Clay P. Wiske, MD

All Publications

• Interventional, Hybrid and Surgical Management of Complicated IVC Filters and Post-thrombotic Iliofemoral and Inferior Vena Cava Obstruction The PERT Consortium Handbook of Pulmonary Embolism: Research, Care and Management Wiske, C., Maldonado, M. 2023
• Evaluating time to treatment and in-hospital outcomes of pulmonary embolism response teams. Journal of vascular surgery. Venous and lymphatic disorders Wiske, C. P., Shen, C., Amoroso, N., Brosnahan, S. B., Goldenberg, R., Horowitz, J., Jamin, C., Sista, A. K., Smith, D., Maldonado, T. S. 2020; 8 (5): 717-724

  Abstract

  Pulmonary embolism response teams (PERTs) have become increasingly popular at institutions around the country, although the evidence to support their efficacy is limited. PERTs are mechanisms for rapid involvement of a multidisciplinary team in the management of a time-sensitive condition with many treatment options.We retrospectively reviewed 201 patients with PERT activations since inception, collecting data on demographics, time to treatment, treatment modality, and in-hospital outcomes.Massive pulmonary embolism accounted for 16 (8.7%) PERT activations. The majority of patients were treated without invasive intervention; 91.4% (95% confidence interval [CI], 87.1%-95.7%) of patients received anticoagulation alone, 4.5% (95% CI, 0%-18.6%) had catheter-directed therapy (CDT), and 3.0% (95% CI, 0%-16.9%) had systemic administration of tissue plasminogen activator (tPA). The average time to intervention was 665 minutes (95% CI, 249-1080 minutes) for CDT and 22 minutes (95% CI, 0-456 minutes) for systemic TPA. The average time to anticoagulation was 2.3 minutes (95% CI, 0-43 minutes). There was a trend toward higher rates of cardiac events (odds ratio [OR], 12.68; 95% CI, 0.62-65.74) and death (OR, 3.19; 95% CI, 0.28-5.18) among patients with massive PE. There was a higher rate of cardiac events (OR, 5.66; 95% CI, 1.34-23.83) among patients who received tPA or an invasive intervention. There was no difference in mortality rates of patients who underwent aggressive management compared with anticoagulation alone.A dedicated PERT results in efficient delivery of care and excellent outcomes, in part owing to the rapid (on average, 8 minutes) time to initiation of a multidisciplinary discussion. Patients who ultimately underwent CDT had an interval of >10 hours on average between diagnosis and CDT. This provisional or delayed approach to CDT in selected patients who were not improving with anticoagulation alone (and therefore had potential for higher net benefit from a procedure with its own inherent risks) may have resulted in a lower rate of CDT.

  View details for DOI 10.1016/j.jvsv.2019.12.077

  View details for PubMedID 32179041

• Reply. Journal of vascular surgery Wiske, C., Arhuidese, I., Malas, M., Patterson, R. 2019; 69 (2): 626-627

  View details for DOI 10.1016/j.jvs.2018.10.057

  View details for PubMedID 30683207

• Decomposing the Value of Health Insurance Ogbechie-Godec, O. A., Wiske, C. P., Schulman, K. A. Health Management Policy and Innovation. 2019
• Comparing the efficacy of shunting approaches and cerebral monitoring during carotid endarterectomy using a national database. Journal of vascular surgery Wiske, C., Arhuidese, I., Malas, M., Patterson, R. 2018; 68 (2): 416-425

