Variation in Oral Board Examination Accommodations Among Specialties.

Importance: Board certification can have broad implications for candidates' career trajectories, and prior research has found sociodemographic disparities in pass rates. Barriers in the format and administration of the oral board examinations may disproportionately affect certain candidates. Objective: To characterize oral certifying examination policies and practices of the 16 Accreditation Council for Graduate Medical Education (ACGME)-accredited specialties that require oral examinations. Design, Setting, and Participants: This cross-sectional study was conducted from March 1 to April 15, 2023, using data on oral examination practices and policies (examination format, dates, and setting; lactation accommodations; and accommodations for military deployment, family emergency, or medical leave) as well as the gender composition of the specialties' boards of directors obtained from websites, telephone calls and email correspondence with certifying specialists. The percentages of female residents and residents of racial and ethnic backgrounds who are historically underrepresented in medicine (URM) in each specialty as of December 31, 2021, were obtained from the Graduate Medical Education 2021 to 2022 report. Main Outcome and Measures: For each specialty, accommodation scores were measured by a modified objective scoring system (score range: 1-13, with higher scores indicating more accommodations). Poisson regression was used to assess the association between accommodation score and the diversity of residents in that specialty, as measured by the percentages of female and URM residents. Linear regression was used to assess whether gender diversity of a specialty's board of directors was associated with accommodation scores. Results: Included in the analysis were 16 specialties with a total of 46 027 residents (26 533 males [57.6%]) and 233 members of boards of directors (152 males [65.2%]). The mean (SD) total accommodation score was 8.28 (3.79), and the median (IQR) score was 9.25 (5.00-12.00). No association was found between test accommodation score and the percentage of female or URM residents. However, for each 1-point increase in the test accommodation score, the relative risk that a resident was female was 1.05 (95% CI, 0.96-1.16), and the relative risk that an individual was a URM resident was 1.04 (95% CI, 1.00-1.07). An association was found between the percentage of female board members and the accommodation score: for each 10% increase in the percentage of board members who were female, the accommodation score increased by 1.20 points (95% CI, 0.23-2.16 points; P = .03). Conclusions and Relevance: This cross-sectional study found considerable variability in oral board examination accommodations among ACGME-accredited specialties, highlighting opportunities for improvement and standardization. Promoting diversity in leadership bodies may lead to greater accommodations for examinees in extenuating circumstances.

Biomechanical profile of varying suture button constructs in cadaveric specimens: a systematic review and meta-analysis.

Background: Suture button fixation of syndesmotic injuries allows for more physiologic motion of the ankle joint while maintaining adequate reduction and may avoid the need for additional surgeries, given the lower risk of syndesmotic diastasis and implant failure. Few studies have examined the optimal number and configuration of suture buttons for syndesmotic disruption. The purpose of this systematic review and meta-analysis is to compare different suture button configurations from the cadaveric literature and to assess their relative effect on the stability of the syndesmotic reduction and functional movement of the ankle. Methods: A literature search in the databases MEDLINE via PubMed, Embase via Elsevier, Scopus via Elsevier, and SPORTDiscus via EBSCO were searched through December 2022 to identify studies related to cadaveric modeling of the syndesmosis. Only cadaveric studies with suture button fixation and studies in English were included. The quality of cadaveric studies was assessed using the Quality Assessment for Cadaveric Studies (QUACS) tool. Revman 5.3 software was used to perform the meta-analysis. Results: The meta-analysis included 5 studies and 86 limbs. The systematic review included 15 studies. When comparing single and double suture button configurations, no difference was found between groups with regard to fibular rotation (MD =-0.9; 95% CI: -2.09 to 0.27; I2=79%; P=0.13) and both groups had similar rotational stability. The double suture button technique did demonstrate less sagittal fibular translation compared to the single suture button (MD =0.48; 95% CI: 0.02-0.94; I2=66%; P=0.04). When comparing two suture buttons in parallel and divergent configurations, studies did not find any differences with regard to strength or stability. Conclusions: There were no significant differences in biomechanical parameters when comparing single and double suture button constructs. While single button suture constructs result in minimal fibular rotation, double suture button constructs minimize fibular translation. This review may serve as a guide for clinicians when approaching these injuries.

Jones Fracture in the National Football League.

