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Introduction: Shoulder stabilization surgery is common among military personnel, causing severe acute postoperative pain that may contribute to the development of chronic pain, thereby reducing military readiness. Battlefield Acupuncture (BFA) has shown promise as a non-pharmaceutical intervention for acute postoperative pain. The purpose of this study was to determine the effectiveness of BFA combined with standard physical therapy on pain, self-reported mood, self-reported improvement, and medication use in patients after shoulder stabilization surgery., Materials and Methods: The study design was a single-blind, randomized clinical trial, approved by the Naval Medical Center Portsmouth Institutional Review Board and registered with ClinicalTrials.gov (NCT04094246). Ninety-five participants were recruited after shoulder stabilization surgery. Participants were randomized via concealed allocation into a standard physical therapy (PT) group or a group receiving standard PT and BFA. Both groups received standard postoperative pain medication. The BFA intervention followed a standard protocol with the insertion of gold aiguille d'acupuncture emiermanente needles at 5 specific points in the ear. At 4 time points (baseline [24-48 hours], 72 hours, 1 week, and 4 weeks post-surgery), participants reported worst and average pain using a Visual Analog Scale (VAS), self-reported mood using the Profile of Mood States (POMS), self-recorded medication intake between study visits, and self-reported improvement in symptoms using a Global Rating of Change (GROC) Scale. Outcome assessors were blinded to treatment allocation. An alpha level of 0.05 was set a priori. For pain, a mixed-model analysis of variance was used to analyze the interaction effect between group and time. Differences in baseline data, total opioid usage, and pain change scores between groups were analyzed using independent t-tests., Results: Of the 95 participants enrolled, 7 failed to provide complete study visits after the baseline, leaving 88 patients (43 BFA, 45 control, mean age 21.8 (2.1) years, 23% female). There were no significant group-by-time interactions for VAS worst pain (F = 0.70, P = .54), VAS average pain (F = 0.99, P = .39), the POMS (F = 1.04, P = .37), or GROC (F = 0.43, P = 0.63). There was a significant main effect of time for VAS worst pain (F = 159.7, P < .001), VAS average pain (F = 122.4, P < .001), the POMS (F = 11.4, P < .001), and the GROC (F = 78.5, P < .001). While both groups demonstrated statistically significant and clinically meaningful improvements in pain and self-reported mood over time, BFA did not provide any additional benefit compared to standard physical therapy alone. There was no significant difference in opioid usage between groups at 4 weeks (t = 0.49, P = .63). Finally, both groups also demonstrated statistically significant and clinically meaningful self-reported improvements in function, but again, there was no additional benefit when adding BFA to standard physical therapy., Conclusion: The results of this study do not support the effectiveness of BFA for postsurgical pain management as there were no significant differences in pain, self-reported mood, self-reported improvement, and medication use between participants who received BFA and those who did not. As this is the only known study of BFA in postsurgical participants, continued research is needed to determine if BFA is effective for pain reduction in that setting., Clinical Trial Registration: ClinicalTrials.gov, NCT04094246. Registered September 16, 2019, http://clinicaltrials.gov/NCT04094246., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2025. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: The United States military strives to prepare soldiers physically and mentally for war while preventing injury and attrition. Previous research has focused on physical injury risk factors but has not prospectively examined psychological risk factors., Purpose: This study's purpose was to investigate whether self-efficacy is a risk factor for musculoskeletal injury in an initial military training environment and compare it to other known risk factors., Study Design: Prospective, Longitudinal Cohort Study., Materials and Methods: Shortly after starting cadet basic training, new cadets rated self-efficacy by an 11-point questionnaire. Other risk factor data including injury history, sex, height, weight, body mass index, age, aerobic fitness, upper body muscular endurance, core muscular endurance and previous military experience were collected by self-report questionnaire and military fitness testing. The primary dependent variable was musculoskeletal injury that originated during the seven-week course. Independent variables were compared between participants who were and were not injured using Chi-squared test, t-tests, Cox regression analysis and time to injury was evaluated using Kaplan-Meyer survival analyses., Results: Seven hundred eighty-one (65.1%) new cadets were eligible and consented to participate. Injured cadets had significantly lower self-efficacy scores (p=0.003 and p=<0.001), shorter height (p=<0.001), lower weight (p=0.036), lower push-up and plank performance (p=<0.001), slower two-mile run performance (p=<0.001), and females sustained a proportionally higher number of injuries than males (p=<0.001). Cadets with low self-efficacy, shorter height, lower hand release push-up performance, lower plank performance and slower two-mile run performance were at greater risk for musculoskeletal injury. Cadets with less self-efficacy were also less likely to continue uninjured throughout cadet basic training according to a Kaplan-Meier survival analysis (log rank test<0.002). Multivariable Cox regression revealed that only aerobic fitness predicted musculoskeletal injury (HR=1.005 [1.003-1.006], p=<0.001)., Conclusions: Participants with less self-efficacy sustained injuries earlier and more often than those with greater self-efficacy. However, aerobic fitness alone predicted future injury after controlling for all risk factors. Resolved prior injury was not a risk factor for future injury., Level of Evidence 2b: Individual cohort study., (© The Author(s).)

Purpose: Extramural funding is critical to career success and advancement in academic surgery, and surgical residents can apply for both societal and federal funding. Many federal funding mechanisms require proposals to be submitted before residents' formal research years., Methods: To better understand the resident experience with grantsmanship, we distributed a validated grantsmanship self-efficacy assessment inventory for voluntary completion at our academic general surgery training program with 2 years of dedicated research. The survey covers 3 domains: conceptualizing, designing and analyzing, and funding a study. All questions are scored 0 to 10 with 0 indicating no confidence and 10 indicating complete confidence. Median scores for the 3 domains were calculated for all respondents and compared between training years using Kruskal-Wallis with post-hoc Dunn testing., Results: Forty-four surveys were completed with a response rate of 84%. Resident self-efficacy in grantsmanship improved throughout the training years with the greatest changes being in their comfort with conceptualizing and funding a study. Dunn testing identified specific differences between PGY2 and PGY7 comfort with conceptualizing studies (median 5 vs. 7.5, p = 0.003) and understanding of funding mechanisms (median 2.0 vs. 7, p = 0.003)., Conclusions: While comfort with conceptualizing and funding studies does increase throughout the training years, this often develops after critical funding deadlines have already passed and can disadvantage surgical residents interested in academic careers. A curriculum that emphasizes familiarity with the grant writing and funding processes may better facilitate long term career success., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: This study aimed to characterize patient satisfaction with navigators and surgical care accessed through a novel navigation program for under-resourced communities., Methods: PSN-I and PSQ-18 questionnaires assessed satisfaction with navigators and care, respectively. Primary outcomes were PSN-I and PSQ-18 scores. Secondary analyses tested associations between satisfaction and patient factors and between PSN-I and PSQ-18 scores., Results: Of 294 patients contacted, 88 (29.9 ​%) responded. Most were Hispanic/Latinx (76.1 ​%), Spanish-speaking (71.5 ​%), and uninsured (85.2 ​%). Participants were highly satisfied with navigators (mean 38.5, SD 7.6; max. 45) and most care domains except Financial Aspects (mean 3.2, SD 1.0; max. 5) and Accessibility/Convenience (mean 3.5, SD 0.6; max. 5). Higher navigator satisfaction was associated with post-consultation need for surgery (coeff. 5.6, 95 ​% CI[0.9, 10.3]) and increased the odds of care satisfaction (OR 1.1, 95 ​% CI[1.0, 1.2])., Conclusions: Patients are satisfied with navigation services-a previously unstudied aspect of this unique surgical equity program., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Increasingly, medical schools integrate clinical skills into early didactic coursework. The Stop the Bleed® Campaign emphasizes prehospital hemorrhage control to reduce preventable deaths; however, this course overlooks team interactions. We assessed the impact of high-fidelity simulation during medical student orientation on identification and treatment of life-threatening hemorrhage in a team setting., Design: In this mixed method, prospective pre-, post-, and follow-up survey analysis assessing student knowledge and attitudes, student teams encountered a standardized patient in a prehospital environment with pulsatile bleeding from an extremity wound. Individual students completed surveys assessing previous experience, willingness and ability to assist bleeding person(s), and knowledge and attitudes about tourniquets. Postscenario, faculty preceptors made qualitative observations on teamwork., Setting: Medical student orientation at a tertiary care academic medical center with long-term follow-up., Participants: Medical students (N = 150)., Results: Ninety students (60%) completed both pre- and postsimulation questionnaires. Sixteen (17%) students had previous tourniquet training experience although none had applied a tourniquet outside of training. Postsimulation, students reported increased likelihood of providing treatment until additional help arrived (p = 0.035), improved ability to identify life-threatening hemorrhage (p < 0.001), and more favorable opinions about tourniquet use (p < 0.001) and potential for limb-salvage (p = 0.018). Long-term follow-up respondents (n = 34, 23%) reported increased ability to identify life-threatening hemorrhage (p = 0.010) and universal willingness to intervene until additional help arrived. Follow-up survey responses elicited themes in hemorrhage control including recognition of the importance of continuous pressure, appropriate use of tourniquets, a desire for repeated team training, and the recognition of clerkship rotations as an optimal setting for skill reinforcement. Preceptors noted variable team responses but uniformly endorsed the exercise., Conclusions: High-fidelity bleeding simulation during medical student orientation improved students' knowledge and attitudes about treating life-threatening hemorrhage and served as an introduction to team-based emergency care. Future studies should further explore team training and hemorrhage control education., (Copyright © 2024 Association of Program Directors in Surgery. All rights reserved.)

