Psoriasis in the Era of Targeted Cancer Therapeutics: A Systematic Review on De Novo and Pre-existing Psoriasis in Oncologic Patients Treated with Emerging Anti-neoplastic Agents.

New advancements in medicine have paved the way for targeted therapies and immune checkpoint inhibitors (ICIs), which have become mainstays of cancer therapy. Targeted therapies work by pinpointing specific molecules in cancer pathways and inhibiting their function, while ICIs target irregularities in the immune system and DNA repair, participating in the induction of cell death. Although these agents have demonstrated great efficacy in treating a diverse set of cancers, they can frequently provoke serious dermatologic adverse effects. The side effects caused by an ICI are classified as immune-related adverse events since ICIs are immunomodulating, while the cutaneous side effects of targeted therapies are known as dermatologic adverse effects. Multiple studies have reported psoriasis and psoriasiform eruptions among the side effects observed in neoplastic patients receiving targeted therapies or ICIs. Psoriasis is an immune-mediated disease characterized by overactive T-cells and keratinocytes. To conduct this review, we retrieved 1363 studies from the PubMed database published between 2008 and 2023 using the terms "psoriasis" AND "cancer treatment." Many of these studies aimed to understand how patients with cancer receiving treatment may develop or even achieve psoriasis remission. Given that cancer and psoriasis involve a delicate balance between immune activation and suppression, ICIs and targeted therapies might produce varying effects. The aim of this review was to explore the relationship between psoriasis and cancer therapeutics while also highlighting the need to prioritize proper management of cutaneous side effects in neoplastic patients.

Mitochondrial Dysfunction: A Roadmap for Understanding and Tackling Cardiovascular Aging.

Cardiovascular aging is a progressive remodeling process constituting a variety of cellular and molecular alterations that are closely linked to mitochondrial dysfunction. Therefore, gaining a deeper understanding of the changes in mitochondrial function during cardiovascular aging is crucial for preventing cardiovascular diseases. Cardiac aging is accompanied by fibrosis, cardiomyocyte hypertrophy, metabolic changes, and infiltration of immune cells, collectively contributing to the overall remodeling of the heart. Similarly, during vascular aging, there is a profound remodeling of blood vessel structure. These remodeling present damage to endothelial cells, increased vascular stiffness, impaired formation of new blood vessels (angiogenesis), the development of arteriosclerosis, and chronic vascular inflammation. This review underscores the role of mitochondrial dysfunction in cardiac aging, exploring its impact on fibrosis and myocardial alterations, metabolic remodeling, immune response remodeling, as well as in vascular aging in the heart. Additionally, we emphasize the significance of mitochondria-targeted therapies in preventing cardiovascular diseases in the elderly.

Acquired Urethral Diverticulum After Holmium Laser Enucleation of the Prostate: A Case Report.

Acquired urethral diverticula (UD) in males is an uncommon entity, and it is rarely reported after an open simple prostatectomy or transurethral resection of the prostate. Here, we report a unique case of a UD presenting after holmium laser enucleation of the prostate (HoLEP) in a 69-year-old male with a prostate of 372 g who had five episodes of urine retention over one year despite combined medical treatment with tamsulosin 0.8 mg and finasteride 5 mg. The patient also has elevated prostate-specific antigen (PSA) with five negative prostate biopsies over the last few years. The procedure lasted six hours with difficult morcellation due to beach balls that took 3.5 hours. There were no intraoperative complications. However, he continued to have mixed urine incontinence and recurrent (six) episodes of urinary tract infection (UTI) in the first postoperative year. On evaluation, his urodynamic study did not reproduce stress urinary incontinence (SUI); however, cystoscopy and retrograde urethrogram diagnosed a 6-cm UD in the bulbar penile urethra with penoscrotal mass. The patient underwent urethral diverticulectomy and urethroplasty with a buccal mucosa graft to correct the defect. Six months after his urethral reconstruction, he continued to have mixed urine incontinence needing two pads/day. Although male UD is a rare condition, our case report seeks to heighten awareness of such a potential rare complication in men with recurrent UTIs and refractory urinary incontinence after prolonged HoLEP for extremely large prostates.

