All Publications

  • Cost-effectiveness of Endovascular Versus Open Arteriovenous Fistula Creation in the United States Mulaney, B., Ho, V. T., Sgroi, M. D., Garcia-Toca, M., George, E. L. MOSBY-ELSEVIER. 2023: E36-E37

    View details for Web of Science ID 000951340500010

  • Most Privately Insured Patients Do Not Receive Federally Recommended Abdominal Aortic Aneurysm Screening. Journal of vascular surgery Ho, V. T., Tran, K., George, E. L., Asch, S. M., Chen, J. H., Dalman, R. L., Lee, J. T. 2023

    Abstract

    Since 2005, the United States Preventative Services Task Force (USPSTF) has recommended abdominal aortic aneurysm (AAA) ultrasound screening for 65- to 75-year-old male ever-smokers. Integrated health systems such as Kaiser Permanente and the Veterans Affairs (VA) healthcare system report 74-79% adherence, but compliance rates in the private sector are unknown.The IBM Marketscan® Commercial and Medicare Supplemental databases (2006 -2017) were queried for male ever-smokers continuously enrolled from age 65 to 75. Exclusion criteria were previous history of abdominal aortic aneurysm, connective tissue disorder, and aortic surgery. Patients with abdominal computed tomographic or magnetic resonance imaging from ages 65 to 75 were also excluded. Screening was defined as a complete abdominal, retroperitoneal, or aortic ultrasound. A logistic mixed-effects model utilizing state as a random intercept was used to identify patient characteristics associated with screening.Of 35,154 eligible patients, 13,612 (38.7%, Table 1) underwent screening. Compliance varied by state, ranging from 24.4% in Minnesota to 51.6% in Montana (p <0.05, Figure 1). Screening activity increased yearly, with 0.7% of screening activity occurring in 2008 versus 22.2% in 2016 (p <0.05, Figure 2). In a logistic mixed-effects model adjusting for state as a random intercept, history of hypertension (OR 1.07, 95% CI [1.03 - 1.13]), coronary artery disease (OR 1.17, 95% CI [1.10, 1.22]), congestive heart failure (OR 1.14, 95% CI [1.01 - 1.22]), diabetes (OR 1.1, 95% CI [1.06 - 1.16]) and chronic kidney disease (OR 1.4 95% CI [1.24 - 1.53]) were associated with screening. Living outside of a census-designated metropolitan area was negatively associated with screening (OR 0.92, 95% CI [0.87 - 0.97], Table 2).In a private claims database representing 250 million claimants, 38.7% of eligible patients received UPSTF-recommended AAA screening. Compliance was nearly half that of integrated health systems and was significantly lower for patients living outside of metropolitan areas. Efforts to improve early detection of AAA should include targeting non-metropolitan areas and modifying Medicare reimbursement and incentivization strategies to improve guideline adherence.

    View details for DOI 10.1016/j.jvs.2023.01.202

    View details for PubMedID 36781115

  • Utilizing Remote Access for Electronic Medical Records Reduces Overall EMR Time for Vascular Surgery Residents. Journal of vascular surgery Ho, V. T., Sgroi, M. D., Chandra, V., Asch, S. M., Chen, J. H., Lee, J. T. 2023

    Abstract

    Survey data suggests that surgical residents spend 20-30% of training time using the electronic medical record (EMR), raising concerns about burnout and insufficient operative experience. We characterize trainee EMR activity in the vascular surgery service of a quaternary care center to identify modifiable factors associated with high EMR use.Resident activity while on the Vascular Surgery service was queried from the EMR. Weekends and holidays were excluded to focus on typical staffing periods. Variables including daily time spent, post-graduate year (PGY), remote access via mobile device or personal laptop, and patient census including operative caseload were extracted. Univariate analysis was performed with t-tests and chi-squared tests where appropriate. We then fit a linear mixed-effects model with normalized daily EMR time as the outcome variable, random slopes for resident and patient census, and fixed effects of PGY level, academic year, and fractional time spent using remote access.EMR activity for 53 residents from July 2015 to June 2019 was included. The mean daily EMR usage was 1.6 hours, ranging from 3.6 hours per day in PGY1 residents to 1.1 hours in PGY4-5 residents. Across all post-graduate years, the most time-consuming EMR activities were chart review (43.0-46.6%) and notes review (22.4-27.0%). In the linear mixed-effects model, increased patient census was associated with increased daily EMR usage (Coefficient = 0.61, p-value < 0.001). Resident seniority (Coefficient = -1.2, p-value < 0.001) and increased remote access (Coefficient = -0.44, p-value < 0.001) were associated with reduced daily EMR usage. Over the study period, total EMR usage decreased significantly from the 2015-2016 academic year to 2018-2019 (mean difference 2.4 hours vs 1.78, p-value <0.001).In an audit of EMR activity logs on a vascular surgery service, mean EMR time was 1.6 hours a day, which is lower than survey estimates. Resident seniority and remote access utilization were associated with reduced time spent on the EMR, independent of patient census. While increasing EMR accessibility via mobile devices and personal computers have been hypothesized to contribute to poor work-life balance, our study suggests a possible time-saving effect by enabling expedient access for data review, which constitutes the majority of resident EMR activity. Further research in other institutions and specialties is needed for external validation and exploring implications for resident wellness initiatives.

    View details for DOI 10.1016/j.jvs.2023.01.198

    View details for PubMedID 36758909

  • Impact of Scalene Muscle Botulinum Toxin Injection With and Without Surgery in Neurogenic Thoracic Outlet Syndrome. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine Fereydooni, A., Ho, V. T., Olson, E. M., Dyrek, P., Harris, T., Kussman, A., Roh, E., Lee, J. T. 2022

    Abstract

    Scalene blocks are part of both the diagnostic and treatment algorithm for patients presenting with symptoms of neurogenic thoracic outlet syndrome (nTOS). However, there is a paucity of data on the utility of scalene botulinum toxin injection (BTI) before surgical decompression. We sought to determine the impact of BTI with and without surgery at a multidisciplinary referral center.Retrospective cohort study.Single institution tertiary academic center, 2011 to 2020.Seventy-seven consecutive patients.Scalene muscle BTI for nTOS with or without surgical decompression.Pain relief and Quick Disability of the Arm, Shoulder and Hand (QDASH) score.Seventy-seven patients, with a mean age of 31.4 years, had BTI for symptoms of nTOS. All patients underwent pretreatment physical therapy through the Edgelow protocol for a mean duration of 3.4 months. However, 72.7% had dynamic vascular compression on duplex ultrasound with provocative maneuvers and 85.7% had a positive physical examination finding. After BTI, 77.9% reported subjective relief, confirmed by an improved QDASH disability score. Thirty-one patients (40.3%) then went on to have further persistent symptoms and proceeded with first rib resection. After BTI + Surgery, 96.8% reported symptomatic relief and had a median QDASH score improvement of 21 (range: 10-40), with all reaching minimal clinically important differences in the QDASH score after combination therapy.In this reported series of chemodenervation in patients with nTOS, BTI is helpful in alleviating symptoms before definitive surgical decompression. BTI followed by first rib resection provides additional symptom improvement over BTI alone.

    View details for DOI 10.1097/JSM.0000000000001094

    View details for PubMedID 36367782

  • Transversus abdominus plane blocks do not reduce rates of postoperative prolonged opioid use following abdominally based autologous breast reconstruction: a nationwide longitudinal analysis. European journal of plastic surgery Chattopadhyay, A., Shah, J. K., Yesantharao, P., Ho, V. T., Sheckter, C. C., Nazerali, R. 2022: 1-11

    Abstract

    Background: The transversus abdominus plane (TAP) block reduces postoperative donor site pain in patients undergoing autologous breast reconstruction with an abdominally based flap. This study aimed to determine the effect of TAP blocks on rates of conversion to chronic opioid use.Methods: The Clinformatics Data Mart was queried from 2003 to 2019, extracting adult encounters for abdominally based free and pedicled flaps based on common procedural terminology (CPT) codes. Patients were excluded if they had filled a narcotic prescription 1 year to 30 days prior to surgery. The exposure variable-TAP block-was identified by CPT codes. Outcomes were evaluated using morphine milligram equivalents (MME) from prescriptions filled between 30 days prior to and 30 days after surgery. Chronic opioid use (COU) was defined as receiving 4 unique prescriptions or a 60-day supply between 30 and 180 days after surgery.Results: Of the 4091 patients, (mean age 51.2±9.0 years), 181 (4.4%) had a TAP block placed. Perioperative MMEs/day, postoperative COU, and length of stay did not differ in patients who received a TAP block (p=0.142; p=0.271). Significant predictors of risk of conversion to COU included younger age, pedicled abdominal flap, Elixhauser comorbidity index score>3, filling a psychiatric medication prescription, and filling a benzodiazepine prescription.Conclusions: In patients undergoing autologous breast reconstruction with abdominally based flap reconstruction, TAP blocks do not decrease perioperative MME/day, conversion to chronic opioid use, or length of stay. These data suggest that intraoperative TAP block placement may be a low-yield opioid-reduction strategy.Level of evidence: Level III, risk/prognostic study.

