BACKGROUND:The authors studied the impact of a new, coordinated interview release date for integrated plastic surgery residencies.METHODS:A cross-sectional study of all 2020 integrated plastic surgery residencies and applicants was performed. Voluntary, anonymous surveys were administered following implementation of the interview policy.RESULTS:Program response rates were 55.6% for the initial survey and 57.1% for the follow-up survey. Programs released an average of 2.1 (95% CI, 1.8 to 2.4) rounds of interview invitations and invited 39.0 (95% CI, 35.3 to 42.6) applicants to interview. Policy adherence was high (91.1%). Most programs believed the interview policy was an improvement for applicants (46.5% yes; 9.1% no) and programs (41.9% yes; 27.0% no). Median rank of matched candidates was 13, and 55.1% of programs matched candidates within the top quartile of their rank list. The average candidate applied to 72 programs, attended 11 interviews, and ranked 12 programs. Interview distribution was bimodal, with peaks at six and 15 total interview invitations. Applicants within the top fifth, tenth, and fifteenth percentile for total interview invites disproportionately accounted for 15.3%, 26.6%, and 36.5%, respectively, of all invitations received. Survey data suggested applicant satisfaction with travel planning, improved scheduling, and cost savings following implementation of the interview policy. Applicants were somewhat dissatisfied with interview distribution.CONCLUSIONS:A coordinated interview release date is facile to adopt and does not adversely impact program interview trends or match rates. Applicants benefit from improved scheduling, travel planning, and cost savings; however, interview distribution continues to favor top-tier candidates.

Establishing normative data for operative skills during residency training can help identify residents whose performance lags behind or exceeds that of their peers. We performed the current study using Operative Entrustability Assessment (OEA) data to map operative progress of plastic surgery residents by post-graduate year (PGY). OEA data were abstracted from MileMarker®, a web-based program that captures resident self-assessments and associated attending assessments of CPT-coded procedures. Ratings are based on a 5-point scale (1 = “observed case,” 5 = “can take junior resident through case”). Data were collected from 7 academic plastic surgery programs. We identified 14,272 completed OEAs assessing 916 unique CPT codes; of these, 28 procedures (comprising 7,157 OEAs) contained > 100 assessments (range: 101–599). Examples of procedures in which resident skills are mastered at different training levels include split-thickness skin grafts (early, junior residents), ulnar nerve release (late, senior residents), and breast reduction (linearly). Establishing normative data for high-volume cases can facilitate recognition of residents whose operative skills are outside the expected range, thereby enabling more individualized learning in surgical education. Using these data, we have identified 28 sentinel procedures that may be used to identify excelling, competent, and struggling residents in the early, middle, and late stages of training. Further studies will be performed to determine if competency maps can be used to predict future performance.

Background: Microsurgery is conducted on tiny anatomical structures such as blood vessels and nerves. Over the past few decades, little has changed in the way plastic surgeons visualize and interact with the microsurgical field. New advances in augmented reality (AR) technology present a novel method for microsurgical field visualization. Voice- and gesture-based commands can be used in real time to adjust the size and position of a digital screen. Surgical decision support and/or navigation may also be used. The authors assess the use of AR in microsurgery. Methods: The video feed from a Leica Microsystems OHX surgical microscope was streamed to a Microsoft HoloLens2 AR headset. A fellowship-trained microsurgeon and three plastic surgery residents then performed a series of four arterial anastomoses on a chicken thigh model using the AR headset, a surgical microscope, a video microscope (or “exoscope”), and surgical loupes. Results: The AR headset provided an unhindered view of the microsurgical field and peripheral environment. The subjects remarked on the benefits of having the virtual screen track with head movements. The ability of participants to place the microsurgical field in a tailored comfortable, ergonomic position was also noted. Points of improvement were the low image quality compared with current monitors, image latency, and the lack of depth perception. Conclusions: AR is a useful tool that has the potential to improve microsurgical field visualization and the way surgeons interact with surgical monitors. Improvements in screen resolution, latency, and depth of field are needed.

