Can a powered knee-ankle prosthesis improve weight-bearing symmetry during stand-to-sit transitions in individuals with above-knee amputations?

BACKGROUND: After above-knee amputation, the missing biological knee and ankle are replaced with passive prosthetic devices. Passive prostheses are able to dissipate limited amounts of energy using resistive damper systems during "negative energy" tasks like sit-down. However, passive prosthetic knees are not able to provide high levels of resistance at the end of the sit-down movement when the knee is flexed, and users need the most support. Consequently, users are forced to over-compensate with their upper body, residual hip, and intact leg, and/or sit down with a ballistic and uncontrolled movement. Powered prostheses have the potential to solve this problem. Powered prosthetic joints are controlled by motors, which can produce higher levels of resistance at a larger range of joint positions than passive damper systems. Therefore, powered prostheses have the potential to make sitting down more controlled and less difficult for above-knee amputees, improving their functional mobility. METHODS: Ten individuals with above-knee amputations sat down using their prescribed passive prosthesis and a research powered knee-ankle prosthesis. Subjects performed three sit-downs with each prosthesis while we recorded joint angles, forces, and muscle activity from the intact quadricep muscle. Our main outcome measures were weight-bearing symmetry and muscle effort of the intact quadricep muscle. We performed paired t-tests on these outcome measures to test for significant differences between passive and powered prostheses. RESULTS: We found that the average weight-bearing symmetry improved by 42.1% when subjects sat down with the powered prosthesis compared to their passive prostheses. This difference was significant (p = 0.0012), and every subject's weight-bearing symmetry improved when using the powered prosthesis. Although the intact quadricep muscle contraction differed in shape, neither the integral nor the peak of the signal was significantly different between conditions (integral p > 0.01, peak p > 0.01). CONCLUSIONS: In this study, we found that a powered knee-ankle prosthesis significantly improved weight-bearing symmetry during sit-down compared to passive prostheses. However, we did not observe a corresponding decrease in intact-limb muscle effort. These results indicate that powered prosthetic devices have the potential to improve balance during sit-down for individuals with above-knee amputation and provide insight for future development of powered prosthetics.

A randomized trial on the effectiveness and safety of 5 water-based personal lubricants.

BACKGROUND: A range of personal lubricants with different formulations and subsequent properties are available for relief of discomfort associated with vaginal dryness; however, there are limited clinical data to support the efficacy and safety of many commercially available lubricants. AIM: To determine the effectiveness and safety of 5 water-based personal lubricants for the relief of intimate discomfort associated with vaginal dryness in pre- and postmenopausal women: 4 that were formulated to meet the World Health Organization (WHO) guidelines for osmolality and pH and 1 preexisting lubricant of higher osmolality and pH. METHODS: An open-label, parallel-design study was performed in women aged 18 to 65 years with mild-to-moderate vaginal dryness and dyspareunia. Participants were randomized to 1 of 5 lubricants (A-E) from 3 brands (Durex, KY, Queen V). They were instructed to use their allocated lubricants during vaginal intercourse at least once a week over a 4-week period. The Female Sexual Function Index (FSFI) measured sexual functioning after 4 weeks of use as an indicator of lubricant performance. OUTCOMES: The primary outcome was change from baseline in total FSFI score after 4 weeks of product use. RESULTS: A total of 174 women completed the study. The primary end point-a prespecified increase in FSFI ≥4 points from baseline after 4 weeks of use-was met by all 5 lubricants tested. A statistically significant improvement was observed across all 6 domains of the FSFI from baseline to 4 weeks of use with all 5 lubricants (P < .0001 for lubrication and pain reduction and P < .05 for all other domains). No serious adverse events occurred in the study, and the tolerance of all 5 lubricants was good/very good. CLINICAL IMPLICATIONS: The efficacy and safety of the tested lubricants are not compromised when formulated to meet the WHO criterion of osmolality ≤1200 mOsm/kg. The lubricants tested in this investigation can be used not only to relieve symptomatology of vaginal dryness and dyspareunia but also to enhance overall sexual satisfaction. STRENGTHS AND LIMITATIONS: This study provides clinical evidence for the efficacy and safety of 5 lubricants, including those formulated to meet WHO guidelines, in relieving symptoms of vaginal dryness and improving the overall sexual experience. The open-label design may have introduced bias into the study. CONCLUSION: All 5 lubricants, including those formulated to be compliant with guidelines on pH and osmolality, can be considered effective and well tolerated for the relief of discomfort associated with vaginal dryness.

