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ABSTRACT: International-United States medical graduates (I-USMGs) are non-US citizen graduates of US medical schools. Although academically equivalent to US-citizen peers, they are subject to the same visa requirements as non-US citizen international medical graduates. We hypothesized that visa sponsorship policies of general surgery programs (GSPs) may be discordant with the enrollment patterns of I-USMGs. A total of 196 GSPs participated in a telephone survey regarding visa sponsorship policies. Whereas GSPs preferred J-1 to H-1B sponsorship (64.2% vs 32.6%), I-USMG enrollment favored programs supporting H-1B sponsorship (72.1% vs 7.5%) (P = .01). University-affiliated programs were more likely to sponsor H1-Bs than independent programs (39.6% vs 24.4%) (P = .03) and trained a greater proportion of I-USMGs than independent programs (40.6% vs 14.0%) (P < .01). Restrictive policies against H-1B sponsorship may limit GSPs' I-USMG applicant pool and restrict I-USMGs' surgical training options.
JAMA surgery. 03/2013; 148(3):292-4.
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ABSTRACT: The current residency training system in the United States (US) has inherent dependence on the international medical graduate (IMG). This article discusses the physician workforce shortage, especially related to general surgery, and examines the distribution of IMGs in general surgery ranks.
We performed a cross-sectional study using the American Medical Association Masterfile database of physicians licensed to practice in at least 1 state and determined the number and location of general surgeons in practice. We then stratified the distribution of these practicing surgeons, both IMGs and non-IMGs, according to rural urban commuting areas into small rural, large rural, or urban areas.
There were 17,727 general surgeons. IMGs were older (52 +/- 8 years versus 47 +/- 8 years; p < 0.001), more likely to be male (93% versus 82%; p < 0.001), and more likely to be further out of training (46% versus 28% > or =20 years out of training; p < 0.001). There were 2,216 IMGs in urban cores, constituting 15% of general surgeons in these areas. Large rural areas contained 223 IMGs (12% of general surgeons in these cores) and small rural areas contained 163 IMG general surgeons (16% of total general surgeons in these cores).
General surgeons are in high demand, and until now have remained inherently dependent on IMGs to reinforce their ranks. Current numbers of IMGs in practice are declining. This decline, coupled with inadequate numbers of trainees in domestic general surgery programs, creates a crisis of urgency.
Journal of the American College of Surgeons 06/2010; 210(6):990-6. · 4.55 Impact Factor
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ABSTRACT: Pregnancy and Cushing's syndrome rarely coexist. When they do, it is generally the result of the presence of an adrenal adenoma. Because of significantly increased morbidity and mortality in both the mother and fetus when hypercortisolism is present, it is imperative that it be treated when recognized. This treatment can take the form of definitive surgical treatment or temporary medical treatment until after delivery, both of which carry risks and benefits. Complicating the evaluation, however, it is well known that pregnancy itself can induce many of the symptoms and laboratory abnormalities associated with hypercortisolism. We present the case of a 35-year-old woman who was noted to have an adrenal mass before pregnancy, but then during evaluation became pregnant. Her case is particularly intriguing because she had only vague clinical symptoms and mild laboratory abnormalities but also had a complicating pituitary mass noted on MRI. We outline the evaluation process and eventual laparoscopic adrenalectomy during the second trimester in this unique and difficult case, and discuss risks and benefits of different treatment options for hypercortisolism during pregnancy.
The American surgeon 04/2009; 75(3):232-4. · 1.28 Impact Factor
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ABSTRACT: An infected urachal cyst is an uncommon finding in adults. We report the first case of a sigmoid-urachal-cutaneous fistula that resulted from rupture of an infected urachal cyst in an adult male. Definitive management consisted of resection of the urachus with a bladder cuff, along with removal of the affected bowel segments and bowel anastomosis.
Urology 05/2008; 73(2):444.e5-7. · 2.43 Impact Factor
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ABSTRACT: In an effort to optimize sentinel lymph node (SLN) mapping for breast cancer, sites of mapping agent administration and types of mapping agents used continue to be evaluated. This study compares SLN mapping using peritumoral (PT) or subareolar (SA) injection of radiolabeled colloid and examines the relative contributions of radiotracer and blue dye to SLN identification.
A retrospective review was performed of 456 patients with breast cancer and clinically negative axillae who underwent SLN mapping. Sequential groups of patients were injected with filtered Tc-99m SC, 326 peritumorally (group 1) and 130 subareolarly (group 2). All patients had intraoperative SA injection of 1% isosulfan blue dye.
The SLN identification and isotope success rates were 97% and 96% in group 1 and 98% and 98% in group 2, respectively. Eighty-one patients (25%) in group 1 and 44 patients (34%) in group 2 had positive SLNs. Of these patients, 15% from group 1 and 14% from group 2 had only positive nodes detected by radiotracer, and 9 of these patients (6 from group 1 and 3 from group 2) had other nodes identified by both radiotracer and blue dye that were negative for metastases. Six percent of patients with positive SLNs were upstaged because of use of radiotracer.
