Arthroscopic Medial Meniscal Root Reconstruction With Gracilis Autograft Is Safe and Improves 2-Year Postoperative Patient-Reported Outcomes.

Purpose: To describe patient-reported clinical outcomes and complications of anatomic medial meniscal root reconstruction with gracilis autograft. Methods: Data on patients who underwent arthroscopic medial meniscal root reconstruction with gracilis autograft were prospectively collected between 2017 and 2021 and retrospectively reviewed. The inclusion criteria were symptomatic posterior medial meniscal LaPrade type 2 root tears with no more than Outerbridge grade 2 chondrosis of any knee compartment with a minimum follow-up period of 1 year. Patients with ligamentous instability and those with Workers' Compensation status were excluded. Patient-reported outcomes (12-item Short Form Survey [SF-12], visual analog scale [VAS], Western Ontario and McMaster Universities Arthritis Index [WOMAC], and Lysholm scores) were collected prospectively and analyzed retrospectively and were scored and recorded both preoperatively and at postoperative intervals. Data were analyzed using cubic spline regression models. The study was approved by the University of South Carolina Institutional Review Board. Results: A consecutive series of 27 patients treated by a single surgeon were evaluated. Twenty-one patients were included for data analysis (4 were excluded per criteria and 2 were lost to follow-up) with an average age of 48.1 years (range, 16-63 years). There were 18 female and 3 male patients. The average follow-up time was 25.2 months (range, 12-42 months). At the postoperative time points captured by the data examined, improvements in Lysholm, WOMAC, VAS, and SF-12 physical component summary scores were found to be statistically significant (P < .001, 95% confidence interval). Improvements in SF-12 mental component summary scores, however, did not reach the level of statistical significance (P = .262). Body mass index greater than 35 and age greater than 50 years were not found to be negative predictors of outcomes. Average patient-reported outcomes at 2 years' follow-up improved from preoperatively as follows: Lysholm score, from 50 to 82.9; WOMAC score, from 53.9 to 87.4; and VAS score, from 5.1 to 1.2. No serious complications were observed. Conclusions: Patients undergoing posterior medial meniscal root reconstruction showed statistically significant improvements in Lysholm, WOMAC, SF-12 physical component summary, and VAS scores but not SF-12 mental component summary scores at short-term follow-up. No serious complications or clinical failures occurred, and no patients required revision surgery. Level of Evidence: Level IV, case series.

Effects of Comorbidities on the Inferior Pedicle Reduction Mammaplasty: A Statistical Analysis.

BACKGROUND: Multiple studies have analyzed the impact of comorbidities on breast reduction surgery with mixed results. The purpose of this investigation was to perform a statistical analysis of all complications by a single surgeon, using a single technique for breast reduction. METHODS: Records of patients undergoing breast reduction from 1984 to 2019 with an inferior pedicle were reviewed. Comorbidities analyzed included hypertension, diabetes, nicotine use, weight of breast tissue resected, pedicle length, and basal metabolic index. The literature on the effects of comorbidities on outcomes for breast reconstruction was also reviewed. RESULTS: Although increasing body mass index significantly increased the rate of fat necrosis, it did not impact those patients requiring reoperation for this complication. Body mass index greater than 35 kg/m 2 , weight of tissue resection greater than 1000 g, and nipple-to-inframammary fold distance greater than 20 cm all increased the odds ratio of having a breast with some fat necrosis. Increasing body mass index increased the risk of wound healing problems (both major and minor), but not for patients requiring reoperation. Body mass index greater than 35 kg/m 2 , breast tissue resection greater than 1000 g, and nipple-to-inframammary fold distance greater than 20 cm only minimally increased the odds ratio for a major wound complication. CONCLUSIONS: Patients with increased body mass index are at greater risk for fat necrosis and wound healing complications. However, these usually can be managed conservatively in patients undergoing inferior pedicle breast reduction. Patients do not require free nipple grafting. The use of nicotine or the presence of diabetes or hypertension does not impact outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Utility of the 5-Factor Modified Frailty Index to Predict Postoperative Risk in Microsurgical Reconstruction.

