Should Organizational Investment in Robotic Surgical Technology Ever Influence Surgeons' Decisions About Surgical Approach to Patients' Surgical Care?

This commentary on a case considers balancing prospective benefits and harms of robotic technology use and argues that health care organizations should invest in centralizing robotic expertise in departments rather than having a mere collection of surgeons trained in robotics. This commentary also examines costs that should be considered in organizational determinations of robotics investments.

Robotic Inguinal Hernia Repair - Update 2022 during the SARS-COVID-19 Pandemic.

INTRODUCTION: Inguinal hernia repair is one of the most common surgical procedures performed by general surgeons. Numerous articles have shown that robotic inguinal hernia repair is safe and effective, but also more costly than other hernia repair techniques. The robotic platform uses high-definition visualization and articulating instruments. A growing number of surgeons are using this technology to refine and obtain a critical view of the myopectineal orifice for hernia repair while lessening the pain associated with the open surgical approach. Lower insufflation pressures and good results without Foley catheterization have been reported. This report presents an update, with a focus on the past 3 years during the SARS COVID-19 pandemic, of a series of robotic, laparoscopic inguinal hernia repairs by a single surgeon with extensive laparoscopic hernia experience at a single institution, along with a review of the recent current literature. METHODS: Over 3000 laparoscopic inguinal hernia operations have been performed by the author since 1990. One hundred-fifty-eight were performed from April 2020 to November 2022, in addition to the previously reported 420 robotic TAPP (trans-abdominal pre-peritoneal) procedures performed from April 2012 to March 2020. Hospital records and follow-up care were prospectively reviewed and the patient's age, sex, American Society of Anesthesia (ASA) class and operative time were obtained. Follow-up was done at 2 weeks and 6 weeks following surgery. All patients consented to the use of their data in the study. RESULTS: Ninety-four percent (94%) of the patients were male. The average age was 64.3 years (range 18-91). Co-morbidities included hypertension, hypercholesterolemia, prostatism and GERD, among others. BMI was between 19 and 37.1 (mean 26.1). In 23 patients (15%), an umbilical hernia repair was performed concomitantly. OR time ranged from 25 to 90 minutes (mean 51.8). Complications were uncommon and urinary retention (2.5%) was an infrequent post-operative occurrence. CONCLUSIONS: 1) Use of a lower insufflation pressure (8-12 mm Hg) was routine. 2) Use of a structural mesh (4x6 inches) gave satisfactory results. 3) While fixation of the mesh was not necessary, fibrin sealant was used routinely. 4) Urinary retention was infrequent, and did not require pre- or intra-op Foley catheterization if the patient voided immediately prior to surgery. Finally, 5) OR time was consistently less than 1 hour. These results support the conclusion that robotic inguinal hernia repair is safe and effective.

A Multicenter Analysis of the Early Impact of COVID-19 on Junior Resident Operative Case Volume.

INTRODUCTION: Institutions have reported decreases in operative volume due to COVID-19. Junior residents have fewer opportunities for operative experience and COVID-19 further jeopardizes their operative exposure. This study quantifies the impact of the COVID-19 pandemic on resident operative exposure using resident case logs focusing on junior residents and categorizes the response of surgical residency programs to the COVID-19 pandemic. MATERIALS AND METHODS: A retrospective multicenter cohort study was conducted; 276,481 case logs were collected from 407 general surgery residents of 18 participating institutions, spanning 2016-2020. Characteristics of each institution and program changes in response to COVID-19 were collected via surveys. RESULTS: Senior residents performed 117 more cases than junior residents each year (P < 0.001). Prior to the pandemic, senior resident case volume increased each year (38 per year, 95% confidence interval 2.9-74.9) while junior resident case volume remained stagnant (95% confidence interval 13.7-22.0). Early in the COVID-19 pandemic, junior residents reported on average 11% fewer cases when compared to the three prior academic years (P = 0.001). The largest decreases in cases were those with higher resident autonomy (Surgeon Jr, P = 0.03). The greatest impact of COVID-19 on junior resident case volume was in community-based medical centers (246 prepandemic versus 216 during pandemic, P = 0.009) and institutions which reached Stage 3 Program Pandemic Status (P = 0.01). CONCLUSIONS: Residents reported a significant decrease in operative volume during the 2019 academic year, disproportionately impacting junior residents. The long-term consequences of COVID-19 on junior surgical trainee competence and ability to reach cases requirements are yet unknown but are unlikely to be negligible.