Effect of Increasing Assistance From a Powered Prosthesis on Weight-Bearing Symmetry, Effort, and Speed During Stand-Up in Individuals With Above-Knee Amputation.

After above-knee amputation, the missing biological knee and ankle are commonly replaced with a passive prosthesis, which cannot provide net-positive energy to assist the user. During activities such as sit-to-stand, above-knee amputees must compensate for this lack of power using their upper body, intact limb, and residual limb, resulting in slower, less symmetric, and higher effort movements. Previous studies have shown that powered prostheses can improve symmetry and speed by providing positive assistive power. However, we still lack a systematic investigation of the effect of powered prosthesis assistance. Without this knowledge, researchers and clinicians have no framework for tuning powered prostheses to optimally assist users. Here we show that varying the assistive knee torque significantly affected weight-bearing symmetry, effort, and speed during the stand-up movement in eight above-knee amputees. Specifically, we observed improvements in the index of asymmetry of the vertical ground reaction force at the point approximating maximum vertical center of mass acceleration, the integral of the intact vastus medialis activation measured using electromyography, and the stand-up duration compared to the passive prosthesis. We saw significant improvements in all three metrics when subjects used the powered prosthesis compared to the passive prosthesis. We saw improvements in all three metrics with increasing assistive torque levels commanded by the powered prosthesis. We also observed increased weight-bearing asymmetry at the end of movement, and increased kinematic asymmetry with increasing assistance from the powered prosthesis. These results show that powered prostheses can improve functional mobility, potentially increasing quality of life for millions of people living with above-knee amputations.

Powered Hip Exoskeleton Reduces Residual Hip Effort Without Affecting Kinematics and Balance in Individuals With Above-Knee Amputations During Walking.

OBJECTIVE: A unilateral, lightweight powered hip exoskeleton has been shown to improve walking economy in individuals with above-knee amputations. However, the mechanism responsible for this improvement is unknown. In this study we assess the biomechanics of individuals with above-knee amputations walking with and without a unilateral, lightweight powered hip exoskeleton. We hypothesize that assisting the residual limb will reduce the net residual hip energy. METHODS: Eight individuals with above-knee amputations walked on a treadmill at 1 m/s with and without a unilateral powered hip exoskeleton. Flexion/extension assistance was provided to the residual hip. Motion capture and inverse dynamic analysis were performed to assess gait kinematics, kinetics, center of mass, and center of pressure. RESULTS: The net energy at the residual hip decreased from 0.05±0.04 J/kg without the exoskeleton to -0.01±0.05 J/kg with the exoskeleton (p = 0.026). The cumulative positive energy of the residual hip decreased on average by 18.2% with 95% confidence intervals (CI) (0.20 J/kg, 0.24 J/kg) and (0.16 J/kg, 0.20 J/kg) without and with the exoskeleton, respectively. During stance, the hip extension torque of the residual limb decreased on average by 37.5%, 95% CI (0.28 Nm/kg, 0.36 Nm/kg), (0.17 Nm/kg, 0.23 Nm/kg) without and with the exoskeleton, respectively. CONCLUSION: Powered hip exoskeleton assistance significantly reduced the net residual hip energy, with concentric energy being the main contributor to this change. We believe that the reduction in residual hip extension torque during early stance is the main contributor to this reduction. SIGNIFICANCE: This analysis shows that by assisting the residual hip, the exoskeleton significantly decreased the net hip energy produced by the residual limb, which may explain the improvements in walking economy previously observed.