    View details for DOI 10.1007/s00238-022-01996-5

    View details for PubMedID 36212234

  • Most Privately Insured Patients do not Receive Federally Recommended Abdominal Aortic Aneurysm Screening Ho, V., Tran, K., George, E., Asch, S., Chen, J., Dalman, R., Lee, J. MOSBY-ELSEVIER. 2022: E78

    View details for Web of Science ID 000868486600054

  • Large Fenestrations Versus Scallops for the SMA During Fenestrated EVAR: Does it Matter? Annals of vascular surgery Sorondo, S. M., Ss, D., K, T., Vt, H., Jr, S., J, L. 2022

    Abstract

    FEVAR is an established customized treatment for aortic aneurysms with three current commercially available configurations for the superior mesenteric artery (SMA) - a single-wide scallop, large fenestration, or small fenestration, with the scallop or large fenestration most utilized. Outcomes comparing SMA single-wide scallops to large fenestrations with the ZFEN device are scarce. As large fenestrations have the benefit of extending the proximal seal zone compared to scalloped configurations, we sought to determine the differences in seal zone and sac regression outcomes between the two SMA configurations.We retrospectively reviewed our prospectively maintained complex EVAR database and included all patients treated with the Cook ZFEN device with an SMA scallop or large fenestration configuration at its most proximal build. All first post-operative CT scans (1-30 days) were analyzed on TeraRecon to determine precise proximal seal zone lengths, and standard follow-up anatomic and clinical metrics were tabulated.A total of 234 consecutive ZFEN patients from 2012-2021 were reviewed, and 137 had either a scallop or large fenestration for the SMA as the proximal-most configuration (72 scallops and 65 large fenestrations) with imaging available for analysis. Mean follow-up was 35 months. Mean proximal seal zone length was 19.5±7.9 mm for scallop vs 41.7±14.4 mm for large fenestration groups (P<.001). There was no difference in sac regression between scallop and large fenestration at one year (10.1±10.9 mm vs 11.0±12.1, P = 0.63). Overall, 30-day mortality (1.3% vs 2.5%, P=.51) and all-cause three-year mortality (72.5% vs 81.7%, P=.77) were not significantly different. Reinterventions within 30 days were primarily secondary to renal artery branch occlusions, with only one patient in the scallop group requiring reintervention for an SMA branch occlusion.Despite attaining longer proximal seal lengths, large SMA fenestrations were not associated with a difference in sac regression compared to scalloped SMA configurations at one-year follow up. There were no significant differences in reinterventions or overall long-term survival between the two SMA strategies.

    View details for DOI 10.1016/j.avsg.2022.07.013

    View details for PubMedID 36058451

  • Interruptive Electronic Alerts for Choosing Wisely Recommendations: A Cluster Randomized Controlled Trial. Journal of the American Medical Informatics Association : JAMIA Ho, V. T., Aikens, R. C., Tso, G., Heidenreich, P. A., Sharp, C., Asch, S. M., Chen, J. H., Shah, N. K. 2022

    Abstract

    OBJECTIVE: To assess the efficacy of interruptive electronic alerts in improving adherence to the American Board of Internal Medicine's Choosing Wisely recommendations to reduce unnecessary laboratory testing.MATERIALS AND METHODS: We administered 5 cluster randomized controlled trials simultaneously, using electronic medical record alerts regarding prostate-specific antigen (PSA) testing, acute sinusitis treatment, vitamin D testing, carotid artery ultrasound screening, and human papillomavirus testing. For each alert, we assigned 5 outpatient clinics to an interruptive alert and 5 were observed as a control. Primary and secondary outcomes were the number of postalert orders per 100 patients at each clinic and number of triggered alerts divided by orders, respectively. Post hoc analysis evaluated whether physicians experiencing interruptive alerts reduced their alert-triggering behaviors.RESULTS: Median postalert orders per 100 patients did not differ significantly between treatment and control groups; absolute median differences ranging from 0.04 to 0.40 for PSA testing. Median alerts per 100 orders did not differ significantly between treatment and control groups; absolute median differences ranged from 0.004 to 0.03. In post hoc analysis, providers receiving alerts regarding PSA testing in men were significantly less likely to trigger additional PSA alerts than those in the control sites (Incidence Rate Ratio 0.12, 95% CI [0.03-0.52]).DISCUSSION: Interruptive point-of-care alerts did not yield detectable changes in the overall rate of undesired orders or the order-to-alert ratio between active and silent sites. Complementary behavioral or educational interventions are likely needed to improve efforts to curb medical overuse.CONCLUSION: Implementation of interruptive alerts at the time of ordering was not associated with improved adherence to 5 Choosing Wisely guidelines.TRIAL REGISTRATION: NCT02709772.

    View details for DOI 10.1093/jamia/ocac139

    View details for PubMedID 36018731

  • Female sex is independently associated with reduced inpatient mortality after endovascular repair of blunt thoracic aortic injury. Journal of vascular surgery Ho, V. T., Sorondo, S., Forrester, J. D., George, E. L., Tran, K., Lee, J. T., Garcia-Toca, M., Stern, J. R. 2022

    Abstract

    Female sex has been associated with decreased mortality following blunt trauma, but whether sex influences outcomes of thoracic endovascular aortic repair (TEVAR) for traumatic blunt thoracic aortic injury (BTAI) is unknown.In this retrospective study of a prospectively maintained database, the Vascular Quality Initiative (VQI) registry was queried from 2013-2020 for patients undergoing TEVAR for BTAI. Univariate Student's t-tests and chi-squared tests were performed, followed by multivariate logistic regression for variables associated with inpatient mortality.211 (26.2%) of 806 patients were female. Female patients were older (47.9 vs. 41.8 years, p<0.0001) and less likely to smoke (38.3% vs. 48.2%, p=0.044). Most patients presented with grade III BTAI (54.5% female, 53.6% male,), followed by grade IV (19.0% female, 19.5% male). Mean Injury Severity Scores (30.9 + 20.3 female, 30.5 + 18.8 male) and regional Abbreviated Injury Score did not vary by sex. Postoperatively, female patients were less likely to die as inpatients (3.8% vs 7.9% , p=0.042) and to be discharged home (41.4% vs. 52.2%, p=0.008). On multivariate logistic regression, female sex (OR 0.05, p=0.002) was associated with reduced inpatient mortality. Advanced age (OR 1.06, p< 0.001), postoperative transfusion (OR 1.05, p=0.043), increased Injury Severity Score (OR 1.03, p=0.039), postoperative stroke (OR 9.09, p= 0.016), postoperative myocardial infarction (OR 9.9, p=0.017), and left subclavian coverage (OR 2.7, p= 0.029) were associated with inpatient death.Female sex is associated with lower odds of inpatient mortality following TEVAR for BTAI, independent of age, injury severity, BTAI grade, and postoperative complications. Further study of the influence of sex on post-discharge outcomes is needed.

    View details for DOI 10.1016/j.jvs.2022.07.178

    View details for PubMedID 35944732

  • Use of an App-Based Exercise Therapy Program Including Cognitive Behavioral Techniques for the Management of Intermittent Claudication. Journal of vascular surgery Aalami, O. O., Lin, J., Savage, D., Ho, V., Bertges, D., Corriere, M. 2022

    Abstract

    OBJECTIVES: Clinical practice guidelines recommend supervised exercise therapy (SET) as first-line therapy for patients with peripheral artery disease (PAD) and intermittent claudication (IC). The Society for Vascular Surgery (SVS) Appropriate Use Criteria (AUC) for IC deems exercise therapy as appropriate for all patients with IC. However, compliance with recommendations for the use of exercise therapy is often poor due to the lack of availability, patient travel requirements, and cost. Results of home-based exercise therapy programs have been mixed with a trend towards improved results with more frequent patient engagement. The feasibility, utilization, and effectiveness of a 12-week app-based structured exercise therapy program using cognitive behavioral techniques (CBT) for IC was evaluated.METHODS: Patients with PAD (confirmed by abnormal ABI or TBI) and IC were recruited prospectively to participate in SVS SET, a 12-week app-based exercise therapy program. Participants performed home six-minute walk tests, completed quality of life (QoL) surveys, received education options via micro training courses (What is PAD?, Exercise, Nutrition), and ongoing health coaching utilizing CBT. They were instructed to record at least three 30-minute exercise therapy walks a week using their personal mobile phones. Programming also included "daily doses" of health education, coaching and reminders sent via text message.RESULTS: One hundred and thirty-nine patients (37% women, mean age 65) were enrolled across 20 institutions (44% offered in-person exercise therapy programs). One hundred twenty (86%) of patients completed the program. Participants recorded 201,163 minutes of walking 8,013,520 steps with the exercise therapy program, completing a total of 5,049 SET Walks. Nineteen (14%) of enrolled participants became inactive because they either paused (14 participants: medical reasons, travel, or other) or withdrew (5 participants: security concerns, lack of motivation). Ninety-two percent of patients met their stated CBT SMART (Specific, Measurable, Achievable, Relevant, and Time-Bound) goals. Freedom from intervention at 6 months was 92% and 69% at 12 months.CONCLUSIONS: Deployment of a 12-Week app-based exercise therapy program for PAD incorporating CBT was feasible in achieving 86% program completion and effective at meeting guideline recommended activity goals. Ninety-two percent of participants achieved their CBT SMART goals. Utilization of exercise therapy was increased by virtue of offering this program at institutions which did not offer exercise therapy.

