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The Gore TAG thoracic branch endoprosthesis (TBE) is the first Food and Drug Administration–approved device for zone 2 thoracic endovascular aortic repair, allowing for graft placement proximal to the left subclavian artery origin and maintaining vessel patency through a side branch. We describe our experience with the Gore TBE device in 20 patients for acute indications, including blunt thoracic aortic injuries, complicated dissections, and ruptured aneurysms. Technical success, with exclusion of pathology and left subclavian patency, was 100% without major complications within 30 days. Our early Gore TBE device experience demonstrates safe use in acute aortic pathology without an increased risk of complications.

Transcarotid artery revascularization (TCAR) provides a safe alternative to carotid endarterectomy. The anatomic requirements include a 5-cm minimum clavicle to carotid bifurcation distance for sheath access proximal to the lesion. In the present report, we describe our experience with conduit use for patients not meeting that requirement. Patients undergoing elective TCAR with a conduit from 2021 to 2022 were retrospectively identified. After carotid artery exposure, a 6-mm prosthetic graft was anastomosed to the common carotid artery in an end-to-side fashion. After stent delivery, the conduit was ligated and oversewn. The patient demographics, procedural details, and outcomes were recorded and compared with our nonconduit TCAR experience. A total of 11 patients (64% male; age, 75 ± 5 years) underwent TCAR with a conduit, 5 (46%) for symptomatic disease, and 77 patients underwent TCAR with no conduit, 52 (60%) with symptomatic disease (P = .50). Other than a higher rate of prior coronary interventions in the conduit group (55% vs 47%; P = .007), no significant differences were found in age, gender, race, comorbidities, or high risk for carotid endarterectomy criteria. In the conduit group, the average skin to carotid artery depth was 4.2 cm (range, 1.9-6.1 cm). The average clavicle to bifurcation distance was 4.4 cm (range, 3.3-4.9 cm) vs 6.5 cm (range, 3.3-9.7 cm; P = .002) in the nonconduit group. Dacron was the most common conduit material used (73%). No differences were found in the mean procedure times (121 ± 32 vs 129 ± 53 minutes; P = .785) or flow reversal times (14 ± 5 vs 19 ± 13 minutes; P =.989) for the conduit and nonconduit cohorts, respectively. Technical success was achieved in 100% of the conduit and nonconduit cases. Excluding one outlier of a prolonged stay (7 days) for management of unrelated medical issues (gastrostomy tube placement for chronic dysphagia after mass resection and neck radiation), the mean hospital stay was 2 days (1.2 ± 0.4 intensive care unit days) compared with 3.8 ± 5.7 days for our nonconduit cohort (P = .2). Hypotension was the most common reason for delayed discharge for the conduit group (n = 3; 27%). The average follow-up was 2.7 months (range, 1-10 months). For all 11 conduit patients, the stent remained patent without stenosis, thrombus, or pseudoaneurysm at the conduit stump site on surveillance duplex ultrasound. No strokes or complications had occurred at 30 days in the conduit group compared with four strokes or transient ischemic attacks (P = .469) and 18 minor complications in the nonconduit group (P = .091). For patients lacking a sufficient distance between the clavicle and carotid artery bifurcation, a prosthetic conduit facilitates safe use of flow reversal for stent delivery and can be ligated at procedural completion without consequences.

Thoracic outlet syndrome (TOS) is a disease pattern that involves compression of neurologic venous or arterial structures as they pass through the thoracic outlet. TOS was first described as a vascular complication arising from the presence of a cervical rib. Over time, a better understanding of TOS has led to its wide range of presenting symptoms being divided into three distinct groups: arterial, venous, and neurogenic. Of the known cases, the current estimates of the incidence of neurogenic TOS, venous TOS, and arterial TOS are 95%, 3%, and 1%, respectively. The different types of TOS have completely different presentations, requiring expertise in the diagnosis, management, and treatment unique to each. We present our evaluation, diagnosis, and management method of TOS patients, with specific attention paid to the transaxillary approach.

Summary:. When the external nasal valve (ENV) is excessively narrow or lacks support, nasal obstruction can develop causing decreased airflow. Although cartilage grafts may support a collapsed nasal ala, addressing severe nasal stenosis requires further intervention. Techniques to move flared ala inward are well-known; however, repositioning a medially displaced alar base is less commonly described. Our surgical team developed an inferiorly based alar groove flap to achieve lateral movement of a malpositioned alar base, with goals of widening the ENV and improving nasal symmetry and cosmesis. A retrospective chart review was performed on a series of five patients over a two-year period. Charts were reviewed for demographic data, medical and surgical history, functional airway complaints, and subjective aesthetic concerns. All patients presented with unilateral ENV collapse, alar base malposition, and nostril asymmetry. Our operative method consisted of repositioning the affected alar base laterally and inferiorly to alleviate nostril stenosis and using an alar rim graft to support the ENV. Postoperatively, all patients demonstrated immediate alleviation of subjective nasal obstruction and improvement in size of ENV aperture, nostril symmetry, and overall cosmesis. Four patients showed lasting postoperative results. One patient experienced restenosis by 4 months and required revision. Our inferiorly based alar groove flap provides a reproducible solution for repositioning a medially displaced alar base. This technique reliably corrects ENV stenosis, relieves airway obstruction, and improves nasal symmetry and cosmesis.