  Abstract

  Carotid endarterectomy practice patterns, including the use of shunts and cerebral monitoring techniques, are typically surgeon-dependent and differ greatly on a national level. Prior literature evaluating these techniques is often underpowered for detecting variations in low-frequency outcomes. The purpose of this study was to evaluate current carotid endarterectomy practice patterns and to allow comparison across surgical approaches using a large national database.We divided carotid cases entered into the Vascular Quality Initiative database between October 2012 and April 2015 into routine shunting, selective shunting, and never shunting cohorts, excluding endarterectomies performed with concomitant procedures and those with incomplete information on the use of a shunt. The selective group was subdivided into cases with awake, electroencephalography, and stump pressure monitoring. We evaluated differences in practice patterns and compared rates of stroke, death, return to the operating room, reperfusion injury, and re-exploration after closure across these groups. Multivariate logistic regression models adjusting for risk factors were used to identify predictors of each outcome.Between October 2012 and April 2015, there were a total of 28,457 endarterectomies included in our analysis, of which 14,128 involved routine shunting, 1740 involved never shunting, and 12,489 involved selective shunting. Of the selective cases, 6144 involved electroencephalography monitoring, 2310 involved stump pressure monitoring, and 2052 involved awake monitoring. Unadjusted rates of in-hospital death and stroke were 0.30% (95% confidence interval [CI], 0.21-0.39) and 0.78% (95% CI, 0.64-0.93) for routine shunting and 0.22% (95% CI, 0.14-0.31) and 0.91% (95% CI, 0.75-1.08) for selective shunting, respectively. The unadjusted rate of in-hospital death was lower in the awake monitoring group than in the routine shunting group (0.05% vs 0.30%; P = .037). After adjustment for patient risk factors, the multivariate models showed no difference in rates of any primary outcomes among the groups, although there was a shorter postoperative length of stay for the awake monitoring group compared with the routine shunting group (1.55 days vs 2.00 days, respectively; P < .01).Analysis of the Vascular Quality Initiative registry shows equivalent unadjusted rates of in-hospital death and stroke across different approaches to shunting and cerebral monitoring with the exception of the awake monitoring group, which has lower unadjusted mortality compared with the routine shunting group. In the risk-adjusted analysis, however, there are no differences across any of the groups. Given the clinical equivalence of approaches to shunting and cerebral monitoring, further work should evaluate the relative cost of these techniques.

  View details for DOI 10.1016/j.jvs.2017.11.077

  View details for PubMedID 29571621

• Practice Patterns of Fenestrated Aortic Aneurysm Repair: Nationwide Comparison of Z-Fen Adoption at Academic and Community Centers Since Commercial Availability VASCULAR AND ENDOVASCULAR SURGERY Wiske, C., Lee, J. T., Rockman, C., Veith, F. J., Cayne, N., Adelman, M., Maldonado, T. 2018; 52 (6): 434–39

  Abstract

  Over the past decade, a number of endovascular approaches have evolved to treat aortic aneurysms with anatomy that is not amenable to traditional endovascular repair, although the optimal practice and referral patterns remain in question. The Zenith fenestrated (Z-Fen) endograft (Cook Medical) represents the first commercially available fenestrated graft product in the United States.We aim to quantify practice patterns in Z-Fen use during the first 5 years of commercial availability, and we identify predictors of high and low uptake.This is a retrospective review of complete order records for Z-Fen endografts since June 2012. We performed univariate and multivariate regressions of predictors that surgeons and centers would be in the top and bottom quartiles of annual Z-Fen use.Since June 15, 2012, 744 surgeons have been trained to use Z-Fen, and 4133 cases have been performed at 409 trained centers. The average annual number of cases per trained surgeon was 4.46 [95% confidence interval (CI), 3.58-5.70]; however, many surgeons performed few or no cases following training, and there was a skew toward users with low average annual volumes (25th percentile 1.23, 50th percentile 2.35, 75th percentile 4.93, and 99th percentile 33.29). Predictors of high annual use in the years following training included academic center (aOR 5.87, P = .001) and training within the first 2 years of availability (aOR 46.23, P < .001).While there is literature supporting the safety and efficacy of Z-Fen, adoption has been relatively slow in an era when the vast majority of vascular surgeons have advanced endovascular skills. Given the training and resources required to use fenestrated or branched aortic endovascular devices, referral patterns should be determined and training should be focused on centers with high expected volumes.

  View details for PubMedID 29843567

• Nutcracker Syndrome: Open and Endovascular Options Current Vascular Surgery Wiske, C., Maldonado, T. 2018
• Disseminating and diffusing internal innovations: Lessons from large innovative healthcare organizations Health Man Pol Innov. Herzlinger, R., Wiske, C. 2017
• Ruptured Pseudoaneurysm of the Dorsalis Pedis Artery Following Ankle Arthroscopy: A Case Report. JBJS case connector Wiske, C. P., Itoga, N. K., Ullery, B. W., Hunt, K. J., Chandra, V. 2016; 6 (4): e102

  Abstract

  We describe the case of a pseudoaneurysm of the dorsalis pedis artery that developed following a repeat ankle arthroscopy for persistent osseous impingement. The patient underwent attempted fluid aspiration for a presumed effusion, and ultimately experienced rupture of the pseudoaneurysm with substantial blood loss, which required emergency vascular repair.Anterior tibial artery and dorsalis pedis artery pseudoaneurysms are relatively rare, but they are well-documented complications of ankle arthroscopy; however, their clinical importance is poorly understood. To our knowledge, this is the first reported case of a ruptured pseudoaneurysm of the dorsalis pedis artery following ankle surgery, and it highlights the need for timely diagnosis.