    View details for DOI 10.1016/j.jvs.2022.06.087

    View details for PubMedID 35872328

  • Real-world Long-term Reinterventions After Fenestrated/Branched Endovascular Aneurysm Repair in the United States Ho, V., Tran, K., Chen, J. H., Stern, J. R., George, E., Dalman, R., Lee, J. T. MOSBY-ELSEVIER. 2022: E263-E264

    View details for Web of Science ID 000798307600287

  • A National Feasibility, Effectiveness, and Utilization Pilot of a Home-Based, Mobile Phone Administered, Exercise Therapy Program Using Cognitive Behavioral Therapy for Intermittent Claudication Aalami, O. O., Lin, J. C., Savage, D. M., Ho, V., Bertges, D., Corriere, M. MOSBY-ELSEVIER. 2022: E76

    View details for Web of Science ID 000798307600424

  • Remote Access to Electronic Medical Records Reduces Overall EMR Time for Vascular Surgery Residents Ho, V., Sgroi, M., Chandra, V., Asch, S., Chen, J. H., Lee, J. T. MOSBY-ELSEVIER. 2022: E135

    View details for Web of Science ID 000798307600104

  • Trends in annual open abdominal aortic surgical volumes for vascular trainees compared to annual national volumes in the endovascular era. Journal of vascular surgery George, E. L., Arya, S., Ho, V. T., Stern, J. R., Sgroi, M. D., Chandra, V., Lee, J. T. 2022

    Abstract

    OBJECTIVE: Prior analysis predicted a shortfall in open abdominal aortic repair (OAR) experience for vascular trainees resulting from the rapid adoption of and increased anatomic suitability of endovascular aortic repair (EVAR) technology. We explored how EVAR has transformed contemporary open aortic surgical education for vascular trainees.METHODS: We examined ACGME case volumes of open abdominal aortic aneurysm (AAA) repair and reconstruction for aorto-iliac occlusive disease (AIOD) via aorto-iliac/femoral bypass (AFB) from integrated vascular surgery residents (VSR) and fellows (VSF) graduating 2006-2017 and compared them to national estimates of total OAR (open AAA repair + AFB) in the Agency for Healthcare Research and Quality National Inpatient Sample based on ICD-9 and ICD-10 procedural codes. Changes over time were assessed using Chi-square test, Student's t-test, and linear regression.RESULTS: During the twelve-year study period, the national annual total OAR and open AAA repair estimates decreased: total OAR by 72.5% (2006: estimate (standard error) 24,255 (1185) vs. 2017: 6,690 (274); p<0.001) and open AAA repair by 84.7% (2006: 18,619 (924) vs. 2017: 2,850 (168); p<0.001); AFB estimates decreased by 33.0% (p<0.001). The percentage of total OAR, open AAA repair, and AFB performed at teaching hospitals significantly increased from 55 to 80% (all p<0.001). There was a 40.9% decrease in open AAA repairs logged by graduating VSF (mean 18.6 vs. 11) but only a 6.9% decrease in total OAR cases (mean 27.6 vs. 25.7) due to increasing AFB volumes (mean 9.0 vs. 14.7). VSR graduates consistently logged an average of 10 open AAA repairs and there was a 31.0% increase in total OAR (mean 23.2 vs. 30.4), again secondary to rising AFB volumes (mean 11.4 vs 17.5). Although there was an absolute decrease in open aortic experience for VSF, the rate of decline for total OAR case volumes was not significantly different after VSR programs were established (p=0.40).CONCLUSIONS: As incidence decreases nationally, OAR is shifting towards teaching hospitals. While open AAA procedures for trainees are declining due to EVAR, open aortic reconstruction for AIOD is rising and plays an important role in ensuring that vascular trainees continue to have satisfactory OAR experience sufficient for meeting minimum graduation requirements. Strategies to maintain and maximize the education and experience from these cases should be top priority for vascular surgery program directors.

    View details for DOI 10.1016/j.jvs.2022.03.887

    View details for PubMedID 35598821

  • Cost effectiveness of computed tomography versus ultrasound-based surveillance following endovascular aortic repair of intact infrarenal abdominal aortic aneurysms. Journal of vascular surgery Ho, V. T., Nguyen, A. T., Stern, J. R., Asch, S. M., Owens, D. K., Salomon, J. A., Dalman, R. L., Lee, J. T. 2022

    Abstract

    BACKGROUND: While Society for Vascular Surgery guidelines recommend computed tomography angiography (CTA) or ultrasound for surveillance following infrarenal endovascular aortic repair (EVAR), there is a lack of consensus regarding optimal timing and modalities. We hypothesized that ultrasound-based approaches would be more cost-effective and developed a cost-effectiveness analysis to estimate the lifetime costs and outcomes of various strategies.METHODS: We developed a decision tree with nested Markov models to compare five surveillance strategies: yearly CTA, yearly CDU, yearly CEU, CTA at first year followed by CDU, and CTA at first year followed by CEU. The model accounted for differential sensitivity, specificity, and risk of acute kidney injury after CTA, and was implemented on a monthly cycle with a willingness-to-pay threshold of $50,000 per quality-adjusted life year (QALY) and 3% annual discounting.RESULTS: Under base case assumptions, the CTA-CDU strategy was cost effective with a lifetime cost of $77950 for 7.74 QALYs. In sensitivity analysis, the CTA-CDU approach remained cost-effective when CEU specificity was less than 95%, and risk of acute kidney injury following CTA was less than 20%. At diagnostic sensitivities below 75% for CEU and 55% for CDU, a yearly CTA strategy maximized QALYs.CONCLUSION: A hybrid strategy in which CTA is performed in the first year and CDU is performed annually thereafter is the most cost-effective strategy for infrarenal EVAR surveillance in patients with less than a 20% risk of contrast-induced nephropathy. If the sensitivity of CEU and CDU are at the lower end of plausible estimates, a yearly CTA strategy is reasonable. Further research should aim to identify patients who may benefit from alternative surveillance strategies.

    View details for DOI 10.1016/j.jvs.2022.02.057

    View details for PubMedID 35278655

  • Systematic review and meta-analysis of the management of incompetent perforators in patients with chronic venous insufficiency. Journal of vascular surgery. Venous and lymphatic disorders Ho, V. T., Adkar, S. S., Harris, E. J. 2022

    Abstract

    OBJECTIVE: Incompetent perforator veins (IPVs) contribute to venous pathology and are surgically treated based on hemodynamic measurement, size, and Clinical, Etiological, Anatomical, and Pathophysiological (CEAP) classification. The objective of this study was to systematically review and synthesize current literature regarding surgical management of IPVs, including open ligation, subfascial endoscopic perforator surgery (SEPS), endovascular laser ablation (EVLA), ultrasound guided sclerotherapy (USGS), and radiofrequency ablation (RFA).METHODS: English-language literature published prior to November 2021 was reviewed from the PubMed, EMBASE, and MEDLINE databases for primary literature reporting safety and efficacy outcomes in the surgical treatment of incompetent perforating veins. Study quality and risk of bias was assessed using the Cochrane risk-of-bias tool for comparative studies and a modified version of the Newcastle-Ottawa Scale for non-comparative studies. A random effects model was used to pool effect sizes for efficacy outcomes of wound healing and freedom from wound recurrence.RESULTS: A total of 81 studies were included for qualitative synthesis representing 7010 patients with a mean age of 54.7 years. Overall evidence quality was low to intermediate, with moderate to high risk of bias in comparative studies. There was an 11.3% complication rate across interventions, with no reported incidences of stroke or air embolism. With regards to efficacy, pooled estimates for short-term (up to 1-year) wound healing were 99.9% for USGS (95% CI 0.81 - 1), 72.2% for ligation (95% CI 0.04, 0.94) and 96.0% for SEPS (95% CI 0.79 -0.99). For short-term freedom from wound recurrence, the pooled estimate for SEPS is 91.0% (95% CI 0.3 - 0.99).CONCLUSION: Current evidence regarding treatment of incompetent perforator veins is limited due to low adherence to reporting standards in observational studies and lack of randomization, blinding, and allocation concealment in comparative studies. Additional comparative studies are needed to guide clinical decision-making regarding invasive treatment options for incompetent perforator veins.

    View details for DOI 10.1016/j.jvsv.2021.12.088

    View details for PubMedID 35217217

  • Predicting Unplanned 7-day Intensive Care Unit Readmissions with Machine Learning Models for Improved Discharge Risk Assessment. AMIA ... Annual Symposium proceedings. AMIA Symposium Shi, K., Ho, V., Song, J. J., Bechler, K., H Chen, J. 2022; 2022: 446-455

    Abstract

    Unplanned readmission to the intensive care unit (ICU) confers excess morbidity and mortality. We explore whether machine learning models can outperform the current standard, the Stability and Workload Index for Transfer (SWIFT) score, in assessing 7-day ICU readmission risk at discharge. Logistic regression, random forest, support vector machine, and gradient boosting models were trained and validated on Stanford Hospital data (2009-2019), externally validated on Beth Israel Deaconess Medical Center (BIDMC) data (2008-2019) and benchmarked against SWIFT. The best performing model was gradient boosting, with AUROC of 0.85 and 0.60 and F1-score of 0.43 and 0.14 on internal and external validation, respectively. SWIFT had an AUROC of 0.67 and 0.51 and F1-score of 0.33 and 0.10 on Stanford and BIDMC data, respectively. Machine learning models predicting 7-day ICU readmission risk can improve current ICU discharge risk assessment standards, but performance may be limited without local training.