Incidental prostate cancer after holmium laser enucleation of the prostate: Critical analysis of independent risk factors and impact on surgical outcomes.

Objectives: The objectives of this study are to evaluate the impact of incidental prostate cancer (iPCa) and its different grade group (GG) on the surgical outcomes of holmium laser enucleation of the prostate (HoLEP) and, furthermore, to assess the independent risk factors associated with the detection of iPCa. Patients or materials and Methods: A retrospective chart review was conducted at a single institution for HoLEP cases that were performed between 2017 and 2022. Patients with a preoperative diagnosis of prostate cancer and those without baseline prostate-specific antigen (PSA) levels within 1 year were excluded. Four hundred seventeen patients were divided into three groups: benign prostatic hyperplasia-377; clinically insignificant (GG 1)-29; and clinically significant prostate cancer (GG 2-5)-11. The preoperative parameters analysed included age, body mass index, race/ethnicity, use of 5-alpha-reductase inhibitors, PSA, prostate size, PSA density, and history of negative prostate biopsy. To evaluate the association between clinical and demographic variables, a multivariable-adjusted logistic regression analysis was performed. We also assessed intraoperative and post-operative outcomes among these three groups. Results: A total of 417 patients were analysed; 40 (9.6%) patients had iPCa, of which 29 (72.5%) and 11 (27.5%) were clinically nonsignificant and significant prostate cancer, respectively. Of all the demographic and preoperative variables analysed, hypertension was significantly associated with overall prostate cancer diagnosis (p < 0.05), and no other variable including patient age, preoperative PSA, PSA density, prostate size, or prior prostate biopsy were associated with increased risk of overall prostate cancer or clinically significant prostate cancer diagnosis. Most cases of iPCa were GG1, and 34 (85%) were managed with active surveillance. Conclusion: The rate of iPCa after HoLEP was 9.6%, with most cases being GG 1 (72.5%) and managed through active surveillance. Age, prostate size, baseline PSA, and prior negative prostate biopsies were not associated with increased risk of iPCa.

Is Holmium Laser Enucleation of the Prostate Truly Size-Independent? A Critical Evaluation at the Extreme Ends of the Spectrum.

OBJECTIVE: To assess the outcomes of holmium laser enucleation of the prostate (HoLEP) at the extremes of the size spectrum, comparing whether the results are consistent for very large and small prostates. METHODS: A retrospective review of 402 patient charts was conducted to compare the outcomes of HoLEP in patients with prostate size ≤40 g (group 1), 41-200 g (group 2), and >200 g (group 3). Various preoperative, perioperative, and postoperative variables were collected. RESULTS: HoLEP showed comparable voiding outcomes among all 3 groups, although patients with small prostates had a higher International Prostate Symptom Score during follow-up (P = .022). We noted a higher rate of perioperative blood transfusion in patients with very large prostates (P = .019) and a higher rate of transient acute urinary retention (AUR) in group 1 when compared to group 3 (P = .048). Patients with smaller prostates had a higher rate of bladder neck stenosis and urethral strictures, but the differences were not found to be statistically significant. The incidence of other complications, length of hospital stay, and catheterization duration did not differ significantly among the groups. CONCLUSION: HoLEP has consistent and safe outcomes across a wide range of prostate sizes. Although, the risk of blood transfusion is higher in patients with very large prostates and the risk of transient AUR is greater in patients with small glands, the overall efficacy and safety of HoLEP are not significantly influenced by prostate size.

Wound Care Adherence in Mohs Micrographic Surgery: A Prospective Cohort Study.