Importance: Socially vulnerable patients with symptomatic cholelithiasis are more likely to face barriers to accessing surgical care. This barrier to access can lead to delays in treatment, the need for emergent cholecystectomy, and worse outcomes., Objectives: To determine the effectiveness of telemedicine vs in-person surgical consultation on access to elective cholecystectomy in socially vulnerable populations and to evaluate the association of scheduling navigation with access to elective cholecystectomy in these populations., Design, Setting, and Participants: This pilot randomized clinical trial conducted in a single academic center enrolled 60 adults from February 1, 2023, to February 21, 2024, with 3-month follow-up of clinical outcomes. Data were also collected retrospectively on a comparison group of 32 patients referred from June 30 to December 29, 2022. Adults with social vulnerability, such as being non-White or Hispanic or having nonprivate insurance or low income, with a diagnosis of symptomatic cholelithiasis and referral for outpatient surgical consultation were included., Interventions: All trial participants were randomized to the telemedicine or in-person surgical consultation group, and received professional scheduling navigation. The latter intervention was compared with a historical cohort without navigation assistance., Main Outcomes and Measures: The primary outcome was completion of outpatient surgical consultation. Secondary outcomes included receipt of treatment and operative urgency., Results: The trial enrolled 60 participants (30 per arm). Their mean (SD) age was 48.2 (18.2) years, 50 (83.3%) were female, 2 (3.3%) were Asian, 39 (65.0%) were Black, 8 (13.3%) were Hispanic, 11 (18.3%) were White, and 41 (68.3%) had no private insurance. The historical patient cohort included 32 participants (mean [SD] age, 45.9 [3.2] years; 27 [84.4%] female; 3 [9.4%] Asian, 15 [46.9%] Black, 10 [31.3%] Hispanic, and 6 [18.8%] White; and 18 [56.3%] without private insurance). In total, 18 trial participants assigned to telemedicine (60.0%) completed surgical consultations compared with 23 trial participants assigned to in-person visits (76.7%; P = .17). For telemedicine participants who underwent cholecystectomy, 3 of 7 (42.9%) underwent emergent cholecystectomy compared with 0 of 14 (0%) participants with in-person consultations (P = .03). Of 30 trial participants who received scheduling navigation, 23 (76.7%) completed surgical consultations compared with 15 of 32 patients in the historical cohort who did not receive scheduling navigation (46.9%; P = .02). Of 14 trial participants who received scheduling navigation and cholecystectomy, no participants underwent emergent cholecystectomy compared with 4 of 16 (25.0%) participants in the historical cohort without scheduling navigation (P = .04)., Conclusions and Relevance: In this pilot randomized clinical trial of socially vulnerable adults with symptomatic cholelithiasis, telemedicine consultation compared with in-person visits did not improve access to elective outpatient surgical care. However, scheduling navigation services may improve access to elective outpatient surgical care. Future large-scale studies are needed to identify possible barriers to virtual health care and mechanisms to address inequities., Trial Registration: ClincialTrials.gov Identifier: NCT05745077.

Background: Lower extremity bone stress injuries (BSI) are common injuries among athletes and military members. Typical management involves a period of restricted weightbearing which can have rapid detrimental effects upon both muscle and bone physiology. Few studies have investigated the effect of blood flow restriction (BFR) training on bone in the rehabilitative setting., Purpose: The purpose of this study was to investigate the effects of lower extremity exercise with the addition of BFR upon bone mineral density, bone mineral content, and lean body mass in military members with tibial BSIs., Study Design: Case series., Methods: Twenty military members with MRI-confirmed tibial BSI were recruited to complete lower extremity exercise with the addition of BFR twice per week for four weeks. The BFR cuff was applied proximally to the participant's involved limb while they performed gluteal, thigh, and leg resistance exercises. Outcomes were assessed at baseline and four weeks. The primary outcomes were whole leg bone mineral density (BMD), bone mineral content (BMC), and lean body mass (LM) as measured by dual-energy x-ray absorptiometry. Secondary outcomes included thigh and leg circumference measures and patient-reported outcomes, including the Lower Extremity Functional Scale (LEFS), Patient-Reported Outcomes Measurement Information System 57 (PROMIS-57), and Global Rating of Change (GROC)., Results: No significant differences were found in BMD (p=0.720) or BMC (p=0.749) between limbs or within limbs over time. LM was generally less in the involved limb (p=0.019), however there were no significant differences between or within limbs over time (p=0.404). For thigh circumference, significant main effects were found for time (p=0.012) and limb (p=0.015), however there was no significant interaction effect (p=0.510). No significant differences were found for leg circumference (p=0.738). Participants showed significant mean changes in LEFS (15.15 points), PROMIS physical function (8.98 points), PROMIS social participation (7.60 points), PROMIS anxiety (3.26 points), and PROMIS pain interference (8.39 points) at four weeks., Conclusion: The utilization of BFR in the early rehabilitative management of tibial BSI may help mitigate decrements in both bone and muscle tissue during periods of decreased physical loading., Level of Evidence: 4., Competing Interests: The authors report no conflicts of interest related to this research., (© The Author(s).)

Abstract: Scott, KM, Kreisel, BR, Florkiewicz, EM, Crowell, MS, Morris, JB, McHenry, PA, and Benedict, TM. The effect of cautionary versus resiliency spine education on maximum deadlift performance and back beliefs: A randomized control trial. J Strength Cond Res 38(7): e341-e348, 2024-The purpose of this study was to determine the effect of cautionary information about the spine vs. a message of spine resiliency on maximum deadlift (MDL) performance and beliefs regarding the vulnerability of the spine. This cluster randomized control trial involved 903 military new cadets (n = 903) during their mandatory fitness test in cadet basic training (mean age 18.3 years, body mass index 23.8 kg·m-2, 22% female). Subjects were cluster randomized to 3 groups. The cautionary group received a message warning them to protect their backs while deadlifting, the resiliency group received a message encouraging confidence while deadlifting, and the control group received the standardized Army deadlift education only. The outcome measures were MDL weight lifted and perceived spine vulnerability. Significance was set at alpha ≤0.05. There were no between-group differences in weight lifted (p=0.40). Most subjects believed that the spine is vulnerable to injury. Three times as many subjects who received the resiliency education improved their beliefs about the vulnerability of their spines compared with those receiving the cautionary education (p<0.001). This study demonstrated the potential for brief resiliency education to positively influence beliefs about spine vulnerability, whereas cautionary education did not impair performance., (Copyright © 2024 National Strength and Conditioning Association.)