    View details for PubMedID 35854743

  • Prescription quantity and duration predict progression from acute to chronic opioid use in opioid-naive Medicaid patients. PLOS digital health Johnson, D. G., Ho, V. T., Hah, J. M., Humphreys, K., Carroll, I., Curtin, C., Asch, S. M., Hernandez-Boussard, T. 2022; 1 (8)

    Abstract

    Opiates used for acute pain are an established risk factor for chronic opioid use (COU). Patient characteristics contribute to progression from acute opioid use to COU, but most are not clinically modifiable. To develop and validate machine-learning algorithms that use claims data to predict progression from acute to COU in the Medicaid population, Adult opioid naive Medicaid patients from 6 anonymized states who received an opioid prescription between 2015 and 2019 were included. Five machine learning (ML) Models were developed, and model performance assessed by area under the receiver operating characteristic curve (auROC), precision and recall. In the study, 29.9% (53820/180000) of patients transitioned from acute opioid use to COU. Initial opioid prescriptions in COU patients had increased morphine milligram equivalents (MME) (33.2 vs. 23.2), tablets per prescription (45.6 vs. 36.54), longer prescriptions (26.63 vs 24.69 days), and higher proportions of tramadol (16.06% vs. 13.44%) and long acting oxycodone (0.24% vs 0.04%) compared to non- COU patients. The top performing model was XGBoost that achieved average precision of 0.87 and auROC of 0.63 in testing and 0.55 and 0.69 in validation, respectively. Top-ranking prescription-related features in the model included quantity of tablets per prescription, prescription length, and emergency department claims. In this study, the Medicaid population, opioid prescriptions with increased tablet quantity and days supply predict increased risk of progression from acute to COU in opioid-naive patients. Future research should evaluate the effects of modifying these risk factors on COU incidence.

    View details for DOI 10.1371/journal.pdig.0000075

    View details for PubMedID 36203857

  • Impact of Scalene Muscle Botulinum Toxin Injection with and without Surgery in Neurogenic Thoracic Outlet Syndrome Fereydooni, A., Ho, V. T., Olson, E., Dyrek, P., Harris, T., Kussman, A., Roh, E. Y., Lee, J. T. MOSBY-ELSEVIER. 2021: E410

    View details for Web of Science ID 000707158200201

  • Open Abdominal Aortic Surgery in the Endovascular Era-Will we have Enough Volume for Vascular Trainees? George, E. L., Arya, S., Anand, A., Ho, V., Stern, J. R., Chandra, V., Lee, J. T. MOSBY-ELSEVIER. 2021: E418

    View details for Web of Science ID 000707158200214

  • Cost Effectiveness of Computed Tomography Versus Ultrasound-Based Surveillance Following Endovascular Aortic Repair of Intact Abdominal Aortic Aneurysms Ho, V. T., Nguyen, A. T., Stern, J. R., Asch, S. M., Owens, D. K., Salomon, J. A., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2021: E414-E415

    View details for Web of Science ID 000707158200208

  • Gaps in standardized postoperative pain management quality measures: A systematic review. Surgery Joseph, J. M., Gori, D., Curtin, C., Hah, J., Ho, V. T., Asch, S. M., Hernandez-Boussard, T. 2021

    Abstract

    BACKGROUND: The goal of this study was an assessment of availability postoperative pain management quality measures and National Quality Forum-endorsed measures. Postoperative pain is an important clinical timepoint because poor pain control can lead to patient suffering, chronic opiate use, and/or chronic pain. Quality measures can guide best practices, but it is unclear whether there are measures for managing pain after surgery.METHODS: The National Quality Forum Quality Positioning System, Agency for Healthcare Research and Quality Indicators, and Centers for Medicare and Medicaid Services Measures Inventory Tool databases were searched in November 2019. We conducted a systematic literature review to further identify quality measures in research publications, clinical practice guidelines, and gray literature for the period between March 11, 2015 and March 11,2020.RESULTS: Our systematic review yielded 1,328 publications, of which 206 were pertinent. Nineteen pain management quality measures were identified from the quality measure databases, and 5 were endorsed by National Quality Forum. The National Quality Forum measures were not specific to postoperative pain management. Three of the non-endorsed measures were specific to postoperative pain.CONCLUSION: The dearth of published postoperative pain management quality measures, especially National Quality Forum-endorsed measures, highlights the need for more rigorous evidence and widely endorsed postoperative pain quality measures to guide best practices.

    View details for DOI 10.1016/j.surg.2021.08.004

    View details for PubMedID 34538340

  • Increasing Chronic Opioid Usage Despite Reduced Prescriptions After Vascular Surgery Ho, V. T., Fu, S., Chattopadhyay, A., Asch, S. M., Stern, J. R., Chen, J. MOSBY-ELSEVIER. 2021: E285-E286

    View details for Web of Science ID 000691401100437

  • Cost Effectiveness of Computed Tomography Versus Ultrasound-Based Surveillance After Endovascular Aortic Repair of Intact Abdominal Aortic Aneurysms Ho, V. T., Nguyen, A. T., Stern, J. R., Asch, S. M., Owens, D. K., Salomon, J. A., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2021: E190-E191

    View details for Web of Science ID 000691401100304

  • Open Abdominal Aortic Surgery in the Endovascular Era - Will We Have Enough Volume for Vascular Trainees? George, E. L., Arya, S., Anand, A., Ho, V. T., Stern, J. R., Chandra, V., Lee, J. T. MOSBY-ELSEVIER. 2021: E259-E260

    View details for Web of Science ID 000691401100398

  • Contemporary Outcomes of Traumatic Popliteal Artery Injury Repair from the POPSAVEIT Study. Journal of vascular surgery O'Banion, L. A., Dirks, R., Saldana-Ruiz, N., Farooqui, E., Yoon, W. J., Pozolo, C., Fox, C. J., Crally, A., Siada, S., Nehler, M. R., Brooke, B. S., Beckstrom, J. L., Kiang, S., Boggs, H. K., Chandra, V., Ho, V. T., Zhou, W., Lee, A., Bowens, N., Cho, Y., Woo, K., Ulloa, J., Magee, G. A. 2021

    Abstract

    OBJECTIVE: Traumatic popliteal artery injuries are associated with the highest risk of limb loss of all peripheral vascular injuries, with amputation rates of 10-15%. The purpose of this study was to examine outcomes of patients undergoing operative repair for traumatic popliteal arterial injuries and identify factors independently associated with limb loss.METHODS: A multi-institutional retrospective review of all patients sustaining traumatic popliteal artery injuries from 2007-2018 was performed. All patients who had operative repair of popliteal arterial injuries were included in the analysis. Patients undergoing major lower extremity amputation (trans-tibial or trans-femoral) were compared to those with successful limb salvage at last follow-up. Significant predictors (p<0.05) for amputation on univariate analysis were included in a multivariable analysis.RESULTS: A total of 302 patients from 11 institutions were included in the analysis. Median age was 32 [IQR: 21-40] years and 79% were male. Median follow-up was 72 days [IQR: 20 - 366]. Overall major amputation rate was 13%. Primary repair was performed in 17% of patients, patch repair in 2%, and interposition/bypass in 81%. One patient underwent endovascular repair with stenting. Overall 1-year primary patency was 89%. Of patients that lost primary patency, 46% ultimately required major amputation. Early loss (within 30 days post-op) of primary patency was 5 times more frequent in patients that went on to amputation. On multivariate regression, significant perioperative factors independently associated with major amputation included: initial POPSAVEIT score, loss of primary patency, absence of detectable immediate postoperative pedal Doppler signals, and lack of postoperative antiplatelet therapy. Concomitant popliteal vein injury, location of popliteal injury (P1, P2, P3), ISS, and tibial vs. popliteal distal bypass target were not independently associated with amputation.CONCLUSION: Traumatic popliteal artery injuries are associated with a significant rate of major amputation. Preoperative POPSAVEIT score remains independently associated with amputation after including perioperative factors. Lack of postoperative pedal Doppler signals and loss of primary patency were highly associated with major amputation. Postoperative antiplatelet therapy is inversely associated with amputation, perhaps indicating a protective effect.

    View details for DOI 10.1016/j.jvs.2021.04.064

    View details for PubMedID 34023429

  • US National Trends in Vascular Surgical Practice During the COVID-19 Pandemic. JAMA surgery Ho, V. T., Eberhard, A. V., Asch, S. M., Leeper, N. J., Fukaya, E., Arya, S., Ross, E. G. 2021

    View details for DOI 10.1001/jamasurg.2021.1708

    View details for PubMedID 33856428

  • Popliteal Scoring Assessment for Vascular Extremity Injuries in Trauma (POPSAVEIT) Study. Journal of vascular surgery O'Banion, L. A., Dirks, R., Farooqui, E., Saldana-Ruiz, N., Yoon, W. J., Pozolo, C., Fox, C., Crally, A., Siada, S., Nehler, M. R., Brooke, B. S., Beckstrom, J. L., Kiang, S., Boggs, H. K., Chandra, V., Ho, V. T., Zhou, W., Lee, A., Bowens, N., Cho, Y., Woo, K., Ulloa, J., Magee, G. A. 2021

    Abstract

    OBJECTIVE: Traumatic popliteal vascular injuries are associated with the highest risk of limb loss of all peripheral vascular injuries. There remains a need to evaluate predictors of amputation as previous scores were unable to be validated. This study aims to provide simplified scoring system that preoperatively risk stratifies patients with traumatic popliteal vascular injuries for amputation.METHODS: A review of patients sustaining traumatic popliteal artery injuries was performed. Patients requiring amputation were compared to those with limb salvage at last follow-up. 80% were randomly assigned into a training group for score generation and 20% to a testing group for validation. Significant predictors of amputation (p<0.1) in univariate analysis were included in a multivariable analysis. Those with p<0.05 in the multivariable analysis were assigned points values based on relative value of their odds ratios. ROC curves were generated to determine low vs high risk scores. AUC of >0.65 was considered adequate for validation.RESULTS: 355 patients were included, with overall amputation rate of 16%. On multivariate regression, risk factors independently associated with amputation in the final model were: SBP <90 mm Hg (OR: 3.2, p = 0.027, 1 point), associated orthopedic injury (OR: 4.9, p = 0.014, 2 points), and lack of preoperative pedal Doppler signals (OR: 5.5, p = 0.002, 2 points, or 1 point for lack of palpable pedal pulses if Doppler signal data unavailable). A score of ≥3 was found to maximize sensitivity (85%) and specificity (49%) for high-risk of amputation. ROC curve for the validation group had an AUC of 0.750, meeting threshold for score validation.CONCLUSIONS: POPSAVEIT score provides a simple and practical means to effectively stratify patients preoperatively into low- and high-risk categories for major amputation.