BACKGROUND: Microsurgical reconstruction is an integral part of plastic surgery. The 5-factor modified frailty index (5-mFI) is an effective tool to predict postoperative complications across multiple subspecialties. We aimed to determine if frailty scores using the 5-mFI can predict postoperative complications specifically in microvascular reconstruction. STUDY DESIGN: Frailty scores were retrospectively assessed in microsurgical reconstruction patients (2012-2016) using the American College of Surgeons National Quality Improvement Program base. The 5 variables that comprise the 5-mFI are history of chronic obstructive pulmonary disease, history of congestive heart failure, functional status, hypertension requiring medication and diabetes. The data were analyzed using the Goodman test, χ2 test, and a logistic regression model. The congruence was also compared between the 5-mFI and the American Society of Anesthesiology (ASA) classification in predicting complications. RESULTS: Of 5894 patients, the highest 5-mFI value was "3." Analyses show an increase in postoperative complications requiring ICU care. Further models indicate an association between readmission with hypertension and chronic obstructive pulmonary disease (P < 0.05). There was an increased risk of a failure to wean from ventilator with a history of chronic obstructive pulmonary disease and diabetes and an increased risk of readmission with a history of hypertension and chronic obstructive pulmonary disease. The 5-mFI and ASA were incongruent in predicting postoperative complications. CONCLUSIONS: The 5-mFI predicts postoperative complications in the microsurgical reconstruction population. Although the 5-mFI and ASA predict different complications, their use provides insight into the potential adjustable risks before surgery.

Modified Carpal Tunnel Release: A New Approach to Minimizing Pillar Pain.

INTRODUCTION: Pillar pain is a frequent postoperative complication of carpal tunnel release (CTR). The precise definition of pillar pain is lacking, but most authors describe it as diffuse aching pain and tenderness in the thenar and hypothenar area. The etiology of pillar pain is unclear. However, the most prevalent theory is the neurogenic theory, which attributes the pain to the damage of small nerve branches of palmar cutaneous branches of median nerve after surgical incision, with resulting entrapment of the nerves in the scar tissue at the incision site. We postulated that a main source of pillar pain is sensory neuromas along the incision site.In this article, we describe a simple modification of the standard CTR technique with intent to decrease neuroma formation and thus minimizing pillar pain. MATERIALS AND METHODS: This is a retrospective study comparing the incidence and duration of pillar pain between patients who underwent standard CTR (SCTR, n = 53) versus the minimizing pillar pain CTR technique (n = 55). Based on duration of pillar pain, the groups were placed into 3 subgroups (<3, 3-6, and >6 months). Presence and duration of pillar pain in each group were recorded along with return to work (RTW), complications, and patient satisfaction. RESULTS: The SCTR group had a total of 17 patients with pillar pain (32.1%), 5 of which resolved within 3 months, 7 within 3 to 6 months, and 5 in more than 6 months. The group that underwent the minimizing pillar pain technique had a total of 4 patients with pillar pain (7.2%). Three resolved within 3 months, 1 resolved within 3 to 6 months, and there were no patients with pillar pain lasting more than 6 months. Average RTW time for minimization of pillar pain CTR (MPPCTR) was 34.9 days. Average RTW time for SCTR was 54.8 days. Satisfaction was higher among patients who underwent surgery with MPPCTR. CONCLUSIONS: Based on these results, we concluded that MPPCTR compared with SCTR had equal complication rate, however, significantly lower incidence and duration of pillar pain, higher rate of satisfaction, and earlier RTW.

Evaluation of a Smoking Cessation Patient Decision Aid That Integrates Information About E-Cigarettes.

