diagnostic acumen can be the difference between a subsequent procedure’s success or failure. Indeed, the vascular surgeon has to make the final interpretation, but if the technologist fails to show the pathology, even the most erudite physician may miss the diagnosis.

Front-desk personnel who sit at check-in and check-out in an office are the face of our practice. Their friendly attitude welcomes our patients and reassures them that they have come to a well-run, professional workplace. A smiling, personal greeting will calm even the most worried patient. Of course, their attention to detail assures that collections will not be misplaced.

Our office nurses exude compassion for the many patients who face immense hurdles in living with vascular disease. They assist in teaching wound care, explain medications, and help in arranging social services. They cry with those that have recently lost a spouse or child and get excited to hear of the birth of a patient’s grandchild. Without their organizational skills, office hours would be interminable, and patients who are kept waiting would complain, or worse, leave the practice. They have learned to laugh at the same joke that they have heard us tell innumerable times, and to ignore the sometimes lousy mood we may bring into the office after a brutal night on call.

The spouses or significant others of our patients also play an important role since it is often from them that we get the most accurate history. They will ask to speak to us privately to make sure we do not cause despair when we discuss treatment options or to ensure that we firmly admonish their loved one to stop smoking, exercise or watch their weight. Unfortunately, they will sometimes have to accept a disparaging remark or gesture from their “spouse” to make sure that we are supplied all the necessary information to come to an appropriate diagnosis.

I can go on about other medical personnel that contribute to our success, but I believe I have made the point. The men and women with whom we interact as vascular surgeons deserve the same respect we grant ourselves. Any insult to them demeans not only the recipient but more so the abuser and those of us who stand by silently.

Finally, there are many female colleagues whose interest and drive has allowed them to not only break into but achieve leadership positions in a specialty that was almost uniformly male and unwelcoming. Their aptitudes and attitudes have broadened the specialty’s ability to help our patients. However, recently the news has been replete with evidence that women have been abused as they tried to enter other male-dominated professions and so it is likely that this has happened in ours.

Other recent news items suggest that these physical and emotional abuses are inflicted not only on women but also men. We may never know the scope of this mistreatment, but we must assure that it stops immediately.

Ethical behavior must be gender neutral. Further, condescending attitudes, cruel language, and a lack of appreciation sometimes can be as damaging as physical or sexual abuse and must be abolished from our workplace. ■

From the Editor

Recent news events have detailed the many humiliations and abuses, both verbal and physical, that women, and some men, have to endure in the workforce. It would not surprise me if some vascular surgeons admit that they have heard of similar instances of egregious behavior occurring in our workplaces. The people that have been impacted have predominantly been women and have come from all walks of life. They have been patients, colleagues, our employees or those of the many institutions in which we work. Unfortunately, the demands of our profession and the pace of our lives may diminish our relationships with these persons. This facelessness and disconnection may allow some surgeons to justify their poor behavior whereas others may not realize that they are negatively impacting these individuals’ lives. The fact that these injustices persist is made more upsetting because we are so indebted for all that these nurses, technologists, office personnel, and even patients, do for us.

Just think how much we owe the nurses on the hospital floors. It is to nurses that we entrust the postoperative care of our patients. They make sure to call us when they detect that a pulse is weakening or suddenly absent, or that a neck is expanding as a hematoma threatens breathing. They timely diagnose a retroperitoneal bleed that may endanger the patient’s life. Dialysis nurses notify us that a puncture looks like it may suddenly bleed out. Our patients’ lives are often entirely dependent on the astute observation of an accomplished nurse.

And what about the operating nurses and scrub technicians? They lay out our surgical tray perfectly with all the tools that we are wont to use. They are there to assist when a sudden event requires the steady hand of an observant nurse who knows just what instrument we need without us having to ask. When you are in a difficult area, an encouraging word will often inspire the confidence required to accomplish a successful outcome. When a procedure is going poorly and tension mounts, their silence accepts our sometimes curt requests. There is a bond that develops between two professionals who recognize each other’s expertise.

Vascular technologists work tirelessly, often in darkened rooms, frequently under challenging positions straining eyes and limbs to detect pathology that may be life or limb saving. Their diagnostic acumen can be the difference between a subsequent procedure’s success or failure. Indeed, the vascular surgeon has to make the final interpretation, but if the technologist fails to show the pathology, even the most erudite physician may miss the diagnosis.