Background: Jones fracture, or proximal fifth metatarsal fracture, is a common injury in National Football League (NFL)-caliber athletes. Combine draft performance can greatly impact the long-term success of these athletes, and substantial emphasis has been placed on early return to play (RTP) and the minimization of post-operative complications after Jones fracture in these athletes. To date, no study has specifically described the treatment and outcomes of this injury specifically in NFL-caliber players, considering factors relevant to this unique population. Thus, the purpose of this review is to delve into Jones fracture in NFL-caliber athletes, evaluating the diagnostic, treatment, and RTP considerations. Methods: We searched Medline (PubMed), Embase (Elsevier), Scopus (Elsevier), and SPORTDiscus (EBSCOhost) for the concept of Jones fractures in the NFL. Using the PRISMA guidelines, a team of three reviewers conducted abstract screenings, full-text screenings, and the extraction of studies describing Jones fractures specifically in the NFL. Results: Of the 1911 studies identified, 6 primary retrospective studies met the inclusion and exclusion criteria. The heterogeneity of the outcome reporting precluded a meta-analysis; thus, a qualitative review of manuscripts describing Jones fracture was carried out. Classification, diagnosis, and treatment considerations, RTP statistics and outcomes, and complications were discussed. Amongst the primary studies, there were 285 Jones fractures, all athletes were able to RTP, and the average time to RTP ranged from 6 weeks to 27 weeks. For complications, with operative treatment, the refracture rate ranged from 4 to 12%, and incomplete healing ranged from 7 to 50%. RTP was 15 weeks for refractures. There were no patient-reported outcomes. Conclusions: The vast majority of Zone 2/3 Jones fractures are treated with IM screw fixation with or without adjunctive orthobiologics, such as bone marrow aspirate concentrate, in NFL-caliber athletes. The six major series investigating outcomes after the operative treatment of Jones fractures in NFL players reveal very positive findings overall with regard to RTP, reoperation, and career continuation.

Can tumor treating fields induce DNA damage and reduce cell motility in medulloblastoma cell lines?

OBJECTIVE: Medulloblastoma (MB) is the most common malignant pediatric brain tumor and accounts for approximately 20% of all pediatric CNS tumors. Current multimodal treatment is associated with a 70%-90% 5-year survival rate; however, the prognosis for patients with tumor dissemination and recurrent MB remains poor. The majority of survivors exhibit long-term neurocognitive complications; thus, more effective and less toxic treatments are critically needed. Tumor treating fields (TTFields) are low-intensity, alternating electric fields that disrupt cell division through physical interactions with key molecules during mitosis. Side effects from TTField therapy are minimal, making it an ideal candidate for MB treatment. METHODS: To determine if TTFields can be an effective treatment for MB, the authors conducted an in vitro study treating multiple MB cell lines. Three MB molecular subgroups (SHH [sonic hedgehog], group 3, and group 4) were treated for 24, 48, and 72 hours at 100, 200, 300, and 400 kHz. Combinatorial studies were conducted with the small-molecule casein kinase 2 inhibitor CX-4945. RESULTS: TTFields reduced MB cell growth with an optimal frequency of 300 kHz, and the most efficacious treatment time was 72 hours. Treatment with TTFields dysregulated actin polymerization and corresponded with a reduction in cell motility and invasion. TTFields also induced DNA damage (γH2AX, 53BP1) that correlated with an increase in apoptotic cells. The authors discovered that CX-4945 works synergistically with TTFields to reduce MB growth. In addition, combining CX-4945 and TTFields increased the cellular actin dysregulation, which correlated with a decrease in MB migration. CONCLUSIONS: The findings of this study demonstrate that TTFields may be a novel and less toxic method to treat patients with MB.

Targeted genomic CRISPR-Cas9 screen identifies MAP4K4 as essential for glioblastoma invasion.

Among high-grade brain tumors, glioblastoma is particularly difficult to treat, in part due to its highly infiltrative nature which contributes to the malignant phenotype and high mortality in patients. In order to better understand the signaling pathways underlying glioblastoma invasion, we performed the first large-scale CRISPR-Cas9 loss of function screen specifically designed to identify genes that facilitate cell invasion. We tested 4,574 genes predicted to be involved in trafficking and motility. Using a transwell invasion assay, we discovered 33 genes essential for invasion. Of the 11 genes we selected for secondary testing using a wound healing assay, 6 demonstrated a significant decrease in migration. The strongest regulator of invasion was mitogen-activated protein kinase 4 (MAP4K4). Targeting of MAP4K4 with single guide RNAs or a MAP4K4 inhibitor reduced migration and invasion in vitro. This effect was consistent across three additional patient derived glioblastoma cell lines. Analysis of epithelial-mesenchymal transition markers in U138 cells with lack or inhibition of MAP4K4 demonstrated protein expression consistent with a non-invasive state. Importantly, MAP4K4 inhibition limited migration in a subset of human glioma organotypic slice cultures. Our results identify MAP4K4 as a novel potential therapeutic target to limit glioblastoma invasion.