Optical recording with fast voltage sensitive dyes makes it possible, in suitable preparations, to simultaneously monitor the action potentials of large numbers of individual neurons. Here we describe methods for doing this, including considerations of different dyes and imaging systems, methods for correlating the optical signals with their source neurons, procedures for getting good signals, and the use of Independent Component Analysis for spike-sorting raw optical data into single neuron traces. These combined tools represent a powerful approach for large-scale recording of neural networks with high temporal and spatial resolution.

Background:. This study investigates laypersons’ perceptions of congenital ear deformities and preferences for treatment, particularly with ear molding therapy—an effective, noninvasive, yet time-sensitive treatment. Methods:. Laypersons were recruited via crowdsourcing to view photographs of normal ears or one of the following ear deformities, pre- and post-molding: constricted, cryptotia, cupped/lopped, helical rim deformity, prominent, and Stahl. Participants answered questions regarding perceptions and treatment preferences for the ear. Statistical analyses included multiple linear and logistic regressions and Wilcoxon signed-rank tests. Results:. A total of 983 individuals participated in the study. All deformities were perceived as significantly abnormal, likely to impair hearing, and associated with lower psychosocial quality of life (all P < 0.001). For all deformities, participants were likely to choose ear molding over surgery despite the logistical and financial implications of ear molding (all P < 0.02). Participants were significantly more satisfied with the outcome of ear molding in all deformities compared with control, except constricted ears (all P < 0.002, except Pconstricted = 0.073). Concern for hearing impairment due to ear deformity was associated with increased likelihoods of seeing a physician (P < 0.001) and choosing ear molding despite treatment logistics and costs (all P < 0.001). Conclusions:. Laypersons perceived all ear deformities as abnormal and associated with low psychosocial quality of life. Despite logistical and financial implications, laypersons generally desired molding therapy for ear deformities; treatment outcomes were satisfactory for all deformities except constricted ears. Timely diagnosis of this condition is crucial to reaping the benefits of ear molding therapy.

Background:. We hypothesize that reusable, on-site specialty instrument trays available to plastic surgery residents in the emergency department (ED) for bedside procedures are more cost-effective than disposable on-site and remote re-usable operating room (OR) instruments at our institution. Methods:. We completed a cost-effectiveness analysis comparing the use of disposable on-site kits and remote OR trays to a hypothetical, custom, reusable tray for ED procedures completed by PRS residents. Material costs of existing OR trays were used to estimate the purchasing and use-cost of a custom on-site tray for the same procedures. Cost of per procedure ‘consult time’ was estimated using procedure and resident salary. Results:. Sixteen bedside procedures were completed over a 4.5 month period. A mean of 2.14 disposable kits were used per-procedure. Mean consultation time was 1.66 hours. Procedures that used OR trays took 3 times as long as procedures that used on-site kits (4 vs. 1.1 hours). Necessary, additional instruments were unavailable for 75% of procedures. Mean cost of using disposable kits and OR trays was $115.03/procedure versus an estimated $26.67/procedure cost of using a custom tray, yielding $88.36/procedure cost-savings. Purchase of a single custom tray ($1,421.55) would be redeemed after 2.3 weeks at 1 procedure/day. Purchasing 4 trays has projected annual cost-savings of $26,565.20. Conclusion:. The purchase of specialized procedure trays will yield valuable time and cost-savings while providing quality patient care. Improving time efficiency will help achieve the Accreditation Council of Graduate Medical Education (ACGME) goals of maintaining resident well-being and developing quality improvement competency.

The fluid movement of an arm requires multiple spatiotemporal parameters to be set independently. Recent studies have argued that arm movements are generated by the collective dynamics of neurons in motor cortex. An untested prediction of this hypothesis is that independent parameters of movement must map to independent components of the neural dynamics. Using a task where three male monkeys made a sequence of reaching movements to randomly placed targets, we show that the spatial and temporal parameters of arm movements are independently encoded in the low-dimensional trajectories of population activity in motor cortex: each movement's direction corresponds to a fixed neural trajectory through neural state space and its speed to how quickly that trajectory is traversed. Recurrent neural network models show that this coding allows independent control over the spatial and temporal parameters of movement by separate network parameters. Our results support a key prediction of the dynamical systems view of motor cortex, and also argue that not all parameters of movement are defined by different trajectories of population activity., Competing Interests: The authors declare no competing financial interests., (Copyright © 2024 Colins Rodriguez et al.)

