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There is a high prevalance of burnout and mental health illness among trainees. Through structured meetings, Program Directors (PDs) have an opportunity to screen and aid residents that may be affected by mental health concerns. However, barriers to this process exist. This study sought to evaluate the perspectives of PDs regarding mental health screening for trainees.A 13-item survey-based study.Electronic distribution of the survey was performed via three individualized requests sent via e-mail to PDs.PDs of 5 ACGME specialties, including Internal Medicine, Pediatrics, Emergency Medicine, General Surgery, and Psychiatry were invited to participate.In total, 595 PDs responded to the survey (response rate = 40.0%) In general, PDs expressed dissatisfaction with the management of burnout and mental health. Most PDs supported periodic screening of residents for burnout (87.0%) and mental health (73.9%). For a resident that could screen positive for mental illness, most PDs were concerned about the possibility of harm to a patient (70.7%) and implications for future licensing (65.7%). Only 30.2% of PDs currently use some form of standardized screening to identify residents struggling with mental health and burnout concerns.The majority of PDs across 5 ACGME specialties support the use of periodic screening of residents for burnout and mental health. However, concerns exist regarding such screening such as the implications for future licensing. Additional work needs to be done to address PD concerns and destigmatizate mental health wellbeing and care among trainees.

Despite awareness regarding financial toxicity in breast cancer care, little is known about the financial strain associated with breast reconstruction. This study aims to describe financial toxicity and identify factors independently associated with financial toxicity for women pursuing post-mastectomy breast reconstruction. A 33-item electronic survey was distributed to members of the Love Research Army. Women over 18 years of age and at least 1 year after post-mastectomy breast reconstruction were invited to participate. The primary outcome of interest was self-reported financial toxicity due to breast reconstruction, while secondary outcomes of interest were patient-reported out-of-pocket expenses and impact of financial toxicity on surgical decision making. In total, 922 women were included (mean age 58.6 years, standard deviation 10.3 years); 216 women (23.8%) reported financial toxicity from reconstruction. These women had significantly greater out-of-pocket medical expenses. When compared with women who did not experience financial toxicity, those who did were more likely to have debt due to reconstruction (50.9% vs. 3.2%, p

The quest to find the ideal prosthetic device interface that enables intuitive control has motivated several recent innovations. Although current prosthetic device control strategies have advanced the field of neuroprosthetic control, they are limited in their ability to generate reliable, stable, and specific signals to replicate the complex movements of the upper extremity. The regenerative peripheral nerve interface (RPNI) is a promising solution to enhance prosthetic device control. This article describes the development of RPNIs and summarizes its successful use in the control of advanced prosthetic devices in patients with upper extremity amputations.

A key factor in the clinical translation of brain-machine interfaces (BMIs) for restoring hand motor function will be their robustness to changes in a task. With functional electrical stimulation (FES) for example, the patient’s own hand will be used to produce a wide range of forces in otherwise similar movements. To investigate the impact of task changes on BMI performance, we trained two rhesus macaques to control a virtual hand with their physical hand while we added springs to each finger group (index or middle-ring-small) or altered their wrist posture. Using simultaneously recorded intracortical neural activity, finger positions, and electromyography, we found that predicting finger kinematics and finger-related muscle activations across contexts led to significant increases in prediction error, especially for muscle activations. However, with respect to online BMI control of the virtual hand, changing either training task context or the hand’s physical context during online control had little effect on online performance. We explain this dichotomy by showing that the structure of neural population activity remained similar in new contexts, which could allow for fast adjustment online. Additionally, we found that neural activity shifted trajectories proportional to the required muscle activation in new contexts, possibly explaining biased kinematic predictions and suggesting a feature that could help predict different magnitude muscle activations while producing similar kinematics.