Just Do It: Participation in Structured Online Curricula Reliably Improves Low ABSITE Scores.

OBJECTIVE: We hypothesized residents enrolled in an Accelerated Clinical Education in Surgery (ACES) program would improve their scores to above the 30th percentile. We analyzed which components of ACES correlated with improvement. DESIGN AND SETTING: A retrospective review of three academic cycles (2018-2021) at an academic general surgery residency. PARTICIPANTS: Residents scoring ≤30th percentile on the ABSITE were enrolled in ACES. Baseline demographics including STEP scores were collected. ACES included: (1) SCORE and DeckerMed assignments (2) Weekly faculty review sessions and (3) Monthly meeting with assigned mentor. Data were analyzed by Student's t-test, one-way ANOVA and Fisher's exact test. RESULTS: Twenty-six surgical residents enrolled in ACES. Compared to residents not in ACES, there was no significant difference females (15 vs. 15; p = 0.19) and STEP 2 scores (241 vs. 246; p = 0.06). Residents in ACES had significantly lower STEP 1 (225 vs. 237; p < 0.001) and STEP 3 (212 vs. 223; p < 0.001) scores. Demographics of ACES residents who subsequently scored >30th percentile were similar to those who didn't, except for STEP 3 scores (216 vs. 204; p = 0.008). For residents in ACES, the completion of assignments between July and January was significantly higher for those who subsequently achieved an ABSITE score >30th percentile: TWIS, 77% vs. 53% (p = 0.022), Decker WC, 80% vs. 49% (p = 0.009) and Decker MR, 53% vs. 29% (p = 0.016). Completion of an online practice exam prior to ABSITE also correlated with score >30th percentile (57% vs. 13%, p = 0.007). There was also no correlation between the number of faculty review sessions and ABSITE (11.5 vs.11.9, p = 0.931). CONCLUSIONS: Participation in a structured online program of reading and quizzes was durably effective in improving ABSITE scores >30th percentile. Completion of online assignments, rather than scores on practice tests or review sessions, appeared to be the most important factor for success.

Effective Large Group Teaching for General Surgery.

Large group settings display no signs of disappearing. Most surgeons charged with this education have received no formal training. Lecturing remains the most common method of educating large groups. Even though factors required for an excellent lecture are known, their inconsistent application results in variation of effectiveness. Long-standing principles of rhetoric and recent advances in neuroscience, cognitive science, learning models, and teaching theory play a role in achieving effectiveness. This article makes recommendations for creating and delivering lectures, including active learning opportunities and modern innovations in information technology supporting teaching methods. Effective lecturing skills are acquired by persistent deliberate practice.

The effect of perturbations of the glycocalyx on microvascular perfusion in the obese trauma population: an in vitro study.