Investigating how, when, and what subjects learn during decision-making tasks requires tracking their choice strategies on a trial-by-trial basis. Here, we present a simple but effective probabilistic approach to tracking choice strategies at trial resolution using Bayesian evidence accumulation. We show this approach identifies both successful learning and the exploratory strategies used in decision tasks performed by humans, non-human primates, rats, and synthetic agents. Both when subjects learn and when rules change the exploratory strategies of win-stay and lose-shift, often considered complementary, are consistently used independently. Indeed, we find the use of lose-shift is strong evidence that subjects have latently learnt the salient features of a new rewarded rule. Our approach can be extended to any discrete choice strategy, and its low computational cost is ideally suited for real-time analysis and closed-loop control., Competing Interests: SM, RH, MO, MB, PM, TB, MS, MH No competing interests declared, (© 2024, Maggi et al.)

The vertebrate basal ganglia play an important role in action selection-the resolution of conflicts between alternative motor programs. The effective operation of basal ganglia circuitry is also known to rely on appropriate levels of the neurotransmitter dopamine. We investigated reducing or increasing the tonic level of simulated dopamine in a prior model of the basal ganglia integrated into a robot control architecture engaged in a foraging task inspired by animal behaviour. The main findings were that progressive reductions in the levels of simulated dopamine caused slowed behaviour and, at low levels, an inability to initiate movement. These states were partially relieved by increased salience levels (stronger sensory/motivational input). Conversely, increased simulated dopamine caused distortion of the robot's motor acts through partially expressed motor activity relating to losing actions. This could also lead to an increased frequency of behaviour switching. Levels of simulated dopamine that were either significantly lower or higher than baseline could cause a loss of behavioural integration, sometimes leaving the robot in a 'behavioral trap'. That some analogous traits are observed in animals and humans affected by dopamine dysregulation suggests that robotic models could prove useful in understanding the role of dopamine neurotransmission in basal ganglia function and dysfunction.

Implantable vascular devices are widely used in clinical treatments for various vascular diseases. However, current approved clinical implantable vascular devices generally have high failure rates primarily due to their surface lacking inherent functional endothelium. Here, inspired by the pathological mechanisms of vascular device failure and physiological functions of native endothelium, we developed a new generation of bioactive parylene (poly(p-xylylene))-based conformal coating to address these challenges of the vascular devices. This coating used a polyethylene glycol (PEG) linker to introduce an endothelial progenitor cell (EPC) specific binding ligand LXW7 (cGRGDdvc) onto the vascular devices for preventing platelet adhesion and selectively capturing endogenous EPCs. Also, we confirmed the long-term stability and function of this coating in human serum. Using two vascular disease-related large animal models, a porcine carotid artery interposition model and a porcine carotid artery-jugular vein arteriovenous graft model, we demonstrated that this coating enabled rapid generation of self-renewable "living" endothelium on the blood contacting surface of the expanded polytetrafluoroethylene (ePTFE) grafts after implantation. We expect this easy-to-apply conformal coating will present a promising avenue to engineer surface properties of "off-the-shelf" implantable vascular devices for long-lasting performance in the clinical settings., Competing Interests: AP, KL, and AW are founders in VasoBio Inc, which has a license to the LXW7 technology. Other authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article., (© 2023 The Authors.)

Objective: Utilization of evidence-based specialty guidelines is low in primary care settings. Early use of ankle-brachial index (ABI) testing and a validated wound classification system allows prompt referral of patients for specialty care. We implemented a program to teach providers ABI testing and the use of the Wound, Ischemia, and foot Infection (WIfI) classification tool. Here, we report program outcomes and provider perceptions., Methods: Physicians and non-physicians from wound care centers, nursing and physician education programs, primary care offices, and federally qualified health centers were invited to participate in the educational program teaching ABI testing and the use of the WIfI tool. Pretest and posttest responses and intention to use content in the future were assessed with descriptive statistics., Results: A total of 101 subjects completed the ABI module, and 84 indicated their occupation (59 physicians, 25 non-physicians). Seventy-nine subjects completed the WIfI module, and 89% indicated their occupation (50 physicians, 20 non-physicians). Physicians had lower pre-test knowledge scores for the ABI module than non-physicians (mean scores of 7.9 and 8.2, respectively). Both groups had improved knowledge scores on the post-test (physicians, 13.4; non-physicians, 13.8; P < .001). Non-physicians in practice longer than 10 years at wound care centers had the lowest baseline knowledge scores, whereas physicians in practice for over 10 years had the highest. In the ABI module, the largest knowledge gap included accurately calculating the ABI, followed by the correct use of the Doppler, and management of incompressible vessels. For the WIfI module, providers struggled to accurately score patients based on wound classification. The greatest barriers to the implementation of ABI testing were the availability of trained personnel, followed by limited time for testing. Barriers to the use of the WIfI tool for physicians included lack of time and national guideline support. For non-physicians, the most notable barrier was a lack of training., Conclusions: Provider understanding of ABI and WIfI tools are limited in wound care centers, primary care offices, and federally qualified health centers. Further barriers include a lack of training in the use of tools, limited potential for point-of-care testing reimbursement, and insufficient dissemination of WIfI guidelines. Such barriers discourage widespread adoption and result in delayed diagnosis of arterial insufficiency., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Thoracic outlet syndrome (TOS) is a disease pattern that involves compression of neurologic venous or arterial structures as they pass through the thoracic outlet. TOS was first described as a vascular complication arising from the presence of a cervical rib. Over time, a better understanding of TOS has led to its wide range of presenting symptoms being divided into three distinct groups: arterial, venous, and neurogenic. Of the known cases, the current estimates of the incidence of neurogenic TOS, venous TOS, and arterial TOS are 95%, 3%, and 1%, respectively. The different types of TOS have completely different presentations, requiring expertise in the diagnosis, management, and treatment unique to each. We present our evaluation, diagnosis, and management method of TOS patients, with specific attention paid to the transaxillary approach., (© 2023 The Author(s).)