Front-desk personnel who sit at check-in and check-out in an office are the face of our practice. Their friendly attitude welcomes our patients and reassures them that they have come to a well-run, professional workplace. A smiling, personal greeting will calm even the most worried patient. Of course, their attention to detail assures that collections will not be misplaced.

Our office nurses exude compassion for the many patients who face immense hurdles in living with vascular disease. They assist in teaching wound care, explain medications, and help in arranging social services. They cry with those that have recently lost a spouse or child and get excited to hear of the birth of a patient’s grandchild. Without their organizational skills, office hours would be interminable, and patients who are kept waiting would complain, or worse, leave the practice. They have learned to laugh at the same joke that they have heard us tell innumerable times, and to ignore the sometimes lousy mood we may bring into the office after a brutal night on call.

The spouses or significant others of our patients also play an important role since it is often from them that we get the most accurate history. They will ask to speak to us privately to make sure we do not cause despair when we discuss treatment options or to ensure that we firmly admonish their loved one to stop smoking, exercise or watch their weight. Unfortunately, they will sometimes have to accept a disparaging remark or gesture from their “spouse” to make sure that we are supplied all the necessary information to come to an appropriate diagnosis.

I can go on about other medical personnel that contribute to our success, but I believe I have made the point. The men and women with whom we interact as vascular surgeons deserve the same respect we grant ourselves. Any insult to them demeans not only the recipient but more so the abuser and those of us who stand by silently.

Finally, there are many female colleagues whose interest and drive has allowed them to not only break into but achieve leadership positions in a specialty that was almost uniformly male and unwelcoming. Their aptitudes and attitudes have broadened the specialty’s ability to help our patients. However, recently the news has been replete with evidence that women have been abused as they tried to enter other male-dominated professions and so it is likely that this has happened in ours.

Other recent news items suggest that these physical and emotional abuses are inflicted not only on women but also men. We may never know the scope of this mistreatment, but we must assure that it stops immediately.

Ethical behavior must be gender neutral. Further, condescending attitudes, cruel language, and a lack of appreciation sometimes can be as damaging as physical or sexual abuse and must be abolished from our workplace. ■

Preop embolization is safe and effective

To embolize or not to embolize ... that is the question when it comes to the management of carotid body tumors. Carotid body tumors (CBTs) are rare benign neoplasms that are almost always nonfunctional and account for up to 80% of all head and neck paragangliomas. Radiographic characteristics include tumor location at the carotid bifurcation, splaying apart the internal and external carotid arteries. Surgical resection is the mainstay of definitive treatment and is preferably performed at diagnosis. CBTs are categorized based upon their involvement with surrounding structures: Shamblin I tumors are small, without encasement of the carotid arteries; Shamblin II tumors partially encase the vessels; and Shamblin III tumors completely encase the vessels. When it comes to operative complications, advanced Shamblin stage is associated with a higher rate of cranial nerve injury when the tumor is resected.¹

Pertinent to the technical aspects of surgical resection, CBTs are characteristically encased with an elaborate network of friable vessels which may contribute to significant intraoperative bleeding, especially with resection of larger tumors. The blood supply to CBTs typically originates from the branches of the external carotid artery. These branches may be sacrificed with minimal consequence using preoperative embolization. This common practice is felt by many to facilitate safe resection while minimizing intraoperative blood loss. Although the reduction of blood loss has not been observed universally, there is enough evidence of this in the literature to support the use of selective preoperative embolization. Several embolic agents have been described in this setting, including polyvinyl alcohol particles (150-1000 microns), polymerized glue (n-butyl cyanoacrylate), and more recently, ethylene-vinyl alcohol copolymer (Onyx, ev3, Irvine, Calif.). Risks of complications related to CBT embolization in experienced hands are quite low with no adverse events reported in a number of reports describing the technique.^2,3

References

1. J Vasc Surg. 2013;57:64-8S.

2. J Vasc Interv Neurol. 2008;1(2):37-41.

3. Am J Neuroradiol. 2009;30:1594-97.

4. J Vasc Surg. 2012;56:979-89.

5. Vasc Endovasc Surg. 2009;43:457-61.

Too many downsides

As vascular surgeons, we are frequently confronting situations where the “best” approach to a problem is far from established. The evidence to make a clinical decision may simply not exist, and we need to choose a course of therapy based more on personal preference than science. Such is the case with preoperative embolization for the resection of carotid body tumors (CBT).