A lightweight robotic leg prosthesis replicating the biomechanics of the knee, ankle, and toe joint.

Robotic leg prostheses promise to improve the mobility and quality of life of millions of individuals with lower-limb amputations by imitating the biomechanics of the missing biological leg. Unfortunately, existing powered prostheses are much heavier and bigger and have shorter battery life than conventional passive prostheses, severely limiting their clinical viability and utility in the daily life of amputees. Here, we present a robotic leg prosthesis that replicates the key biomechanical functions of the biological knee, ankle, and toe in the sagittal plane while matching the weight, size, and battery life of conventional microprocessor-controlled prostheses. The powered knee joint uses a unique torque-sensitive mechanism combining the benefits of elastic actuators with that of variable transmissions. A single actuator powers the ankle and toe joints through a compliant, underactuated mechanism. Because the biological toe dissipates energy while the biological ankle injects energy into the gait cycle, this underactuated system regenerates substantial mechanical energy and replicates the key biomechanical functions of the ankle/foot complex during walking. A compact prosthesis frame encloses all mechanical and electrical components for increased robustness and efficiency. Preclinical tests with three individuals with above-knee amputation show that the proposed robotic leg prosthesis allows for common ambulation activities with close to normative kinematics and kinetics. Using an optional passive mode, users can walk on level ground indefinitely without charging the battery, which has not been shown with any other powered or microprocessor-controlled prostheses. A prosthesis with these characteristics has the potential to improve real-world mobility in individuals with above-knee amputation.

Powered knee and ankle prostheses enable natural ambulation on level ground and stairs for individuals with bilateral above-knee amputation: a case study.

Ambulation with existing prostheses is extremely difficult for individuals with bilateral above-knee amputations. Commonly prescribed prostheses are passive devices that cannot replace the biomechanical functions of the missing biological legs. As a result, most individuals with bilateral above-knee amputations can only walk for short distances, have a high risk of falling, and are unable to ascend stairs with a natural gait pattern. Powered prostheses have the potential to address this issue by replicating the movements of the biological leg. Previous studies with individuals with bilateral above-knee amputations have shown that walking with powered prostheses is possible. However, stair ambulation requires different kinematics, kinetics, and power than walking. Therefore, it is not known whether powered prostheses can restore natural ambulation on stairs for bilateral above knee individuals. Here we show a case study with an individual with bilateral above-knee amputations using a pair of lightweight powered knee and ankle prostheses for walking and stair ambulation. The kinematic analysis shows that powered prostheses can restore natural leg movements, enabling the individual to walk and climb stairs using different gait patterns, such as step-over-step or step-by-step, one step or two steps at a time. The kinetic analysis shows that the powered prostheses can restore natural ankle push-off in walking and positive knee power generation in stair ascent, which are fundamental biomechanical functions of the missing biological legs. This case study is a first step towards enhancing functional mobility and quality of life for individuals with bilateral above-knee amputations through powered knee and ankle prostheses.

Powered Knee and Ankle Prosthesis with Adaptive Control Enables Climbing Stairs with Different Stair Heights, Cadences, and Gait Patterns.

Powered prostheses can enable individuals with above-knee amputations to ascend stairs step-over-step. To accomplish this task, available stair ascent controllers impose a pre-defined joint impedance behavior or follow a pre-programmed position trajectory. These control approaches have proved successful in the laboratory. However, they are not robust to changes in stair height or cadence, which is essential for real-world ambulation. Here we present an adaptive stair ascent controller that enables individuals with above-knee amputations to climb stairs of varying stair heights at their preferred cadence and with their preferred gait pattern. We found that modulating the prosthesis knee and ankle position as a function of the user's thigh in swing provides toe clearance for varying stair heights. In stance, modulating the torque-angle relationship as a function of the prosthesis knee position at foot contact provides sufficient torque assistance for climbing stairs of different heights. Furthermore, the proposed controller enables individuals to climb stairs at their preferred cadence and gait pattern, such as step-by-step, step-over-step, and two-steps. The proposed adaptive stair controller may improve the robustness of powered prostheses to environmental and human variance, enabling powered prostheses to more easily move from the lab to the real-world.

