The Upcoming Pass/Fail USMLE Step 1 Score Reporting: An Impact Assessment From Medical School Deans.

Background: The US Medical Licensing Examination (USMLE) Step 1 change to pass/fail has been met with mixed reviews, and the impact on medical student education and residency match is unknown. We surveyed medical school student affairs deans regarding their thoughts on the upcoming transition of Step 1 to pass/fail. Methods: A questionnaire was emailed to medical school deans. Deans were asked to rank the importance of the following after the Step 1 reporting change: Step 2 Clinical Knowledge (Step 2 CK), clerkship grades, letters of recommendation, personal statement, medical school reputation, class rank, Medical Student Performance Evaluation, and research. They were asked how the score change will affect curriculum, learning, diversity, and student mental health. Deans were asked to select 5 specialties they thought would be most affected. Results: Regarding perceived importance of residency applications following the scoring change, the most frequent number 1 choice was Step 2 CK. The majority of deans (93.5%, n = 43) felt that the change to pass/fail would benefit medical student education/learning environment; however, most (68.2%, n = 30) did not believe their school curriculum would change. Students applying to dermatology, neurosurgery, orthopedic surgery, ENT, and plastic surgery were felt to be most affected by the scoring change; 58.7% (n = 27) felt it would not adequately address future diversity. Conclusion: The majority of deans feel the USMLE Step 1 change to pass/fail would benefit medical student education. Deans feel that students applying to traditionally more competitive specialties (ie, programs with fewer overall residency positions available) will be most affected.

Contexte : Le changement de l'épreuve 1 de l'USMLE pour un résultat de type réussite/échec a été accueilli par des opinions variées et son impact sur la formation des étudiants en médecine et l'adéquation des résidences est inconnu. Nous avons mené une enquête auprès des doyens des affaires étudiantes des facultés de médecine pour connaître leur opinion sur la transition prochaine de l'épreuve 1 à un score réussite/échec. Méthodes : Un questionnaire a été envoyé par courriel aux doyens des facultés de médecine. Il leur a été demandé de classer l'importance des éléments suivants après la modification de déclaration des résultats de l'Épreuve 1: Épreuve 2 CK, notes d'externat, lettres de recommandation, déclaration personnelle, réputation de l'école de médecine, classement, évaluation des performances des étudiants en médecins (MSPE) et recherche. Il leur a été demandé comment le changement de notation allait affecter les programmes, l'apprentissage, la diversité et la santé mentale des étudiants. Les doyens devaient sélectionner les 5 spécialités qui, à leur avis, allaient être les plus touchées. Résultats : Pour ce qui concerne l'importance perçue des demandes de résidence après le changement de notation, le choix numéro 1 le plus fréquent a été l'épreuve 2 CK. La majorité des doyens (93,5%, n = 43) a eu le sentiment que le changement en Réussite/Échec serait bénéfique pour la formation des étudiants en médecine et leur environnement pédagogique; toutefois, la plupart d'entre eux (68,2%, n = 30) ne croyaient pas que les programmes d'études changeraient. Les étudiants faisant des demandes en dermatologie, neurochirurgie, chirurgie orthopédique, ORL, et chirurgie plastique étaient perçus comme les plus touchés par le changement de notation. Par ailleurs 58,7% des répondants (n = 27) ont estimé que cela n'aborderait pas de manière adéquate la diversité future. Conclusion : La majorité des doyens a le sentiment que le passage à une notation Réussite/Échec de l'Épreuve 1 de l'USMLE serait bénéfique à la formation des étudiants en médecine. Les doyens estiment que les étudiants faisant des demandes pour des spécialités où règne traditionnellement une plus grande concurrence (c.-à-d. les programmes avec un moins grand nombre global de postes de résidents) seront les plus touchés.

Opioid-sparing Strategies in Alloplastic Breast Reconstruction: A Systematic Review.

INTRODUCTION: Pain and discomfort are frequently experienced following mastectomy with concomitant breast implant- or tissue expander-based alloplastic breast reconstruction (AlBR). Unfortunately, postoperative opioids have decreased efficacy in AlBR, short-term complication profiles, and are fraught by long-term dependence. This systematic review aims to identify opioid-sparing pain management strategies in AlBR. METHODS: A systematic literature search of MEDLINE, Embase, Web of Science, and Cochrane Central Register was performed in September 2018. PRISMA guidelines were followed, and the review was prospectively registered in PROSPERO (CRD42018107911). The search identified 1184 articles. Inclusion criteria were defined as patients 18 years or older undergoing AlBR. RESULTS: Fourteen articles were identified assessing opioid-sparing strategies in AlBR. This literature included articles evaluating enhanced recovery protocols (two), intercostal blocks (two), paravertebral blocks (four), liposomal bupivacaine (three), diclofenac (one), and local anesthesia infusion pumps (two). The literature included five randomized trials and nine cohort studies. Study characteristics, bias (low to high risk), and reporting outcomes were extensively heterogeneous between articles. Qualitative analysis suggests reduced opioid utilization in enhanced recovery after surgery (ERAS) pathways, paravertebral blocks, and use of liposomal bupivacaine. CONCLUSIONS: A variety of opioid-sparing strategies are described for pain management in AlBR. Multimodal analgesia should be provided via ERAS pathways as they appear to reduce pain and spare opioid use. Targeted paravertebral blocks and liposomal bupivacaine field blocks appear to be beneficial in sparing opioids and should be considered as essential components of ERAS protocols. Additional prospective, randomized trials are necessary to delineate the efficacy of other studied modalities.