It has been over 35 years since the technique for preoperative embolization of CBT was described, the aim being reduction in blood loss, decreased operative time, and improved visualization for safer tumor resection. This is based on the fact that most of the arterial supply to these tumors arises from external carotid branches (particularly the ascending pharyngeal), and these that can be safely sacrificed. Although this technique is certainly now a standard part of treatment for many vascular surgeons, the evidence of benefit is certainly not overwhelming, and like all interventions, nothing comes without risks.

References

1. Surgery. 1980;87:459-464.

2. Head Neck. 2016;38:E2386-E2394.

3. J Vasc Surg. 2015;61:1081-91.

4. Otolaryngol Head Neck Surg. 2015;153:942-950.

Preop embolization is safe and effective

To embolize or not to embolize ... that is the question when it comes to the management of carotid body tumors. Carotid body tumors (CBTs) are rare benign neoplasms that are almost always nonfunctional and account for up to 80% of all head and neck paragangliomas. Radiographic characteristics include tumor location at the carotid bifurcation, splaying apart the internal and external carotid arteries. Surgical resection is the mainstay of definitive treatment and is preferably performed at diagnosis. CBTs are categorized based upon their involvement with surrounding structures: Shamblin I tumors are small, without encasement of the carotid arteries; Shamblin II tumors partially encase the vessels; and Shamblin III tumors completely encase the vessels. When it comes to operative complications, advanced Shamblin stage is associated with a higher rate of cranial nerve injury when the tumor is resected.¹

Pertinent to the technical aspects of surgical resection, CBTs are characteristically encased with an elaborate network of friable vessels which may contribute to significant intraoperative bleeding, especially with resection of larger tumors. The blood supply to CBTs typically originates from the branches of the external carotid artery. These branches may be sacrificed with minimal consequence using preoperative embolization. This common practice is felt by many to facilitate safe resection while minimizing intraoperative blood loss. Although the reduction of blood loss has not been observed universally, there is enough evidence of this in the literature to support the use of selective preoperative embolization. Several embolic agents have been described in this setting, including polyvinyl alcohol particles (150-1000 microns), polymerized glue (n-butyl cyanoacrylate), and more recently, ethylene-vinyl alcohol copolymer (Onyx, ev3, Irvine, Calif.). Risks of complications related to CBT embolization in experienced hands are quite low with no adverse events reported in a number of reports describing the technique.^2,3

References

1. J Vasc Surg. 2013;57:64-8S.

2. J Vasc Interv Neurol. 2008;1(2):37-41.

3. Am J Neuroradiol. 2009;30:1594-97.

4. J Vasc Surg. 2012;56:979-89.

5. Vasc Endovasc Surg. 2009;43:457-61.

Too many downsides

As vascular surgeons, we are frequently confronting situations where the “best” approach to a problem is far from established. The evidence to make a clinical decision may simply not exist, and we need to choose a course of therapy based more on personal preference than science. Such is the case with preoperative embolization for the resection of carotid body tumors (CBT).

It has been over 35 years since the technique for preoperative embolization of CBT was described, the aim being reduction in blood loss, decreased operative time, and improved visualization for safer tumor resection. This is based on the fact that most of the arterial supply to these tumors arises from external carotid branches (particularly the ascending pharyngeal), and these that can be safely sacrificed. Although this technique is certainly now a standard part of treatment for many vascular surgeons, the evidence of benefit is certainly not overwhelming, and like all interventions, nothing comes without risks.

