Search

Background: Endovascular interventions for peripheral artery disease have increased in prevalence over time given the inherent benefits of minimally invasive approaches. Although it is essential that vascular surgery graduates are facile with endovascular techniques, the results of the BEST-CLI (Best Endovascular vs. Best Surgical Therapy in Patients With Critical Limb Ischemia) trial highlight the equivalent importance of ensuring trainee competence in open skills. Recent studies demonstrate increasing case volume of both endovascular and open procedures during vascular surgery training. Case volume is merely a surrogate marker for competence, however, and the objective competence attained by trainees at the time of graduation is unknown. We sought to investigate operative autonomy and competence of graduating vascular surgery trainees performing endovascular as compared with open peripheral vascular revascularization procedures., Methods: Operative performance and autonomy ratings for infrainguinal endovascular and open revascularizations from the Society for Improving Professional Learning Operative application database were collected for all vascular surgery participating institutions from 2018 to 2023. The distribution for autonomy and performance ratings were determined by training level for endovascular and open procedures, respectively. Mixed effects logistic regressions were conducted to estimate the predictive association between procedure type and autonomy and performance assessment, adjusting for training level and case complexity. Subsequently, the estimated model was applied to predict the probability of a graduating trainee being rated as meaningfully autonomous or competent while performing endovascular and open procedures across various case complexities., Results: Sixty-nine residents from 23 programs (12 fellowship, 11 residency) were assessed on 706 revascularization procedures (n = 383 endovascular; n = 323 open). When controlling for training level and case complexity, there were no differences in autonomy (odds ratio [OR], 1.11; 95% confidence interval [CI], 0.62-1.99) or competency assessment (OR, 0.86; 95% CI, 0.46-1.59) for endovascular, as compared with open, peripheral revascularization procedures. For average complexity procedures, the predicted probability of a trainee being assessed as competent and autonomous at the time of graduation was high (competent: 88% endovascular, 86% open; autonomous: 96% endovascular, 97% open). The predicted probability of competence and autonomy for complex procedures was lower, but remained similar between groups (competent: 73% endovascular, 70% open; autonomous: 92% endovascular, 92% open)., Conclusions: There is no difference in the graduating level of autonomy and competence of endovascular as compared with open peripheral revascularization procedures for vascular surgery trainees. These findings suggest that vascular surgery trainees enter independent practice with adequate proficiency to use the full scope of techniques to care for patients requiring peripheral revascularization procedures., Competing Interests: Disclosures M.L.W. is a consultant for W. L. Gore & Associates and Cook Medical, unrelated to this work., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Integrated vascular surgery residency positions have doubled more than the last decade. Studies have investigated the impact of co-existing subspecialty surgical training programs on case volume of general surgery residents (GSRs). However, no studies have explored the impact of subspecialty training on GSR operative competency. The aim of this study is to understand the impact of integrated residencies on operative performance and autonomy of GSR performing vascular procedures., Methods: Autonomy and performance ratings of GSR participating in vascular surgery cases were collected from all institutions participating in the Society for Improving Medical Professional Learning application database from 2015 to 2023. Faculty and self-assessments of autonomy and performance on vascular cases performed by GSRs at programs with co-existing vascular integrated residency (VIR), vascular surgery fellowship (VSF), or no subspecialty vascular training (VX) were compared using Fisher's exact tests with Bonferroni corrections across training levels and case complexity., Results: Eleven thousand one hundred seventy five assessments (26% at institutions with VIR, 46% VSF, and 28% VX) were submitted by 920 GSRs and 343 faculty. Senior GSRs at programs with VSF achieved lower autonomy than those with VIR (P = 0.049) or VX (P = 0.042) based on faculty assessment. GSRs achieved a level of "practice ready" at significantly higher rates when training at programs with VIR, and at the lowest rates with VSF (P < 0.001). However, self-perception of autonomy and performance was highest among GSRs at programs with VX compared with VIR and VSF (P < 0.001)., Conclusions: The presence of VIR was associated with higher achievement of "practice ready" competency and higher levels of operative autonomy among senior GSRs performing vascular procedures. Shared-learning among peers and faculty expertise in teaching resident-level trainees may contribute to this finding., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: The graduate medical education community implemented virtual residency interviews in response to travel restrictions during the COVID-19 pandemic, and this approach has persisted. Although many residency applicants wish to visit in-person prospective training sites, such opportunities could bias programs toward those who are able to meet this financial burden, exacerbating equity concerns. One proposed solution is to offer applicants the opportunity to visit only after a program's rank list is "locked," avoiding favoritism to applicants who visit, but allowing applicants to experience some of the camaraderie, geography, and local effects of an in-person visit. As debate about the optimal format of residency interviews continues, it is important to investigate whether in-person program visits, completed after program rank list certification, provide meaningful benefits to applicants in the residency match process., Methods: All vascular programs entering the 2023 integrated vascular surgery residency match were invited to participate. Programs agreed to certify their National Resident Matching Program rank lists by February 1, 2023. Applicants then had the opportunity to visit the programs at which they interviewed. The particulars of the visit were determined by the individual programs. Applicants completed their standard rank list and locked on the standard date: March 1, 2023. Applicants then completed a survey regarding the impact of the visits on their rank order list decision-making. Program directors (PDs) completed a survey regarding their experiences as well. Data were collected using REDCap., Results: Twenty-one of the 74 (28%) programs participated. Nineteen PDs completed the postinterview site visit survey (response rate 90%). Applicants interviewing at the participating programs (n = 112) were informed of the study, offered the opportunity to attend postinterview site visits, and received the survey. Forty-seven applicants responded (response rate 42%). Eighty-six percent of applicants stated that the visit impacted their rank list. Most important factors were esprit de corps of the program (86%), the faculty/trainees/staff (81%), and the physical setting (62%). Seventy-one percent of those participating spent ≤$800 on their visit. Eighty-one percent were satisfied with the process. Twenty-one percent of PDs would have changed their rank list if they could have based on the applicants' in-person visit. Sixty-three percent of the visit sessions cost the programs ≤$500, and 63% were satisfied with the process., Conclusions: This study is the first to document the impact of in-person site visits by applicants on a graduate medical education match process in one specialty. Our results suggest that this process provides meaningful data to applicants that helped them with their decision-making evidenced by most altering their rank lists, while avoiding some of the critical equity issues that accompany traditional in-person interviews. This may provide a model for future interview processes for residency programs., Competing Interests: Disclosures D.A.R. is a speaker for WL Gore and Associates. M.H. is a speaker for Shockwave Medical, Boston Scientific, and WL Gore and Associates. The remaining authors report no conflicts., (Published by Elsevier Inc.)