Objectives: Determine patient and provider perspectives on widespread rapid telemedicine implementation, understand the key components of a surgical telemedicine visit and identify factors that affect future telemedicine use., Summary of Background Data: Compared to other specialties, the field of surgery heretofore has had limited adoption of telemedicine. During the COVID-19 pandemic Healthcare, including the surgical specialties, saw new widespread use of telemedicine., Methods: We conducted a prospective cohort study during the COVID-19 California stay-at-home and physical distancing executive orders. Utilization data were collected from clinics and compared to usage data during the same time 1 year later. All patients and providers who participated in a telemedicine visit during the study period were asked to complete a survey after each encounter and the surveys were analyzed for trends in opinions on future use by stakeholders., Results: Over the 10-week period, the median percentage of telemedicine visits per clinic was 33% (17%-51%) which peaked 3 weeks into implementation. One hundred and ninety-one patients (48% women) with a median age of 64 years (IQR 53-73) completed the patient survey. Patients were first-time participants in telemedicine in 41% ( n  = 79) of visits. Fifty-seven percent ( n  = 45) of first-time users preferred that future visits be in-person versus 31% of prior users ( p  = 0.007). The median travel time from home to the clinic was 40 min (IQR = 20-90). Patients with longer travel times were not more likely to use telemedicine in the future (61% with longer travel vs. 53% shorter, p  = 0.11). From the 148 provider responses, 90% of the visits providers were able to create a definitive plan with the telemedicine visit. A physical exam was determined not to be needed in 45% of the visits. An attempt at any physical exam was not performed in 84% of routine follow-up or new-patient visits, compared to 53% of post-op visits ( p  = 0.001)., Conclusion: Telemedicine is a viable ambulatory visit option for surgical specialists and their patients. During rapid telemedicine deployment, travel distance did not correlate with increased use of telemedicine, and in-person visits are still preferred. However, nearly half of all visits did not need a physical exam, which favors telemedicine use., Competing Interests: The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MDH has received funding from the NHLBI and Society for Vascular Surgeons., (© The Author(s) 2023.)