OBJECTIVE:To assess the feasibility of motor unit number index (MUNIX) in quantitatively evaluating Hirayama disease (HD) with proximal involvement and to identify the effectiveness of anterior cervical fusion (ACF) in treating atypical HD with proximal involvement.METHODS:This study included 28 atypical HD patients with proximal involvement (proximal-distal vs. distal-proximal groups: 5 vs. 23) and 41 healthy controls. All patients underwent pre- and postoperative 1-year MUNIX tests on abductor pollicis brevis (APB), abductor digiti minimi (ADM), biceps brachii (BB) and deltoid (Del). The disabilities of arm, shoulder and hand (DASH) and Medical Research Council (MRC) scales were also performed in these patients before and one year after operation.RESULTS:Preoperatively, the patients in the distal-proximal group showed reduced compound muscle action potential (CMAP), decreased MUNIX and increased motor unit size index (MUSIX) in bilateral distal muscles and symptomatic-side proximal muscles (P < 0.05), and similar abnormalities were also observed in ADM, BB and Del on the symptomatic side in the proximal-distal groups (P < 0.05). Postoperative follow-up analysis identified increased MUNIX in the symptomatic-side proximal muscles with improved motor function in the proximal-distal groups (P < 0.05), and distal-proximal group patients showed an increase in both CMAP and MUSIX in the symptomatic-side proximal muscles (P < 0.05).CONCLUSIONS:MUNIX may serve as an available supplementary test to quantitatively evaluate the motor dysfunction and treatment outcome in HD with proximal involvement. ACF procedures can effectively treat these atypical HD patients, especially for those whose symptoms started in proximal muscles.

