The Power of Preference Signaling: A Monumental Shift in the Orthopaedic Surgery Application Process.

INTRODUCTION: Orthopaedic surgery has consistently been one of the most competitive specialties in the US residency selection process. This is due in part to the steady upward trend in average applications received per program and average applications submitted per applicant, which is of growing concern. With the implementation of the Preference Signaling Program, the total number of applications has now dropped for the first time in many years, indicating signaling may improve the application process. The hypothesis is that signaling has led to a decrease in applications sent by applicants and a decrease in applications received by programs. METHODS: A 7-question survey regarding their interview and match statistics was sent to orthopaedic surgery residency programs that participated in the Electronic Residency Application Service during the 2023-2024 application cycle. A response from the program director/administrator was then recorded. RESULTS: Our program search yielded 159 programs with 106 respondents (66.7%). 82 programs (78.8%) solely interviewed applicants who signaled their program. 92.7% of current interns signaled the program where they matched, and 88 programs (84.6%) matched only applicants who signaled. 95 programs (89.6%) revealed that implementing signaling has improved the application process. CONCLUSION: Most of the programs only interviewed applicants who also signaled, and nearly all matched orthopaedic surgery applicants from the 2022-2023 cycle signaled their matching program. Orthopaedic surgery applicants should consider only applying to 30 programs and using all 30 available signals. Applicants should also be more confident knowing that beyond the 30 signals they use, there is limited support to say that they will receive an interview outside of these 30 applications. Orthopaedic surgery programs will also now have the ability to allocate more time to applicants most interested in their program, given the reduction of applications.

The Effects of Rearing Environment on Organization of the Olfactory System and Brain of Juvenile Sockeye Salmon, Oncorhynchus nerka.

Pacific salmon (Oncorhynchus spp.) hatch and feed in freshwater habitats, migrate to sea to mature, and return to spawn at natal sites. The final, riverine stages of the return migrations are mediated by chemical properties of the natal stream that they learned as juveniles. Like some other fish, salmon growth is asymptotic; they grow continuously throughout life toward a maximum size. The continued growth of the nervous system may be plastic in response to environmental variables. Due to the ecological, cultural, and economic importance of Pacific salmon, individuals are often reared in hatcheries and released into the wild as juveniles to supplement natural populations. However, hatchery-reared individuals display lower survivorship and may also stray (i.e., spawn in a non-natal stream) at higher rates than their wild counterparts. Hatchery environments may lack stimuli needed to promote normal development of the nervous system, thus leading to behavioral deficits and a higher incidence of straying. This study compared the peripheral olfactory system and brain organization of hatchery-reared and wild-origin sockeye salmon fry (Oncorhynchus nerka). Surface area of the olfactory rosette, diameter of the olfactory nerve, total brain size, and size of major brain regions were measured from histological sections and compared between wild and hatchery-origin individuals. Hatchery-origin fish had significantly larger optic tecta, and marginally insignificant, yet noteworthy trends, existed in the valvula cerebelli (hatchery > wild) and olfactory bulbs (hatchery < wild). We also found a putative difference in olfactory nerve diameter (dmin) (hatchery > wild), but the validity of this finding needs further analyses with higher resolution methods. Overall, these results provide insight into the potential effects of hatchery rearing on nervous system development in salmonids, and may explain behavioral deficits displayed by hatchery-origin individuals post-release.

Epithelioid angiosarcoma of the calf: a case report of an atypical imaging appearance.

Angiosarcoma is an uncommon cause of soft tissue malignancy, accounting for approximately 2% of all soft tissue sarcomas. Of these, epithelioid angiosarcoma represents a morphologic subtype, where the malignant endothelial cells demonstrate a predominantly or exclusively epithelioid appearance. Overall, epithelioid angiosarcoma shares similar imaging characteristics to conventional angiosarcoma including a T1 hypointense to isointense and T2 hyperintense mass, which demonstrates avid enhancement, serpentine feeding vessels, and overlying skin thickening on MRI. The case herein describes a case of epithelioid angiosarcoma in a 65-year-old female presenting with an enlarging calf mass and lower extremity pain. Initial imaging features, particularly on MRI, were highly unusual for angiosarcoma which was thus not strongly considered in the initial differential diagnosis. However, once diagnosis of epithelioid angiosarcoma was confirmed following resection, pathologic correlates were utilized to account for the unusual imaging findings retrospectively. The goal of this study is to not only describe an atypical presentation of an uncommon diagnosis but also attempt to rationalize the unexpected imaging findings with gross and microscopic correlates. Further, the utility of radiology-pathology correlation demonstrated in this case may be useful to others when evaluating similar lesions with unexpected MRI characteristics.

