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Famciclovir administered preoperatively and after craniotomies resulted in a smaller percentage of patients developing delayed facial weakness. We are continuing the routine use of famciclovir in perioperative acoustic tumor management and recommend that others do so.

Chronic scaphoid fracture nonunion continues to present a significant challenge to the treating orthopedic surgeon. Internal fixation with threaded compression screws leads to high union rates, and is currently the gold standard, but there are certainly circumstances where a scaphoid screw does not provide the stability necessary for nonunion repair. Results using a volar buttress plate have been promising, but have not been described in conjunction with the use of vascularized bone graft. Vascularized bone grafts have been shown to be highly effective in achieving rapid and reproducible rates of union. We describe a novel combination of a vascularized volar distal radius wedge autograft pedicled on the volar carpal artery and volar buttress plating for salvage treatment of chronic scaphoid nonunion.

Resident cost awareness and ability to accurately estimate laboratory order costs improved significantly after implementation of a comprehensive EHR cost display for all laboratory orders. The improvement in cost estimation accuracy for imaging orders, which did not have costs displayed, suggested a possible spillover effect generated by providing a cost context for residents.

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Background Cost awareness, to ensure physician stewardship of limited resources, is increasingly recognized as an important skill for physicians. The Accreditation Council for Graduate Medical Education has made cost awareness part of systems-based practice, a core competency of resident education. However, little is known about resident cost awareness. Objective We sought to assess senior resident self-perceived cost awareness and cost knowledge. Methods In March 2014, we conducted a cross-sectional survey of all emergency medicine, internal medicine, obstetrics and gynecology, orthopaedic surgery pediatrics, and medicine-pediatrics residents in their final year at Yale-New Haven Hospital. The survey examined attitudes toward health care costs and residents' estimates of order prices. We considered resident price estimates to be accurate if they were between 50% and 200% of the Connecticut-specific Medicare price. Results We sent the survey to 84 residents and received 47 completed surveys (56% response rate). Although more than 95% (45 of 47) felt that containing costs is the responsibility of every clinician, and 49% (23 of 47) agreed that cost influenced their decision when ordering, only 4% (2 of 47) agreed that they knew the cost of tests being ordered. No residents accurately estimated the price of a complete blood count with differential, and only 2.1% (1 of 47) were accurate for a basic metabolic panel. The overall accuracy of all resident responses was 25%. Conclusions In our study, many trainees exit residency with self-identified deficiencies in knowledge about costs. The findings show the need for educational approaches to improve cost awareness among trainees.

A cross the United States and around the world, the past several weeks have brought enormous changes to the way orthopedic surgeons practice. At our academic medical practice, all elective cases were cancelled or rescheduled beginning on March 16. Within a week, we had consolidated clinics, changed call schedules, embraced telehealth, and reimagined how we deliver care during the COVID-19 outbreak. Intensivists, infectious disease specialists, and emergency department personnel are working on the front lines to diagnose and treat the sequelae of COVID-19. In some places with a heavy burden of patients, orthopedic surgeons have been asked to work in emergency departments or on inpatient services. However, even behind the front lines of this pandemic, there is a clear need for all practitioners to rapidly work to evolve our medical system and to care for patients safely and efficiently. We suggest that orthopedic surgeons can have a huge impact on community and individual safety by taking organized and thoughtful steps to safeguard their patients, their colleagues, and themselves.