Oral examination of fourth-year medical students on surgery rotations allows faculty to assess Core Entrustable Professional Activities for entering Residency (CEPAR): Proof-of-concept and analysis of student submissions.

BACKGROUND: As a community-based medical school which recruited faculty preceptors new to teaching, we sought to create objective assessments for fourth-year surgery experiences via administration of an oral exam. Students provided three authentic cases, which faculty used as a springboard to ascertain student proficiency in five entrustable professional activities: 1-oral presentation, 2-recognition of urgency/instability, 3-calling consults, 4-transitions of care, 5-informed consent. We present proof-of-concept and analysis of student case submissions. METHODS: Twenty-seven student submissions (79 cases in total) were evaluated for case complexity, level-appropriateness, and an estimation of the ability to conduct a quality exam based on the information provided (subjective measures). Objective metrics included word count, instruction adherence, inclusion of figures/captions. A resident-in-training rated cases via the same metrics. In-examination data was separately culled. RESULTS: The average word count was 281.70 (SD 140.23; range 40-743). Figures were included in 26.1% of cases. Faculty raters scored 29.0% as low-complexity, 37.7% medium-complexity, and 33.3% high-complexity. Raters felt 62.3% of cases provided enough information to conduct a quality exam. The majority of cases submitted (65.2%) were level-appropriate or higher. The resident rater scored cases more favorably than surgeons (Cohen's kappa of -0.5), suggesting low inter-rater agreement between those of differing experience levels. CONCLUSION: Student's case submissions lessened faculty burden and provided assessors with adequate information to deliver a quality exam to assess proficiency in clinical skills essential for residency. Cases demonstrated sufficient complexity and level-appropriateness. The request to correlate case rating with exam performance is under review by our institution's assessment office. Near-peer tutoring by resident alumni is a program under development.

Central ray deficiency: subjective and objective outcome of cleft reconstruction.

PURPOSE: To assess the long-term subjective and objective outcome of cleft reconstruction in patients with central ray deficiency. METHODS: Twelve patients with 16 central ray deficiency hands were included. Each hand had been treated with cleft reconstruction using soft tissue and/or bony procedures. A surgeon and parent assessed the subjective outcome using a visual analog scale to compare preoperative and postoperative appearance. Objective outcome was assessed with a clinical examination for digital range of motion and with a radiographic examination for preoperative and postoperative divergence angles of the index finger and ring finger metacarpals and phalanges. RESULTS: The surgeon's visual analog scale score significantly increased from 4 to 7. Nine parents were very satisfied, 4 were satisfied, and 3 were somewhat satisfied with hand appearance. A ring finger proximal interphalangeal joint flexion contracture averaging 31 degrees was the most notable clinical finding. The metacarpal divergence angle significantly improved from 33 degrees to 12 degrees , and the phalangeal divergence angle significantly improved from 38 degrees to 12 degrees . CONCLUSIONS: Cleft reconstruction improves hand appearance in patients with central deficiency. A new technique of quantifying the radiographic divergence of the border rays of the cleft demonstrates improved alignment at long-term follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Extra-articular steroid injection: early patient response and the incidence of flare reaction.

PURPOSE: To evaluate the timing of improvement after extra-articular steroid injection, the incidence of a postinjection pain flare (a delayed postinjection transient increase in pain), and the role of the injection acidity in the postinjection flare. METHODS: One hundred twenty-five patients with trigger finger (88 patients) or de Quervain's tenosynovitis (37 patients) were prospectively randomized in this double-blind study to receive either an injection of steroid, lidocaine, and bupivacaine alone (standard injection, acidic pH) or an injection of steroid, lidocaine, bupivacaine, and bicarbonate (balanced injection, neutral pH). All patients completed a visual analog scale for pain before and immediately after the injection, daily for 7 days, and then again at 6 weeks. A flare reaction was defined as an increase in the visual analog scale score by 2 or more points any time after the injection. RESULTS: All patients immediately responded to the steroid injection, but pain rebounded to preinjection levels by day 1. In both groups the pain then gradually declined over the course of 7 days. In the balanced group, 23 of the 68 patients had flare reactions. In the standard group, 18 of the 57 patients had flare reactions. The difference between groups was not significant. CONCLUSIONS: Patients respond to extra-articular steroid injections with gradual improvement over the course of the first week. An increase in pain, or flare reaction, in the days following a steroid injection was noted in 33% of patients. A pH-balanced injection did not significantly decrease the risk of a flare reaction. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Objective features and aesthetic outcome of pollicized digits compared with normal thumbs.

