Vascular surgery training in the United States: A half-century of evolution

The purpose of this report is to succinctly review the history, evolution, and accreditation process of postgraduate surgical training programs in the United States, with emphasis on recent dramatic changes in vascular surgery training. Vascular surgery became a distinct specialty of surgery on March 17, 2005, when the American Board of Surgery (ABS) received approval from the American Board of Medical Specialties (ABMS) to offer a Primary Certificate in Vascular Surgery. The traditional requirement for 5 years of training and certification in general surgery was eliminated. Effective July 1, 2006, the ABS converted its certificate in vascular surgery from a subspecialty certificate to a specialty (primary) certificate. These landmark changes allowed the simultaneous development of new training paradigms. Multiple flexible training pathways leading to either dual certification (Traditional 5-2; Early Specialization Program 4-2) or vascular surgery certification alone (Integrated 0-5; Independent 3-3) now exist. New pathways require a minimum of 2 years of core surgery training and 3 years of advanced vascular training. There are currently 96 accredited traditional 5-2 programs, five 4-2 programs, and 11 0-5 integrated programs, with multiple additional institutions in the process of submitting 0-5 applications. The main obstacle preventing more rapid transition to the new pathways seems to be difficulty in obtaining funding for additional resident positions. Multiple flexible training paradigms are likely to coexist as vascular surgery continues to evolve

Plutchik\u27s Emotive Theory as Applied to Eschatological Elements in Key Works of Graham Greene

An abstract presented to the faculty of the School of Humanities at Morehead State University in partial fulfillment of the requirements for the Degree of Master of Arts by Joseph L. Mills Summer of 1967

Effect of Tidal Cycling Rate on the Distribution and Abundance of Nitrogen-Oxidizing Bacteria in a Bench-Scale Fill-and-Drain Bioreactor

Most domestic wastewater can be effectively treated for secondary uses by engineered biological systems. These systems rely on microbial activity to reduce nitrogen (N) content of the reclaimed water. Such systems often employ a tidal-flow process to minimize space requirements for the coupling of aerobic and anaerobic metabolic processes. In this study, laboratory-scale tidal-flow treatment systems were studied to determine how the frequency and duration of tidal cycling may impact reactor performance. Fluorescent in situ hybridization and epifluorescence microscopy were used to enumerate the key functional groups of bacteria responsible for nitrification and anaerobic ammonium oxidation (anammox), and N-removal efficiency was calculated via a mass-balance approach. When water was cycled (i.e., reactors were filled and drained) at high frequencies (16–24 cycles day−1), nitrate accumulated in the columns—presumably due to inadequate periods of anoxia that limited denitrification. At lower frequencies, such as 4 cycles day−1, nearly complete N removal was achieved (80–90%). These fill-and-drain systems enriched heavily for nitrifiers, with relatively few anammox-capable organisms. The microbial community produced was robust, surviving well through short (up to 3 h) anaerobic periods and frequent system-wide perturbation

Tenure and Due Process

The legal significance of tenure is reviewed in this article as it relates to the new and developing laws of due process. The authors suggest that expectancy of re-employment may become a new form of property right

The Diabetic Rapid Response Acute Foot Team: 7 Essential Skills for Targeted Limb Salvage

Objective: People with diabetes are prone to develop lower-extremity ulcerations and infections, both of which serve as major risk factors for limb amputation. The development of lower-extremity complications of diabetes is associated with increased morbidity and mortality. Recently, there has been increasing interest in the development of interdisciplinary teams to manage the myriad factors that complicate the treatment of high-risk patients, particularly in the perihospitalization period. Methods: This article presents 7 essential skills that necessarily allow the limb salvage team to appropriately manage the most common presenting comorbidities in patients with diabetes, including vasculopathy, infection, and deformity. Results: Seven essentials skills have been demonstrated to promote the greatest salvage outcomes, and these are the ability to (1) perform hemodynamic and anatomic vascular assessment with revascularization, as necessary; (2) perform neurologic workup; (3) perform site-appropriate culture technique; (4) perform wound assessment and staging/grading of infection and ischemia; (5) perform site-specific bedside and intraoperative incision and debridement; (6) initiate and modify culture-specific and patient-appropriate antibiotic therapy; and (7) perform appropriate postoperative monitoring to reduce risk of reulceration and infection. Conclusions: Utilization of these 7 essential skills as the core basis for interdisciplinary limb salvage team models will provide clinicians guidance when establishing such teams. Interdisciplinary teams have been demonstrated to improve quality and efficiency of patient care, thus improving overall outcomes and reducing amputation rates

An economic appraisal of lower extremity bypass graft maintenance

AbstractObjective: Infrainguinal graft surveillance leads to intervention on the basis of duplex-identified stenoses. We have become increasingly concerned about the high frequency with which such revisions are required to maximize graft patency and limb salvage rates. The economic implications of these procedures have not been carefully analyzed or justified. Methods: We retrospectively reviewed 155 consecutive autogenous infrainguinal bypass grafts performed for chronic leg ischemia in 141 patients. All patients were enrolled in a prospective surveillance program using color flow duplex imaging. Full economic appraisal (cost analysis, cost-effect analysis, and cost-benefit analysis) was performed for all graft surveillance and limb salvage–related interventions through use of standard accounting and valuation techniques. Results: Mean follow-up was 27 months. Five-year assisted primary patency (72%) and limb salvage rates (91%) were calculated by means of life table analysis. A total of 61 grafts required 86 revisions. Within 1 year of implantation, 36% of the grafts required revision. During this first year, the mean cost per graft enrolled was $9417. Time intervals after the initial year demonstrated a reduced annual revision rate (6$1725 per graft). The mean 5-year cost of graft maintenance ($16,318) approached that of the initial bypass graft ($19,331). The sum of the initial cost of bypass graft and 5-year graft maintenance cost ($35,649) was similar to the cost of amputation ($36,273). Grafts revised for duplex-detected stenoses (n = 46), in comparison with those revised after thrombosis (n = 15), had an improved 1-year patency (93% vs 57%; P <.01), required fewer amputations (2% vs 33%; P <.01), less frequently required multiple graft revisions (P =.06), and generated fewer expenses (at 12 months after revision, $17,688 vs$45,252, P <.01). Conclusion: The cost associated with graft maintenance is significant, particularly within the first year, and demands consideration. Revision of a duplex-identified stenosis was significantly less costly than revision after graft thrombosis. Compared with the cost of limb amputation, limb salvage–related expenses appear to be justified. (J Vasc Surg 2000;32:1-12.