  View details for DOI 10.2106/JBJS.CC.16.00069

  View details for PubMedID 29252755

  View details for PubMedCentralID PMC5901686

• Physician Specialty Influences Care of Pelvic Inflammatory Disease. Journal of women's health (2002) Wiske, C. P., Palisoul, M., Tapé, C., Baird, J., McGregor, A. J. 2016; 25 (7): 723-8

  Abstract

  CDC guidelines recommend Neisseria gonorrhoeae, Chlamydia trachomatis, and HIV testing, as well as specific antibiotic regimens in the diagnosis and treatment of pelvic inflammatory disease (PID), although latitude in adhering to these guidelines is common. We hypothesized that adherence to CDC guidelines for antibiotic regimens and laboratory testing, coverage for anaerobic organisms, and the use of diagnostic imaging techniques do not differ significantly between practitioners with emergency medicine (EM) versus obstetrics and gynecology (OB-GYN) training.We conducted a retrospective medical chart review on patients (N = 351) discharged with a diagnosis of PID over a 20-month period at two neighboring emergency care facilities-one with EM-trained providers and the other with OB-GYN-trained providers.Adjusted for demographic predictors and chief complaint, there was no significant difference in adherence to N. gonorrhoeae and C. trachomatis antibiotic coverage guidelines between the two facilities (adjusted odds ratio [AOR] 1.34; 95% CI 0.66-2.74), using the OB-GYN facility in the numerator of the AOR. Anaerobic coverage was significantly more common at the OB-GYN facility (AOR 9.11; 95% CI 5.36-15.48). Both sites had very low rates of adherence to CDC laboratory testing guidelines with overall rates of adherence at 4.0% (95% CI 1.9%-5.9%). Utilization of diagnostic tests differed greatly between facilities: ultrasound utilization was 66.7% (95% CI 58.2%-75.2%) at the OB-GYN facility and 39.7% (95% CI 33.4%-45.9%) at the EM facility.The diagnostic pathway for PID and adherence to guidelines differ significantly depending on physician specialty and practice environment, suggesting the need for further standardization, perhaps with cross-disciplinary training.

  View details for DOI 10.1089/jwh.2015.5349

  View details for PubMedID 26720306

• Options to Promote Competitive Generics Markets in the United States JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Wiske, C. P., Ogbechie, O. A., Schulman, K. A. 2015; 314 (20): 2129–30

  View details for PubMedID 26513309

• Castlight Health and the Transparency Movement Gandhi, S., Wiske, C., Ayogu, N., Herzlinger, R. Harvard Business School. 2015
• Diffusing Innovation: Building on the NHS Five Year Forward View Wiske, C., Herzlinger, R. NHS leadership. 2015
• Engineering insights for multiplexed real-time nucleic acid sequence-based amplification (NASBA): implications for design of point-of-care diagnostics. Molecular diagnosis & therapy Morabito, K., Wiske, C., Tripathi, A. 2013; 17 (3): 185-92

  Abstract

  Nucleic acid sequence-based amplification (NASBA) offers huge potential for low-cost, point-of-care (POC) diagnostic devices, but has been limited by high false-positive rates and the challenges of primer design.We offer a systematic analysis of NASBA design with a view toward expanding its applicability.We examine the parameters that effect dimer formations, and we provide a framework for designing NASBA primers that will reduce false-positive results and make NASBA suitable for more POC diagnostic applications. Then we compare three different oligonucleotide sets to examine (1) the inhibitory effect of dimer formations, (2) false positives with poorly designed primers, and (3) the effect of beacon target location during real-time NASBA. The required T7 promoter sequence adversely affects the reaction kinetics, although the common abridged sequence can improve kinetics without sacrificing accuracy.We demonstrate that poorly designed primers undergo real-time exponential amplification in the absence of target RNA, resulting in false positives with a time to half of the peak value (t(1/2)) of 50 min compared to 45 min for true positives. Redesigning the oligonucleotides to avoid inhibitory dimers eliminated false positives and reduced the true positive t(1/2) by 10 min. Finally, we confirm the efficacy of two molecular beacon design schemes and discuss their multiplexing utility in two clinical scenarios.This study provides a pathway for using NASBA in developing POC diagnostic assays.

  View details for DOI 10.1007/s40291-013-0029-4

  View details for PubMedID 23677856

  View details for PubMedCentralID PMC7099912