OBJECTIVES: Patients with morbid obesity have impaired responses to resuscitation following severe injury, which may contribute to adverse outcomes. Obesity is associated with microvascular dysfunction and metabolic changes associated with altered hemorheological profiles. These include decreased red blood cell (RBC) deformity associated with increased aggregation and adhesion. These RBC changes may be impacted by the glycocalyx layer of the endothelial cell (EC) and RBC. Degradation of either or both glycocalyx layers may impair microvascular perfusion. This was studied from blood obtained from patients with obesity and in an in vitro microfluidic device to mimic the microvascular environment. METHODS: RBCs were obtained from fresh whole blood from normal controls and patients with obesity (body mass index 37.6-60.0). RBC glycocalyx was indexed by fluorescent intensity and shedding of EC glycocalyx components into the serum was determined by measurement of syndecan-1 and hyaluronic acid. In a second set of experiments, human umbilical vein endothelial cell monolayers (HUVEC) were perfused with RBC suspensions from control and patients with obesity using a microfluidic device and RBC adherence under normoxic or shock conditions (hypoxia+epinephrine) was determined using confocal microscopy. HUVEC glycocalyx thickness and shedding were also measured. RESULTS: Microfluidic studies demonstrated that RBC obtained from subjects with obesity had increased adhesion to the endothelial layer, which was more profound under shock conditions versus normal subjects. This appeared to be related to increased shedding of the endothelial glycocalyx following shock as well as a diminished RBC glycocalyx layer in the obese population. CONCLUSION: Blood from patients with obesity have decreased RBC glycocalyx thickness accompanied by evidence of increased EC glycocalyx shedding. In vitro adhesion to the endothelium was more pronounced with RBC from patients with obesity and was significantly greater under 'shock conditions'. Hemorheological properties of RBC from patients with obesity may account for failure of standard resuscitation procedures in the trauma patient.

Signet-Ring Cell Colon Cancer in a Teenager: A Case Report.

The majority of colon cancers are diagnosed in the older population, though recent trends have demonstrated an increase in younger patients. Most colon cancers are considered adenocarcinoma. There are multiple histologic subtypes with varying prognoses. Mucinous types such as signet-ring cell carcinoma (SRCC) are more aggressive with poor outcomes. SRCC frequently presents with metastatic disease which contributes to its poor prognosis. It is most commonly diagnosed around age 40. SRCC of colonic origin is very rare and comprises only 1% of colorectal cancers. Rarer still is presentation in the teenaged patient, especially in the absence of any risk factors. We present a case of an 18-year-old male with colonic SRCC. The patient presented initially with vague abdominal discomfort and three weeks later was found to have a near-obstructing right-sided colon mass. He was taken to the operating room and found to have diffuse carcinomatosis. The patient underwent palliative loop ileostomy with plans for subsequent chemotherapy.

Ulnar Collateral Ligament Reconstruction in Adolescents: A Systematic Review.

BACKGROUND: Ulnar collateral ligament (UCL) reconstruction is an established surgical technique to restore UCL deficiency, especially in the overhead throwing athlete. Over the past decade, the number of patients requiring UCL reconstruction has increased significantly, particularly in the adolescent patient population. Return-to-play rates after UCL reconstruction reported in the literature have ranged from 33% to 92%, and a recent systematic review noted a return-to-play rate of 89.40% in all high school athletes. PURPOSE: To evaluate the outcomes, particularly return-to-play rates and subjective outcome scores, of UCL reconstruction of the elbow in adolescent throwing athletes. STUDY DESIGN: Systematic review. METHODS: A systematic review of the literature was conducted via the electronic databases Embase, PubMed, and Cochrane. Studies that reported on outcomes, particularly return-to-play rates, in adolescent throwing athletes met the inclusion criteria and were included in our analysis. Studies that did not report on adolescent throwing athletes and studies that reported on adolescent throwing athletes but did not specify the return-to-play outcomes for these athletes were excluded from our analysis. RESULTS: Nine studies met the inclusion criteria and were included in this review. There were 404 baseball players and 10 javelin throwers included in our analysis. A total of 349 of the 414 patients (84.30%) were successfully able to return to play at the same level of competition or higher. Successful rates of return to prior performance ranged from 66.67% to 91.49% in our analysis. Javelin throwers had a mean 80.00% rate of return to prior performance, while baseball players had a mean return-to-play rate of 84.40%. Complications were evaluated for 8 (88.9%) studies and 283 (68.4%) patients. There were 11 (3.9%) reported complications and 5 (1.8%) reoperations. CONCLUSION: The findings of this systematic review revealed that adolescent patients are generally able to return to their preinjury level of performance or higher with limited complications. Further investigation is necessary to determine long-term outcomes for return to play after UCL reconstruction of the elbow in adolescent throwing athletes.