INTRODUCTION: Smokers increasingly use e-cigarettes to try to quit smoking, even more than recommended cessation methods. However, few smokers discuss the range of cessation options with their physicians. Decision aids can inform smokers about smoking cessation options, including evidence about e-cigarettes, and encourage smokers to engage in shared decision making with their physician. AIMS AND METHODS: This study aimed to evaluate a smoking cessation decision aid that included e-cigarette risks and benefits. Adult smokers were recruited from primary care clinics for two research phases: (1) usability and acceptability testing of the decision aid (n = 37); and (2) pre-post study that compared usual care (n = 90) with implementation of the decision aid in clinics (n = 90). For the latter, outcome measures included frequency of clinical discussions of readiness to quit, methods to quit in general, and of specific cessation methods, in addition to decisional conflict, communication satisfaction, and overall patient satisfaction. RESULTS: Smokers indicated high usability and acceptability of the decision aid. In the pre-post evaluation, decision aid implementation was associated with higher rates of smokers: being asked if they were ready to quit smoking (89% vs. 67%, respectively; p < .001); discussing methods for smoking cessation in general (81% vs. 48%; p < .001); and discussing specific cessation methods (NRT 55% vs. 26%, p < .001; prescription medications 26% vs. 12%, p = .022). Decision aid use was also associated with higher overall patient satisfaction with the physician visit. CONCLUSIONS: Smoking cessation decision aids that incorporate information about e-cigarettes are acceptable among smokers and can lead to evidence-based clinical discussions about smoking cessation. IMPLICATIONS: Smokers use e-cigarettes more than recommended cessation methods when they are trying to quit smoking, yet few physicians discuss the risks and benefits of e-cigarettes with their patients who smoke. This study presents preliminary findings about the feasibility and usability of a clinically based iPad-delivered smoking cessation decision aid that integrates information about e-cigarettes. Although promising, further research with randomized designs, larger samples, and longer-term follow-up is needed to determine whether this type of intervention can effectively promote cessation of all tobacco products and, for those not ready to quit smoking, the use of e-cigarettes for harm reduction.

Evaluation of Time to Resolution of Medical Necrotizing Enterocolitis Using Severity-Guided Management in a Neonatal Intensive Care Unit.

OBJECTIVE: No studies, to our knowledge, have determined the relationship between symptom resolution and timing of antimicrobial discontinuation in necrotizing enterocolitis (NEC). Our study seeks to determine the period to NEC resolution by using severity-guided management, based on surrogate markers used in the diagnosis of NEC. METHODS: This retrospective, observational review included patients in our NICU with NEC from June 1, 2012, to June 1, 2018. Patients were excluded for surgical NEC, a positive blood culture or transfer from an outside institution at the time of NEC, presence of a peritoneal drain, or death prior to NEC resolution. The primary outcome was time to resolution of NEC, measured by return to baseline of surrogate markers used in the diagnosis of NEC. RESULTS: The median times to resolution in days, based on our institution's NEC severity group, were as follows: mild 3 (range, 1-4); moderate 4 (range, 1-17); severe 9 (range, 5-21). No difference in NEC recurrence was found based on antibiotic duration (OR 0.803; 95% CI, 0.142-4.225). CONCLUSIONS: Time to resolution of NEC differs by severity group, suggesting a need for different treatment durations. Recurrence of NEC did not differ between groups, suggesting that shorter antibiotic durations do not lead to an increased incidence of NEC recurrence. Further exploration of the optimal antimicrobial treatment duration for NEC is warranted.

Knowledge and Attitudes of Psychiatrists About the Gun Rights of Persons With Mental Illness.

Individuals with mental illness have often been misperceived by the public to pose a higher risk of violence to others. Consequently, the United States government and many individual states have enacted laws barring firearm access for certain individuals with mental illness. Many of these laws allow for eventual restoration of firearm access (i.e., relief from firearm disability (RFD)). This study assesses the knowledge base and attitudes of psychiatrists practicing in South Carolina regarding these gun laws. Results of this study indicate that psychiatrists in South Carolina have significant knowledge deficits pertaining to gun laws that both restrict gun ownership and allow restoration of gun ownership rights for persons with mental illness; these deficits may apply to practitioners in other states as well. The only variable that predicted a greater knowledge about limitations on gun rights was whether a psychiatrist had a patient who was prohibited from gun ownership. South Carolina psychiatrists had more favorable attitudes about restricting gun access for persons with mental illness than about supporting the right of persons with mental illness to own a gun. Finally, if psychiatrists owned a firearm, they were more likely to support the right of persons with mental illness to own a firearm.

Sternotomy Wound Closure: Equivalent Results with Less Surgery.

