Vascular Medicine

The Program

The Focus

There are several cogent reasons for developing new centers in Vascular Medicine. Foremost is the improvement in patient care that will result. Because vascular disorders often affect the entire vascular system rather than a single vascular bed, recognition of disease in one vascular bed should trigger comprehensive evaluation, management, and prevention of associated vascular disease. This concept provides the rationale for an integrated and multidisciplinary approach involving specialists with various skills and expertise in the management of vascular disease. In addition to providing optimal and comprehensive care, another objective of this clinical group will be to evaluate the quality and cost-efficacy of diagnostic and therapeutic procedures by tracking patient outcomes. New therapeutic approaches will be introduced and critically evaluated with an objectivity that will be ensured by the multiple disciplines that are represented. New therapeutic collaborations will result. For example, the application of stented grafts for aortic aneurysms and dissections has been made possible at Stanford due to the close cooperation of vascular surgeons and interventional radiologists. Both groups work closely with vascular internists, cardiologists, and allied professionals to modify risk factors, and to evaluate and treat disease in other circulations.

In this clinical milieu, young physicians with an interest in vascular diseases will be exposed to the breadth and depth of clinical concepts and skills that will allow them to mature into well-rounded vascular internists. Their education will be supplemented by vascular biologists, recruited to instruct the fellows in pathophysiology and to offer them the opportunity for basic research experience. Interdisciplinary seminars will disseminate the latest insights in vascular biology, promote collaborative research programs, and hasten the transfer of basic concepts into clinical practice.

Current fellow in the research lab

Although the advances in vascular imaging and therapies have been impressive in the past decade, they have lagged far behind the rapid evolution of vascular biology. This is in part due to the scarcity of medical specialists who are knowledgeable in the biology and natural history of vascular disease. Vascular internists trained in these centers will be empowered to link the insights in vascular biology to clinical applications and thereby accelerate the growth of this discipline. In these centers, the emphasis on research and education will lead to new technology. However, the development of this new technology will occur in an environment of multidisciplinary assessment and critique, with a premium placed on cost-efficacy as well as quality. This will ensure more cost-effective care of vascular patients, with better outcomes. For example, early recognition of peripheral arterial disease enables aggressive risk factor modification targeted at subset of patients that are at high risk for future cardiovascular and cerebrovascular events. The vascular internist will make rational and selective use of technology by favoring a careful physical exam over non-invasive diagnostic modalities and conservative medical therapy over interventional procedures. In addition to providing integrated, cost-effective care for patients with vascular disorders, these specialists will spearhead clinical trials that will introduce new strategies for the improved management of vascular disease. The development of vascular medicine will thereby address a major cause of morbidity and mortality - vascular disease - in an enlightened and cost-effective fashion.

 

The Core Curriculum

The core curriculum provides the fellow with the fundamentals of vascular medicine. Following completion of this curriculum, the fellow is skilled in the clinical assessment and medical management of vascular disease, and is able to effectively use and interpret noninvasive diagnostic modalities. The fellow is expected to be expert in all of the vascular diseases as defined by the NHLBI, and will have special expertise in the noninvasive vascular laboratory, including segmental pressure and pulse volume recordings (plethysmography) to assess the arterial circulation, duplex ultrasonography of the arterial and venous system, transcutaneous oximetry, etc.

The clinical exposure consists of inpatient and outpatient experience in vascular medicine. On the inpatient rotation, the trainee will manage the vascular consultation service. He/She will perform preoperative evaluations and learn to select echocardiography, nuclear medicine, or coronary angiography to evaluate these high-risk patients for myocardial ischemia or dysfunction, and becomes familiar with the indications for invasive therapy.  The trainee will be responsible for post-operative consultation on vascular surgery patients, including electrocardiographic and non-invasive vascular hemodynamic assessment interpretation, suggesting medical management based on this information, and will initiate and monitor antiplatelet, anti-thrombotic, and anticoagulant therapy for these patients. The fellow will modify risk factors associated with vascular disease in surgical patient. He/She will be responsible for the initial monitoring and total management of thrombolytic therapy for patients with arterial and venous disease, and thereby gain a complete understanding of the use of these forms of therapy. Expertise in the diagnosis and treatment of venous thrombosis, pulmonary embolism, lipid disturbances, hypertension, and all forms of degenerative atherosclerotic disease are part of this rotation.

In the outpatient clinics, the spectrum of disease entities encountered is different from that in the inpatient service. The fellow will be responsible for performing history and physical examinations, consultations, and follow-up visits on patients with all aspects of vascular disease. Emphasis is placed on the diagnosis and management of arteriosclerosis obliterans, chronic venous insufficiency, deep venous thrombosis, superficial thrombophlebitis, leg ulcers, vasospastic diseases, vasculitis, hypertension, lipids, atherosclerotic heart disease, diabetes, the diabetic foot, lymphedema, coagulation disorders, thromboangiitis obliterans, chronic pernio, and all other common and rare forms of vascular disease. A program for the diagnosis and management of complicated hypertension, secondary hypertension, and lipid disturbances is fostered during this outpatient rotation.

Characterization of iPSCs. iPSCs derived from human fibroblast reprogrammed with lentiviral vectors expressing Oct-3/4, Sox2, and Klf4 maintain colony morphology characteristic of ESCs (A, magnification 4; B, magnification 20), demonstrate alkaline phosphatase activity (C), and express pluripotency markers as
detected by immunocytochemistry including Nanog (D), TRA-1-81 (E), and SSEA-4 (stage-specific embryonic antigen 4; F). For panels D through F, pluripotency markers were detected with antibodies tagged by Alexa-594 (red), and nuclei are marked by DAPI staining (blue). Notably, control plates of differentiated fibroblasts that were mock transfected failed to give rise to any human ESC–like colonies.

 

THE PROGRAM

The Clinical Year

Trainees will also have an active vascular clinic.

The education experience is greatly enhanced by a multitude of clinical and research conferences. Clinical conferences include vascular medicine, vascular surgery, and several multidisciplinary conferences. Research conferences range from clinical research to vascular biology.

 

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