Preference Signaling and the Integrated Plastic Surgery Match: A National Survey Study.

OBJECTIVE: Rooted in economics market strategies, preference signaling was introduced to the Plastic Surgery Common Application (PSCA) in 2022 for integrated plastic surgery residency applicants. This study surveyed program and applicant experience with preference signaling and assessed how preference signals influenced likelihood of interview invitations. DESIGN: Two online surveys were designed and distributed to all program directors and 2022-2023 applicants to integrated plastic surgery. Opinions regarding the utility of preference signaling were solicited, and the influence of preference signals on likelihood of interview offers was assessed. SETTING: All integrated plastic surgery programs. PARTICIPANTS: All 88 program directors and 2022-2023 applicants to integrated plastic surgery. RESULTS: A total of 45 programs and 99 applicants completed the survey (response rates, 54.2% and 34.2%, respectively). Overall, 79.6% of applicants and 68.9% of programs reported that preference signals were a useful addition to the application cycle. Programs reported that 41.4% of students who sent preference signals received interview offers, compared to 84.6% of home students, 64.8% of away rotators, and 7.1% of other applicants; overall, students who signaled were 5.8 times more likely to receive an interview offer compared to students who were not home students and did not rotate or signal. After multivariable adjustment, programs with higher Doximity rankings, numbers of away rotators, and numbers of integrated residents per year received more preference signals (all p < 0.05). CONCLUSIONS: Applicants and programs report that preference signaling was a useful addition to the integrated plastic surgery application cycle. Sending preference signals resulted in a higher likelihood of interview offers among nonrotators. Preference signaling may be a useful tool to reduce congestion in the integrated plastic surgery application cycle.

New Frontiers of Natural Language Processing in Surgery.

The vast and ever-growing volume of electronic health records (EHR) have generated a wealth of information-rich data. Traditional, non-machine learning data extraction techniques are error-prone and laborious, hindering the analytical potential of these massive data sources. Equipped with natural language processing (NLP) tools, surgeons are better able to automate, and customize their review to investigate and implement surgical solutions. We identify current perioperative applications of NLP algorithms as well as research limitations and future avenues to outline the impact and potential of this technology for progressing surgical innovation.

Ethical, Legal, and Financial Considerations of Artificial Intelligence in Surgery.

Machine learning systems have become integrated into some of the most vital decision-making aspects of humanity, including hiring decisions, loan applications, and automobile safety, to name just a few. As applications increase in both gravity and complexity, the data quality and algorithmic interpretability of the systems must rise to meet those challenges. This is especially vital for navigating the nuances of health care, particularly among the high stakes of surgical operations. In addition to inherent ethical challenges of enabling a "black box" system to influence decision-making in patient care, the creation of biased datasets leads to biased algorithms with the power to perpetuate discrimination and reinforce disparities. Transparency and responsibility are paramount to the implementation of artificial intelligence in surgical decision-making and autonomous robotic surgery. Machine learning has been permeating health care across diverse clinical and surgical contexts but continues to face sizable obstacles, including apprehension from patients and providers alike. To integrate the technology fully while upholding standard of care and patient-provider trust, one must acknowledge and address the ethical, financial, and legal implications of using artificial intelligence for patient care.

Developing a Dedicated Leadership Curriculum for Radiation Oncology Residents.

The increasing complexity of healthcare emphasizes the need for continued physician leadership and leadership training. This study aims to determine baseline attitudes toward the perceptions and utility of a leadership development curriculum (LDC) for radiation oncology (RO) residents. A novel longitudinal LDC was implemented for RO residents at our institution from 2018 to 2019. Prior to the curriculum, current and past residents in our institution's RO residency program were surveyed on their attitudes towards leadership in healthcare, emotional intelligence competencies, and leadership training interests. After the completion of the LDC, a post-curriculum survey was forwarded to current residents. The response rate was 84% (21 of 24) for the baseline survey and 90% (9 of 10) for the post-curriculum survey. Having a leadership training curriculum during residency was rated as extremely useful, with top training interests involving leading clinical teams, effective communication strategies, and conflict management. After the LDC, the residents reported high satisfaction with the curriculum and utilization of leadership training into their daily work. Our LDC demonstrates significant potential to engage trainees and improve their leadership skills at the graduate medical education level.

Non-surgical Management of Complex Refractory Pyoderma Gangrenosum With Negative Pressure Wound Therapy With Instillation.