Objective: Gender disparities in surgical training and assessment are described in the general surgery literature. Assessment disparities have not been explored in vascular surgery. We sought to investigate gender disparities in operative assessment in a national cohort of vascular surgery integrated residents (VIRs) and fellows (VSFs)., Methods: Operative performance and autonomy ratings from the Society for Improving Medical Professional Learning (SIMPL) application database were collected for all vascular surgery participating institutions from 2018 to 2023. Logistic generalized linear mixed models were conducted to examine the association of faculty and trainee gender on faculty and self-assessment of autonomy and performance. Data were adjusted for post-graduate year and case complexity. Random effects were included to account for clustering effects due to participant, program, and procedure., Results: One hundred three trainees (n = 63 VIRs; n = 40 VSFs; 63.1% men) and 99 faculty (73.7% men) from 17 institutions (n = 12 VIR and n = 13 VSF programs) contributed 4951 total assessments (44.4% by faculty, 55.6% by trainees) across 235 unique procedures. Faculty and trainee gender were not associated with faculty ratings of performance (faculty gender: odds ratio [OR], 0.78; 95% confidence interval [CI], 0.27-2.29; trainee gender: OR, 1.80; 95% CI, 0.76-0.43) or autonomy (faculty gender: OR, 0.99; 95% CI, 0.41-2.39; trainee gender: OR, 1.23; 95% CI, 0.62-2.45) of trainees. All trainees self-assessed at lower performance and autonomy ratings as compared with faculty assessments. However, women trainees rated themselves significantly lower than men for both autonomy (OR, 0.57; 95% CI, 0.43-0.74) and performance (OR, 0.40; 95% CI, 0.30-0.54)., Conclusions: Although gender was not associated with differences in faculty assessment of performance or autonomy among vascular surgery trainees, women trainees perceive themselves as performing with lower competency and less autonomy than their male colleagues. These findings suggest utility for exploring gender differences in real-time feedback delivered to and received by trainees and targeted interventions to align trainee self-perception with actual operative performance and autonomy to optimize surgical skill acquisition., Competing Interests: Disclosures M.L.W. is a consultant for W. L Gore & Associates., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The limited availability of academic surgery positions has led to increased competition for these jobs. Integrated vascular surgery residency (IVSR) allows for earlier specialization, with some programs providing professional development time (PDT). We hypothesized that IVSR and PDT lead to academic employment and increased research productivity., Design: This is a retrospective study of vascular surgery fellowship (VSF) and IVSR graduates., Setting: Training, number of publications, H-index, NIH funding, and employment history were collected using institutional websites, Doximity, Scopus, PubMed, and NIH Research Portfolio Reporting., Participants: After a review of the research protocol, the Association of Program Directors in Vascular Surgery (APDVS) provided a list of vascular surgery fellowship (VSF) and IVSR graduates., Methods: After review of the research protocol, the Association of Program Directors in Vascular Surgery (APDVS) provided a list of vascular surgery fellowship (VSF) and IVSR graduates. Training, number of publications, H-index, NIH funding, and employment history were collected using institutional websites, Doximity, Scopus, PubMed, and NIH Research Portfolio Reporting., Results: From 2013-2017, comparison of IVSR (n=131) to VSF (n=603) graduates showed that IVSR graduates were more likely to be women (38.17% vs 28.19%; p = 0.024), be MD graduates (99.24% vs 93.37%; p = 0.008), attended programs in the northeast (41.98% vs 27.5%; p < 0.001), have advanced degrees (13.74% vs 6.97%; p = 0.01) and graduate from larger programs (median 15 vs 14 faculty; p = 0.013). There was no significant difference in number of publications per trainee by the end of training (median 4 vs 3; P=0.61) or annual trend in average number of publications. After training, there was no significant difference in the type of practice, academic affiliation, practice region, publication number, H-index, NIH funding, level of academic appointment, or leadership positions. From 2013-2019, a comparison of IVSR graduates with (n=32) and without PDT (n=190) demonstrated that those with PDT were more likely to be women (53.13% vs 34.74%; p = 0.038), have advanced degrees (28.12% vs 8.95%; p = 0.002), be at larger programs (median 14 vs 9 faculty; p < 0.001), train at a top 10 NIH funded program (65.62% vs 21.58%; p < 0.001) and publish more by the end of IVSR (median 9 vs 3; p < 0.001). Graduates with PDT were more likely to have academic employment and affiliation, a higher yearly publication rate, and greater H-index., Conclusion: IVSR and VSF graduates have comparable academic employment and research productivity. However, PDT during IVSR correlates with an eventual academic career and greater research productivity. This study supports the importance of PDT in developing academic vascular surgeons. It remains necessary to continue both IVSR and VSF training paradigms as healthcare needs of the population are met through both academic and non-academic surgeons., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Several studies have explored factors affecting academic employment in surgical subspecialties; however, vascular surgery has not yet been investigated. We examined which elements of surgical training predict future academic productivity and studied characteristics of NIH-funded vascular surgery attendings., Methods: With approval from the Association of Program Directors in Vascular Surgery (APDVS), the database of recent vascular surgery fellowship (VSF) and integrated vascular surgery residency (IVSR) graduates was obtained, and public resources (Doximity, Scopus, PubMed, NIH, etc.) were queried for research output during and after training, completion of dedicated research years, individual and program NIH funding, current practice setting, and academic rank. Adjusted multivariate regression analyses were conducted for postgraduate academic productivity., Results: From 2013 to 2017, there were 734 graduates. Six hundred three completed VSF and 131 IVSR; 220 (29%) were female. Academic employment was predicted by MD degree, advanced degree, training at a top NIH-funded program, number publications by end of training, and H-index. Dedicated research time before or during vascular training, advanced degree, or graduating from a top NIH-funded program were predictors of publishing >1 paper/year. Number of publications by end of training and years in practice were predictive of H-index ≥5. VSF versus IVSR pathway did not have an impact on future academic employment, annual publication rate as an attending, or H-index. Characterization of NIH-funded attendings showed that they often completed dedicated research time (72%) and trained at a top NIH-funded program (79%). Mean publications by graduation among this group was 15.82 ± 11.3, and they averaged 4.31 ± 4.2 publications/year as attendings., Conclusions: Research output during training, advanced degrees, and training at a top NIH-funded program predict an academic vascular surgery career. VSF and IVSR constitute equally valid paths to productive academic careers., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: As medical education systems increasingly move toward competency-based training, it is important to understand the tools available to assess competency and how these tools are utilized. The Society for Improving Medical Professional Learning (SIMPL) offers a smart phone-based assessment system that supports workplace-based assessment of residents' and fellows' operative autonomy, performance, and case complexity. The purpose of this study was to characterize implementation of the SIMPL app within vascular surgery integrated residency (0+5) and fellowship (5+2) training programs., Methods: SIMPL operative ratings recorded between 2018 and 2022 were collected from all participating vascular surgery training institutions (n = 9 institutions with 5+2 and 0+5 programs; n = 4 institutions with 5+2 program only). The characteristics of programs, trainees, faculty, and SIMPL operative assessments were evaluated using descriptive statistics., Results: Operative assessments were completed for 2457 cases by 85 attendings and 86 trainees, totaling 4615 unique operative assessment ratings. Attendings included dictated feedback in 52% of assessments. Senior-level residents received more assessments than junior-level residents (postgraduate year [PGY]1-3, n = 439; PGY4-5, n = 551). Performance ratings demonstrated increases from junior to senior trainees for both resident and fellow cohorts with "performance-ready" or "exceptional performance" ratings increasing by nearly two-fold for PGY1 to PGY5 residents (28.1% vs 40.6%), and from first- to second-year fellows (PGY6, 46.7%; PGY7, 60.3%). Similar gains in autonomy were demonstrated as trainees progressed through training. Senior residents were more frequently granted autonomy with "supervision only" than junior residents (PGY1, 8.7%; PGY5, 21.6%). "Supervision only" autonomy ratings were granted to 21.8% of graduating fellows. Assessment data included a greater proportion of complex cases for senior compared with junior fellows (PGY6, 20.9% vs PGY7, 26.5%). Program Directors felt that faculty and trainee buy-in were the main barriers to implementation of the SIMPL assessment app., Conclusions: This is the first description of the SIMPL app as an operative assessment tool within vascular surgery that has been successfully implemented in both residency and fellowship programs. The assessment data demonstrates expected progressive gains in trainees' autonomy and performance, as well as increasing case complexity, across PGY years. Given the selection of SIMPL as the assessment platform for required American Board of Surgery and Vascular Surgery Board Entrustable Professional Activities assessments, understanding facilitators and barriers to implementation of workplace-based assessments using this app is imperative, particularly as we move toward competency-based medical education., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Ticks and tick-borne diseases represent major threats to the public health of the Mongolian population, of which an estimated 26% live a traditional nomadic pastoralist lifestyle that puts them at increased risk for exposure. Ticks were collected by dragging and removal from livestock in Khentii, Selenge, Tuv, and Umnugovi aimags (provinces) during March-May 2020. Using next-generation sequencing (NGS) with confirmatory PCR and DNA sequencing, we sought to characterize the microbial species present in Dermacentor nuttalli (n = 98), Hyalomma asiaticum (n = 38), and Ixodes persulcatus (n = 72) tick pools. Rickettsia spp. were detected in 90.4% of tick pools, with Khentii, Selenge, and Tuv tick pools all having 100% pool positivity. Coxiella spp. were detected at an overall pool positivity rate of 60%, while Francisella spp. were detected in 20% of pools and Borrelia spp. detected in 13% of pools. Additional confirmatory testing for Rickettsia-positive pools demonstrated Rickettsia raoultii (n = 105), Candidatus Rickettsia tarasevichiae (n = 65) and R. slovaca/R. sibirica (n = 2), as well as the first report of Candidatus Rickettsia jingxinensis (n = 1) in Mongolia. For Coxiella spp. reads, most samples were identified as a Coxiella endosymbiont (n = 117), although Coxiella burnetii was detected in eight pools collected in Umnugovi. Borrelia species that were identified include Borrelia burgdorferi sensu lato (n = 3), B. garinii (n = 2), B. miyamotoi (n = 16), and B. afzelii (n = 3). All Francisella spp. reads were identified as Francisella endosymbiont species. Our findings emphasize the utility of NGS to provide baseline data across multiple tick-borne pathogen groups, which in turn can be used to inform health policy, determine regions for expanded surveillance, and guide risk mitigation strategies., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2023 The Author(s). Published by Elsevier GmbH.. All rights reserved.)

United States Medical Licensing Examination® (USMLE®) STEP 1 score reporting has been changed to a binary pass/fail format since January 26, 2022. The motives behind this change were (1) the questionable validity of using USMLE STEP 1 as a screening tool during the candidate selection process and (2) the negative impact of using standardized examination scores as an initial gatekeeping threshold for the underrepresented in medicine (URiM) candidates applying to graduate medical education programs, given their generally lower mean standardized exams scores compared to non-URiM students. The USMLE administrators justified this change as a tactic to enhance the overall educational experience for all students and to increase the representation of URiM groups. Moreover, they advised the program directors (PDs) to give more attention to other important qualities and components such as the applicant's personality traits, leadership roles and other extracurricular accomplishments, as part of a holistic evaluation strategy. At this early stage, it is unclear how this change will impact Vascular Surgery Integrated residency (VSIR) programs. Several questions are outstanding, most importantly, how VSIR PDs will evaluate applicants absent the variable which heretofore was the primary screening tool. Our previously published survey showed that VSIR PDs will move their attention to other measures such as USMLE STEP 2 Clinical Knowledge (CK) and letters of recommendation during the VSIR selection process. Furthermore, more emphasis on subjective measures such as the applicant's medical school rank and extracurricular student activities is expected. Given the expected higher weight of USMLE STEP 2CK in the selection process than ever, many anticipate that medical students will dedicate more of their limited time to its preparation at the expense of both clinical and nonclinical activities. Potentially leaving less time to explore specialty pathways and to determine whether Vascular Surgeons  is the appropriate career for them. The critical juncture in the VSIR candidate evaluation paradigm presents an opportunity to thoughtfully transform the process via current (Standardized Letter of Recommendation, USMLE STEP 2CK, and clinical research) and future (Emotional Intelligence, Structure Interview and Personality Assessment) measures which constitute a framework to follow in the USMLE STEP 1 pass/fail era., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: In order to effectively create and implement an educational program to improve opioid prescribing practices, it is important to first consider the unique perspectives of residents on the frontlines of the opioid epidemic. We sought to better understand resident perspectives on opioid prescribing, current practices in pain management, and opioid education as a needs assessment for designing future educational interventions., Design: This is a qualitative study using focus groups of surgical residents at 4 different institutions., Setting: We conducted focus groups using a semistructured interview guide in person or over video conferencing. The residency programs selected for participation represent a broad geographic range and varying residency sizes., Participants: We used purposeful sampling to recruit general surgery residents from the University of Utah, University of Wisconsin, Dartmouth-Hitchcock Medical Center, and the University of Alabama at Birmingham. All general surgery residents at these locations were eligible for inclusion. Participants were assigned to focus groups by residency site and their status as junior (PGY-2, PGY-3) or senior resident (PGY-4, PGY-5)., Results: We completed 8 focus groups with a total of 35 residents included. We identified 4 main themes. First, residents relied on clinical and nonclinical factors when making decisions about opioid prescribing. However, hidden curricula based on unique institutional cultures and attending preferences heavily influenced residents' prescribing practices. Second, residents acknowledged that stigma and biases towards certain patient groups influenced opioid prescribing practices. Third, residents encountered barriers within their health systems to evidence-based opioid prescribing. Fourth, residents did not routinely receive formal education on pain management or opioid prescribing. Residents recommended several interventions to improve the current state of opioid prescribing, including standardized prescribing guidelines, improved patient education, and formal training during the first year of residency., Conclusions: Our study highlighted several areas of opioid prescribing that can be improved upon through educational interventions. These findings can be used to develop programs aimed at improving residents' opioid prescribing practices, both during and after training, and ultimately the safe care of surgical patients., Ethics Statement: This project was approved by the University of Utah Institutional Review Board, ID # 00118491. All participants provided written informed consent., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