The Value of Signaling an Orthopaedic Surgery Program: A Survey to Orthopaedic Surgery Programs.

INTRODUCTION: A new system was implemented by the Association of American Medical Colleges called the preference signaling program for the 2022 to 2023 orthopaedic surgery residency match. Applicants were able to signal 30 orthopaedic surgery programs to indicate high interest in a specific program. The purpose of this study was to address how important signaling was to an orthopaedic surgery program this 2022 to 2023 application cycle. METHODS: A five-question survey was sent to orthopaedic surgery residency programs participating in the Electronic Residency Application Service this application cycle. Contact information was gathered through the Accreditation Council for Graduate Medical Education residency website and program websites. RESULTS: Responses were obtained from 69 of the 151 programs (46%) contacted. The average number of applicants per program was 727 (range, 372 to 1031, SD 155). Thirty-four of 61 respondents (56%) stated that 100% of their interviewees signaled their program. Fifty-five of 61 respondents (90%) indicated that their interviewee pool consisted of 75% or more applicants who signaled. Applicants who signaled had a 24.4% (range, 12.77 to 47.41, SD 8.04) chance of receiving an interview. Applicants who did not signal had just a 0.92% (range, 0 to 13.10, SD 2.08) chance of receiving an interview. Fifty-four of the 63 applicants (86%) answered that signaling played an important role in considering an applicant for an interview. CONCLUSION: Over half of the responding programs only interviewed applicants who signaled their program, and over 90% of programs' interview lists consisted of at least 75% of signaling applicants. Eighty-six percent of programs indicated that signaling played an important role in considering an applicant for an interview. Applicants who signaled were 26.5 times more likely to receive an interview than those who did not (P < 0.0001). With this information, applicants can narrow down their list of programs to apply to, knowing that their signal to a program will give them a better chance at receiving an interview.

Tumoral calcinosis of the knee treated with open, physeal sparing iliotibial band ACL reconstruction.

Tumoral calcinosis is a hereditary disease of calcium and phosphate metabolism causing peri-articular tumors of calcium deposits. We present a case of tumoral calcinosis in a 13-year-old male with a history of a 12q13.11 genetic deletion. Surgical resection of the tumor necessitated resection of the ACL in its entirety with curettage and adjuvant therapy to the lateral femoral notch, which resulted in ligamentous instability and bony structural incompetency at the femoral insertion. Given the patient's radiographically-apparent skeletal immaturity, and lack of reliable bony architecture to accommodate a femoral ACL tunnel, ACL reconstruction was performed using a physeal-sparing technique. This is a case of tumoral calcinosis treated with, to our knowledge, the first ACL reconstruction using this modified open technique.

Intraoperative navigation and preoperative templating software are associated with increased glenoid baseplate screw length and use of augmented baseplates in reverse total shoulder arthroplasty.

BACKGROUND: Preoperative templating software and intraoperative navigation have the potential to impact baseplate augmentation utilization and increase screw length for baseplate fixation in reverse total shoulder arthroplasty (rTSA). We aimed to assess their impact on the (1) baseplate screw length, (2) number of screws used, and (3) frequency of augmented baseplate use in navigated rTSA. METHODS: We compared 51 patients who underwent navigated rTSA with 63 controls who underwent conventional rTSA at a single institution. Primary outcomes included the screw length, composite screw length, number of screws used, percentage of patients in whom 2 screws in total were used, and use of augmented baseplates. RESULTS: Navigation resulted in the use of significantly longer individual screws (36.7 mm vs. 30 mm, P < .0001), greater composite screw length (84 mm vs. 76 mm, P = .048), and fewer screws (2.5 ± 0.7 vs. 2.8 ± 1, P = .047), as well as an increased frequency of using 2 screws in total (35 of 51 patients [68.6%] vs. 32 of 63 controls [50.8%], P = .047). Preoperative templating resulted in more frequent augmented baseplate utilization (76.5% vs. 19.1%, P < .0001). CONCLUSION: The difference in the screw length, number of screws used, and augmented baseplate use demonstrates the evolving role that computer navigation and preoperative templating play in surgical planning and the intraoperative technique for rTSA.