PURPOSE: To evaluate the objective features and subjective aesthetic outcome of pollicized digits compared with normal thumbs. METHODS: Thirty-one pollicized digits in 26 patients were evaluated at an average 41 months after surgery. The length, girth, and nail width were measured and compared with previously reported data for normal thumbs. A surgeon, therapist, and caregiver completed Visual Analog Scales (VAS) to subjectively assess the aesthetic outcome; they also provided the principal reasons for their assessment of the altered appearance compared with normal thumbs. All data were statistically analyzed. RESULTS: The average length of the pollicized digit relative to the long finger proximal phalanx was 90% (+/-26%), compared with an age-matched normal average of 71%. The girth of the pollicized digit relative to the long finger was 92% (+/-8%), compared with an age-matched normal thumb average of 132%. The nail width of the pollicized digit relative to the nail width of the long finger was 96% (+/-9%), compared with an age-matched normal thumb average of 104%. The VAS scores averaged 7.3 for the caregiver, 6 for the therapist, and 6.4 for the surgeon. The most frequently cited (altered) features were narrow girth, angulation, and excess length of the pollicized digit. CONCLUSIONS: Pollicized digits are longer and have reduced girth and nail width compared with age-matched normal thumbs. The most significantly abnormal features are decreased girth, excess length, and angulation.

Early endocytosis pathways in SSN-1 cells infected by dragon grouper nervous necrosis virus.

Many fish undergo betanodavirus infection. To study the infection process of dragon grouper nervous necrosis virus (DGNNV), native virus and virus-like particles (VLPs) were used to analyse the binding and internalization in SSN-1 cells. The binding of DGNNV and VLPs to SSN-1 cells was demonstrated using Western blotting and immunofluorescence microscopy. As estimated by indirect ELISA, the DGNNV particles bound SSN-1 cells in a dose-dependent manner up to 8 x 10(4) particles per cell. The binding of VLPs was sensitive to neuraminidase and tunicamycin, suggesting that cell-surface sialic acid is involved in binding. The penetration of DGNNV into cells, which was monitored by electron microscopy, appeared to occur mainly via the spherical pit and membrane ruffling pathways. Occasionally, a spherical pit was engulfed by membrane ruffling so as to form a large figure-of-eight-shaped vesicle with an open connection. Our observations suggest that DGNNV utilizes both micro- and macropinocytosis pathways to enter SSN-1 cells.

Histological, ultrastructural, and in situ hybridization study on enlarged cells in grouper Epinephelus hybrids infected by grouper iridovirus in Taiwan (TGIV).

Grouper iridovirus in Taiwan (TGIV) infection in the Epinephelus hybrid is a major problem in the grouper industry. ATPase gene sequences indicate that this virus is closely related to cell hypertrophy iridoviruses. Histologically, the appearance of basophilic or eosinophilic enlarged cells in internal organs is the most characteristic feature of this disease. These cells are acid-phosphatase positive and are able to phagocytose injected carbon particles. In our study, TGIV infection inhibited normal phagocytic ability in these cells in vivo after 4 d post-infection (p.i.) but not before 2 d p.i. Their staining properties and phagocytic ability suggested a monocyte origin of enlarged cells, which appeared in high numbers in the trunk kidney, head kidney, spleen and gill. After infection, the enlarged cells first appeared in the spleen, with an abundance peak at 64 h p.i. (Peak 1); at 120 h p.i., a second peak (Peak 2) occurred in the spleen, head kidney, trunk kidney and gill. Lower numbers of enlarged cells were observed in the liver, muscle, heart, eye, intestine, but no enlarged cells were found in the brain. A TGIV-specific DNA probe labeled most of the basophilic but not eosinophilic enlarged cells. Nuclei of infected cells were labeled during an early stage of the infection; at later stages, both nuclei and cytoplasms were labeled. Ultrastructurally, heterochromatins of the infected cells were marginated or aggregated to one side of the nuclei during the early stages of infection. Damage and rupture of the nuclear membrane started before formation of the viromatrix. Capsids were assembled in ring-shaped or disc-shaped structures. Bullet-shaped electron-dense material was present near the incomplete virus particles, and is speculated to be inserted into the capsids later.