References

1. Surgery. 1980;87:459-464.

2. Head Neck. 2016;38:E2386-E2394.

3. J Vasc Surg. 2015;61:1081-91.

4. Otolaryngol Head Neck Surg. 2015;153:942-950.

Preop embolization is safe and effective

To embolize or not to embolize ... that is the question when it comes to the management of carotid body tumors. Carotid body tumors (CBTs) are rare benign neoplasms that are almost always nonfunctional and account for up to 80% of all head and neck paragangliomas. Radiographic characteristics include tumor location at the carotid bifurcation, splaying apart the internal and external carotid arteries. Surgical resection is the mainstay of definitive treatment and is preferably performed at diagnosis. CBTs are categorized based upon their involvement with surrounding structures: Shamblin I tumors are small, without encasement of the carotid arteries; Shamblin II tumors partially encase the vessels; and Shamblin III tumors completely encase the vessels. When it comes to operative complications, advanced Shamblin stage is associated with a higher rate of cranial nerve injury when the tumor is resected.¹

Pertinent to the technical aspects of surgical resection, CBTs are characteristically encased with an elaborate network of friable vessels which may contribute to significant intraoperative bleeding, especially with resection of larger tumors. The blood supply to CBTs typically originates from the branches of the external carotid artery. These branches may be sacrificed with minimal consequence using preoperative embolization. This common practice is felt by many to facilitate safe resection while minimizing intraoperative blood loss. Although the reduction of blood loss has not been observed universally, there is enough evidence of this in the literature to support the use of selective preoperative embolization. Several embolic agents have been described in this setting, including polyvinyl alcohol particles (150-1000 microns), polymerized glue (n-butyl cyanoacrylate), and more recently, ethylene-vinyl alcohol copolymer (Onyx, ev3, Irvine, Calif.). Risks of complications related to CBT embolization in experienced hands are quite low with no adverse events reported in a number of reports describing the technique.^2,3

References

1. J Vasc Surg. 2013;57:64-8S.

2. J Vasc Interv Neurol. 2008;1(2):37-41.

3. Am J Neuroradiol. 2009;30:1594-97.

4. J Vasc Surg. 2012;56:979-89.

5. Vasc Endovasc Surg. 2009;43:457-61.

Too many downsides

As vascular surgeons, we are frequently confronting situations where the “best” approach to a problem is far from established. The evidence to make a clinical decision may simply not exist, and we need to choose a course of therapy based more on personal preference than science. Such is the case with preoperative embolization for the resection of carotid body tumors (CBT).

It has been over 35 years since the technique for preoperative embolization of CBT was described, the aim being reduction in blood loss, decreased operative time, and improved visualization for safer tumor resection. This is based on the fact that most of the arterial supply to these tumors arises from external carotid branches (particularly the ascending pharyngeal), and these that can be safely sacrificed. Although this technique is certainly now a standard part of treatment for many vascular surgeons, the evidence of benefit is certainly not overwhelming, and like all interventions, nothing comes without risks.

References

1. Surgery. 1980;87:459-464.

2. Head Neck. 2016;38:E2386-E2394.

3. J Vasc Surg. 2015;61:1081-91.

4. Otolaryngol Head Neck Surg. 2015;153:942-950.

Studies have shown that most of you already have deep-seated beliefs regarding guns. Some of you would frame the issue as Gun Rights, others as Gun Violence. I am not here to change your opinion. I am not in the habit of wasting my time. Logic has been drained from this discussion and emotion infused. As vascular surgeons, it is far past time to overcome these limitations and join the national discussion. Opinions and consensus statements have already been rendered from the American College of Surgeons, the American Medical Association, the American Academy of Pediatrics, the Society of Thoracic Surgeons, and even the American College of Phlebology. Where does the SVS stand?

In January 2013, the Board of Directors of the SVS voted to support the ACS Statement on Firearm Injuries. There is virtually no public record of this endorsement, it does not appear on the SVS website and it was essentially ignored by the public.

Even the diligent National Rifle Association (NRA) left the SVS off their list of “National Organizations with Anti-Gun Policies” (Ed note: for more information, see “The Evolution of the NRA and Our Modern Gun Debate” at www.vascularspecialistonline.com).

We need to do better. If we are truly an independent specialty it is time to behave as such. Vascular surgeons are on the front lines of this battle. We have cared for the injured, revived the dying, and bear witness to the dead. To not have a voice and be counted is a disservice to our patients and ourselves.