Impact of Surgery Program Characteristics on Fate of Non-designated Preliminary Surgery Interns.

OBJECTIVE: Non-designated preliminary (NDP) general surgery residents face the daunting challenge of obtaining a categorical residency position while undertaking the rigors of a general surgery residency. This additional application cycle represents a stressful time for these trainees and limited data exists to help guide applicants and program directors regarding the factors predictive of application success. While previous studies have focused solely on applicant related factors, no study to date has evaluated the effect of the residency program structure, institutional resources, or administrative support on these outcomes. DESIGN/SETTING: A multicenter retrospective review of 10 general surgery residency programs over a 5-year period from 2014 to 2019 was performed. Applicant related information was compiled from NDP general surgery residents and the results of their attempted second application into a categorical position. Applicant factors including age, gender, standardized test scores (USMLE/ABSITE), and professional training were examined. Program and administrative structure including residency class size, number of NDP PGY-2 positions, number of assistant program directors and program director (PD) background were also examined. Primary success was defined as a NDP resident successfully obtaining a categorical position within general surgery or a surgical subspecialty. Secondary success was obtaining a categorical residency position in any field of medical practice other than surgery or a surgical subspecialty in the United States. RESULTS: A total of 260 NDP trainees were evaluated with an average age of 29.1. Almost seventy percent of applicants were male, 40% graduated from a non-U.S. medical school and 24.2% required a visa to work in the United States. Thirty 4 percent of NDPs successfully obtained a categorical surgery position and an additional 35% obtained a categorical residency position in a nonsurgical field for an overall match success rate of 68.9%. Factors associated with primary success included ABSITE score (p < 0.001), US medical school graduation (p = 0.02), visa status (p = 0.03), presence of preliminary PGY-2 positions (p = 0.02), and PD professional development time (p = 0.004). Overall success was associated USMLE Step 1 scores (p = 0.02), number of approved chiefs (p = 0.03), presence of dedicated faculty researchers (p = 0.001), and PD professional development time (p < 0.001). CONCLUSIONS: Applicant, program-related, and administrative factors all have a significant impact on the success of NDP general surgery residents in obtaining a categorical surgical position. Trainees should consider all of these factors when applying to NDP residencies and in approaching their second application cycle to maximize their likelihood of a successful match.

A data-driven examination of which patients follow trial protocol.

Protocol adherence in behavioral intervention clinical trials is critical to trial success. There is increasing interest in understanding which patients are more likely to adhere to trial protocols. The objective of this study was to demonstrate the use of a data-driven approach to explore patient characteristics associated with the lowest and highest rates of adherence in three trials assessing interventions targeting behaviors related to lifestyle and risk for cardiovascular disease. Each trial included a common set of baseline variables. Model-based recursive partitioning (MoB) was applied in each trial to identify participant characteristics of subgroups characterized by these baseline variables with differences in protocol adherence. Bootstrap resampling was conducted to provide optimism-corrected c-statistics of the final solutions. In the three trials, rates of protocol adherence varied from 56.9% to 87.5%. Evaluation of heterogeneity of protocol adherence via MoB in each trial resulted in trees with 2-4 subgroups based on splits of 1-3 variables. In two of the three trials, the first split was based on pain in the past week, and those reporting lower pain were less likely to be adherent. In one of these trials, the second and third splits were based on education and employment, where those with lower education levels and who were employed were less likely to be adherent. In the third trial, the two splits were based on smoking status and then marriage status, where smokers who were married were least likely to be adherent. Optimism-corrected c-statistics ranged from 0.54 to 0.63. Model-based recursive partitioning can be a useful approach to explore heterogeneity in protocol adherence in behavioral intervention trials. An important next step would be to assess whether patterns hold in other similar studies and samples. Identifying subgroups who are less likely to be adherent to an intervention can help inform modifications to the intervention to help tailor the intervention to these subgroups and increase future uptake and impact. TRIAL REGISTRATION: ClinicalTrials.gov identifiers: NCT01828567, NCT02360293, and NCT01838226.