A preliminary investigation of psychometric properties of the youth-reported Pediatric Symptom Checklist (PSC-Y) in Chinese elementary, middle, and high schools.

The current study validated the youth-reported Pediatric Symptom Checklist-Youth (PSC-Y) using a Chinese youth sample (N = 20,996). The factor structure, measurement invariance, and criterion validity were examined. First, factor analysis documented that the correlated three-factor structure, including externalizing problems, internalizing problems, and attention problems fit the data best, which aligns with the prior factor structure of the PSC-Y in other settings (e.g., teacher ratings). In addition, measurement invariance was established across gender and age groups. The latent mean differences revealed that middle and high school students and females reported more internalizing and attention problems than elementary students and males. Additionally, high school students and females were less likely to report externalizing problems than elementary students and males. Finally, the criterion validity of the PSC-Y was established using external scales assessing subjective wellbeing and prosocial behavior. Teachers, school administrators, and school psychologists can utilize the results of this study to more precisely identify youth at risk for psychosocial problems.

Evaluation of Pharmacologic Interventions for Weight Management in a Veteran Population.

BACKGROUND: Veterans are disproportionately impacted by weight-related morbidity: 40% of veterans are categorized as obese and an additional 38.5% are overweight. Medications are recommended as an adjunct to lifestyle and dietary changes. Guidelines recommend 7 weight management medications, including orlistat, liraglutide, phentermine, phentermine/topiramate, lorcaserin, and naltrexone/bupropion. METHODS: A single-center, retrospective chart review was conducted for patients who started weight management medications at Veteran Health Indiana in Indianapolis. The primary outcomes included total weight loss and weight loss as a percentage of baseline weight at 3, 6, 12, and > 12 months of therapy. Secondary outcomes included weight loss of 5% from baseline, rate of successful weight maintenance after initial weight loss of 5% from baseline, adverse drug reaction monitoring, and use of weight management medications across clinics at this site. RESULTS: The absolute weight difference over 12 months of weight management medication therapy was 15.8 kg. At each time point, weight loss was found to be statistically significant when compared with baseline (P < .001). Average weight change was greatest with orlistat (-25.9 kg) and naltrexone/bupropion was associated with a gain of 2.1 kg over the duration of the study. A majority of the patients analyzed lost the guideline-recommended 5 to 10% from baseline while taking weight management medication. CONCLUSIONS: Weight management medications in a veteran population produced initial weight loss consistent with previous studies. However, there is room for improvement in follow-up strategies to promote greater weight maintenance after initial weight loss. Considering the high health care costs, personal burden, and potential long-term complications associated with obesity, efforts to promote continued development of programs that support weight management and maintenance are imperative.

Stand-Up, Squat, Lunge, and Walk With a Robotic Knee and Ankle Prosthesis Under Shared Neural Control.

Emerging robotic knee and ankle prostheses present an opportunity to restore the biomechanical function of missing biological legs, which is not possible with conventional passive prostheses. However, challenges in coordinating the robotic prosthesis movements with the user's neuromuscular system and transitioning between activities limit the real-world viability of these devices. Here we show that a shared neural control approach combining neural signals from the user's residual limb with robot control improves functional mobility in individuals with above-knee amputation. The proposed shared neural controller enables subjects to stand up and sit down under a variety of conditions, squat, lunge, walk, and seamlessly transition between activities without explicit classification of the intended movement. No other available technology can enable individuals with above-knee amputations to achieve this level of mobility. Further, we show that compared to using a conventional passive prosthesis, the proposed shared neural controller significantly reduced muscle effort in both the intact limb (21-51% decrease) and the residual limb (38-48% decrease). We also found that the body weight lifted by the prosthesis side increased significantly while standing up with the robotic leg prosthesis (49%-68% increase), leading to better loading symmetry (43-46% of body weight on the prosthesis side). By decreasing muscle effort and improving symmetry, the proposed shared neural controller has the potential to improve amputee mobility and decrease the risk of falls compared to using conventional passive prostheses.