BACKGROUND: Mediastinitis after a median sternotomy can be life-threatening. The advent of pedicle flap-based treatment has resulted in an improvement in both morbidity and mortality. However, significant morbidities can still occur following the use of flaps for sternal closure, particularly in patients with comorbidities. To minimize an extensive surgical dissection, we modified our approach to reconstruction using a modified subpectoral approach, leaving the overlying skin attached. This technique focuses primarily on controlling wound tension rather than on maximal muscle coverage. This study is a retrospective review of 58 consecutive patients treated with this approach, by a single surgeon. METHODS: Fifty-eight consecutive patients treated between 2008 and 2019 were included. All patients received the same procedure regardless of the degree of illness, the extent of tissue loss, and the size of sternal defect. Treatment included thorough debridement, with total sternectomy (if required); limited dissection of the pectoralis major muscle off the chest wall to the level of the pectoralis minor without skin and subcutaneous undermining; no release of the insertion of the pectoralis or use of the rectus abdominis; and midline closure over drains connected to wall suction to obliterate dead space. RESULTS: Reoperations were required in 7 patients (12%). Of these, only 4 (6.9%) were related to continued sternal osteomyelitis. The other reoperations were for hematoma evacuation, breast fat necrosis, and skin necrosis. There were no operative mortalities. CONCLUSION: Chest closure using minimal dissection and tension release is safe, efficient, and associated with a complication rate equivalent to more extensive procedures reported in the literature despite significant comorbidities.

Simulation-based clinical learning for the third year medical student: Effectiveness of transabdominal and transvaginal ultrasound for elucidation of OB/GYN scenarios.

PURPOSE: Point-of-care ultrasound (POCUS) is gaining recognition as a teaching modality that acts as an integrative learning tool during medical student transition to clinical rotations. This study aimed to determine if the use of ultrasound simulation enhances understanding of Obstetrical and Gynecological (Ob/Gyn) anatomy and pathology in third-year medical students (M3), and if M3 students found the simulator useful. METHODS: M3 students taking the OB/Gyn clerkship were invited to participate. Baseline knowledge of pelvic ultrasound anatomy and pathology was assessed with a multiple-choice question test. Participants received a one-hour OB/Gyn ultrasound simulation training session. A post-test assessed knowledge after the intervention. Survey data was collected regarding learning styles and learner satisfaction. RESULTS: Following simulator-based training, the median correct number of responses to the knowledge questions increased from 11 of 18 to 14 of 18 correct (P < .001). Statistically significant increases were also observed in comfort level with OB/GYN ultrasound (P < .001). All 68 students answered that the ultrasound simulator was helpful and enjoyed using the simulator. CONCLUSIONS: This study suggests that ultrasound simulators are useful for improvement in knowledge, comfort level, and ability to identify pathology in Ob/Gyn scenarios in M3 students.

Triple-Negative Breast Cancer: A Comparison of Race and Survival.

Triple-negative breast cancer (TNBC) is an aggressive subtype of breast cancer with a high prevalence in blacks. South Carolina demographically has a high percentage of blacks. This study examines survival and recurrence associated with TNBC in black and white women. A retrospective review of breast cancer patients within the Palmetto Health Cancer Registry was performed from 1999 to 2015. Patient demographics and tumor characteristics were collected and correlated with outcomes. Overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were analyzed. The total number of breast cancer patients in the registry was 1723 (1085-white and 638-black). The median follow-up was 48.4 months. The majority of cancers diagnosed in both cohorts were early stage (I, IIA, IIB, 93.4% vs 90.4% P = NS). We identified 332 patients with TNBC. Of those 332 patients, 144 (43.4%) were whites and 188 (56.6%) were blacks. Older age (P = 0.01), high-grade (P < 0.001), and black race (P < 0.001) were significantly associated with TNBC on multivariate analysis. Five- and 10-year OS was significantly worse in blacks with TNBC (P < 0.001). There was no difference in DSS or RFS between the two cohorts. TNBC disproportionately affects black women and is an aggressive subtype of breast cancer with limited treatment options compared with receptor-positive breast cancer. Black patients with TNBC in our study had statistically worse OS. These findings are similar to what has been reported in the literature and prompts further research in newer targeted therapies.