Objective: The optimal revascularization modality following complete resection of aortic graft infection (AGI) without enteric involvement remains unclear. The purpose of this investigation is to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients undergoing complete excision of AGI., Methods: A retrospective, multi-institutional study of AGI from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and perioperative variables were recorded. The primary outcome was infection-free survival. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariable analyses were performed., Results: A total of 241 patients at 34 institutions from seven countries presented with AGI during the study period (median age, 68 years; 75% male). The initial aortic procedures that resulted in AGI were 172 surgical grafts (71%), 66 endografts (27%), and three unknown (2%). Of the patients, 172 (71%) underwent complete excision of infected aortic graft material followed by in situ (in-line) bypass (ISB), including antibiotic-treated prosthetic graft (35%), autogenous femoral vein (neo-aortoiliac surgery) (24%), and cryopreserved allograft (41%). Sixty-nine patients (29%) underwent extra-anatomic bypass (EAB). Overall median Kaplan-Meier estimated survival was 5.8 years. Perioperative mortality was 16%. When stratified by ISB vs EAB, there was a significant difference in Kaplan-Meier estimated infection-free survival (2910 days; interquartile range, 391-3771 days vs 180 days; interquartile range, 27-3750 days; P < .001). There were otherwise no significant differences in presentation, comorbidities, or perioperative variables. Multivariable Cox regression showed lower infection-free survival among patients with EAB (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.6-3.6; P < .001), polymicrobial infection (HR, 2.2; 95% CI, 1.4-3.5; P = .001), methicillin-resistant Staphylococcus aureus infection (HR, 1.7; 95% CI, 1.1-2.7; P = .02), as well as the protective effect of omental/muscle flap coverage (HR, 0.59; 95% CI, 0.37-0.92; P = .02)., Conclusions: After complete resection of AGI, perioperative mortality is 16% and median overall survival is 5.8 years. EAB is associated with nearly a two and one-half-fold higher reinfection/mortality compared with ISB. Omental and/or muscle flap coverage of the repair appear protective., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Medial prefrontal cortex (mPfC) activity represents information about the state of the world, including present behavior, such as decisions, and the immediate past, such as short-term memory. Unknown is whether information about different states of the world are represented in the same mPfC neural population and, if so, how they are kept distinct. To address this, we analyze here mPfC population activity of male rats learning rules in a Y-maze, with self-initiated choice trials to an arm end followed by a self-paced return during the intertrial interval (ITI). We find that trial and ITI population activity from the same population fall into different low-dimensional subspaces. These subspaces encode different states of the world: multiple features of the task can be decoded from both trial and ITI activity, but the decoding axes for the same feature are roughly orthogonal between the two task phases, and the decodings are predominantly of features of the present during the trial but features of the preceding trial during the ITI. These subspace distinctions are carried forward into sleep, where population activity is preferentially reactivated in post-training sleep but differently for activity from the trial and ITI subspaces. Our results suggest that the problem of interference when representing different states of the world is solved in mPfC by population activity occupying different subspaces for the world states, which can be independently decoded by downstream targets and independently addressed by upstream inputs. SIGNIFICANCE STATEMENT Activity in the medial prefrontal cortex plays a role in representing the current and past states of the world. We show that during a maze task, the activity of a single population in medial prefrontal cortex represents at least two different states of the world. These representations were sequential and sufficiently distinct that a downstream population could separately read out either state from that activity. Moreover, the activity representing different states is differently reactivated in sleep. Different world states can thus be represented in the same medial prefrontal cortex population but in such a way that prevents potentially catastrophic interference between them., (Copyright © 2022 Maggi and Humphries.)

The striatum's complex microcircuit is made by connections within and between its D1- and D2-receptor expressing projection neurons and at least five species of interneuron. Precise knowledge of this circuit is likely essential to understanding striatum's functional roles and its dysfunction in a wide range of movement and cognitive disorders. We introduce here a Bayesian approach to mapping neuron connectivity using intracellular recording data, which lets us simultaneously evaluate the probability of connection between neuron types, the strength of evidence for it, and its dependence on distance. Using it to synthesize a complete map of the mouse striatum, we find strong evidence for two asymmetries: a selective asymmetry of projection neuron connections, with D2 neurons connecting twice as densely to other projection neurons than do D1 neurons, but neither subtype preferentially connecting to another; and a length-scale asymmetry, with interneuron connection probabilities remaining non-negligible at more than twice the distance of projection neuron connections. We further show that our Bayesian approach can evaluate evidence for wiring changes, using data from the developing striatum and a mouse model of Huntington's disease. By quantifying the uncertainty in our knowledge of the microcircuit, our approach reveals a wide range of potential striatal wiring diagrams consistent with current data. SIGNIFICANCE STATEMENT To properly understand a neuronal circuit's function, it is important to have an accurate picture of the rate of connection between individual neurons and how this rate changes with the distance separating pairs of neurons. We present a Bayesian method for extracting this information from experimental data and apply it to the mouse striatum, a subcortical structure involved in learning and decision-making, which is made up of a variety of different projection neurons and interneurons. Our resulting statistical map reveals not just the most robust estimates of the probability of connection between neuron types, but also the strength of evidence for them, and their dependence on distance., (Copyright © 2022 the authors.)