The use of a robotic surgical platform has become common place in thoracic surgery programs throughout the United States. Formal training paradigms need to be reevaluated to allow for effective and efficient training of thoracic surgery residents and fellows. The utilization of video-based coaching and simulation are effective adjuncts in robotics training., Competing Interests: Disclosure B. Mitzman—Proctor, Intuitive Surgical., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Program directors in surgical disciplines need more tools from the ACGME to help them use Milestone ratings to improve trainees' performance. This is especially true in competencies that are notoriously difficult to measure, such as professionalism (PROF) and interpersonal and communication skills (ICS). It is now widely understood that skills in these two areas have direct impact on patient care outcomes. This study investigated the potential for generating early predictors of final Milestone ratings within the PROF and ICS competency categories., Design: This retrospective cohort study utilized Milestone ratings from all ACGME-accredited vascular surgery training programs, covering residents and fellows who completed training in June 2019. The outcome measure studied was the rate of achieving the recommended graduation target of Milestone Level 4 (possible range: 1-5), while the predictors were the Milestone ratings attained at earlier stages of training. Predictive probability values (PPVs) were calculated for each of the 3 PROF and two ICS sub-competencies to estimate the probability of trainees not reaching the recommended graduation target based on their previous Milestone ratings., Setting: All ACGME-accredited vascular surgery training programs within the United States., Participants: All trainees completing a 2 year vascular surgery fellowship (VSF) in June 2019 (n = 119) or a 5 year integrated vascular surgery residency (IVSR) in June 2019 (n = 52) were included in the analyses., Results: The overall rate of failing to achieve the recommended graduation target across all PROF and ICS sub-competencies ranged from 7.7% to 21.8% of all trainees. For trainees with a Milestone rating at ≤ 2.5 with 1 year remaining in their training program, the predictive probability of not achieving the recommended graduation target ranged from 37.0% to 71.5% across sub-competencies, with the highest risks observed under PROF for "Administrative Tasks" (71.5%) and under ICS for "Communication with the Healthcare Team" (56.7%)., Conclusions: As many as 1 in 4 vascular surgery trainees did not achieve the ACGME vascular surgery Milestones targets for graduation in at least one of the PROF and ICS sub-competencies. Biannual ACGME Milestone assessment ratings of PROF and ICS during early training can be used to predict achievement of competency targets at time of graduation. Early clues to problems in PROF and ICS enable programs to address potential deficits early in training to ensure competency in these essential non-technical skills prior to entering unsupervised practice., (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Frailty is a clinical syndrome associated with slow recovery after vascular surgery. However, the degree and length of functional impairment frail patients experience after surgery is unclear. The objective of this study was to prospectively measure changes in functional status among frail and non-frail patients undergoing a spectrum of different vascular surgery procedures., Methods: Patients consented to undergo elective minor and major vascular surgery procedures at an academic medical center between May 2018 and March 2019 were prospectively identified. Prior to surgery, all patients underwent provider assessment of frailty using the validated Clinical Frailty Scale (CFS), as well as baseline assessment of functional status using the Katz Activities of Daily Living (ADL) index and the Lawton Instrumental Activities of Daily Living (iADL) index. These same instruments were used to evaluate each patient's functional status at 2-weeks, 1-month, 1-year, and 2-year time points following surgery. Changes in iADL and ADL scores among frail (CFS ≥5) and non-frail patients were compared using paired Wilcoxon signed-rank tests and logistic regression models., Results: A total of 126 patients were assessed before and after minor (55%) and major (45%) vascular procedures, of which 43 patients (34%) were determined to be frail prior to surgery. Frail patients were older and more likely than non-frail patients to have medical comorbidities including chronic kidney disease, chronic obstructive pulmonary disease, or diabetes (all P < .05). When compared with the non-frail cohort, frail patients had significantly lower ADL and iADL scores before surgery and experienced a greater decline in ability to independently complete ADL and iADL activities after surgery that was sustained at 2 years (P < .05 and P < .001, respectively). After risk-adjustment, frailty was associated with an increased likelihood of decline in ADLs (odds ratio, 5.4; 95% confidence interval, 1.9-15.4; P < .05) and iADLs (odds ratio, 6.3; 95% confidence interval, 2.6-15.1; P < .001) at 2 years following surgery., Conclusions: Frail patients experience a significant decline in ability to perform ADL and iADLs that persists 2 years following vascular surgery. These data highlight the degree of functional decline occurring immediately following surgery, as well as risk for long-term, sustained impairment that should be shared with frail patients before undergoing a procedure., (Published by Elsevier Inc.)

Objective: Statins are considered standard-of-care medical therapy for patients undergoing lower extremity bypass (LEB) procedures for chronic limb-threatening ischemia (CLTI). It is unclear, however, whether up-titrating and maintaining patients on higher-intensity statin medications following LEB improves limb salvage outcomes. This study was designed to evaluate whether high-intensity statin therapy impacts the risk of amputation and reintervention following LEB for patients with CLTI., Methods: The IBM MarketScan database was used to identify adult patients (18-99 years old) who underwent a LEB for CLTI between 2008 and 2017. Patients lacking insurance covering drug reimbursement or those who already had undergone amputation before time of bypass were excluded. Using pharmacy claims and national drug codes to define statin intensity, patients were stratified into three groups: high-intensity, low-intensity, and limited statin therapy. The association between intensity of statin therapy and need for reintervention and/or major amputation after LEB was analyzed using Kaplan-Meier curves and risk-adjusted Cox proportional hazard models., Results: A total of 25,907 patients who underwent LEB for CLTI were identified, of which 6696 (26%) were maintained on high-dose statins, 9297 (36%) were on low-dose statins, and 9914 (38%) had inconsistent pharmacy claims for statin therapy after surgery. Patients on high-intensity statins were, on average, younger and more likely to be male with comorbid disease (diabetes, hypertension, hyperlipidemia, obesity, renal insufficiency, ischemic heart disease, cerebrovascular disease, and tobacco abuse) than patients on low-intensity statins or limited statin therapy (P < .001 for all comparisons). Following LEB, 6649 patients (25.6%) required a reintervention, and 2550 patients (9.8%) went on to have a major amputation during follow-up. Patients maintained on high-intensity statins after LEB had a significantly lower likelihood of requiring a reintervention (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.45-0.51; P < .001) or amputation (HR, 0.27; 95% CI, 0.24-0.30; P < .001) as compared with patients on limited statin therapy. Further, there was a dose-dependent effect for these outcomes relative to patients on low-intensity statins in risk-adjusted models, and it was independent of whether an autologous vein graft was used for the LEB. Finally, among patients who underwent a reintervention, high-dose statin therapy also significantly reduced the HR for subsequent amputation (HR, 0.21; 95% CI, 0.18-0.25; P < .001)., Conclusions: Patients with CLTI on high-intensity therapy following LEB had a significantly lower risk of requiring subsequent reintervention and amputation when compared with patients on low-intensity statins or with limited statin use. These data suggest that patients with CLTI should be up-titrated and/or maintained on high-intensity statins following revascularization whenever possible., (Published by Elsevier Inc.)