BACKGROUND: Patients undergoing Mohs micrographic surgery (MMS) are given detailed wound care instructions to prevent postoperative complications. Previous studies have revealed low treatment adherence in general dermatology, but adherence to postoperative wound care and its potential association with poor surgical outcomes remain largely unstudied. OBJECTIVE: To determine the frequency and causes of wound care nonadherence in patients who underwent MMS. MATERIALS AND METHODS: A questionnaire containing a modified Eight-Item Morisky Medication Adherence Measure Scale was administered to Mohs patients at their 1 to 2 weeks postoperative visit. RESULTS: Sixty-three patients were solicited and consented to completing the questionnaire. The average modified Eight-Item Morisky Medication Adherence Measure Scale score was 7.4 of 8, indicating high adherence. Old age and wound care assistance were associated with increased adherence. Factors contributing to nonadherence included feeling well, being too busy, wound care causing discomfort, and being with friends or family. One patient (1.6%) with high adherence developed an epidermal inclusion cyst within the scar. No other complications were observed. CONCLUSION: Most MMS patients demonstrated high adherence to wound care instructions, and nonadherence was not associated with postoperative complications.

Increased degradation of FMRP contributes to neuronal hyperexcitability in tuberous sclerosis complex.

Autism spectrum disorder (ASD) is a highly prevalent neurodevelopmental disorder, but new therapies have been impeded by a lack of understanding of the pathological mechanisms. Tuberous sclerosis complex (TSC) and fragile X syndrome are associated with alterations in the mechanistic target of rapamycin (mTOR) and fragile X messenger ribonucleoprotein 1 (FMRP), which have been implicated in the development of ASD. Previously, we observed that transcripts associated with FMRP were down-regulated in TSC2-deficient neurons. In this study, we find that FMRP turnover is dysregulated in TSC2-deficient rodent primary neurons and human induced pluripotent stem cell (iPSC)-derived neurons and is dependent on the E3 ubiquitin ligase anaphase-promoting complex. We also demonstrate that overexpression of FMRP can partially rescue hyperexcitability in TSC2-deficient iPSC-derived neurons. These data indicate that FMRP dysregulation represents an important pathological mechanism in the development of abnormal neuronal activity in TSC and illustrate a molecular convergence between these two neurogenetic disorders.

Angiotensin II differentially affects hippocampal glial inflammatory markers in young adult male and female mice.

Hypertension is a risk factor for neurodegenerative disorders involving inflammation and inflammatory cytokine-producing brain cells (microglia and astrocytes) in the hippocampus and medial prefrontal cortex (mPFC). Here we investigated the effect of slow-pressor angiotensin II (AngII) on gliosis in the hippocampus and mPFC of young adult (2-mo-old) male and female mice. In males, AngII induced hypertension, and this resulted in an increase in the density of the astrocyte marker glial fibrillary acidic protein (GFAP) in the subgranular hilus and a decrease in the density of the microglial marker ionized calcium binding adapter molecule (Iba-1) in the CA1 region. Females infused with AngII did not show hypertension but, significantly, showed alterations in hippocampal glial activation. Compared with vehicle, AngII-infused female mice had an increased density of Iba-1 in the dentate gyrus and CA2/3a region. Like males, females infused with AngII exhibited decreased Iba-1 in the CA1 region. Neither male nor female mice showed differences in GFAP or Iba-1 in the mPFC following AngII infusion. These results demonstrate that the hippocampus is particularly vulnerable to AngII in young adulthood. Differences in gonadal hormones or the sensitivity to AngII hypertension may account for divergences in GFAP and Iba-1 in males and females.

Seizure Prediction using Convolutional Neural Networks and Sequence Transformer Networks.

Accurate seizure prediction is important for design of wearable and implantable devices that can improve the lives of subjects with epilepsy. Such implantable devices can be used for closed-loop neuromodulation. However, there are many challenges that inhibit the performance of prediction models. One challenge in accurately predicting seizures is the nonstationarity of the EEG signals. This paper presents a patient-specific deep learning approach to improve predictive performance by transforming EEG data before extracting features for seizure prediction. In the proposed approach, a Sequence Transformer Network (STN) is first used to learn temporal and magnitude invariances in EEG data. The proposed method further computes the short-time Fourier transform (STFT) of the transformed EEG signals as input features to a convolutional neural network (CNN). A k-out-of-n post-processing method is used to reduce the significance of isolated false positives. The approach is tested using intracranial EEG from the American Epilepsy Society Seizure Prediction Challenge dataset. Leave-one-out cross validation is used to evaluate the model. The proposed model achieves an overall sensitivity of 82%, false prediction rate of 0.38/hour, and average AUC of 0.746.