Primary bone sarcoma with BCOR internal tandem duplication.

BCOR internal tandem duplications (ITDs) and rearrangements are implicated in the oncogenesis of a subset of undifferentiated sarcomas. To date, BCOR ITD sarcomas have been exclusively found in non-appendicular infantile soft tissues, whereas BCOR-rearranged sarcomas occur in both bones and soft tissues affecting a wider patient age range. Little is known about patient outcome in BCOR ITD sarcomas. We present a BCOR-expressing, primary bone, undifferentiated sarcoma case involving an adolescent male's left tibia that, unexpectedly, harbored a BCOR ITD instead of a BCOR rearrangement. Furthermore, the patient achieved a partial histologic response after receiving a Ewing sarcoma chemotherapy regimen. Our case expands the clinical spectrum of BCOR ITD sarcomas and suggests that childhood and adult BCOR-expressing sarcomas with an undifferentiated histology should be considered for both BCOR rearrangement and ITD screening. Accurate BCOR mutation identification in undifferentiated sarcomas is essential to define their clinical spectrum and to develop effective management strategies.

Adolescent vertebral osteomyelitis mimicking a neoplasm.

A 14-year-old previously healthy girl presented with atraumatic onset of low back and flank pain and mildly elevated inflammatory markers. Magnetic resonance imaging disclosed an L5 superior endplate fracture, and cultures grew methicillin-susceptible Staphylococcus aureus. We discuss the variable presentations and appropriate treatments of adolescent vertebral osteomyelitis.

Genetic Architecture of Soybean Yield and Agronomic Traits.

Soybean is the world's leading source of vegetable protein and demand for its seed continues to grow. Breeders have successfully increased soybean yield, but the genetic architecture of yield and key agronomic traits is poorly understood. We developed a 40-mating soybean nested association mapping (NAM) population of 5,600 inbred lines that were characterized by single nucleotide polymorphism (SNP) markers and six agronomic traits in field trials in 22 environments. Analysis of the yield, agronomic, and SNP data revealed 23 significant marker-trait associations for yield, 19 for maturity, 15 for plant height, 17 for plant lodging, and 29 for seed mass. A higher frequency of estimated positive yield alleles was evident from elite founder parents than from exotic founders, although unique desirable alleles from the exotic group were identified, demonstrating the value of expanding the genetic base of US soybean breeding.

Patients' knowledge about the outcomes of thyroid biopsy: a patient survey.

PURPOSE: Fine-needle aspiration biopsy of the thyroid is an increasingly common outpatient procedure. Patients are counseled about the indications and risks of this procedure and informed consent is obtained. We aimed to assess the extent to which patients acquired necessary knowledge during this process. METHODS: Survey study conducted in a thyroid nodule clinic at a referral center. Adult patients who had just undergone a thyroid biopsy were asked to complete a survey, including eight questions regarding the indications and potential outcomes of thyroid biopsy. The main outcome of the study was to assess the patients' knowledge based on the response to each individual survey question. RESULTS: Two-hundred and ninety-seven patients were eligible, of which 196 (66%) completed the survey: most were women (76%), had adequate reading health literacy (95%) and a mean age of 58 years. Although 86% of patients correctly identified evaluation for thyroid cancer as the main indication for their biopsy, 56% were not aware of the likelihood of this diagnosis. Almost all (>90%) of respondents knew that results could be benign or malignant; fewer were aware of non-diagnostic (71%) or indeterminate (68%) outcomes, or of the need for additional diagnostic testing after the biopsy (33%). CONCLUSIONS: After undergoing thyroid biopsy, a high proportion of well-educated patients remained unaware of their risk for thyroid cancer, potential outcomes, and downstream consequences of their biopsy. This quality gap raises the possibility that informed consent procedures that meet legal standards may leave patients undergoing thyroid biopsy paradoxically uninformed.

Single fraction spine stereotactic ablative body radiotherapy with volumetric modulated arc therapy.