What can be done to reduce gun violence? In Australia, between 1979 and 1996, there were 13 mass shootings. After a semiautomatic weapon ban was instituted in 1996 there have been none. The U.S. ban on military style weapons lapsed in 2004. While it is difficult to characterize “mass shootings” in a country our size, there certainly seems to be an increase since then. If defined as “four or more shot and/or killed in a single event, at the same general time and location not including the shooter,” then we have seen 275 mass shootings this year as of Oct. 5, 2017.

The other statistics are familiar and sobering. More Americans have died from guns since 1968 than have died in all the wars since our country’s inception. The United States accounts for 91% of gun deaths of children among developed countries. Our casualty figures more closely mirror Somalia and Honduras, not Britain or Germany.

Contemporary, large-scale research in limiting gun violence is essentially nonexistent since a 1993 Centers for Disease Control and Prevention (CDC) funded study found a link between keeping a gun in the home with an increased risk of homicide. Quick to respond, Congress passed the 1996 Dickey Amendment that prohibits the CDC from funding efforts that “advocate or promote gun control.” This amendment has been renewed every year despite the author of the bill, Representative Jay Dickey, expressing regret for halting all gun research, stating that was not his intention. Rep. Dickey died earlier this year.

In the U.S., gun laws have actually relaxed over time. In 1988, 18 states had laws allowing civilians to carry concealed hand guns in public places, now this practice is legal in 40 states. In a 2008 landmark decision, the Supreme Court struck down a personal handgun ban in the District of Columbia. The Second Amendment rights afforded to a “well-regulated militia” to “keep and bear arms” were now extended to private individuals. Guns are clearly more prevalent and available in the U.S. than ever before.

The congressional ban on firearms research now extends to all Department of Health and Human Services agencies, including the NIH. We need the Dickey Amendment lifted so we can study the relationship of gun ownership and crime. As physicians, we need to deal from an informed, intelligent position and not an emotional one.

Over 50 medical societies, comprising essentially every physician in the U.S., have released statements on gun violence. The AMA has labeled it a “public health crisis.” The ACS stated, in the aftermath of the Las Vegas shooting, “It is important that the American College of Surgeons, whose Fellows care for the victims of these events, be part of the solution.”

Aside from ethical or moral obligations, why should we dive into this quagmire? Most of us are already represented in the discussion through other groups. The answer lies in our identity. If vascular surgery is to become a truly independent specialty, we can’t hide behind the ACS or the AMA when the politics become sticky.

To protect the 30,000 people who die from aneurysm rupture yearly we literally forced an act of Congress. Where do we stand on the more than 33,000 people who die yearly from gun violence? For vascular surgery to have a true public presence, we must be prepared to enter the most public of all discussions.

Luckily, there is already a pathway to consensus. The American College of Surgeons Committee on Trauma (ACS COT) surveyed its members and found that only 15% had no strong opinions on firearms. Just over 50% felt that guns were important for personal safety and defense, while 30% felt the large number of guns in the U.S. was a threat to safety.

Individuals who felt that firearms were important were most likely to associate guns with personal freedom, while those who felt they were a threat were most likely to associate guns with violence.

To further the discussion, the emotional battle between personal freedom and violence needed to be minimized. In doing so, the ACS COT was able to produce a consensus statement despite the seemingly diametrically opposed opinions of its members.

An independent specialty needs an independent voice. If we don’t know our own position, obviously the public doesn’t either.

As a starting point, here is the ACS Statement on Firearms Injuries:

Because violence inflicted by guns continues to be a daily event in the United States and mass casualties involving firearms threaten the health and safety of the public, the American College of Surgeons supports:

1. Legislation banning civilian access to assault weapons, large ammunition clips, and munitions designed for military and law enforcement agencies.

2. Enhancing mandatory background checks for the purchase of firearms to include gun shows and auctions.

3. Assuring that health care professionals can fulfill their role in preventing firearm injuries by health screening, patient counseling, and referral to mental health services for those with behavioral medical conditions. 4. Developing and promoting proactive programs directed at improving safe gun storage and the teaching of nonviolent conflict resolution for a culture that often glorifies guns and violence in media and gaming.

5. Evidence-based research on firearm injury and the creation of a national firearm injury database to inform federal health policy. 