Robotic Inguinal Hernia Repair.

INTRODUCTION: Laparoscopic inguinal hernia repair has certain advantages over open repair including less pain and earlier return to normal activity. Robotic surgery adds high definition visualization and articulating instruments. This enhanced dexterity can make laparoscopic hernia repair more refined while obtaining a critical view of the myopectineal orifice that should lead to fewer recurrences and complications. A series of robotic, laparoscopic, inguinal hernia repairs by a single surgeon with extensive laparoscopic hernia experience at a single institution along with a review of the literature was undertaken to determine the role of robotic laparoscopic inguinal hernia repair in minimally invasive surgery. MATERIALS AND METHODS: One thousand laparoscopic inguinal hernia operations were performed from April 2012 through March 2020. There were 420 cases of robotic trans-abdominal pre-peritoneal (TAPP) procedures done during that time. Hospital records and follow-up care were prospectively reviewed and data was collected for age, sex, American Society of Anesthesia (ASA) class, and operative time. Follow up was done at two weeks, eight weeks, and 16 weeks following surgery. All patients consented for study. RESULTS: Ninety-four percent (94%) of the patients were male. Age averaged 57.8 years with a range of 18-85 years. ASA averaged 2.01 with comorbidities of hypertension, hypercholesterolemia, and GERD being the most common. Body mass index (BMI) was between 19-40.5 averaging 26.6. Sixty-three patients (15%) had an umbilical hernia repair done concomitantly. Operating room (OR) time ranged from 25-140 minutes, with an average of 54.36 minutes, and decreased as experience increased. One patient with a large, left scrotal hernia was converted to open, one patient developed perforated sigmoid diverticulitis seven days postoperative and four recurred indirectly after a direct hernia repair. Urinary retention was the most problematic postoperative occurrence. CONCLUSIONS: Robotic inguinal hernia repair is safe and effective. 1) Proper training, including simulators and proctors, is necessary; 2) having the same operating room team and an interested first assistant at the OR table is very helpful; 3) the learning curve is about 50 patients; 4) postoperative narcotics are rarely more than three hydrocodone pills; 4) no fixation of the mesh is necessary, but fibrin sealant was used routinely in these patients; and 5) urinary retention is the most common postoperative issue and is best planned for by knowing the patients urinary history, use of peripheral alpha-blockers, and straight catheterization in the OR at the conclusion of the surgery. OR time was longer than standard laparoscopic herniorrhaphy but decreased with experience. The robotic technique allowed for an excellent view of the myopectineal orifice and appears to have a low complication rate.

Author Correction: Clinical Implications of Sub-grouping HER2 Positive Tumors by Amplicon Structure and Co-amplified Genes.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

A Prospective Evaluation of Adverse Reactions to Single-Dose Intravenous Antibiotic Prophylaxis During Outpatient Hand Surgery.

Background: While it is established that routine prophylactic antibiotics are not needed for all hand surgery, some cases do require it. The purpose of this study was to determine the rate of adverse reactions resulting from prophylactic antibiotic administration on patients undergoing outpatient hand and upper extremity surgical procedures. We hypothesize that the rate of complications resulting from the use of antibiotic prophylaxis is smaller than that reported in the currently referenced literature. Methods: We prospectively evaluated 570 consecutive patients undergoing outpatient upper extremity surgery. Patients were excluded if they were on antibiotics prior to surgery, were discharged on antibiotics, or if they wished to be excluded. Nineteen patients were excluded, resulting in a study cohort of 551 patients. Patients were monitored perioperatively, 2 to 3 days postoperatively, during the first postoperative visit and 1 month postoperatively for adverse reactions. The type and timing of the adverse reaction was recorded. Results: Five hundred fifty-one patients were included for evaluation and 8 patients (1.5%) developed an adverse reaction to antibiotics. Five patients (0.9%) reported a rash and 3 patients (0.5%) reported diarrhea within 3 days of surgery. There were no anaphylactic reactions or complications necessitating hospital transfer or admission in the postoperative period. Conclusion: This study represents a prospective investigation designed to determine the rate of adverse reactions to single-dose antibiotics given during outpatient hand surgery. We conclude that the use of intravenous, single-dose prophylactic antibiotic is safe in the outpatient setting for cases that require it.