Objective. Brain–machine interfaces (BMIs) have shown promise in extracting upper extremity movement intention from the thoughts of nonhuman primates and people with tetraplegia. Attempts to restore a user’s own hand and arm function have employed functional electrical stimulation (FES), but most work has restored discrete grasps. Little is known about how well FES can control continuous finger movements. Here, we use a low-power brain-controlled functional electrical stimulation (BCFES) system to restore continuous volitional control of finger positions to a monkey with a temporarily paralyzed hand. Approach. We delivered a nerve block to the median, radial, and ulnar nerves just proximal to the elbow to simulate finger paralysis, then used a closed-loop BMI to predict finger movements the monkey was attempting to make in two tasks. The BCFES task was one-dimensional in which all fingers moved together, and we used the BMI’s predictions to control FES of the monkey’s finger muscles. The virtual two-finger task was two-dimensional in which the index finger moved simultaneously and independently from the middle, ring, and small fingers, and we used the BMI’s predictions to control movements of virtual fingers, with no FES. Main results. In the BCFES task, the monkey improved his success rate to 83% (1.5 s median acquisition time) when using the BCFES system during temporary paralysis from 8.8% (9.5 s median acquisition time, equal to the trial timeout) when attempting to use his temporarily paralyzed hand. In one monkey performing the virtual two-finger task with no FES, we found BMI performance (task success rate and completion time) could be completely recovered following temporary paralysis by executing recalibrated feedback-intention training one time. Significance. These results suggest that BCFES can restore continuous finger function during temporary paralysis using existing low-power technologies and brain-control may not be the limiting factor in a BCFES neuroprosthesis.

Brain-machine interfaces have shown promise in extracting upper extremity movement intention from the thoughts of nonhuman primates and people with tetraplegia. Attempts to restore a user’s own hand and arm function have employed functional electrical stimulation (FES), but most work has restored discrete grasps. Little is known about how well FES can control continuous finger movements. Here, we use a low-power brain-controlled functional electrical stimulation (BCFES) system to restore continuous volitional control of finger positions to a monkey with a temporarily paralyzed hand. In a one-dimensional, continuous, finger-related target acquisition task, the monkey improved his success rate to 83% (1.5s median acquisition time) when using the BCFES system during temporary paralysis from 8.8% (9.5s median acquisition, equivalent to chance) when attempting to use his temporarily paralyzed hand. With two monkeys under general anesthesia, we found FES alone could control the monkeys’ fingers to rapidly reach targets in a median 1.1s but caused oscillation about the target. Finally, when attempting to perform a virtual two-finger continuous target acquisition task in brain-control mode following temporary hand paralysis, we found performance could be completely recovered by executing recalibrated feedback-intention training one time following temporary paralysis. These results suggest that BCFES can restore continuous finger function during temporary paralysis using existing low-power technologies and brain-control may not be the limiting performance factor in a BCFES neuroprosthesis.

In response to increasing dependence on US Medical Licensing Examination Step 1 scores for resident selection, and to improve medical student well-being and education, the Federation of State Medical Boards and the National Board of Medical Examiners announced that no sooner than 2022, Step 1 score reporting would change from numeric to pass/fail. To gauge the impact that this change will have on the residency application process in physical medicine and rehabilitation, an anonymous survey was electronically distributed to program directors of all accredited physical medicine and rehabilitation residency programs in the United States. A response rate of 49% was obtained. In total, 13% of program directors agreed that the scoring change was a good idea. Eighty percent of program directors felt that the change would increase emphasis on Step 2 clinical knowledge in the application process and that it will be more difficult to objectively compare applicants. Among free-text responses to the survey, 70% disapproved, 10% approved, and the remaining 20% were neutral to the change. The results of this survey show that many physical medicine and rehabilitation program directors are concerned about the implications of the Step 1 score reporting change. These data can serve as a helpful guide to program directors and students preparing for a pass/fail Step 1.

Objective This study sought to evaluate the perspectives of surgical program directors regarding the change of USMLE Step 1 to pass/fail grading. Design Validated electronic survey. Setting Vanderbilt University Medical Center Department of Plastic Surgery. Participants Program directors of all ACMGE-accredited General Surgery, Integrated Vascular Surgery, Integrated Thoracic Surgery, and Integrated Plastic Surgery residency programs. Results The overall response rate was 55.5%. Most PDs (78.1%) disagreed with the scoring change. Only 19.6% believe this change will improve medical student well-being. For 63.5% of PDs, medical school pedigree will become more important, and 52.7% believe it will place international medical graduates at a disadvantage. Only 6.2% believe Step 2 CK should also be pass/fail, while 88.7% will increase the weight of Step 2 CK and 88.4% will now require Step 2 CK score submission with the electronic residency application service. Conclusions While well-intentioned, changing USMLE Step 1 to pass/fail may have unintended consequences and may disadvantage certain groups of applicants. The emphasis on Step 1, and resulting test-taking apprehension, will likely shift to Step 2 CK. Proponents of equitable evaluation should direct their efforts toward increasing, not decreasing, the number of objective measures available for student assessment.