Objective: To examine access to cholecystectomy and postoperative outcomes among non-English primary-speaking patients., Background: The population of U.S. residents with limited English proficiency is growing. Language affects health literacy and is a well-recognized barrier to health care in the United States of America. Historically marginalized communities are at greater risk of requiring emergent gallbladder operations. However, little is known about how primary language affects surgical access and outcomes of common surgical procedures, such as cholecystectomy., Methods: We conducted a retrospective cohort study of adult patients after receipt of cholecystectomy in Michigan, Maryland, and New Jersey utilizing the Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery and Services Database (2016-2018). Patients were classified by primary spoken language: English or non-English. The primary outcome was admission type. Secondary outcomes included operative setting, operative approach, in-hospital mortality, postoperative complications, and length of stay. Multivariable logistics and Poisson regression were used to examine outcomes., Results: Among 122,013 patients who underwent cholecystectomy, 91.6% were primarily English speaking and 8.4% were non-English primary language speaking. Primary non-English speaking patients had a higher likelihood of emergent/urgent admissions (odds ratio: 1.22, 95% CI: 1.04-1.44, P = 0.015) and a lower likelihood of having an outpatient operation (odds ratio: 0.80, 95% CI: 0.70-0.91, P = 0.0008). There was no difference in the use of a minimally invasive approach or postoperative outcomes based on the primary language spoken., Conclusions: Non-English primary language speakers were more likely to access cholecystectomy through the emergency department and less likely to receive outpatient cholecystectomy. Barriers to elective surgical presentation for this growing patient population need to be further studied., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Comprehensive, socially-minded healthcare has historically been delivered in the primary care setting. For underserved patient populations, however, a surgical care episode may serve as the health care access point. To maximize patient wellbeing during the perioperative period, our surgical center developed the Additional Needs Screener (ANS). Operationalized into practice by GME and UME trainees, this tool screens surgical patients across 3 domains (social, emotional, and immigration needs) and connects patients to partner organizations if appropriate. This study describes the pilot utilization of the ANS among underserved and underinsured surgical patients., Design: Clinical quality improvement and retrospective cohort study of patients completing the ANS from implementation in September 2021 to September 2022., Setting: The Hospital of the University of Pennsylvania, PA-a tertiary care center., Participants: One hundred and 10 underinsured and/or underserved patients completed at least 1 ANS domain., Results: Patients were majority female (55F, 53M, 2 other) and Hispanic/Latinx (72%) with a median age of 38 (IQR = 34-48). Most patients spoke a primary language other than English (77%), and nearly all were either uninsured (82%) or received emergency medical assistance or Medicaid (14%) at referral. Patients demonstrated significant needs; 39% endorsed difficulty affording housing, 32% endorsed difficulty paying for food, 29% endorsed experiencing current life-interfering distress, and 75% had undocumented immigration status. Ultimately, 57% of screened patients accepted referrals to our needs response teams., Conclusions: Underserved and underinsured patients presenting for surgical care face significant challenges relating to social, emotional, and immigration needs. Through adoption of the ANS, trainees gained competency identifying and addressing these barriers in the perioperative period. Future works will focus on categorizing referral outcomes, developing interventions to increase patient trust, and improving screener dissemination., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Despite its common nature, there is no data on the educational quality of publicly available laparoscopic jejunostomy training videos. The LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) video assessment tool, released in 2020, has been developed to ensure that teaching videos are of appropriate quality. This study applies the LAP-VEGaS tool to currently available laparoscopic jejunostomy videos., Methods: A retrospective review of YouTube ® videos was conducted for "laparoscopic jejunostomy." Included videos were rated by three independent investigators using LAP-VEGaS video assessment tool (0-18). Wilcoxon rank-sum test was used to evaluate differences in LAP-VEGaS scores between video categories and date of publication relative to 2020. Spearman's correlation test was performed to measure association between scores and length, number of views and likes., Results: 27 unique videos met selection criteria. Academic and physician video walkthroughs did not demonstrate a significant difference in median scores (9.33 IQR 6.33, 14.33 vs. 7.67 IQR 4, 12.67, p = 0.3951). Videos published after 2020 demonstrated higher median scores than those published before 2020 (13 IQR 7.5, 14.67 vs. 5 IQR 3, 9.67, p = 0.0081). A majority of videos failed to provide patient position (52%), intraoperative findings (56%), operative time (63%), graphic aids (74%), and audio/written commentary (52%). A positive association was demonstrated between scores and number of likes (r s  = 0.59, p = 0.0011) and video length (r s  = 0.39, p = 0.0421), but not number of views (r s  = 0.17, p = 0.3991)., Conclusion: The majority of available YouTube ® videos on laparoscopic jejunostomy fail to meet the basic educational needs of surgical trainees, and there is no difference between those produced by academic centers or independent physicians. However, there has been improvement in video quality following the release of the scoring tool. Standardization of laparoscopic jejunostomy training videos with the LAP-VEGaS score can ensure that videos are of appropriate educational value with logical structure., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Military physical therapists practicing direct-access routinely utilize diagnostic imaging and numerous published case reports demonstrate the ability of physical therapists to diagnose and appropriately disposition patients with foot/ankle and wrist/hand fractures. However, no larger cohort studies have explored the utilization of diagnostic imaging by physical therapists to detect fractures., Hypothesis/purpose: To describe the utilization of diagnostic imaging in foot/ankle and wrist/hand injuries by physical therapists in a direct-access sports physical therapy clinic., Study Design: Retrospective cohort study., Methods: The Agfa Impax Client 6 image viewing software (IMPAX) was searched from 2014 to 2018 for patients with diagnostic imaging ordered for foot/ankle and wrist/hand injuries. The Armed Forces Health Longitudinal Technology Application (AHLTA) electronic medical record was independently reviewed by the principal and co-investigator physical therapists. Data extracted were demographics and elements from the patient history and physical examination., Results: In foot/ankle injuries, physical therapists diagnosed a fracture in 16% of the 177 cases and waited for an average of 3.9 days and 1.3 visits before ordering imaging. In wrist/hand injuries, physical therapists diagnosed a fracture in 24% of the 178 cases and waited for an average of 3.7 days and 1.2 visits before ordering imaging. The time to definitive care from the initial physical therapy evaluation was significantly different (p = 0.04) for foot/ankle fractures (0.6 days) compared to wrist/hand fractures (5.0 days). The Ottawa Ankle Rules demonstrated a negative likelihood ratio (-LR) of 0.11 (0.02, 0.72) and a positive likelihood ratio (+LR) of 1.99 (1.62, 2.44) for the diagnosis of foot/ankle fracture., Conclusions: Physical therapists utilizing diagnostic imaging in a direct-access sports physical therapy clinic diagnosed fractures in similar proportions for foot/ankle and wrist/hand injuries and quickly dispositioned patients to definitive care for those fractures. The diagnostic accuracy of the Ottawa Ankle Rules was similar to previously reported values., Level of Evidence: Level 3.

Objective: To date, education about health equity for early-stage healthcare trainees is largely situated outside of surgical disciplines. This study aims to evaluate the effectiveness of a surgical equity curriculum offered to a voluntary group of medical and graduate students., Design: Mixed-methods cohort study from January to June 2021. Pre- and post-course surveys measured domains of attitudes, self-reported confidence, and knowledge via 5-point Likert scale and multiple-choice questions. Paired t tests were used to analyze quantitative responses. Qualitative responses were studied via iterative thematic analysis., Setting: At the University of Pennsylvania in Philadelphia, PA which provides tertiary level, institutional care, 10, interdisciplinary 1.5-hour sessions were held over 1 semester, teaching surgical equity topics that spanned the peri-operative continuum., Participants: Twenty-four medical and graduate students from across the University of Pennsylvania enrolled. Twenty completed both surveys., Results: From pre- to post-course, students improved across all domains. Students improved in their self-rated ability to identify strategies to talk about sensitive health topics with patients (pre: 20%, post: 90%) and identify strategies to address healthcare disparities in surgery (pre: 10%, post: 90%). Qualitatively, from pre- to post-course, more students could articulate the role of bias and identify opportunities for surgeons to engage in surgical equity. The course strengthened any pre-existing interest in surgical equity, and for 1 student, created interest in a surgical career where it had not previously existed. Many also expressed greater resolve to provide patient-centric care., Conclusions: Formal curricula can improve students' ability to advocate for surgical equity. A similar framework may fill a need for medical students interested in health equity and surgical careers at other institutions., Competing Interests: CONFLICT OF INTEREST This work was supported by the Penn Graduate Center Community Impact Fund and Perelman School of Medicine Medical Student Government funding, which was used toward books and educational supplies for this initiative., (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Sesame is one of the important oilseed crops in the world. Natural genetic variation exists in the sesame germplasm collection. Mining and utilizing the genetic allele variation from the germplasm collection is an important approach for seed quality improvement. The sesame germplasm accession, PI 263470, which has a significantly higher level of oleic acid (54.0%) than the average (39.5%), was identified by screening the entire USDA germplasm collection. The seeds from this accession were planted in a greenhouse. Leaf tissues and seeds were harvested from individual plants. DNA sequencing of the coding region of the fatty acid desaturase gene ( FAD2 ) confirmed that this accession contained a natural mutation of G425A which may correspond to the deduced amino acid substitution of R142H leading to the high level of oleic acid, but it was a mixed accession with three genotypes (G/G, G/A, and A/A at the position). The genotype with A/A was selected and self-crossed for three generations. The purified seeds were used for EMS-induced mutagenesis to further enhance the level of oleic acid. A total of 635 M 2 plants were generated from mutagenesis. Some mutant plants had significant morphological changes including leafy flat stems and others. M 3 seeds were used for fatty acid composition analysis by gas chromatography (GC). Several mutant lines were identified with high oleic acid (70%). Six M 3 mutant lines plus one control line were advanced to M 7 or M 8 generations. Their high oleate traits from M 7 or M 8 seeds harvested from M 6 or M 7 plants were further confirmed. The level of oleic acid from one mutant line (M 7 915-2) was over 75%. The coding region of FAD2 was sequenced from these six mutants, but no mutation was identified. Additional loci may contribute to the high level of oleic acid. The mutants identified in this study can be used as breeding materials for sesame improvement and as genetic materials for forward genetic studies.

The warm season essential oil producing grass species including lemongrass ( Cymbopogon citratus ), palmarosa grass ( C. martini ), geranium grass ( C. schoenanthus ), vetiver grass ( Chrysopogon zizanioides ), and scented top grass ( Capillipedium parviflorum ) are used worldwide for their cosmetic and health properties. A discussion providing evidence from literature reviews about the potential uses of these grass species for antimicrobial and other health uses are presented. These species could be used as new therapies for treating microbial infections. The purpose of this study is to discuss in detail, evidence from literature reviews supporting potential health uses and to provide some discussion regarding some agronomic traits for these essential oil producing species.

Blackeye peas ( Vigna unguiculata L. Walp.) are mainly used as a vegetable throughout the world, however they may contain significant concentrations of quercetin, myricetin, cyanidin, and delphinidin for potential use as a functional vegetable. Thirty-eight blackeye pea genotypes were selected from the core collection in the USDA, ARS, Plant Genetic Resources Conservation Unit's cold storage at 4 °C during 2016. Information regarding concentrations of quercetin, myricetin, cyanidin, delphindin, and correlations among these as well as additional seed traits including seed coat color, seed pattern color, seed pattern, seed texture, and years in storage would add value to the blackeye pea genotypes for use as a functional vegetable. Using high performance liquid chromatography (HPLC), the red seeded accession originating from Mozambique, PI 367927 produced the highest quercetin (469.53 µg/g) and myricetin (212.23 µg/g) concentrations. The black seeded genotype, PI 353236, originating from India, produced the highest cyanidin (1,388.82 µg/g) concentration. However, PI 353236 and the brown seeded genotype, PI 353352 from India produced the highest concentrations of delphinidin (1,343.27 and 1,353.94 µg/g), respectively. Several correlations were observed and interestingly only delphinidin showed a significant negative correlation ( r  = -0.293*) with years in cold storage indicating that delphinidin declined in the seeds stored the longest (from 4-45 years) at 4 °C. Principal component analysis (PCA) explained how the flavonols, anthocyanidins, and the additional seed traits contributed to the variation of the blackeye pea genotypes. The cluster analysis showed six clusters representing low to high phytochemical concentrations. The genetic parameters including σ 2 g, σ 2 p, GCV, PCV, h 2 h , and GG indicate that improvement in these phytochemical traits is possible through selection. The genotypic and phenotypic correlations showed that improving one phytochemical significantly improved the other except for cyanidin with delphinidin. These results can be used by scientists to develop blackeye pea cultivars with high flavonol and anthocyanidin concentrations.

