Girardo, Marlene

Objective: The aim of this research was to evaluate intraoperative visual detection of endometriosis compared to final histopathologic diagnosis based on lesion type. Materials and Methods: This prospective clinical study at a tertiary-care, academic medical center involved 77 patients who had surgery by high-volume endometriosis surgeons for suspected endometriosis. Pelvic peritonectomy was performed with documentation of visual presence or absence of endometriosis and lesion type. Powder burn lesions were defined as typical lesions. White scarring, clear vesicles, red flame, and peritoneal pockets were defined as atypical lesions. Results: Of 1069 peritoneal specimens, there was visual detection of endometriosis in 352 (32.93%). Endometriosis was confirmed on histopathologic evaluation of: powder-burn, 65.8%; white scarring, 51.6%; clear vesicles, 45.7%; red-flame, 39.1%; and peritoneal pockets, 28.9% ( p = 0.003). Additionally, 11.3% of specimens with no visible endometriosis demonstrated a positive histopathologic diagnosis. Overall sensitivity was 68.36%; specificity was 78.15%; positive predictive value (PPV) was 49.72%; and negative predictive value was 88.66%. All lesions had high specificity (powder-burn, 96.20%; white scarring, 91.34%; clear vesicles; 92.54%; red-flame, 97.84%; and peritoneal pockets; 95.91%). PPV depended on lesion type (powder-burn, 65.75%; white scarring, 51.61 %; clear vesicles, 45.74%; red-flame, 39.13% peritoneal pockets, 28.95%). Conclusions: Visual detection of endometriosis during surgical evaluation is not reliable. The potential for atypical-lesion appearance and disease not macroscopically visible suggests a role for complete pelvic peritonectomy. (J GYNECOL SURG 39:235)

Introduction: The association of patient satisfaction with hospital ACS care and risk for long-term outcomes is incompletely described. This is particularly relevant to the Gulf region, where the ACS burden is high and literature on patient satisfaction and outcomes is lacking. The aim was to compare determinants of 1-year mortality based on patient satisfaction with ACS care in the Gulf region. Methods: In a prospective registry of 3566 ACS patients from Bahrain, Kuwait, Oman, and UAE (Gulf COAST registry), we grouped patients by their self-reported overall satisfaction with ACS care reported at 1-month following ACS (low satisfaction [n=1654] vs. high satisfaction [n=1912]; Table). We examined associations of baseline characteristics and risk for 1-year mortality in logistic regression models adjusted for Global Registry of Acute Coronary Events (GRACE) score. Results: Mortality at 1-year following ACS was higher in patients reporting low satisfaction (8.8%; n=146/1654) vs. high satisfaction (5.4%; n=103/1912) ( P <.0001). Women, compared with men, had higher 1-year mortality risk in both satisfaction groups, and statistically significant risk in the low satisfaction group (aOR 1.45 [1.01–2.07]; P <.05). Lack of employment (vs. any employment) was associated with higher 1-year mortality risk in both the low satisfaction (aOR 6.44 [2.58–16.03]) and high satisfaction (aOR 2.58 [1.35–4.93]) groups with borderline significant interaction ( P interaction = .08). In both satisfaction groups, lack of education, hypertension and prior angina were associated with higher 1-year mortality risk, whereas dyslipidemia and diabetes showed no association. Conclusions: Low patient satisfaction with ACS care was associated with higher 1-year mortality risk. Socioeconomic factors such as employment and education were associated with higher 1-year mortality, independent of patient satisfaction, and may guide mortality reduction interventions.