The use of social media (SoMe) in medicine has demonstrated the ability to advance networking among clinicians and other healthcare staff, disseminate research, increase access to up-to-date information, and inform and engage medical trainees and the public at-large. With increasing SoMe use by vascular surgeons and other vascular specialists, it is important to uphold core tenets of our commitment to our patients by protecting their privacy, encouraging appropriate consent and use of any patient-related imagery, and disclosing relevant conflicts of interest. Additionally, we recognize the potential for negative interactions online regarding differing opinions on optimal treatment options for patients. The Society for Vascular Surgery (SVS) is committed to supporting appropriate and effective use of SoMe content that is honest, well-informed, and accurate. The Young Surgeons Committee of the SVS convened a diverse writing group of SVS members to help guide novice as well as veteran SoMe users on best practices for advancing medical knowledge-sharing in an online environment. These recommendations are presented here with the goal of elevating patient privacy and physician transparency, while also offering support and resources for infrequent SoMe users to increase their engagement with each other in new, virtual formats., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Medical schools and surgical residencies have seen an increase in the proportion of female matriculants, with 30% of current vascular surgery trainees being women over the past decade. There is widespread focus on increasing diversity in medicine and surgery in an effort to provide optimal quality of patient care and the advancement of science. The presence of gender diversity and opportunities to identify with women in leadership positions positively correlates with women choosing to enter traditionally male-dominated fields. The purpose of this study was to evaluate the representation of women in regional and national vascular surgical societies over the last 20 years., Methods: A retrospective review of the meeting programs of vascular surgery societies was performed. Data were collected on abstract presenters, moderators, committee members and chairs, and officers (president, president-elect, vice president, secretary, and treasurer). The data were divided into early (1999-2009) and late (2010-2019) time periods., Results: Five regional and five national societies' data were analyzed, including 139 meetings. The mean percentage of female abstract presenters increased significantly from 10.9% in the early period to 20.6% in the late period (P < .001). Female senior authors increased slightly from 8.7% to 11.5%, but this change was not statistically significant (P = .22). Female meeting moderators increased significantly from 7.8% to 17.2% (P < .001), as well as female committee members increased from 10.9% to 20.3% (P = .003). Female committee chairs increased slightly from 10.9% to 16.9%, but this difference was not statistically significant (P = .13). Female society officers increased considerably from 6.4% to 14.8%. (P = .002). Significant variation was noted between societies, with five societies (three regional and two national) having less than 10% women at the officer level in 2019. There was a wide variation noted between societies in the percentage of female abstract presenters (range, 7.6%-34.9%), senior authors (3.9%-17.9%), and meeting moderators (5.4%-40.7%)., Conclusions: Over the past two decades, there has been a significant increase in the representation of women in vascular surgery societies among those presenting scientific work, serving as meeting moderators, and serving as committee members. However, the representation of women among committee chairs, senior authors, and society leadership has not kept up pace with the increase noted at other levels. Efforts to recruit women into the field of vascular surgery as well as to support the professional development of female vascular surgeons are facilitated by the presence of women in leadership roles. Increasing the representation of women in vascular society leadership positions may be a key strategy in promoting gender diversity in the vascular surgery field., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Discovering low-dimensional structure in real-world networks requires a suitable null model that defines the absence of meaningful structure. Here we introduce a spectral approach for detecting a network's low-dimensional structure, and the nodes that participate in it, using any null model. We use generative models to estimate the expected eigenvalue distribution under a specified null model, and then detect where the data network's eigenspectra exceed the estimated bounds. On synthetic networks, this spectral estimation approach cleanly detects transitions between random and community structure, recovers the number and membership of communities, and removes noise nodes. On real networks spectral estimation finds either a significant fraction of noise nodes or no departure from a null model, in stark contrast to traditional community detection methods. Across all analyses, we find the choice of null model can strongly alter conclusions about the presence of network structure. Our spectral estimation approach is therefore a promising basis for detecting low-dimensional structure in real-world networks, or lack thereof., Competing Interests: The authors have declared that no competing interests exist.

Patients with chronic limb-threatening ischemia (CLTI) face numerous barriers to caring for lower extremity wounds. We explored the perceptions of CLTI patients to their wound/management and sought to determine attitudes towards their vascular provider as well as willingness for management through telemedicine. Patients admitted to hospital for treatment of Rutherford Grade 5 and 6 CLTI were asked complete a wound evaluation survey and took part in a semi-structured interview. Semi-structured interviews were recorded, transcribed, and analyzed using an inductive coding strategy. Codes were grouped for thematic analysis and aggregated into assertions. Eleven patients with a mean age of 60 years (35-79 years) were interviewed. All patients had peripheral artery disease (PAD) and eight patients had diabetes as well. Three overarching themes were identified. First, patients appear to have limited coping mechanisms and are overwhelmed by the care of their wounds. Second, in this cohort of patients, many had become passive observers of their care as demonstrated by a limited understanding of their disease processes and detachment from wound management. The third theme was how strong the desire to do everything to prevent limb loss was, but patients acknowledged this is hard to translate into real life with limited resources. Patients with CLTI have concerns that vascular providers must recognize and address to build strong patient-provider relationships and increase activation for management of their wounds and other medical conditions. Patients who have access to technology and with guidance may be able to understand getting care through remote medicine.

Diversity, equity, and inclusion represent interconnected goals meant to ensure that all individuals, regardless of their innate identity characteristics, feel welcomed and valued among their peers. Equity is achieved when all individuals have equal access to leadership and career advancement opportunities as well as fair compensation for their work. It is well-known that the unique backgrounds and perspectives contributed by a diverse workforce strengthen and improve medical organizations overall. The Society for Vascular Surgery (SVS) is committed to supporting the highest quality leadership, patient care, surgical education, and societal recommendations through promoting diversity, equity, and inclusion within the SVS. The overarching goal of this document is to provide specific context and guidance for enhancing diversity, equity, and inclusion within the SVS as well as setting the tone for conduct and processes beyond the SVS, within other national and regional vascular surgery organizations and practice settings., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Implementation of telemedicine for patient encounters optimizes personal safety and allows for continuity of patient care. Embracing telehealth reduces the use of personal protective equipment and other resources consumed during in-person visits. The use of telehealth has increased to historic levels in response to the coronavirus disease 2019 (COVID-19) pandemic. Telehealth may be a key modality to fight against COVID-19, allowing us to take care of patients, conserve personal protective equipment, and protect health care workers all while minimizing the risk of viral spread. We must not neglect vascular health issues while the coronavirus pandemic continues to flood many hospitals and keep people confined to their homes. Patients are not immune to diseases and illnesses such as stroke, critical limb ischemia, and deep vein thrombosis while being confined to their homes and afraid to visit hospitals. Emerging from the COVID-19 crisis, incorporating telemedicine into routine medical care is transformative. By leveraging digital technology, the authors discuss their experience with the implementation, workflow, coding, and reimbursement issues of telehealth during the COVID-19 era., (Copyright © 2020. Published by Elsevier Inc.)