Summary Background Although acellular dermal matrix (ADM) is widely used in expander-implant-based breast reconstructions, previous analyses have been unable to demonstrate improvements in patient-reported outcomes (PROs) with this approach over non-ADM procedures. This study aims to develop a more selective, evidence-based approach to the use of ADM in expander-implant-based breast reconstruction by identifying patient subgroups in which ADM improved clinical outcomes and PROs. Study design The Mastectomy Reconstruction Outcomes Consortium Study prospectively evaluated immediate expander-implant reconstructions at 11 centers from 2012 to 2015. Complications (any/overall and major), and PROs (satisfaction, physical, psychosocial, and sexual well-being) were assessed two years postoperatively using medical records and the BREAST-Q, respectively. Using mixed-models accounting for centers and with interaction terms, we analyzed for differential ADM effects across various clinical subgroups, including age, body mass index, radiation timing, and chemotherapy. Results Expander-implant-based breast reconstruction was performed in 1451 patients, 738 with and 713 without ADM. Major complication risk was higher in ADM users vs. nonusers (22.9% vs. 16.4% and p = 0.04). Major complication risk with ADM increased with higher BMI (BMI=30, OR=1.70; BMI=35, OR=2.29, interaction p = 0.02). No significant ADM effects were observed for breast satisfaction, psychosocial, sexual, and physical well-being within any subgroups. Conclusion In immediate expander-implant-based breast reconstruction, ADM was associated with a greater risk of major complications, particularly in high-BMI patients. We were unable to identify patient subgroups where ADM was associated with significant improvements in PROs. Given these findings and the financial costs of ADM, a more critical approach to the use of ADM in expander-implant reconstruction may be warranted.

Objective(s): To compare otolaryngology program director, house-staff, and medical student perspectives on the score reporting change of USMLE Step 1 to pass/fail. Methods: Separate electronic surveys were sent to program directors of ACGME-accredited otolaryngology programs (Cronbach’s alpha = .87), otolaryngology house-staff (Cronbach’s alpha = .91), and medical students interested in otolaryngology (Cronbach’s alpha = .76). Results: Among the 51 otolaryngology program directors that completed the survey (response rate of 46.8%), 17.6% favored reporting USMLE Step 1 as pass/fail. A majority believed the reporting change would make it more difficult to screen (74.5%) and objectively compare applicants (82.4%). Step 2 CK scores will be more important to most program directors due to the reporting change (83.7%). Of the 93 house-staff that completed surveys, most did not favor the reporting change (61.3%). Over half (54.0%) of the 87 medical students that completed surveys did not support the scoring change, and most (65.5%) did not feel that it would decrease anxiety around residency applications (65.5%). Most house-staff and medical students felt that the scoring change would put non-U.S. MD students at a disadvantage (65.6% of house-staff, 69.8% of medical students). Conclusion: Most survey respondents do not agree with the decision to report Step 1 as pass/fail. Despite its intended goals, most do not believe pass/fail Step 1 reporting will improve medical student well-being and believe it will put certain student populations at a greater disadvantage.

Objective Measures Needed A large majority of U.S. residency program directors do not agree with changing scoring on the USMLE Step 1 exam to pass/fail, and they believe that scores on the Step 2 C...

To understand perspectives of urology program directors (PDs) regarding the management and screening of resident mental health and burnout.After piloting and survey validation, an IRB-exempt 14 question survey was distributed to PDs of all 145 ACGME accredited urology residency programs. Statistical significance was determined using an alpha value of 0.05 and response plurality was determined by non-overlapping 95% confidence intervals.A total of 72 PDs completed the survey (response rate = 49.6%). The majority of PDs (59.7%) do not use standardized screening for resident burnout or mental health. A statistically significant proportion of PDs agreed to implementing periodic mental health (75.0%, 95% CI [65.0%-75.0%]) and burnout (87.6%, 95% CI [79.9%-95.1%]) screening. Female PDs were more likely to agree to implementing mental health screening compared to male PDs (female=94.4% vs male=68.5%; P =.03). If mental health screening was implemented and a resident tested positive, PDs were most concerned about harm to a patient (72.2%, 95% CI [61.9-82.6]) and implications of a positive screen on future licensing and practice (55.6%, 95% CI [44.1-67.0]).Although the majority of urology PDs believe residents should be periodically screened for burnout and mental health, most do not currently screen their trainees. If mental health screening was implemented, PDs expressed concern about patient harm and challenges associated with future licensing. Our survey results suggest opportunities for improving management of resident burnout and mental health.