Butterfly pea ( Clitoria ternatea L.) is a legume used as tea, forage, ornamental, salad, and medicinal plant. The flowers range from white to dark purple with little known about the variation for seed and flower color in the United States Department of Agriculture, Agricultural Research Service, Plant Genetic Resources Conservation Unit germplasm collection. Therefore, 26 butterfly pea accessions were analyzed using a principal component analysis (PCA) and average linkage cluster analysis (ALCA). These butterfly pea genotypes ranged from 56% to 99% for viabilities, 2.57 to 5.88   g for 100 seed weight, 34.07 to 226.26   g for total seed weight, and 1,326 to 3,874 for total seed numbers. PCA accounted for 40%, 57%, 70%, 79%, and 86% of the variation using principal components (PCs) 1 through 5, respectively. PC1 was most correlated with 100 and total seed weight, while PC2 correlated with blue, white, and purple flowers. PC3 correlated mostly with germination, purple flowers, and total seed weight. PCs 4 and 5 primarily correlated with blue and purple flowers, respectively. Several significant correlations were also observed. ALCA grouped the 26 butterfly pea genotypes into four distinct seed number-producing clusters. Clusters 1 to 4 represent the lowest to highest seed numbers produced by the butterfly pea genotypes. Several potential health benefits from butterfly pea flowers, leaves, seeds, and roots for human use were identified from the literature.

Background: Traumatic shoulder instability is a common injury in athletes and military personnel. Surgical stabilization reduces recurrence, but athletes often return to sport before recovering upper extremity rotational strength and sport-specific abilities. Blood flow restriction (BFR) may stimulate muscle growth without the need for heavy resistance training post-surgically., Hypothesis/purpose: To observe changes in shoulder strength, self-reported function, upper extremity performance, and range of motion (ROM) in military cadets recovering from shoulder stabilization surgery who completed a standard rehabilitation program with six weeks of BFR training., Study Design: Prospective case series., Methods: Military cadets who underwent shoulder stabilization surgery completed six weeks of upper extremity BFR training, beginning post-op week six. Primary outcomes were shoulder isometric strength and patient-reported function assessed at 6-weeks, 12-weeks, and 6-months postoperatively. Secondary outcomes included shoulder ROM assessed at each timepoint and the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST), the Upper Extremity Y-Balance Test (UQYBT), and the Unilateral Seated Shotput Test (USPT) assessed at the six-month follow-up., Results: Twenty cadets performed an average 10.9 BFR training sessions over six weeks. Statistically significant and clinically meaningful increases in surgical extremity external rotation strength ( p < 0.001; mean difference, .049; 95% CI: .021, .077), abduction strength ( p < 0.001; mean difference, .079; 95% CI: .050, .108), and internal rotation strength ( p < 0.001; mean difference, .060; CI: .028, .093) occurred from six to 12 weeks postoperatively. Statistically significant and clinically meaningful improvements were reported on the Single Assessment Numeric Evaluation ( p < 0.001; mean difference, 17.7; CI: 9.4, 25.9) and Shoulder Pain and Disability Index ( p < 0.001; mean difference, -31.1; CI: -44.2, -18.0) from six to 12 weeks postoperatively. Additionally, over 70 percent of participants met reference values on two to three performance tests at 6-months., Conclusion: While the degree of improvement attributable to the addition of BFR is unknown, the clinically meaningful improvements in shoulder strength, self-reported function, and upper extremity performance warrant further exploration of BFR during upper extremity rehabilitation., Level of Evidence: 4, Case Series., Competing Interests: The authors have no relevant or material financial interests that relate to this study. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the United States Army or Department of Defense.

Importance: Prosthetic reinforcement of critically sized incisional hernias is necessary to decrease hernia recurrence, but long-term prosthetic-mesh footprint may increase complication risk during subsequent abdominal operations., Objective: To investigate the association of prior incisional hernia repair with mesh (IHRWM) with postoperative outcomes and health care utilization after common abdominal operations., Design, Setting, and Participants: This was a population-based, retrospective cohort study of patients undergoing inpatient abdominal surgical procedures during the period of January 2009 to December 2016, with at least 1 year of follow-up within 5 geographically diverse statewide inpatient/ambulatory databases (Florida, Iowa, Nebraska, New York, Utah). History of an abdominal operation was ascertained within the 3-year period preceding the index operation. Patients admitted to the hospital with a history of an abdominal operation (ie, bariatric, cholecystectomy, small- or large-bowel resection, prostatectomy, gynecologic) were identified using the International Classification of Diseases, Ninth Revision and Tenth Revision, Clinical Modification procedure codes. Patients with prior IHRWM were propensity score matched (1:1) to controls both with and without a history of an abdominal surgical procedure based on clinical and operative characteristics. Data analysis was conducted from March 1 to November 27, 2021., Main Outcomes and Measures: The primary outcome was a composite of adverse postoperative outcomes (surgical and nonsurgical). Secondary outcomes included health care utilization determined by length of hospital stay, hospital charges, and 1-year readmissions. Logistic and Cox regression determined the association of prior IHRWM with the outcomes of interest. Additional subanalyses matched and compared patients with prior IHR without mesh (IHRWOM) to those with a history of an abdominal operation., Results: Of the 914 105 patients undergoing common abdominal surgical procedures (81 123 bariatric [8.9%], 284 450 small- or large-bowel resection [31.1%], 223 768 cholecystectomy [24.5%], 33 183 prostatectomy [3.6%], and 291 581 gynecologic [31.9%]), all 3517 patients (age group: 46-55 years, 1547 [44.0%]; 2396 majority sex [68.1%]) with prior IHRWM were matched to patients without a history of abdominal surgical procedures. After matching, prior IHRWM was associated with increased overall complications (odds ratio [OR], 1.43; 95% CI, 1.27-1.60), surgical complications (OR, 1.51; 95% CI, 1.34-1.70), length of hospital stay (mean increase of 1.03 days; 95% CI, 0.56-1.49 days; P < .001), index admission charges (predicted mean difference of $11 896.10; 95% CI, $6096.80-$17 695.40; P < .001), and 1-year unplanned readmissions (hazard ratio, 1.14; 95% CI, 1.05-1.25; P = .002). This trend persisted even when comparing matched patients with prior IHRWM to patients with a history of abdominal surgical procedures, and the treatment outcome disappeared when comparing patients with prior IHRWOM to those without a previous abdominal operation., Conclusions and Relevance: Reoperation through a previously prosthetic-reinforced abdominal wall was associated with increased surgical complications and health care utilization. This risk appeared to be independent of a history of abdominal surgical procedures and was magnified by the presence of a prosthetic-mesh footprint in the abdominal wall.

Musculoskeletal injury (MSI) presents the greatest threat to military mission readiness. Atraumatic shoulder pain is a common military MSI that often results in persistent functional limitations. Shoulder orthopedic evaluation presents many diagnostic challenges, due in part to the possibility of a spinal source of symptoms. This case series outlines the use of mechanical diagnosis and therapy to screen the cervical and thoracic spine in active duty (AD) service members (SMs) with a chief complaint of unchanging or worsening shoulder pain. All three SMs previously received shoulder-specific diagnoses from experienced clinicians, yet repeated movements revealed a possible spinal nociceptive driver that guided targeted intervention. Treatment directed only at the cervical spine resulted in a clinically important improvement within an average of 10 days from the initial evaluation, return to duty (RTD) within an average of 32 days, and continued resolution at 3 months. SMs can independently complete the screening process with guidance from healthcare providers, ultimately shaping the treatment strategy and possibly facilitating self-management of future recurrence. This case series demonstrates that identification of shoulder pain of spinal source in the military population may be an important step in facilitating timely RTD. These cases also highlight the use of a standardized, systematic method to screen the cervical and thoracic spine that concurrently reveals the indicated treatment. Further research to determine the prevalence of shoulder pain of spinal source in the AD population and its impact on RTD rates has the potential to reduce the substantial burden of MSI in the military., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Lopinavir/ritonavir (LPV/r-A, Kaletra®), a fixed dose, co-formulated antiviral therapy for the treatment of HIV infection has been used worldwide for over two decades. Both active substances have low solubility in water and low membrane permeability. LPV/r-A tablets contain key excipients critical to ensuring acceptable bioavailability of lopinavir and ritonavir in humans. An established dog pharmacokinetic model demonstrated several generic LPV/r tablet formulations have significant oral bioavailability variability compared to LPV/r-A., Methods: Analytical characterizations of LPV/r-B tablets were performed and a clinical study was conducted to assess the relative bioavailability of Kalidavir® (LPV/r-B) 400/100 mg tablets relative to Kaletra® (LPV/r-A) 400/100 mg tablets under fasting conditions., Results: The presence of active substances were confirmed in LPV/r-B tablets in an apparent amorphous state at essentially the labeled amounts, and dissolution profiles were generally similar to LPV/r-A tablets. Excipients in the tablet formulation were found to be variable and deviate from the labeled composition. Lopinavir and ritonavir exposures (AUC) following LPV/r-B administration were approximately 90% and 20% lower compared to that of LPV/r-A., Conclusions: LPV/r-B was not shown to be bioequivalent to LPV/r-A., (Copyright © 2021 American Pharmacists Association. Published by Elsevier Inc. All rights reserved.)