The global SARS-CoV-2/COVID-19 pandemic has required a reduction in nonemergency treatment for a variety of disorders. This report summarizes conclusions of an international multidisciplinary consensus group assembled to address evaluation and treatment of patients with thoracic outlet syndrome (TOS), a group of conditions characterized by extrinsic compression of the neurovascular structures serving the upper extremity. The following recommendations were developed in relation to the three defined types of TOS (neurogenic, venous, and arterial) and three phases of pandemic response (preparatory, urgent with limited resources, and emergency with complete diversion of resources). • In-person evaluation and treatment for neurogenic TOS (interventional or surgical) are generally postponed during all pandemic phases, with telephone/telemedicine visits and at-home physical therapy exercises recommended when feasible. • Venous TOS presenting with acute upper extremity deep venous thrombosis (Paget-Schroetter syndrome) is managed primarily with anticoagulation, with percutaneous interventions for venous TOS (thrombolysis) considered in early phases (I and II) and surgical treatment delayed until pandemic conditions resolve. Catheter-based interventions may also be considered for selected patients with central subclavian vein obstruction and threatened hemodialysis access in all pandemic phases, with definitive surgical treatment postponed. • Evaluation and surgical treatment for arterial TOS should be reserved for limb-threatening situations, such as acute upper extremity ischemia or acute digital embolization, in all phases of pandemic response. In late pandemic phases, surgery should be restricted to thrombolysis or brachial artery thromboembolectomy, with more definitive treatment delayed until pandemic conditions resolve., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Studies evaluating major amputation after initial minor amputation are few with rates of subsequent major amputation ranging from 14% to 35% with limited understanding of associated comorbidities and time to limb loss. The aim of this study is to determine the major amputation rates for patients who had already undergone an initial minor amputation and determine which factors are associated with the need for subsequent major amputation., Methods: Using statewide data between 2005 and 2013, patients with peripheral artery disease (PAD), diabetes mellitus (DM), and combined PAD/DM who had a lower extremity ulcer and who had also undergone a minor amputation were identified. These patients were evaluated for the rate of subsequent major amputation and competing risk Cox proportional hazards modeling was used to study which factors were associated with the risk of subsequent limb loss., Results: The cohort consisted of 11,597 patients (DM, n = 4254; PAD, n = 2142; PAD/DM, n = 5201) with lower extremity ulcers who underwent an initial minor amputation. The rate of any subsequent amputation was highest in patients with PAD/DM (23% vs DM = 17%, PAD = 17%; P = not statistically significant). The rate of subsequent minor amputation was 16% in the PAD/DM versus 15.2% in PAD and 12.2% in patients with DM (P < .001). Patients with PAD/DM had the highest rate of subsequent major amputation (6.3% vs DM = 5.2%, PAD = 2.1%; P < .001). There was no statistically significant difference in the median time to major amputation among the three groups (PAD/DM, 13 months; DM, 14 months; PAD, 8.6 months; P = NS). Patients who were revascularized before a repeat minor amputation had a decreased risk of a major amputation compared with those who were intervened on after a repeat minor amputation (hazard ratio, 0.002; 95% confidence interval, 0-0.22). Patients treated completely in the outpatient setting were also less likely to undergo subsequent major amputation (hazard ratio, 0.7; 95% confidence interval, 0.5-0.98) compared with those who required hospitalization or presented to the emergency room., Conclusions: Patients with ulcers and combined PAD and DM have a higher risk for secondary major and minor amputation than patients with either disease alone with half of the limb loss occurring at approximately 1 year after the initial minor amputation. Additionally, early diagnosis and appropriate referral may result in decreased limb loss for these patients., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Critical limb ischemia remains a difficult disease to treat, with limited level one data. The BEST-CLI trial (Best Endovascular vs Best Open Surgical Therapy in Patients with Critical Limb Ischemia) is attempting to answer whether initial treatment with open surgical bypass or endovascular therapy improves outcomes, although it remains in enrollment. This study aims to compare amputation-free survival and reintervention rates in patients treated with initial open surgical bypass or endovascular intervention for ischemic ulcers of the lower extremities., Methods and Results: Using California nonfederal hospital data linked to statewide death data, all patients with lower extremity ulcers and a diagnosis of peripheral artery disease who underwent a revascularization procedure from 2005 to 2013 were identified. Propensity scores were formulated from baseline patient characteristics. Inverse probability weighting was used with Kaplan-Meier analysis to determine amputation-free survival and time to reintervention for open versus endovascular treatment. Mixed-effects Cox proportional hazards modeling was used to adjust for patient ability to manage their disease and hospital revascularization volume. A total of 16 800 patients were identified. Open surgical bypass was the initial treatment in 5970 (36%) while 10 830 (64%) underwent endovascular interventions. Patients in the endovascular group were slightly younger compared with the open group (70 versus 71 years, ±12 years; P<0.001). Endovascular-first patients were more likely to have comorbid renal failure (36% versus 24%), coronary artery disease (34% versus 32%), congestive heart failure (19% versus 15%), and diabetes mellitus (65% versus 58%; all P values <0.05). After inverse propensity weighting as well as adjustment for patient ability to manage their disease and hospital revascularization experience, open surgery first was associated with a worse amputation-free survival (hazard ratio, 1.16; 95% CI, 1.13-1.20) with no difference in mortality (hazard ratio, 0.94; 95% CI, 0.89-1.11). Endovascular first was associated with higher rates of reintervention (hazard ratio, 1.19; 95% CI, 1.14-1.23)., Conclusions: Patients with critical limb ischemia have multiple comorbidities, and initial surgical bypass is associated with poorer amputation-free survival compared with an endovascular-first approach, perhaps due to increased severity of wounds at the time of presentation.