A colleague recently hired two new plastic surgeons for his department. They are bright, excellent clinicians who are proven investigators, and are eager to work with medical students and residents. Within the first few weeks of joining his staff, they both raised a variation of the same question, “I really enjoy teaching the students, and I want to do it better, but I'm really busy trying to establish my practice. I'm overwhelmed by the thought of how much time it would take to read a book on teaching and do not know the field of education well enough to attempt to find key articles online; I'm not sure I'd know where to begin looking. Where can I go to learn to be a better teacher, and how can I do it in a way that fits into my schedule?” How long does it take to develop into a good teacher and role model, and did you have any questions along the way? Perhaps the more important question is, are you truly a good teacher now? How can you become even better? Because of the tremendous necessity to develop true plastic surgery educators and role models today, Plastic and Reconstructive Surgery has developed a new Plastic Surgery Educator article series. The forthcoming series of articles arises out of the realization that most plastic surgeons are hired by academic institutions or clinical enterprises because of their patient care skills, with little attention paid to their teaching ability. I have asked Dr. Robert Weber to spearhead this article series, in the hope that it will benefit other plastic surgeons. He has developed into an exemplary plastic surgery educator and has worked hard at becoming a talented plastic surgery teacher. An informal survey of plastic surgeons showed that fewer than one in 10 have had any training in the theory or practice of adult education, yet they are expected to be training the next generation of practitioners. Plastic surgery residents are also expected to be teachers, but the curriculum of medical schools and surgical residencies has contained scant amounts of teacher training. As the need for practicing plastic surgeons continues to increase, more plastic surgery educators are required. The necessity to learn how to teach is not confined to academic plastic surgeons; rather, the necessity is placed on all of us. Robert Ruberg points out that all plastic surgeons should be teachers. He writes, “We have a unique opportunity—maybe even an obligation—to also become lifelong teachers.”1 Rather than “hiding out” in office practices, he admonishes plastic surgeons to present plastic surgery topics at medical staff meetings or offer in-services to nursing and office personnel in an effort to teach colleagues what a plastic surgeon does and why. Most importantly, Ruberg reminds us that patient education is a critical aspect of patient care.1 Good teachers make good doctors. Every discipline is one generation from extinction. The pejorative adage “Those who can, do; those who cannot, teach” reflects the low esteem many practitioners have toward teaching. Professional schools often have difficulty attracting good teachers because of the disparity of compensation between a practitioner and an educator. Medical institutions have had the tendency to reward professors more for research than for education. Surgery faces the situation where decreasing reimbursement and increasing patient loads have made it harder to carve out time to teach, let alone spend the time to learn how to improve teaching skills. THE HEART OF THE MATTER There are myriad articles and books that try to distill what it means to be a good teacher and how to accomplish effective learning. To a greater or lesser degree, most of them capture essential components that must be present for quality education to occur. In brief, essential elements of good teaching can be summarized as follows: Learner-focused teaching. Appropriate and stimulating learning environment. Supportive relationship between teacher and students. Clear, effective instruction (verbal, physical, and tactile) from teacher to students, modified to best suit the content, audience, and desired learning effect. Different content and desired impact of the content on the students require different teaching methods. Meaningful assessment/measurement of learning for both teacher and learner, and modification of techniques based on results. Of course, each element represents numerous additional subdivisions that fuel ongoing development of new learning theories and strategies. In general, we have found it very helpful to ask the following questions in advance: Who is my audience? What special things about them do I need to consider as I prepare my content and delivery? What content do I need to teach my audience? What is the best way to communicate the content? How can I best engage my audience? How do I know they have learned the content? Taking just a few minutes to think about and answer those questions mentally in advance can make the difference between a highly successful teaching encounter and a flop. To further distill good teaching to its essence, we think that it comes down to two crucial items that serve as the foundational components: love and patience. Love of the material being taught, love of the students themselves, and love of seeing people's lives change for the good because they have learned something new. Patience with ourselves as teachers and as communicators who are always working on getting better, patience with our students who may need more time than we think, and patience to see newly found knowledge transform into life-changing behaviors. Love and patience will enable you to become a truly good teacher over time, and at the end of the day, although your students may remember that it was you who taught them some specialized technique, they will never forget that it was you who shared your life with them and introduced them to the joys of plastic surgery. FROM THEORY TO PRACTICE The goal of this educator series in Plastic and Reconstructive Surgery is simple: to efficiently teach plastic surgeons how to be better teachers. Recognizing that most surgeons are busy and would appreciate having a single resource that cuts to the chase; speaks in a surgeon's language; provides easy-to-apply, effective, concrete tools; and serves as a starting point for further study if desired, this series will present articles covering the key aspects of adult education and explain how they can be applied in surgical education. Because how we learn should determine how we teach, the first article (in this month's Journal) will discuss how adult students learn. Recognizing that there are a large number of educational theories offering useful insights, and that it is possible to be paralyzed by a multiplicity of choices, we chose to introduce the concepts of the Kolb cycle because it is readily adaptable to plastic surgery.2 The article contains a greater portion dedicated to theory than the subsequent articles because it provides the principles with which each person can develop a set of teaching tools that fits his or her unique set of skills and situations. The next article will explore the idea of how a learner moves from novice to expert. Equipped with a basic understanding of learning theory, the following articles will provide some principles of effective teaching, including the qualities of a good teacher. Additional articles will apply these principles to lectures and small group discussions, teaching in the clinical environment, and the unique challenge of teaching surgical skills. Because our goal of producing competent plastic surgeons and informed colleagues should determine what we teach, there will be an article explaining the various aspects of a curriculum and their importance. There will be a separate article on a particular application of curriculum, the Accreditation Council for Graduate Medical Education competencies. Finally, curriculum drives assessment; we need to know whether we are on the right path to achieve our goal and determine whether and when we arrive. Consequently, a later article describes the nature of assessment and student/resident evaluations. Each article has at least two authors. One is an individual who is well respected within the field of medical education, and one is a plastic surgeon who has demonstrated excellence in teaching plastic surgeons. The aim is to bridge the fields of education and plastic surgery and share information already available so that the wheel need not be reinvented. The references are not meant to be exhaustive, but to provide a source to begin self-directed learning. Half the battle of becoming a better educator is recognizing that teaching is a skill that can be improved. There is actually a second goal of this series, namely, to encourage plastic surgeons as they teach. One participant in a surgical educators course that covers the topics discussed in this series summarizes our objective, “I come from a family of educators, and I realized I was just flying by the seat of my pants trying to teach the best I can. Before I saw myself as an attending. Now I see myself as a college professor. My excitement for teaching has changed; my enthusiasm for taking care of patients has been rekindled.” Robert A. Weber, M.D. Division of Plastic Surgery Scott and White Healthcare 2401 South 31st Street Temple, Texas 76508 [email protected]