This study investigated a single institution's experience with volumetric modulated arc therapy (VMAT) directed stereotactic ablative body radiotherapy (SABR) for vertebral metastases. From 2010 to 2014, 95 lesions of spinal metastases in 73 patients were treated with SABR using VMAT. Clinical local control, pain level, and use of steroid medication were employed to evaluate treatment responses. The majority (79%) of patients were treated with a radiation dose of 20 Gy in a single fraction. However, when normal tissue constraints could not be achieved, the dose was reduced to 18 Gy (11%) or 16 Gy (8%) in 1 fraction. At the median follow up of 12.7 months (mean 18.0, range 1-56 months), clinical local control was 97% (92 out of 95). There was a mean 81% (median 100%, range 28-100%) decrease in subjective pain score. Seventy-seven percent of patients had a decrease in narcotic pain medication use. Pain was completely resolved at the treatment site for 69% (66/95) of patients. Prior to the SABR treatment, 33% (31/95) of patients had epidural extension of tumor. Among patients with epidural involvement, 45% (14/31) exhibited neurologic impairment prior to treatment. Twenty-three percent (7/31) experienced spinal cord compression. Prior to treatment, 34 patients experienced some form of neurologic impairment. Of these patients, 24% (8/34) experienced improved motor functioning; the remaining 76% (26/34) of patients' neurological dysfunction were stable. Our results indicate the SABR regimen using VMAT technique is clinically effective in achieving clinical local control and palliation. This is the first publication reporting clinical outcomes of VMAT directed SABR.

Fibrous Dysplasia in the Calcaneus.

Fibrous dysplasia in the calcaneus is extremely rare; the most common locations of monostotic fibrous dysplasia of extremity bones being the proximal femoral shaft, tibia, humerus, and radius. An extensive literature search has revealed only 3 case reports that have been published concerning this topic, the most recent published in 2003. This is a case report of fibrous dysplasia in the calcaneus of a young male, including a discussion of the classical presentation of fibrous dysplasia and how this case differed. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case study.

Close To You? How Parent-Adult Child Contact Is Influenced by Family Patterns.

OBJECTIVES: Intergenerational contacts occur in the context of other family relationships. We examine how in-person contacts among parents and all adult children affect each other, focusing on proximity and other predictors to assess whether and how visiting is correlated across adult children. METHODS: We use a modeling approach derived from an adaptation of multilevel models to provide a convenient mechanism by which to write child-specific equations, each with its own set of predictors, and wherein one child's attribute values can be attached to other children's records. RESULTS: We find that parent-adult child visiting is positively correlated across siblings, but the frequency of visiting within families is not directly reciprocated. Rather, visiting responds to common family factors. Visiting declines with distance, but there are strong discontinuities in the effect. Distance between parents and a focal child is positively associated with visiting with other children. DISCUSSION: The empirical patterns we report can be framed within enhancement and compensation models. Positive correlations and cross-sibling interactions that juxtapose levels of visiting against not seeing a child in last 12 months are consistent with the enhancement model. The cross-sibling interaction for distance, whereby one child's farther distance leads to more visits reported with others, provides evidence of a countervailing, though, weaker, pattern of compensation for proximity.

Ultrasound-guided fine-needle aspiration of a posterior neck dedifferentiated liposarcoma with MDM2 fluorescence in situ hybridization performed on a Pap-stained smear.

Head and neck liposarcomas, while rare, tend to be subcutaneous and well-differentiated. Dedifferentiated liposarcomas of the head and neck are exceedingly rare in the literature. We present a case of a dedifferentiated liposarcoma arising in the soft tissue of the posterior neck of an 86-year-old man and diagnosed by fine-needle aspiration. Aspirate smears showed a dual population of atypical lipomatous and spindled cells. MDM2 (murine double minute 2) amplification was demonstrated on a Pap-stained smear using fluorescence in situ hybridization (FISH). To the best of our knowledge, this is the first report of MDM2 FISH amplification in a liposarcoma performed on an aspirate smear.

Life-course changes and parent-adult child contact.

Despite increased interest in parent-adult child relations, there has been little attention to how these are influenced by changes in their lives, reflecting transitions and linked lives within a life-course perspective. Hybrid multilevel models are used to analyze the change in parent-adult child contact over two waves of the National Survey of Families and Households. Changes in parent-child proximity, parent and child marital status, and child parental status are associated with change in contact; continued coresidence with another adult child is related to contact with non-coresidential children; but change in parent health does not affect contact. Some patterns are stronger for daughters and biological children who tend to have stronger relationships with their parents. These analyses demonstrate how life-course transitions of parents and adult children can be examined in family context to understand how changes in the life of one family member may influence relations with another.