PT and SA injection of radiotracer have comparable success rates for axillary SLN identification. Given that 15% of patients in group 1 and 14% in group 2 had only positive SLNs detected by radiotracer, independent of site of administration, radiotracer remains essential for optimizing breast SLN mapping.
Clinical Nuclear Medicine 10/2006; 31(9):527-33. · 3.67 Impact Factor
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ABSTRACT: The neural correlate of object recognition in non-canonical views is uncertain, but there is evidence for involvement of neural pathways, possibly separate from those used for object recognition in canonical views.
Boxcar functional MRI (fMRI) techniques were used to detect neural activity while eight normal subjects were instructed to identify digital photographs of objects in non-canonical and canonical orientations.
The right angular gyrus, the left inferior temporal gyrus, and the right cerebellum showed significant fMRI activity during non-canonical as opposed to canonical viewing.
Subjects recognizing objects in non-canonical orientations engage in a process separate from, or in addition to, the process used in recognizing objects in canonical orientations.
Journal of Neuro-Ophthalmology 01/2006; 25(4):273-9. · 1.45 Impact Factor
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Susan B Kesmodel,
Giorgos C Karakousis,
Jeffrey D Botbyl,
Robert J Canter,
Robert T Lewis,
Peter M Wahl, Kyla P Terhune,
Abass Alavi,
David E Elder,
Michael E Ming,
DuPont Guerry,
Phyllis A Gimotty,
Douglas L Fraker,
Brian J Czerniecki,
Francis R Spitz
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ABSTRACT: Lymphatic mapping and sentinel lymphadenectomy (LM/SL) provide important prognostic information for patients with early-stage melanoma. Although the use of this technique in patients with thin melanomas (< or =1.00 mm) is not routine, risk factors that may predict sentinel lymph node (SLN) positivity in this patient population are under investigation. We sought to determine whether mitotic rate (MR) is associated with SLN positivity in thin-melanoma patients and, therefore, whether it may be used to risk-stratify and select patients for LM/SL.
Clinical and histopathologic variables were reviewed for 181 patients with thin melanomas who underwent LM/SL from January 1996 through January 2004. Univariate and multivariate logistic regression analyses were performed to identify factors associated with SLN positivity. Risk groups were defined on the basis of the development of a classification tree.
The overall SLN positivity rate was 5%. All patients with positive SLNs had an MR of >0. By univariate analysis, MR and thickness were significant predictors of SLN positivity. The association between MR and SLN positivity remained significant controlling for each of the other variables evaluated. On the basis of a classification tree, patients with an MR >0 and tumor thickness > or =.76 mm were identified as a higher-risk group, with an SLN positivity rate of 12.3%.
In patients with thin melanomas, MR >0 seems to be a significant predictor of SLN positivity that may be used to risk-stratify and select patients for LM/SL. To confirm these results, the predictive value of MR for SLN positivity needs to be validated in other populations of thin-melanoma patients.
Annals of Surgical Oncology 06/2005; 12(6):449-58. · 4.17 Impact Factor
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American Journal of Roentgenology 03/2005; 184(2):555-9. · 2.78 Impact Factor
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ABSTRACT: Given the difference in surgical management between follicular neoplasms and papillary thyroid carcinoma (PTC), we sought to determine the sensitivity of fine-needle aspiration (FNA) and intraoperative pathologic study (IP), frozen section and cytologic study, in establishing a diagnosis of follicular variant of papillary thyroid carcinoma (FVPTC) and how these techniques impact operative management.
A retrospective chart review was performed of patients who underwent thyroidectomy for nodular disease between June 1997 and June 2002 identifying patients with a final diagnosis of FVPTC. FNA and IP results were reviewed in this group of patients and correlated with those of final histopathologic study. The sensitivity of FNA and IP was calculated.
Eighty-two patients had a final diagnosis of FVPTC. Eighty-six preoperative FNAs were obtained in 80 patients, leading to a diagnosis of PTC in 7 (sensitivity 9%). Intraoperative pathologic study was performed in 31 patients with suspicious FNA results, of which 13 were definitive for PTC (sensitivity 42%). Overall, IP was obtained in 42 patients, of which 15 were positive for PTC (sensitivity 36%).
Although the sensitivity of FNA in establishing a diagnosis of FVPTC is low, FNA identifies patients with suspicious lesions in whom IP is important in guiding operative management.
Surgery 01/2004; 134(6):1005-12; discussion 1012. · 3.10 Impact Factor
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ABSTRACT: Vernier acuity refers to the ability to discern a small offset within a line. However, while Vernier acuity has been extensively studied psychophysically, its neural correlates are uncertain. Based upon previous psychophysical and electrophysiologic data, we hypothesized that extrastriate areas of the brain would be involved in Vernier acuity tasks, so we designed event-related functional MRI (fMRI) paradigms to identify cortical regions of the brain involved in this behavior. Normal subjects identified suprathreshold and subthreshold Vernier offsets. The results suggest a cortical network including frontal, parietal, occipital, and cerebellar regions subserves the observation, processing, interpretation, and acknowledgment of briefly presented Vernier offsets.
Current Eye Research 32(7-8):717-28. · 1.28 Impact Factor
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Journal of Surgical Education 66(1):51-7. · 1.38 Impact Factor