Background Previous studies have shown men and women attending physicians rate or provide operating room (OR) autonomy differently to men and women residents, with men attendings providing higher ratings and more OR autonomy to men residents. Particularly with the advent of competency-based training in plastic surgery, differential advancement of trainees influenced by gender bias could have detrimental effects on resident advancement and time to graduation. Objective We determined if plastic surgery residents are assessed differently according to gender. Methods Three institutions' Operative Entrustability Assessment (OEA) data were abstracted from inception through November 2018 from MileMarker, a web-based program that stores trainee operative skill assessments of CPT-coded procedures. Ratings are based on a 5-point scale. Linear regression with postgraduate year adjustment was applied to all completed OEAs to compare men and women attendings' assessments of men and women residents. Results We included 8377 OEAs completed on 64 unique residents (25% women) by 51 unique attendings (29% women): men attendings completed 83% (n = 6972; 5859 assessments of men residents; 1113 of women residents) and women attendings completed 17% (n = 1405; 1025 assessments of men residents; 380 of women residents). Adjusted analysis showed men attendings rated women residents lower than men residents (P < .001); scores by women attendings demonstrated no significant difference (P = .067). Conclusions Our dataset including 4.5 years of data from 3 training programs showed men attendings scored women plastic surgery residents lower than their men counterparts.

Objective: To investigate the impact of early vs. delayed surgical decompression on peripheral motor axonal dysfunction following acute traumatic central cord syndrome (ATCCS). Methods: Both axonal excitability testing and motor unit number estimation (MUNE) were performed in 30 ATCCS patients (early-vs. delayed-surgical treatment: 12 vs. 18) before operation and 28 healthy subjects. Axonal excitability testing was repeated 3-5 days and 1-year after operation, and MUNE was reevaluated 1-year after operation. Results: Preoperatively, an obvious modification in membrane potentials was observed in ATCCS patients that mostly coincided with depolarization-like features, and MUNE further revealed reduced motor units in tested muscles (P < 0.05). Unlike delayed-surgical cases, early-surgical cases showed recoveries of most measurements of axonal excitabilities soon after operation (P < 0.05). Postoperative one-year follow-up demonstrated that greater motor unit numbers in tested muscles were obtained in early-surgical cases than in delayed-surgical cases (P < 0.05). Conclusions: ATCCS has adverse downstream effects on peripheral nervous system, even in the early stage of ATCCS. Early surgical treatment can ameliorate both excitability abnormalities and motor unit loss in distal motor axons. Significance: Optimizing axonal excitability in the early phases of ATCCS may alleviate peripheral nerve injury secondary to lesions of upper motor neuron and improve clinical outcomes. (c) 2021 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.

BACKGROUND:Previous studies show female residents tend to underrate and male residents to overrate their own performance. We sought to determine if plastic surgery resident trainee self-evaluations differ by resident sex.METHODS:We extracted Operative Entrustability Assessment (OEA) data for plastic surgery programs from MileMarker™, a program capable of storing assessment data for CPT-coded procedures. Complete OEAs contain a trainee self-assessment and attending surgeon assessment. We used simple statistics and linear regression to assess differences, stratifying by trainee sex and post-graduate year (PGY).RESULTS:We analyzed 8149 OEAs from 3 training programs representing 64 residents (25% female) and 51 attendings. Compared to attending assessments, both male and female residents significantly underrated their performance during PGY1. However, during PGY2-6 male residents' self-evaluations were significantly higher and female residents' self-evaluations significantly lower than their attending evaluations.CONCLUSIONS:Results demonstrated female plastic surgery residents underestimated and male residents overestimated their performance. Further studies are needed to determine reasons for these differences.