Clinical Implications of Sub-grouping HER2 Positive Tumors by Amplicon Structure and Co-amplified Genes.

ERBB2 amplification is a prognostic marker for aggressive tumors and a predictive marker for prolonged survival following treatment with HER2 inhibitors. We attempt to sub-group HER2+ tumors based on amplicon structures and co-amplified genes. We examined five HER2+ cell lines, three HER2+ xenographs and 57 HER2+ tumor tissues. ERBB2 amplification was analyzed using digital droplet PCR and low coverage whole genome sequencing. In some HER2+ tumors PPM1D, that encodes WIP1, is co-amplified. Cell lines were treated with HER2 and WIP1 inhibitors. We find that inverted duplication is the amplicon structure in the majority of HER2+ tumors. In patients suffering from an early stage disease the ERBB2 amplicon is composed of a single segment while in patients suffering from advanced cancer the amplicon is composed of several different segments. We find robust WIP1 inhibition in some HER2+ PPM1D amplified cell lines. Sub-grouping HER2+ tumors using low coverage whole genome sequencing identifies inverted duplications as the main amplicon structure and based on the number of segments, differentiates between local and advanced tumors. In addition, we found that we could determine if a tumor is a recurrent tumor or second primary tumor and identify co-amplified oncogenes that may serve as targets for therapy.

A Prospective Evaluation of Complications after Use of Exposed Pins in the Hand and Wrist.

BACKGROUND: Kirschner wires are commonly used during hand surgical procedures. These pins are often left exposed (protruding from the skin) for ease of removal. Complications such as loosening, migration, or infection are not uncommon (ranging from 7 to 18 percent in current retrospective studies) and can compromise surgical outcome. This study evaluated the frequency of Kirschner wire-related complications. METHODS: All patients who had Kirschner wires placed as part of their surgical procedure in the hand or wrist by one of 12 attending hand surgeons over a 6-month period were enrolled prospectively. Complications were recorded by the attending surgeon at follow-up visits. Demographics and patient comorbidities including diabetes mellitus and smoking history were recorded. RESULTS: There were 141 patients enrolled and 230 pins used, including 65 women and 76 men. The mean age was 40.7 years. Thirteen patients were smokers, and eight had a history of diabetes. There were 35 soft-tissue procedures and 106 fractures. There were 35 complications (25 percent). There was a 12 percent rate of infection (n = 17), including two cases of osteomyelitis. There were 18 other complications, nine of which were major complications (6.4 percent). Smoking, age, and location (hand/fingers versus wrist) were significantly associated with infection. CONCLUSIONS: In this study, one in four patients treated with Kirschner wires developed a minor or major complication, a rate that is substantially higher than reported in existing retrospective studies. Although Kirschner wires are often needed during hand surgery, surgeons should be aware that adverse events are frequent. Patients and surgeons should be vigilant in the perioperative period. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Temporary Bridge Plate Stabilization of Unstable Elbow Fractures and Dislocations.

Unstable fracture-dislocations of the elbow, and in particular the "terrible triad" injury consisting of an elbow dislocation with a fracture of the radial head and coronoid, are complex injuries that can be plagued and complicated by persistent instability. Acute and chronic instability is a difficult problem and is best managed early by avoidance and restoration of stability. A number of treatment options have been proposed to manage acute postfixation instability of the elbow joint. Traditional stabilization options include immobilization with splinting or casting, cross-articular pinning, and external fixation (hinged or static), followed by early physical therapy. However, each of these approaches can still yield persistent elbow instability. We are proposing a new technique of acute but temporary bridge plate stabilization of the elbow joint to protect the concentrically reduced elbow joint following repair of all injured structures to restore stability followed by staged removal and the delayed initiation of therapy.