Perceptual decision making is an active process where animals move their sense organs to extract task-relevant information. To investigate how the brain translates sensory input into decisions during active sensation, we developed a mouse active touch task where the mechanosensory input can be precisely measured and that challenges animals to use multiple mechanosensory cues. Male mice were trained to localize a pole using a single whisker and to report their decision by selecting one of three choices. Using high-speed imaging and machine vision, we estimated whisker-object mechanical forces at millisecond resolution. Mice solved the task by a sensory-motor strategy where both the strength and direction of whisker bending were informative cues to pole location. We found competing influences of immediate sensory input and choice memory on mouse choice. On correct trials, choice could be predicted from the direction and strength of whisker bending, but not from previous choice. In contrast, on error trials, choice could be predicted from previous choice but not from whisker bending. This study shows that animal choices during active tactile decision making can be predicted from mechanosensory and choice-memory signals, and provides a new task well suited for the future study of the neural basis of active perceptual decisions. SIGNIFICANCE STATEMENT Due to the difficulty of measuring the sensory input to moving sense organs, active perceptual decision making remains poorly understood. The whisker system provides a way forward since it is now possible to measure the mechanical forces due to whisker-object contact during behavior. Here we train mice in a novel behavioral task that challenges them to use rich mechanosensory cues but can be performed using one whisker and enables task-relevant mechanical forces to be precisely estimated. This approach enables rigorous study of how sensory cues translate into action during active, perceptual decision making. Our findings provide new insight into active touch and how sensory/internal signals interact to determine behavioral choices., (Copyright © 2019 Campagner, Evans et al.)

The prefrontal cortex (PFC) is thought to learn the relationships between actions and their outcomes. But little is known about what changes to population activity in PFC are specific to learning these relationships. Here we characterize the plasticity of population activity in the medial PFC (mPFC) of male rats learning rules on a Y-maze. First, we show that the population always changes its patterns of joint activity between the periods of sleep either side of a training session on the maze, regardless of successful rule learning during training. Next, by comparing the structure of population activity in sleep and training, we show that this population plasticity differs between learning and nonlearning sessions. In learning sessions, the changes in population activity in post-training sleep incorporate the changes to the population activity during training on the maze. In nonlearning sessions, the changes in sleep and training are unrelated. Finally, we show evidence that the nonlearning and learning forms of population plasticity are driven by different neuron-level changes, with the nonlearning form entirely accounted for by independent changes to the excitability of individual neurons, and the learning form also including changes to firing rate couplings between neurons. Collectively, our results suggest two different forms of population plasticity in mPFC during the learning of action-outcome relationships: one a persistent change in population activity structure decoupled from overt rule-learning, and the other a directional change driven by feedback during behavior. SIGNIFICANCE STATEMENT The PFC is thought to represent our knowledge about what action is worth doing in which context. But we do not know how the activity of neurons in PFC collectively changes when learning which actions are relevant. Here we show, in a trial-and-error task, that population activity in PFC is persistently changing, regardless of learning. Only during episodes of clear learning of relevant actions are the accompanying changes to population activity carried forward into sleep, suggesting a long-lasting form of neural plasticity. Our results suggest that representations of relevant actions in PFC are acquired by reward imposing a direction onto ongoing population plasticity., (Copyright © 2019 the authors.)