Radiofrequency ablation of hepatocellular carcinoma guided by real-time physics-based ablation simulation: a prospective study.

OBJECTIVES: To assess the safety and efficacy of radiofrequency ablation (RFA) guidance software that incorporated patient-specific physics-based simulation of each ablation volume. MATERIALS AND METHODS: Patients referred for curative ablation of hepatocellular carcinoma (HCC) of 2-5 cm diameter were prospectively enrolled. RFA was performed under general anesthesia. Procedure planning and intraprocedural modifications were guided by computer simulation of each ablation. The segmented target (tumor with 5 mm margin) was registered to and superimposed on subsequent 3D multiplanar images. The applied RF energy was used to calculate a simulated ablation volume which was displayed relative to the electrode and segmented target, to depict any untreated target tissue. After each additional ablation, the software updated the accumulated simulated ablation volume in relation to the target. The primary endpoints were technical efficacy and rate of local tumor progression (LTP). RESULTS: Sixty-eight tumors were ablated during 57 procedures in 52 patients (68.3 ± 9.2 years old, 78.8% male); 15 (26.3%) had multiple lesions and 23 (39.1%) had prior HCC treatment. The mean tumor diameter was 2.73 (±0.64) cm. The intraprocedural simulation directed additional overlapping ablations in 75.9% of tumors. Technical success and efficacy were 100% at 3-month contrast enhanced CT or MRI follow-up after the single treatment session. Cumulative incidence function estimates for 1- and 2-year LTP were 3.9% and 20.2%, respectively. CONCLUSION: This prospective study found computer-assisted guidance that simulated each ablation was both safe and efficacious. The low rate of LTP was similar to studies that employed stereotactic guidance and ablation confirmation, without requiring a second contrast enhanced study.

The Need for More Mentorship in Medical School.

Introduction Mentorship, a supportive relationship that actively provides knowledge and insight, has many benefits. Although not extensively studied, medical students pursuing various specialties have diverse experiences with mentorship. Objective To understand how mentorship impacts medical student decisions involving rotation choices, residency programs, field of practice, interest in research, and career trajectory. Methods We hypothesized that effective mentor-mentee relationships would strongly impact medical students' decisions. Distributed to fourth-year osteopathic medical students at a single medical school, this study used a survey design to assess mentorship's impact on their aforementioned decisions. Results Sixty-one students responded to this survey. Fifty-nine percent of respondents said they did not receive enough mentorship in medical school while 63.9% of respondents said their quality of mentorship was good/very good. Most survey respondents strongly agreed/agreed that the amount and quality of mentorship impacted their decisions involving rotation choices, residency programs, field of practice, and career trajectory. Qualitative data analysis led to the emergence of three themes: students pursuing primary care had positive mentorship experiences as compared to students pursuing non-primary care careers, female students stated they did not receive enough mentorship, and a majority of students cited the lack of formal mentorship as an area of improvement. Conclusions Our study demonstrates the profound impact mentorship has on a medical student's career. Respondents believed their mentorship experiences strongly impacted their decisions involving rotation choices, residency programs, field of practice, and career trajectory. Participants also believed availability in the amount and quality of mentorship could be improved. The perceived lack in the amount and quality of mentorship may have negative implications on medical students' career prospects.

A systematic review of paraneoplastic syndromes associated with thymoma: Treatment modalities, recurrence, and outcomes in resected cases.