Powered knee and ankle prosthesis with indirect volitional swing control enables level-ground walking and crossing over obstacles.

Powered prostheses aim to mimic the missing biological limb with controllers that are finely tuned to replicate the nominal gait pattern of non-amputee individuals. Unfortunately, this control approach poses a problem with real-world ambulation, which includes tasks such as crossing over obstacles, where the prosthesis trajectory must be modified to provide adequate foot clearance and ensure timely foot placement. Here, we show an indirect volitional control approach that enables prosthesis users to walk at different speeds while smoothly and continuously crossing over obstacles of different sizes without explicit classification of the environment. At the high level, the proposed controller relies on a heuristic algorithm to continuously change the maximum knee flexion angle and the swing duration in harmony with the user's residual limb. At the low level, minimum-jerk planning is used to continuously adapt the swing trajectory while maximizing smoothness. Experiments with three individuals with above-knee amputation show that the proposed control approach allows for volitional control of foot clearance, which is necessary to negotiate environmental barriers. Our study suggests that a powered prosthesis controller with intrinsic, volitional adaptability may provide prosthesis users with functionality that is not currently available, facilitating real-world ambulation.

The Humanistic and Economic Impact of Vaginal Dryness in Premenopausal, Perimenopausal, and Postmenopausal Women.

Background: Vaginal dryness is a highly prevalent condition. Much of previous research has focused on postmenopausal women. The aim of this study was to evaluate the impact of vaginal dryness on a predominantly premenopausal sample of women. Methods: The study was conducted online. Participants with self-reported vaginal dryness completed the Work Productivity and Activity Impairment (WPAI) scale, and a generic quality-of-life instrument, the assessment of quality of life instrument (AQoL)-4D. Information regarding sociodemographics was also collected. National (United Kingdom) median age-specific weekly wages were used to derive the economic cost of vaginal dryness. Results: A total of 524 women completed the study. The average age was 40.18 years (range 18-70 years) and just under 62% of the sample was premenopausal. Around 40% of women reported severe or very severe vaginal dryness. The average AQoL-4D score was 0.584 (standard deviation [SD]: 0.286) and decreased in line with level of severity (p = 0.014). Quality of life was not related to either age (p = 0.14) or menopausal status (p = 0.055). Of those women in employment (n = 369), 16.5% (SD: 24.3%) of their working hours were lost due to vaginal dryness; work impairment level was 34.4% (SD: 31.8%). The average lost weekly wage was £67.82 (SD: £130.88). The estimated average loss to employers was £82.56 (SD: £109.38) with a total weekly loss of £31,622. Conclusions: This study has shown the significant impact vaginal dryness has on premenopausal and postmenopausal women in terms of quality of life and economic burden, as well as the potential cost of this condition to society.

A kinematic and kinetic dataset of 18 above-knee amputees walking at various speeds.

Motion capture is necessary to quantify gait deviations in individuals with lower-limb amputations. However, access to the patient population and the necessary equipment is limited. Here we present the first open biomechanics dataset for 18 individuals with unilateral above-knee amputations walking at different speeds. Based on their ability to comfortably walk at 0.8 m/s, subjects were divided into two groups, namely K2 and K3. The K2 group walked at [0.4, 0.5, 0.6, 0.7, 0.8] m/s; the K3 group walked at [0.6, 0.8, 1.0, 1.2, 1.4] m/s. Full-body biomechanics was collected using a 10-camera motion capture system and a fully instrumented treadmill. The presented open dataset will enable (i) clinicians to understand the biomechanical demand required to walk with a knee and ankle prosthesis at various speeds, (ii) researchers in biomechanics to gain new insights into the gait deviations of individuals with above-knee amputations, and (iii) engineers to improve prosthesis design and function.