Background The Plastic Surgery Milestones Project was implemented in 2014 to establish standards for competency based resident education. In restructuring educational activities under the Milestones, various pedagogical tools have been revised. However, these standards have not yet been applied to the Plastic Surgery In-Service Training Examination. The purpose of this study was to determine the representation of the various components of the Plastic Surgery Milestones Project, on the In-Service Training Examination. Methods All questions from the 2014 ‐ 2018 In-Service Examinations were evaluated within the framework of the current Plastic Surgery Milestones. Using content analysis, each Examination question was mapped to a single Milestone. Descriptive analysis of Milestone subject area and Core Competency breakdown, as well as year to year trends, were performed. Results Of the 1,150 questions analyzed, there was an unequal representation of individual Milestones (0-7.4%). Of the 36 Plastic Surgery Milestones, 10 represented more than 50% of the PSITEs while 8 Milestones had less than 1% representation. The most common subject area was Head and Neck (12.7%) and least common was Reconstruction of the Trunk and Perineum. Among Core Competencies, more than half (50.4%) tested Patient Care while Interpersonal and Communication Skills was the lowest represented, 0.2%. Conclusions The Plastic Surgery In-Service Examination tests a variable proportion of Milestones. Currently, the PSITE is not well integrated with competency based education in spite of a shift towards such a training model. Going forward, the PSITE may include an associated Milestone with each question in order to better incorporate Competencies into this important annual evaluation metric.

Background Cervical dystonia is a disabling medical condition that drastically decreases quality of life. Surgical treatment consists of peripheral nerve denervation procedures with or without myectomies or deep brain stimulation (DBS). The current objective was to compare the efficacy of peripheral denervation versus DBS in improving the severity of cervical dystonia through a systematic review and meta-analysis. Methods A search of PubMed, MEDLINE, EMBASE, and Web of Science electronic databases was conducted in accordance with PRISMA guidelines. Preoperative and postoperative Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) total scores were used to generate standardized mean differences and 95% confidence intervals (CIs), which were combined in a random-effects model. Both mean percentage and absolute reduction in TWSTRS scores were calculated. Absolute reduction was used for forest plots. Results Eighteen studies met the inclusion criteria, comprising 870 patients with 180 (21%) undergoing DBS and 690 (79%) undergoing peripheral denervation procedures. The mean follow-up time was 31.5 months (range, 12–38 months). In assessing the efficacy of each intervention, forest plots revealed significant absolute reduction in total postoperative TWSTRS scores for both peripheral denervation (standardized mean difference 1.54; 95% CI 1.42–1.66) and DBS (standardized mean difference 2.07; 95% CI 1.43–2.71). On subgroup analysis, DBS therapy was significantly associated with improvement in postoperative TWSTRS severity (standardized mean difference 2.08; 95% CI 1.66–2.50) and disability (standardized mean difference 2.12; 95% CI 1.57–2.68) but not pain (standardized mean difference 1.18; 95% CI 0.80–1.55). Conclusions Both peripheral denervation and DBS are associated with a significant reduction in absolute TWSTRS total score, with no significant difference in the magnitude of reduction observed between the 2 treatments. Further comparative data are needed to better evaluate the long-term results of both interventions.

Learning objectives After studying this article, the participant should be able to: 1. Describe treatment options for phalangeal fractures. 2. Choose an appropriate fracture management plan that optimizes patient goals and range of motion. 3. Describe closed and open reduction techniques of commonly encountered phalangeal fracture patterns. Summary Phalangeal fractures are the second most common upper extremity fracture. Although many can be treated with splinting, operative intervention may be required for unstable fracture patterns and those involving the articular surface. Failure to appropriately treat these fractures can result in finger stiffness, loss in range of motion, and functional deficits. The type of fixation method can range from percutaneous pinning to open reduction and internal fixation. This article presents a series of cases to illustrate the appropriate management of phalangeal fractures using an evidence-based approach.