Pyoderma gangrenosum (PG) is a rare skin disorder primarily treated with immunosuppression medication. We report a case of a large, chronic PG wound treated with adjunct negative pressure wound therapy with instillation and dwell time (NPWTi-d) using nonadherent dressing (Mepitel) and reticular open-cell foam with through holes (ROCF-CC) with positive outcomes. The patient was a 62-year-old female with rheumatoid arthritis, Hashimoto's thyroiditis, lymphedema, and morbid obesity who presented with a 19.5 cm x 13.2 cm x 2.1 cm wound of three years duration on the right posterolateral lower extremity that successfully responded to a multimodality approach of immunosuppression and wound vac therapy. We conclude in our case that NPWTi-d with Mepitel and ROCF-CC enhanced the wound healing process, and we discuss NPWTi-d's potential role and benefit as an adjunctive therapy option for chronic and poorly controlled PG on patients taking concurrent immunosuppression.

Colorectal Cancer Risk Factors and Screening Among the Uninsured of Tampa Bay: A Free Clinic Study.

INTRODUCTION: Uninsured patients with low socioeconomic status are at high risk for developing colorectal cancer (CRC), and data on risk factors and prevalence of CRC in this population are limited. The purpose of this study was to assess the risk factors for CRC in uninsured patients from free clinics in the Tampa Bay area of Florida. METHODS: We conducted a retrospective cohort study among patients 50 years or older who were provided service at 9 free clinics in the Tampa Bay area between 2016 and 2018. Demographics, chronic disease characteristics, and screening data were collected via a query of paper and electronic medical records. RESULTS: Of the 13,982 patients seen, 5,139 (36.8%) were aged 50 years or older. Most were female (56.8%), non-Hispanic White (41.1%), and unemployed (54.9%). Patients with CRC screening were more likely to be employed compared with patients without CRC screening (54.4% vs 44.4%, P = .01). Within the cohort, 725 (22.7%) patients were active smokers, 771 (29.2%) patients currently consumed alcohol, and 23 patients (0.4%) had a history of inflammatory bowel disease. Patients had a median body mass index of 29.4 (interquartile range, 25.4-34.2) kg/m2, and 1,455 (28.3%) had diabetes. Documented CRC screening was found among 341 (6.6%) patients. CONCLUSION: Uninsured patients had a high prevalence of CRC risk factors but a low reported screening rate for CRC. Free clinics are uniquely positioned to provide patients at high risk for CRC with strategies to decrease their risk and to be screened for CRC.

Use of Botulinum Toxin A to Treat Chemotherapy-Induced Raynaud's Phenomenon.

Raynaud's phenomenon (RP) is a vasospastic disorder of the digital blood vessels leading to pain, paresthesias, and pallor in response to cold or stress. RP can develop secondary to a number of pathologies or factors, including the use of chemotherapy agents. Typical first-line therapies for secondary RP may be contraindicated in patients with certain comorbidities. Here, we discuss a case in which botulinum toxin A (BTX-A) was used to treat chemotherapy-induced RP in a patient with non-small cell lung cancer (NSCLC). We provide a review of the existing literature on the clinical course and treatment modalities, including the use of BTX-A, for patients with secondary RP. A 56-year-old female with NSCLC received treatment with bevacizumab and pemetrexed. Her initial symptoms included progressive discoloration and pain in her fingertips, which hastily progressed to ischemia and subsequent dry gangrene. She was diagnosed with chemotherapy-induced RP, but traditional management options were complicated by acute congestive heart failure. BTX-A injections were administered at key locations on the wrist and hand, significantly improving her symptoms and slowing the progression of the gangrenous changes. RP can develop as sequelae of chemotherapy regimens. Clinical management may be complicated by underlying pathology and/or patient symptoms. BTX-A injections are an excellent non-operative therapeutic option for patients with secondary RP in cases where mainstay therapies may be contraindicated, thus decreasing pain, improving patient quality of life, and slowing the progression of gangrenous changes.

Isolated Scaphoid Dislocation From Low-Energy Wrist Trauma.