OBJECTIVE: Paraneoplastic syndromes associated with thymomas remain incompletely understood. The objective was to examine the association between surgically resected thymomas and paraneoplastic syndromes over the past half century. METHODS: A primary PubMed/MEDLINE search was used to identify published articles describing paraneoplastic syndromes associated with thymomas from 1960 to 2019. A secondary search identified additional articles referenced in the articles found in the primary search. Kaplan-Meier and log-rank test were used for time-to-event data analyses. RESULTS: From 407 articles describing 507 patients, 123 different paraneoplastic syndromes were associated with thymoma. The 5 most common paraneoplastic syndromes were myasthenia gravis, pure red cell aplasia, lichen planus, Good syndrome, and limbic encephalitis. Complete or partial resolution of paraneoplastic syndrome symptoms after surgery was noted in 76% of patients, of whom 21% had a relapse or new paraneoplastic syndrome onset after surgery. The most common adjunctive therapy associated with resolution of paraneoplastic syndrome was corticosteroids (30%). For all patients after surgery, thymoma recurrence was observed in 17% of cases, whereas recurrence of paraneoplastic syndrome was observed in 34% of cases, and both were observed in approximately 11% of cases. The 5- and 10-year overall survivals were 78% and 66%, respectively. Improved overall survival was associated with patients who had total resolution from paraneoplastic syndrome. CONCLUSIONS: A comprehensive assessment of publications over the past half century suggests that a multimodal treatment approach that includes surgical resection of thymomas is able to achieve paraneoplastic syndrome resolution in a majority of patients. Onset of new paraneoplastic syndromes after surgery is associated with the recurrence of the first paraneoplastic syndrome, and resolution of paraneoplastic syndrome is associated with improved overall survival.

A "U-shaped" Curve: Appreciating How Primary Care Residency Intention Relates to the Cost of Board Preparation and Examination.

INTRODUCTION: The shortage of primary care physicians in the United States has warranted an investigation into how medical education debt and other factors influence medical students' interests in primary care (PC) residencies. However, sparse research has studied how the cost of board preparation and examination relates to career choice. The objective of this study was to determine if there is an association between the cost of preparing and sitting for board examinations and the intention to enter a PC residency for osteopathic medical students. METHODS: We postulated that students who incurred higher financial costs from preparing and sitting for board examinations would be more likely to be interested in non-primary care (NPC) residencies. Using a non-experimental survey design, this study asked respondents to evaluate the following: "I plan to enter a Primary Care Residency (Family Medicine OR General Internal Medicine OR Pediatrics)" using a Likert scale. Respondents were also asked to select which board examination(s) and pertinent resource(s) they had purchased. Total costs were calculated per student. RESULTS: A total of 25,852 osteopathic medical students received the survey, of which 1,280 students responded to and completed it, yielding a 4.95% response rate. The distribution of respondents' intentions to pursue a primary care residency and costs spent yielded a "U" shaped curve. Respondents who Strongly Agreed and Strongly Disagreed to the statement "I plan to enter a Primary Care Residency" spent $5,744 and $5,070 on board-preparation and examination, respectively. No statistically significant differences were found between the cost of preparing and sitting for board examinations and the intention to enter primary care residencies when individuals were grouped by year in school and gender. CONCLUSIONS: Because competitive NPC specialties have relatively higher salaries, we suspected that students who intended to pursue these specialties would have had higher financial costs from board examination and preparation compared to students who intended to pursue PC residencies such as family medicine. Our findings further illustrate these specific educational costs do not correlate with students' stated intentions to enter primary care residencies. As efforts continue to determine a solution for the primary care physician shortage, it becomes clearer that the focus must also encompass non-financial influences that shape career choice.

Multiple Evanescent White Dot Syndrome Presenting in Possibly Contracted Hand-Foot-and-Mouth Disease: A Rare Presentation.

Multiple evanescent white dot syndrome (MEWDS), an inflammatory retinal condition seen predominantly in young adult patients, is characterized by unilateral vision loss with variable scotomas. The etiology of MEWDS is currently elusive and the formal mechanism is unknown. However, it must be differentiated from other white dot syndromes (WDS). Fundus fluorescein angiography in MEWDS exhibits a "wreath-like" arrangement of hyperfluorescent lesions predominantly located in the outer retina. Herein we present a case of a 32-year-old Southeast Asian female who presented to the emergency department with peripheral blindness and central scotomas. The patient's daughter was diagnosed with hand-foot-and-mouth disease seven days earlier, which often presents as an extremely debilitating condition. Below, we elaborate on the etiology, pathogenesis, and diagnostic methods to elucidate the multifactorial causes of MEWDS and aid clinicians in diagnosis and treatment. Although associated with certain viral illnesses, to the best of our knowledge, there have been no reported cases of MEWDS in conjunction with hand-foot-and-mouth disease.

The Cost of Board Examination and Preparation: An Overlooked Factor in Medical Student Debt.