Despite awareness regarding financial toxicity in breast cancer care, little is known about the financial strain associated with breast reconstruction. This study aims to describe financial toxicity and identify factors independently associated with financial toxicity for women pursuing post-mastectomy breast reconstruction.A 33-item electronic survey was distributed to members of the Love Research Army. Women over 18 years of age and at least 1 year after post-mastectomy breast reconstruction were invited to participate. The primary outcome of interest was self-reported financial toxicity due to breast reconstruction, while secondary outcomes of interest were patient-reported out-of-pocket expenses and impact of financial toxicity on surgical decision making.In total, 922 women were included (mean age 58.6 years, standard deviation 10.3 years); 216 women (23.8%) reported financial toxicity from reconstruction. These women had significantly greater out-of-pocket medical expenses. When compared with women who did not experience financial toxicity, those who did were more likely to have debt due to reconstruction (50.9% vs. 3.2%, p 0.001). Younger age, lower annual household income, greater out-of-pocket expenses, and a postoperative major complication were independently associated with an increased risk for financial toxicity. If faced with the same decision, women experiencing financial toxicity were more likely to decide against reconstruction (p 0.001) compared with women not experiencing financial toxicity.Nearly one in four women experienced financial toxicity from breast reconstruction. Women who reported higher levels of financial toxicity were more likely to change their decisions about surgery. Identified factors predictive of financial toxicity could guide preoperative discussions to inform decision making that mitigates undesired financial decline.

Background Patients with symptomatic Crohn's disease who undergo abdominoperineal resection can experience impaired postoperative wound healing. This results in significant morbidity, burdensome dressing changes, and increased postoperative pain. When abdominoperineal resection is performed for oncological reasons, autologous flap reconstruction is occasionally performed to optimize wound healing and reconstruction outcomes. However, the role of flap reconstruction after abdominoperineal resection for Crohn's disease has not been established. Objective This study examines the utility of flap reconstruction in patients with symptomatic Crohn's disease undergoing abdominoperineal resection. We hypothesize that patients with immediate flap reconstruction after abdominoperineal resection will demonstrate improved wound healing. Design This study is a retrospective chart review. Settings Eligible patients at our institution were identified from 2010 to 2018 by using a combination of Current Procedural Terminology, International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision codes. Patients Of 40 adult patients diagnosed with Crohn's disease, 20 underwent abdominoperineal resection only and 20 underwent abdominoperineal resection with flap reconstruction. Interventions Immediate autologous flap reconstruction was performed after abdominoperineal resection. Main outcome measures The primary outcomes measured were the presence of postoperative perineal wounds and postoperative wound care burden. Results Patients in the abdominoperineal resection with flap reconstruction group demonstrated significantly worse preoperative disease traits, including fistula burden, than patients in the abdominoperineal resection only group. A lower number of patients tended to be associated with a persistent perineal wound in the flap group at 30 days (abdominoperineal resection with flap reconstruction = 55% vs abdominoperineal resection only = 70%; p = 0.327) and at 6 months (abdominoperineal resection with flap reconstruction = 25% vs abdominoperineal resection only = 40%; p = 0.311) postoperatively. There was also a trend toward a lower incidence of complications in the flap group. Patients in the abdominoperineal resection with flap reconstruction group tended to experience lower postoperative pain than patients in the abdominoperineal resection only group. Limitations This retrospective cohort study was limited by its reliance on data in electronic medical records, and by its small sample size and the fact that it was a single-institution study. Conclusions In select patients who have severe perianal fistulizing Crohn's disease, there may be a benefit to immediate flap reconstruction after abdominoperineal resection to lower postoperative wound care burden without significant intraoperative or postoperative risk. In addition, flap reconstruction may lead to lower postoperative pain. See Video Abstract at http://links.lww.com/DCR/B416. El rol de la reconstruccin con colgajo autlogo en pacientes con enfermedad de crohn sometidos a reseccin abdominoperineal ANTECEDENTES:Los pacientes con enfermedad de Crohn sintomatica que se someten a una reseccion abdominoperineal pueden experimentar una curacion posoperatoria deficiente de la herida. Esto da como resultado una morbilidad significativa, cambios de aposito molestos y un aumento del dolor posoperatorio. Cuando se realiza una reseccion abdominoperineal por razones oncologicas, ocasionalmente se realiza una reconstruccion con colgajo autologo para optimizar los resultados de la curacion y reconstruccion de la herida. Sin embargo, no se ha establecido la funcion de la reconstruccion con colgajo despues de la reseccion abdominoperineal para la enfermedad de Crohn.OBJETIVO:Este estudio examina la utilidad de la reconstruccion con colgajo en pacientes con enfermedad de Crohn sintomatica sometidos a reseccion abdominoperineal. Presumimos que los pacientes con reconstruccion inmediata con colgajo despues de la reseccion abdominoperineal demostraran una mejor curacion de la herida.DISENO:Revision retrospectiva de expedientes.MARCO:Los pacientes elegibles en nuestra institucion se identificaron entre 2010 y 2018 mediante una combinacion de los codigos de Terminologia actual de procedimientos, Clasificacion internacional de enfermedades 9 y Clasificacion internacional de enfermedades 10.PACIENTES:Cuarenta pacientes adultos diagnosticados con enfermedad de Crohn que se someten a reseccion abdominoperineal solamente (APR-solo = 20) y reseccion abdominoperineal con reconstruccion con colgajo (APR-colgajo = 20).INTERVENCION (ES):Reconstruccion inmediata con colgajo autologo despues de la reseccion abdominoperineal.MEDIDAS DE RESULTADOS PRINCIPALES:Presencia de herida perineal posoperatoria y carga de cuidado de la herida posoperatoria.RESULTADOS:Los pacientes del grupo APR-colgajo demostraron rasgos de enfermedad preoperatoria significativamente peores, incluida la carga de la fistula, en comparacion con los pacientes del grupo APR-solo. Un numero menor de pacientes tendio a asociarse con una herida perineal persistente en el grupo de colgajo a los 30 dias (APR-colgajo = 55% vs APR-solo = 70%; p = 0.327) y 6 meses (APR-colgajo = 25% vs APR-solo = 40%; p = 0.311) postoperatoriamente. Tambien hubo una tendencia hacia una menor incidencia de complicaciones en el grupo APR-colgajo. Los pacientes del grupo APR-colgajo tendieron a experimentar menos dolor posoperatorio en comparacion con el grupo APR-solo.LIMITACIONES:Estudio de cohorte retrospectivo basado en datos de historias clinicas electronicas. Tamano de muestra pequeno y estudio de una sola institucion.CONCLUSIONES:En pacientes seleccionados que tienen enfermedad de Crohn fistulizante perianal grave, la reconstruccion inmediata del colgajo despues de la reseccion abdominoperineal puede beneficiar a reducir la carga posoperatoria del cuidado de la herida sin riesgo intraoperatorio o posoperatorio significativo. Ademas, la reconstruccion con colgajo puede resultar un dolor posoperatorio menor. Consulte Video Resumen en http://links.lww.com/DCR/B416.