GABAB-Receptor Agonist-Based Immunotherapy for Type 1 Diabetes in NOD Mice.

Some immune system cells express type A and/or type B γ-aminobutyric acid receptors (GABAA-Rs and/or GABAB-Rs). Treatment with GABA, which activates both GABAA-Rs and GABAB-Rs), and/or a GABAA-R-specific agonist inhibits disease progression in mouse models of type 1 diabetes (T1D), multiple sclerosis, rheumatoid arthritis, and COVID-19. Little is known about the clinical potential of specifically modulating GABAB-Rs. Here, we tested lesogaberan, a peripherally restricted GABAB-R agonist, as an interventive therapy in diabetic NOD mice. Lesogaberan treatment temporarily restored normoglycemia in most newly diabetic NOD mice. Combined treatment with a suboptimal dose of lesogaberan and proinsulin/alum immunization in newly diabetic NOD mice or a low-dose anti-CD3 in severely hyperglycemic NOD mice greatly increased T1D remission rates relative to each monotherapy. Mice receiving combined lesogaberan and anti-CD3 displayed improved glucose tolerance and, unlike mice that received anti-CD3 alone, had some islets with many insulin+ cells, suggesting that lesogaberan helped to rapidly inhibit ß-cell destruction. Hence, GABAB-R-specific agonists may provide adjunct therapies for T1D. Finally, the analysis of microarray and RNA-Seq databases suggested that the expression of GABAB-Rs and GABAA-Rs, as well as GABA production/secretion-related genes, may be a more common feature of immune cells than currently recognized.

Convolutional neural networks to automate the screening of malaria in low-resource countries.

Malaria is an infectious disease caused by Plasmodium parasites, transmitted through mosquito bites. Symptoms include fever, headache, and vomiting, and in severe cases, seizures and coma. The World Health Organization reports that there were 228 million cases and 405,000 deaths in 2018, with Africa representing 93% of total cases and 94% of total deaths. Rapid diagnosis and subsequent treatment are the most effective means to mitigate the progression into serious symptoms. However, many fatal cases have been attributed to poor access to healthcare resources for malaria screenings. In these low-resource settings, the use of light microscopy on a thin blood smear with Giemsa stain is used to examine the severity of infection, requiring tedious and manual counting by a trained technician. To address the malaria endemic in Africa and its coexisting socioeconomic constraints, we propose an automated, mobile phone-based screening process that takes advantage of already existing resources. Through the use of convolutional neural networks (CNNs), we utilize a SSD multibox object detection architecture that rapidly processes thin blood smears acquired via light microscopy to isolate images of individual red blood cells with 90.4% average precision. Then we implement a FSRCNN model that upscales 32 × 32 low-resolution images to 128 × 128 high-resolution images with a PSNR of 30.2, compared to a baseline PSNR of 24.2 through traditional bicubic interpolation. Lastly, we utilize a modified VGG16 CNN that classifies red blood cells as either infected or uninfected with an accuracy of 96.5% in a balanced class dataset. These sequential models create a streamlined screening platform, giving the healthcare provider the number of malaria-infected red blood cells in a given sample. Our deep learning platform is efficient enough to operate exclusively on low-tier smartphone hardware, eliminating the need for high-speed internet connection.

Preoperative Opioid Prescription Is Associated With Major Complications in Patients With Crohn's Disease Undergoing Elective Ileocolic Resection.