A problem-solving intervention for cardiovascular disease risk reduction in veterans: Protocol for a randomized controlled trial.

BACKGROUND: Health behaviors related to diet, tobacco usage, physical activity, medication adherence, and alcohol use are highly determinative of risk for developing cardiovascular disease. This paper describes a study protocol to evaluate a problem-solving intervention that aims to help patients at risk for developing cardiovascular disease address barriers to adopting positive health behaviors in order to reduce cardiovascular risk. METHODS: Eligible patients are adults enrolled in Veterans Affairs (VA) health care who have not experienced a cardiovascular event but are at elevated risk based on their Framingham Risk Score (FRS). Participants in this two-site study are randomized to either the intervention or care as usual, with a target of 400 participants. The study intervention, Healthy Living Problem-Solving (HELPS), consists of six group sessions conducted approximately monthly interspersed with individualized coaching calls to help participants apply problem-solving principles. The primary outcome is FRS, analyzed at the beginning and end of the study intervention (6months). Participants also complete measures of physical activity, caloric intake, self-efficacy, group cohesion, problem-solving capacities, and demographic characteristics. CONCLUSION: Results of this trial will inform behavioral interventions to change health behaviors in those at risk for cardiovascular disease and other health conditions. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT01838226.

A survey of current state of training of plastic surgery residents.

BACKGROUND: Plastic surgery training is undergoing major changes however there is paucity of data detailing the current state of training as perceived by plastic surgical trainees. Our aim was to determine the quality of training as perceived by the current trainee pool and their future plans. METHODS: A 25-item anonymous survey with three discrete sections (demographics, quality of training, and post-graduate career plans) was developed and distributed to plastic surgery residents during the academic year 2013. With the confidence interval of 95% and margin of error of 10%, our target response rate was 87 responders. RESULTS: We received a total of 114 respondents with all levels of Post Graduate Year in training represented. Upon comparison of residents with debt of <100,000 to residents with a debt of >250,000, those with higher debt were significantly less interested in fellowship training (p value 0.05) and were more likely to pursue private practice (p value <0.01). Disciplines within plastic surgery least offered as a separate rotation were microsurgery (45%) followed by aesthetic surgery (33%). 53.7% of the residents felt that they were least trained in aesthetic surgery followed by burn surgery 45.4%. Of note 56.4% intended to seek additional training after residency. Moreover residents with an average of 6.4 months of experience in an individual subspecialty were more likely to feel comfortable with that specialty. CONCLUSIONS: This survey highlights the areas and subspecialties that deserve attention as perceived by the current trainee pool.

Treatment inferred from mutations identified using massive parallel sequencing leads to clinical benefit in some heavily pretreated cancer patients.

Molecular portraits of numerous tumors have flooded oncologists with vast amounts of data. In parallel, effective inhibitors of central pathways have shown great clinical benefit. Together, this promises potential clinical benefits to otherwise end-stage cancer patients. Here, we report a clinical service offering mutation detection of archived samples using the ion Ampliseq cancer panel coupled with clinical consultation.A multidisciplinary think tank consisting of oncologists, molecular-biologists, genetic counselors, and pathologists discussed 67 heavily pretreated, advanced cancer patient cases, taking into account mutations identified using ion Ampliseq cancer panel, medical history, and relevant literature.The team generated a treatment plan, targeting specific mutations, for 41 out of 64 cases. Three patients died before results were available. For 32 patients, the treating oncologists chose not to include the panel recommendation in the treatment plan for various reasons. Nine patients were treated as recommended by the panel, 5 with clinical benefit, and 4 with disease progression.This study suggests that routine use of massive parallel tumor sequencing is feasible and can judiciously affect treatment decisions when coupled with multidisciplinary team-based decision making. Administration of personalized based therapies at an earlier stage of disease, expansion of genetic alterations examined, and increased availability of targeted therapies may lead to further improvement in the clinical outcome of metastatic cancer patients.