Academic commencements ceremonies usually do not result in memorable occasions and once ended usually are forgotten. Not so for the University of Pennsylvania's School of Medicine commencement on May 1,1889, which was marked by an address by William Osler, the retirement of the renowned Professor of Surgery, D. Hayes Agnew, and the presentation to the University of Thomas Eakins' remarkable masterpiece, "The Agnew Clinic." Osler had been on the faculty of the University for 5 years and in his keynote address, Aequanimitas, he laid out 2 elements, imperturbability and equanimity, that he stated would "make or mar" the lives of the students he was addressing. His words and message that day have continued to resonate for medical students and many others up to the present day. Osler ended his address on a more somber note, seemingly surprising the assembled, by announcing his imminent departure from the University. He would soon be one of the 4 founders of the Johns Hopkins Hospital along with fellow Penn faculty member, Howard Kelly. Osler was not the only one on the verge of leaving as this commencement also marked the end of the career of D. Hayes Agnew. To honor him on this occasion of his retirement the 3 classes of medical students had commissioned Eakins to paint a portrait of their revered professor, which was presented on this commencement day and accepted by Trustee Dr S. Weir Mitchell on behalf of the University. The day was indeed one to be remembered., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Running-related musculoskeletal injury (RRI) among U.S. military service members continues to negatively impact force readiness. There is a paucity of evidence supporting the use of RRI interventions, such as gait retraining, in military populations. Gait retraining has demonstrated effectiveness in altering running biomechanics and reducing running load. The purpose of this pilot study was to investigate the clinical effect of a gait retraining intervention on a military cadet population recovering from a lower-extremity RRI., Materials and Methods: The study design is a pilot study. Before study initiation, institutional approval was granted by the Keller Army Community Hospital Office of Human Research Protections. Nine rearfoot strike (RFS) runners recovering from a lower-extremity RRI at the U.S. Military Academy were prospectively enrolled and completed a gait retraining intervention. Participants followed-up with their assigned medical provider 6 times over 10 weeks for a clinical evaluation and running gait retraining. Gait retraining was provided utilizing verbal, visual, and audio feedback to facilitate a change in running foot strike pattern from RFS to non-rearfoot strike (NRFS) and increase preferred running step rate. At pre-intervention and post-intervention running ground reaction forces (GRF) [average vertical loading rate (AVLR), peak vertical GRF], kinematic (foot strike pattern) and temporospatial (step rate, contact time) data were collected. Participants self-reported their level of function via the Single Assessment Numeric Evaluation, Patient-Specific Functional Scale, and total weekly running minutes. Paired samples t-tests and Wilcoxon signed rank tests were used to compare pre- and post-intervention measures of interest. Values of P < .05 were considered statistically significant., Results: Nine patients completed the 10-week intervention (age, 20.3 ± 2.2 years; height, 170.7 ± 13.8 cm; mass, 71.7 ± 14.9 kg; duration of injury symptoms, 192.4 ± 345.5 days; running speed, 2.8 ± 0.38 m/s). All nine runners (100%) transitioned from RFS to NRFS. Left AVLR significantly decreased from 60.3 ± 17.0 bodyweight per second (BW/s) before intervention to 25.9 ± 9.1 BW/s after intervention (P = 0.008; effect size (d) = 2.5). Right AVLR significantly decreased from 60.5 ± 15.7 BW/s to 32.3 ± 12.5 BW/s (P < .001; d = 2.0). Similarly, step rate increased from 169.9 ± 10.0 steps per minute (steps/min) before intervention to 180.5 ± 6.5 steps/min following intervention (P = .005; d = 1.3). Single Assessment Numeric Evaluation scores improved significantly from 75 ± 23 to 100 ± 8 (P = .008; d = 1.5) and Patient-Specific Functional Scale values significantly improved from 6 ± 2.3 to 9.5 ± 1.6 (P = .007; d = 1.8) after intervention. Peak vertical GRF (left, P = .127, d = 0.42; right, P = .052, d = 0.53), contact time (left, P = 0.127, d = 0.42; right, P = 0.052, d = 0.53), and total weekly continuous running minutes (P = 0.095, d = 0.80) remained unchanged at post-intervention. All 9 patients remained injury free upon a 6-month medical record review., Conclusions: In 9 military service members with a RRI, a 10-week NRFS gait retraining intervention was effective in improving running mechanics and measures of function. Patients remained injury-free 6 months following enrollment. The outcomes of this pilot study suggest that individuals recovering from certain lower-extremity RRIs may benefit from transitioning to an NRFS running pattern., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

We are the Center for Surgical Health (CSH), an academic community partnership that supports, educates, and advocates for vulnerable Philadelphians with surgical diseases, founded in 2016 by Dr. Jon B. Morris, a leader in surgical education and a general surgeon at the University of Pennsylvania, and Dr. Alan Herbst, a current third-year Penn general surgery resident. At the time, Dr. Morris, raised in a Reform Jewish household, had been participating in an RCIA Program to convert to Catholicism. The mission of providing surgery to uninsured patients, primarily undocumented individuals, by helping them obtain insurance and see Penn providers was seen by Dr. Morris as a form of Catholic charity, which he has continued to remain dedicated to as his faith in Jesus Christ has deepened. Dr. Herbst, now Associate Director of Clinics for the CSH, recalls working with Dr. Morris as a sub-intern during his conversion, beginning with passion and a neon poster board inviting people to "See the Surgeon." Since that time, the CSH has grown from an organization with 10 volunteers, called "personal patient navigators," who provide insurance support and advocacy at every step of the perioperative continuum, to one with over 50, who have now seen 156 patients and assisted in providing 49 needed procedures. Much of this growth has been brought about through the dedication and vision of Dr. Matthew Goldshore, the Deputy Director of the CSH and a fifth-year Penn general surgery resident, as well as Dr. Carrie Z. Morales, Associate Deputy Director of the CSH and a recent Perelman School of Medicine graduate. Through their leadership, and the talent and commitment of other members of the CSH board, overseen by Director Dr. Morris, the CSH now has policy and research divisions, a surgical equity curriculum, and continues to develop new ways of providing better care., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© Catholic Medical Association 2021.)