BACKGROUND: Opioid use has grown exponentially over the last decade. The effect of preoperative opioid prescription in patients with Crohn's disease undergoing surgery is unknown. OBJECTIVE: The purpose of this study was to identify whether preoperative opioid prescription is associated with adverse postoperative outcomes in Crohn's disease. DESIGN: This is a single-institution retrospective observational study. SETTINGS: This study was performed at an academic tertiary care center. Details of preoperative opioid prescription were collected from the Kentucky All-Schedule Prescription Electronic Reporting database and the electronic databases of bordering states. PATIENTS: Consecutive patients undergoing ileocolic resection for Crohn's disease from 2014 to 2018 were included. MAIN OUTCOME MEASURES: The outcomes examined were major complications (Clavien-Dindo ≥3a), length of stay, and 30-day hospital readmission. RESULTS: Fifty one of 118 patients were prescribed opioids within 6 months preoperatively (range, 0-33,760 morphine milligram equivalents). Patients with preoperative opioid prescription compared with no preoperative opioid prescription required more daily opioids during hospital admission (p = 0.024). Nineteen patients had a major postoperative complication (preoperative opioid prescription: 26% (13/51) vs no preoperative opioid prescription: 9% (6/67)). On multivariable analysis, preoperative opioid prescription (OR = 2.994 (95% CI, 1.024-8.751); p = 0.045) was a significant risk factor for a major complication. Preoperative opioid prescription was associated with increased length of stay (p < 0.001) and was a risk factor for readmission (OR = 2.978 (95% CI, 1.075-8.246); p = 0.036). Twenty-four patients were readmitted. Using a cutoff for higher opioid prescription of 300 morphine milligram equivalents within 6 months preoperation (eg, 60 tablets of hydrocodone/acetaminophen 5/325), preoperative opioid prescription remained a risk factor for major postoperative complications (OR = 3.148 (95% CI, 1.110-8.928); p = 0.031). LIMITATIONS: This was a retrospective study and could not assess nonprescribed opioid use. CONCLUSIONS: Preoperative opioid prescription was a significant risk factor for adverse outcomes in patients with Crohn's disease undergoing elective ileocolic resection. See Video Abstract at http://links.lww.com/DCR/B113. LA PRESCRIPCIÓN PREOPERATORIA DE OPIOIDES SE ASOCIA CON COMPLICACIONES MAYORES EN PACIENTES CON ENFERMEDAD DE CROHN SOMETIDOS A RESECCIÓN ILEOCÓLICA ELECTIVA: El uso de opioides ha crecido exponencialmente en la última década. Se desconoce el efecto de la prescripción preoperatoria de opioides en pacientes con enfermedad de Crohn sometidos a cirugía.Identificar si la prescripción preoperatoria de opioides está asociada con resultados postoperatorios adversos en la enfermedad de Crohn.Este es un estudio observacional retrospectivo de una sola institución.Este estudio se realizó en un centro académico de atención terciaria. Los detalles de la prescripción preoperatoria de opiáceos se recopilaron de la base de datos de "Kentucky All-Schedule Prescription Electronic Reporting" y de las bases de datos electrónicas de los estados fronterizos.Pacientes consecutivos sometidos a resección ileocólica por enfermedad de Crohn entre 2014-2018.Los resultados examinados fueron complicaciones mayores (Clavien-Dindo ≥3a), duración de la estancia y el reingreso hospitalario de 30 días.A cincuenta y uno de 118 pacientes se le recetaron opioides dentro de los 6 meses preoperatorios (rango, 0 a 33,760 equivalentes de miligramos de morfina). Los pacientes con prescripción preoperatoria de opioides en comparación con ninguna prescripción preoperatoria de opioides requirieron más opioides diarios durante el ingreso hospitalario (p = 0,024). Diecinueve pacientes tuvieron una complicación postoperatoria importante (prescripción preoperatoria de opioides: 26% [13/51] frente a ninguna prescripción preoperatoria de opioides: 9% [6/67]). En el análisis multivariable, la prescripción de opioides preoperatorios (OR = 2.994, IC 95%: 1.024-8.751, p = 0.045) fueron factores de riesgo significativos para una complicación mayor. La prescripción preoperatoria de opioides se asoció con un aumento de la duración de la estadía (p <0.001) y fue un factor de riesgo para el reingreso (OR = 2.978, IC 95%: 1.075-8.246, p = 0.036). Veinticuatro pacientes fueron readmitidos. Utilizando un límite para una mayor prescripción de opioides de 300 miligramos equivalentes de morfina dentro de los 6 meses previos a la operación (p. Ej., 60 tabletas de hidrocodona / acetaminofén 5/325), la prescripción preoperatoria de opioides siguió siendo un factor de riesgo para complicaciones postoperatorias mayores (OR = 3.148 IC 95%: 1.110-8.928, p = 0.031).Este fue un estudio retrospectivo y no pudo evaluar el uso de opioides no prescritos.La prescripción preoperatoria de opioides fue un factor de riesgo significativo para los resultados adversos en pacientes con enfermedad de Crohn sometidos a resección ileocólica electiva. Consulte Video Resumen en http://links.lww.com/DCR/B113.