    View details for DOI 10.1016/j.jvs.2021.02.015

    View details for PubMedID 33639233

  • Female sex is independently associated with in-hospital mortality after endovascular aortic repair for ruptured aortic aneurysm. Annals of vascular surgery Ho, V. T., Rothenberg, K. A., George, E. L., Lee, J. T., Stern, J. R. 2021

    Abstract

    Endovascular aortic repair (EVAR) can treat anatomically compatible ruptured abdominal aortic aneurysms (rAAA), but registry data suggests that women undergo more open abdominal aneurysm repairs than men. We evaluate in-hospital outcomes of EVAR for rAAA by sex.The Vascular Quality Initiative (VQI) registry was queried from 2013 to 2019 for rAAA patients treated with EVAR. Univariate analysis was performed with Student's t-test and chi-squared tests. Multivariable logistic regression was then performed to assess the association between female sex and inpatient mortality.1775 patients were included (23.8% female). Female rAAA patients were older (p < 0.01) and weighed less (p < 0.01). They were less likely to have smoked (p <. 001) and had lower creatinine (1.29 vs 1.43, p <0.01) and hemoglobin (10.7 vs 11.7, p < 0.01). Women had smaller maximum aortic diameters (74 vs 66 mm, p < 0.01) and were less likely to have iliac aneurysms (p <.001). Women were more likely to have concomitant femoral endarterectomy (8.5% vs 4.6%, p=.03). Despite having no significant difference in complication or reintervention rates, women had higher rates of in-hospital mortality (45.9% vs 34.5%, p < 0.01). In a logistic regression model for predictors of in-hospital mortality (χ2 < .01), increased age (OR 1.08, p < 0.01), female sex (OR 1.7, p=0.02), preoperative cardiac arrest (OR 5.29, p<0.01), concurrent iliac stenting (OR 2.38, p =0.02), postoperative mesenteric ischemia (OR 2.51, p<0.01) and postoperative transfusion (OR 1.06, p <0.01) were independently associated with in-hospital mortality. Increased preoperative hemoglobin was protective (OR 0.89, p < 0.01) CONCLUSIONS: Female sex is independently associated with in-hospital mortality after EVAR for rAAA, suggesting a relationship beyond anatomical, biochemical, and procedural covariates.

    View details for DOI 10.1016/j.avsg.2021.08.043

    View details for PubMedID 34752855

  • Intraoperative heparin use is associated with reduced mortality without increasing hemorrhagic complications after thoracic endovascular aortic repair for blunt aortic injury. Journal of vascular surgery Ho, V. T., George, E. L., Rothenberg, K. A., Lee, J. T., Garcia-Toca, M., Stern, J. R. 2020

    Abstract

    OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) is an effective treatment for blunt thoracic aortic injury (BTAI), but the risks and benefits of administering intraoperative heparin in trauma patients are not well-defined, especially with regard to bleeding complications.METHODS: The Vascular Quality Initiative (VQI) registry was queried from 2013 to 2019 to identify patients who underwent TEVAR for BTAI with or without administration of intraoperative heparin. Univariate analyses were performed with Student's t-test, Fisher exact, and chi-squared tests where appropriate. Multivariable logistic regression was then performed to assess the association of heparin with inpatient mortality.RESULTS: 655 patients were included, of whom the majority presented with grade III (53.3%) or IV (20%) BTAI. Patients receiving heparin were less likely to have an injury severity score (ISS) ≥ 15 (70.2% vs. 90.5%, p<0.0001), or major head or neck injury (39.6% vs. 62.9%, p<0.0001). Patients receiving heparin had lower incidence of inpatient death (5.1% vs. 12.9%, p<0.01). Across all injury grades, heparin use was not associated with intraoperative transfusion, postoperative transfusion, or hematoma. In patients with grade III BTAI, non-use of heparin was associated with an increased risk of lower extremity embolization events (7.4% vs 1.8%, P < 0.05). On multivariable logistic regression for inpatient mortality, intraoperative heparin use (OR = 0.31, 95% Confidence Interval [CI] 0.11 - 0.86, P < 0.05) and female gender (OR = 0.11, 95% CI 0.11 - 0.86, P < 0.05) were associated with better survival, even when controlling for head and neck trauma and injury grade. In contrast, increased age (OR = 1.06, 95% CI 1.03 - 1.1, P <0.001), postoperative transfusion (OR = 1.06, 95% CI 1.02 - 1.11, P < 0.01), Higher ISS (OR = 1.04, 95% CI 1.01 - 1.07, P < 0.05), postoperative dysrhythmia (OR = 4.48, 95% CI 1.10 - 18.18, P < 0.05), and postoperative stroke or transient ischemic attack (OR = 5.54, 95% CI 1.11 - 27.67, P < 0.05) were associated with increased odds of inpatient mortality.CONCLUSIONS: Intraoperative heparin use is associated with reduced inpatient mortality in patients undergoing during TEVAR for BTAI, including those with major head or neck trauma and high injury severity scores. Heparin did not increase risk of hemorrhagic complications across all injury grades, and in patients with grade III BTAI heparin use was associated with a reduced risk of lower extremity embolic events. Heparin appears to be safe during TEVAR for BTAI, and should be administered when no specific contraindication exists.

    View details for DOI 10.1016/j.jvs.2020.12.068

    View details for PubMedID 33348003

  • Conversion to Chronic High Opiate Use after Intervention for Peripheral Arterial Disease Stern, J. R., Kou, A., Desai, A., Ho, V. T., Regala, S., Stafford, R. S., Mudumbai, S. ELSEVIER SCIENCE INC. 2020: E67–E68

    View details for Web of Science ID 000582798100129

  • Mid-Term Survival after Thoracic Endovascular Aortic Repair by Indication in the Medicare Population. Journal of the American College of Surgeons Ho, V. T., Itoga, N. K., Tran, K., Lee, J. T., Stern, J. R. 2020

    Abstract

    BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is indicated for treatment of aneurysms, dissections, and traumatic injury. We describe mid-term mortality and re-intervention rates in Medicare beneficiaries undergoing TEVAR.STUDY DESIGN: Patients who underwent TEVAR between 2006-2014 were identified by Current Procedural Terminology (CPT) codes in a 20% Medicare sample. Indication for aortic repair (aneurysm, dissection, trauma) was ascertained via International Classification of Diseases (ICD-9) codes. Follow-up was evaluated until 2015. Kaplan Meier survival analysis and Cox regression were used to compare mortality, with re-intervention and mortality rates expressed as a composite outcome in a hazard ratio with 95% confidence interval (HR 95%CI).RESULTS: 3095 patients underwent TEVAR during the study period: 1465 (47%) for aneurysm 1448 (47%) for dissection, and 182 (5.9%) for trauma. Mean patient age was 74.4 years, and 44.5% were female. Median follow-up was 2.7 years. The overall 30-day, 1-year, and 5-year, and 8-year survival was 93%, 78%, 49%, and 33%, respectively. 30-day mortality was highest in traumatic indications, but overall mortality was highest in patients undergoing TEVAR for aneurysm. Freedom from combined re-intervention and mortality at 30-days, 1-year, 5-years and 8-years was 89%, 73%, 43%, and 29% respectively. Reintervention was highest in patients undergoing TEVAR for dissection (12.8%), followed by aneurysm (10.0%) and trauma (5.5%). Advanced age (HR 1.03 per year, 95%CI 1.02-1.03), congestive heart failure (CHF) (HR 1.48, 95%CI 1.33-1.65), dementia (HR 1.40, 95%CI 1.14-1.28), and rupture (HR 1.38, 95%CI 1.24-1.54) were associated with mortality.CONCLUSION: Midterm survival is lower in patients who undergo TEVAR for dissection and aneurysm compared to trauma. Aneurysmal disease, advanced age, CHF, dementia and aortic rupture are associated with mortality and re-intervention in TEVAR.