Case series with literature review: Surgical approach to megarectum and/or megasigmoid in children with unremitting constipation.

BACKGROUND: The role of surgery in treating children with functional constipation (FC) is controversial, because of the efficacy of bowel management programs. This case series is comprised of failures: 43 children, spanning 25 years' practice, who had megarectosigmoid (MRS) and unremitting constipation. PURPOSE: To determine whether these children were helped by surgery, and to contribute to formulating a standard of care for children with megarectum (MR) and/or redundancy of the sigmoid colon (MS) who fail medical management. METHOD: We describe our selection criteria and the procedures we utilized - mucosal proctectomy and endorectal pull-through (MP) or sigmoidectomy (SE) with colorectal anastomosis at the peritoneal reflection. The internet (social media) allowed us to contact most of these patients and obtain extremely long follow-up data. RESULTS: 30/43 patients had MP and 13/43 had SE. Follow-up was obtained in 83% MP and 70% SE patients. 60% of MP and 78% of SE patients reported regular evacuations and no soiling. 20% MP patients had occasional urgency or soiling or episodic constipation. 12% MP and 22% SE patients required antegrade continence enemas (ACE) or scheduled cathartics and/or stool softeners. 4% MP had no appreciable benefit, frequent loose stools and soiling, presumably from encopresis. CONCLUSION: MR is characterized by diminished sensation, poor compliance and defective contractility. Patients with MR do better with MP, which effectively removes the entire rectum versus SE, where normal caliber colon is anastomosed to MR at the peritoneal reflection; furthermore, MP reliably preserves continence; whereas total proctectomy (trans-anal or trans-abdominal) may cause incontinence.

Impact of Body Mass Index and Bacterial Resistance in Osteomyelitis after Antibiotic Prophylaxis of Open Lower-Extremity Fractures.

BACKGROUND: We investigated the clinical effectiveness of antimicrobial prophylaxis in lower-extremity open fractures following the Eastern Association for the Surgery of Trauma Guidelines. METHODS: This observational, retrospective, single-center study included adults with lower-extremity open fractures of the ankle, tibia, fibula, or femur. The primary endpoint was the incidence of osteomyelitis within 12 months of the fracture. Secondary endpoint comparisons were the time of antibiotic initiation and drug selection. RESULTS: A total of 90 patients were included. Patients suffered from Gustilo and Anderson grades I (14%), II (54.7%), and III (31.3%) fractures. Almost all patients received cefazolin (98%). Among grade III fractures, 59.3% (16/27) of patients received additional gram-negative coverage as recommended by the guidelines. The osteomyelitis rate was 8.9%. There was no difference in osteomyelitis rates among patients with grade III fractures who received or did not receive additional gram-negative coverage: 18.8% (3/16) and 0 (0/11) (p = 0.248), respectively. There was no correlation between median antibiotic start time or antibiotic stop time after closure and the development of osteomyelitis, respectively. Resistant organisms caused 50% (4/8) of the osteomyelitis cases. On univariate analysis, obesity had the most significant association with osteomyelitis (p = 0.026). CONCLUSIONS: Bacterial resistance was common among cases of osteomyelitis in our cohort. Obesity was associated with a higher rate of osteomyelitis.

Comparative efficacy of CPAP, MADs, exercise-training, and dietary weight loss for sleep apnea: a network meta-analysis.

STUDY OBJECTIVE: To synthesize evidence from available studies on the relative efficacies of continuous positive airway pressure (CPAP), mandibular advancement device (MAD), supervised aerobic exercise training, and dietary weight loss in patients with obstructive sleep apnea (OSA). DESIGN: Network meta-analysis of 80 randomized controlled trials (RCTs) short-listed from PubMed, SCOPUS, Web of science, and Cochrane register (inception - September 8, 2015). PATIENTS: Individuals with OSA. INTERVENTIONS: CPAP, MADs, exercise training, and dietary weight loss. RESULTS: CPAP decreased apnea-hypopnea index (AHI) the most [by 25.27 events/hour (22.03-28.52)] followed by exercise training, MADs, and dietary weight loss. While the difference between exercise training and CPAP was non-significant [-8.04 (-17.00 to 0.92), a significant difference was found between CPAP and MADs on AHI and oxygen desaturation index (ODI) [-10.06 (-14.21 to -5.91) and -7.82 (-13.04 to -2.59), respectively]. Exercise training significantly improved Epworth sleepiness scores (ESS) [by 3.08 (0.68-5.48)], albeit with a non-significant difference compared to MADs and CPAP. CONCLUSIONS: CPAP is the most efficacious in complete resolution of sleep apnea and in improving the indices of saturation during sleep. While MADs offer a reasonable alternative to CPAP, exercise training which significantly improved daytime sleepiness (ESS) could be used as adjunctive to the former two.