Bodywide fluctuations support manual exploration: Fractal fluctuations in posture predict perception of heaviness and length via effortful touch by the hand.

The human haptic perceptual system respects a bodywide organization that responds to local stimulation through full-bodied coordination of nested tensions and compressions across multiple nonoverlapping scales. Under such an organization, the suprapostural task of manually hefting objects to perceive their heaviness and length should depend on roots extending into the postural control for maintaining upright balance on the ground surface. Postural sway of the whole body should thus carry signatures predicting what the hand can extract by hefting an object. We found that fractal fluctuations in Euclidean displacement in the participants' center of pressure (CoP) contributed to perceptual judgments by moderating how the participants' hand picked up the informational variable of the moment of inertia. The role of fractality in CoP displacement in supporting heaviness and length judgments increased across trials, indicating that the participants progressively implicate their fractal scaling in their perception of heaviness and length. Traditionally, we had to measure fractality in hand movements to predict perceptual judgments by manual hefting. However, our findings suggest that we can observe what is happening at hand in the relatively distant-from-hand measure of CoP. Our findings reveal the complex relationship through which posture supports manual exploration, entailing perception of the intended properties of hefted objects (heaviness or length) putatively through the redistribution of forces throughout the body.

Delayed fatigue in finger flexion forces through transcutaneous nerve stimulation.

OBJECTIVE: Weakness of the hand is a major impairment which limits independent living. Neuromuscular electrical stimulation (NMES) is a common approach to help restore muscle strength. Traditional NMES directly over the muscle often leads to a rapid onset of muscle fatigue. In this study, we investigated the force sustainability of finger flexor muscles using a transcutaneous nerve stimulation approach. APPROACH: Finger flexion forces and high-density electromyogram (HD EMG) signals were obtained while electrical stimulation was applied to the ulnar and median nerve bundles through a stimulation grid on the proximal arm segment. Stimulation was also applied to the finger flexor muscle belly targeting the motor point, serving as a control condition. The force produced from the two stimulation approaches were initially matched, and muscle fatigue was subsequently induced with 5 min of continuous stimulation. The rate of decay of the force and EMG amplitude were quantified, and the spatial distribution of the muscle activation during the sustained contraction was also evaluated. MAIN RESULTS: The proximal nerve stimulation approach induced a slower decay in both force and EMG, compared with the stimulation at the motor point. The spatial distribution of the elicited muscle activation showed that the proximal nerve stimulation led to a distributed activation across the intrinsic and extrinsic finger flexor muscles and also activated a wider area within the extrinsic muscle. SIGNIFICANCE: Our findings demonstrated that the stimulation of the proximal nerve bundles can elicit sustained force output and delayed decrease in the rate of force decline. This is potentially due to a spatially distributed activation of the muscle fibers, compared with the traditional motor point stimulation. Future development of our nerve stimulation approach may enable prolonged usage during rehabilitation or assistance for better functional outcomes.

c-Fos mapping of brain regions activated by multi-modal and electric foot shock stress.