Selected References

1) Gun Violence Research: History of Federal Funding Freeze (www.apa.org/science/about/psa/2013/02/gun-violence.aspx)

2) Childhood Firearm Injuries in the United States (www.apa.org/science/about/psa/2013/02/gun-violence.aspx)

3) Gun Violence Letter to the U.S. House of Representatives (2013) (www.acponline.org/acp_policy/letters/gun_violence_letter_house_2013.pdf)

4) Survey of American College of Surgeons Committee on Trauma members on firearm injury: Consensus and opportunities (2016) (www.facs.org).

5) American College of Surgeons Statement on Firearm Injuries (www.facs.org)

Studies have shown that most of you already have deep-seated beliefs regarding guns. Some of you would frame the issue as Gun Rights, others as Gun Violence. I am not here to change your opinion. I am not in the habit of wasting my time. Logic has been drained from this discussion and emotion infused. As vascular surgeons, it is far past time to overcome these limitations and join the national discussion. Opinions and consensus statements have already been rendered from the American College of Surgeons, the American Medical Association, the American Academy of Pediatrics, the Society of Thoracic Surgeons, and even the American College of Phlebology. Where does the SVS stand?

In January 2013, the Board of Directors of the SVS voted to support the ACS Statement on Firearm Injuries. There is virtually no public record of this endorsement, it does not appear on the SVS website and it was essentially ignored by the public.

Even the diligent National Rifle Association (NRA) left the SVS off their list of “National Organizations with Anti-Gun Policies” (Ed note: for more information, see “The Evolution of the NRA and Our Modern Gun Debate” at www.vascularspecialistonline.com).

We need to do better. If we are truly an independent specialty it is time to behave as such. Vascular surgeons are on the front lines of this battle. We have cared for the injured, revived the dying, and bear witness to the dead. To not have a voice and be counted is a disservice to our patients and ourselves.

What can be done to reduce gun violence? In Australia, between 1979 and 1996, there were 13 mass shootings. After a semiautomatic weapon ban was instituted in 1996 there have been none. The U.S. ban on military style weapons lapsed in 2004. While it is difficult to characterize “mass shootings” in a country our size, there certainly seems to be an increase since then. If defined as “four or more shot and/or killed in a single event, at the same general time and location not including the shooter,” then we have seen 275 mass shootings this year as of Oct. 5, 2017.

The other statistics are familiar and sobering. More Americans have died from guns since 1968 than have died in all the wars since our country’s inception. The United States accounts for 91% of gun deaths of children among developed countries. Our casualty figures more closely mirror Somalia and Honduras, not Britain or Germany.

Contemporary, large-scale research in limiting gun violence is essentially nonexistent since a 1993 Centers for Disease Control and Prevention (CDC) funded study found a link between keeping a gun in the home with an increased risk of homicide. Quick to respond, Congress passed the 1996 Dickey Amendment that prohibits the CDC from funding efforts that “advocate or promote gun control.” This amendment has been renewed every year despite the author of the bill, Representative Jay Dickey, expressing regret for halting all gun research, stating that was not his intention. Rep. Dickey died earlier this year.

In the U.S., gun laws have actually relaxed over time. In 1988, 18 states had laws allowing civilians to carry concealed hand guns in public places, now this practice is legal in 40 states. In a 2008 landmark decision, the Supreme Court struck down a personal handgun ban in the District of Columbia. The Second Amendment rights afforded to a “well-regulated militia” to “keep and bear arms” were now extended to private individuals. Guns are clearly more prevalent and available in the U.S. than ever before.

The congressional ban on firearms research now extends to all Department of Health and Human Services agencies, including the NIH. We need the Dickey Amendment lifted so we can study the relationship of gun ownership and crime. As physicians, we need to deal from an informed, intelligent position and not an emotional one.

Over 50 medical societies, comprising essentially every physician in the U.S., have released statements on gun violence. The AMA has labeled it a “public health crisis.” The ACS stated, in the aftermath of the Las Vegas shooting, “It is important that the American College of Surgeons, whose Fellows care for the victims of these events, be part of the solution.”

Aside from ethical or moral obligations, why should we dive into this quagmire? Most of us are already represented in the discussion through other groups. The answer lies in our identity. If vascular surgery is to become a truly independent specialty, we can’t hide behind the ACS or the AMA when the politics become sticky.