Isolated scaphoid dislocation is an extremely rare injury typically caused by high-energy trauma. We present the first observed case of isolated scaphoid dislocation resulting from a non-traumatic injury of the wrist in power-grip tension in a patient with a questionable history of Marfan Syndrome. A 20-year-old right-hand dominant man presented to the emergency department with right wrist pain and deformation after carrying a table. The patient reported a possible history of Marfan Syndrome, but it had never been definitively diagnosed. Imaging revealed radial dislocation of the scaphoid. Bedside closed reduction was performed followed by outpatient ligament reconstruction with return to normal activities at 6 months. Early diagnosis and management lead to an improved prognosis for isolated scaphoid dislocation. Regardless of patient history or mechanism of injury, treatment options include closed reduction, percutaneous fixation, and/or open reduction with internal fixation and ligamentous reconstruction.

Pretreatment CT and 18 F-FDG PET-based radiomic model predicting pathological complete response and loco-regional control following neoadjuvant chemoradiation in oesophageal cancer.

INTRODUCTION: To develop a radiomic-based model to predict pathological complete response (pCR) and outcome following neoadjuvant chemoradiotherapy (NACRT) in oesophageal cancer. METHODS: We analysed 68 patients with oesophageal cancer treated with NACRT followed by esophagectomy, who had staging 18F-fluorodeoxyglucose (18 F-FDG) positron emission tomography (PET) and computed tomography (CT) scans performed at our institution. An in-house data-chjmirocterization algorithm was used to extract 3D-radiomic features from the segmented primary disease. Prediction models were constructed and internally validated. Composite feature, Fc  = α * FPET  + (1 - α) * FCT , 0 ≤ α ≤ 1, was constructed for each corresponding CT and PET feature. Loco-regional control (LRC), recurrence-free survival (RFS), metastasis-free survival (MFS) and overall survival (OS) were estimated by Kaplan-Meier analysis, and compared using log-rank test. RESULTS: Median follow-up was 59 months. pCR was achieved in 34 (50%) patients. Five-year RFS, LRC, MFS and OS were 67.1%, 88.5%, 75.6% and 57.6%, respectively. Tumour Regression Grade (TRG) 0-1 indicative of complete response or minimal residual disease was significantly associated with improved 5-year LRC [93.7% vs 71.8%; P = 0.020; HR 0.19, 95% CI 0.04-0.85]. Four sepjmirote pCR predictive models were built for CT alone, PET alone, CT+PET and composite. CT, PET and CT+PET models had AUC 0.73 ± 0.08, 0.66 ± 0.08 and 0.77 ± 0.07, respectively. The composite model resulted in an improvement of pCR predicting power with AUC 0.87 ± 0.06. Stratifying patients with a low versus high radiomic score showed clinically relevant improvement in 5-year LRC favouring low-score group (91.1% vs. 80%, 95% CI 0.09-1.77, P = 0.2). CONCLUSION: The composite CT/PET radiomics model was highly predictive of pCR following NACRT. Validation in larger data sets is warranted to determine whether the model can predict clinical outcomes.

Recommendations for Medical Students Completing Virtual Rotations: Lessons Learned from Our Experience During the COVID-19 Pandemic.

This article was migrated. The article was marked as recommended. The COVID-19 pandemic prevents medical students who are applying for residency during the 2020-2021 application cycle from completing away rotations. One solution to address this education gap is the creation of virtual sub-internships. The authors provide recommendations to other medical students completing these novel rotations, as well as encourage residency programs to create virtual education opportunities for interested students.

Pyoderma Gangrenosum after Fat Grafting in Alloplastic Breast Reconstruction: An Unusual Outcome.

Pyoderma gangrenosum (PG) is a rare and painful inflammatory skin disorder that has been recently associated with breast surgery. It is commonly mistaken for postoperative ischemia or wound infection and does not show response to antibiotics or debridement. We describe the first case of post-surgical PG (PSPG) after alloplastic breast reconstruction involving fat grafting. A 47-year-old woman underwent bilateral mastectomy and 2-stage alloplastic breast reconstruction, with fat grafting from the abdomen. Two days post-surgery, she developed bilateral erythema with tender grouped pustules that progressed rapidly into necrotic ulcerations. She did not respond to antibiotics and serial debridement. Subsequent biopsy confirmed a diagnosis of PG. She was started on steroid therapy and responded well. She was discharged on a steroid regimen, local wound care, and eventually a T-cell inhibitor. Over the next 12 months, her wounds healed without surgical intervention. PSPG has been observed in a variety of reconstructive breast surgeries, but never reported in the setting of fat grafting. As PG involves subcutaneous fat, fat grafting may accelerate and exacerbate the course of disease. Treatment for PSPG includes systemic steroid therapy or other immunomodulatory agents (or both). Surgical management remains controversial, as serial debridement and reconstruction have shown to exacerbate and stimulate disease progression. A long-term follow-up is recommended to monitor for wound healing. Delayed diagnosis of PG in breast reconstruction patients can lead to severe morbidity and disfigurement. This is first case of PSPG following fat grafting in the literature.