Real-world stressors are complex and multimodal, involving physical, psychological, and social dimensions. However, the brain networks that mediate stress responses to these stimuli need to be further studied. We used c-Fos mapping in mice to characterize brain circuits activated by exposure to a single episode of multimodal stress (MMS), and compared these to circuits activated by electric foot shocks (EFS). We focused on characterizing c-Fos activity in stress-relevant brain regions including the paraventricular nucleus (PVN) of the hypothalamus and the bed nucleus of the stria terminalis (BNST). We also assessed stress-induced activation of CRH-positive neurons in each of these structures. MMS and EFS activated an overlapping network of brain regions with a similar time course. c-Fos expression within the PVN and the BNST peaked 30-60 min after exposure to both MMS and EFS, and returned to baseline levels within 24 h. Quantification of c-Fos expression within BNST subregions revealed that while c-Fos expression peaked in all subregions 30-60 min after MMS and EFS exposure, the neuronal density of c-Fos expression was significantly higher in the dorsomedial and ventral BNST relative to the dorsolateral BNST. Our preliminary assessment indicated that a great majority of MMS or EFS-activated neurons in the PVN were CRH-positive (>87%); in contrast, about 6-35% of activated neurons in the BNST were CRH-positive. Our findings indicate that both MMS and EFS are effective at activating stress-relevant brain areas and support the use of MMS as an effective approach for studying multidimensional stress in animal models. The results also reveal that the PVN and BNST are part of a common neural circuit substrate involved in neural processing related to stress.

Computer Modeling to Evaluate the Impact of Technology Changes on Resident Procedural Volume.

BACKGROUND: As resident "index" procedures change in volume due to advances in technology or reliance on simulation, it may be difficult to ensure trainees meet case requirements. Training programs are in need of metrics to determine how many residents their institutional volume can support. OBJECTIVE: As a case study of how such metrics can be applied, we evaluated a case distribution simulation model to examine program-level mediastinoscopy and endobronchial ultrasound (EBUS) volumes needed to train thoracic surgery residents. METHODS: A computer model was created to simulate case distribution based on annual case volume, number of trainees, and rotation length. Single institutional case volume data (2011-2013) were applied, and 10 000 simulation years were run to predict the likelihood (95% confidence interval) of all residents (4 trainees) achieving board requirements for operative volume during a 2-year program. RESULTS: The mean annual mediastinoscopy volume was 43. In a simulation of pre-2012 board requirements (thoracic pathway, 25; cardiac pathway, 10), there was a 6% probability of all 4 residents meeting requirements. Under post-2012 requirements (thoracic, 15; cardiac, 10), however, the likelihood increased to 88%. When EBUS volume (mean 19 cases per year) was concurrently evaluated in the post-2012 era (thoracic, 10; cardiac, 0), the likelihood of all 4 residents meeting case requirements was only 23%. CONCLUSIONS: This model provides a metric to predict the probability of residents meeting case requirements in an era of changing volume by accounting for unpredictable and inequitable case distribution. It could be applied across operations, procedures, or disease diagnoses and may be particularly useful in developing resident curricula and schedules.

Achieving Accreditation Council for Graduate Medical Education duty hours compliance within advanced surgical training: a simulation-based feasibility assessment.

BACKGROUND: Certain operative cases occur unpredictably and/or have long operative times, creating a conflict between Accreditation Council for Graduate Medical Education (ACGME) rules and adequate training experience. METHODS: A ProModel-based simulation was developed based on historical data. Probabilistic distributions of operative time calculated and combined with an ACGME compliant call schedule. RESULTS: For the advanced surgical cases modeled (cardiothoracic transplants), 80-hour violations were 6.07% and the minimum number of days off was violated 22.50%. There was a 36% chance of failure to fulfill any (either heart or lung) minimum case requirement despite adequate volume. CONCLUSIONS: The variable nature of emergency cases inevitably leads to work hour violations under ACGME regulations. Unpredictable cases mandate higher operative volume to ensure achievement of adequate caseloads. Publically available simulation technology provides a valuable avenue to identify adequacy of case volumes for trainees in both the elective and emergency setting.