Representation of women in vascular surgery science and societies.

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.

Why the ABCs Matter More than Ever in Medical Education.

Addressing social drivers of health in medical education-through community engagement experiences-is essential for health equity and the development of future physicians. While this was written before the COVID-19 pandemic, these practices will gain even more importance as we come together to better understand its health and community implications in North Carolina and the United States.

Diagnostic accuracy of physician and self-referred patients for thoracic outlet syndrome is excellent.

BACKGROUND: The purpose of this study was to categorize patients referred to a specialized thoracic outlet syndrome (TOS) practice to determine the diagnostic accuracy of those who are physician and self-referred. METHODS: Demographic and clinical data on all patients who were referred for TOS between 2006 and 2010 were retrospectively reviewed from a prospectively maintained institutional review board-approved database and patient records. RESULTS: Between 2006 and 2010, 621 patients were referred for TOS (433 women and 188 men; mean age 39 years [range 10-87]). Five hundred seventy-one patients (92%) were diagnosed with TOS, with 421 (74%) neurogenic, 126 (22%) venous, and 24 (4%) arterial TOS cases. Of the 525 physician referrals, 478 (91%) had TOS, and of the 93 self-referrals, 90 (97%) had TOS. The 421 patients with neurogenic TOS (NTOS, 304 women and 117 men) had symptoms on average for 56 months (range 1-516). Two hundred seventy-one patients (64%) were initially treated with TOS-specific physical therapy (PT), and 100 (37%) improved. One hundred seventy-eight patients (42%) underwent a lidocaine block, and 145 patients (81%) had a positive block. Seventy-four patients (18%) underwent Botox injections 44 (60%) of which were positive and the average number of Botox injections was 1.3. One hundred forty patients (33%) underwent transaxillary first rib resection and scalenectomy (FRRS), and 128 patients (91%) improved. Of patients undergoing FRRS, 92 (66%) had a lidocaine block, 82 (89%) of which were positive. Of patients with a positive lidocaine block, 74 (90%) improved after FRRS. Of patients undergoing FRRS, 31 (22%) underwent Botox injections, 15 (48%) of which were positive. Of patients with a positive Botox block, 14 (93%) improved after FRRS. Average length of time between initial visit and operation was 6.4 months (range 2 weeks to 34 months), and average follow-up time was 13 months (range 1 week to 49 months). CONCLUSIONS: 1) Both referring physicians and patients are very accurate in their preliminary diagnosis of TOS (neurogenic, venous, or arterial TOS). 2) In a specialized TOS practice, two-thirds of patients are sent to TOS-specific PT and one-third improve from this treatment alone. 3) One-third of patients referred for NTOS eventually undergo FRRS with a 91% success rate.

The significance of cervical ribs in thoracic outlet syndrome.

OBJECTIVE: The purpose of this study was to review our operative experience in patients with thoracic outlet syndrome (TOS) resulting from cervical ribs causing clinical symptoms. METHODS: This study is a retrospective review of a prospectively acquired database of patients with TOS treated with first rib resection and scalenectomy with or without cervical rib resection at the Johns Hopkins Medical Institutions. RESULTS: Between October 2003 and June 2011, a total of 23 cervical rib resections were performed on 20 patients, three of whom had bilateral cervical ribs resected during separate operations. Seven patients presented with subclavian artery thrombosis. Three of seven patients had subclavian artery aneurysms and underwent cervical rib resection through a supraclavicular approach to facilitate subclavian artery bypass. Five patients presented with an ischemic upper extremity without thrombosis and underwent transaxillary first rib and cervical rib resection. Three patients presented with subclavian vein thrombosis; two of the three patients underwent balloon dilation 2 weeks postoperatively for stenosis. Additionally, five patients presented with neurogenic TOS evidenced by pain, numbness, and weakness without vascular compromise in the affected arm. Cervical ribs with bony fusion to the first rib were found in 17 of 23 cases (74%). CONCLUSIONS: Cervical ribs causing clinical symptoms are large and frequently fused to the first rib, and can result in aneurysm formation or thrombosis. In our experience, both the cervical rib and the first rib must be removed to relieve arterial compression and can usually be done through a transaxillary approach. Only patients with aneurysms needing arterial reconstruction require resection of the artery from a supraclavicular approach.

Anterior Scalene Anomaly in a Patient With Arterial and Neurogenic Thoracic Outlet Syndrome.

Compression of the neurovascular structures of the upper extremity as they pass through the thoracic outlet result in thoracic outlet syndrome. The myriad of symptoms associated with the syndrome vary based on the structure(s) compressed: the subclavian artery/vein or the inferior trunk of the brachial plexus. This is a common site of compression especially in the presence of upper extremity injury, overuse or anatomical abnormalities. Majority of patients present with neurogenic pain and weakness; herein, we present the case of a patient with symptoms of both arterial and neurogenic compression caused by aberrant anterior scalene anatomy. These patients are excellent surgical candidates for first rib resection and anterior scalenectomy. A transaxillary approach offers the clinician an adequate window to identify anatomical abnormalities intraoperatively and safely excise the first rib and anterior scalene muscle.

Academic medical centers write their own rules.

The interaction between pharmaceutical and device companies and hospitals and physicians has undergone significant transformation in the past few years due to the public's perception that bias may result when such relationships are not disclosed and monitored. Policies need to be written by medical centers and hospitals to preserve and retain the trust of the public. The policy written by Johns Hopkins Medical Institutions is outlined and its implications discussed in this article. The importance of such policies in guiding young faculty and staff as they begin their careers cannot be overemphasized.

First rib resection and scalenectomy for chronically occluded subclavian veins: what does it really do?

First rib resection and scalenectomy is an acceptable therapy for those with axillosubclavian vein thrombosis who have responded to lytic therapy and demonstrated subclavian vein patency. However, the treatment for those patients who present with a chronically occluded subclavian vein is controversial. We present four such patients who underwent first rib resection and scalenectomy and whose subclavian vein spontaneously opened within the first year following surgery while anticoagulated, as well as the ultrasound protocol we employ at our institution to identify such reopening. The average age of these patients was 20 (range 17-23) years; three were male and one was female. The average time interval prior to surgery when the initial thrombosis occurred was 25 (12-34) weeks. All patients were symptomatic and underwent a transaxillary first rib resection and scalenectomy with attention to incise the subclavius tendon. All were maintained on warfarin postoperatively and surveilled by duplex scan. In all four patients the subclavian vein subsequently opened after an average of 7 (2-11) months and anticoagulation was stopped. The resultant patent subclavian vein correlated with improvement in symptoms in all four patients. All patients were asymptomatic in the postoperative follow-up period at an average of 14 (2-33 months). In conclusion, selective symptomatic patients with subclavian vein occlusion can be aggressively treated with first rib resection and scalenectomy along with anticoagulation that will lead to recanalization and opening of vein over time. This treatment correlates with improvement of their symptoms.