Objective Board examinations in undergraduate medical education are imperative for competency assessment and a standard licensure process. While the cost of attendance and mean indebtedness of medical students have been quantified, the financial burden experienced by medical students from board preparation and examination has never been quantified. Materials and methods A total of 290 fourth-year osteopathic medical students from 38 osteopathic medical schools completed an anonymous survey that asked them to select the resources they had purchased for board preparation. Along with demographic information, respondents were asked which board examinations they had taken during their medical school education. The price for each resource was located by going to the resource website and finding the "list price" of a brand-new copy/version of that resource. If a price was not found, a current Amazon.com "list price" was utilized. These prices best approximate the maximum a student would spend per resource. Response and statistical analysis such as analysis of variance, post hoc comparison (Scheffé and Bonferronis test), and chi-square tests were conducted using the Statistical Package for Social Sciences (SPSS) Statistics, version 25.0 (IBM SPSS Statistics, Armonk, NY). Results This study found that osteopathic medical students spent, on average, $7,499 (s.d.=$2,506) for board preparation and examination. This cost when isolated is $3,370 for the cost of taking board examinations and $4,129 for the cost of board preparation. Respondents from the West were found to spend most at $9,432, while students from the Northeast spent the least, $7.090. Additionally, non-traditional medical students, those who matriculated after the age of 30 were found to spend more than individuals who began when they were under the age of 25 or between the ages of 25-30. The two most commonly used resources for both Level 1/Step 1 and Level 2/Step 2 examinations were COMBANK and UWorld.  Conclusions/relevance This study is the first of its kind to quantify the mean cost of board preparation and examination in undergraduate medical education at $7,499. When considering the mean indebtedness of the osteopathic graduating class of 2017-2018, 2.94% of medical education debt can be attributed to the cost of board preparation and assessments. As competitiveness for graduate medical education increases, individuals will spend more money to ensure a competitive board exam performance, a key selection factor. Stakeholders in undergraduate medical education are encouraged to further understand the interplay between medical student debt and the cost of board examinations and preparation.

Defining the learning curve in robot-assisted thoracoscopic lobectomy.

BACKGROUND: Robot-assisted thoracoscopic lobectomy has been shown to be a safe approach to pulmonary lobectomy. This study sought to define, mathematically, the learning curve for RATS lobectomy. METHODS: Patients undergoing robot-assisted thoracoscopic lobectomy at a single institution from 2010 through 2016 were considered. Covariates included patient demographics, comorbidities, operating time, length of stay, estimated blood loss, and postoperative complications. A cumulative sum analysis of operating time was performed to define the learning curve. RESULTS: A total of 101 patients were included. Three distinct phases of the learning curve were identified: cases 1-22, cases 23-63, and cases 64-101. There was a statistically significant difference in operating time and estimated blood loss between phases 1 and 2 (P < .05, P = .016, respectively) and between phases 1 and 3 (P < .05, P = .006, respectively). There was no statistically significant difference in comorbidities, chest tube duration, length of stay, postoperative complications, or conversion rate across the learning curve. CONCLUSION: Based on operating time, the learning curve for robot-assisted thoracoscopic lobectomy is 22 cases, with mastery achieved after 63 cases. No differences in length of stay, chest tube duration, conversion rate, or complication rate were observed in the learning curve. Other factors not measured in this study may play a role in the learning process and warrant further study.

Measuring Medicaid Expansion's Impact on an Academic Medical Center's Emergency Department.

Medicaid expansion's impact has been studied on national and statewide levels with respect to the patient outcomes, access to health services and uncompensated care. The objective of this study was to examine the effect of the Medicaid expansion on an emergency department (ED) at a large, academic center by evaluating changes in total charges, services rendered, types of providers, number of visits, and length of stay. Findings from this study include more males frequenting the ED for health services and a bottleneck in operations with an average waiting time in the ED increasing by 17%. Additionally, Medicaid recipients required non-emergent services that could be delivered by primary care providers, albeit at the ED, with average total charges for Emergency Medicine services seeing a statistically significant reduction with increases in average total charges for Family Medicine. While Medicaid expansion provided more individuals with coverage, a large academic medical center adapted in concordance.