    View details for DOI 10.1016/j.jamcollsurg.2020.09.011

    View details for PubMedID 33022404

  • The Effect of Interfacility Transfer in Patients With Blunt Thoracic Aortic Injury Rothenberg, K. A., George, E. L., Ho, V., Barreto, N. B., Lee, J. T., Garcia-Toca, M., Stern, J. R. MOSBY-ELSEVIER. 2020: E167

    View details for Web of Science ID 000544100700255

  • Real-World Outcomes of EKOS Ultrasound-Enhanced Catheter-Directed Thrombolysis for Acute Limb Ischemia. Annals of vascular surgery George, E. L., Colvard, B., Ho, V., Rothenberg, K. A., Lee, J. T., Stern, J. R. 2020

    Abstract

    OBJECTIVES: Ultrasound-enhanced catheter-directed thrombolysis (UET) using the EKOS device for acute, peripheral arterial ischemia has been purported in clinical trials to accelerate the fibrinolytic process in order to reduce treatment time and lytic dosage. We aim to describe outcomes of UET in a real-world clinical setting.METHODS: We performed a retrospective review of all patients undergoing UET for acute limb ischemia at a single institution. Data collected included patient demographics, procedural details, and 30-day and 1-year outcomes. The primary endpoints for analysis were major adverse limb events (MALE; reintervention and/or amputation) and mortality within 30-days and 1-year. Secondary endpoints included technical success, use of adjunctive therapies, and postoperative complications.RESULTS: 32 patients (mean age 67.4 ± 14.9 years; 25% female) underwent UET for acute limb ischemia between 2014-2018. Rutherford Acute Limb Ischemia Classification was R1 in 56.3%, R2a in 31.3%, and R2b in 12.5%. Etiology was thrombosis of native artery in 12.5% of patients, prosthetic bypass in 31.3%, autogenous bypass in 6.3%, and stented native vessel in 50.0%. Mean duration of thrombolytic therapy was 22.2 ± 11.3 hours, and mean tissue plasminogen activator dose was 24.5 ± 15.3 mg. Major adverse limb events occurred in 16.7% of patients within the first 30-days and 38.9% experienced a MALE by 1-year. Limb salvage at 30-days and 1-year was 93.8% and 87.5%, respectively. Ipsilateral reintervention was required in 12.5% of patients within 30 days and 37.5% of patients within 1 year. Overall mortality was 6.2% at 30-days and 13.5% at 1-year. In-line flow to the foot was re-established in 90.6% of patients, with a significant improvement in pre- to post-op ABI (0.31+0.29 vs. 0.78+0.34, p<0.001) and number of patent tibial runoff vessels (1.31+1.20 vs. 1.96+0.86, p <0.001). There was no significant difference in revascularization success between occluded vessel types. All but one patient required adjunctive therapy such as further thromboaspiration, stenting, or balloon angioplasty. Major bleeding complications occurred in 3 patients (9.4%), including 1 intracranial hemorrhage (3.1%).CONCLUSIONS: UET with the EKOS device demonstrates acceptable real-world outcomes in the treatment of acute limb ischemia. UET is generally safe and effective at re-establishing in line flow to yield high limb salvage rates. However, UET is associated with a high rate of reintervention. Further investigation is needed into specific predictors of limb salvage and need for reintervention, as well as cost-efficacy of this technology compared to traditional methods.

    View details for DOI 10.1016/j.avsg.2019.12.026

    View details for PubMedID 31917220

  • Contemporary Practices and Complications of Surgery for Thoracic Outlet Syndrome in the United States. Annals of vascular surgery George, E. L., Arya, S. n., Rothenberg, K. A., Hernandez-Broussard, T. n., Ho, V. T., Stern, J. R., Gelabert, H. A., Lee, J. T. 2020

    Abstract

    Thoracic outlet syndrome (TOS) surgery is relatively rare and controversial given the challenges in diagnosis as well as wide variation in symptomatic and functional recovery. Our aims were to measure trends in utilization of TOS surgery, complications, and mortality rates in a nationally representative cohort and compare higher- versus lower-volume centers.The National Inpatient Sample was queried using ICD-9 codes for rib resection and scalenectomy paired with axillo-subclavian aneurysm [arterial (aTOS)], subclavian DVT [venous (vTOS)], or brachial plexus lesions [neurogenic (nTOS)]. Basic descriptive statistics, non-parametric tests for trend, and multivariable hierarchical regression models with random intercept for center were used to compare outcomes for TOS types, trends over time, and higher- and lower-volume hospitals, respectively.There were 3,547 TOS operations (for an estimated 18,210 TOS operations nationally) performed between 2010-2015 (89.2% nTOS, 9.9% vTOS, 0.9% aTOS) with annual case volume increasing significantly over time (p=0.03). Higher-volume centers (≥10 cases/year) represented 5.2% of hospitals and 37.0% of cases, and these centers achieved significantly lower overall major complication (defined as neurologic injury, arterial or venous injury, vascular graft complication, pneumothorax, hemorrhage/hematoma or lymphatic leak) rates [adjusted Odds Ratio (OR) 0.71 (95% confidence interval 0.52-0.98); p=0.04], but no difference in neurologic complications such as brachial plexus injury (aOR 0.69 (0.20-2.43); p=0.56) or vascular injuries/graft complications [aOR 0.71 (0.0.33=1.54); p=0.39]. Overall mortality was 0.6%, neurologic injury was rare (0.3%), and the proportion of patients experiencing complications decreased over time (p=0.03). However, vTOS & aTOS had >2.5 times the odds of major complication compared to nTOS [OR 2.68 (1.88-3.82) & aOR 4.26 (1.78-10.17); p<0.001], and ∼10 times the odds of a vascular complication [aOR 10.37 (5.33-20.19) & aOR 12.93 (3.54-47.37); p<0.001], respectively. As the number of complications decreased, average hospital charges also significantly decreased over time (p<0.001). Total hospital charges were on average higher when surgery was performed in lower-volume centers (< 10 cases/year) compared to higher-volume centers [mean $65,634 (standard deviation 98,796) vs. $45,850 (59,285), p<0.001].The annual number of TOS operations have increased in the United States from 2010-2015, while complications and average hospital charges have decreased. Mortality and neurologic injury remain rare. Higher-volume centers delivered higher-value care: less or similar operative morbidity with lower total hospital charges.

    View details for DOI 10.1016/j.avsg.2020.10.046

    View details for PubMedID 33340669

  • Comparison of mid-term graft patency in common femoral versus superficial femoral artery inflow for infra-geniculate bypass in the vascular quality initiative. Vascular Tran, K. n., Ho, V. T., Itoga, N. K., Stern, J. R. 2020: 1708538120924908

    Abstract

    The superficial femoral artery can be used as inflow for infra-geniculate bypass, but progressive proximal occlusive disease may affect graft durability. We sought to evaluate the effect of superficial femoral artery versus common femoral artery inflow on infra-geniculate bypass patency within a large contemporary multicenter registry.The vascular quality initiative was queried from 2013 to 2019 to identify patients with >30-day patency follow-up, Rutherford chronic limb ischemia stage 1-6, and an infra-geniculate bypass, excluding those with prior ipsilateral bypass. The cohort was stratified by inflow vessel, with primary, primary-assisted, and secondary patency serving as the primary outcome variables. Multivariate Cox-proportional hazard models and radius-based propensity-score matching were performed to reduce treatment-selection bias due to clinical covariates.A total of 11,190 bypass procedures were performed (8378 common femoral artery inflow, 2812 superficial femoral artery) on 10,110 patients, with a mean follow-up of 12.8 months (range 1-98). Patients receiving superficial femoral artery inflow bypasses were more commonly male (p = 0.002), obese (p < 0.0001) and had chronic, limb threatening ischemia (p < 0.0001), whereas those with common femoral artery inflow were older (p < 0.0004), and had higher baseline comorbidities including smoking (p < 0.0001), coronary disease (p < 0.0001), and pulmonary disease (p < 0.0001). On life-table analysis, there was no significant difference in three year estimated primary (32.1 vs 30.1%, p = 0.928), primary assisted (60.5 vs 65.8%, p = 0.191), or secondary patency (62.5 vs 66.7%, p = 0.139) between superficial femoral artery and common femoral artery inflow groups, respectively. A multivariate Cox model found no significant association between inflow vessel and primary patency (0.96 [0.88-1.04], HR [95%CI]), primary-assisted (1.07 [0.95-1.20], HR [95%CI]), or secondary patency (1.08 [0.96-1.22]). In a propensity-matched cohort (n = 11,151), there were small but statistically significant differences in primary, primary-assisted, and secondary patency at latest follow-up (non-time-to-event data) between groups. The largest difference was observed when evaluating secondary patency, with common femoral artery inflow having a marginally higher secondary patency of 88.1% compared to 85.6% for those with superficial femoral artery inflow at latest follow-up (p = 0.009).Within the vascular quality initiative, there is no significant difference in life-table determined three-year primary, primary-assisted, and secondary patency between infra-geniculate bypasses using common femoral artery inflow compared to superficial femoral artery inflow. Small, statistically significant differences exist in primary, primary-assisted, and secondary patency favoring common femoral artery inflow after propensity score matching. Long-term follow-up data are required in the vascular quality initiative to better evaluate bypass graft durability as this study was limited by a mean follow-up of one year.