Non-tuberculous mycobacterial bloodstream infections in patients with indwelling vascular catheters - the role of sickle cell anaemia.

INTRODUCTION: Few studies have examined risk factors for nontuberculous mycobacteria (NTM) bloodstream infections (BSI) involving indwelling vascular catheters (IDVC). Sickle cell anaemia (HbSS/SC) is known to affect several aspects of the immune system leading to relative immune deficiency. The purpose of this retrospective nested case-control study was to determine if HbSS/SC is a risk factor for NTM BSI among individuals with IDVCs. METHODS: All NTM IDVC infections (cases) at two tertiary hospitals from 2008 to 2014 were reviewed. Cases were matched 2:1 with controls who had IDVC infections due to organisms other than NTM. Matching criteria included age within 10 years and IDVC infection within three months of index case. Logistic regression was used to identify risk factors for IDVC infection due to NTM. RESULTS: Nineteen NTM BSIs were identified. Three cases were excluded because they did not have IDVCs at the time their BSI was identified. Sixteen cases of NTM IDVC infection were matched to 32 controls with IDVC infections due to other organisms. The mean age of patients with IDVC infections was 48.5 years and 28 (58%) were male. Compared to the control group those with NTM BSI were more likely to have HbSS/SC 38% (6/16) versus 6% (2/32) (p = .006). CONCLUSION: IDVCs are a risk factor for NTM BSI. Sickle cell anaemia appears to be a risk factor for IDVC infections due to NTM. This study is limited by the small sample size. A larger study is needed to further investigate the association between HbSS/SC and NTM IDVC infections.

Diagnostic yield of electromagnetic navigational bronchoscopy.

OBJECTIVES: Peripheral lung nodules (PLNs) are a common and diagnostically challenging finding. Electronavigational bronchoscopy (ENB) is used to increase the diagnostic yield and is considered safe. Multiple factors have been correlated with a better diagnostic yield. We sought to assess the effect of nodule characteristics and prior workup on the diagnostic yield in ENB. METHODS: This was a retrospective chart review of 98 ENB procedures in a community referral center. Two investigators reviewed patients' charts and images independently. Multiple logistic regression analyses was used to determine if factors such as bronchus sign, ground glass opacification (GGO), distance from pleura, prior use of endobronchial ultrasound (EBUS) and positron emission tomography (PET) had an impact on the diagnostic yield. RESULTS: We evaluated 98 ENBs performed in 92 patients. Most of the lesions were in the upper lobes. The diagnostic yield was 60%. A PET scan was performed prior to ENB in 47% of cases. EBUS was performed in 24% of cases. Bronchus sign was present in 60% of cases and GGO in only 6% of nodules. The odds ratio for diagnostic yield with a bronchus sign was 1.89 [95% confidence interval (CI): 0.83-4.33] and with nodules showing GGO characteristics it was 4.51 (95% CI: 0.51-39.68). Pneumothorax occurred in 6% of cases. CONCLUSION: In our cohort, diagnostic yield was 60% with a 6% pneumothorax rate. A suggestive trend for the presence of bronchus sign on computed tomography scan, albeit statistically nonsignificant, as a predictor for improved diagnostic yield needs to be validated in a larger cohort.

The association between Myers-Briggs Type Indicator and Psychiatry as the specialty choice.