Objectives: Vascular surgery integrated residency (VSIR) programs are highly competitive; however, criteria for resident selection remain opaque and non-standardized. The already unclear selection criteria will be further impacted by the impending transition of the United States Medical Licensing Examination (USMLE) Step 1 from numeric scores to a binary pass/fail outcome. The purpose of this study was to investigate the historical and anticipated selection criteria of VSIR applicants., Methods: This was a cross-sectional, nationwide, 59-item survey that was sent to all VSIR program directors (PDs). Data was analyzed using the Fisher exact test if categorical and the Mann-Whitney U test and the Kruskal-Wallis test if ordinal., Results: Forty of 69 PDs (58%) responded to the survey. University-based programs constituted 85% of responders. Most VSIR PDs (65%) reported reviewing between 101 to 150 applications for 1 to 2 positions annually. Forty-two percent of the responding PDs reported sole responsibility for inviting applicants to interview, whereas 50% had a team of faculty responsible for reviewing applications. On a five-point Likert scale, letters of recommendation (LOR) from vascular surgeons or colleagues (a person the PD knows) were the most important objective criteria. Work within a team structure was rated highest among subjective criteria. The majority of respondents (72%) currently use the Step 1 score as a primary method to screen applicants. Regional differences in use of Step 1 score as a primary screening method were: Midwest (100%), Northeast (76%), South (43%), and West (40%) (P = .01). PDs responded that that they will use USMLE Step 2 score (42%) and LOR (10%) to replace USMLE Step 1 score. The current top ranked selection criteria are letters from a vascular surgeon, USMLE Step 1 score and overall LOR. The proposed top ranked selection criteria after transition of USMLE Step 1 to pass/fail include LOR overall followed by Step 2 score., Conclusions: This is the first study to evaluate the selection criteria used by PDs for VSIR. The landscape of VSIR selection criteria is shifting and increasing transparency is essential to applicants' understanding of the selection process. The transition of USMLE Step 1 to a pass/fail report will shift the attention to Step 2 scores and elevate the importance of other relatively more subjective criteria. Defining VSIR program selection criteria is an important first step toward establishing holistic review processes that are transparent and equitable., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The quality and effectiveness of vascular surgery education should be evaluated based on patient care outcomes. To investigate predictive associations between trainee performance and subsequent patient outcomes, a critical first step is to determine the conceptual alignment of educational competencies with clinical outcomes in practice. We sought to generate expert consensus on the conceptual alignment of the Accreditation Council for Graduate Medical Education (ACGME) Vascular Surgery subcompetencies with patient care outcomes across different Vascular Quality Initiative (VQI) registries., Methods: A national panel of vascular surgeons with expertise in both clinical care and education were recruited to participate in a modified Delphi expert consensus building process to map ACGME Vascular Surgery subcompetencies (educational markers of resident performance) to VQI clinical modules (patient outcomes). A master list of items for rating was created, including the 31 ACGME Vascular Surgery subcompetencies and 8 VQI clinical registries (endovascular abdominal aortic aneurysm repair, open abdominal aortic aneurysm, thoracic endovascular aortic repair, carotid endarterectomy, carotid artery stent, infrainguinal, suprainguinal, and peripheral vascular intervention). These items were entered into an iterative Delphi process. Positive consensus was reached when 75% or more of the participants ranked an item as mandatory. Intraclass correlations (ICCs) were used to evaluate consistency between experts for each Delphi round., Results: A total of 13 experts who contributed to the development of the Vascular Surgery Milestones participated; 12 experts (92%) participated in both rounds of the Delphi process. Two rounds of Delphi were conducted, as suggested by excellent expert agreement (round 1, ICC = 0.79 [95% confidence interval, 0.74-0.84]; round 2, ICC = 0.97 [95% confidence interval, 0.960-.98]). Using the predetermined consensus cutoff threshold, the Delphi process reduced the number of subcompetencies mapped to patient care outcomes from 31 to a range of 9 to 15 across the 8 VQI clinical registries. Practice-based learning and improvement, and professionalism subcompetencies were identified as less relevant to patient outcome variables captured by the VQI registries after the final round, and the only the systems-based practice subcompetency that was identified as relevant was radiation safety in two of the endovascular registries., Conclusions: A national panel of vascular surgeon experts reported a high degree of agreement on the relevance of ACGME subcompetencies to patient care outcomes as captured in the VQI clinical registry. Systems-based practice, practice-based learning and improvement, and professionalism competencies were identified as less relevant to patient outcomes after specific surgical procedures., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Psychological safety is known to improve team performance and organizational learning. The related concept of "educational safety" has recently emerged to describe an environment in which learners can unreservedly focus on learning and professional growth, without worrying about the potential repercussions of interpersonal risk-taking. Educational safety is crucial for optimal learning in clinical environments, and yet is difficult to establish due to constant performance assessment, fear of failure, and pervasive hierarchies. In this perspective, we propose a framework for conceptualizing educational safety in surgical learning environments, and explore current threats to educational safety. We also discuss strategies for combating these threats, as well as the importance of further research to evaluate the impact of educational safety on surgical learning outcomes., (Published by Elsevier Inc.)

Background: Vascular surgery is facing an impending workforce shortage as the population ages and the demand for vascular surgical services increases. The integrated vascular surgery residency (0+5) paradigm is well-established and provides a mechanism to increase the number of board-certified vascular surgeons. Recruitment of medical students to these programs has proven challenging with unfilled positions in each of the past 2 years. The aim of this study is to explore factors that influence medical students' interest in vascular surgery and their decision to ultimately pursue a career in the field., Methods: Medical students listed on the Society for Vascular Surgery "Find a VSIG (Vascular Surgery Interest Group)" webpage were contacted via email to participate in the study. A snowball sampling technique was employed to recruit additional participants, including recent medical school graduates who had matched into a 0+5 program. Fifteen students participated in 5 focus groups. Directed content analysis was employed to qualitatively analyze focus group transcripts., Results: Five domains were identified as influencing students' decision to pursue vascular surgery. Experiential learning facilitated early exploration of the field. The intellectuality of the specialty was a feature that attracted students to vascular surgery. In addition, the professional identify of vascular surgeons as comprehensive care providers was appealing. Students identified with their mentors' relationships as observed during clinical encounters. Long-term mentorship was important in sustaining students' interest., Conclusion: Medical students pursue a career in vascular surgery based on early exposure to the specialty, experiential learning through hands-on VSIG events, clinical experiences, and longitudinal faculty mentorship. The unique aspects of the specialty, including professional identity and intellectuality, should be highlighted to both attract and maintain students' interest in the field. These findings can be used by national vascular surgery leaders, practicing vascular surgeons, and faculty and student leadership of VSIGs to optimize recruitment programs and increase the vascular surgery workforce., (Copyright © 2021. Published by Elsevier Inc.)

Objective: To assess the current barriers in robotic surgery training for general surgery residents., Design: Multi-institutional web-based survey., Setting: 9 academic medical centers with a general surgery residency., Participants: General surgery residents of at least PGY-3 training level., Results: 163 general surgery residents were contacted with 80 responses (49.1%). The most common responders were PGY-3s (38.8%) followed by PGY-5s (27.5%). The Northeast represented 42.5% of responses. Colorectal cases were the most common robotic case residents were involved in (51.3%). Residents' typical roles were assisting at the bedside (31.3%) and splitting time between assisting at the bedside and operating at the surgeon console (31.3%). 43% report to be either extremely or somewhat dissatisfied with their robotic surgery experience. 62.5% report they do not intend to integrate robotic surgery into their future practice. 93.8% of residents have a standardized robotic curriculum. 47.5% report using the simulator only during required didactic time with 52.5% having the robotic simulator conveniently located. The majority of residents report that the presence of dual consoles and first-assists in robotic cases enhance their robotic training (93% - 62%, respectively). 72.5% felt like they had more autonomy during laparoscopic cases and 96.8% of residents felt that an attendings' lack of experience impacted their time operating at the surgeon console., Conclusions: General surgery residents report lack of effective OR teaching, real clinical experience, and simulated experience as main barriers in their robotic surgery training. Dual consoles and first-assistants are favorably looked upon. Lack of attending experience and comfort were universally negatively associated with resident participation. For residents interested in robotic surgery, advocating for more robust investment in dual consoles, first-assistants, and faculty development would likely improve their robotic surgery training experience. However, residency programs should consider whether robotic surgery should be a core competency of an already time restricted training paradigm., (Copyright © 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Expiratory muscle weakness and impaired airway clearance are early signs of respiratory dysfunction in Duchenne muscular dystrophy (DMD), a degenerative muscle disorder in which muscle cells are damaged and replaced by fibrofatty tissue. Little is known about expiratory muscle pathology and its relationship to cough and airway clearance capacity; however, the level of muscle replacement by fat can be estimated using MRI and expressed as a fat fraction (FF)., Research Question: How does abdominal expiratory muscle fatty infiltration change over time in DMD and relate to clinical expiratory function?, Study Design and Methods: Individuals with DMD underwent longitudinal MRI of the abdomen to determine FF in the internal oblique, external oblique, and rectus abdominis expiratory muscles. FF data were used to estimate a model of expiratory muscle degeneration by using nonlinear mixed effects and a cumulative distribution function. FVC, maximal inspiratory and expiratory pressures, and peak cough flow were collected as clinical correlates to MRI., Results: Forty individuals with DMD (aged 6-18 years at baseline) participated in up to five visits over 36 months. Modeling estimated the internal oblique progresses most quickly and reached 50% replacement by fat at a mean patient age of 13.0 years (external oblique, 14.0 years; rectus abdominis, 16.2 years). Corticosteroid-untreated individuals (n = 4) reached 50% muscle replacement by fat 3 to 4 years prior to treated individuals. Individuals with mild clinical dystrophic phenotypes (n = 3) reached 50% muscle replacement by fat 4 to 5 years later than corticosteroid-treated individuals. Internal and external oblique FFs near 50% were associated with maximal expiratory pressures < 60 cm H 2 O and peak cough flows < 270 L/min., Interpretation: These data improve understanding of the early phase of respiratory compromise in DMD, which typically presents as airway clearance dysfunction prior to the onset of hypoventilation, and links expiratory muscle fatty infiltration to pulmonary function measures., (Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Objectives: The COVID-19 pandemic resulted in the cancellation of in-person testing across the country. We sought to understand the feasibility of conducting virtual oral examinations as well as solicit opinions of vascular surgery program directors (PD) regarding the use of virtual platforms to conduct both low stakes mock oral examinations with their trainees and potentially "real" high stakes certifying examinations (CE) moving forward., Methods: Forty-four senior vascular surgery trainees from 17 institutions took part in a virtual mock oral examination conducted by 38 practicing vascular surgeons via Zoom. Each examination lasted 30 minutes with four clinical scenarios. An anonymous survey pertaining to the conduct of the examination and opinions on feasibility of using virtual examinations for the vascular surgery CE was sent to all examiners and examinees. A similar survey was sent to all vascular surgery program directors., Results: The overall pass rate was 82% (36/44 participants) with no correlation with training paradigm. 32/44 (73%) of trainees, 29/38 (76%) of examiners and 49/103 (48%) of PDs completed the surveys. Examinees and examiners thought the experience was beneficial and PDs also thought the experience would be beneficial for their trainees. While the majority of trainees and examiners believed they were able to communicate and express (or evaluate) knowledge and confidence as easily virtually as in person, PDs were less likely to agree confidence could be assessed virtually. The majority of respondents thought the CE of the Vascular Surgery Board of the American Board of Surgery could be offered virtually, although no groups thought virtual exams were superior to in person exams. While cost benefit was perceived in virtual examinations, the security of the examination was a concern., Conclusions: Performing virtual mock oral examinations for vascular surgery trainees is feasible. Both vascular surgery trainees as well as PDs feel that virtual CEs should be considered by the Vascular Surgery Board., Competing Interests: Conflict of Interests The authors have no competing interests to declare, (Copyright © 2021. Published by Elsevier Inc.)