Background Pass/fail USMLE Step 1 score reporting may have varying implications for trainees of different demographic and training backgrounds. Objective To characterize the perspectives of a diverse cohort of trainees on the impact of pass/fail Step 1 score reporting. Methods In 2020, 197 US and international medical school deans and 822 designated institutional officials were invited to distribute anonymous electronic surveys among their trainees. Separate surveys for medical students and residents/fellows were developed based on the authors' prior work surveying program directors on this topic. Underrepresented in medicine (UiM) was defined in accordance with AAMC definitions. Descriptive and comparative analyses were performed, and results were considered statistically significant with P < .05. Results A total of 11 633 trainees responded (4379 medical students and 7254 residents/fellows; 3.3% of an estimated 285 000 US trainees). More students favored the score reporting change than residents/fellows (43% vs 31%; P < .001; 95% CI 0–24). Trainees identifying as UiM were more likely to favor the change (50% vs 34%; P < .001; 95% CI 0–32) and to agree it would decrease socioeconomic disparities (44% vs 25%; P < .001; 95% CI 0–38) relative to non-UiM trainees. Nearly twice as many osteopathic and international medical graduate students felt they would be disadvantaged compared to MD students because of pass/fail score reporting (61% vs 31%; P < .001; 95% CI 0–60). Conclusions Trainee perspectives regarding USMLE Step 1 score reporting are mixed. UiM trainees were more likely to favor the score reporting change, while osteopathic and international medical students were less in favor of the change.

Modern brain-machine interfaces can return function to people with paralysis, but current upper extremity brain-machine interfaces are unable to reproduce control of individuated finger movements. Here, for the first time, we present a real-time, high-speed, linear brain-machine interface in nonhuman primates that utilizes intracortical neural signals to bridge this gap. We created a non-prehensile task that systematically individuates two finger groups, the index finger and the middle-ring-small fingers combined. During online brain control, the ReFIT Kalman filter could predict individuated finger group movements with high performance. Next, training ridge regression decoders with individual movements was sufficient to predict untrained combined movements and vice versa. Finally, we compared the postural and movement tuning of finger-related cortical activity to find that individual cortical units simultaneously encode multiple behavioral dimensions. Our results suggest that linear decoders may be sufficient for brain-machine interfaces to execute high-dimensional tasks with the performance levels required for naturalistic neural prostheses.