OBJECTIVE: The purpose of this pilot study is to examine the association between Myers-Briggs Type Indicator (MBTI) and prospective psychiatry residents. METHODS: Forty-six American medical schools were contacted and asked to participate in this study. Data were collected and an aggregated list was compiled that included the following information: date of MBTI administration, academic year, MBTI form/version, residency match information and student demographic information. The data includes 835 American medical students who completed the MBTI survey and matched into a residency training program in the United States. All analyses were performed using R 3.1.2. RESULTS: The probability of an introvert matching to a psychiatry residency is no different than that of an extravert (p= 0.30). The probability of an intuitive individual matching to a psychiatry residency is no different than that of a sensing type (p=0.20). The probability of a feeling type matching to a psychiatry residency is no different than that of a thinking type (p= 0.50). The probability of a perceiving type matching to a psychiatry residency is no different than that of a judging type (p= 0.60). CONCLUSIONS: Further analyses may elicit more accurate information regarding the personality profile of prospective psychiatry residents. The improvement in communication, team dynamics, mentor-mentee relationships and reduction in workplace conflicts are possible with the awareness of MBTI personality profiles.

Accuracy of double Maddox rod with induced hypertropia in normal subjects.

BACKGROUND AND PURPOSE: The double Maddox rod is a commonly used instrument to test for cyclotorsion in the clinical setting. This paper assesses the ability of patients without torsional complaint to accurately demonstrate torsional status with varying degrees of induced hypertropia as tested by double Maddox rod. METHODS: Thirty-seven orthophoric subjects underwent double Maddox rod testing with vertical prism of 3(Δ), 10(Δ), 16(Δ), 20(Δ), and 30(Δ). Subjective torsion was recorded for each prism diopter. RESULTS: Mean subjective torsion was recorded as 0.95°, 1.6°, 1.9°, 2.1°, and 2.2° for 3(Δ), 10(Δ), 16(Δ), 20(Δ), and 30(Δ), respectively. Torsion increased in a logarithmic manner as modeled by R™ software version 2.15.2. CONCLUSIONS: The double Maddox rod test as commonly used in clinical practice is both subjective and prone to administrator and subject error. Subjects have more difficulty properly aligning the double Maddox rod as distance between images is increased. It is also possible that recruitment of the oblique muscles during attempted vertical fusion leads to subjective torsion during double Maddox rod testing in otherwise normal participants.

Starting dialysis at eGFR >5 ml/min per1.73 m(2): are we barking up the wrong tree?

Although the goal glomerular filtration rate (GFR) for chronic dialysis initiation is currently above 5 ml/min per 1.73 m(2), there is no convincing evidence that patients will benefit from this approach. With close follow-up of advanced chronic kidney disease patients, aiming to start dialysis at an estimated GFR (eGFR) less than 5 ml/min per 1.73 m(2) may result in the avoidance of potentially unnecessary end-of-life dialysis and could result in significant dialysis-free time for a large segment of the world's future dialysis population.

Factors that influence physicians' and medical students' confidence in counseling patients about physical activity.

Less than half of US adults and two-thirds of US high school students do not meet current US guidelines for physical activity. We examined which factors promoted physicians' and medical students' confidence in counseling patients about physical activity. We established an online exercise survey targeting attending physicians, resident and fellow physicians, and medical students to determine their current level of physical activity and confidence in counseling patients about physical activity. We compared their personal level of physical activity with the 2008 Physical Activity Guidelines of the US Department of Health and Human Services (USDHHS). We administered a survey in 2009 and 2010 that used the short form of the International Physical Activity Questionnaire. A total of 1,949 individuals responded to the survey, of whom 1,751 (i.e., 566 attending physicians, 138 fellow physicians, 806 resident physicians, and 215 medical students) were included in this analysis. After adjusting for their BMI, the odds that physicians and medical students who met USDHHS guidelines for vigorous activity would express confidence in their ability to provide exercise counseling were more than twice that of physicians who did not meet these guidelines. Individuals who were overweight were less likely to be confident than those with normal BMI, after adjusting for whether they met the vigorous exercise guidelines. Physicians with obesity were even less likely to express confidence in regards to exercise counseling. We conclude that physicians and medical students who had a normal BMI and met vigorous USDHHS guidelines were more likely to feel confident about counseling their patients about physical activity. Our findings suggest that graduate medical school education should focus on health promotion in their students, as this will likely lead to improved health behaviors in their students' patient populations.