Background: Surgeons provide patient care in complex health care systems and must be able to participate in improving both personal performance and the performance of the system. The Accreditation Council for Graduate Medical Education (ACGME) Vascular Surgery Milestones are utilized to assess vascular surgery fellows' (VSF) achievement of graduation targets in the competencies of Systems Based Practice (SBP) and Practice Based Learning and Improvement (PBLI). We investigate the predictive value of semiannual milestones ratings for final achievement within these competencies at the time of graduation., Methods: National ACGME milestones data were utilized for analysis. All trainees entering the 2-year vascular surgery fellowship programs in July 2016 were included in the analysis (n = 122). Predictive probability values (PPVs) were obtained for each SBP and PBLI sub-competencies by biannual review periods, to estimate the probability of VSFs not reaching the recommended graduation target based on their previous milestones ratings., Results: The rate of nonachievement of the graduation target level 4.0 on the SBP and PBLI sub-competencies at the time of graduation for VSFs was 13.1-25.4%. At the first time point of assessment, 6 months into the fellowship program, the PPV of the SBP and PBLI milestones for nonachievement of level 4.0 upon graduation ranged from 16.3-60.2%. Six months prior to graduation, the PPVs across the 6 sub-competencies ranged from 14.6-82.9%., Conclusions: A significant percentage of VSFs do not achieve the ACGME Vascular Surgery Milestone targets for graduation in the competencies of SBP and PBLI, suggesting a need to improve curricula and assessment strategies in these domains across vascular surgery fellowship programs. Reported milestones levels across all time point are predictive of ultimate achievement upon graduation and should be utilized to provide targeted feedback and individualized learning plans to ensure graduates are prepared to engage in personal and health care system improvement once in unsupervised practice., (Copyright © 2021. Published by Elsevier Inc.)

Objective: The coronavirus disease 2019 (COVID-19) pandemic has resulted in a marked increase in hospital usage, medical resource scarcity, and rationing of surgical procedures. This has created the need for strategies to triage surgical patients. We have described our experience using the American College of Surgeons (ACS) COVID-19 guidelines for triage of vascular surgery patients in an academic surgery practice., Methods: We used the ACS guidelines as a framework to direct the triage of vascular surgery patients during the COVID-19 pandemic. We retrospectively analyzed the results of this triage during the first month of surgical restriction at our hospital. Patients undergoing surgery were identified by reviewing the operating room schedule. We reviewed the electronic medical records (EMRs) and assigned an ACS category, condition, and tier class to each completed surgery. Surgeries that were postponed during the same period were identified from a prospectively maintained list. We reviewed the EMRs for all postponed surgeries and assigned an ACS category, condition, and tier class to each surgery. We reviewed the EMRs for all postponed procedures to identify any adverse events related to the treatment delay., Results: We performed 69 surgeries in 52 patients during the study period. All surgeries were performed to treat emergent, urgent, or time-sensitive elective diagnoses. Of the 69 surgeries, 47 (68%) were from tier 3 and 22 (32%) from tier 2b. We did not perform any surgeries from tier 1 or 2a. We postponed surgery for 66 patients during the same period, of which 36 (55%) were from tier 1, 22 (33%) from tier 2a, 5 (8%) from tier 2b, and 3 (5%) could not be assigned a tier class. No tier 3 surgeries were postponed. Of the 66 patients, 3 (4.5%) experienced an adverse event that could be attributed to the treatment delay., Conclusions: The ACS triage guidelines provided an effective method to decrease vascular surgical volumes during the COVID-19 pandemic without an increase in patient morbidity. We believe the clinical utility of the guidelines would be strengthened by incorporating the SURGCON/VASCCON (surgical activity condition/vascular activity condition) threat level alert system., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Frailty is a syndrome where the ability to cope with acute physiological stress is compromised, although it is unclear what impact this stress has on long-term outcomes. Vascular-Physiological and Operative Severity Score for enumeration of Mortality and Morbidity is a validated method for calculating levels of stress associated with vascular procedures. We designed this study to evaluate the long-term impact of different levels of surgical stress among frail older patients undergoing vascular surgery procedures., Methods: We identified all independently living patients who underwent prospective frailty assessment followed by an elective vascular surgery procedure captured in the Vascular Quality Initiative registry (endovascular abdominal aortic aneurysm [AAA] repair, thoracic endovascular aortic repair, suprainguinal and infrainguinal bypass, peripheral vascular intervention, carotid endarterectomy, and open AAA) at an academic institution between January 2016 and July 2018. Patient- and procedure-level data were obtained from our institutional data warehouse and Vascular Quality Initiative database, and used to calculate Vascular-Physiological and Operative Severity Score for enumeration of Mortality and Morbidity scores. The association between frailty and composite outcome of any major complications (surgical site infection; graft thrombectomy; major amputation; adverse cardiac, pulmonary, or neurologic event; acute renal insufficiency; and/or reoperation related to the index procedure), nonhome living status, or death within 1 year after low-, medium-, and high-stress vascular procedures was evaluated using bivariate and logistic regression models., Results: A total of 163 patients were identified (70% male, mean age 67.8 years) who underwent open AAA repair (6%), endovascular AAA repair (21%), thoracic endovascular aortic repair (7%), suprainguinal bypass (5%), infrainguinal bypass (18%), carotid endarterectomy (18%), or peripheral vascular interventions (25%), which included 44 (27%) patients diagnosed with frailty before surgery. Overall, frail patients had significantly higher rates of the 1-year composite outcome (48% frail versus 27% nonfrail; P = 0.012) when compared with nonfrail patients, with a significant dose-dependent effect as the level of stress increased. In comparison, increasing levels of surgical stress had a negligible effect on long-term outcomes among nonfrail patients. The interaction between frailty and high surgical stress was found in adjusted regression models to be a significant predictor of adverse outcomes within 1 year after vascular surgery (odds ratio, 3.3; 95% confidence interval, 1.3-8.6; P < 0.01)., Conclusions: Frail patients who undergo high-stress vascular procedures have a significantly higher rate of complications leading to loss of functional independence and mortality within the year after their surgery. These data suggest that estimates of surgical stress should be incorporated into clinical decision making for frail older patients before and after surgery., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Over one third of general surgery residents interrupt their clinical training to pursue dedicated research time (DRT), which has financial implications for programs and residents. Studies have examined the impact of DRT on academic outcomes, but little is known about why residents pursue DRT. Therefore, this study aimed to examine resident motivations regarding DRT in order to gain an understanding of resident goals and challenges surrounding this phase of training., Design: Surgical residents currently participating in DRT and residents considering completing DRT were recruited to participate. Members of the research team at each institution conducted interviews and focus groups, which were recorded and transcribed. Data was analyzed using the qualitative method of open and focused coding. Identified themes guided the development of a conceptual framework., Setting: Interviews and focus groups were held at three geographically diverse US academic health centers., Participants: Twenty-one surgery residents participated., Results: Reasons for pursuing DRT fell into 1 of 3 themes: strategic career planning, professional development, and personal rejuvenation. Residents described the perceived need for publications or networking to enhance future competitiveness for desired fellowships or academic appointments. Residents also expressed the desire to have time for career exploration and to cultivate mentorship for their professional career. The need to take time off for more personal reasons, including burnout, was pervasive. Additionally, many in DRT felt under-supported in developing their research skills and expressed a desire for more formal instruction and guidance from mentors., Conclusions: General surgery residents' motivations to pursue DRT are multifactorial. Professional development is a pervasive motivation and includes learning skills that can be applied to future research. Current DRT programs may be inadequate in supporting residents to achieve this goal. These results can be used to inform programmatic efforts to optimize DRT for residents and mentors alike., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: During the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns, and outcomes of these vascular access teams during the COVID-19 pandemic., Methods: We conducted a cross-sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. To participate in the study, hospitals were required to meet one of the following criteria: development of a formal plan for a central venous access line team during the pandemic; implementation of a central venous access line team during the pandemic; placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice; or management of an iatrogenic complication related to central venous access in a patient with COVID-19., Results: Participants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis (Santa Clara, Calif) catheters, and nontunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience in placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of the hospitals. Less than 50% (24 [41%]) of the participating sites reported managing thrombosed central lines in COVID-19 patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group)., Conclusions: Implementation of a dedicated central venous access line team during a pandemic or other health care crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed health care system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained intensive care unit, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future health care crises., (Copyright © 2020 Society for Vascular Surgery. All rights reserved.)

Background: Integrated vascular surgery residency, or "0+5," programs provide education in the Accreditation Council for Graduate Medical Education (ACGME) competencies of Systems-Based Practice (SBP) and Practice-Based Learning and Improvement (PBLI), which include milestones related to quality improvement (QI). It is unclear what QI curricula are in place in 0+5 programs nationally or how 0+5 residents perceive the importance of QI., Objective: The purpose of this study is to assess current 0+5 residents' knowledge, experiences with, and attitudes about QI., Design: A survey was developed using the ACGME Common Program Requirements and Milestones pertaining to QI. All 0+5 residents from 2017 to 2018 academic year were emailed an electronic link to the survey. Descriptive statistics and cross-tabulations were calculated using Stata/MP version 13.1., Setting: All 0+5 vascular surgery residency programs in the United State (n = 52)., Participants: The survey was completed by 35% (n = 90/257) of 0+5 residents, representing 75% of 0+5 programs in the United States (n = 39/52)., Results: Forty-one percent of respondents felt that applying QI methods is very important and 33% felt that QI education is very important for their future work, however, just 13% felt very prepared to lead a QI initiative. Residents' perceptions of preparedness to lead QI projects and the importance they attached to QI education were significantly influenced by their participation in a QI project (p = 0.003 and p = 0.038 respectively). Finally, just 8% (n = 6) of residents responded correctly to all 13 knowledge-based questions and these residents felt better prepared to lead a QI initiative compared to those who answered incorrectly (p = 0.002)., Conclusions: Most 0+5 residents report participation in a QI project during residency, however, few feel prepared to lead a QI initiative in practice. Furthermore, only half of PGY5 0+5 residents report achieving specific ACGME targets for graduation pertaining to QI. Current QI curricula in 0+5 programs may be inadequate in teaching fundamental QI concepts and achieving ACGME competency targets for graduation., (Copyright © 2019 Association of Program Directors in Surgery. All rights reserved.)