Simultaneous Bilateral Patellar Tendon Rupture in a Young Adult Male: A Case Report and Review of the Literature.

A bilateral patellar tendon rupture is extremely rare and has only been documented in case reports. Although the etiology remains unknown, predisposing factors include steroid usage, systemic diseases, and tendinopathies. In the present case, a healthy 33-year-old male with a prior history of bilateral patellar tendonitis and a diagnosis of Osgood-Schlatter disease during adolescence experienced simultaneous bilateral patellar tendon rupture after playing volleyball. He underwent bilateral patellar repair without complications. In the absence of trauma, spontaneous bilateral patellar tendon ruptures are associated with several predisposing factors, including systemic diseases, prior corticosteroid or fluoroquinolone usage, and history of tendinopathy. Injuries can be classified based on the location of the rupture. Bilateral patellar tendon ruptures can be misdiagnosed due to the rarity of cases and the lack of a normal comparative knee. Radiographic techniques can aid in the diagnosis, leading to early surgical treatment and improved outcomes. Early diagnosis and prompt surgical repair contribute to good functional outcomes in this potentially debilitating injury pattern.

Substance Use in Uninsured Cancer Survivors: A Multicenter Cross-Sectional Study of Free Clinics.

Introduction Substance use disorders occur in about 5% of the cancer population and can decrease treatment adherence, impede pain management, and undermine a cancer survivor's network of social support. Although current literature demonstrates substance use is associated with socioeconomic disparity, there is limited research on the prevalence of alcohol, tobacco, and illicit drug use among uninsured cancer survivors in the United States. Our multicenter cross-sectional study describes the prevalence of substance use in uninsured cancer survivors in the Tampa Bay Area. Methods A comprehensive retrospective chart review of electronic medical records and paper charts was conducted at nine free clinics in the Tampa Bay Area of Florida between January 1, 2016, and December 31, 2017. Substance use prevalence was compared between uninsured cancer survivors and uninsured patients without reported cancer history after adjusting for available demographic risk factors. Results There were 222 patients with a history of cancer and 6,768 patients without a history of cancer included for analysis. Cancer survivors had a median age of 55 years (interquartile range 48-61 years), were mostly female (n = 146, 66.1%), and of Hispanic ethnicity (n = 94, 52.5%). Cancer survivors were more likely to be current smokers (n = 42, 25.1%) compared to patients without a cancer history (n = 759, 16.1%). Patients with a history of cancer were more likely to be current drinkers (n = 34, 26%) compared to non-cancer patients (n = 942, 22.9%). There was no significant difference in illicit drug use history between the two groups. Conclusions Our study demonstrates that uninsured cancer survivors are more likely to be smokers and alcohol consumers than uninsured patients without a history of cancer. There was no significant difference in illicit drug use in cancer survivors and patients without a history of cancer. Future educational interventions should target substance use among uninsured cancer survivors.

Cutaneous Carcinosarcoma: A Small Case Series and Review of the Literature of a Rare Skin Tumor.

Carcinosarcomas are composed of epithelial and mesenchymal elements and primarily present within visceral organs. Despite being potentially aggressive, they are a rare diagnosis in the skin, and few manifestations have been reported to date. In this report, we describe two separate cases of carcinosarcoma presenting as nonhealing scalp wounds. Patient A: a 57-year-old male with a nonhealing skin lesion of ten years successfully treated with wide-local excision and local ortichochea flap reconstruction. Patient B: a 75-year-old female that presented with a painless, slow-growing hemorrhagic mass of 7 years invading the skull and dura ultimately requiring craniectomy and free-tissue transfer with anterolateral thigh flap. Cutaneous carcinosarcomas have more favorable outcomes due to low metastatic rates likely due to earlier detection, but delayed presentation can be fatal. Histopathological analysis is critical for determining diagnosis and prognosis. Adequate reconstruction after wide base excision varies and follows the reconstructive ladder/elevator ranging from primary closure up through free-tissue transfer. With cutaneous manifestations of carcinosarcoma seldom reported in the literature, it is our hope that reporting unusual instances such as this will raise awareness and allow for earlier diagnoses, treatments, and reconstructions.