Change in perceived age in middle and later life.

Analyses examine change in the age people "feel" (felt age) and "would like to be" (ideal age) (relative to current age) in middle and later life. Data are from 1,815 respondents in two waves (1995-96, 2004-06) of the Midlife in the United States Survey (MIDUS) who were age 40+ at Wave 1. In aggregate, people feel about the same amount younger but become increasingly distant from preferred age. Favorable health trends between waves and better expected future health are related to younger felt age, cross-sectionally and longitudinally. Health is not related to ideal age, but education and (for respondents younger than 60) better financial expectations are associated with less youthful ideal age. Patterns for felt age appear to reflect images of later life as a time of physical decline, whereas ideal age appears to be shaped more by socioeconomic considerations.

Atypical intradermal smooth muscle neoplasms (formerly cutaneous leiomyosarcomas): case series, immunohistochemical profile and review of the literature.

Atypical intradermal smooth muscle neoplasms (AISMN, formerly known as cutaneous leiomyosarcomas) are uncommon neoplasms, which seem to be remarkable for their excellent prognosis in contrast to their deeper counterparts. The rarity of AISMN has posed a challenge for characterizing the morphologic spectrum, immunohistochemical staining pattern, and behavior. In this study we evaluated the histologic and immunohistochemical features of 20 cases of AISMN. Clinical follow-up was available on 19 out of 20 patients and ranged from 1 to 124 months with an average of 35 months and a median of 20 months with a male predominance (male to female ratio was 2.3:1). Our data show a wide variation in differentiation and atypical features. Among these, the presence of mitotic figures is diagnostically valuable in rendering the final diagnosis. A broad panel of immunohistochemical stains revealed that smooth muscle actin and muscle specific actin, when used in combination, identified smooth muscle differentiation in 100% of the cases. With some caveats, CD34, S100, and CK 5/6 were helpful in ruling out other important cutaneous spindle cell neoplasms. Significantly, loss of phosphatase and tensin homolog (PTEN) staining was seen in the majority of our cases (80%), supporting a role for PTEN loss in the etiology of these lesions. Logistic regression analysis revealed that positive margin status was helpful for predicting recurrence (100% sensitivity and 94% specificity). We conclude that AISMN can have significant morphologic variation and overlap with other spindle cell neoplasms of the skin and that a limited panel of key immunohistochemical stains should be used to distinguish this lesion. The different surgical measures such as wide excision versus Mohs procedure showed a similar clinical outcome. Although the significance of frequent PTEN loss supports a molecular mechanism of tumor genesis, the diagnostic utility of the stain remains to be determined.

The effects of hypothermia and L-arginine on skeletal muscle function in ischemia-reperfusion injury.

OBJECTIVES: Ischemia-reperfusion (I/R) injury can have detrimental effects on skeletal muscle. We have shown that vessel permeability can be minimized in a hypothermic setting and also by administering the nitric oxide synthase (NOS) stimulator, L-arginine, at physiologic temperatures. The purpose of this study was to examine and compare skeletal muscle contractility after an I/R insult during hypothermic conditions, warm conditions, and also with the administration of L-arginine at physiologic temperatures. We hypothesized that hypothermia and L-arginine administration will also demonstrate protective effects to skeletal muscle contractility. METHODS: Using Sprague-Dawley rats, the extensor digitorum longus muscle was rotated on its vascular pedicle to a thermo-controlled stage. Ischemia was established using an atraumatic femoral artery tourniquet. Reperfusion was performed under control and experimental conditions including local hypothermia and intravenous L-arginine. After harvesting experimental muscles, contractility was then quantified by using a tissue bath stimulator with force transducers. RESULTS: Warm reperfusion resulted in marked decrease in muscle contractility compared with sham animals. Local hypothermia showed statistically significant preservation of contractility compared with the sham group. This protective effect was recapitulated by the application of NOS inducers (L-arginine) at warm conditions. CONCLUSIONS: These findings demonstrate that hypothermia and L-arginine are protective of skeletal muscle contractility after an I/R injury. The results presented may have profound effects on future therapeutic recommendations and suggest possible pathways for clinical intervention to modulate I/R injury, which is commonplace in orthopaedic trauma and reconstructive surgery.