The First Descriptions of Dorsal Preservation Rhinoplasty in the 19th and Early- to Mid-20th Centuries and Relevance Today.

INTRODUCTION: The basis of dorsal preservation rhinoplasty goes back to the late 19th and the early 20th centuries. In that era, pioneers such as Drs. Goodale, Lothrop, and Cottle were prominent surgeons who reported on this technique. Currently, there has been a renewed interest of this technique that stems from the nasal anatomy and an interest in less destructive techniques. In this review, we discuss examples of the contributions of those surgeons, which represent some of the earliest experiences in this field. METHODS: We reviewed several journals from the late 19th and early 20th centuries as detailed in the references section. We collected the related publications on closed reduction techniques performed by Drs. Goodale, Lothrop, and Cottle. RESULTS: The publications on closed reduction techniques by Drs. Goodale, Lothrop, and Cottle described similar thought processes and techniques comparable to current dorsal preservation rhinoplasty techniques. The thought processes of these 3 renowned rhinoplasty surgeons appear to be very much relevant today. CONCLUSIONS: Although there has been recent resurgence in dorsal preservation rhinoplasty techniques due to anatomical and functional aspects of the nose, the basis of dorsal preservation rhinoplasty goes far back to more than 100 years ago.

A paintable phosphorescent bandage for postoperative tissue oxygen assessment in DIEP flap reconstruction.

Flaps are common in plastic surgery to reconstruct large tissue defects in cases such as trauma or cancer. However, most tissue oximeters used for monitoring ischemia in postoperative flaps are bulky, wired devices, which hinder direct flap observation. Here, we present the results of a clinical trial using a previously untried paintable transparent phosphorescent bandage to assess the tissue's partial pressure of oxygen (pO2). Statistical analysis revealed a strong relationship (P < 0.0001) between the rates of change of tissue oxygenation measured by the bandage and blood oxygen saturation (%stO2) readings from a standard-of-care ViOptix near-infrared spectroscopy oximeter. In addition, the oxygen-sensing bandage showed no adverse effects, proved easy handling, and yielded bright images across all skin tones with a digital single-lens reflex (DSLR) camera. This demonstrates the feasibility of using phosphorescent materials to monitor flaps postoperatively and lays the groundwork for future exploration in other tissue oxygen sensing applications.

Treating Symptomatic Midvault Soft Tissue Collapse in Revision Rhinoplasty with a Nasal Wall Implant.

Persistent nasal airway obstruction (NAO) due to midvault soft tissue collapse in patients following rhinoplasty or nasal surgery is a clinical challenge for surgeons. An absorbable lateral nasal wall implant is one option available to help treat midvault soft tissue collapse and to improve NAO symptoms. Previous studies have not investigated its use in complex revision functional rhinoplasty with respect to patient-reported outcomes. Data were collected on all patients with a history of previous nasal procedures who underwent Latera implant placement in conjunction with functional rhinoplasty from January to December 2018. The Nasal Obstructive Symptom Evaluation and Visual Analogue Scale were used to evaluate functional outcomes. Eight implants were placed in 6 revision functional rhinoplasty patients with midvault collapse. All patients responded to the survey. Mean follow-up was 16 ± 4 months. There were no implant-related adverse events. Mean Nasal Obstructive Symptom Evaluation score was 33 ± 33, and mean Visual Analogue Scale score was 20 ± 9. In total, 1 patient reported complete resolution of NAO, whereas 2 patients reported mild, 1 reported moderate, 1 reported severe, and 1 reported extreme symptoms. Four of the 6 patients reported nasal obstruction improvement, with all reporting improvement in midvault soft tissue collapse. Apart from being used in nasal valve collapse treatment, a lateral nasal wall implant is a potentially useful solution that may help surgeons improve patients' NAO symptoms in complex functional rhinoplasty cases. However, in certain cases, a patient's nasal obstructive symptoms may continue to be multifactorial.