Background We conducted a segmental volumetric analysis of pre-operative brain magnetic resonance images (MRIs) of glioblastoma patients to identify brain- and tumor-related features that are prognostic of survival. Methods Using a dataset of 210 single-institutional adult glioblastoma patients, total volumes of the following tumor- and brain-related features were quantified on pre-operative MRIs using a fully automated segmentation tool: tumor enhancement, tumor non-enhancement, tumor necrosis, peri-tumoral edema, grey matter, white matter, and cerebrospinal fluid (CSF). Their association with survival using Cox regression models, adjusting for the well-known predictors of glioblastoma survival. The findings were verified in a second dataset consisting of 96 glioblastoma patients from The Cancer Imaging Archive and The Cancer Genome Atlas (TCIA/TCGA). Results CSF volume and edema were independently and consistently associated with overall survival of glioblastoma patients in both datasets. Greater edema was associated with increased hazard or decreased survival [adjusted hazard ratio (aHR) with 95% confidence interval (CI): 1.34 [1.08–1.67], p = 0.008 (institutional dataset); and, 1.44 [1.08–1.93], p = 0.013 (TCIA/TCGA dataset)]. Greater CSF volume also correlated with increased hazard or decreased survival [aHR 1.27 [1.02–1.59], p = 0.035 (institutional dataset), and 1.42 [1.03–1.95], p = 0.032 (TCIA/TCGA dataset)]. Conclusions Higher brain CSF volume and higher edema levels at diagnosis are independently associated with decreased survival in glioblastoma patients. These results highlight the importance of a broader, quantitative brain-wide radiological analyses and invite investigations to understand tumor-related causes of increased edema and possibly increased CSF volume.

Background The neurosurgery match is among the most competitive across all specialties. As a result, numerical Step U.S. Medical Licensing Examination Step 1 scores have historically played a major role in selecting applicants for interviews. With the anticipated change in Step 1 scoring to pass/fail will come significant ramifications for how program directors (PDs) screen and select applicants. The present study characterized the responses of PDs to the change in U.S. Medical Licensing Examination Step 1 scoring and its consequences on medical students applying to neurosurgery. Methods After receipt of an institutional review board exemption, a validated 19-item survey was electronically distributed to 99 PDs of neurosurgery training programs as a part of a national study across 30 residency specialties. Descriptive statistical analyses were performed, and statistical significance was determined by nonoverlapping 95% confidence intervals. Results A total of 48 responses were obtained (48.5%). Most PDs were men, with a mean age of 52 years, and, on average, had served 7.4 years as a PD. Most PDs (79%) disagreed with binary Step 1 scoring. Most (85%) believed the change will make objective comparison of applicants more difficult, and 83% reported they will begin to require Step 2 clinical knowledge scores with application submission. More than one half (71%) believed medical school reputation will become more important in resident selection. Only 15% believed that pass/fail Step 1 scoring will improve medical student well-being. Conclusion Binary Step 1 scoring represents a significant change in medical student evaluations, with consequences for the neurosurgery residency application process. The results from the present study might help guide PD practices and prepare medical students for the anticipated changes to the application process.

Background: Carpal tunnel release (CTR) is the most common hand surgery operation performed in the United States. While serious complications are rare, they can be life-altering to patients. In some cases, patients will pursue malpractice claims against the surgeon. This study aimed to understand the patient, procedure, and surgeon factors involved in CTR malpractice litigation. Methods: The Westlaw legal database was queried for all recorded CTR malpractice cases resulting in jury verdicts and settlements. Only cases directly related to injury after CTR were included in this study. Cases were reviewed to determine plaintiff demographics, defendant training, liability, injury, outcomes, and monetary awards. Results: Ninety-two unique cases were identified. Plaintiffs were predominantly female (n = 65, 71%). Most surgeons were orthopedic-trained (n = 37, 52%). Only 27% of defendants (n = 19) were hand fellowship-trained. Only 19% of cases resulting in a monetary award were against surgeons who had hand fellowship training. The majority of cases (n = 61, 66%) were found in favor of the defendant. Monetary awards averaged $305 923 (range = $12 000-1 338 147), while settlements averaged $266 250. Alleged liability was most for surgeon negligence (n = 69, 75%) with a third of cases resulting in monetary awards. Median nerve injury was claimed in 41 cases (45%), with 17 (41%) resulting in monetary awards. Conclusion: Although CTR is generally safe and effective, some patients will experience complications. Median nerve injury was the most common reason for successful litigation in this study. Adequate training and experience in hand surgery may lower the risk of injuries resulting in successful malpractice suits.