To protect the 30,000 people who die from aneurysm rupture yearly we literally forced an act of Congress. Where do we stand on the more than 33,000 people who die yearly from gun violence? For vascular surgery to have a true public presence, we must be prepared to enter the most public of all discussions.

Luckily, there is already a pathway to consensus. The American College of Surgeons Committee on Trauma (ACS COT) surveyed its members and found that only 15% had no strong opinions on firearms. Just over 50% felt that guns were important for personal safety and defense, while 30% felt the large number of guns in the U.S. was a threat to safety.

Individuals who felt that firearms were important were most likely to associate guns with personal freedom, while those who felt they were a threat were most likely to associate guns with violence.

To further the discussion, the emotional battle between personal freedom and violence needed to be minimized. In doing so, the ACS COT was able to produce a consensus statement despite the seemingly diametrically opposed opinions of its members.

An independent specialty needs an independent voice. If we don’t know our own position, obviously the public doesn’t either.

As a starting point, here is the ACS Statement on Firearms Injuries:

Because violence inflicted by guns continues to be a daily event in the United States and mass casualties involving firearms threaten the health and safety of the public, the American College of Surgeons supports:

1. Legislation banning civilian access to assault weapons, large ammunition clips, and munitions designed for military and law enforcement agencies.

2. Enhancing mandatory background checks for the purchase of firearms to include gun shows and auctions.

3. Assuring that health care professionals can fulfill their role in preventing firearm injuries by health screening, patient counseling, and referral to mental health services for those with behavioral medical conditions. 4. Developing and promoting proactive programs directed at improving safe gun storage and the teaching of nonviolent conflict resolution for a culture that often glorifies guns and violence in media and gaming.

5. Evidence-based research on firearm injury and the creation of a national firearm injury database to inform federal health policy. 

Selected References

1) Gun Violence Research: History of Federal Funding Freeze (www.apa.org/science/about/psa/2013/02/gun-violence.aspx)

2) Childhood Firearm Injuries in the United States (www.apa.org/science/about/psa/2013/02/gun-violence.aspx)

3) Gun Violence Letter to the U.S. House of Representatives (2013) (www.acponline.org/acp_policy/letters/gun_violence_letter_house_2013.pdf)

4) Survey of American College of Surgeons Committee on Trauma members on firearm injury: Consensus and opportunities (2016) (www.facs.org).

5) American College of Surgeons Statement on Firearm Injuries (www.facs.org)

Studies have shown that most of you already have deep-seated beliefs regarding guns. Some of you would frame the issue as Gun Rights, others as Gun Violence. I am not here to change your opinion. I am not in the habit of wasting my time. Logic has been drained from this discussion and emotion infused. As vascular surgeons, it is far past time to overcome these limitations and join the national discussion. Opinions and consensus statements have already been rendered from the American College of Surgeons, the American Medical Association, the American Academy of Pediatrics, the Society of Thoracic Surgeons, and even the American College of Phlebology. Where does the SVS stand?

In January 2013, the Board of Directors of the SVS voted to support the ACS Statement on Firearm Injuries. There is virtually no public record of this endorsement, it does not appear on the SVS website and it was essentially ignored by the public.

Even the diligent National Rifle Association (NRA) left the SVS off their list of “National Organizations with Anti-Gun Policies” (Ed note: for more information, see “The Evolution of the NRA and Our Modern Gun Debate” at www.vascularspecialistonline.com).

We need to do better. If we are truly an independent specialty it is time to behave as such. Vascular surgeons are on the front lines of this battle. We have cared for the injured, revived the dying, and bear witness to the dead. To not have a voice and be counted is a disservice to our patients and ourselves.

What can be done to reduce gun violence? In Australia, between 1979 and 1996, there were 13 mass shootings. After a semiautomatic weapon ban was instituted in 1996 there have been none. The U.S. ban on military style weapons lapsed in 2004. While it is difficult to characterize “mass shootings” in a country our size, there certainly seems to be an increase since then. If defined as “four or more shot and/or killed in a single event, at the same general time and location not including the shooter,” then we have seen 275 mass shootings this year as of Oct. 5, 2017.

The other statistics are familiar and sobering. More Americans have died from guns since 1968 than have died in all the wars since our country’s inception. The United States accounts for 91% of gun deaths of children among developed countries. Our casualty figures more closely mirror Somalia and Honduras, not Britain or Germany.