Objective: Frailty and sarcopenia are related but independent conditions commonly diagnosed in older patients that can be used to assess their ability to tolerate the stress of major vascular surgery. For surgical decision-making, however, it is important to know the prognostic implications associated with each of these conditions. The study was designed to assess the association of frailty and sarcopenia phenotypes with long-term survival of patients undergoing surgical and nonsurgical management of vascular disease., Methods: We retrospectively reviewed all patients presenting to the vascular surgery clinic at an academic hospital between December 2015 and August 2017 who underwent prospective frailty assessment with the Clinical Frailty Scale and who had abdominal computed tomography (CT) scans performed within the preceding 12 months. A single axial CT image at the caudal end of the third lumbar vertebra was assessed to measure cross-sectional areas of skeletal muscle. Sarcopenia was defined by established criteria specific for male and female patients. After patients were stratified by frailty and sarcopenia diagnoses along with comorbidities, the association with all-cause mortality was analyzed by Kaplan-Meier curves and Cox regression models., Results: A total of 415 patients underwent both frailty and sarcopenia assessment, of whom 112 (27%) met sarcopenia criteria alone, 48 (12%) met only frailty criteria, and 56 (13%) met criteria for both phenotypes. There were 199 (48%) controls who met neither criterion. Vascular operations were performed in 167 (40%) patients after frailty and sarcopenia assessment, whereas 248 (60%) patients were managed nonoperatively with median (interquartile range) follow-up after CT imaging of 1.5 (1.1-2.2) years. Patients diagnosed with either phenotype were older (mean, 65 years vs 59 years; P < .001) and more likely to be male (69% vs 54%; P < .001) compared with patients without sarcopenia or frailty. Long-term survival was significantly decreased for patients diagnosed with either frailty alone or frailty and sarcopenia who underwent surgical or nonsurgical management (log-rank, P < .001 for both comparisons). In multivariate regression models, however, frailty was the only independent variable (hazard ratio, 7.7; 95% confidence interval, 3.2-18.7; P < .001) that predicted mortality., Conclusions: Frailty and sarcopenia overlap to varying degrees in patients presenting to vascular surgery clinics and can be used alone or in combination to predict long-term survival of older patients. However, our data indicate that it was only the diagnosis of frailty that was an independent predictor of mortality and had the strongest prognostic significance in patients undergoing both surgical and nonoperative management., (Published by Elsevier Inc.)

Background: The 0+5 integrated vascular surgery residency program (IVSR) was introduced as a training model toward board certification in vascular surgery over 10 years ago. The pros and cons of this training model have been debated., Objective: The purpose of this review is to investigate, using qualitative methods, what is known about the development, implementation, and outcomes of the IVSR paradigm., Design: A systematic search of the literature pertaining to the IVSR training model was conducted to include literature from 2005 to 2016. A search strategy involving use of 4 literature databases, 4 search terms, and 4 inclusion criteria was used. Three independent reviewers screened titles and abstracts for inclusion. Data abstraction was performed by 1 reviewer. Qualitative content analysis was completed using the method of constant comparative analysis associated with a grounded theory design by all 3 reviewers., Results: Of 890 articles initially identified, 33 articles were found to meet inclusion criteria for full review. Nineteen (57%) were research articles with an average Medical Education Research Study Quality Instrument score of 6.3 out of 18. The remaining articles were categorized as editorials, presidential addresses, invited commentaries, and historical summaries. Three major themes related to the IVSR program were identified: context of program development, processes of the program once implemented, and outcomes., Conclusions: The literature on the IVSR paradigm reflects contextual, process, and outcome issues. Research articles are of generally low quality and there is a paucity of analyses of outcome issues. Further research is recommended to identify and understand the outcomes of the model., (Copyright © 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Frailty, a clinical syndrome associated with loss of metabolic reserves, is prevalent among patients who present to vascular surgery clinics for evaluation. The Clinical Frailty Scale (CFS) is a rapid assessment method shown to be highly specific for identifying frail patients. In this study, we sought to evaluate whether the preoperative CFS score could be used to predict loss of independence after major vascular procedures., Methods: We identified all patients living independently at home who were prospectively assessed using the CFS before undergoing an elective major vascular surgery procedure (admitted for >24 hours) at an academic medical center between December 2015 and December 2017. Patient- and procedure-level clinical data were obtained from our institutional Vascular Quality Initiative registry database. The composite outcome of discharge to a nonhome location or 30-day mortality was evaluated using bivariate and multivariate regression models., Results: A total of 134 independent patients were assessed using the CFS before they underwent elective open abdominal aortic aneurysm repair (8%), endovascular aneurysm repair (26%), thoracic endovascular aortic repair (6%), suprainguinal bypass (6%), infrainguinal bypass (16%), carotid endarterectomy (19%), or peripheral vascular intervention (20%). Among 39 (29%) individuals categorized as being frail using the CFS, there was no significant difference in age or American Society of Anesthesiologists physical status compared with nonfrail patients. However, frail patients were significantly more likely to need mobility assistance after surgery (62% frail vs 22% nonfrail; P < .01) and to be discharged to a nonhome location (22% frail vs 6% nonfrail; P = .01) or to die within 30 days after surgery (8% frail vs 0% nonfrail; P < .01). Preoperative frailty was associated with a >12-fold higher risk (odds ratio, 12.1; 95% confidence interval, 2.17-66.96; P < .01) of 30-day mortality or loss of independence, independent of the vascular procedure undertaken., Conclusions: The CFS is a practical tool for assessing preoperative frailty among patients undergoing elective major vascular surgery and can be used to predict likelihood of requiring discharge to a nursing facility or death after surgery. The identification of frail patients before major surgery can help manage postoperative expectations and optimize transitions of care., (Published by Elsevier Inc.)

Objective: Arteriovenous (AV) fistulas are the preferred hemodialysis access for patients with end-stage renal disease, although multiple interventions are typically needed to maintain patency. When AV fistulas thrombose, however, there is debate as to whether open thrombectomy should be attempted, particularly for salvage of upper arm fistulas. This study was designed to evaluate outcomes after open thrombectomy of upper arm and forearm AV fistulas compared with AV grafts., Methods: We identified all patients who underwent an open thrombectomy procedure for a thrombosed AV fistula or graft at a single academic medical center between January 2006 and March 2017. The specific type of AV fistula or graft was evaluated, as were the patients' demographics, comorbidities, medications, adjunctive procedures during thrombectomy, and secondary interventions. The primary outcome measures, postintervention primary patency and postintervention secondary patency, were analyzed using Kaplan-Meier curves and Cox regression models for risk adjustment., Results: During the study period, 209 open thrombectomy procedures were performed in 139 patients; 73 (35%) were undertaken in AV fistulas and 136 (65%) in grafts. Patients with upper arm fistulas (n = 52; 54% brachiocephalic, 46% brachiobasilic) and forearm fistulas (n = 16) were more likely to be male but less likely to have cerebrovascular disease or ischemic heart disease and to be receiving anticoagulation therapy compared with graft patients. After thrombectomy, the majority of patients underwent dialysis successfully (70% upper arm fistulas, 56% forearm fistulas, 63% grafts; P > .05), and 1-year survival rates were similar in all three cohorts. Postintervention primary patency at 1 year was significantly higher for AV fistulas vs grafts (33% for upper arm fistulas and 25% for forearm fistulas vs 9% for grafts; P < .05), which was confirmed in multivariate analysis, where upper arm AV fistulas had a 46% lower risk of recurrent thrombosis or secondary intervention (hazard ratio, 0.56; 95% confidence interval, 0.35-0.85; P < .05). Postintervention secondary patency at 1 year was similar between AV fistulas and grafts (44% for upper arm fistulas vs 43% for forearm fistulas vs 31% for grafts; P = .16), but in multivariate analysis, upper arm fistulas were significantly less likely to fail (hazard ratio, 0.63; 95% confidence interval, 0.40-1.00; P = .05)., Conclusions: Our data suggest that AV fistula thrombectomy is successful in up to 70% of cases, with significantly improved risk-adjusted 1-year primary and secondary patency rates for upper arm fistulas compared with grafts. Whereas the risk of access failure is high after thrombectomy, efforts to salvage upper arm AV fistulas are effective in most patients and should be undertaken when feasible., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Frailty assessment can help vascular surgeons predict perioperative risk and long-term mortality for their patients. Unfortunately, comprehensive frailty assessments take too long to integrate into clinic workflow. This study was designed to evaluate 2 rapid methods for assessing frailty during vascular clinics-a short patient-reported survey and a provider-reported frailty scale., Methods: We prospectively enrolled 159 patients presenting to an academic medical center vascular surgery clinic between May and November 2016. Patients underwent frailty assessment using 2 rapid methods: (1) the Frail Nondisabled (FiND) survey (5 questions) and (2) the Clinical Frailty Scale (CFS; 9-point scale from robust to severely frail). These were followed by administering the Fried Index, a validated frailty assessment method with 5 measures (weight loss, exhaustion, grip strength, walking speed, and activity level). The correlation between Fried scores (reference standard) with frailty diagnoses derived from FiND and CFS was analyzed using the Spearman-rank test, Cohen's kappa, sensitivity/specificity tests, and receiver operating curves., Results: The evaluated cohort included 87 (55%) females, a mean age of 61 years, 126 (79%) preoperative patients, and 32 (20%) categorized as frail using the Fried Index criteria. The FiND survey was very sensitive (91%) but less specific for diagnosing frailty. In comparison, the CFS was highly specific (96%) for diagnosing frailty and exhibited high inter-rater reliability between surgeon and medical assistant scores (kappa: 0.79; 95% CI: 0.72-0.87; P < 0.001). There was moderate correlation between frailty assigned using the Fried Index and the CFS (rho: 0.41-0.44)., Conclusions: Frailty can be quickly and effectively assessed during vascular surgery clinic using a combination of patient-reported (FiND) and provider-reported (CFS) methods to improve diagnostic accuracy. Implementing routine frailty assessment into clinic workflow can be a valuable tool for risk prediction and surgical decision-making., (Published by Elsevier Inc.)