Background Rhinoplasty remains one of the most common aesthetic procedures performed in the United States. Current literature on rhinoplasty complications is inconclusive and is based on retrospective reviews and small cohorts. Objectives The purpose of this study was to examine the incidence and identify predictive risk factors for major complications following rhinoplasty alone or in combination with other aesthetic operations in a large, prospective, multicenter database study. Methods A prospective cohort of patients undergoing rhinoplasty between May 2008 and May 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major complications, defined as complications requiring an emergency room visit, hospital admission, or a reoperation within 30 days of the index operation. Univariate and multivariate analysis evaluated potential risk factors for major complications including age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, and combined procedures. Results A total of 129,007 patients were identified, of which 4978 (3.9%) underwent a rhinoplasty. The overall complication rate was 0.7% (n = 37). Hematoma was the most common complication (0.2%), followed by infection (0.2%), and pulmonary complications (0.1%). Age ≥40 years was found to be an independent risk factor for developing complications. Age ≥40 years was found to have a relative risk of 2.05 (P = 0.04) for any major complication. Complications increased from 0.58% in rhinoplasty alone cases to 1.02% (P < 0.05) with the addition of 1 other body region to 2.09% with the addition of 2 other body regions (P < 0.05). The risk of pulmonary complications increased from 0.1% to 1% (P < 0.05) with the addition of rhinoplasty with 2 other body regions. Gender, type of facility, smoking status, and BMI ≥25 did not appear to significantly impact the risk for major complications. Conclusions The major complication rate following rhinoplasty remains low. The risk is increased with age ≥40 years and with the addition of other cosmetic procedures. Pulmonary complications, although rare, do occur, and also increase when combining rhinoplasty with other aesthetic surgery. These findings are important to consider when planning rhinoplasty and educating patients on the safety of combined aesthetic surgeries. Level of Evidence 2.

The numerous office visits required to complete expansion in implant-based breast reconstruction impact patient satisfaction, office resources, and time to complete reconstruction. This study aimed to determine whether prepectoral compared to subpectoral immediate implant-based breast reconstruction offers expedited tissue expansion without affecting complication rates.Consecutive patients who underwent immediate implant-based breast reconstruction with tissue expanders from January of 2016 to July of 2017 by a single surgeon were grouped into subpectoral (partial submuscular/partial acellular dermal matrix) or prepectoral (complete acellular dermal matrix coverage), and reviewed. The primary outcomes were total days and number of visits to complete expansion. Groups were compared by univariate analysis with significance set at p0.05.In total, 101 patients (subpectoral, n = 69; prepectoral, n = 32) underwent 184 immediate implant-based breast reconstructions (subpectoral, n = 124; prepectoral, n = 60). There was no difference in age, body mass index, smoking, or diabetes between the groups (all p0.05). Follow-up was similar between groups (179.3 ± 98.2 days versus 218.3 ± 119.8 days; p = 0.115). Prepectoral patients took fewer days to complete expansion (40.4 ± 37.8 days versus 62.5 ± 50.2 days; p0.001) and fewer office visits to complete expansion (2.3 ± 1 .7 versus 3.9 ± 1.8; p0.001), and were expanded to greater final volumes than subpectoral patients (543.7 ± 122.9 ml versus 477.5 ± 159.6 ml; p = 0.017). Between prepectoral and subpectoral reconstructions, there were similar rates of minor complications (25 percent versus 18.5 percent; p = 0.311), readmissions (5 percent versus 2.4 percent; p = 0.393), seromas (8.3 percent versus 5.6 percent; p = 0.489), reoperations for hematoma (3.3 percent versus 1.6 percent; p = 0.597), and explantations (5 percent versus 2.4 percent; p = 0.393).This novel analysis demonstrates that prepectoral immediate implant-based breast reconstruction can facilitate expansion to higher total volumes in nearly half the office visits compared to subpectoral placement in similar populations without increasing complication rates.Therapeutic, III.

The texting of protected health information (PHI) has raised concerns about breach of privacy as it relates to the Health Insurance Portability and Accountability Act (HIPAA). Within psychiatry, limited guidelines exist on HIPAA-permissible texting. Given the legal implications of a breach, we sought to better understand texting patterns among psychiatrists by surveying members of the Association for Academic Psychiatry, 53 of whom responded. Only 63% of respondents felt confident in their knowledge of HIPAA. While 64% reported that texting PHI is prohibited, most (53%) still used texting to communicate PHI. Currently, HIPAA is technology neutral and texting PHI is not explicitly prohibited, provided safeguards are taken and physicians securely communicate PHI.