    View details for DOI 10.1177/1708538120924908

    View details for PubMedID 32408857

  • Increased vertebral exposure in anterior lumbar interbody fusion associated with venous injury and deep venous thrombosis. Journal of vascular surgery. Venous and lymphatic disorders Ho, V. T., Martinez-Singh, K. n., Colvard, B. n., Lee, J. T., Chandra, V. n. 2020

    Abstract

    Published outcomes on anterior lumbar interbody fusion (ALIF) have focused on 1-2 level fusion with and without vascular surgery assistance. We examined the influence of multi-level fusion on exposure-related outcomes when performed by vascular surgeons.We retrospectively reviewed clinical and radiographic data for patients undergoing anterior lumbar interbody fusion (ALIF) with exposure performed by vascular surgeons at a single practice.From 2017-2018, 201 consecutive patients underwent vascular-assisted ALIF. Patients were divided by number of vertebral levels exposed (90 patients with 1 level exposed, 71 with 2, 40 with 3+). Demographically, 3+ level fusion patients were older (p=.0045) and more likely to have had prior ALIF (p=.0383). Increased vertebral exposure was associated with higher rates of venous injury (p=.0251), increased procedural time (p= .0116), length of stay (p=.0001), and incidence of postoperative DVT (p=.0032). There was a 6.5% rate of intraoperative vascular injury, comprised of 3 major and 10 minor venous injuries. In patients who experienced complications, 92.3% of injuries were repaired primarily. 23% of patients with venous injuries developed postoperative deep venous thrombosis. In a multivariate logistic regression model, increased levels of exposure (RR = 6.23, p = .026) and a history of degenerative spinal disease (RR = .033, p = .033) were predictive of intraoperative venous injury.Increased vertebral exposure in anterior lumbar interbody fusion is associated with increased risk of intraoperative venous injury and postoperative deep venous thrombosis, with subsequently greater lengths of procedure time and length of stay. Rates of arterial and sympathetic injury were not affected by exposure extent.

    View details for DOI 10.1016/j.jvsv.2020.08.006

    View details for PubMedID 32795618

  • Open, percutaneous, and hybrid deep venous arterialization technique for no-option foot salvage. Journal of vascular surgery Ho, V. T., Gologorsky, R., Chandra, V., Prent, A., Lee, J., Dua, A. 2019

    Abstract

    OBJECTIVE: Deep venous arterialization (DVA) is a technique aimed at providing an option for chronic limb-threatening ischemia patients with no options except amputation. In patients with no outflow distal targets permitting bypass, DVA involves creating a connection between a proximal arterial inflow and a distal venous outflow in conjunction with disruption of the vein valves in the foot. This permits blood flow to reach the foot and potentially to resolve rest pain or to assist in healing of a chronic wound. We aimed to provide an up-to-date review of DVA indications; to describe the open, percutaneous, and hybrid technique; to detail outcomes of each of the available techniques; and to relay the postoperative considerations for the DVA approach.METHODS: A literature review of relevant articles containing all permutations of the terms "deep venous arterialization" and "distal venous arterialization" was undertaken with the MEDLINE, Cochrane, and PubMed databases to find cases of open, percutaneous, and hybrid DVA in the peer-reviewed literature. The free text and Medical Subject Headings search terms included were "ischemia," "lower extremity," "venous arterialization," "arteriovenous reversal," and "lower limb salvage." Studies were primarily retrospective case series but did include two studies with matched controls. Recorded primary outcomes were patency, limb salvage, wound healing, amputation, and resolution of rest pain, with secondary outcomes of complication and overall mortality. Studies were excluded if there was insufficient discussion of technical details (graft type, target vein) or lack of reported outcome measure.RESULTS: Studies that met inclusion criteria (12 open, 3 percutaneous, 2 hybrid) were identified, reviewed, and summarized to compare technique, patient selection, and outcomes between open, percutaneous, and hybrid DVA. For open procedures, 1-year primary patency ranged from 44.4% to 87.5%; secondary patency was less reported but ranged from 55.6% at 1year to 72% at 25-month follow-up. Limb salvage rates ranged from 25% to 100%, wound healing occurred in 28.6% to 100% of cases, and rest pain resolved in 11.9% to 100% across cohorts. For the endovascular approach, primary patency ranged from 28.6% to 40% at 6-month and 10-month follow-up. Limb salvage rates ranged from 60% to 71%, with rates of major amputation ranging from 20% to 28.5%.CONCLUSIONS: This review provides an up-to-date review of DVA indications, description of various DVA techniques, patient selection associated with each approach, and outcomes for each technique.

    View details for DOI 10.1016/j.jvs.2019.10.085

    View details for PubMedID 31901360

  • Increased Vertebral Exposure in Anterior Lumbar Interbody Fusion Associated With Venous Injury and Deep Venous Thrombosis Ho, V. T., Colvard, B., Lee, J. T., Chandra, V. MOSBY-ELSEVIER. 2019: E248–E249

    View details for DOI 10.1016/j.jvs.2019.04.376

    View details for Web of Science ID 000469220300368

  • Real-World Outcomes of EKOS Ultrasound-Enhanced Catheter-Directed Thrombolysis for Acute Limb Ischemia George, E. L., Colvard, B., Ho, V. T., Rothenberg, K. A., Lee, J. T., Stern, J. R. MOSBY-ELSEVIER. 2019: E170–E171

    View details for DOI 10.1016/j.jvs.2019.04.236

    View details for Web of Science ID 000469220300232

  • Metformin prescription status and abdominal aortic aneurysm disease progression in the US veteran population JOURNAL OF VASCULAR SURGERY Itoga, N. K., Rothenberg, K. A., Suarez, P., Ho, T., Mell, M. W., Xu, B., Curtin, C. M., Dalman, R. L. 2019; 69 (3): 710-+

    View details for DOI 10.1016/j.jvs.2018.06.194

    View details for Web of Science ID 000459249300033

  • Early Real-World Experience with Endoanchors by Indication. Annals of vascular surgery Ho, V. T., George, E. L., Dua, A. n., Lavingia, K. S., Sgroi, M. D., Dake, M. D., Lee, J. T. 2019

    Abstract

    The Heli-Fx Endoanchor system is a transmural aortic fixation device with Federal Drug Administration (FDA) approval for treatment of endoleaks, endograft migration, or high-risk seal zones. Published data is primarily from industry-sponsored registries highlighting safety and efficacy. Our objective is to evaluate real-world outcomes of Endoanchor usage after FDA approval across a variety of stent-grafts and indications at a single institution.We retrospectively reviewed our prospectively maintained aneurysm database for patients undergoing endovascular aortic repair with Heli-Fx Endoanchors (EAs). Technical success was defined as successful EA deployment, while procedural success was defined as absence of endoleak on completion aortogram. Cohorts were divided by indication and outcomes assessed via review of clinical and radiographic data.From 2016-2018, 37 patients underwent EA fixation. We divided the cohort by indication: Group A (Prior EVAR with endoleak), B (intraoperative type 1A endoleak), C (high-risk seal zone), and D (TEVAR). In Group A (n=11), all endoleaks were type 1A and a mean of 10 EAs were deployed with 100% technical and 45.4% procedural success. Two perioperative re-interventions were performed (translumbar coil embolization; proximal graft extension with bilateral renal artery stents). At a mean 10.6 months follow-up, 45.4% of patients had persistent endoleaks, with 100% aortic related survival. In Group B (n=10), a mean of 8.7 EAs were used with 100% technical and procedural success. One immediate adverse event occurred (right iliac dissection from wire manipulation, treated with a covered stent). At 13.6 month mean follow-up, there was significant sac regression (mean 9.75 mm) with no type 1A endoleaks. In Group C (n=10), a mean of 9.5 EAs were deployed with 100% technical and procedural success. At 11.2 month mean follow-up, there were no residual endoleaks and significant sac regression (mean 3.4 mm). Overall survival was 100%. In Group-D (n=6), a mean of 8.3 EAs were used with 83.3% technical and 66.6% procedural success. One immediate adverse event occurred, in which an EA embolized to the left renal artery. At 9.4 month mean follow-up, overall survival was 83.3% with a mean 2.2 mm increase in sac diameter.Early experience suggests EAs effectively treat intraoperative type-1A endoleaks and high-risk seal zones, with significant sac regression and no proximal endoleaks on follow-up. In patients treated for prior EVAR with postoperative type-1A endoleaks, fewer than half resolved after EA attempted repair. Further experience and longer-term followup will be necessary to determine which patients most benefit from postoperative EA fixation.

    View details for DOI 10.1016/j.avsg.2019.05.006

    View details for PubMedID 31201976

  • Preprocedural Cross-Sectional Imaging Prior to Percutaneous Peripheral Arterial Disease Interventions. Vascular and endovascular surgery Itoga, N. K., Ho, V. T., Tran, K. n., Chandra, V. n., Dalman, R. L., Harris, E. J., Lee, J. T., Mell, M. W. 2019: 1538574419887585

    Abstract

    Preprocedural cross-sectional imaging (PCSI) for peripheral artery disease (PAD) may vary due to patient complexity, anatomical disease burden, and physician preference. The objective of this study was to determine the utility of PCSI prior to percutaneous vascular interventions (PVIs) for PAD. Patients receiving first time lower extremity angiograms from 2013 to 2015 at a single institution were evaluated for PCSI performed within 180 days, defined as computed tomography angiography (CTA) or magnetic resonance angiography (MRA) evaluating abdominal to pedal vasculature. The primary outcome was technical success defined as improving the target outflow vessels to <30% stenosis. Of the 346 patients who underwent lower extremity angiograms, 158 (45.7%) patients had PCSI, including 150 patients had CTA and 8 patients had MRA. Of these, 48% were ordered by the referring provider (84% at an outside institution). Preprocedural cross-sectional imaging was performed at a median of 26 days (interquartile range: 9-53) prior to the procedure. The analysis of the institution's 5 vascular surgeons identified PCSI rates ranging from 31% to 70%. On multivariate analysis, chronic kidney disease (odds ratio [OR] = 0.35; 95% confidence interval [CI]: 0.17-0.73) was associated with less PSCI usage, and inpatient/emergency department evaluation (OR = 3.20; 95% CI: 1.58-6.50) and aortoiliac disease (OR = 2.78; 95% CI: 1.46-5.29) were associated with higher usage. After excluding 31 diagnostic procedures, technical success was not statistically significant with PSCI (91.3%) compared to without PCSI (85.6%), P = .11. When analyzing 89 femoral-popliteal occlusions, technical success was higher with PCSI (88%) compared to procedures without (69%) P = .026. Our analysis demonstrates that routine ordering of PCSI may not be warranted when considering technical success of PVI; however, PCSI may be helpful in treatment planning. Further studies are needed to confirm these findings in another practice setting, with more prescriptive use of PCSI to improve procedural success, and thereby improve the value of PCSI.