Purpose: Despite the overall shift in care delivery to an ambulatory setting, the majority of general surgical education still relies on the experience of caring for inpatients. We aimed to investigate how the inpatient practice patterns of newly minted general surgeons (GS) have changed since 2008, in order to better inform education policies regarding both training approach and setting for modern surgical trainees., Methods: State discharge data from NY and FL (2008-2017) were linked to data on GS from the American Medical Association Masterfile, and to hospital data from the American Hospital Association annual survey. Mean annual inpatient case volume (CV) and case type breadth (CB) were compared between surgeons who were new-to-practice (0-3 years of experience) in 2008 and in 2013. Each new surgeon cohort was followed for 5 years. Case type was classified by organ system., Results: The 2008 cohort included 328 GS with a mean age of 37.1, 79.6% male and 94.2% board-certified. The 2013 cohort included 359 GS with a mean age of 36.2, 73.0% male and 93.9% board-certified. CV was higher among the 2008 cohort than the 2013 cohort for each year of practice in the study period. CB included at least 4 organ system types for all new GS with greater breadth among the 2008 cohort for each year in the study period., Conclusions: Declining rates of inpatient surgery affect general surgeons who were new-to-practice in 2013 significantly more than those entering practice only 5 years ahead of them. New surgeons continue to start their practices broadly, suggesting a need to continue broad training while expanding formal educational policies to include the full spectrum of ambulatory surgery., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study is the examine the effect of a holistic review process on the recruitment of women and students underrepresented in medicine (UIM) in a general surgery residency program., Design: A retrospective study comparing the proportion of women and UIM students ranked and matched into categorical positions from 2013 to 2020 before and after the implementation of the holistic application review process. United States Medical Licensing Exam (USMLE) scores and American Board of Surgery In-training Exam (ABSITE) scores were also compared between groups., Setting: General Surgery residency program at a tertiary, academic center., Participants: Medical students applying for and matriculated to categorical positions., Results: After the implementation of holistic review in 2017, there was a statistically significant increase in the proportion of women (42% vs. 61%, p < 0.01) and UIM students (14% vs. 20%, p = 0.046) ranked in our program compared with the prior "traditional" approach. The proportion of matched female (33% vs. 54%, p = 0.11) and UIM applicants (14% vs. 21%, p = 0.48) also increased after holistic review, although the changes were not statistically significant. The median USMLE Step 1 scores were equivalent for both ranked (250 vs. 250, p = 0.81) and matched (250 vs. 249, p = 0.32) applicants before and after the intervention. The median ABSITE scores for the matched intern classes was lower after initiation of holistic review (519 vs. 483, p = 0.01). However, these scores were consistently above the national medians and subgroup analysis showed no difference between the median aggregate ABSITE scores for UIM and female categorical interns and non-UIM males (475 vs. 520, p = 0.09)., Conclusions: Increasing emphasis is being placed on the diversification of residency training to reflect an expanding, diverse patient population. The incorporation of a holistic review process, providing broader assessment of applicants, can play a pivotal role in increasing the proportion of women and UIM students represented in the general surgery recruitment process., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Surgical boot camps enhance the confidence of medical students and surgical interns. The impact of boot camps on the confidence of post-graduate year (PGY) 2 residents is unknown. We hypothesized that a postinternship boot camp would improve the confidence of PGY-2 residents in managing their newfound responsibilities. We also hypothesized that the effect of a tailored high-impact boot camp would persist over time., Design: A 2-hour boot camp at our simulation center was implemented for PGY-2 residents in 2016 and 2017. Confidence in handling boot camp scenarios was measured on a 1 to 5 Likert scale before and after the boot camp. Three-month follow-up was assessed in the 2017 cohort., Participants: Thirty-one PGY-2 residents (n = 16 in 2016, n = 15 in 2017) completed the boot camp., Results: Residents reported increased confidence in placing central lines (p < 0.001), placing chest tubes (p = 0.01), managing emergency airways (p < 0.001), running a code (p = 0.03), and fulfilling the role of in-house senior resident (p < 0.001). Three-month follow-up in 2017 (n = 10) demonstrated no difference in confidence compared to postboot camp results., Conclusions: Boot camps can durably improve confidence in skills expected of PGY-2 residents assuming in-house senior resident responsibilities., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Several strategies have been proposed to reduce loading of the lower extremity while running including step rate manipulation. It is unclear however, whether step rate influences the incidence of lower extremity injuries., Purpose: To examine the association between step rate and risk of injury in an adult recreational runner population., Study Design: Prospective Cohort., Methods: A total of 381 runners were prospectively followed for an average of nine months. Two-dimensional video was used to assess preferred step rate during a timed two-mile run or a 5K race. Injury surveillance to record sub-clinical injuries (those for which medical treatment was not sought) was performed via semi-monthly email surveys over the course of one year. Injury surveillance for clinical injuries (those for which medical treatment was sought) was performed via a full medical record review using the Armed Forces Health Longitudinal Technology Application. Clinical, sub-clinical and combined clinical and sub-clinical injury incidence were assessed in separate analyses. Injury was operationally defined as seven or more days of reduced activity due to pain. To assess the predictive validity of running step rate, the step rate of participants who did not develop a musculoskeletal injury during the observation period were compared with the running step rate of participants who did develop an injury during the observation period., Results: Out of 381 runners, 16 sustained a clinical overuse injury for which medical treatment was sought. Mean step rate for clinically un-injured runners was 172 steps/min and mean step rate for clinically injured runners was 173 steps/min which was not statistically significantly different (p = 0.77.) Out of 381 runners, 95 completed all four sub-clinical injury surveys (95/381 = 25%). Out of those 95 runners, 19 sustained a clinical (n=4) or sub-clinical injury (n=15). The step rate of sub-clinically injured and non-injured runners in this sub-sample was also not statistically significantly different (p = 0.08), with a mean of 174 steps/min for the uninjured group and a mean step rate of 170 steps/min for those in the sub-clinical injured group., Conclusion: Preferred step rate was not associated with lower extremity injury rates in this sample of DoD runners. Additional research is needed to justify preferred step rate manipulation as a means to reduce lower extremity injury risk., Level of Evidence: Level 3., (© 2020 by the Sports Physical Therapy Section.)

Background: Although most surgery residents pursue fellowships, data regarding those decisions are limited. This study describes associations with interest in fellowship and specific subspecialties., Methods: Anonymous surveys were distributed to 607 surgery residents at 19 US programs. Subspecialties were stratified by levels of burnout and quality of life using data from recent studies., Results: 407 (67%) residents responded. 372 (91.4%) planned to pursue fellowship. Fellowship interest was lower among residents who attended independent or small programs, were married, or had children. Residents who received AOA honors or were married were less likely to choose high burnout subspecialties (trauma/vascular). Residents with children were less likely to choose low quality of life subspecialties (trauma/transplant/cardiothoracic)., Conclusions: Surgery residents' interest in fellowship and specific subspecialties are associated with program type and size, AOA status, marital status, and having children. Variability in burnout and quality of life between subspecialties may affect residents' decisions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Importance: In general surgery, women earn less money and hold fewer leadership positions compared with their male counterparts., Objective: To assess whether differences exist between the perspectives of male and female general surgery residents on future career goals, salary expectations, and salary negotiation that may contribute to disparity later in their careers., Design, Setting, and Participants: This study was based on an anonymous and voluntary survey sent to 19 US general surgery programs. A total of 606 categorical residents at general surgery programs across the United States received the survey. Data were collected from August through September 2017 and analyzed from September through December 2017., Main Outcomes and Measures: Comparison of responses between men and women to detect any differences in career goals, salary expectation, and perspectives toward salary negotiation at a resident level., Results: A total of 427 residents (70.3%) responded, and 407 responses (230 male [58.5%]; mean age, 30.0 years [95% CI, 29.8-30.4 years]) were complete. When asked about salary expectation, female residents had lower expectations compared with men in minimum starting salary ($249 502 [95% CI, $236 815-$262 190] vs $267 700 [95% CI, $258 964-$276 437]; P = .003) and in ideal starting salary ($334 709 [95% CI, $318 431-$350 987] vs $364 663 [95% CI, $351 612-$377 715]; P < .001). Women also had less favorable opinions about salary negotiation. They were less likely to believe they had the tools to negotiate (33 of 177 [18.6%] vs 73 of 230 [31.7%]; P = .03) and were less likely to pursue other job offers as an aid in negotiating a higher salary (124 of 177 [70.1%] vs 190 of 230 [82.6%]; P = .01). Female residents were also less likely to be married (61 of 177 [34.5%] vs 116 of 230 [50.4%]; P = .001), were less likely to have children (25 of 177 [14.1%] vs 57 of 230 [24.8%]; P = .008), and believed they would have more responsibility at home than their significant other (77 of 177 [43.5%] vs 35 of 230 [15.2%]; P < .001). Men and women anticipated working the same number of hours, expected to retire at the same age, and had similar interest in holding leadership positions, having academic careers, and pursuing research., Conclusions and Relevance: This study found no difference in overall career goals between male and female residents; however, female residents' salary expectations were lower, and they viewed salary negotiation less favorably. Given the current gender disparities in salary and leadership within surgery, strategies are needed to help remedy this inequity.

: Norvir® (ritonavir) is a Biopharmaceutical Classification System Class IV compound with poor solubility in water (~5 µg/mL) and limited oral bioavailability. Early stage development efforts were focused on an oral solution (OS) which provided reasonable bioavailability but exhibited taste-masking challenges and required the use of solvents with potential pediatric toxicity. Norvir® oral powder, 100 mg (NOP) was developed to replace OS. The objective of this study is to provide an overview of the development of NOP and palatability assessment strategy. Palatability of NOP was assessed using the flavor profile method: (1) As an aqueous suspension dose/response and (2) evaluation with foods. The dose/response sensory analysis indicated that NOP has strong intensity bitterness and burnt aromatics (3 on the 0⁻3 flavor profile scale) at the clinical dose (100 mg/10 mL) and the recognition threshold was determined to be 0.3 mg/10 mL. To improve palatability, 100 mg/10 mL NOP aqueous suspension was evaluated with foods. Consuming foods high in fat and/or sugar content after NOP administration successfully reduced bitterness to a 1.5 intensity. In summary, NOP provides dose flexibility, enhanced stability, eliminated solvents, and maintains consistent bioavailability, with reduced bitterness and improved palatability via administration with common food products., Competing Interests: John B. Morris and David Cheng Thiam Tan are employees of AbbVie Inc. and may own AbbVie stock options. David A. Tisi and Jeffrey H. Worthington are employees of Senopsys LLC. AbbVie sponsored and funded the study; contributed to the design, participated in the collection of data. AbbVie and Senopsys participated in the interpretation of data, in writing, reviewing, and approval of the final publication.