Introduction: Peripheral artery disease (PAD) is a risk factor for adverse limb events (LE) and cardiovascular events (CVE) that often coexists with type 1 (T1) and type 2 (T2) diabetes mellitus (DM), which differ mechanistically. There is a paucity of data on comparative risk of LE and CVE in T1DM and T2DM patients with PAD. Methods: We queried our database of 40,144 patients ≥18y old who underwent ankle brachial index (ABI) measurement from 01/1996-02/2020. We isolated patients with T1DM or T2DM and with PAD diagnosed by ABI (low [<1.0] or elevated [>1.4]). We retrieved demographics including hemoglobin A1c (A1c). Primary outcomes were LE (critical limb ischemia or vascular amputation) and CVE (myocardial infarction or ischemic stroke). All-cause mortality was a secondary outcome. Multivariable Cox proportional regression yielded hazard ratios (HR) with 95% confidence intervals (CI) after adjusting for age, sex, A1c, hypertension, hyperlipidemia, coronary artery disease (CAD), chronic kidney disease (CKD), and tobacco use. Results: Our study found 9,271 patients with PAD and DM (36% T1DM, 64% T2DM) with median follow-up time 34 mo (interquartile range [IQR] 85 mo). T1DM patients were younger than T2DM (mean age 67 vs 70y), with higher median A1c (7.7 [IQR 1.9] vs 6.7% [IQR 1.6]), and higher prevalence of hypertension, hyperlipidemia, CAD, and CKD. Antiplatelet and statin use did not differ. Elevated ABI was more common in T1DM (47 vs 27%). LE occurred in 23% and CVE in 12% of patients. LE risk was higher in T1DM patients than T2DM (HR 1.59[95% CI 1.45,1.74], p<0.0001), but CVE and all-cause mortality did not differ significantly. Conclusions: PAD patients with T1DM had a higher LE risk than those with T2DM, even after adjustment for A1c and pertinent risk factors, but CVE risk and all-cause mortality were equivocal. These data suggest a potential role for more intensive LE risk modification in PAD patients with T1DM, but further investigation is needed to minimize limb morbidity.

Summary: Background: Peripheral artery disease (PAD) impacts 3–12% of patients worldwide and is characterized by endothelial dysfunction and inflammatory pathways which are also common to venous thromboembolism (VTE), but there is a paucity of evidence regarding VTE risk in PAD patients. We investigated whether PAD is an independent risk factor for VTE. Patients and methods: We reviewed medical records of patients undergoing ABI studies at Mayo Clinic from 01/1996-02/2020. We classified patients by ABI (low [<1.0], normal [1.0–1.4], or elevated [>1.4]), as well as by specific low ABI subgroup: severely reduced (ABI: 0.00–0.39), moderately reduced (0.40–0.69), mildly reduced (0.70–0.90), and borderline reduced (0.91–0.99). The primary outcome was incident VTE event (acute lower extremity deep vein thrombosis or pulmonary embolism) after ABI measurement. Multivariable Cox proportional regression was used to calculate hazard ratios (HR) with 95% confidence intervals (CI) after adjusting for age, sex, active smoking, cancer, previous VTE, thrombophilia, anticoagulation, and revascularization. Results: 39,834 unique patients (mean age 66.3±14.3 years, median follow-up 34 months) were identified. 2,305 VTE events occurred in patients without PAD (13.0%), 2,218 in low ABI patients (13.0%), and 751 in elevated ABI patients (14.8%). After risk factor adjustment, VTE risk was modestly increased for PAD overall (HR: 1.12, 95% CI [1.06, 1.18]), including low ABI (HR: 1.11, 95% CI [1.04, 1.18]) and elevated ABI groups (HR: 1.15, 95% CI [1.04, 1.26]), compared to patients without PAD. The greatest VTE risk was in severely low ABI patients (HR: 1.46, 95% CI [1.31, 1.64]). Conclusions: In a large longitudinal cohort, we present strong clinical evidence of PAD, with low and elevated ABI, as an independent VTE risk factor, with the highest risk seen in patients with severely low ABI. Continued research is required to further investigate this relationship and its intersection with functional performance status to optimize VTE risk reduction or anticoagulation strategies in the PAD population.