OBJECTIVES:The ability to assess a trainee's technical skill in a manner that maintains patient safety is critical to resident education. To do so, senior plastic surgery educators frequently ask residents to draw their proposed operation, presuming that a surgeon's ability to perform a surgery is reflected in his or her ability to diagram the procedure, independent of artistic ability. The purpose of this study was to delineate the relationship between the ability to draw a surgical procedure and execute it in a simulated model, and to determine if the ability to draw a procedure depends on artistic ability. DESIGN:Participants in varying levels of knowledge and surgical skill were asked to draw a 4-strand cruciate tendon repair and subsequently perform the procedure on a validated, simulated model. The participants were graded according to Objective Structured Assessment of Technical Skills scales by 2 blinded hand surgeon examiners. Statistical analysis was performed in SAS 9.4 with Spearman's rank correlation coefficient. SETTING:The study was performed at Baylor Scott and White Health in Temple, TX in an office-based laboratory setting. Participants Forty participants comprised of senior medical students, plastic/orthopedic surgery residents, and plastic/hand surgery attendings. All 40 participants entered and completed the study. RESULTS:A statistically significant strongly positive correlation was found between overall assessment of drawing and overall assessment of performing the surgical procedure (p = 0.004). At the same time, the assessment of ability to draw the procedure was not associated with a general ability to draw or previous art training (p = 0.28). CONCLUSIONS:Our findings support the use of drawing a specific procedure as an assessment tool to evaluate a surgeon's ability to perform a procedure.

INTRODUCTION:We investigated the feasibility of motor unit number index (MUNIX) in quantitatively assessing motor root lesions and tracking different treatment outcomes in lumbosacral radiculopathy (LR). METHODS:Bilateral MUNIX was recorded from the abductor hallucis, extensor digitorum brevis, and tibialis anterior in 44 normal controls and 108 patients with LR, and this was repeated approximately 12 months after treatment in 60 patients with LR. RESULTS:More abnormalities were observed when side-to-side differences of MUNIX measurements were used to evaluate LR (P < .05). Motor unit number index measurements worsened without progression of muscle weakness after conservative treatment, and MUNIX measurements improved with or without increased muscle strength after surgical treatment (P < .05). DISCUSSION:Motor unit number index may identify a specific L5 or S1 motor root lesion even before muscle weakness occurs, especially when side-to-side differences are used. Changes in MUNIX were larger than those in motor function measures after treatments for LR.

Background: Forming a better understanding of how quickly resident physicians demonstrate skill advancement in the operating room is vital to providing more efficient and effective training. We performed the current study to determine how long it takes residents to progress in skill level for two common plastic surgery cases, Breast Reconstruction (CPT 19357) and Endoscopic Carpal Tunnel Release (CPT 29848). Methods: Operative Entrustability Assessment (OEA) data were abstracted from MileMarkerTM, a web-based program capable of storing trainee self-assessments and their associated attending assessments of any CPT-coded procedure. Ratings are based on a 5-point scale (1=“observed case,” 5=“can take junior resident through case”); a score of 4 (“resident can perform entire surgery”) demonstrates operative competence. We used data from two plastic surgery training programs to identify cases for which OEAs are most often completed. We stratified OEAs by CPT code, resident, and score level to assess the number of cases for which OEAs are completed before OEA score increase. We used descriptive statistics (e.g., average, range) to assess outcomes. Results: We identified 682 OEAs completed by 54 unique residents for CPT 19357 (n=400) and 29848 (n=282). For CPT 19357, residents logged the greatest number of OEAs to progress between levels 3 and 4 (mean=5.2). For CPT 29848, residents logged the greatest number of OEAs to progress from level 4 to level 5 (mean=3.4). For CPT 19357, the next greatest number of cases were logged between levels 2 and 3 (mean=3.5) while in CPT 29848 the next greatest number were logged between levels 3 and 4 (mean=3.2). Conclusion: Our dataset including 5.5 years of data from 2 plastic surgery training programs showed that residents logged the most cases to progress between OEA skill level 3 (“needs verbal guidance”) and 4 (“operates independently”) for CPT 19357 and from level 4 to 5 (“can take junior resident through case”) for CPT 29848. By aligning instructional approaches with the Conscious Competence Matrix wherein OEA level 3 correlates with conscious incompetence, level 4 with conscious competence, and level 5 with unconscious competence, attending surgeons may more efficiently assist learners with operative skills acquisition.