An important step to incriminate a mosquito as a vector of a disease pathogen is finding evidence of direct contact between the mosquito and humans. Typically, this is accomplished through landing/biting catches, or host blood meal analysis in engorged mosquitoes via immunologic assays. An alternate approach is to identify the presence of specific mosquito anti-saliva protein antibodies in the blood of exposed hosts. Following the discovery of dengue infected, free roaming non-human primates in Puerto Rico, we investigated which mosquito species had bitten these primates using a serologic assay. Serum samples from 20 patas monkeys (Erythrocebus patas) and two rhesus macaques (Macaca mulatta) were used to evaluate mosquito bite exposure to Aedes aegypti, Aedes mediovittatus, Aedes taeniorhynchus, and Culex quinquefasciatus mosquitoes. Of 22 non-human primates examined 20 (90%), 17 (77%), 13 (59%), and 7 (31%) were positive for exposure to Ae. mediovittatus, Cx. quinquefasciatus, Ae. taeniorhynchus, and Ae. aegypti, respectively. Our findings indicated that free-roaming primates in Puerto Rico were exposed to the bites of one proven dengue vector, Ae. aegypti and one potential dengue vector, Ae. mediovittatus., (Published by Elsevier B.V.)

Objective: Integrated (0 + 5) vascular surgery (VS) residency programs must include 24 months of training in core general surgery. The Accreditation Council for Graduate Medical Education currently does not require specific case numbers in general surgery for 0 + 5 trainees; however, program directors have structured this time to optimize operative experience. The aim of this study is to determine the case volume and type of cases that VS residents are exposed to during their core surgery training., Design: Accreditation council for graduate medical education operative logs for current 0 + 5 VS residents were obtained and retrospectively reviewed to determine general surgery case volume and distribution between open and laparoscopic cases performed. Standard statistical methods were applied., Setting: A total of 12 integrated VS residency programs provided operative case logs for current residents., Participants: A total of 41 integrated VS residents in clinical years 2 through 5., Results: During the postgraduate year-1 training year, residents participated in significantly more open than laparoscopic general surgery cases (p < 0.0001). This difference was consistent over the first 3 years of training. The most frequently logged open general surgery cases are hernia repair (20%), skin and soft tissue (7.4%), and breast (6.3%). Residents in programs with core surgery over 3 years participated in significantly more general surgery operations compared with residents in programs with core surgery spread out over 4 years (p = 0.035)., Conclusions: 0 + 5 VS residents perform significantly more open operations than laparoscopic operations during their core surgery training. The majority of these operations are minor, nonabdominal procedures. The 0 + 5 VS residency program general surgery operative training requirements should be reevaluated and case minimums defined. The general surgery training component of 0 + 5 VS residencies may need to be restructured to meet the needs of current and future trainees., (Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Investigate both the utility and feasibility of perioperative nutritional supplementation with an arginine-enriched immunonutrition formula to high-risk head and neck cancer surgical patients and examine its effects on acute post-operative clinical outcomes., Materials & Methods: This prospective, non-randomized, interventional cohort study compared high-risk head and neck cancer surgical patients who consumed a pre- and post-operative arginine-based nutritional supplement to those that did not. Outcome measures included post-operative complications, length of hospitalization, readmission rates and measurement of nutritional biomarkers., Results: 195 high-risk head and neck cancer surgical patients were enrolled. 59% of the patients used the nutritional supplement, 41% did not. Of the 80 patients who did not receive the immunonutrition formula, 38 (47.5%) experienced post-operative complications of all types as compared to 29 of the 115 (25.2%) patients who did consume the product (p=0.0021). Pharyngeal leaks or fistulas were the most common post-operative complications in both groups and more common in patients who did not receive supplementation (p=0.007). Length of stay was on average 2.8 days longer in patients who did not have enhanced nutrition (p=0.02), while readmission rates between the two groups were similar (p=0.91). Measurements of nutritional biomarkers were not reported secondary to low collection rates., Conclusion: Enhanced perioperative nutrition may result in significant reductions of post-operative fistula formations and decreased length of stay in a high-risk head and neck cancer population, even in the setting of poor compliance. The potential quality improvement in both patient care and healthcare cost is both real and significant., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Dietary supplementation with almonds has demonstrated dose-dependent decreases in low-density lipoprotein cholesterol (LDL-C), likely because of their composition of beneficial nutrients including mono- and polyunsaturated fatty acids, fiber, and protein., Objective: The primary objective of this study was to determine the changes in the lipid profile (LDL-C, high-density lipoprotein cholesterol [HDL-C], triglycerides, total cholesterol, non-HDL-C), LDL-C particle size, and lipoprotein (a) when 100 g of almonds daily were added to background statin therapy for 4 weeks., Methods: Subjects (N = 48) receiving a consistent statin dose were randomized to 100 g of almonds daily and to The National Cholesterol Education Program Adult Treatment Panel's third report Therapeutic Lifestyle Changes Diet counseling (almond group; n = 22) or solely Adult Treatment Panel's third report Therapeutic Lifestyle Changes Diet counseling (non-almond group; n = 26), for 4 weeks., Results: No significant changes in weight and weekly physical activity were noted between the 2 groups from baseline. However, the almond group consumed significantly more calories at 4 weeks compared with controls. The almond group experienced a 4.9% reduction in non-HDL-C compared with a 3.5% increase for the non-almond group (P = .02). Additionally, notable improvements were observed in LDL-C and triglycerides, but did not achieve statistical significance (P = .068 for both parameters). There was also a shift from LDL pattern A to pattern B particles (P = .003) in the almond group. No significant differences in total cholesterol (P = .1), HDL-C (P = .3), or lipoprotein (a) (P = .1) were observed., Conclusion: Adding 100 g of almonds daily to chronic statin therapy for 4 weeks significantly reduced non-HDL-C., Trial Registration: clinicaltrials.gov Identifier: NCT00603876., (Copyright © 2015 National Lipid Association. Published by Elsevier Inc. All rights reserved.)

Background: Since their introduction several years ago, integrated (0 + 5) vascular surgery residency programs are being increasingly developed across the country. To date, however, there is no defined "universal" curriculum for these programs and each program is responsible for creating its own curriculum. The aim of this study was to review the experiences of current 0 + 5 program directors (PDs) to determine what factors contributed to the curricular development within their institution., Methods: Semistructured interviews were conducted with 0 + 5 PDs to explore their experiences with program development, factors influencing the latter, and rationale for current curricula. The interview script was loosely structured to explore several factors including time of incoming residents' first exposure to the vascular surgical service, timing and rationale behind the timing of core surgical rotations throughout the 5 year program, educational value of nonsurgical rotations, opportunities for leadership and scholarly activity, and influence the general surgery program and institutional climate had on curricular structure. All interviews were conducted by a single interviewer. All interviews were qualitatively analyzed using emergent theme analysis., Results: Twenty-six 0 + 5 PDs participated in the study. A total of 69% believed establishing professional identity early reduces resident attrition and recommend starting incoming trainees on vascular surgical services. Sixty-two percent spread core surgical rotations over the first 3 years to optimize general surgical exposure and most of the programs have eliminated specific rotations, as they were not considered valuable to the goals of training. Factors considered most important by PDs in curricular development include building on existing institutional opportunities (96%), avoiding rotations considered unsuccessful by "experienced" programs (92%), and maintaining a good working relationship with general surgery (77%). Fifty-eight percent of PDs voiced concern over the lack of standardization among the differing programs and most of the PDs agree that some degree of programmatic standardization is critical for the continued success of the 0 + 5 training paradigm., Conclusions: Qualitative evaluation of PD experiences with the development of 0 + 5 vascular surgery residency programs reveals the key factors that commonly influence program design. Programs continue to evolve in both structure and content as PDs respond to these influences. Learning from the collective experience of PDs and some standardization of the curricula may help current and future programs avoid common pitfalls in curricular development., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Androgens regulate body composition and skeletal muscle mass in males, but the molecular mechanisms are not fully understood. Recently, we demonstrated that trenbolone (a potent synthetic testosterone analogue that is not a substrate for 5-alpha reductase or for aromatase) induces myotrophic effects in skeletal muscle without causing prostate enlargement, which is in contrast to the known prostate enlarging effects of testosterone. These previous results suggest that the 5α-reduction of testosterone is not required for myotrophic action. We now report differential gene expression in response to testosterone versus trenbolone in the highly androgen-sensitive levator ani/bulbocavernosus (LABC) muscle complex of the adult rat after 6weeks of orchiectomy (ORX), using real time PCR. The ORX-induced expression of atrogenes (Muscle RING-finger protein-1 [MuRF1] and atrogin-1) was suppressed by both androgens, with trenbolone producing a greater suppression of atrogin-1 mRNA compared to testosterone. Both androgens elevated expression of anabolic genes (insulin-like growth factor-1 and mechano-growth factor) after ORX. ORX-induced increases in expression of glucocorticoid receptor (GR) mRNA were suppressed by trenbolone treatment, but not testosterone. In ORX animals, testosterone promoted WNT1-inducible-signaling pathway protein 2 (WISP-2) gene expression while trenbolone did not. Testosterone and trenbolone equally enhanced muscle regeneration as shown by increases in LABC mass and in protein expression of embryonic myosin by western blotting. In addition, testosterone increased WISP-2 protein levels. Together, these findings identify specific mechanisms by which testosterone and trenbolone may regulate skeletal muscle maintenance and growth., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The prevalence of obesity is high resulting from chronic imbalances between energy intake and expenditure. On the expenditure side, regular exercise is associated with health benefits, including enhanced brain function. The benefits of exercise are not immediate and require persistence to be realized. Brain regions associated with health-related decisions, such as whether or not to exercise or controlling the impulse to engage in immediately rewarding activities (e.g., sedentary behavior), include reward processing and cognitive control regions. A 9 month aerobic exercise study will be conducted in 180 sedentary adults (n = 90 healthy weight [BMI = 18.5 to 26.0 kg/m(2)]; n = 90 obese [BMI = 29.0 to 41.0 kg/m(2)) to examine the brain processes underlying reward processing and impulse control that may affect adherence in a new exercise regimen. The primary aim is to use functional magnetic resonance imaging (fMRI) to examine reward processing and impulse control among participants that adhere (exercise >80% of sessions) and those that do not adhere to a nine-month exercise intervention with secondary analyses comparing sedentary obese and sedentary healthy weight participants. Our results will provide valuable information characterizing brain activation underlying reward processing and impulse control in sedentary obese and healthy weight individuals. In addition, our results may identify brain activation predictors of adherence and success in the exercise program along with measuring the effects of exercise and improved fitness on brain activation., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Weight management for individuals with intellectual and developmental disabilities (IDD) has received limited attention. Studies on weight management in this population have been conducted over short time frames, in small samples with inadequate statistical power, infrequently used a randomized design, and have not evaluated the use of emerging effective dietary strategies such as pre-packaged meals (PMs). Low energy/fat PMs may be useful in individuals with IDD as they simplify meal planning, limit undesirable food choices, teach appropriate portion sizes, are convenient and easy to prepare, and when combined with fruits and vegetables provide a high volume, low energy dense meal. A randomized effectiveness trial will be conducted in 150 overweight/obese adults with mild to moderate IDD, and their study partners to compare weight loss (6 months) and weight maintenance (12 months) between 2 weight management approaches: 1. A Stop Light Diet enhanced with reduced energy/fat PMs (eSLD); and 2. A recommended care reduced energy/fat meal plan diet (RC). The primary aim is to compare weight loss (0-6 months) and weight maintenance (7-18 months) between the eSLD and RC diets. Secondarily, changes in chronic disease risk factors between the eSLD and RC diets including blood pressure, glucose, insulin, LDL-cholesterol, and HDL-cholesterol will be compared during both weight loss and weight maintenance. Finally, potential mediators of weight loss including energy intake, physical activity, data recording, adherence to the diet, study partner self-efficacy and daily stress related to dietary change will be explored., (© 2013. Published by Elsevier Inc. All rights reserved.)