Clinical Factors and Outcomes of Octogenarians Receiving Curative Surgery for Esophageal Cancer.

BACKGROUND: The incidence of esophageal cancer is increasing in the United States. Although neoadjuvant therapy (NAT) for locally advanced cancers followed by surgical resection is the standard of care, there are no clearly defined guidelines for patients aged ≥79 y. METHODS: Query of an institutional review board-approved database of 1031 esophagectomies at our institution revealed 35 patients aged ≥79 y from 1999 to 2017 who underwent esophagectomy. Age, gender, tumor location, histology, clinical stage, Charlson Comorbidity Index (CCI), NAT administration, pathologic response rate to NAT, surgery type, negative margin resection status, postoperative complications, postoperative death, length of stay, 30- and 90-d mortality, and disease status parameters were analyzed in association with clinical outcome. RESULTS: The median age of the octogenarian cohort was 82.1 y with a male preponderance (91.4%). American Joint Committee on Cancer clinical staging was stage I for 20% of patients, stage II for 27% of patients, and stage III for 50% of patients, which was not statistically significant compared with the younger cohort (P = 0.576). Within the octogenarian group, 54% received NAT compared with 67% in the younger group (P = 0.098). There was no difference in postoperative complications (P = 0.424), postoperative death (P = 0.312), and recurrence rate (P = 0.434) between the groups. However, CCI was significantly different between the octogenarian and nonoctogenarian cohort (P = 0.008), and octogenarians had shorter overall survival (18 versus 62 mo, P<0.001). None of the other parameters assessed were associated with clinical outcomes. CONCLUSIONS: Curative surgery is viable and safe for octogenarians with esophageal cancer. Long-term survival was significantly shorter in the octogenarian group, suggesting the need for better clinical selection criteria for esophagectomy after chemoradiation and that identification of complete responders for nonoperative management is warranted.

Clinical factors associated with the development of postoperative atrial fibrillation in esophageal cancer patients receiving multimodality therapy before surgery.

BACKGROUND: The incidence of esophageal cancer (EC) is increasing in the USA. Neoadjuvant therapy for locally advanced cancers followed by surgical resection is the standard of care. The most common post-esophagectomy cardiac complication is atrial fibrillation (AF). New-onset postoperative AF can require a prolonged hospital stay and may confer an overall poorer prognosis. In this study, we seek to identify clinical factors associated with postoperative AF. METHODS: Query of an IRB approved database of 1,039 esophagectomies at our institution revealed 677 patients with EC from 1999 to 2017 who underwent esophagectomy after neoadjuvant treatment. Age, treatment location (primary vs. other), gender, neoadjuvant radiation type [2D vs. 3D vs. intensity modulated radiation therapy (IMRT)], radiation dose, surgery type (transthoracic vs. transhiatal vs. three field), smoking history, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), operative time, blood transfusions, fluid management, and length of stay (LOS) were analyzed in relationship to the development of AF. Statistical analysis was performed with SPSS 24. RESULTS: The mean age of the entire cohort was 64.3 (range, 28-86 years), with a Caucasian and male preponderance (White: 94.5%; male: 83.6%). Of the 677 patients, 14.9% (n=101) developed postoperative AF. Increasing age (P<0.001), increased radiation dose (P=0.034), operative time (P=0.001), and blood transfusions (P=0.027) were associated with AF. LOS was longer in patients with AF than those without AF (10.5 vs. 10.0 days, P=0.001). On multivariate analysis, increasing age (95% CI: 1.023-1.080, P<0.001) and radiation dose (95% CI: 1.000-1.001, P=0.034) remained significant. None of the other parameters assessed were associated with the development of AF. CONCLUSIONS: Increasing age and radiation dose were associated with the development of postoperative AF in this cohort. This study suggests that older patients or patients receiving higher radiation dose should be monitored more closely in the postoperative setting and potentially referred earlier preoperatively for cardio-oncology assessment. Future study is required to determine if modification of current radiation techniques and cardiac dose constraints in this patient population may be warranted.