PURPOSE:Distal-type cervical spondylotic amyotrophy (CSA) is an uncommon syndrome associated with cervical spondylosis. The pathogenic mechanism of distal-type CSA is still unclear. The aim of the current study was to analyze central motor conduction time (CMCT) in the cases with distal-type CSA and to investigate the role of cervical cord compressive injury in the distal-type CSA.METHODS:Both 28 cases with distal-type CSA and 21 healthy subjects accepted CMCT measures, motor unit number estimation, handgrip strength examination, and magnetic resonance imaging evaluation.RESULTS:In this study, nine (9/28, 32.1%) cases with CSA presented with prolonged CMCT, and both reduced number of motor units and decreased handgrip strength were found in these 9 cases (P < 0.05). Magnetic resonance imaging evaluation showed that 7 of these 9 patients presented with proximal cervical cord compression with or even without distal selective compression consistent with segmental atrophy. A negative relationship between CMCT and both number of motor units and handgrip strength was found on the symptomatic side (P < 0.05), and there was a positive correlation between CMCT and amplitude of single motor unit potentials on the less symptomatic side (P < 0.05).CONCLUSIONS:Corticospinal tract damage caused by proximal spinal cord compression may induce distal motor unit loss to worsen in some cases with distal-type CSA, which may contribute to the dysfunction of the distal upper limb in some cases with distal-type CSA. Therefore, treatment and rehabilitation efforts should account for both distal selective compression and proximal cord compression in distal-type CSA.

BACKGROUND: Previous studies have shown that male and female attendings rate or provide operating room (OR) autonomy differently to male and female residents, with male attendings providing higher ratings and more OR autonomy to male residents. We conducted the current study to determine if plastic surgery resident trainees are evaluated differently according to attending physician sex. METHODS: Operative Entrustability Assessment (OEA) data were abstracted from MileMarkerTM, a web-based program capable of storing trainee operative skill assessments of any CPT-coded procedure. Ratings are based on a 5-point scale (1=“observed case” and 5=“can take junior resident through case”). We extracted all complete OEAs (those containing self-assessments and attending evaluations) from three institutions. We used linear regression adjusting for post-graduate year (PGY) to compare male and female attendings’ assessments of male and female residents. RESULTS: We included 8,149 OEAs completed by 64 unique residents (25% female) and 51 unique attendings (29% female). Adjusted analysis showed that male attendings rated female residents significantly lower than male residents (p<0.001, 95%CI= -0.311 to -0.197). Scores by female attendings demonstrated no significant difference between male and female residents (p=0.067, 95%CI= -0.198 to 0.007). CONCLUSION: Our dataset including 4.5 years of data from three training programs showed that female plastic surgery residents are scored lower than their male counterparts by male attendings. As plastic surgery begins its pilot of competency-based training, further studies are needed to determine reasons for these differences to ensure appropriate advancement of all trainees.

OBJECTIVE:To assess the feasibility of motor unit number index (MUNIX) in the quantitative assessment of the cervical spondylotic amyotrophy (CSA). METHODS:MUNIX was recorded bilaterally on the abductor pollicis brevis, abductor digiti minimi, biceps brachii and middle deltoid in 41 normal controls and 47 patients with CSA (distal-type to proximal-type ratio: 25 to 22). Additionally, patients were assessed on handgrip strength (HGS), the disabilities of arm, shoulder and hand (DASH) and Medical Research Council (MRC) scales. These examinations were re-evaluated approximately 18 months after surgery in 37 of these CSA patients. RESULTS:MUNIX values were noticeably lower in the mainly affected muscles of CSA patients than those in controls (P < 0.05), and 49.0% (51/104) of the tested muscles with abnormal MUNIX measurements showed normal muscle strength. Significant correlations between MUNIX measurements and both DASH and MRC scores were observed in both CSA patient groups (P < 0.05). Postoperative longitudinal follow-up analysis identified significant increase in motor unit number in both CSA patient groups within approximately 18 months (P < 0.05), with or without improved measures of motor function. CONCLUSIONS:A significant reduction in MUNIX values related to motor impairment was observed in CSA patients, even in the subclinical stage. Compared to measures of motor function, the MUNIX measurements in the patients with CSA improved more noticeably after surgical intervention. SIGNIFICANCE:MUNIX may serve as an available supplementary test to quantitatively evaluate the motor dysfunction in CSA and to track its progression, that is complementary to conventional electromyography.