    View details for DOI 10.1177/1538574419887585

    View details for PubMedID 31746279

  • A Challenge for Psychocardiology: Addressing the Causes and Consequences of Patients' Perceptions of Enduring Somatic Threat AMERICAN PSYCHOLOGIST Edmondson, D., Birk, J. L., Ho, V. T., Meli, L., Abdalla, M., Kronish, I. M. 2018; 73 (9): 1160–71

    Abstract

    The enduring somatic threat (EST) model of posttraumatic stress disorder (PTSD) due to life-threatening medical events suggests that PTSD-like symptoms represent patients' sensitization to cues of ongoing threat in the body. In this article, we review research on the prevalence and consequences of such reactions in cardiovascular disease patients, discuss early tests of the EST model, and then report a new test of the EST model in 143 patients enrolled during their first acute coronary syndrome (ACS; i.e., non-ST elevation myocardial infarction or unstable angina-colloquially, "heart attack"). Invasive coronary revascularization procedures are commonly used to reduce secondary ACS risk and may reduce patients' EST, as revascularized patients often report being "cured." We assessed ACS patients' initial threat perceptions during emergency department (ED) evaluation and followed them for 1 month for PTSD symptoms (specific for ACS, by telephone). We compared PTSD symptoms in participants who were revascularized (n = 65), catheterized but not revascularized (n = 35), and medically managed (n = 43). PTSD symptoms were lower for revascularized versus medically managed participants (B = -5.32, 95% confidence interval [-9.77, -0.87]), t(98.19) = -2.37, p = .020. In a multiple regression model adjusted for clinical and psychosocial covariates, the interaction of threat perception in the ED and ACS management group was significant (greater ED threat predicted greater 1-month PTSD symptoms only in medically managed participants). These findings offer further support for the EST model and suggest that psychological interventions to preempt patients' development of EST should be considered in the hospital. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

    View details for DOI 10.1037/amp0000418

    View details for Web of Science ID 000452426700015

    View details for PubMedID 30525797

  • Comparison of Bovine Carotid Xenograft Versus Expanded Polytetrafluoroethylene Grafts for Forearm Loop Hemodialysis Access Colvard, B., Lavignia, K., Ho, V. T., Itoga, N., Dua, A., Harris, E., Me, M., Sorial, E., Garcia-Toca, M. MOSBY-ELSEVIER. 2018: E35

    View details for Web of Science ID 000442339800065

  • Outcomes of Gracilis Muscle Flaps in the Management of Groin Complications after Arterial Bypass with Prosthetic Graft. Annals of vascular surgery Dua, A., Ho, V. T., Rao, C., Desai, S. S. 2018

    Abstract

    INTRODUCTION: This study details two-year outcomes of a modified gracilis muscle flap (GMF) technique in providing tissue coverage for groin complications after arterial bypass surgery with synthetic graft.METHODS: All patients who developed groin infections after lower extremity arterial bypass with synthetic graft that underwent a GMF were included from June 2014 to March 2017 from a prospectively collected, purpose-built institutional database. Modifications to the standard technique included identification of the muscle using ultrasound to ensure precise skip incisions, preservation of the segmental blood supply, widening of the tunnel through which the muscle is retroflexed, placement of a wound VAC for healing, and lifelong antibiotics. Demographics, laboratory values, bypass procedure, length of stay (LOS), disposition, and 1, 3, 6, 12, and 24 month follow up were collected. Analysis was performed via descriptive statistics.RESULTS: Over the 3-year study period, 22 patients underwent GMF following complications after arterial bypass surgery. Types of bypass included aortobifemoral (32%), axillobifemoral (14%), femoral-femoral (23%), femoral-popliteal or mixed distal (27%), and thigh graft for dialysis (4%). 45% of patients presented with graft infection, 50% with wound dehiscence and 5% with graft disruption and bleeding. Only 23% of patients were candidates for sartorius muscle flap at the time of their initial procedure. The average case length was 64+19 minutes. 64% of patients were discharged to home with home health and the remainder to a skilled nursing facility. The average LOS was 6.1+3.4 days. 54% of wounds were healed at 1 month and 100% at 3 months with adjunctive VAC therapy and life-long antibiotics. 60% of patients were still alive at 24 months, with 33% of grafts still patent at that time. Median survival was 18.1 months, and median graft patency was 17.9 months.CONCLUSIONS: GMF is a safe and effective treatment for groin complications following arterial bypass surgery with synthetic graft. Due to its versatility, area of coverage, ease of use, and durability it potentially should be considered as a primary form of muscle coverage for groin complications.

    View details for DOI 10.1016/j.avsg.2018.02.009

    View details for PubMedID 29660388

  • Thrombolysis for Venous Thromboembolism During Pregnancy: A Literature Review. Vascular and endovascular surgery Ho, V. T., Dua, A., Lavingia, K., Rothenberg, K., Rao, C., Desai, S. S. 2018: 1538574418777822

    Abstract

    BACKGROUND: Pregnancy is a hypercoagulable state, conferring an increased risk of venous thromboembolism (VTE). However, treatment algorithms for deep venous thrombosis and pulmonary embolism are based on studies of nonpregnant patients.METHODS: A literature review of cases in which thrombolysis was used for the treatment of VTE during pregnancy was conducted using the PubMed (National Institutes of Health) database.RESULTS: A PubMed database search of English language articles for reports of thrombolysis for the treatment of VTE in pregnancy identified 215 cases, including 183 cases of systemic thrombolysis, 19 cases of catheter-directed thrombolysis, and 13 cases of mechanical thrombectomy. For systemic thrombolysis, the maternal complication rate was 4.40% and the fetal complication rate was 1.65%. For catheter-directed thrombolysis, the maternal complication rate was 14.75% and the fetal complication rate was 5.2%. In cases of mechanical thrombectomy, there were no reported maternal or fetal complications.CONCLUSIONS: Although conservative strategies are preferred in pregnancy, thrombolysis is an adjunct for limb or life-threatening VTE. Review of past reports suggests low rates of maternal and fetal complications following systemic thrombolysis and mechanical thrombectomy but higher rates of complications after catheter-directed thrombolysis in the treatment of VTE during pregnancy.

    View details for DOI 10.1177/1538574418777822

    View details for PubMedID 29804522

  • Septic Pulmonary Emboli From Peripheral Suppurative Thrombophlebitis: A Case Report and Literature Review. Vascular and endovascular surgery Ho, V. T., Rothenberg, K. A., McFarland, G., Tran, K., Aalami, O. O. 2018: 1538574418779469

    Abstract

    BACKGROUND: We report the case of a 90-year old woman who presented with septic pulmonary emboli due to suppurative thrombophlebitis at an old peripheral intravenous site.METHODS: After unsuccessful treatment with antibiotics, the patient was taken to the operating room for excision and drainage of the purulent superficial vein.RESULTS: We review the literature and discuss the presentation, risk factors, treatment options, and complications of this often-overlooked disease entity.CONCLUSIONS: Suppurative thrombophlebitis is a rare but morbid disease that requires a high level of clinical suspicion to diagnose.

    View details for DOI 10.1177/1538574418779469

    View details for PubMedID 29909751

  • Mycotic Renal Artery Aneurysm Presenting as Critical Limb Ischemia in Culture-Negative Endocarditis CASE REPORTS IN SURGERY Vy Thuy Ho, Itoga, N. K., Wu, T., Sorial, E., Garcia-Toca, M. 2018: 7080813

    Abstract

    Mycotic renal artery aneurysms are rare and can be difficult to diagnose. Classic symptoms such as hematuria, hypertension, or abdominal pain can be vague or nonexistent. We report a case of a 53-year-old woman with a history of intravenous drug abuse presenting with critical limb ischemia, in which CT angiography identified a mycotic renal aneurysm. This aneurysm tripled in size from 0.46 cm to 1.65 cm in a 3-week interval. Echocardiography demonstrated aortic valve vegetations leading to a diagnosis of culture-negative endocarditis. The patient underwent primary resection and repair of the aneurysm, aortic valve replacement, and left below-knee amputation after bilateral common iliac and left superficial femoral artery stenting. At 1-year follow-up, her serum creatinine is stable and repaired artery remains patent.

    View details for PubMedID 29854544

    View details for PubMedCentralID PMC5964565

  • How Can Health Systems Develop Physician Leaders to Implement Better? Lessons From the Stanford-Intermountain Fellowship in Population Health, Delivery Science, and Primary Care. Quality management in health care Olsen, G. n., Knighton, A. n., Vilendrer, S. n., Taylor, N. K., Ho, V. T., Thomas, S. n., Carmichael, H. n., Brunisholz, K. n., Wolfe, D. n., Allen, L. n., Belnap, T. n., Asch, S. n., Srivastava, R. n. ; 30 (2): 140–43

    View details for DOI 10.1097/QMH.0000000000000317

    View details for PubMedID 33783427

https://orcid.org/0000-0002-5570-0536