Objective: To examine patient safety event reporting behavior by trainees caring for surgical patients compared to other clinicians., Design: Qualitative analysis of a patient safety event reporting system comparing reports entered by trainees to those entered by attending physicians and nurses. Categorical data associated with reports were compared, and free-text event descriptions underwent content analysis focusing on themes related to report completeness and report focus., Setting: The Hospital of the University of Pennsylvania, an academic tertiary care hospital in Philadelphia, Pennsylvania., Participants: All patient safety event reports related to surgical patients from a 6-month period (July-December 2016)., Results: One thousand four hundred twenty-three reports were entered by trainees (T), attendings (A), and nurses (N). Trainees had a lower number of reports entered per reporter compared to nurses (T median [IQR]: 1 [1-2], N: 2 [1-3]), and the highest percentage of reports entered anonymously for any group (T: 28.7%, N: 9.9%, A: 4.6%). The overall distribution of event location and event type differed significantly between groups (p < 0.001). Trainee reports were found to have a broader range of focus, more elements associated with completeness of reports, and more frequent use of blame language., Conclusions: Surgical trainees report a wide variety of issues in the perioperative, floor, and ICU settings. Their reports often include more details than those entered by other clinicians, but feature higher rates of anonymous reporting and use of blame language. Analysis of patient safety event reports by trainees compared with other healthcare professionals can reveal important insights into the clinical learning environment and areas for safety improvement., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Subtotal cholecystectomy (SC) involves removal of a portion of the gallbladder typically due to hazardous inflammation. While this technique reliably prevents common bile duct (CBD) injury, future procedures can be required if the gallbladder remnant becomes symptomatic. The morbidity associated with resection of gallbladder remnants in patients that previously underwent SC is reviewed., Methods: Records for patients having undergone redo cholecystectomy for symptomatic gallbladder remnants in a tertiary care system from 2013 to 2017 were retrospectively reviewed., Results: Fourteen patients underwent repeat cholecystectomy. Five surgeons dictated the initial procedure as a subtotal cholecystectomy. All patients returned with symptomatic cholelithiasis between zero months and seven years after the index cholecystectomy. Redo cholecystectomy was attempted laparoscopically in two patients but ultimately required an open approach in all. One patient had a recognized CBD injury requiring a hepaticojejunostomy, and a second patient had a minor wound infection. Symptoms resolved in 13/14 patients., Conclusions: Redocholecystectomy (RC) for gallbladder remnants has been detailed in case reports, but no sizable North American series have been presented. These results illustrate a drawback to the reconstituting technique of SC. RC effectively resolves symptoms but requires adherence to safe principles of cholecystectomy and is one indication for an open approach., (Copyright © 2018 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Objective: We sought to compare postoperative outcomes of female surgeons (FS) and male surgeons (MS) within general surgery., Summary of Background Data: FS in the workforce are increasing in number. Female physicians provide exceptional care in other specialties. Differences in surgical outcomes of FS and MS have not been examined., Methods: We linked the AMA Physician Masterfile to discharge claims from New York, Florida, and Pennsylvania (2012 to 2013) to examine practice patterns and to compare surgical outcomes of FS and MS. We paired FS and MS operating at the same hospital using cardinality matching with refined balance and compared inpatient mortality, any postoperative complication, and prolonged length of stay (pLOS) in FS and MS., Results: Overall practice patterns differed between the 663 FS and 3219 MS. We identified 2462 surgeons (19% FS, 81% MS) at 429 hospitals who met inclusion criteria for outcomes analysis. FS were younger (mean age ± SD FS: 48.5 ± 8.4 years, MS: 54.3 ± 9.4y; P < 0.001) with less clinical experience (mean years ± SD FS: 11.6 ± 8.3 y, MS: 17.6 ± 10.0 years; P < 0.001) than MS before matching. FS had lower rates of inpatient mortality (FS: 1.51%, MS: 2.30%; P < 0.001), any postoperative complication (FS: 12.6%, MS: 16.1%; P < 0.001), and pLOS (FS: 18.4%, MS: 20.7%; P < 0.001) before matching. After matching, FS and MS outcomes were equivalent., Conclusion: Surgeon practice patterns vary by sex and experience. FS and MS with similar characteristics who treat similar patients at the same hospital have equivalent rates of inpatient morality, postoperative complications, and prolonged length of hospital stay. Patients should select the surgeon who is the best fit for them regardless of sex.

Background: Focusing on high-value delivery of health care, we describe our implementation of telephone postoperative visits as alternatives to in-person follow-up after routine, low-risk surgery in an urban setting. Our pilot program assessed telephone postoperative visit feasibility as well as patient satisfaction and clinical outcomes., Methods: We offered telephone postoperative visits to all clinically eligible, in-state patients scheduled for appropriate low-risk operations. An advanced practitioner conducted the telephone postoperative visit within 2 weeks of the operation and discharged patients from routine follow-up if recovery was satisfactory. We reviewed the medical records to identify encounters and adverse events in the 30-day postoperative period., Results: Telephone postoperative visits were opted for by 92/94 (98%) clinically eligible, in-state patients. Most patients cited convenience (55%), travel (34%), and time (22%) as their main motivations. The average patient opting in was 55 ± 16 years old (range 23-88, 8% > 65) and lived 22 ± 26 miles from our clinic (range 0.9-124). Of 50 patients completing telephone postoperative visits, 48 (96%, 2 were not asked) were satisfied with the telephone postoperative visit as their sole postoperative visit, 44 (88%) of whom required no additional follow-up. On average, telephone postoperative visits lasted 8.6 ± 3.9 minutes, compared with the 82.8 ± 33.4 minutes for preintervention, postoperative visit time. Adding travel times, we estimate each patient saved an average of 139-199 minutes or 94-96% of the time they would have spent coming to clinic. No instances of major morbidity or mortality were identified on chart review., Conclusion: Many patients find telephone postoperative visits more convenient than in-clinic visits. Moreover, estimates of time saved are compelling. Amid changing regulations and reimbursement, our findings support the growing use of telehealth for postoperative care of routine, low risk operations., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: The ability to use electronic medical records (EMR) is an essential skill for surgical residents. However, frustration and anxiety surrounding EMR tasks may detract from clinical performance. We created a series of brief, 1-3 minutes "how to" videos demonstrating 7 key perioperative EMR tasks: booking OR cases, placing preprocedure orders, ordering negative-pressure wound dressing supplies, updating day-of-surgery history and physical notes, writing brief operative notes, discharging patients from the postanesthesia care unit, and checking vital signs. Additionally, we used "Cutting Insights"-a locally developed responsive mobile application for surgical trainee education-as a platform for providing interns with easy access to these videos. We hypothesized that exposure to these videos would lead to increased resident efficiency and confidence in performing essential perioperative tasks, ultimately leading to improved clinical performance., Methods: Eleven surgery interns participated in this initiative. Before watching the "how to" videos, each intern was timed performing the aforementioned 7 key perioperative EMR tasks. They also underwent a simulated perioperative emergency requiring the performance of 3 of these EMR tasks in conjunction with 5 other required interventions (including notifying the chief resident, the anesthesia team, and the OR coordinator; and ordering fluid boluses, appropriate laboratories, and blood products). These simulations were scored on a scale from 0 to 8. The interns were then directed to watch the videos. Two days later, their times for performing the 7 tasks and their scores for a similar perioperative emergency simulation were once again recorded. Before and after watching the videos, participants were surveyed to assess their confidence in performing each EMR task using a 5-point Likert scale. We also elicited their opinions of the videos and web-based mobile application using a 5-point scale. Statistical analyses to assess for statistical significance (p ≤ 0.05) were conducted using paired t-test for parametric variables and a Wilcoxon matched-pair test for nonparametric variables., Setting: Hospital of the University of Pennsylvania, Philadelphia, PA (a quaternary teaching hospital within the University of Pennsylvania Health System)., Participants: Eleven out of 15 interns (12 entered and 11 completed the study) from our categorical and preliminary general surgery residency programs during the 2016 academic year., Results: Before exposure to the brief "how to" videos, 6 of 11 interns were unable to complete all 7 EMR tasks; after exposure, all 11 interns were able to complete all 7 EMR tasks. Moreover, interns' times for each task improved following exposure. Interns self-reported improved confidence in booking an OR case (4 ± 0.9 vs. 4.7 ± 0.6, p = 0.05), ordering negative-pressure wound therapy supplies (3.1 ± 1.6 vs. 4.5 ± 0.7, p < 0.05), writing a brief operative note (3.7 ± 1.2 vs. 4.6 ± 0.7, p = 0.05), discharging patients from the postanesthesia care unit (3.3 ± 1.0 vs. 4.4 ± 0.8, p < 0.05), checking vital signs (2.5 ± 1.4 vs. 4.5 ± 0.8, p ≤ 0.01), and performing necessary EMR tasks during an emergency situation (2.4 ± 0.8 vs. 4.6 ± 0.7, p ≤ 0.0001). Participants also demonstrated a significant improvement in average clinical score on the emergency simulations (5.2 ± 1.7 vs. 6.6 ± 0.9, p < 0.05). Interns' opinions of the videos and the mobile phone application were favorable., Conclusions: In our group of 11 surgery interns, exposure to a series of short "how to" videos led to increased confidence and shortened times in performing 7 essential EMR tasks. Additionally, during a simulated perioperative emergency, EMR tasks were performed significantly faster. Clinical performance also improved significantly following exposure to the videos. This just-in-time educational intervention could improve workflow efficiency and clinical performance, both of which may ultimately enhance perioperative patient safety., (Copyright © 2017. Published by Elsevier Inc.)

Context: As future physicians, osteopathic medical students will play a critical role in helping patients make informed decisions regarding treatment options., Objective: To examine the influence that the time, cost, and cosmetic effects associated with treatment options for basal cell carcinoma (BCC), along with students' demographic characteristics, have on treatment decision-making. The influence that different sources of information have on students was also studied., Methods: Medical students were recruited from the Nova Southeastern University College of Osteopathic Medicine for this cross-sectional study. Students were presented with a case scenario in which they were a patient with primary nodular BCC in a low-risk zone, and they were asked to select standard surgical excision (SSE) or Mohs micrographic surgery (MMS) as a treatment option. They also completed an anonymous survey that assessed the way that factors associated with the treatment options (time, cost, and cosmetic effects) influenced their treatment choice, along with the influence that different sources of information have. Measures of central tendency, frequencies, and other descriptive analyses were used to define the characteristics of the sample. χ2 analysis, correlational analysis, and t tests were used to examine the associations between the treatment decision, treatment-related factors (time, cost, cosmetics), and year in medical school. Statistical significance was set at P≤.05., Results: A total of 450 students completed the survey and were included in the bivariate analysis. Three hundred forty-five students (76.7%) selected MMS as a treatment option and 105 (23.3%) selected SSE. Significant differences were found in the influence of time, cost, and cosmetic effects associated with treatment between students who selected MMS and those who selected SSE (P<.001). Cost played a more influential role in treatment decision-making for students who selected SSE than for those who selected MMS. Time and cosmetic effects played a more influential role in treatment choice for those who selected MMS. The most influential sources of information were health care professionals and medical literature, with 398 (88.4%) and 313 (69.6%) students, respectively, indicating that these sources were highly influential when making medical treatment decisions. The internet had a low influence over students' treatment decision-making (238 [52.9%])., Conclusions: This study represents an initial step toward understanding factors that influence patients' treatment decision-making in a situation in which there is no medically preferred treatment option. The findings point to the importance of time, cost, and cosmetics as influential factors for patients choosing between different treatment options.