Introduction: Patients with concomitant peripheral artery disease (PAD) and heart failure (HF) are known to have increased morbidity and mortality. Though they share common risk factors, the utility of HF screening in patients with PAD remains controversial and without international consensus. We sought to clarify whether PAD is an independent risk factor for HF. Methods: We performed a retrospective analysis of adult patients without a history of heart failure who underwent ankle brachial index (ABI) measurement for any indication between 1995-2020. Patients were then stratified by ABI: PAD with low ABI (<1.10), healthy (ABI= 1.10-1.39), and PAD with elevated ABI (>1.39). The associations between PAD and incident diagnosis of heart failure, systolic dysfunction (HF with reduced ejection fraction, HFrEF), and diastolic dysfunction (HF with preserved ejection fraction, HFpEF) were assessed. All patient and outcomes variables were obtained using the institutional electronic health record. Multivariable Cox proportional regression was used to calculate hazard ratios (HR) with 95% confidence intervals (CI) after adjusting for age, sex, hypertension, diabetes, and active tobacco use. Results: The cohort included 36,816 patients (median follow-up 4.21 years), of whom 2,116 (5.7%) were diagnosed with HF. Among HF patients, 1,110 (3.0%) had HFrEF and 1,006 (2.7%) had HFpEF. Both low and elevated ABI groups were associated with an increased risk of HF, both HFrEF, and HFpEF. After multivariable analysis, PAD with elevated ABI was associated with higher overall HF risk (HR, 2.36 [95% CI, 2.03, 2.73]) than low ABI (HR, 1.56 [95% CI, 1.40, 1.74]) when compared to normal ABI. Similarly, PAD with elevated ABI was associated with greater risk of HFrEF (HR, 2.37 [95% CI, 1.93, 2.92]) and HFpEF (HR, 1.82 [95% CI, 1.48, 2.25]) than PAD with low ABI (HFrEF: HR 1.77 [95% CI, 1.52, 2.07], HFpEF: HR 1.31 [95% CI, 1.12, 1.52]). Conclusions: PAD, especially with elevated ABI, is an independent risk factor for heart failure even after adjusting for common HF risk factors. Our findings support HF screening in PAD patients, but longitudinal data on HF morbidity and mortality is necessary to evaluate the value of this practice.

Introduction: Peripheral arterial disease (PAD) increases cardiovascular (CV) morbidity and mortality, but remains underdiagnosed and undertreated. Several trials support low-dose rivaroxaban in PAD treatment, although this has yet to be widely adopted in clinical practice. The effect of warfarin and direct oral anticoagulants (DOACs) on comprehensive PAD outcomes warrants further study. Hypothesis: Anticoagulant therapy, particularly DOACs, improves CV outcomes in PAD. Methods: We conducted a retrospective study of patients who underwent ankle-brachial index testing (ABI) from 1996 – 2020 at Mayo Clinic. We included patients with PAD defined by abnormal ABI (<1.0 or >/=1.4). Prolonged (>6 months) DOAC or warfarin use was compared to no anticoagulant therapy. Multivariable (MV) regression, controlling for baseline CV risk factors, was used. Results: 21,891 patients had abnormal ABI readings; 3,093 were on warfarin and 267 were on DOAC for any indication. Anticoagulation improved mortality, with DOACs superior to warfarin. DOACs improved critical limb ischemia (CLI)/amputation in univariate analysis, although this was not significant in MV. Patients with poorly compressible vessels (ABI >/=1.4) had increased limb outcomes compared to reduced ABI (<1.0). Ischemic stroke and myocardial infarction occurred more frequently in those on anticoagulation, but the risk was less for DOACs vs. warfarin. Notably, both anticoagulant groups had greater baseline comorbidity than the non-anticoagulant group; the DOAC and warfarin groups were similar. Major bleeding (6.7%) was increased in both anticoagulant groups, but less so with DOACs and this was similar to the bleeding risk seen with aspirin (HR 1.20). Conclusion: Anticoagulant therapy improved mortality in a large cohort of PAD patients. The risk of limb events appears improved in those on DOACs. DOACs showed improved risk profiles compared to warfarin regarding CV and bleeding outcomes.