Background There has been a relatively rapid increase in the number and size of “integrated” residency programs in plastic surgery (PS) over the past decade. The objective of this study is to evaluate trends of US senior applicants of PS compared with other surgical specialties from 2007 to 2016. Methods Data were obtained from “NRMP: Main Residency Match” and from “NRMP: Charting Outcomes in the Match.” Frequencies, percentages, and proportions were calculated for categorical variables. Odds ratios with 95% confidence interval were calculated to evaluate the relationship of Alpha Omega Alpha membership and match success. Results The overall National Resident Matching Program match rate ranged from 93.1% to 95.1%, but rates were lower for surgical specialties, ranging from 74.7% to 86.6% in 2016. From 2008 to 2016, PS had a relatively high growth rate in the number of positions (65.2%) from 2008 to 2016. Matched PS and Otolaryngology applicants routinely had the highest mean United States Medical Licensing Examination Step 1 and Step 2 Clinical Knowledge scores. Alpha Omega Alpha membership has a significant impact on successfully matching into a surgical specialty (P < 0.1). Matched applicants of surgical subspecialties (PS, Otolaryngology, orthopedics, and neurosurgery) had similar mean number of research, work, and volunteer experiences. However, PS and neurosurgery matched applicants had notably higher mean research productivity. Conclusions The rapid increase in the number of positions in PS residency training has not resulted in a decrease in caliber of matched applicants, even though match rates have dramatically increased. Currently, PS continues to attract and successfully match highly qualified applicants, but other surgical specialties have increasingly similar board scores and mean number of extracurricular experiences.

Objective: To clarify the effectiveness of anterior cervical fusion (ACF) in the treatment of Hirayama disease (HD). Methods: Sixty-nine HD patients who accepted ACF procedures underwent dynamic F-waves before and soon after operation, and 36 of the 69 patients underwent pre- and postoperative magnetic resonance imaging (MRI). Motor unit number estimation, handgrip strength (HGS) and disabilities of arm, shoulder and hand (DASH) were performed in these 36 HD patients and in the other 24 patients who accepted neither neck-collar support nor operation, and these tests were reassessed about one year after initial test. Results: Postoperatively, dynamic F-wave abnormalities were observed in fewer HD cases (2/69 vs. 25/69), and neck-flexion MRI abnormalities decreased significantly (P < 0.05). Compared with motor unit loss in patients who were untreated, follow-up analysis demonstrated no differences in motor unit, HGS or DASH in HD patients who underwent operation (P > 0.05), and mild recovery of motor units was observed in patients with preoperative abnormal dynamic F-waves (P < 0.05). Conclusions: ACF procedures can immediately remove neck-flexion abnormalities and prevent or delay the progression of HD. Significance: ACF procedures may provide effective, reliable and alternative methods for the treatment of HD, especially in HD patients with functional evidence of neck-flexion abnormalities. (C) 2018 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.