Contemporary, large-scale research in limiting gun violence is essentially nonexistent since a 1993 Centers for Disease Control and Prevention (CDC) funded study found a link between keeping a gun in the home with an increased risk of homicide. Quick to respond, Congress passed the 1996 Dickey Amendment that prohibits the CDC from funding efforts that “advocate or promote gun control.” This amendment has been renewed every year despite the author of the bill, Representative Jay Dickey, expressing regret for halting all gun research, stating that was not his intention. Rep. Dickey died earlier this year.

In the U.S., gun laws have actually relaxed over time. In 1988, 18 states had laws allowing civilians to carry concealed hand guns in public places, now this practice is legal in 40 states. In a 2008 landmark decision, the Supreme Court struck down a personal handgun ban in the District of Columbia. The Second Amendment rights afforded to a “well-regulated militia” to “keep and bear arms” were now extended to private individuals. Guns are clearly more prevalent and available in the U.S. than ever before.

The congressional ban on firearms research now extends to all Department of Health and Human Services agencies, including the NIH. We need the Dickey Amendment lifted so we can study the relationship of gun ownership and crime. As physicians, we need to deal from an informed, intelligent position and not an emotional one.

Over 50 medical societies, comprising essentially every physician in the U.S., have released statements on gun violence. The AMA has labeled it a “public health crisis.” The ACS stated, in the aftermath of the Las Vegas shooting, “It is important that the American College of Surgeons, whose Fellows care for the victims of these events, be part of the solution.”

Aside from ethical or moral obligations, why should we dive into this quagmire? Most of us are already represented in the discussion through other groups. The answer lies in our identity. If vascular surgery is to become a truly independent specialty, we can’t hide behind the ACS or the AMA when the politics become sticky.

To protect the 30,000 people who die from aneurysm rupture yearly we literally forced an act of Congress. Where do we stand on the more than 33,000 people who die yearly from gun violence? For vascular surgery to have a true public presence, we must be prepared to enter the most public of all discussions.

Luckily, there is already a pathway to consensus. The American College of Surgeons Committee on Trauma (ACS COT) surveyed its members and found that only 15% had no strong opinions on firearms. Just over 50% felt that guns were important for personal safety and defense, while 30% felt the large number of guns in the U.S. was a threat to safety.

Individuals who felt that firearms were important were most likely to associate guns with personal freedom, while those who felt they were a threat were most likely to associate guns with violence.

To further the discussion, the emotional battle between personal freedom and violence needed to be minimized. In doing so, the ACS COT was able to produce a consensus statement despite the seemingly diametrically opposed opinions of its members.

An independent specialty needs an independent voice. If we don’t know our own position, obviously the public doesn’t either.

As a starting point, here is the ACS Statement on Firearms Injuries:

Because violence inflicted by guns continues to be a daily event in the United States and mass casualties involving firearms threaten the health and safety of the public, the American College of Surgeons supports:

1. Legislation banning civilian access to assault weapons, large ammunition clips, and munitions designed for military and law enforcement agencies.

2. Enhancing mandatory background checks for the purchase of firearms to include gun shows and auctions.

3. Assuring that health care professionals can fulfill their role in preventing firearm injuries by health screening, patient counseling, and referral to mental health services for those with behavioral medical conditions. 4. Developing and promoting proactive programs directed at improving safe gun storage and the teaching of nonviolent conflict resolution for a culture that often glorifies guns and violence in media and gaming.

5. Evidence-based research on firearm injury and the creation of a national firearm injury database to inform federal health policy. 

Selected References

1) Gun Violence Research: History of Federal Funding Freeze (www.apa.org/science/about/psa/2013/02/gun-violence.aspx)

2) Childhood Firearm Injuries in the United States (www.apa.org/science/about/psa/2013/02/gun-violence.aspx)

3) Gun Violence Letter to the U.S. House of Representatives (2013) (www.acponline.org/acp_policy/letters/gun_violence_letter_house_2013.pdf)

4) Survey of American College of Surgeons Committee on Trauma members on firearm injury: Consensus and opportunities (2016) (www.facs.org).

5) American College of Surgeons Statement on Firearm Injuries (www.facs.org)