Abstract Background: Despite widespread efforts to create wellness programming in medical schools, there is a paucity of literature examining students’ perception of wellness and perceptions of these programs. With the inaugural class at the Arizona campus of Mayo Clinic Alix School of Medicine (MCASOM-AZ), an opportunity arose to establish an empirically evaluated wellness curriculum that most inclusively and effectively enables medical students to flourish for years to come. The initial wellness offerings included mental health, academic success, and disability services, curriculum-embedded seminars, wellness committee driven programming, and student-proposed wellness activities. We aimed to improve the relevance and impact of medical school wellness curricula by soliciting in-depth and longitudinal perspectives of medical students themselves. As MCASOM-AZ opened in 2017, the student body at the time of study consisted of first- and second-year medical students. Methods: Employing a mixed methods analysis of qualitative and longitudinal quantitative data,first- and second-year students at a MCASOM-AZ were invited to respond to an anonymous, online year-long survey (baseline, six months and 12 months) during the 2018-2019 academic year and participate in a structured, in-depth and in-person, peer-to-peer interview about their conceptions of wellness and the MCASOM-AZ wellness curriculum and resources. Qualitative data was coded for themes using thematic analysis strategies by independent raters. Results: Nearly half of eligible students completed the baseline survey,1/3 completed all 3 time-points, and 1/5 participated in an in-depth interview. Participant age, gender, and year of school were representative of the larger student body. Although individual conceptions varied, Wellness was consistently highly valued. Family, Academic Performance, and Friends emerged as most important to well-being across time-points. Academic work arose as the largest barrier to wellness. Analysis of qualitative data revealed five themes. Despite individual differences in approaches to wellness, wellbeing was interrelated to the learning environment; mandatory wellness efforts that didn’t address the medical culture met with skepticism.Conclusions: Interview responses provided understanding and context by which to interpret questionnaire responses. Academics was critical to students’ identity and wellness, while also the largest barrier. Suggested curricular improvements include restructuring academic work, seamlessly integrating wellness within coursework, and offering optional individualized approaches.

Background: Left atrial appendage occlusion (LAAO) devices have successfully provided an alternative therapeutic option in patients with atrial fibrillation and high bleeding risk. However, patients with thrombocytopenia (TP) were underrepresented in the milestone trials, and the optimal strategy of postprocedural antithrombotic therapy in this group of patients remains unclear. Methods: Patients were identified from the National Cardiac Database Registry - LAAO database at all three Mayo Clinic sites in the period from 1/2016-10/2019. Patients were further divided into TP (platelet &lt; 150 x 10^9/L) and control (platelet &gt; 150 x 10^9 /L) groups for clinical outcome analysis. Outcome endpoints include composite of bleeding (GI bleeding, hemorrhagic stroke, and other non-intracranial hemorrhage) and composite thrombotic events (device thrombus, ischemic stroke, TIA and undetermined stroke). Results: A total of 249 consecutive patients were included in the final analysis. The mean age was 76.7 ± 7.2 years, and 169 (67.9%) were male; 242 (97.2%) were white. The mean CHA2DS2-VASc score was 5.3 ±1.5, and the HAS-BLED score was 3.0 ± 1.1. TP at baseline was present in 74 (29.7%) patients. The median follow-up time was 6.8 months. The use of post-procedural antithrombotic regimens was similar between the two groups (Table 1). When comparing the TP group to control, there was no significant difference in composite bleeding events (10.8% vs. 8.0%, P = 0.069) and thrombotic events (2.7% vs. 2.3%, P= 0.170). Conclusions: The presence of baseline TP does not significantly increase post-procedural bleeding risk in atrial fibrillation/atrial flutter patients who underwent an LAAO occlusion procedure with the Watchman device (Boston Scientific). This group of patients can be treated with the same antithrombotic regimen as patients with normal platelet levels. Future studies are still warranted to determine the optimal antithrombotic regimen.