Dorsalis pedis artery impingement is an extremely rare cause of foot claudication, with a single case reported in the literature. In this report, we describe the case of a 17-year-old female Irish dancer who presented with intermittent bilateral foot pain and discoloration during active plantar flexion., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Since limited data exist on adults with Prader-Willi syndrome (PWS) and growth hormone (GH) treatment, we report our experience on the effects of treatment for one year on body composition, physical activity, strength and energy expenditure, diet, general chemistry and endocrine data with quality of life measures., Design: We studied 11 adults with PWS (6F:5M; average age=32 yrs) over a 2 year period with GH treatment during the first year only. Electrolytes, IGF-I, glucose, thyroid, insulin, lipids, body composition, physical activity and strength, diet, energy expenditure and quality of life data were collected and analyzed statistically using linear modeling at baseline, at 12 months following GH therapy and at 24 months after treatment cessation for 12 months., Results: Total lean muscle mass was significantly increased (p<0.05) during GH treatment along with moderate-vigorous physical activity and plasma IGF-I and HDL levels, but returned to near baseline after treatment. Percent body fat decreased during the 12 months of GH treatment but increased after treatment., Conclusions: Previously reported beneficial effects of GH treatment in children with PWS were found in our adults regarding body composition, physical activity and plasma HDL and IGF-I levels. Several beneficial effects diminished to near baseline after cessation of GH treatment for 12 months supporting the continuation of treatment in PWS into adulthood and possibly adults not previously treated during childhood., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: Compare weight loss and maintenance between a face-to-face (FTF) weight management clinic and a clinic delivered via virtual reality (VR)., Methods: Participants were randomized to 3 months of weight loss with a weekly clinic delivered via FTF or VR and then 6 months' weight maintenance delivered with VR. Data were collected at baseline and 3 and 6 months for weight and process variables. Twenty overweight and obese individuals (31.1 ± 3.6 years of age; body mass index, 32.8 ± 5.1; 85% females; 20% minorities) responded to advertisement and met inclusion criteria. Diets (1,200-1,800 kcal/d) used prepackaged meals, fruits and vegetables, and physical activity (300 min/wk)., Results: Weight loss was significantly greater for FTF at 10.8% compared with 7.6% for VR (P < .05). However, weight maintenance was significantly greater for VR at 14.0% compared with 9.5% for FTF (P < .05)., Conclusions and Implications: Virtual reality compares favorably with FTF for weight loss and may facilitate greater weight maintenance., (Copyright © 2013 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

State-of-the-art treatment for weight management consists of a behavioral intervention to facilitate decreased energy intake and increased physical activity. These interventions are typically delivered face-to-face (FTF) by a health educator to a small group of participants. There are numerous barriers to participation in FTF clinics including availability, scheduling, the expense and time required to travel to the clinic site, and possible need for dependent care. Weight management clinics delivered by conference call have the potential to diminish or eliminate these barriers. The conference call approach may also reduce burden on providers, who could conduct clinic groups from almost any location without the expenses associated with maintaining FTF clinic space. A randomized trial will be conducted in 395 overweight/obese adults (BMI 25-39.9 kg/m(2)) to determine if weight loss (6 months) and weight maintenance (12 months) are equivalent between weight management interventions utilizing behavioral strategies and pre-packaged meals delivered by either a conference call or the traditional FTF approach. The primary outcome, body weight, will be assessed at baseline, 6, 12 and 18 months. Secondary outcomes including waist circumference, energy and macronutrient intake, and physical activity and will be assessed on the same schedule. In addition, a cost analysis and extensive process evaluation will be completed., (Copyright © 2012 Elsevier Inc. All rights reserved.)

The increased prevalence of obesity and the lack of treatment success both argue for the design and evaluation of strategies to prevent the development of overweight and obesity. To date, the role of resistance training (RT) in this regard is largely unexplored. RT may be effective for weight management as a result of increased fat-free mass (FFM), which may result in increased resting metabolic rate and increased physical activity energy expenditure. However, the literature relative to the efficacy of RT protocols recommended for healthy adults to alter the aforementioned parameters is inconsistent or inadequately evaluated. We will conduct a 9 month randomized controlled efficacy trial to compare changes in body composition (fat mass, FFM, % body fat) and energy balance in response to 2 volumes of RT (1 vs. 3 sets vs. non-exercise control) both at the completion of training (9 months) and 1 year later (body composition). This investigation will be conducted in a sample of healthy, normal and overweight, sedentary, young adult men and women; a group at high risk for development of overweight and obesity. Our results will provide information relative to the minimum volume of RT that may be associated with body weight/fat gain which may inform the development of guidelines for RT to prevent weight gain or to alter body composition., (Copyright © 2012 Elsevier Inc. All rights reserved.)

We evaluated weight loss response to 16 months of supervised exercise (45 min/day, 5 days/week, 75% heart-rate-reserve) in sedentary, overweight/obese participants without energy restriction in the Midwest Exercise Trial (MET1). Results indicated men lost weight, women did not. The gender differences were associated with differences in the energy expenditure of exercise (EEEx) (men=667±116; women=439±88 kcal/session) when exercise was prescribed by frequency, intensity and duration. MET2 is a randomized control trial designed and powered to examine differences in weight loss and gender in response to EEEx for men and women of 400 or 600 kcal/session, 5 days/week, for 10 months without energy restriction. One hundred forty-one participants will be randomized to 1 of 2 exercise groups or a non-exercise control. EEEx will be verified by indirect calorimetry monthly during the intervention. This study will evaluate: (1) the weight change response to two levels of EEEx versus non-exercise control; (2) gender differences in weight response to two levels of EEEx; (3) potential compensatory changes in energy intake and/or daily physical activity that may explain the observed weight changes. Results from this study may impact how exercise is prescribed for weight loss and prevention of weight regain and may clarify if men and women differ in response to exercise., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: The soluble guanylate cyclase (sGC) activator Cinaciguat (BAY 58-2667) represents a novel class of drugs that selectively activate oxidised sGC. The extent of oxidised sGC depends on the patient's oxidative burden. We here describe two platelet-based assays that allow determining the extent of oxidised sGC and thus provide a basis for an individualised pharmacotherapy., Methods/results: Platelets obtained from patients with (n=12) and without (n=12) coronary artery disease (CAD) were examined by flow cytometry (P-selectin expression), and Western blots (vasodilator associated phosphoprotein, VASP-phosphorylation). Results were compared to maximal oxidation of sGC achieved by the oxidising agent ODQ (1H-[1,2,4]oxadiazole[4,3-a]quinoxalin-1-one). Treatment of platelets with Cinaciguat resulted in differential activation of oxidised sGC. Platelet P-selectin expression and VASP-phosphorylation revealed significant differences (p=0.012, p=0.039, respectively) between CAD and non-CAD patients., Conclusion: We describe platelet-based assays that allow the determination of patients' oxidative status and thus allow the prediction of pharmacological response to direct sGC activators., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: The purpose of this study was to compare the efficacy of two home-based weight loss interventions that differ only in the amount of outside support provided., Methods: This was a 12-week, randomized, controlled trial. One group received limited support (LWS, n = 35) via a single 10 min phone call each week while another group received no weekly support (NWS, n = 28). Both the LWS and NWS received pre-packaged meals (PM) and shakes. A third group served as control (CON, n = 30) and received no components of the intervention. Weight loss at 12 weeks was the primary outcome. Diet (PM, shake, and fruit/vegetable (F/V) intake) and physical activity (PA) were self-monitored, recorded daily and reported weekly. An exit survey was completed by participants in the intervention groups upon completion of the study., Results: Weight loss and percent weight loss in the LWS, NWS, and CON groups were 7.7 ± 4.4 kg (8.5 ± 4.2%), 5.9 ± 4.1 kg (6.0 ± 4.2%), and 0.3 ± 1.9 kg (0.4 ± 1.2%), respectively. The decrease in body weight and percent weight loss was significantly greater in the LWS and NWS groups when compared to the CON group and the percent weight loss was significantly greater in the LWS when compared to both the NWS and CON groups., Conclusion: A home-based weight loss program utilizing PM and shakes results in clinically significant percent weight loss and the addition of a brief weekly call promotes additional percent weight loss., (© 2009 Asian Oceanian Association for the Study of Obesity . Published by Elsevier Ltd. All rights reserved.)