Importance: Previous studies of resident attrition have variably included preliminary residents and likely overestimated categorical resident attrition. Whether program director attitudes affect attrition has been unclear., Objectives: To determine whether program director attitudes are associated with resident attrition and to measure the categorical resident attrition rate., Design, Setting, and Participants: This multicenter study surveyed 21 US program directors in general surgery about their opinions regarding resident education and attrition. Data on total resident complement, demographic information, and annual attrition were collected from the program directors for the study period of July 1, 2010, to June 30, 2015. The general surgery programs were chosen on the basis of their geographic location, previous collaboration with some coauthors, prior work in surgical education and research, or a program director willing to participate. Only categorical surgical residents were included in the study; thus, program directors were specifically instructed to exclude any preliminary residents in their responses., Main Outcomes and Measures: Five-year attrition rates (2010-2011 to 2014-2015 academic years) as well as first-time pass rates on the General Surgery Qualifying Examination and General Surgery Certifying Examination of the American Board of Surgery (ABS) were collected. High- and low-attrition programs were compared., Results: The 21 programs represented different geographic locations and 12 university-based, 3 university-affiliated, and 6 independent program types. Programs had a median (interquartile range [IQR]) number of 30 (20-48) categorical residents, and few of those residents were women (median [IQR], 12 [5-17]). Overall, 85 of 966 residents (8.8%) left training during the study period: 15 (17.6%) left after postgraduate year 1, 34 (40.0%) after postgraduate year 2, and 36 (42.4%) after postgraduate year 3 or later. Forty-four residents (51.8%) left general surgery for another surgical discipline, 21 (24.7%) transferred to a different surgery program, and 18 (21.2%) exited graduate medical education altogether. Each program had an annual attrition rate ranging from 0.73% to 6.0% (median [IQR], 2.5% [1.5%-3.4%]). Low-attrition programs were more likely than high-attrition programs to use resident remediation (21.0% vs 6.8%; P < .001). Median (IQR) Qualifying Examination pass rates (93% [90%-98%] vs 92% [86%-100%]; P = .92) and Certifying Examination pass rates (83% [68%-84%] vs 81% [71%-86%]; P = .47) were similar. Program directors at high-attrition programs were more likely than their counterparts at low-attrition programs to agree with this statement: "I feel that it is my responsibility as a program director to redirect residents who should not be surgeons.", Conclusions and Relevance: The overall 5-year attrition rate of 8.8% was significantly lower than previously reported. Program directors at low-attrition programs were more likely to use resident remediation. Variations in attrition may be explained by program director attitudes, although larger studies are needed to further define program factors affecting attrition.

Objective: Nontechnical skills are an essential component of surgical education and a major competency assessed by the ACGME milestones project. However, the optimal way to integrate nontechnical skills training into existing curricula and then objectively evaluate the outcome is still unknown. The aim of this study was to determine the effect laparoscopic team-based task training would have on the nontechnical skills needed for laparoscopic surgery., Design: 9 PGY-1 residents underwent an established training curriculum for teaching the knowledge and technical skills involved in laparoscopic cholecystectomy. Initial training involved a didactic session, expert-led practice on a porcine model in a simulated operating room and laparoscopic skills practice on a virtual reality trainer. Residents then performed a laparoscopic cholecystectomy on the same porcine model as a preintervention test. Three to four months following this, residents were subjected to specific nontechnical skills training involving 2 simple team-based laparoscopic tasks. They then practiced a further 4 to 6 hours on the virtual reality trainer. A repeat postintervention laparoscopic cholecystectomy was then performed 3 to 4 months after nontechnical skills training. Both the preintervention and postintervention laparoscopic cholecystectomies were audiovisually recorded and then evaluated by 2 independent surgeons in a blinded fashion. Technical skills were assessed using objective structured assessment of technical skills (OSATS) and a technique specific rating scale (TRS) that we developed for laparoscopic cholecystectomy. Nontechnical skills were assessed using nontechnical skills for surgeons (NOTSS). Residents also completed a survey at the beginning and end of the training., Setting: Tertiary care, university based teaching institution., Participants: A total of 9 general surgery residents at the intern level., Results: The mean OSATS score improved from 13.7 ± 1.24 to 26.7 ± 0.31 (p < 0.001), the mean TRS score improved from 6 ± 0.46 to 13.1 ± 0.36 (p < 0.001) and the mean NOTSS score improved from 21.7 ± 1.83 to 36.3 ± 0.87 (p < 0.001) following the training. There was a strong correlation between OSATS and NOTSS scores (Pearson's R = 0.98) and TRS and NOTSS (R = 0.94). The inter-rater agreement was 0.79 for NOTSS, 0.9 for OSATS, and 0.82 for TRS. Following completion of the training, residents self-reported improvements in exchanging information (p < 0.01), coordinating activities (p < 0.01) and coping with pressure in the operating room (p < 0.001)., Conclusion: Simple, team-based nontechnical skills training for laparoscopic cholecystectomy that was separate from technical skills training led to a sustained increase in residents' nontechnical skills 3 to 4 months after training. This was associated with a self-reported improvement in many nontechnical skills based on resident survey. Based on these results, we recommend that such designated nontechnical skills training is a valid alternative to other methods such as coaching and debriefing. We, therefore, plan to continue our efforts to develop team-based simulation tasks aimed at improving nontechnical skills for multiple surgical modalities., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The Accreditation Council for Graduate Medical Education requires accredited residency programs to implement competency-based assessments of medical trainees based upon nationally established Milestones. Clinical competency committees (CCC) are required to prepare biannual reports using the Milestones and ensure reporting to the Accreditation Council for Graduate Medical Education. Previous research demonstrated a strong correlation between CCC and resident scores on the Milestones at 1 institution. We sought to evaluate a national sampling of general surgery residency programs and hypothesized that CCC and resident assessments are similar., Design: Details regarding the makeup and process of each CCC were obtained. Major disparities were defined as an absolute mean difference of ≥0.5 on the 4-point scale. A negative assessment disparity indicated that the residents evaluated themselves at a lower level than did the CCC. Statistical analysis included Wilcoxon rank sum and Sign tests., Setting: CCCs and categorical general surgery residents from 15 residency programs completed the Milestones document independently during the spring of 2016., Results: Overall, 334 residents were included; 44 (13%) and 43 (13%) residents scored themselves ≥0.5 points higher and lower than the CCC, respectively. Female residents scored themselves a mean of 0.08 points lower, and male residents scored themselves a mean of 0.03 points higher than the CCC. Median assessment differences for postgraduate year (PGY) 1-5 were 0.03 (range: -0.94 to 1.28), -0.11 (range: -1.22 to 1.22), -0.08 (range: -1.28 to 0.81), 0.02 (range: -0.91 to 1.00), and -0.19 (range: -1.16 to 0.50), respectively. Residents in university vs. independent programs had higher rates of negative assessment differences in medical knowledge (15% vs. 6%; P = 0.015), patient care (17% vs. 5%; P = 0.002), professionalism (23% vs. 14%; P = 0.013), and system-based practice (18% vs. 9%; P = 0.031) competencies. Major assessment disparities by sex or PGY were similar among individual competencies., Conclusions: Surgery residents in this national cohort demonstrated self-awareness when compared to assessments by their respective CCCs. This was independent of program type, sex, or level of training. PGY 5 residents, female residents, and those from university programs consistently rated themselves lower than the CCC, but these were not major disparities and the significance of this is unclear., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Family physicians (FPs) play a critical role in the early detection of skin cancers. Dermoscopy can improve diagnostic accuracy but its use by FPs in the United States (US) remains understudied., Objectives: To examine dermoscopy use, factors associated with ever having used (Model 1) and currently using the dermascope (Model 2), and barriers., Methods: We recruited 705 practicing FPs in-person at conferences and on-line to complete an anonymous, 46 item survey measuring: demographic factors, physician and practice characteristics; confidence in differentiating skin lesions; knowledge and use of dermoscopy; intentions to use; and barriers to use. We conducted bivariate analysis for each outcome and entered the significant predictors into two logistic regressions., Results: Almost 20% had ever used a dermascope and 8.3% were currently using it. Ever having used a dermascope was associated with being 39 years of age or younger, practicing in academia or community centers, and having higher confidence differentiating skin lesions. Current use was associated with seeing more than 400 patients per month and being 60 years-of-age or older., Conclusion: Use of dermoscopy by FPs is low. This study is an initial step in understanding its use among US FPs., Competing Interests: Competing interests: The authors have no conflicts of interest to disclose.