Preliminary Analysis Of Positive Knee Energy Injection In A Transfemoral Amputee Walking With A Powered Prosthesis.

Individuals with lower limb amputations show higher metabolic costs during ambulation than able-bodied individuals. This high metabolic cost may be explained by the inability of available passive prostheses to replicate the biomechanics of intact legs during walking. Powered prostheses promise to address this issue by imitating the power generation of intact legs. Several studies have investigated the effect of power generation and energy injection at the ankle joint in transtibial amputees. In contrast, no study has directly addressed knee power generation in transfemoral amputees. This study investigates the effect of knee power generation in late stance in one transfemoral amputee subject using a lightweight powered prosthesis. Experimental results suggest that injecting positive energy into the gait cycle at the knee level may improve gait ability by reducing effort.

National Internal Medicine Milestone Ratings: Validity Evidence From Longitudinal Three-Year Follow-up.

PURPOSE: To evaluate validity evidence for internal medicine milestone ratings across programs for three resident cohorts by quantifying "not assessable" ratings; reporting mean longitudinal milestone ratings for individual residents; and correlating medical knowledge ratings across training years with certification examination scores to determine predictive validity of milestone ratings for certification outcomes. METHOD: This retrospective study examined milestone ratings for postgraduate year (PGY) 1-3 residents in U.S. internal medicine residency programs. Data sources included milestone ratings, program characteristics, and certification examination scores. RESULTS: Among 35,217 participants, there was a decreased percentage with "not assessable" ratings across years: 1,566 (22.5%) PGY1s in 2013-2014 versus 1,219 (16.6%) in 2015-2016 (P = .01), and 342 (5.1%) PGY3s in 2013-2014 versus 177 (2.6%) in 2015-2016 (P = .04). For individual residents with three years of ratings, mean milestone ratings increased from around 3 (behaviors of an early learner or advancing resident) in PGY1 (ranging from a mean of 2.73 to 3.19 across subcompetencies) to around 4 (ready for unsupervised practice) in PGY3 (mean of 4.00 to 4.22 across subcompetencies, P < .001 for all subcompetencies). For each increase of 0.5 units in two medical knowledge (MK1, MK2) subcompetency ratings, the difference in examination scores for PGY3s was 19.5 points for MK1 (P < .001) and 19.0 for MK2 (P < .001). CONCLUSIONS: These findings provide evidence of validity of the milestones by showing how training programs have applied them over time and how milestones predict other training outcomes.

Association Between Medication Adherence and the Outcomes of Heart Failure.

BACKGROUND: Previous studies of heart failure patients demonstrated an association between cardiovascular medication adherence and hospitalizations or a composite end point of hospitalization and death. Few studies have assessed the impact of treatment adherence within large general medical populations that distinguish the health outcomes of emergency department visits, hospitalization, and death. OBJECTIVE: To determine the association of incremental cardiovascular medication adherence on emergency department visits, hospitalization, and death in adult heart failure patients in Indiana. DESIGN: Retrospective cohort study conducted using electronic health record data from the statewide Indiana Network for Patient Care between 2004 and 2009. METHODS: Patients were at least 18 years of age with a diagnosis of heart failure and prescribed at least one cardiovascular medication for heart failure. Adherence was measured as the proportion of days covered (PDC) using pharmacy transaction data. Clinical end points included emergency department visits, hospital admissions, length of hospital stay, and mortality. Generalized linear models were used to determine the effect of a 10% increase in PDC on clinical end points adjusting for age, sex, race, Charlson Comorbidity Index, and medications. RESULTS: Electronic health records were available for 55,312 patients (mean age ± standard deviation 68 ± 16 yrs; 54% women; 65% white). Mean PDC for all heart failure medications was 63% ± 23%. For every 10% increase in PDC, emergency department visits decreased 11% (rate ratio [RR] 0.89, 95% confidence interval [CI] 0.89-0.89), hospital admissions decreased 6% (RR 0.94, 95% CI 0.94-0.94), total length of hospital stay decreased 1% (RR 0.99, 95% CI 0.99-1.00), and all-cause mortality decreased 9% (odds ratio 0.91; 95% CI 0.90-0.92). CONCLUSION: Incremental medication adherence was associated with reductions in emergency department visits, hospital admissions, length of hospital stay, and all-cause mortality.