In H reflex studies, H waves are recruited from the reflex-elicited depolarization of the Alpha motor neurons, which follows the Henneman’s size principle that the small motor neurons are responsible for the early portion of the recruitment of the H-reflex. However, there has not been a successful experiment in human with EMG techniques to demonstrate this principle. The goal of this study is to demonstrate that small motor fibers are responsible for the elicitation of the H-reflex in the soleus and flexor carpi radialis (FCR) muscles by blocking the conduction of large motor nerve fibers of the tibial and median nerve using partial ischemia via blood pressure cuff. This prospective study recruited 8 health resident physicians (4 m, 4 F). Electrical stimulation to the tibial nerve at the popliteal fossa, with recording from the soleus and to median nerve at above the elbow with recording from FCR was titrated to elicit both M and H waves, with ratios of amplitudes at 1:1. Compression by a blood pressure cuff was placed at the proximal tibia during tibial nerve stimulations, and at the forearm just distal to the elbow for median nerve stimulation. Stimulations with pulse duration of 1 ms at intervals of 2 s were delivered to the two nerves before, during, and post compression/ischemia. In all the subjects tested, during blood pressure cuff inflation, the M-waves of the two muscles consistently demonstrated significant loss of amplitude (or disappeared) with mild increase of latency, while the H-reflex showed no, or very mild amplitude reductions without changes in latency. After blood pressure cuff deflation, the M-waves immediately returned to their previous amplitude and latency patterns. There was a significant dissociation between the changes of M and H waves during acute partial compression/ischemia. Acute compression/ischemia instantly causes nerve conduction block of the tibial and median nerves motor fibers and reduces the amplitude of the M waves, but not the H-reflexes. M waves elicited by electrical stimulation recruit large motor fibers first, and are more susceptible to the ischemic blockade applied. By contrast, the H reflex first recruits small motor neurons, with their smaller motor nerve fibers less susceptible to partial acute compression/ischemia. This experiment demonstrates the Henneman’s size principle that the smallest motor units are recruited first during spinal reflexes and volitional muscle contraction. It is also of important significance in the application of motor rehabilitation with therapeutic and functional electrical stimulation of nerves and muscles.

Objective: To investigate the changes in motor axonal excitability properties in cervical spondylotic amy-otrophy (CSA). Methods: Threshold tracking was used to measure the median motor axons in 21 patients with CSA, 10 patients with cervical spondylotic radiculopathy (CSR) and 16 normal controls. Results: Compared with normal controls, patients with distal-type CSA showed increased threshold elec-trotonus hyperpolarization (TEh [90-100]) and increased superexcitability on the symptomatic side (P< 0.05), which are suggestive of distal motor axonal hyperpolarization, presumably due to motor axonal regeneration. More importantly, compared with normal controls and CSR cases, both distal- and proximal-type CSA cases showed lower accommodation during depolarising currents (reduced S2 accom-modation, decreased TEd [undershoot] and/or lower subexcitability) (P<0.05), indicating that slow K+ conductance may be less active in motor axons in patients with CSA. Conclusions: The present study demonstrated changes in motor axonal excitability in patients with CSA compared with both normal controls and patients with CSR. Significance: Less expression of slow K+ conductance may confer greater instability in membrane poten-tial in CSA, thereby presumably contributing to the increased vulnerability of motor axons in patients with CSA. (C) 2018 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.

OBJECTIVE:To quantify the replacement cost of patient care provided by surgical residents and build a Graduate Medical Education (GME) value analysis model.DESIGN:Our Graduate Medical Education Executive Steering Committee designed a resident replacement cost model, based on patient care hours (adjusted for educational activities and a clinical efficiency factor, differential cost of faculty supervision for residents vs. APPs, and current program financials (revenue minus expenses). Strategic value planning included: academic productivity (local and national conference presentations, book chapters and publications and Senior Staff recruitment and retention.SETTING:Department of Surgery at Baylor Scott & White Medical Center, a tertiary institution located in Temple, TX.PARTICIPANTS:Our replacement model was applied to a sample 30-position residency program.RESULTS:Modeling a 30-position residency program, replacement cost approaches 4.5 million dollars, based on a 1:3 Senior Staff-to-APP replacement ratio. A complete APP replacement complement has a projected cost of 3.1 million dollars, while replacement with Senior Staff approaches 9 million dollars.CONCLUSIONS:We present a novel model for residency value analysis allowing for reproducible and standardized results across multiple residency programs. Challenges inherent to GME, such as clinical efficiency and the cost of faculty supervision, are accounted for. Quantifying resident replacement cost and financial value is a powerful tool when discussing institutional workforce planning within the current financial climate of healthcare.