The PNR to Relaxor Transition in PSN with nearest neighbor Pb-O divacancies.

In previous work, molecular dynamics simulations based on a first-principles-derived effective Hamiltonian for Pb1-X(Sc1/2Nb1/2)O3-X (PSN), with nearest-neighbor Pb-O divacancy pairs, was used to calculate X[Pb-O] vs. T, phase diagrams for PSN with: ideal rock-salt type chemical order; nanoscale chemical short-range order; and random chemical disorder. Here, we show that the phase diagrams should include additional regions in which a glassy relaxor-phase (or state) is predicted. With respect to phase diagram topology, these results strongly support the analogy between relaxors and magnetic spin-glass-systems.

Correlations Between Ratings on the Resident Annual Evaluation Summary and the Internal Medicine Milestones and Association With ABIM Certification Examination Scores Among US Internal Medicine Residents, 2013-2014.

Importance: US internal medicine residency programs are now required to rate residents using milestones. Evidence of validity of milestone ratings is needed. Objective: To compare ratings of internal medicine residents using the pre-2015 resident annual evaluation summary (RAES), a nondevelopmental rating scale, with developmental milestone ratings. Design, Setting, and Participants: Cross-sectional study of US internal medicine residency programs in the 2013-2014 academic year, including 21 284 internal medicine residents (7048 postgraduate-year 1 [PGY-1], 7233 PGY-2, and 7003 PGY-3). Exposures: Program director ratings on the RAES and milestone ratings. Main Outcomes and Measures: Correlations of RAES and milestone ratings by training year; correlations of medical knowledge ratings with American Board of Internal Medicine (ABIM) certification examination scores; rating of unprofessional behavior using the 2 systems. Results: Corresponding RAES ratings and milestone ratings showed progressively higher correlations across training years, ranging among competencies from 0.31 (95% CI, 0.29 to 0.33) to 0.35 (95% CI, 0.33 to 0.37) for PGY-1 residents to 0.43 (95% CI, 0.41 to 0.45) to 0.52 (95% CI, 0.50 to 0.54) for PGY-3 residents (all P values <.05). Linear regression showed ratings differed more between PGY-1 and PGY-3 years using milestone ratings than the RAES (all P values <.001). Of the 6260 residents who attempted the certification examination, the 618 who failed had lower ratings using both systems for medical knowledge than did those who passed (RAES difference, -0.9; 95% CI, -1.0 to -0.8; P < .001; milestone medical knowledge 1 difference, -0.3; 95% CI, -0.3 to -0.3; P < .001; and medical knowledge 2 difference, -0.2; 95% CI, -0.3 to -0.2; P < .001). Of the 26 PGY-3 residents with milestone ratings indicating deficiencies on either of the 2 medical knowledge subcompetencies, 12 failed the certification examination. Correlation of RAES ratings for professionalism with residents' lowest professionalism milestone ratings was 0.44 (95% CI, 0.43 to 0.45; P < .001). Conclusions and Relevance: Among US internal medicine residents in the 2013-2014 academic year, milestone-based ratings correlated with RAES ratings but with a greater difference across training years. Both rating systems for medical knowledge correlated with ABIM certification examination scores. Milestone ratings may better detect problems with professionalism. These preliminary findings may inform establishment of the validity of milestone-based assessment.